PNLE COMPREHENSIVE EXAM
1. A pregnant woman who is at term is admitted to the birthing unit
in active labor. The client has only progressed from 2cm to 3 cm in 8
hours. She is diagnosed with hypotonic dystocia and the physician
ordered Oxytocin (Pitocin) to augment her contractions. Which of
the following is the most important aspect of nursing intervention at
this time?
A. Timing and recording length of contractions.
B. Monitoring.
C. Preparing for an emergency cesarean birth.
D. Checking the perineum for bulging.
2. A client who hallucinates is not in touch with reality. It is
important for the nurse to:
A. Isolate the client from other patients.
B. Maintain a safe environment.
C. Orient the client to time, place, and person.
D. Establish a trusting relationship.
3. The nurse is caring to a child client who has had a tonsillectomy.
The child complains of having dryness of the throat. Which of the
following would the nurse give to the child?
A. Cola with ice
B. Yellow noncitrus Jello
C. Cool cherry Kool-Aid
D. A glass of milk
4. The physician ordered Phenylephrine (Neo-Synephrine) nasal
spray to a 13-year-old client. The nurse caring to the client provides
instructions that the nasal spray must be used exactly as directed to
prevent the development of:
A. Increased nasal congestion.
B. Nasal polyps.
C. Bleeding tendencies.
D. Tinnitus and diplopia.
5. A client with tuberculosis is to be admitted in the hospital. The
nurse who will be assigned to care for the client must institute
appropriate precautions. The nurse should:
A. Place the client in a private room.
B. Wear an N 95 respirator when caring for the client.
C. Put on a gown every time when entering the room.
D. Don a surgical mask with a face shield when entering the room.
6. Which of the following is the most frequent cause of
noncompliance to the medical treatment of open-angle glaucoma?
A. The frequent nausea and vomiting accompanying use of miotic
drug.
B. Loss of mobility due to severe driving restrictions.
C. Decreased light and near-vision accommodation due to miotic
effects of pilocarpine.
D. The painful and insidious progression of this type of glaucoma.
7. In the morning shift, the nurse is making rounds in the nursing
care units. The nurse enters in a client’s room and notes that the
client’s tube has become disconnected from the Pleurovac. What
would be the initial nursing action?
A. Apply pressure directly over the incision site.
B. Clamp the chest tube near the incision site.
C. Clamp the chest tube closer to the drainage system.
D. Reconnect the chest tube to the Pleurovac.
8. Which of the following complications during a breech birth the
nurse needs to be alarmed?
A. Abruption placenta.
B. Caput succedaneum.
C. Pathological hyperbilirubinemia.
D. Umbilical cord prolapse.
9. The nurse is caring to a client diagnosed with severe depression.
Which of the following nursing approach is important in depression?
A. Protect the client against harm to others.
B. Provide the client with motor outlets for aggressive, hostile
feelings.
C. Reduce interpersonal contacts.
D. Deemphasizing preoccupation with elimination, nourishment, and
sleep.
10. A 3-month-old client is in the pediatric unit. During assessment,
the nurse is suspecting that the baby may have hypothyroidism
when mother states that her baby does not:
A. Sit up.
B. Pick up and hold a rattle.
C. Roll over.
D. Hold the head up.
11. The physician calls the nursing unit to leave an order. The senior
nurse had conversation with the other staff. The newly hired nurse
answers the phone so that the senior nurses may continue their
conversation. The new nurse does not knowthe physician or the
client to whom the order pertains. The nurse should:
A. Ask the physician to call back after the nurse has read the hospital
policy manual.
B. Take the telephone order.
C. Refuse to take the telephone order.
D. Ask the charge nurse or one of the other senior staff nurses to
take the telephone order.
12. The staff nurse on the labor and delivery unit is assigned to care
to a primigravida in transition complicated by hypertension. A new
pregnant woman in active labor is admitted in the same unit. The
nurse manager assigned the same nurse to the second client. The
nurse feels that the client with hypertension requires one-to-one
care. What would be the initial actionof the nurse?
A. Accept the new assignment and complete an incident report
describing a shortage of nursing staff.
B. Report the incident to the nursing supervisor and request to be
floated.
C. Report the nursing assessment of the client in transitional labor to
the nurse manager and discuss misgivings about the new
assignment.
D. Accept the new assignment and provide the best care.
13. A newborn infant with Down syndrome is to be discharged
today. The nurse is preparing to give the discharge teaching
regarding the proper care at home. The nurse would anticipate that
the mother is probably at the:
A. 40 years of age.
B. 20 years of age.
C. 35 years of age.
D. 20 years of age.
14. The emergency department has shortage of staff. The nurse
manager informs the staff nurse in the critical care unit that she has
to float to the emergency department. What should the staff nurse
expect under these conditions?
A. The float staff nurse will be informed of the situation before the
shift begins.
B. The staff nurse will be able to negotiate the assignments in the
emergency department.
C. Cross training will be available for the staff nurse.
D. Client assignments will be equally divided among the nurses.
15. The nurse is assigned to care for a child client admitted in the
pediatrics unit. The client is receiving digoxin. Which of the following
questions will be asked by the nurse to the parents of the child in
order to assess the client’s risk for digoxin toxicity?
A. “Has he been exposed to any childhood communicable diseases in
the past 2-3 weeks?”
B. “Has he been taking diuretics at home?”
C. “Do any of his brothers and sisters have history of cardiac
problems?”
D. “Has he been going to school regularly?”
16. The nurse noticed that the signed consent form has an error. The
form states, “Amputation of the right leg” instead of the left leg that
is to be amputated. The nurse has administered already the
preoperative medications. What should the nurse do?
A. Call the physician to reschedule the surgery.
B. Call the nearest relative to come in to sign a new form.
C. Cross out the error and initial the form.
D. Have the client sign another form.
17. The nurse in the nursing care unit checks the fluctuation in the
water-seal compartment of a closed chest drainage system. The
fluctuation has stopped, the nurse would:
A. Vigorously strip the tube to dislodge a clot.
B. Raise the apparatus above the chest to move fluid.
C. Increase wall suction above 20 cm H2O pressure.
D. Ask the client to cough and take a deep breath.
18. The pediatric nurse in the neonatal unit was informed that the
baby that is brought to the mother in the hospital room is wrong.
The nurse determines that two babies were placed in the wrong
cribs. The most appropriate nursing action would be to:
A. Determine who is responsible for the mistake and terminate his
or her employment.
B. Record the event in an incident/variance report and notify the
nursing supervisor.
C. Reassure both mothers, report to the charge nurse, and do not
record.
D. Record detailed notes of the event on the mother’s medical
record.
19. Before the administration of digoxin, the nurse completes an
assessment to a toddler client for signs and symptoms of digoxin
toxicity. Which of the following is the earliest and most significant
sign of digoxin toxicity?
A. Tinnitus
B. Nausea and vomiting
C. Vision problem
D. Slowing in the heart rate
20. Which of the following treatment modality is appropriate for a
client with paranoid tendency?
A. Activity therapy.
B. Individual therapy.
C. Group therapy.
D. Family therapy.
21. The client with rheumatoid arthritis is for discharge. In preparing
the client for discharge on prednisone therapy, the nurse should
advise the client to:
A. Wear sunglasses if exposed to bright light for an extended period
of time.
B. Take oral preparations of prednisone before meals.
C. Have periodic complete blood counts while on the medication.
D. Never stop or change the amount of the medication without
medical advice.
22. A pregnant client tells the nurse that she is worried about having
urinary frequency. What will be the most appropriate nursing
response?
A. “Try using Kegel (perineal) exercises and limiting fluids before
bedtime. If you have frequency associated with fever, pain on
voiding, or blood in the urine, call your doctor/nurse-midwife.
B. “Placental progesterone causes irritability of the bladder
sphincter. Your symptoms will go away after the baby comes.”
C. “Pregnant women urinate frequently to get rid of fetal wastes.
Limit fluids to 1L/daily.”
D. “Frequency is due to bladder irritation from concentrate urine
and is normal in pregnancy. Increase your daily fluid intake to 3L.”
23. Which of the following will help the nurse determine that the
expression of hostility is useful?
A. Expression of anger dissipates the energy.
B. Energy from anger is used to accomplish what needs to be done.
C. Expression intimidates others.
D. Degree of hostility is less than the provocation.
24. The nurse is providing an orientation regarding case
management to the nursing students. Which characteristics should
the nurse include in the discussion in understanding case
management?
A. Main objective is a written plan that combines discipline-specific
processes used to measure outcomes of care.
B. Main purpose is to identify expected client, family and staff
performance against the timeline for clients with the same
diagnosis.
C. Main focus is comprehensive coordination of client care, avoid
unnecessary duplication of services, improve resource utilization and
decrease cost.
D. Primary goal is to understand why predicted outcomes have not
been met and the correction of identified problems.
25. The physician orders a dose of IV phenytoin to a child client. In
preparing in the administration of the drug, which nursing action is
not correct?
A. Infuse the phenytoin into a smaller vein to prevent purple glove
syndrome.
B. Check the phenytoin solution to be sure it is clear or light yellow
in color, never cloudy.
C. Plan to give phenytoin over 30-60 minutes, using an in-line filter.
D. Flush the IV tubing with normal saline before starting phenytoin.
26. The pregnant woman visits the clinic for check –up. Which
assessment findings will help the nurse determine that the client is
in 8-week gestation?
A. Leopold maneuvers.
B. Fundal height.
C. Positive radioimmunoassay test (RIA test).
D. Auscultation of fetal heart tones.
27. Which of the following nursing intervention is essential for the
client who had pneumonectomy?
A. Medicate for pain only when needed.
B. Connect the chest tube to water-seal drainage.
C. Notify the physician if the chest drainage exceeds 100mL/hr.
D. Encourage deep breathing and coughing.
28. The nurse is providing a health teaching to a group of parents
regarding Chlamydia trachomatis. The nurse is correct in the
statement, “Chlamydia trachomatis is not only an intracellular
bacterium that causes neonatal conjunctivitis, but it also can cause:
A. Discoloration of baby and adult teeth.
B. Pneumonia in the newborn.
C. Snuffles and rhagades in the newborn.
D. Central hearing defects in infancy.
29. The nurse is assigned to care to a 17-year-old male client with a
history of substance abuse. The client asks the nurse, “Have you
ever tried or used drugs?” The most correct response of the nurse
would be:
A. “Yes, once I tried grass.”
B. “No, I don’t think so.”
C. “Why do you want to know that?”
D. “How will my answer help you?”
30. Which of the following describes a health care team with the
principles of participative leadership?
A. Each member of the team can independently make decisions
regarding the client’s care without necessarily consulting the other
members.
B. The physician makes most of the decisions regarding the client’s
care.
C. The team uses the expertise of its members to influence the
decisions regarding the client’s care.
D. Nurses decide nursing care; physicians decide medical and other
treatment for the client.
31. A nurse is giving a health teaching to a woman who wants to
breastfeed her newborn baby. Which hormone, normally secreted
during the postpartum period, influences both the milk ejection
reflex and uterine involution?
A. Oxytocin.
B. Estrogen.
C. Progesterone.
D. Relaxin.
32. One staff nurse is assigned to a group of 5 patients for the 12-
hour shift. The nurse is responsible for the overall planning, giving
and evaluating care during the entire shift. After the shift, same
responsibility will be endorsed to the next nurse in charge. This
describes nursing care delivered via the:
A. Primary nursing method.
B. Case method.
C. Functional method.
D. Team method.
33. The ambulance team calls the emergency department that they
are going to bring a client who sustained burns in a house fire. While
waiting for the ambulance, the nurse will anticipate emergency care
to include assessment for:
A. Gas exchange impairment.
B. Hypoglycemia.
C. Hyperthermia.
D. Fluid volume excess.
34. Most couples are using “natural” family planning methods. Most
accidental pregnancies in couples preferred to use this method have
been related to unprotected intercourse before ovulation. Which of
the following factor explains why pregnancy may be achieved by
unprotected intercourse during the preovulatory period?
A. Ovum viability.
B. Tubal motility.
C. Spermatozoal viability.
D. Secretory endometrium.
35. An older adult client wakes up at 2 o’clock in the morning and
comes to the nurse’s station saying, “I am having difficulty in
sleeping.” What is the best nursing response to the client?
A. “I’ll give you a sleeping pill to help you get more sleep now.”
B. “Perhaps you’d like to sit here at the nurse’s station for a while.”
C. “Would you like me to show you where the bathroom is?”
D. “What woke you up?”
36. The nurse is taking care of a multipara who is at 42 weeks of
gestation and in active labor, her membranes ruptured
spontaneously 2 hours ago. While auscultating for the point of
maximum intensity of fetal heart tones before applying an external
fetal monitor, the nurse counts 100 beats per minute. The
immediate nursing action is to:
A. Start oxygen by mask to reduce fetal distress.
B. Examine the woman for signs of a prolapsed cord.
C. Turn the woman on her left side to increase placental perfusion.
D. Take the woman’s radial pulse while still auscultating the FHR.
37. The nurse must instruct a client with glaucoma to avoid taking
over-the-counter medications like:
A. Antihistamines.
B. NSAIDs.
C. Antacids.
D. Salicylates.
38. A male client is brought to the emergency department due to
motor vehicle accident. While monitoring the client, the nurse
suspects increasing intracranial pressure when:
A. Client is oriented when aroused from sleep, and goes back to
sleep immediately.
B. Blood pressure is decreased from 160/90 to 110/70.
C. Client refuses dinner because of anorexia.
D. Pulse is increased from 88-96 with occasional skipped beat.
39. The nurse is conducting a lecture to a class of nursing students
about advance directives to preoperative clients. Which of the
following statement by the nurse js correct?
A. “The spouse, but not the rest of the family, may override the
advance directive.”
B. “An advance directive is required for a “do not resuscitate”
order.”
C. “A durable power of attorney, a form of advance directive, may
only be held by a blood relative.”
D. “The advance directive may be enforced even in the face of
opposition by the spouse.”
40. A client diagnosed with schizophrenia is shouting and banging on
the door leading to the outside, saying, “I need to go to an
appointment.” What is the appropriate nursing intervention?
A. Tell the client that he cannot bang on the door.
B. Ignore this behavior.
C. Escort the client going back into the room.
D. Ask the client to move away from the door.
41. Which of the following action is an accurate tracheal suctioning
technique?
A. 25 seconds of continuous suction during catheter insertion.
B. 20 seconds of continuous suction during catheter insertion.
C. 10 seconds of intermittent suction during catheter withdrawal.
D. 15 seconds of intermittent suction during catheter withdrawal.
42. The client’s jaw and cheekbone is sutured and wired. The nurse
anticipates that the most important thing that must be ready at the
bedside is:
A. Suture set.
B. Tracheostomy set.
C. Suction equipment.
D. Wire cutters.
43. A mother is in the third stage of labor. Which of the following
signs will help the nurse determine the signs of placental
separation?
A. The uterus becomes globular.
B. The umbilical cord is shortened.
C. The fundus appears at the introitus.
D. Mucoid discharge is increased.
44. After therapy with the thrombolytic alteplase (t-PA. , what
observation will the nurse report to the physician?
A. 3+ peripheral pulses.
B. Change in level of consciousness and headache.
C. Occasional dysrhythmias.
D. Heart rate of 100/bpm.
45. A client who undergone left nephrectomy has a large flank
incision. Which of the following nursing action will facilitate deep
breathing and coughing?
A. Push fluid administration to loosen respiratory secretions.
B. Have the client lie on the unaffected side.
C. Maintain the client in high Fowler’s position.
D. Coordinate breathing and coughing exercise with administration
of analgesics.
46. The community nurse is teaching the group of mothers about
the cervical mucus method of natural family planning. Which
characteristics are typical of the cervical mucus during the “fertile”
period of the menstrual cycle?
A. Absence of ferning.
B. Thin, clear, good spinnbarkeit.
C. Thick, cloudy.
D. Yellow and sticky.
47. A client with ruptured appendix had surgery an hour ago and is
transferred to the nursing care unit. The nurse placed the client in a
semi-Fowler’s position primarily to:
A. Facilitate movement and reduce complications from immobility.
B. Fully aerate the lungs.
C. Splint the wound.
D. Promote drainage and prevent subdiaphragmatic abscesses.
48. Which of the following will best describe a management
function?
A. Writing a letter to the editor of a nursing journal.
B. Negotiating labor contracts.
C. Directing and evaluating nursing staff members.
D. Explaining medication side effects to a client.
49. The parents of an infant client ask the nurse to teach them how
to administer Cortisporin eye drops. The nurse is correct in advising
the parents to place the drops:
A. In the middle of the lower conjunctival sac of the infant’s eye.
B. Directly onto the infant’s sclera.
C. In the outer canthus of the infant’s eye.
D. In the inner canthus of the infant’s eye.
50. The nurse is assessing on the client who is admitted due to
vehicle accident. Which of the following findings will help the nurse
that there is internal bleeding?
A. Frank blood on the clothing.
B. Thirst and restlessness.
C. Abdominal pain.
D. Confusion and altered of consciousness.
51. The nurse is completing an assessment to a newborn baby boy.
The nurse observes that the skin of the newborn is dry and flaking
and there are several areas of an apparent macular rash. The nurse
charts this as:
A. Icterus neonatorum
B. Multiple hemangiomas
C. Erythema toxicum
D. Milia
52. The client is brought to the emergency department because of
serious vehicle accident. After an hour, the client has been declared
brain dead. The nurse who has been with the client must now talk to
the family about organ donation. Which of the following
consideration is necessary?
A. Include as many family members as possible.
B. Take the family to the chapel.
C. Discuss life support systems.
D. Clarify the family’s understanding of brain death.
53. The nurse is teaching exercises that are good for pregnant
women increasing tone and fitness and decreasing lower backache.
Which of the following should the nurse exclude in the exercise
program?
A. Stand with legs apart and touch hands to floor three times per
day.
B. Ten minutes of walking per day with an emphasis on good
posture.
C. Ten minutes of swimming or leg kicking in pool per day.
D. Pelvic rock exercise and squats three times a day.
54. A client with obsessive-compulsive behavior is admitted in the
psychiatric unit. The nurse taking care of the client knows that the
primary treatment goal is to:
A. Provide distraction.
B. Support but limit the behavior.
C. Prohibit the behavior.
D. Point out the behavior.
55. After ileostomy, the nurse expects that the drainage appliance
will be applied to the stoma:
A. When the client is able to begin self-care procedures.
B. 24 hours later, when the swelling subsided.
C. In the operating room after the ileostomy procedure.
D. After the ileostomy begins to function.
56. A female client who has a 28-day menstrual cycle asks the
community health nurse when she get pregnant during her cycle.
What will be the best nursing response?
A. It is impossible to determine the fertile period reliably. So it is
best to assume that a woman is always fertile.
B. In a 28-day cycle, ovulation occurs at or about day 14. The egg
lives for about 24 hours and the sperm live for about 72 hours. The
fertile period would be approximately between day 11 and day 15.
C. In a 28- day cycle, ovulation occurs at or about day 14. The egg
lives for about 72 hours and the sperm live for about 24 hours. The
fertile period would be approximately between day 13 and 17.
D. In a 28-day cycle, ovulation occurs 8 days before the next period
or at about day 20. The fertile period is between day 20 and the
beginning of the next period.
57. Which of the following statement describes the role of a nurse as
a client advocate?
A. A nurse may override clients’ wishes for their own good.
B. A nurse has the moral obligation to prevent harm and do well for
clients.
C. A nurse helps clients gain greater independence and self-
determination.
D. A nurse measures the risk and benefits of various health
situations while factoring in cost.
58. A community health nurse is providing a health teaching to a
woman infected with herpes simplex 2. Which of the following
health teaching must the nurse include to reduce the chances of
transmission of herpes simplex 2?
A. “Abstain from intercourse until lesions heal.”
B. “Therapy is curative.”
C. “Penicillin is the drug of choice for treatment.”
D. “The organism is associated with later development of
hydatidiform mole.
59. The nurse in the psychiatric ward informed the male client that
he will be attending the 9:00 AM group therapy sessions. The client
tells the nurse that he must wash his hands from 9:00 to 9:30 AM
each day and therefore he cannot attend. Which concept does the
nursing staff need to keep in mind in planning nursing intervention
for this client?
A. Depression underlines ritualistic behavior.
B. Fear and tensions are often expressed in disguised form through
symbolic processes.
C. Ritualistic behavior makes others uncomfortable.
D. Unmet needs are discharged through ritualistic behavior.
10. The nurse assesses the health condition of the female client. The
client tells the nurse that she discovered a lump in the breast last
year and hesitated to seek medical advice. The nurse understands
that, women who tend to delay seeking medical advice after
discovering the disease are displaying what common defense
mechanism?
A. Intellectualization.
B. Suppression.
C. Repression.
D. Denial.
61. Which of the following situations cannot be delegated by the
registered nurse to the nursing assistant?
A. A postoperative client who is stable needs to ambulate.
B. Client in soft restraint who is very agitated and crying.
C. A confused elderly woman who needs assistance with eating.
D. Routine temperature check that must be done for a client at end
of shift.
62. In the admission care unit, which of the following client would
the nurse give immediate attention?
A. A client who is 3 days postoperative with left calf pain.
B. A client who is postoperative hip pinning who is complaining of
pain.
C. New admitted client with chest pain.
D. A client with diabetes who has a glucoscan reading of 180.
63. A couple seeks medical advice in the community health care
unit. A couple has been unable to conceive; the man is being
evaluated for possible problems. The physician ordered semen
analysis. Which of the following instructions is correct regarding
collection of a sperm specimen?
A. Collect a specimen at the clinic, place in iced container, and give
to laboratory personnel immediately.
B. Collect specimen after 48-72 hours of abstinence and bring to
clinic within 2 hours.
C. Collect specimen in the morning after 24 hours of abstinence and
bring to clinic immediately.
D. Collect specimen at night, refrigerate, and bring to clinic the next
morning.
64. The physician ordered Betamethasone to a pregnant woman at
34 weeks of gestation with sign of preterm labor. The nurse expects
that the drug will:
A. Treat infection.
B. Suppress labor contraction.
C. Stimulate the production of surfactant.
D. Reduce the risk of hypertension.
65. A tracheostomy cuff is to be deflated, which of the following
nursing intervention should be implemented before starting the
procedures?
A. Suction the trachea and mouth.
B. Have the obdurator available.
C. Encourage deep breathing and coughing.
D. Do a pulse oximetry reading.
66. A client is diagnosed with Tuberculosis and respiratory isolation
is initiated. This means that:
A. Gloves are worn when handling the client’s tissue, excretions, and
linen.
B. Both client and attending nurse must wear masks at all times.
C. Nurse and visitors must wear masks until chemotherapy is begun.
Client is instructed in cough and tissue techniques.
D. Full isolation; that is, caps and gowns are required during the
period of contagion.
67. A client with lung cancer is admitted in the nursing care unit. The
husband wants to know the condition of his wife. How should the
nurse respond to the husband?
A. Find out what information he already has.
B. Suggest that he discuss it with his wife.
C. Refer him to the doctor.
D. Refer him to the nurse in charge.
68. A hospitalized client cannot find his handkerchief and accuses
other cient in the room and the nurse of stealing them. Which is the
most therapeutic approach to this client?
A. Divert the client’s attention.
B. Listen without reinforcing the client’s belief.
C. Inject humor to defuse the intensity.
D. Logically point out that the client is jumping to conclusions.
69. After a cystectomy and formation of an ileal conduit, the nurse
provides instruction regarding prevention of leakage of the pouch
and backflow of the urine. The nurse is correct to include in the
instruction to empty the urine pouch:
A. Every 3-4 hours.
B. Every hour.
C. Twice a day.
D. Once before bedtime.
70. Which telephone call from a student’s mother should the school
nurse take care of at once?
A. A telephone call notifying the school nurse that the child’
pediatrician has informed the mother that the child will need cardiac
repair surgery within the next few weeks.
B. A telephone call notifying the school nurse that the child’s
pediatrician has informed the mother that the child has head lice.
C. A telephone call notifying the school nurse that a child has a
temperature of 102ºF and a rash covering the trunk and upper
extremities of the body.
D. A telephone call notifying the school nurse that a child underwent
an emergency appendectomy during the previous night.
71. Which of the following signs and symptoms that require
immediate attention and may indicate most serious complications
during pregnancy?
A. Severe abdominal pain or fluid discharge from the vagina.
B. Excessive saliva, “bumps around the areolae, and increased
vaginal mucus.
C. Fatigue, nausea, and urinary frequency at any time during
pregnancy.
D. Ankle edema, enlarging varicosities, and heartburn.
72. The nurse is assessing the newborn boy. Apgar scores are 7 and
9. The newborn becomes slightly cyanotic. What is the initial nursing
action?
A. Elevate his head to promote gravity drainage of secretions.
B. Wrap him in another blanket, to reduce heat loss.
C. Stimulate him to cry,, to increase oxygenation.
D. Aspirate his mouth and nose with bulb syringe.
73. The nurse is formulating a plan of care to a client with a
somatoform disorder. The nurse needs to have knowledge of which
psychodynamic principle?
A. The symptoms of a somatoform disorder are an attempt to adjust
to painful life situations or to cope with conflicting sexual,
aggressive, or dependent feelings.
B. The major fundamental mechanism is regression.
C. The client’s symptoms are imaginary and the suffering is faked.
D. An extensive, prolonged study of the symptoms will be reassuring
to the client, who seeks sympathy, attention and love.
74. An infant is brought to the health care clinic for three
immunizations at the same time. The nurse knows that hepatitis B,
DPT, and Haemophilus influenzae type B immunizations should:
A. Be drawn in the same syringe and given in one injection.
B. Be mixed and inject in the same sites.
C. Not be mixed and the nurse must give three injections in three
sites.
D. Be mixed and the nurse must give the injection in three sites.
75. A female client with cancer has radium implants. The nurse
wants to maintain the implants in the correct position. The nurse
should position the client:
A. Flat in bed.
B. On the side only.
C. With the foot of the bed elevated.
D. With the head elevated 45-degrees (semi-Fowler’s).
76. The nurse wants to know if the mother of a toddler understands
the instructions regarding the administration of syrup of ipecac.
Which of the following statement will help the nurse to know that
the mother needs additional teaching?
A. “I’ll give the medicine if my child gets into some toilet bowl
cleaner.”
B. “I’ll give the medicine if my child gets into some aspirin.”
C. “I’ll give the medicine if my child gets into some plant bulbs.”
D. “I’ll give the medicine if my child gets into some vitamin pills.”
77. To assess if the cranial nerve VII of the client was damaged,
which changes would not be expected?
A. Drooling and drooping of the mouth.
B. Inability to open eyelids on operative side.
C. Sagging of the face on the operative side.
D. Inability to close eyelid on operative side.
78. The community health nurse makes a home visit to a family.
During the visit, the nurse observes that the mother is beating her
child. What is the priority nursing intervention in this situation?
A. Assess the child’s injuries.
B. Report the incident to protective agencies.
C. Refer the family to appropriate support group.
D. Assist the family to identify stressors and use of other coping
mechanisms to prevent further incidents.
79. The nurse in the neonatal care unit is supervising the actions of a
certified nursing assistant in giving care to the newborns. The
nursing assistant mistakenly gives a formula feeding to a newborn
that is on water feeding only. The nurse is responsible for the
mistake of the nursing assistant:
A. Always, as a representative of the institution.
B. Always, because nurses who supervise less-trained individuals are
responsible for their mistakes.
C. If the nurse failed to determine whether the nursing assistant was
competent to take care of the client.
D. Only if the nurse agreed that the newborn could be fed formula.
80. The nurse is assigned to care for a client with urinary calculi.
Fluid intake of 2L/day is encouraged to the client. the primary
reason for this is to:
A. Reduce the size of existing stones.
B. Prevent crystalline irritation to the ureter.
C. Reduce the size of existing stones
D. Increase the hydrostatic pressure in the urinary tract.
81. The nurse is counseling a couple in their mid 30’s who have been
unable to conceive for about 6 months. They are concerned that one
or both of them may be infertile. What is the best advice the nurse
could give to the couple?
A. “it is no unusual to take 6-12 months to get pregnant, especially
when the partners are in their mid-30s. Eat well, exercise, and avoid
stress.”
B. “Start planning adoption. Many couples get pregnant when they
are trying to adopt.”
C. “Consult a fertility specialist and start testing before you get any
older.”
D. “Have sex as often as you can, especially around the time of
ovulation, to increase your chances of pregnancy.”
82. The nurse is caring for a cient who Is a retired nurse. A 24-hour
urine collection for Creatinine clearance is to be done. The client
tells the nurse, “I can’t remember what this test is for.” The best
response by the nurse is:
A. “It provides a way to see if you are passing any protein in your
urine.”
B. “It tells how well the kidneys filter wastes from the blood.”
C. “It tells if your renal insufficiency has affected your heart.”
D. “The test measures the number of particles the kidney filters.”
83. The nurse observes the female client in the psychiatric ward that
she is having a hard time sleeping at night. The nurse asks the client
about it and the client says, “I can’t sleep at night because of fear of
dying.” What is the best initial nursing response?
A. “It must be frightening for you to feel that way. Tell me more
about it.”
B. “Don’t worry, you won’t die. You are just here for some test.”
C. “Why are you afraid of dying?”
D. “Try to sleep. You need the rest before tomorrow’s test.”
84. In the hospital lobby, the registered nurse overhears a two staff
members discussing about the health condition of her client. What
would be the appropriate action for the registered nurse to take?
A. Join in the conversation, giving her input about the case.
B. Ignore them, because they have the right to discuss anything they
want to.
C. Tell them it is not appropriate to discuss such things.
D. Report this incident to the nursing supervisor.
85. The client has had a right-sided cerebrovascular accident. In
transferring the client from the wheelchair to bed, in what position
should a client be placed to facilitate safe transfer?
A. Weakened (L) side of the cient next to bed.
B. Weakened (R) side of the client next to bed.
C. Weakened (L) side of the client away from bed.
D. Weakened (R) side of the cient away from bed.
86. The child client has undergone hip surgery and is in a spica cast.
Which of the following toy should be avoided to be in the child’s
bed?
A. A toy gun.
B. A stuffed animal.
C. A ball.
D. Legos.
87. The LPN/LVN asks the registered nurse why oxytocin (Pitocin), 10
units (IV or IM) must be given to a client after birth fo the fetus. The
nurse is correct to explain that oxytocin:
A. Minimizes discomfort from “afterpains.”
B. Suppresses lactation.
C. Promotes lactation.
D. Maintains uterine tone.
88. The nurse in the nursing care unit is aware that one of the
medical staff displays unlikely behaviors like confusion, agitation,
lethargy and unkempt appearance. This behavior has been reported
to the nurse manager several times, but no changes observed. The
nurse should:
A. Continue to report observations of unusual behavior until the
problem is resolved.
B. Consider that the obligation to protect the patient from harm has
been met by the prior reports and do nothing further.
C. Discuss the situation with friends who are also nurses to get
ideas .
D. Approach the partner of this medical staff member with these
concerns.
89. The physician ordered tetracycline PO qid to a child client who
weights 20kg. The recommended PO tetracycline dose is 25-50
mg/kg/day. What is the maximum single dose that can be safely
administered to this child?
A. 1 g
B. 500 mg
C. 250 mg
D. 125 mg
90. The nurse is completing an obstetric history of a woman in labor.
Which event in the obstetric history will help the nurse suspects
dysfunctional labor in the current pregnancy?
A. Total time of ruptured membranes was 24 hours with the second
birth.
B. First labor lasting 24 hours.
C. Uterine fibroid noted at time of cesarean delivery.
D. Second birth by cesarean for face presentation.
91. The nurse is planning to talk to the client with an antisocial
personality disorder. What would be the most therapeutic
approach?
A. Provide external controls.
B. Reinforce the client’s self-concept.
C. Give the client opportunities to test reality.
D. Gratify the client’s inner needs.
92. The nurse is teaching a group of women about fertility
awareness, the nurse should emphasize that basal body
temperature:
A. Can be done with a mercury thermometer but no a digital one.
B. The average temperature taken each morning.
C. Should be recorded each morning before any activity.
D. Has a lower degree of accuracy in predicting ovulation than the
cervical mucus test.
93. The nursing applicant has given the chance to ask questions
during a job interview at a local hospital. What should be the most
important question to ask that can increase chances of securing a
job offer?
A. Begin with questions about client care assignments, advancement
opportunities, and continuing education.
B. Decline to ask questions, because that is the responsibility of the
interviewer.
C. Ask as many questions about the facility as possible.
D. Clarify information regarding salary, benefits, and working hours
first, because this will help in deciding whether or not to take the
job.
94. The nurse advised the pregnant woman that smoking and
alcohol should be avoided during pregnancy. The nurse takes into
account that the developing fetus is most vulnerable to environment
teratogens that cause malformation during:
A. The entire pregnancy.
B. The third trimester.
C. The first trimester.
D. The second trimester.
95. A male client tells the nurse that there is a big bug in his bed. The
most therapeutic nursing response would be:
A. Silence.
B. “Where’s the bug? I’ll kill it for you.”
C. “I don’t see a bug in your bed, but you seem afraid.”
D. “You must be seeing things.”
96. A pregnant client in late pregnancy is complaining of groin pain
that seems worse on the right side. Which of the following is the
most likely cause of it?
A. Beginning of labor.
B. Bladder infection.
C. Constipation.
D. Tension on the round ligament.
97. The nurse is conducting a lecture to a group of volunteer nurses.
The nurse is correct in imparting the idea that the Good Samaritan
law protects the nurse from a suit for malpractice when:
A. The nurse stops to render emergency aid and leaves before the
ambulance arrives.
B. The nurse acts in an emergency at his or her place of
employment.
C. The nurse refuses to stop for an emergency outside of the scope
of employment.
D. The nurse is grossly negligent at the scene of an emergency.
98. A woman is hospitalized with mild preeclampsia. The nurse is
formulating a plan of care for this client, which nursing care is least
likely to be done?
A. Deep-tendon reflexes once per shift.
B. Vital signs and FHR and rhythm q4h while awake.
C. Absolute bed rest.
D. Daily weight.
99. While feeding a newborn with an unrepaired cardiac defect, the
nurse keeps on assessing the condition of the client. The nurse notes
that the newborn’s respiration is 72 breaths per minute. What
would be the initial nursing action?
A. Burp the newborn.
B. Stop the feeding.
C. Continue the feeding.
D. Notify the physician.
100. A client who undergone appendectomy 3 days ago is scheduled
for discharge today. The nurse notes that the client is restless,
picking at bedclothes and saying, “I am late on my appointment,”
and calling the nurse by the wrong name. The nurse suspects:
A. Panic reaction.
B. Medication overdose.
C. Toxic reaction to an antibiotic.
D. Delirium tremens.
Answers & Rationale
1. A. The oxytocic effect of Pitocin increases the intensity and
durations of contractions; prolonged contractions will jeopardize the
safetyof the fetus and necessitate discontinuing the drug.
2. B. It is of paramount importance to prevent the client from
hurting himself or herself or others.
3. B. After tonsillectomy, clear, cool liquids should be given. Citrus,
carbonated, and hot or cold liquids should be avoided because they
may irritate the throat. Red liquids should be avoided because they
give the appearance of blood if the child vomits. Milk and milk
products including pudding are avoided because they coat the
throat, cause the child to clear the throat, and increase the risk of
bleeding.
4. A. Phenylephrine, with frequent and continued use, can cause
rebound congestion of mucous membranes.
5. B. The N 95 respirator is a high-particulate filtration mask that
meets the CDC performance criteria for a tuberculosis respirator.
6. C. The most frequent cause of noncompliance to the treatment of
chronic, or open-angle glaucoma is the miotic effects of pilocarpine.
Pupillary constriction impedes normal accommodation, making night
driving difficult and hazardous, reducing the client’s ability to read
for extended periods and making participation in games with fast-
moving objects impossible.
7. B. This stops the sucking of air through the tube and prevents the
entry of contaminants. In addition, clamping near the chest wall
provides for some stability and may prevent the clamp from pulling
on the chest tube.
8. D. Because umbilical cord’s insertion site is born before the fetal
head, the cord may be compressed by the after-coming head in a
breech birth.
9. B. It is important to externalize the anger away from self.
10. D. Development normally proceeds cephalocaudally; so the first
major developmental milestone that the infant achieves is the ability
to hold the head up within the first 8-12 weeks of life. In
hypothyroidism, the infant’s muscle tone would be poor and the
infant would not be able to achieve this milestone.
11. D. Get a senior nurse who know s the policies, the client, and the
doctor. Generally speaking, a nurse should not accept telephone
orders. However, if it is necessary to take one, follow the hospital’s
policy regarding telephone orders. Failure to followhospital policy
could be considered negligence. In this case, the nurse was new and
did not know the hospital’s policy concerning telephone orders. The
nurse was also unfamiliar with the doctor and the client. Therefore
the nurse should not take the order unless A. no one else is available
and B. it is an emergency situation.
12. C. The nurse is obligated to inform the nurse manager about
changes in the condition of the client, which may change the
decision made by the nurse manager.
13. A. Perinatal risk factors for the development of Down syndrome
include advanced maternal age, especially with the first pregnancy.
14. B. Assignments should be based on scope of practice and
expertise.
15. B. The child who is concurrently taking digoxin and diuretics is at
increased risk for digoxin toxicity due to the loss of potassium. The
child and parents should be taught what foods are high in
potassium, and the child should be encouraged to eat a high-
potassium diet. In addition, the child’s serum potassium level should
be carefully monitored.
16. A. The responsible for an accurate informed consent is the
physician. An exception to this answer would be a life-threatening
emergency, but there are no data to support another response.
17. D. Asking the client to cough and take a deep breath will help
determine if the chest tube is kinked or if the lungs has reexpanded.
18. B. Every event that exposes a client to harm should be recorded
in an incident report, as well as reported to the appropriate
supervisors in order to resolve the current problems and permit the
institution to prevent the problem from happening again.
19. D. One of the earliest signs of digoxin toxicity is Bradycardia. For
a toddler, any heart rate that falls below the norm of about 100-120
bpm would indicate Bradycardia and would necessitate holding the
medication and notifying the physician.
20. B. This option is least threatening.
21. D. In preparing the client for discharge that is receiving
prednisone, the nurse should caution the client to (A. take oral
preparations after meals; (B. remember that routine checks of vital
signs, weight, and lab studies are critical; (C. NEVER STOP OR
CHANGE THE AMOUNT OF MEDICATION WITHOUT MEDICAL
ADVICE; (D. store the medication in a light-resistant container.
22. A. Progesterone also reduces smooth muscle motility in the
urinary tract and predisposes the pregnant woman to urinary tract
infections. Women should contact their doctors if they exhibit signs
of infection. Kegel exercise will help strengthen the perineal
muscles; limiting fluids at bedtime reduces the possibility of being
awakened by the necessity of voiding.
23. B. This is the proper use of anger.
24. C. There are several models of case management, but the
commonality is comprehensive coordination of care to better
predict needs of high-risk clients, decrease exacerbations and
continually monitor progress overtime.
25. A. Phenytoin should be infused or injected into larger veins to
avoid the discoloration know as purple glove syndrome; infusing into
a smaller vein is not appropriate.
26. C. Serum radioimmunoassay (RIA. is accurate within 7days of
conception. This test is specific for HCG, and accuracy is not
compromised by confusion with LH.
27. D. Surgery and anesthesia can increase mucus production. Deep
breathing and coughing are essential to prevent atelectasis and
pneumonia in the client’s only remaining lung.
28. B. Newborns can get pneumonia (tachypnea, mild hypoxia,
cough, eosinophiliA. and conjunctivitis from Chlamydia.
29. D. The client may perceive this as avoidance, but it is more
important to redirect back to the client, especially in light of the
manipulative behavior of drug abusers and adolescents.
30. C. It describes a democratic process in which all members have
input in the client’s care.
31. A. Contraction of the milk ducts and let-down reflex occur under
the stimulation of oxytocin released by the posterior pituitary gland.
32. B. In case management, the nurse assumes total responsibility
for meeting the needs of the client during the entire time on duty.
33. A. Smoke inhalation affects gas exchange.
34. C. Sperm deposited during intercourse may remain viable for
about 3 days. If ovulation occurs during this period, conception may
result.
35. B. This option shows acceptance (key concept) of this age-typical
sleep pattern (that of waking in the early morning).
36. D. Taking the mother’s pulse while listening to the FHR will
differentiate between the maternal and fetal heart rates and rule
out fetal Bradycardia.
37. A. Antihistamines cause pupil dilation and should be avoided
with glaucoma.
38. A. This suggests that the level of consciousness is decreasing.
39. D. An advance directive is a form of informed consent, and only a
competent adult or the holder of a durable power of attorney has
the right to consent or refuse treatment. If the spouse does not hold
the power of attorney, the decisions of the holder, even if opposed
by the spouse, are enforced.
40. C. Gentle but firm guidance and nonverbal direction is needed to
intervene when a client with schizophrenic symptoms is being
disruptive.
41. C. Suctioning is only done for 10 seconds, intermittently, as the
catheter is being withdrawn.
42. D. The priority for this client is being able to establish an airway.
43. A. Signs of placental separation include a change in the shape of
the uterus from ovoid to globular.
44. B. This could indicate intracranial bleeding. Alteplase is a
thrombolytic enzyme that lyses thrombi and emboli. Bleeding is an
adverse effect. Monitor clotting times and signs of any
gastrointestinal or internal bleeding.
45. D. Because flank incision in nephrectomy is directly below the
diaphragm, deep breathing is painful. Additionally, there is a greater
incisional pull each time the person moves than there is with
abdominal surgery. Incisional pain following nephrectomy generally
requires analgesics administration every 3-4 hours for 24-48 hours
after surgery. Therefore, turning, coughing and deep-breathing
exercises should be planned to maximize the analgesic effects.
46. B. Under high estrogen levels, during the period surrounding
ovulation, the cervical mucus becomes thin, clear, and elastic
(spinnbarkeit), facilitating sperm passage.
47. D. After surgery for a ruptured appendix, the client should be
placed in a semi-Fowler’s position to promote drainage and to
prevent possible complications.
48. C. Directing and evaluation of staff is a major responsibility of a
nursing manager.
49. A. The recommended procedure for administering eyedrops to
any client calls for the drops to be placed in the middle of the lower
conjunctival sac.
50. B. Thirst and restlessness indicate hypovolemia and hypoxemia.
Internal bleeding is difficult to recognized and evaluate because it is
not apparent.
51. C. Erythema toxicum is the normal, nonpathological macular
newborn rash.
52. D. The family needs to understand what brain death is before
talking about organ donation. They need time to accept the death of
their family member. An environment conducive to discussing an
emotional issue is needed.
53. A. Bending from the waist in pregnancy tends to make backache
worse.
54. B. Support and limit setting decrease anxiety and provide
external control.
55. C. The stoma drainage bag is applied in the operating room.
Drainage from the ileostomy contains secretions that are rich in
digestive enzymes and highly irritating to the skin. Protection of the
skin from the effects of these enzymes is begun at once. Skin
exposed to these enzymes even for a short time becomes reddened,
painful and excoriated.
56. B. It is the most accurate statement of physiological facts for a
28-day menstrual cycle: ovulation at day 14, egg life span 24 hours,
sperm life span of 72 hours. Fertilization could occur from sperm
deposited before ovulation.
57. C. An advocate role encourage freedom of choice, includes
speaking out for the client, and supports the client’s best interests.
58. A. Abstinence will eliminate any unnecessary pain during
intercourse and will reduce the possibility of transmitting infection
to one’s sexual partner.
59. B. Anxiety is generated by group therapy at 9:00 AM. The
ritualistic behavioral defense of hand washing decreases anxiety by
avoiding group therapy.
60. D. Denial is a very strong defense mechanism used to allay the
emotional effects of discovering a potential threat. Although denial
has been found to be an effective mechanism for survival in some
instances, such as during natural disasters, it may in greater
pathology in a woman with potential breast carcinoma.
61. B. The registered nurse cannot delegate the responsibility for
assessment and evaluation of clients. The status of the client in
restraint requires further assessment to determine if there are
additional causes for the behavior.
62. C. The client with chest pain may be having a myocardial
infarction, and immediate assessment and intervention is a priority.
63. B. Is correct because semen analysis requires that a freshly
masturbated specimen be obtained after a rest (abstinence) period
of 48-72 hours.
64. C. Betamethasone, a form of cortisone, acts on the fetal lungs to
produce surfactant.
65. A. Secretions may have pooled above the tracheostomy cuff. If
these are not suctioned before deflation, the secretions may be
aspirated.
66. C. Proper handling of sputum is essential to allay droplet
transference of bacilli in the air. Clients need to be taught to cover
their nose and mouth with tissues when sneezing or coughing.
Chemotherapy generally renders the client noninfectious within
days to a few weeks, usually before cultures for tubercle bacilli are
negative. Until chemical isolation is established, many institutions
require the client to wear a mask when visitors are in the room or
when the nurse is in attendance. Client should be in a well-
ventilated room, without air recirculation, to prevent air
contamination.
67. A. It is best to establish baseline information first.
68. B. Listening is probably the most effective response of the four
choices.
69. A. Urine flow is continuous. The pouch has an outlet valve for
easy drainage every 3-4 hours. (the pouch should be changed every
3-5 days, or sooner if the adhesive is loose).
70. C. A high fever accompanied by a body rash could indicate that
the child has a communicable disease and would have exposed
other students to the infection. The school nurse would want to
investigate this telephone call immediately so that plans could be
instituted to control the spread of such infection.
71. A. Severe abdominal pain may indicate complications of
pregnancy such as abortion, ectopic pregnancy, or abruption
placenta; fluid discharge from the vagina may indicate premature
rupture of the membrane.
72. D. Gentle aspiration of mucus helps maintain a patent airway,
required for effective gas exchange.
73. A. Somatoform disorders provide a way of coping with conflicts.
74. C. Immunization should never be mixed together in a syringe,
thus necessitating three separate injections in three sites. Note:
some manufacturers make a premixed combination of immunization
that is safe and effective.
75. A. Clients with radioactive implants should be positioned flat in
bed to prevent dislodgement of the vaginal packing. The client may
roll to the side for meals but the upper body should not be raised
more than 20 degrees.
76. A. Syrup of ipecac is not administered when the ingested
substances is corrosive in nature. Toilet bowl cleaners, as a collective
whole, are highly corrosive substances. If the ingested substance
“burned” the esophagus going down, it will “burn” the esophagus
coming back up when the child begins to vomit after administration
of syrup of ipecac.
77. B. Inability to open eyelids on operative side is seen with cranial
nerve III damage.
78. A. Assessment of physical injuries (like bruises, lacerations,
bleeding and fractures) is the first priority.
79. C. The nurse who is supervising others has a legal obligation to
determine that they are competent to perform the assignment, as
well as legal obligation to provide adequate supervision.
80. D. Increasing hydrostatic pressure in the urinary tract will
facilitate passage of the calculi.
81. A. Infertility is not diagnosed until atleast 12months of
unprotected intercourse has failed to produce a pregnancy. Older
couples will experience a longer time to get pregnant.
82. B. Determining how well the kidneys filter wastes states the
purpose of a Creatinine clearance test.
83. A. Acknowledging a feeling tone is the most therapeutic
response and provides a broad opening for the client to elaborate
feelings.
84. C. The behavior should be stopped. The first is to remind the
staff that confidentiality maybe violated.
85. C. With a right-sided cerebrovascular accident the client would
have left-sided hemiplegia or weakness. The client’s good side
should be closest to the bed to facilitate the transfer.
86. D. Legos are small plastic building blocks that could easily slip
under the child’s cast and lead to a break in skin integrity and even
infection. Pencils, backscratchers, and marbles are some other
narrow or small items that could easily slip under the child’s cast and
lead to a break in skin integrity and infection.
87. D. Oxytocin (Pitocin) is used to maintain uterine tone.
88. B. The submission of reports about incidents that expose clients
to harm does not remove the obligation to report ongoing behavior
as long as the risk to the client continues.
89. C. The recommended dosage of tetracycline is 25-50mg/kg/day.
If the child weighs 20kg and the maximum dose is 50mg/kg, this
would indicate a total daily dose of 1000mg of tetracycline. In this
case, the child is being given this medication four times a day.
Therefore the maximum single dose that can be given is 250mg
(1000 mg of tetracycline divided by four doses.)
90. C. An abnormality in the uterine muscle could reduce the
effectiveness of uterine contractions and lengthen the duration of
subsequent labors.
91. A. Personality disorders stem from a weak superego, implying a
lack of adequate controls.
92. C. The basal body temperature is the lowest body temperature
of a healthy person that is taken immediately after waking and
before getting out of bed. The BBT usually varies from 36.2 ºC to
36.3ºC during menses and for about 5-7 days afterward. About the
time of ovulation, a slight drop in temperature may be seen, after
ovulation in concert with the increasing progesterone levels of the
early luteal phase, the BBT rises 0.2-0.4 ºC. This elevation remains
until 2-3 days before menstruation, or if pregnancy has occurred.
93. A. This choice implies concern for client care and self-
improvement.
94. C. The first trimester is the period of organogenesis, that is, cell
differentiation into the various organs, tissues, and structures.
95. C. This response does not contradict the client’s perception, is
honest, and shows empathy.
96. D. Tension on round ligament occurs because of the erect human
posture and pressure exerted by the growing fetus.
97. D. The Good Samaritan Law does not impose a duty to stop at
the scene of an emergency outside of the scope of employment,
therefore nurses who do not stop are not liable for suit.
98. C. Although reducing environment stimuli and activity is
necessary for a woman with mild preeclampsia, she will most
probably have bathroom privileges.
99. B. A normal respiratory rate for a newborn is 30-40 breaths per
minute.
100. D. The behavior described is likely to be symptoms of delirium
tremens, or alcohol withdrawal (often unsuspected on a surgical
unit.)
TEST 2
1. A 10 year old who has sustained a head injury is brought to the
emergency department by his mother. A diagnosis of a mild
concussion is made. At the time of discharge, nurse Ron should
instruct the mother to:
A. Withhold food and fluids for 24 hours.
B. Allow him to play outdoors with his friends.
C. Arrange for a follow up visit with the child’s primary care provider
in one week.
C. Check for any change in responsiveness every two hours until the
follow-up visit.
2. A male client has suffered a motor accident and is now suffering
from hypovolemic shock. Nurse Helen should frequency assess the
client’s vital signs during the compensatory stage of shock, because:
A. Arteriolar constriction occurs
B. The cardiac workload decreases
C. Decreased contractility of the heart occurs
D. The parasympathetic nervous system is triggered
3. A paranoid male client with schizophrenia is losing weight,
reluctant to eat, and voicing concerns about being poisoned. The
best intervention by nurse Dina would be to:
A. Allow the client to open canned or pre-packaged food
B. Restrict the client to his room until 2 lbs are gained
C. Have a staff member personally taste all of the client’s food
D. Tell the client the food has been x-rayed by the staff and is safe
4. One day the mother of a young adult confides to nurse Frida that
she is very troubled by he child’s emotional illness. The nurse’s most
therapeutic initial response would be:
A. “You may be able to lessen your feelings of guilt by seeking
counseling”
B. “It would be helpful if you become involved in volunteer work at
this time”
C. “I recognize it’s hard to deal with this, but try to remember that
this too shall pass”
D. “Joining a support group of parents who are coping with this
problem can be quite helpful.
5. To check for wound hemorrhage after a client has had a surgery
for the removal of a tumor in the neck, nurse grace should:
A. Loosen an edge of the dressing and lift it to see the wound
B. Observe the dressing at the back of the neck for the presence of
blood
C. Outline the blood as it appears on the dressing to observe any
progression
D. Press gently around the incision to express accumulated blood
from the wound
6. A 16-year-old primigravida arrives at the labor and birthing unit in
her 38th week of gestation and states that she is labor. To verify that
the client is in true labor nurse Trina should:
A. Obtain sides for a fern test
B. Time any uterine contractions
C. Prepare her for a pelvic examination
D. Apply nitrazine paper to moist vaginal tissue
7. As part of the diagnostic workup for pulmonic stenosis, a child has
cardiac catheterization. Nurse Julius is aware that children with
pulmonic stenosis have increased pressure:
A. In the pulmonary vein
B. In the pulmonary artery
C. On the left side of the heart
D. On the right side of the heart
8. An obese client asks nurse Julius how to lose weight. Before
answering, the nurse should remember that long-term weight loss
occurs best when:
A. Eating patterns are altered
B. Fats are limited in the diet
C. Carbohydrates are regulated
D. Exercise is a major component
9. As a very anxious female client is talking to the nurse May, she
starts crying. She appears to be upset that she cannot control her
crying. The most appropriate response by the nurse would be:
A. “Is talking about your problem upsetting you?”
B. “It is Ok to cry; I’ll just stay with you for now”
C. “You look upset; lets talk about why you are crying.”
D. “Sometimes it helps to get it out of your system.”
10. A patient has partial-thickness burns to both legs and portions of
his trunk. Which of the following I.V. fluids is given first?
A. Albumin
B. D5W
C. Lactated Ringer’s solution
D. 0.9% sodium chloride solution with 2 mEq of potassium per 100
ml
11. During the first 48 hours after a severe burn of 40% of the clients
body surface, the nurse’s assessment should include observations
for water intoxication. Associated adaptations include:
A. Sooty-colored sputum
B. Frothy pink-tinged sputum
C. Twitching and disorientation
D. Urine output below 30ml per hour
12. After a muscle biopsy, nurse Willy should teach the client to:
A. Change the dressing as needed
B. Resume the usual diet as soon as desired
C. Bathe or shower according to preference
D. Expect a rise in body temperature for 48 hours
13. Before a client whose left hand has been amputated can be
fitted for a prosthesis, nurse Joy is aware that:
A. Arm and shoulder muscles must be developed
B. Shrinkage of the residual limb must be completed
C. Dexterity in the other extremity must be achieved
D. Full adjustment to the altered body image must have occurred
14. Nurse Cathy applies a fetal monitor to the abdomen of a client in
active labor. When the client has contractions, the nurse notes a 15
beat per minute deceleration of the fetal heart rate below the
baseline lasting 15 seconds. Nurse Cathy should:
A. Change the maternal position
B. Prepare for an immediate birth
C. Call the physician immediately
D. Obtain the client’s blood pressure
15. A male client receiving prolonged steroid therapy complains of
always being thirsty and urinating frequently. The best initial action
by the nurse would be to:
A. Perform a finger stick to test the client’s blood glucose level
B. Have the physician assess the client for an enlarged prostate
C. Obtain a urine specimen from the client for screening purposes
D. Assess the client’s lower extremities for the presence of pitting
edema
16. Nurse Bea recognizes that a pacemaker is indicated when a
client is experiencing:
A. Angina
B. Chest pain
C. Heart block
D. Tachycardia
17. When administering pancrelipase (Pancreases capsules) to child
with cystic fibrosis, nurse Faith knows they should be given:
A. With meals and snacks
B. Every three hours while awake
C. On awakening, following meals, and at bedtime
C. After each bowel movement and after postural draianage
18. A preterm neonate is receiving oxygen by an overhead hood.
During the time the infant is under the hood, it would be
appropriate for nurse Gian to:
A. Hydrate the infant q15 min
B. Put a hat on the infant’s head
C. Keep the oxygen concentration consistent
D. Remove the infant q15 min for stimulation
19. A client’s sputum smears for acid fast bacilli (AFB) are positive,
and transmission-based airborne precautions are ordered. Nurse
Kyle should instruct visitors to:
A.Limit contact with non-exposed family members
B. Avoid contact with any objects present in the client’s room
C. Wear an Ultra-Filter mask when they are in the client’s room
D. Put on a gown and gloves before going into the client’s room
20. A client with a head injury has a fixed, dilated right pupil;
responds only to painful stimuli; and exhibits decorticate posturing.
Nurse Kate should recognize that these are signs of:
A. Meningeal irritation
B. Subdural hemorrhage
C. Medullary compression
D. Cerebral cortex compression
21. After a lateral crushing chest injury, obvious right-sided
paradoxic motion of the client’s chest demonstrates multiple rib
fraactures, resulting in a flail chest. The complication the nurse
should carefully observe for would be:
A. Mediastinal shift
B. Tracheal laceration
C. Open pneumothorax
D. Pericardial tamponade
22. When planning care for a client at 30-weeks gestation, admitted
to the hospital after vaginal bleeding secondary to placenta previa,
the nurse’s primary objective would be:
A. Provide a calm, quiet environment
B. Prepare the client for an immediate cesarean birth
C. Prevent situations that may stimulate the cervix or uterus
D. Ensure that the client has regular cervical examinations assess for
labor
23. When planning discharge teaching for a young female client who
has had a pneumothorax, it is important that the nurse include the
signs and symptoms of a pneumothorax and teach the client to seek
medical assistance if she experiences:
A. Substernal chest pain
B. Episodes of palpitation
C. Severe shortness of breath
D. Dizziness when standing up
24. After a laryngectomy, the most important equipment to place at
the client’s bedside would be:
A. Suction equipment
B. Humidified oxygen
C. A nonelectric call bell
D. A cold-stream vaporizer
25. Nurse Oliver interviews a young female client with anorexia
nervosa to obtain information for the nursing history. The client’s
history is likely to reveal a:
A. Strong desire to improve her body image
B. Close, supportive mother-daughter relationship
C. Satisfaction with and desire to maintain her present weight
D. Low level of achievement in school, with little concerns for grades
26. Nurse Bea should plan to assist a client with an obsessive-
compulsive disorder to control the use of ritualistic behavior by:
A. Providing repetitive activities that require little thought
B. Attempting to reduce or limit situations that increase anxiety
C. Getting the client involved with activities that will provide
distraction
D. Suggesting that the client perform menial tasks to expiate feelings
of guilt
27. A 2 ½ year old child undergoes a ventriculoperitoneal shunt
revision. Before discharge, nurse John, knowing the expected
developmental behaviors for this age group, should tell the parents
to call the physician if the child:
A. Tries to copy all the father’s mannerisms
B. Talks incessantly regardless of the presence of others
C. Becomes fussy when frustrated and displays a shortened
attention span
D. Frequently starts arguments with playmates by claiming all toys
are “mine”
28. A urinary tract infection is a potential danger with an indwelling
catheter. Nurse Gina can best plan to avoid this complication by:
A. Assessing urine specific gravity
B. Maintaining the ordered hydration
C. Collecting a weekly urine specimen
D. Emptying the drainage bag frequently
29. A client has sustained a fractured right femur in a fall on stairs.
Nurse Troy with the emergency response team assess for signs of
circulatory impairment by:
A. Turning the client to side lying position
B. Asking the client to cough and deep breathe
C. Taking the client’s pedal pulse in the affected limb
D. Instructing the client to wiggle the toes of the right foot
30. To assess orientation to place in a client suspected of having
dementia of the alzheimers type, nurse Chris should ask:
A. “Where are you?”
B. “Who brought you here?”
C. “Do you know where you are?”
D. “How long have you been there?”
31. Nurse Mary assesses a postpartum client who had an abruption
placentae and suspects that disseminated intravascular coagulation
(DIC) is occurring when assessments demonstrate:
A. A boggy uterus
B. Multiple vaginal clots
C. Hypotension and tachycardia
D. Bleeding from the venipuncture site
32. When a client on labor experiences the urge to push a 9cm
dilation, the breathing pattern that nurse Rhea should instruct the
client to use is the:
A. Expulsion pattern
B. Slow paced pattern
C. Shallow chest pattern
D. blowing pattern
33. Nurse Ronald should explain that the most beneficial between-
meal snack for a client who is recovering from the full-thickness
burns would be a:
A. Cheeseburger and a malted
B. Piece of blueberry pie and milk
C. Bacon and tomato sandwich and tea
D. Chicken salad sandwich and soft drink
34. Nurse Wilma recognizes that failure of a newborn to make the
appropriate adaptation to extrauterine life would be indicated by:
A. flexed extremities
B. Cyanotic lips and face
C. A heart rate of 130 beats per minute
D. A respiratory rate of 40 breath per minute
35. The laboratory calls to state that a client’s lithium level is 1.9
mEq/L after 10 days of lithium therapy. Nurse Reese should:
A. Notify the physician of the findings because the level is
dangerously high
B. Monitor the client closely because the level of lithium in the blood
is slightly elevated
C. Continue to administer the medication as ordered because the
level is within the therapeutic range
D. Report the findings to the physician so the dosage can be
increased because the level is below therapeutic range
36. A client has a regular 30-day menstrual cycles. When teaching
about the rhythm method, Which the client and her husband have
chosen to use for family planning, nurse Dianne should emphasize
that the client’s most fertile days are:
A. Days 9 to 11
B. Days 12 to 14
C. Days 15 to 17
D. Days 18 to 20
37. Before an amniocentesis, nurse Alexandra should:
A. Initiate the intravenous therapy as ordered by the physiscian
B. Inform the client that the procedure could precipitate an infection
C. Assure that informed consent has been obtained from the client
D. Perform a vaginal examination on the client to assess cervical
dilation
38. While a client is on intravenous magnesium sulfate therapy for
preeclampsia, it is essential for nurse Amy to monitor the client’s
deep tendon reflexes to:
A. Determine her level of consciousness
B. Evaluate the mobility of the extremities
C. Determine her response to painful stimuli
D. Prevent development of respiratory distress
39. A preschooler is admitted to the hospital with a diagnosis of
acute glomerulonephritis. The child’s history reveals a 5-pound
weight gain in one week and peritoneal edema. For the most
accurate information on the status of the child’s edema, nursing
intervention should include:
A. Obtaining the child’s daily weight
B. Doing a visual inspection of the child
C. Measuring the child’s intake and output
D. Monitoring the child’s electrolyte values
40. Nurse Mickey is administering dexamethasome (Decadron) for
the early management of a client’s cerebral edema. This treatment
is effective because:
A. Acts as hyperosmotic diuretic
B. Increases tissue resistance to infection
C. Reduces the inflammatory response of tissues
D. Decreases the information of cerebrospinal fluid
41. During newborn nursing assessment, a positive Ortolani’s sign
would be indicated by:
A. A unilateral droop of hip
B. A broadening of the perineum
C. An apparent shortening of one leg
D. An audible click on hip manipulation
42. When caring for a dying client who is in the denial stage of grief,
the best nursing approach would be to:
A. Agree and encourage the client’s denial
B. Allow the denial but be available to discuss death
C. Reassure the client that everything will be OK
D. Leave the client alone to confront the feelings of impending loss
43. To decrease the symptoms of gastroesophageal reflux disease
(GERD), the physician orders dietary and medication management.
Nurse Helen should teach the client that the meal alteration that
would be most appropriate would be:
A. Ingest foods while they are hot
B. Divide food into four to six meals a day
C.Eat the last of three meals daily by 8pm
D. Suck a peppermint candy after each meal
44. After a mastectomy or hysterectomy, clients may feel
incomplete as women. The statement that should alert nurse Gina
to this feeling would be:
A. “I can’t wait to see all my friends again”
B. “I feel washed out; there isn’t much left”
C. “I can’t wait to get home to see my grandchild”
D. “My husband plans for me to recuperate at our daughter’s home”
45. A client with obstruction of the common bile duct may show a
prolonged bleeding and clotting time because:
A. Vitamin K is not absorbed
B. The ionized calcium levels falls
C. The extrinsic factor is not absorbed
D. Bilirubin accumulates in the plasma
46. Realizing that the hypokalemia is a side effect of steroid therapy,
nurse Monette should monitor a client taking steroid medication for:
A. Hyperactive reflexes
B. An increased pulse rate
C. Nausea, vomiting, and diarrhea
D. Leg weakness with muscle cramps
47. When assessing a newborn suspected of having Down syndrome,
nurse Rey would expect to observe:
A. long thin fingers
B. Large, protruding ears
C. Hypertonic neck muscles
D. Simian lines on the hands
48. A 10 year old girl is admitted to the pediatric unit for recurrent
pain and swelling of her joints, particularly her knees and ankles. Her
diagnosis is juvenile rheumatoid arthritis. Nurse Janah recognizes
that besides joint inflammation, a unique manifestation of the
rheumatoid process involves the:
A. Ears
B. Eyes
C. Liver
D. Brain
49. A disturbed client is scheduled to begin group therapy. The client
refuses to attend. Nurse Lolit should:
A. Accept the client’s decision without discussion
B. Have another client to ask the client to consider
C. Tell the client that attendance at the meeting is required
D. Insist that the client join the group to help the socialization
process
50. Because a severely depressed client has not responded to any of
the antidepressant medications, the psychiatrist decides to try
electroconvulsive therapy (ECT). Before the treatment the nurse
should:
A. Have the client speak with other clients receiving ECT
B. Give the client a detailed explanation of the entire procedure
C. Limit the client’s intake to a light breakfast on the days of the
treatment
D. Provide a simple explanation of the procedure and continue to
reassure the client
51. Nurse Vicky is aware that teaching about colostomy care is
understood when the client states, “I will contact my physician and
report ____”:
A. If I notice a loss of sensation to touch in the stoma tissue”
B. When mucus is passed from the stoma between irrigations”
C. The expulsion of flatus while the irrigating fluid is running out”
D. If I have difficulty in inserting the irrigating tube into the stoma”
52. The client’s history that alerts nurse Henry to assess closely for
signs of postpartum infection would be:
A. Three spontaneous abortions
B. negative maternal blood type
C. Blood loss of 850 ml after a vaginal birth
D. Maternal temperature of 99.9° F 12 hours after delivery
53. A client is experiencing stomatitis as a result of chemotherapy.
An appropriate nursing intervention related to this condition would
be to:
A. Provide frequent saline mouthwashes
B. Use karaya powder to decrease irritation
C. Increase fluid intake to compensate for the diarrhea
D. Provide meticulous skin care of the abdomen with Betadine
54. During a group therapy session, one of the clients ask a male
client with the diagnosis of antisocial personality disorder why he is
in the hospital. Considering this client’s type of personality disorder,
the nurse might expect him to respond:
A. “I need a lot of help with my troubles”
B. “Society makes people react in old ways”
C. “I decided that it’s time I own up to my problems”
D. “My life needs straightening out and this might help”
55. A child visits the clinic for a 6-week checkup after a tonsillectomy
and adenoidectomy. In addition to assessing hearing, the nurse
should include an assessment of the child’s:
A. Taste and smell
B. Taste and speech
C. Swallowing and smell
D. Swallowing and speech
56. A client is diagnosed with cancer of the jaw. A course of radiation
therapy is to be followed by surgery. The client is concerned about
the side effects related to the radiation treaments. Nurse Ria should
explain that the major side effects that will experienced is:
A. Fatigue
B. Alopecia
C. Vomiting
D. Leucopenia
57. Nurse Katrina prepares an older-adult client for sleep, actions
are taken to help reduce the likelihood of a fall during the night.
Targeting the most frequent cause of falls, the nurse should:
A. Offer the client assistance to the bathroom
B. Move the bedside table closer to the client’s bed
C. Encourage the client to take an available sedative
D. Assist the client to telephone the spouse to say “goodnight”
58. When evaluating a growth and development of a 6 month old
infant, nurse Patty would expect the infant to be able to:
A. Sit alone, display pincer grasp, wave bye bye
B. Pull self to a standing position, release a toy by choice, play peek-
a-boo
C. Crawl, transfer toy from one hand to the other, display of fear of
strangers
D. Turn completely over, sit momentarily without support, reach to
be picked up
59. A breastfeeding mother asks the nurse what she can do to ease
the discomfort caused by a cracked nipple. Nurse Tina should
instruct the client to:
A. Manually express milk and feed it to the baby in a bottle
B. Stop breastfeeding for two days to allow the nipple to heal
C. Use a breast shield to keep the baby from direct contact with the
nipple
D. Feed the baby on the unaffected breast first until the affected
breast heals
60. Nurse Sandy observes that there is blood coming from the
client’s ear after head injury. Nurse Sandy should:
A. Turn the client to the unaffected side
B. Cleanse the client’s ear with sterile gauze
C. Test the drainage from the client’s ear with Dextrostix
D. Place sterile cotton loosely in the external ear of the client
61. Nurse Gio plans a long term care for parents of children with
sickle-cell anemia, which includes periodic group conferences. Some
of the discussions should be directed towards:
A. Finding special school facilities for the child
B. Making plans for moving to a more therapeutic climate
C. Choosing a means of birth control to avoid future pregnancies
D. Airing their feelings regarding the transmission of the disease to
the child
62. The central problem the nurse might face with a disturbed
schizophrenic client is the client’s:
A. Suspicious feelings
B. Continuous pacing
C. Relationship with the family
D. Concern about working with others
63. When planning care with a client during the postoperative
recovery period following an abdominal hysterectomy and bilateral
salpingo-oophorectomy, nurse Frida should include the explanation
that:
A. Surgical menopause will occur
B. Urinary retention is a common problem
C. Weight gain is expected, and dietary plan are needed
D. Depression is normal and should be expected
64. An adolescent client with anorexia nervosa refuses to eat,
stating, “I’ll get too fat.” Nurse Andrea can best respond to this
behavior initially by:
A. Not talking about the fact that the client is not eating
B. Stopping all of the client’s privileges until food is eaten
C. Telling the client that tube feeding will eventually be necessary
D. Pointing out to the client that death can occur with malnutrition.
65. A pain scale is used to assess the degree of pain. The client rates
the pain as an 8 on a scale of 10 before medication and a 7 on a
scale of 10 after being medicated. Nurse Glenda determines that
the:
A. Client has a low pain tolerance
B. Medication is not adequately effective
C. Medication has sufficiently decreased the pain level
D. Client needs more education about the use of the pain scale
66. To enhance a neonate’s behavioral development, therapeutic
nursing measures should include:
A. Keeping the baby awake for longer periods of time before each
feeding
B. Assisting the parents to stimulate their baby through touch,
sound, and sight.
C. Encouraging parental contact for at least one 15-minute period
every four hours.
D. Touching and talking to the baby at least hourly, beginning within
two to four hours after birth
67. Before formulating a plan of care for a 6 year old boy with
attention deficit hyperactivity disorder (ADHD), nurse Kyla is aware
that the initial aim of therapy is to help the client to:
A. Develop language skills
B. Avoid his own regressive behavior
C. Mainstream into a regular class in school
D. Recognize himself as an independent person of worth
68. Nurse Wally knows that the most important aspect of the
preoperative care for a child with Wilms’ tumor would be:
A. Checking the size of the child’s liver
B. Monitoring the child’s blood pressure
C. Maintaining the child in a prone position
D. Collecting the child’s urine for culture and sensitivity
69. At 11:00 pm the count of hydrocodone (Vicodin) is incorrect.
After several minutes of searching the medication cart and
medication administration records, no explanation can be found.
The primary nurse should notify the:
A. Nursing unit manager
B. Hospital administrator
C. Quality control manager
D. Physician ordering the medication
70. When caring for the a client with a pneumothorax, who has a
chest tube in place, nurse Kate should plan to:
A. Administer cough suppressants at appropriate intervals as
ordered
B. Empty and measure the drainage in the collection chamber each
shift
C. Apply clamps below the insertion site when ever getting the client
out of bed
D. Encourage coughing, deep breathing, and range of motion to the 80. The PHN bag is an important tool in providing nursing care
arm on the affected side during a home visit. The most important principle of bag technique
71. According to C.E.Winslow, which of the following is the goal of states that it:
Public Health? A. Should save time and effort.
A. For people to attain their birthrights of health and longevity B. Should minimize if not totally prevent the spread of infection.
B. For promotion of health and prevention of disease C. Should not overshadow concern for the patient and his family.
C. For people to have access to basic health services D. May be done in a variety of ways depending on the home
D. For people to be organized in their health efforts situation, etc.
72. What other statistic may be used to determine attainment of 81. Nurse Willy reads about Path Goal theory. Which of the
longevity? following behaviors is manifested by the leader who uses this
A. Age-specific mortality rate theory?
B. Proportionate mortality rate A. Recognizes staff for going beyond expectations by giving them
C. Swaroop’s index citations
D. Case fatality rate B. Challenges the staff to take individual accountability for their own
73. Which of the following is the most prominent feature of public practice
health nursing? C. Admonishes staff for being laggards
A. It involves providing home care to sick people who are not D. Reminds staff about the sanctions for non performance
confined in the hospital 82. Nurse Cathy learns that some leaders are transactional leaders.
B. Services are provided free of charge to people within the Which of the following does NOT characterize a transactional
catchment area. leader?
C. The public health nurse functions as part of a team providing a A. Focuses on management tasks
public health nursing services. B. Is a caretaker
D. Public health nursing focuses on preventive, not curative, C. Uses trade-offs to meet goals
services. D. Inspires others with vision
74. Which of the following is the mission of the Department of 83. Functional nursing has some advantages, which one is an
Health? EXCEPTION?
A. Health for all Filipinos A. Psychological and sociological needs are emphasized.
B. Ensure the accessibility and quality of health care B. Great control of work activities.
C. Improve the general health status of the population C. Most economical way of delivering nursing services.
D. Health in the hands of the Filipino people by the year 2020 D. Workers feel secure in dependent role
75. Nurse Pauline determines whether resources were maximized in 84. Which of the following is the best guarantee that the patient’s
implementing Ligtas Tigdas, she is evaluating: priority needs are met?
A. Effectiveness A. Checking with the relative of the patient
B. Efficiency B. Preparing a nursing care plan in collaboration with the patient
C. Adequacy C. Consulting with the physician
D. Appropriateness D. Coordinating with other members of the team
76. Lissa is a B.S.N. graduate. She want to become a Public Health 85. Nurse Tony stresses the need for all the employees to follow
Nurse. Where will she apply? orders and instructions from him and not from anyone else. Which
A. Department of Health of the following principles does he refer to?
B. Provincial Health Office A. Scalar chain
C. Regional Health Office B. Discipline
D. Rural Health Unit C. Unity of command
77. As an epidemiologist, Nurse Celeste is responsible for reporting D. Order
cases of notifiable diseases. What law mandates reporting of cases 86. Nurse Joey discusses the goal of the department. Which of the
of notifiable diseases? following statements is a goal?
A. Act 3573 A. Increase the patient satisfaction rate
B. R.A. 3753 B. Eliminate the incidence of delayed administration of medications
C. R.A. 1054 C. Establish rapport with patients
D. R.A. 1082 D. Reduce response time to two minutes
78. Nurse Fay is aware that isolation of a child with measles belongs 87. Nurse Lou considers shifting to transformational leadership.
to what level of prevention? Which of the following statements best describes this type of
A. Primary leadership?
B. Secondary A. Uses visioning as the essence of leadership
C. Intermediate B. Serves the followers rather than being served
D. Tertiary C. Maintains full trust and confidence in the subordinates
79. Nurse Gina is aware that the following is an advantage of a home D. Possesses innate charisma that makes others feel good in his
visit? presence.
A. It allows the nurse to provide nursing care to a greater number of 88. Nurse Mae tells one of the staff, “I don’t have time to discuss the
people. matter with you now. See me in my office later” when the latter asks
B. It provides an opportunity to do first hand appraisal of the home if they can talk about an issue. Which of the following conflict
situation. resolution strategies did she use?
C. It allows sharing of experiences among people with similar health A. Smoothing
problems. B. Compromise
D. It develops the family’s initiative in providing for health needs of C. Avoidance
its members. D. Restriction
89. Nurse Bea plans of assigning competent people to fill the roles A. Inability to drink
designed in the hierarchy. Which process refers to this? B. High grade fever
A. Staffing C. Signs of severe dehydration
B. Scheduling D. Cough for more than 30 days
C. Recruitment 99. Food fortification is one of the strategies to prevent
D. Induction micronutrient deficiency conditions. R.A. 8976 mandates
90. Nurse Linda tries to design an organizational structure that fortification of certain food items. Which of the following is among
allows communication to flow in all directions and involve workers these food items?
in decision making. Which form of organizational structure is this? A. Sugar
A. Centralized B. Bread
B. Decentralized C. Margarine
C. Matrix D. Filled milk
D. Informal 100. The major sign of iron deficiency anemia is pallor. What part is
91. When documenting information in a client’s medical record, the best examined for pallor?
nurse should: A. Palms
A. erase any errors. B. Nailbeds
B. use a #2 pencil. C. Around the lips
C. leave one line blank before each new entry. D. Lower conjunctival sac
D. end each entry with the nurse’s signature and title. [divider] Answers & Rationale
92. Which of the following factors are major components of a 1. C. Check for any change in responsiveness every two hours until
client’s general background drug history? the follow-up visit
A. Allergies and socioeconomic status Signs of an epidural hematoma in children usually do not appear for
B. Urine output and allergies 24 hours or more hours; a follow-up visit usually is arranged for one
C. Gastric reflex and age to two days after the injury.
D. Bowel habits and allergies 2. A. Arteriolar constriction occurs
93. Which procedure or practice requires surgical asepsis? The early compensation of shock is cardiovascular and is seen in
A. Hand washing changes in pulse, BP, and pulse pressure; blood is shunted to vital
B. Nasogastric tube irrigation centers, particularly heart and brain.
C. I.V. cannula insertion 3. A. Allow the client to open canned or pre-packaged food
D. Colostomy irrigation The client’s comfort, safety, and nutritional status are the priorities;
94. The nurse is performing wound care using surgical asepsis. the client may feel comfortable to eat if the food has been sealed
Which of the following practices violates surgical asepsis? before reaching the mental health facility.
A. Holding sterile objects above the waist 4. D. “Joining a support group of parents who are coping with this
B. Pouring solution onto a sterile field cloth problem can be quite helpful.
C. Considering a 1″ (2.5-cm) edge around the sterile field Taking with others in similar circumstances provides support and
contaminated allows for sharing of experiences.
D. Opening the outermost flap of a sterile package away from the 5. B. Observe the dressing at the back of the neck for the presence
body of blood
95. On admission, a client has the following arterial blood gas (ABG) Drainage flows by gravity.
values: PaO2, 50 mm Hg; PaCO2, 70 mm Hg; pH, 7.20; HCO3–, 28 6. C. Prepare her for a pelvic examination
mEq/L. Based on these values, Pelvic examination would reveal dilation and effacement
the nurse should formulate which nursing diagnosis for this client? 7. D. On the right side of the heart
A. Risk for deficient fluid volume Pulmonic stenosis increases resistance to blood flow, causing right
B. Deficient fluid volume ventricular hypertrophy; with right ventricular failure there is an
C. Impaired gas exchange increase in pressure on the right side of the heart.
D. Metabolic acidosis 8. A. Eating patterns are altered
96. The use of larvivorous fish in malaria control is the basis for A new dietary regimen, with a balance of foods from the food
which strategy of malaria control? pyramid, must be established and continued for weight reduction to
A. Stream seeding occur and be maintained.
B. Stream clearing 9. B. “It is ok to cry; I’ll just stay with you for now”
C. Destruction of breeding places This portrays a nonjudgmental attitude that recognizes the client’s
D. Zooprophylaxis needs.
97. In Integrated Management of Childhood Illness, severe 10. C. Lactated Ringer’s solution
conditions generally require urgent referral to a hospital. Which of Lactated Ringer’s solution replaces lost sodium and corrects
the following severe conditions DOES NOT always require urgent metabolic acidosis, both of which commonly occur following a burn.
referral to a hospital? Albumin is used as adjunct therapy, not primary fluid replacement.
A. Mastoiditis Dextrose isn’t given to burn patients during the first 24 hours
B. Severe dehydration because it can cause pseudodiabetes. The patient is hyperkalemic
C. Severe pneumonia from the potassium shift from the intracellular space to the plasma,
D. Severe febrile disease so potassium would be detrimental.
98. A mother brought her daughter, 4 years old, to the RHU because 11. C. Twitching and disorientation
of cough and colds. Following the IMCI assessment guide, which of Excess extracellular fluid moves into cells (water intoxication);
the following is a danger sign that indicates the need for urgent intracellular fluid excess in sensitive brain cells causes altered
referral to a hospital? mental status; other signs include anorexia nervosa, nausea,
vomiting, twitching, sleepiness, and convulsions.
12. B. Resume the usual diet as soon as desired
As long as the client has no nausea or vomiting, there are no dietary
restriction.
13. B. Shrinkage of the residual limb must be completed
Shrinkage of the residual limb, resulting from reduction of
subcutaneous fat and interstitial fluid, must occur for an adequate fit
between the limb and the prosthesis.
14. A. Change the maternal position
Stimulation of the sympathetic nervous system is an initial response
to mild hypoxia that accompanies partial cord compression
(umbilical vein) during contractions; changing the maternal position
can alleviate the compression.
15. A. Perform a finger stick to test the client’s blood glucose level
The client has signs of diabetes, which may result from steroid
therapy, testing the blood glucose level is a method of screening for
diabetes, thus gathering more data.
16. C. Heart block
This is the primary indication for a pacemaker because there is an
interfere with the electrical conduction system of the heart.
17. A. With meals and snacks
Pancreases capsules must be taken with food and snacks because it
acts on the nutrients and readies them for absorption.
18. B. Put a hat on the infant’s head
Oxygen has cooling effect, and the baby should be kept warm so
that metabolic activity and oxygen demands are not increased.
19. C. Wear an Ultra-Filter mask when they are in the client’s room
Tubercle bacilli are transmitted through air currents; therefore
personal protective equipment such as an Ultra-Filter mask is
necessary.
20. D. Cerebral cortex compression
Cerebral compression affects pyramidal tracts, resulting in
decorticate rigidity and cranial nerve injury, which cause pupil
dilation.
21. A. Mediastinal shift
Mediastinal structures move toward the uninjured lung, reducing
oxygenation and venous return.
22. C. Prevent situations that may stimulate the cervix or uterus
Stimulation of the cervix or uterus may cause bleeding or
hemorrhage and should be avoided.
23. C. Severe shortness of breath
This could indicate a recurrence of the pneumothorax as one side of
the lung is inadequate to meet the oxygen demands of the body.
24. A. Suction equipment
Respiratory complications can occur because of edema of the glottis
or injury to the recurrent laryngeal nerve.
25. A. Strong desire to improve her body image
Clients with anorexia nervosa have a disturbed self image and
always see themselves as fat and needing further reducing.
26. B. Attempting to reduce or limit situations that increase anxiety
Persons with high anxiety levels develop various behaviors to relieve
their anxiety; by reducing anxiety, the need for these obsessive-
compulsive action is reduced.
27. C. Becomes fussy when frustrated and displays a shortened
attention span
Shortened attention span and fussy behavior may indicate a change
in intracranial pressure and/or shunt malfunction.
28. B. Maintaining the ordered hydration
Promoting hydration maintains urine production at a higher rate,
which flushes the bladder and prevents urinary stasis and possible
infection.
29. C. Taking the client’s pedal pulse in the affected limb
Monitoring a pedal pulse will assess circulation to the foot.
30. A. “Where are you?”
“Where are you?” is the best question to elicit information about
the client’s orientation to place because it encourages a response
that can be assessed.
31. D. Bleeding from the venipuncture site
This indicates a fibrinogenemia; massive clotting in the area of the
separation has resulted in a lowered circulating fibrinogen.
32. D. blowing pattern
Clients should use a blowing pattern to overcome the premature
urge to push.
33. A. Cheeseburger and a malted
Of the selections offered, this is the highest in calories and protein,
which are needed for increased basal metabolic rate and for tissue
repair.
34. B. Cyanotic lips and face
Central cyanosis (blue lips and face) indicates lowered oxygenation
of the blood, caused by either decreased lung expansion or right to
left shunting of blood.
35. A. Notify the physician of the findings because the level is
dangerously high
Levels close to 2 mEq/L are dangerously close to the toxic level;
immediate action must be taken.
36. C. Days 15 to 17
Ovulation occurs approximately 14 days before the next menses,
about the 16th day in 30 day cycle; the 15th to 17th days would be
the best time to avoid sexual intercourse.
37. C. Assure that informed consent has been obtained from the
client
An invasive procedure such as amniocentesis requires informed
consent.
38. D. Prevent development of respiratory distress
Respiratory distress or arrest may occur when the serum level of
magnesium sulfate reaches 12 to 15 mg/dl; deep tendon reflexes
disappear when the serum level is 10 to 12 mg/dl; the drug is
withheld in the absence of deep tendon reflexes; the therapeutic
serum level is 5 to 8 mg/dl.
39. A. Obtaining the child’s daily weight
Weight monitoring is the most useful means of assessing fluid
balance and changes in the edematous state; 1 liter of fluid weighs
about 2.2 pounds.
40. C. Reduces the inflammatory response of tissues
Corticosteroids act to decrease inflammation which decreases
edema.
41. D. An audible click on hip manipulation
With specific manipulation, an audible click may be heard of felt as
he femoral head slips into the acetabulum.
42. B. Allow the denial but be available to discuss death
This does not remove client’s only way of coping, and it permits
future movement through the grieving process when the client is
ready.
43. B. Divide food into four to six meals a day
The volume of food in the stomach should be kept small to limit
pressure on the cardiac sphincter.
44. B. “I feel washed out; there isn’t much left”
The client’s statement infers an emptiness with an associated loss.
45. A. Vitamin K is not absorbed
Vitamin K, a fat soluble vitamin, is not absorbed from the GI tract in
the absence of bile; bile enters the duodenum via the common bile
duct.
46. D. Leg weakness with muscle cramps
Impulse conduction of skeletal muscle is impaired with decreased
potassium levels, muscular weakness and cramps may occur with
hypokalemia.
47. D. Simian lines on the hands
This is characteristic finding in newborns with Down syndrome.
48. B. Eyes
Rheumatoid arthritis can cause inflammation of the iris and ciliary
body of the eyes which may lead to blindness.
49. A. Accept the client’s decision without discussion
This is all the nurse can do until trust is established; facing the client
to attend will disrupt the group.
50. D. Provide a simple explanation of the procedure and continue
to reassure the client
The nurse should offer support and use clear, simple terms to allay
client’s anxiety.
51. D. If I have difficulty in inserting the irrigating tube into the
stoma”
This occurs with stenosis of the stoma; forcing insertion of the tube
could cause injury.
52. C. Blood loss of 850 ml after a vaginal birth
Excessive blood loss predisposes the client to an increased risk of
infection because of decreased maternal resistance; they expected
blood loss is 350 to 500 ml.
53. A. Provide frequent saline mouthwashes
This is soothing to the oral mucosa and helps prevent infection.
54. B. “Society makes people react in old ways”
The client is incapable of accepting responsibility for self-created
problems and blames society for the behavior.
55. A. Taste and smell
Swelling can obstruct nasal breathing, interfering with the senses of
taste and smell.
56. A. Fatigue
Fatigue is a major problem caused by an increase in waste products
because of catabolic processes.
57. A. Offer the client assistance to the bathroom
Statistics indicate that the most frequent cause of falls by
hospitalized clients is getting up or attempting to get up to the
bathroom unassisted.
58. D. Turn completely over, sit momentarily without support,
reach to be picked up
These abilities are age-appropriate for the 6 month old child.
59. D. Feed the baby on the unaffected breast first until the
affected breast heals
The most vigorous sucking will occur during the first few minutes of
breastfeeding when the infant would be on the unaffected breast;
later suckling is less traumatic.
60. D. Place sterile cotton loosely in the external ear of the client
This would absorb the drainage without causing further trauma.
61. D. Airing their feelings regarding the transmission of the
disease to the child
Discussion with parents who have children with similar problems
helps to reduce some of their discomfort and guilt.
62. A. Suspicious feelings
The nurse must deal with these feelings and establish basic trust to
promote a therapeutic milieu.
63. A. Surgical menopause will occur
When a bilateral oophorectomy is performed, both ovaries are
excised, eliminating ovarian hormones and initiating response.
64. D. Pointing out to the client that death can occur with
malnutrition.
The client expects the nurse to focus on eating, but the emphasis
should be placed on feelings rather than actions.
65. B. Medication is not adequately effective
The expected effect should be more than a one point decrease in
the pain level.
66. B. Assisting the parents to stimulate their baby through touch,
sound, and sight.
Stimuli are provided via all the senses; since the infant’s behavioral
development is enhanced through parent-infant interactions, these
interactions should be encouraged.
67. D. Recognize himself as an independent person of worth
Academic deficits, an inability to function within constraints required
of certain settings, and negative peer attitudes often lead to low self-
esteem.
68. B. Monitoring the child’s blood pressure
Because the tumor is of renal origin, the rennin angiotensin
mechanism can be involved, and blood pressure monitoring is
important.
69. A. Nursing unit manager
Controlled substance issues for a particular nursing unit are the
responsibility of that unit’s nurse manager.
70. D. Encourage coughing, deep breathing, and range of motion to
the arm on the affected side
All these interventions promote aeration of the re-expanding lung
and maintenance of function in the arm and shoulder on the
affected side.
71. A. For people to attain their birthrights of health and longevity
According to Winslow, all public health efforts are for people to
realize their birthrights of health and longevity.
72. C. Swaroop’s index
Swaroop’s index is the percentage of the deaths aged 50 years or
older. Its inverse represents the percentage of untimely deaths
(those who died younger than 50 years).
73. D. Public health nursing focuses on preventive, not curative,
services.
The catchment area in PHN consists of a residential community,
many of whom are well individuals who have greater need for
preventive rather than curative services.
74. B. Ensure the accessibility and quality of health care
Ensuring the accessibility and quality of health care is the primary
mission of DOH.
75. B. Efficiency
Efficiency is determining whether the goals were attained at the
least possible cost.
76. D. Rural Health Unit
R.A. 7160 devolved basic health services to local government units
(LGU’s ). The public health nurse is an employee of the LGU.
77. A. Act 3573
Act 3573, the Law on Reporting of Communicable Diseases, enacted
in 1929, mandated the reporting of diseases listed in the law to the
nearest health station.
78. A. Primary
The purpose of isolating a client with a communicable disease is to
protect those who are not sick (specific disease prevention).
79. B. It provides an opportunity to do first hand appraisal of the
home situation.
Choice A is not correct since a home visit requires that the nurse
spend so much time with the family. Choice C is an advantage of a
group conference, while choice D is true of a clinic consultation.
80. B. Should minimize if not totally prevent the spread of
infection.
Bag technique is performed before and after handling a client in the
home to prevent transmission of infection to and from the client.
81. A. Bag technique is performed before and after handling a
client in the home to prevent transmission of infection to and from
the client.
Path Goal theory according to House and associates rewards good
performance so that others would do the same.
82. D. Inspires others with vision
Inspires others with a vision is characteristic of a transformational
leader. He is focused more on the day-to-day operations of the
department/unit.
83. A. Psychological and sociological needs are emphasized.
When the functional method is used, the psychological and
sociological needs of the patients are neglected; the patients are diagnosis of Fluid volume deficit (or excess) or Risk for deficient fluid
regarded as ‘tasks to be done” volume. Metabolic acidosis is a medical, not nursing, diagnosis; in
84. B. Preparing a nursing care plan in collaboration with the any event, these ABG values indicate respiratory, not metabolic,
patient acidosis.
The best source of information about the priority needs of the 96. A. Stream seeding
patient is the patient himself. Hence using a nursing care plan based Stream seeding is done by putting tilapia fry in streams or other
on his expressed priority needs would ensure meeting his needs bodies of water identified as breeding places of the Anopheles
effectively. mosquito.
85. C. Unity of command 97. B. Severe dehydration
The principle of unity of command means that employees should The order of priority in the management of severe dehydration is as
receive orders coming from only one manager and not from two follows: intravenous fluid therapy, referral to a facility where IV
managers. This averts the possibility of sowing confusion among the fluids can be initiated within 30 minutes, Oresol/nasogastric tube,
members of the organization. Oresol/orem. When the foregoing measures are not possible or
86. A. Increase the patient satisfaction rate effective, tehn urgent referral to the hospital is done.
Goal is a desired result towards which efforts are directed. Options 98. A. Inability to drink
AB, C and D are all objectives which are aimed at specific end. A sick child aged 2 months to 5 years must be referred urgently to a
87. A. Uses visioning as the essence of leadership hospital if he/she has one or more of the following signs: not able to
Transformational leadership relies heavily on visioning as the core of feed or drink, vomits everything, convulsions, abnormally sleepy or
leadership. difficult to awaken.
88. C. Avoidance 99. A. Sugar
This strategy shuns discussing the issue head-on and prefers to R.A. 8976 mandates fortification of rice, wheat flour, sugar and
postpone it to a later time. In effect the problem remains unsolved cooking oil with Vitamin A, iron and/or iodine.
and both parties are in a lose-lose situation. 100. A. Palms
89. A. Staffing The anatomic characteristics of the palms allow a reliable and
Staffing is a management function involving putting the best people convenient basis for examination for pallor.
to accomplish tasks and activities to attain the goals of the
organization.
90. B. Decentralized
Decentralized structures allow the staff to make decisions on
matters pertaining to their practice and communicate in downward,
upward, lateral and diagonal flow.
91. D. end each entry with the nurse’s signature and title.
The end of each entry should include the nurse’s signature and title;
the signature holds the nurse accountable for the recorded
information. Erasing errors in documentation on a legal document
such as a client’s chart isn’t permitted by law. Because a client’s
medical record is considered a legal document, the nurse should
make all entries in ink. The nurse is accountable for the information
recorded and therefore shouldn’t leave any blank lines in which
another health care worker could make additions.
92. A. Allergies and socioeconomic status
General background data consist of such components as allergies,
medical history, habits, socioeconomic status, lifestyle, beliefs, and
sensory deficits. Urine output, gastric reflex, and bowel habits are
significant only if a disease affecting these functions is present.
93. C. I.V. cannula insertion
Caregivers must use surgical asepsis when performing wound care
or any procedure in which a sterile body cavity is entered or skin
integrity is broken. To achieve surgical asepsis, objects must be
rendered or kept free of all pathogens. Inserting an I.V. cannula
requires surgical asepsis because it disrupts skin integrity and
involves entry into a sterile cavity (a vein). The other options are
used to ensure medical asepsis or clean technique to prevent the
spread of infection. The GI tract isn’t sterile; therefore, irrigating a
nasogastric tube or a colostomy requires only clean technique.
94. B. Pouring solution onto a sterile field cloth
Pouring solution onto a sterile field cloth violates surgical asepsis
because moisture penetrating the cloth can carry microorganisms to
the sterile field via capillary action. The other options are practices
that help ensure surgical asepsis.
95. C. Impaired gas exchange
The client has a below-normal value for the partial pressure of
arterial oxygen (PaO2) and an above-normal value for the partial
pressure of arterial carbon dioxide (PaCO2), supporting the nursing
diagnosis of Impaired gas exchange. ABG values can’t indicate a