INP RBE
1. The nurse is reviewing laboratory
results for the clinic patients to seen
today. Which patients meets the
diagnostic criteria for diabetes mellitus?
a. A 48-year-old woman with a
hemoglobin A1C of 8.4%
b. A 58-year-old man with a fasting blood
glucose of 111 mg/dL
c. A 68-year-old woman with a random
plasma glucose of 190 mg/dL
d. A 78-year-old man with a 2-hour
glucose tolerance plasma glucose of
184 mg/dL
2. The nurse teaches a 38-year-old man
who was recently diagnosed with type 1
diabetes mellitus about insulin
administration. Which statement by the
patient requires an intervention by the
nurse?
a. “I will discard any insulin bottle that is
cloudy in appearance.”
b. “The best injection site for insulin
administration is in my abdomen.”
c. “I can wash the site with soap and
water before insulin administration.”
d. “I may keep my insulin at room
temperature (75o F) for up to a
month.”
3. The nurse instructs a 22-year-old
female patient with diabetes mellitus
about a healthy eating plan. Which
statement made by the patient indicates
that teaching was successful?
a. "I plan to lose 25 pounds this year by
following a high-protein diet."
b. "I may have a hypoglycemic reaction if I
drink alcohol on an empty stomach."
c. "I should include more fiber in my diet
than a person who does not have diabetes."
d. "If I use an insulin pump, I will not need
to limit the amount of saturated fat in my
diet.
4. A 54-year-old patient admitted with
type 2 diabetes asks the nurse what
"type 2" means. What is the most
appropriate response by the nurse?
a. "With type 2 diabetes, the body of the
pancreas becomes inflamed."
b. "With type 2 diabetes, insulin secretion is
decreased, and insulin resistance is
increased."
c. "With type 2 diabetes, the patient is
totally dependent on an outside source of
insulin."
d. "With type 2 diabetes, the body produces
autoantibodies that destroy β-cells in the
pancreas."
5. The nurse is assigned to the care of a
64-year-old patient diagnosed with type
2 diabetes. In formulating a teaching
plan that encourages the patient to
actively participate in management of
the diabetes, what should be the nurse's
initial intervention?
a. Assess patient's perception of what it
means to have diabetes.
b. Ask the patient to write down current
knowledge about diabetes.
c. Set goals for the patient to actively
participate in managing his diabetes.
d. Assume responsibility for all of the
patient's care to decrease stress level.
6. The nurse is evaluating a 45-year-old
patient diagnosed with type 2 diabetes
mellitus. Which symptom reported by
the patient is considered one of the
classic clinical manifestations of
diabetes?
a. Excessive thirst
b. Gradual weight gain
c. Overwhelming fatigue
d. Recurrent blurred vision
7. A patient, who is admitted with
diabetes mellitus, has a glucose level of
380 mg/dL and a moderate level of
ketones in the urine. As the nurse
assesses for signs of ketoacidosis,
which respiratory pattern would the
nurse expect to find?
a. Central apnea
b. Hypoventilation
c. Kussmaul respirations
INP RBE
d. Cheyne-Stokes respirations
8. The nurse has taught a patient
admitted with diabetes, cellulitis, and
osteomyelitis about the principles of
foot care. The nurse evaluates that the
patient understands the principles of
foot care if the patient makes what
statement?
a. "I should only walk barefoot in nice dry
weather."
b. "I should look at the condition of my feet
every day."
c. "I am lucky my shoes fit so nice and tight
because they give me firm support."
d. "When I am allowed up out of bed, I
should check the shower water with my
toes."
9. The diabetic educator is teaching a
class on diabetes Type 1 and is
discussing sick-day rules. Which
interventions should the diabetes
educator include in the discussion?
a. Take diabetic medication even if
unable to eat the client's normal
diabetic diet.
b. If unable to eat, drink liquids that are
equal to the client's normal caloric
intake.
c. Call the health-care provider if glucose
levels are higher than 180 mg/dL.
d. All of the above
10. The client diagnosed with type 2
diabetes is admitted to the intensive
care unit with hyperosmolar
hyperglycemic nonketonic syndrome
(HHNS) coma. Which assessment data
should the nurse expect the client to
exhibit?
a. Kussmaul's respirations.
b. Diarrhea and epigastric pain.
c. Dry mucous membranes.
d. Ketone breath odor.
11. Which electrolyte replacement
should the nurse anticipate being
ordered by the health-care provider in
the client diagnosed with DKA who has
just been admitted to the ICU?
a. Glucose.
b. Potassium.
c. Calcium.
d. Sodium.
12. A client is admitted to the hospital
with signs and symptoms of diabetes
mellitus. Which findings is the nurse
most likely to observe in this client?
a. Excessive thirst
b. Excessive hunger
c. Frequent, high-volume urination
d. All of the above
13. A diabetic patient has a serum
glucose level of 824 mg/dL (45.7
mmol/L) and is unresponsive. After
assessing the patient, the nurse
suspects diabetic ketoacidosis rather
than hyperosmolar hyperglycemic
syndrome based on the finding of
a. polyuria.
b. severe dehydration.
c. rapid, deep respirations.
d. decreased serum potassium.
14. Which assessment data indicate to
the nurse the clients gastric ulcer has
perforated?
A. Complaints of sudden, sharp, substernal
pain
B. Rigid, boardlike abdomen with rebound
tenderness
C. Frequent, clay-colored, liquid stool
D. Complaints of vague abdominal pain in
the right upper quadrant
15. Which specific data should the nurse
obtain from the client who is suspected
of having peptic ulcer disease?
A. History of side effects experienced from
all medications
B. Use of non steroidal anti inflammatory
drugs (NSAIDs)
C. Any known allergies to drugs and
environmental factors
D. Medical histories of at lease 3 generations
INP RBE
16. Which physical examination should
the nurse implement first when
assessing the client diagnosed with
peptic ulcer disease?
A. Auscultate the clients bowel sounds in all
four quadrants
B. Palpate the abdominal area for tenderness
C. Percuss the abdominal borders to identify
organs
D. Assess the tender area progressing to
nontender
17. Which expected outcome should the
nurse include for a client diagnosed
with peptic ulcer disease?
A. The clients pain is controlled with the use
of NSAIDs
B. The client maintains lifestyle modifications
C. The client has no signs and symptoms of
hemoptysis
D. The client take s antacids with each meal
18. The nurse has been assigned to care
for a client diagnosed with peptic ulcer
disease. Which assessment data require
further intervention?
A. Bowel sour s auscultated 15 times in 1
minute
B. Belching after eating a heavy and fatty
meal late at night
C. A decrease in systolic BP of 20 mm Hg
from lying to sitting
D. A decreased frequency of distress located
in the epigastric region
19. The nurse has administered an
antibiotic, a proton pump inhibitor, and
Pepto- Bismol for peptic ulcer disease
secondary to H. pylori. Which data
would indicate to the nurse the
medications are effective?
A. A decrease in alcohol intake
B. Maintaining a bland diet
C. A return to previous activities
D. A decrease in gastric distress
20. The client with a history of peptic
ulcer disease is admitted into the
intensive care unit with frank gastric
bleeding. Which priority intervention
should the nurse implement?
A. Maintain a strict record of intake and
output
B. Insert a nasogastric tube and begin saline
lavage
C. Assist the client with keeping a detailed
calorie count
D. Provide a quiet environment to promote
rest
21. The client with peptic ulcer disease
(PUD) asks the nurse whether licorice
and slippery elm might be useful in
managing the disease. What is the
nurse's best response?
A. "No, they probably won't be useful. You
should use only prescription medications in
your treatment plan."
B. "These herbs could be helpful. However,
you should talk with your physician before
adding them to your treatment regimen."
C. "Yes, these are known to be effective in
managing this disease, but make sure you
research the herbs thoroughly before taking
them."
D. "No, herbs are not useful for managing
this disease. You can use any type of over-
the-counter drugs though. They have been
shown to be safe."
22. The nurse would increase the
comfort of the patient with appendicitis
by:
a. Having the patient lie prone
b. Flexing the patient's right knee
c. Sitting the patient upright in a chair
d. Turning the patient onto his or her left
side
23. A client is admitted with a diagnosis
of acute appendicitis. When assessing
the abdomen, the nurse would expect to
find rebound tenderness at which
location?
a) Left lower quadrant
b) Left upper quadrant
c) Right upper quadrant
d) Right lower quadrant
INP RBE
24.The nurse is monitoring a client
diagnosed with appendicitis who is
scheduled for surgery in 2 hours. The
client begins to complain of increased
abdominal pain and begns to vomit. On
assessment, the nurse notes that the
abdomen is distended and bowel sounds
are diminished. Which is the appropriate
nursing intervention?
a. Notify the Physician
b. Administer the prescribed pain
medication
c. Call and ask the operating room team to
perform the surgery as soon as possible
d. Reposition the client and apply a heating
pad on warm setting to the client's
abdomen
25. A client telephones the health clinic
with complaints of generalized
abdominal pain which is aggravated by
moving or walking. The client has not
been able to eat for a day and is
nauseated. Which advice should the
nurse provide to this client?
A. "Take a warm shower and apply a heating
pad to the abdomen."
B. "Rest in bed and drink warm fluids."
C. "Seek immediate medical attention."
D. "Take an over-the-counter laxative."
26. Which clinical manifestation does
the nurse expect with acute
appendicitis?
A. High fever
B. Nausea and vomiting
C. Rebound tenderness
D. Pain relieved with ambulation
27. A client presents with suspected
appendicitis. The nurse should prepare
the client for which collaborative
intervention?
A. Chest x-ray
B. Abdominal ultrasound
C. Electrolytes
D. Complete blood count (CBC)
28. Refers to an excavation that forms
in the mucosal wall of the stomach, the
pylorus, duodenum or in the esophagus-
generally occur alone, commonly found
in the duodenum
a. Peptic ulcer disease
b. Appendicitis
c. Gastritis
d. Stomach cancer
29. A client is in DKA, secondary to
infection. As the condition progresses,
which of the following symptoms might
the nurse see?
a) Kussmaul's respirations & a fruity odor
on breath
b) Shallow respirations & severe abd pain
c) Decreased respirations & increased urine
output
d) Cheyne-stokes respirations & foul-
smelling urine
30. A client with a diagnosis of diabetic
ketoacidosis (DKA) is being treated in
the ER. Which finding would a nurse
expect to note as confirming this
diagnosis?
a) Elevated blood glucose level & low
plasma bicarbonate
b) Decreased urine output
c) Increased respirations & increase in pH
d) Comatose state
31. The nurse assisting in the admission
of a client with diabetic ketoacidosis will
anticipate the physician ordering which
of the following types of intravenous
solution if the client cannot take fluids
orally?
a. Lactated Ringer's solution
b. 0.9 normal saline solution
c. 5% dextrose in water (D5W)
d. 0.45% normal saline solution
32. Which of the following if stated by
the nurse is correct about
Hyperglycemic Hyperosmolar
Nonketotic Syndrome (HHNS)?
a. This syndrome occurs mainly in people
with Type I Diabetes
b. It has a higher mortality rate than
Diabetic Ketoacidosis
INP RBE
c. The client with HHNS is in a state of
overhydration
d. This condition develops very rapidly
33. Dr. Hugo has prescribed
sulfonylureas for Rebecca in the
management of diabetes mellitus type
2. As a nurse, you know that the
primary purpose of sulfonylureas, such
as long-acting glyburide (Micronase), is
to:
A. Induce hypoglycemia by decreasing
insulin sensitivity.
B. Improve insulin sensitivity and decrease
hyperglycemia.
C. Stimulate the beta cells of the pancreas
to secrete insulin.
D. Decrease insulin sensitivity by
enhancing glucose uptake.
34. When a client is first admitted with
hyperglycemic hyperosmolar nonketotic
syndrome (HHNS), the nurse's priority
is to provide:
a) Oxygen
b) Carbohydrates
c) Fluid replacement
d) Dietary instruction
35. A nurse performs a physical
assessment on a client with type 2
diabetes mellitus. Findings include a
fasting blood glucose of 120 mg/dL,
temp of 101 F, pulse of 88 bpm,
respirations of 22, and blood pressure
of 100/72. Which finding would be of
most concern to the nurse?
a) Pulse
b) Respiration
c) Temperature
d) Blood pressure
36. The principal goals of therapy for
older patients who have poor glycemic
control are:
A. Enhancing quality of life.
B. Decreasing the chance of complications.
C. Improving self-care through education.
D. All of the above.
37. You are teaching the patient with
chronic kidney disease about what
symptoms to report to the doctor when
outside of the hospital. Which
statement, if made by the patient,
indicates correct understanding?
A) "I should call my doctor if my stomach
starts feeling sick or my breath smells
funny like pea"
B) "Muscle weakness and abdominal
cramps are a sign of worsening condition
and I should report this to my doctor"
C) "My doctor wants me to call him if I feel
a vibrating or buzzing sensation over my
hemodialysis graft.
D) "I should call immediately if I see
swelling at my dialysis port"
38. Nurse Shelby is preparing to
administer selvemer hydrochloride
(Renagel) to the patient with CKF
(Chronic Kidney Disease). Which of the
following does the nurse know to be
true?
A) This medication should be given on an
empty stomach
B) It is used to treat hyperphosphatemia
C) To administer at bedtime
D) Renagel can be used to help with
hypercalcemia
39. Nurse Vincent is looking over the
patient chart and is preparing to
administer erythropoietin to the patient
with CKF. Which of the following pieces
of information in the chart would cause
Nurse Heather to question this order?
A) Hgb of 9
B) Hx of uncontrolled HTN
C) Pt. complains of fatigue
D) Ferric Gluconate (Ferrlecit) is also
ordered
40. You are teaching the patient starting
hemodialysis. Which statement, if made
by the patient, indicates the need for
further teaching?
A) "To protect my fistula I shouldn't wear
tight fitting clothing on that side"
INP RBE
B) "If I see any redness or swelling on the
site I should call my doctor"
C) "I shouldn't sleep on my side with the
graft but it's ok to take a blood pressure on
that arm"
D) "I need to wait to take my medications
until after my dialysis treatment"
41. A patient with CKF arrives for his
dialysis treatment complaining of
muscle aches and digestive upset. He
also says "my skin has been feeling
itchy and gets red if I scratch too much"
The patients vitals are BP 146/73 HR 89
RR 24 T 99.5 Spo2 94%. The nurse
suspects which of the following?
A) The patient is experiencing adverse
reaction from his erythropoietin
B) Most likely a clot has formed at the
dialysis access, broken off, and spread
systemically
C) These signs indicate worsening CKF.
Dialysis treatment may need to be
adjusted
D) The patient is experiencing a rejection
reaction from the dialysis procedures
42. Nurse Felix is preparing to teach the
patient with CKF about dietary
modifications. Which of the following
aspects of the patient is most important
for the nurse evaluate before teaching
begins?
A) Family Hx
B) Attention span
C) Uric Acid level
D) Support system
43. You are working at a dialysis center
and are taking care of Ms. Hector. She
has a history of diabetes, CKF, and HTN.
She says "I hate having to come here all
the time. Can't I just do this stuff at
home?" What is the nurse's best
response?
A) "Yes, home hemodialysis is an option for
you. In fact, we can start setting you up
within the next week"
B) "In order to have hemodialysis you need
to have friends or family to help you. Do
you even have any friends?"
C) "Home hemodialysis is a possibility but
it will be necessary to inspect your home"
D) "Because of your preexisting conditions,
you would not be a good candidate for
home dialysis"
44. The nurse is performing peritoneal
dialysis exchange on the patient with
CKF. This is the first peritoneal dialysis
treatment. The nurse inspects the
drainage. Which should the nurse report
to the physician immediately?
A) Bloody drainage
B) More than 2 L of drainage
C) Cloudy drainage
D) Glucose in drainage
45. The nurse is performing peritoneal
dialysis and infuses 2 L of fluid into the
patient. The drainage is measured to be
only 1800 ml. What is the nurse's
priority action?
A) Raise the head of the bed
B) Administer 02
C) Call the doctor
D) Infuse 200 ml
46. The patient undergoing peritoneal
dialysis complains of abdominal pain.
The nurse notes the drainage to be
cloudy. She also palpates rebound
tenderness. Which complication does
the nurse suspect?
A) Leakage around catheter
B) Internal Bleeding
C) Hypertriglycerdemia
D) Peritonitis
47. You have a patient that is receiving
peritoneal dialysis. What should you do
when you notice the return fluid is
slowly draining?
a. Check for kinks in the outflow tubing.
b. Raise the drainage bag above the level
of the abdomen.
c. Place the patient in a reverse
Trendelenburg position.
INP RBE
d. Ask the patient to cough.
48. What is the appropriate infusion
time for the dialysate in your 38 y.o.
patient with chronic renal failure?
A. 15 minutes
B. 30 minutes
C. 1 hour
D. 2 to 3 hours
49. A 30 y.o. female patient is
undergoing hemodialysis with an
internal arteriovenous fistula in place.
What do you do to prevent
complications associated with this
device?
A. Insert I.V. lines above the fistula.
B. Avoid taking blood pressures in the arm
with the fistula
C. Palpate pulses above the fistula
D. Report a bruit or thrill over the fistula
to the doctor
50. Your patient becomes restless and
tells you she has a headache and feels
nauseous during hemodialysis. Which
complication do you suspect?
A. Infection
B. Disequilibrium syndrome
C. Air embolus
D. Acute hemolysis
51. Mrs. Gian, an 18-year-old, is 20
weeks pregnant. although she says she
knows she should have stopped
smoking before pregnancy, she has not
been able to do this as yet. twice during
the pregnancy (at the 4th and 10th
week), she drank beer at summer
picnics. today, at a clinic visit, she tells
you she has felt her fetus move. she
states, "feeling the baby move made me
realize there's someone inside me, you
know what i mean? it made me realize
it's time i started being more careful
with what i do." what is the most
relevant nursing diagnosis with this
statement?
a. Readiness for enhanced knowledge
related to usual fetal development
b. Anxiety related to lack of fetal
movement
c. Deficient knowledge related to the
need for good prenatal care for
healthy fetal well-being
d. Pain related to fetal movements
52. Which among the statement below
indicates a nursing process for
"Evaluation"
a. Couple attends all scheduled prenatal
visits
b. Nurse helps couple to understand the
importance of implementing healthy
behaviors, such as eating well and
avoiding substances that may be
dangerous to a fetus such as
recreational drugs
c. Anxiety related to lack of fetal
movement
d. Nurse includes ways to educate patient
potential parents about teratogens
53. Which of the following is true about
hormone progesterone?
a. It helps maintain the endometrial
lining during the pregnancy
b. It is also known as “hormone of
women.”
c. Mammary gland development in
preparation for lactation
d. Stimulates uterine growth to
accommodate growing fetus
54. A systematic method of observation
and palpation to determine fetal
presentation and position and are done
as part of a physical examination. What
do you call this method?
a. Leopold’s maneuver
b. Palwik’s maneuver
c. Ritgen’s maneuver
d. Brandt-andrews maneuver
55. In what phase of puerperium when
the postpartum mother prefers having a
nurse attend her needs and make
decisions for her rather than do these
things herself?
a. Taking-in phase
INP RBE

b. Taking-hold phase 60. A gravid woman at G2P1, just

c. Letting-go phase arrived in the clinic this afternoon,
d. Letting-in phase reported abdominal pains, with varied
56. A nurse is knowledgeable when she contractions and reported frequency in
knows that “puerperium” or postpartum urinations. Which among the following
period refers to? are signs of TRUE LABOR contractions?
a. 10 weeks period after childbirth a. Begin irregular but become
b. 12 weeks period after childbirth regular and predictable
c. 3 weeks period after childbirth b. Begin and remain irregular
d. 6 weeks period after childbirth c. Increase in duration,
57. Mrs. Allawic has expressed that she frequency and intensity
is excited to "get to know" her new d. Has achieved cervical
baby. the nurse determines which of the dilatation
following actions will support Mrs. e. Often disappears with
Allawic's transition into a postpartal ambulation or sleep
taking-hold phase? f. Felt first in lower back and
a. Tell her that she did well in labor and sweep around to the
that it was “all worth it.” abdomen in a wave
b. Encourage her to take as much time g. Does not increase in
as she needs to recover from her labor duration, frequency or
c. Help her to give her new baby a bath intensity
d. Help her and her husband to choose h. Continues no matter what
their baby’s name as soon as possible the woman’s level of activity
58. Mrs. Villorente, a community health i. Felt first abdominally and
nurse (CHN) in Samar assesses the remains confined to the
vaginal discharge of a recently abdomen and groin
postpartum woman, Mrs. Samson, a. A B C D G
G5P1T3A0L1, went on a home visit. The b. A C D F H
patient manifests a sanguinous blood, c. B C E G I
mucus and invading leukocytes with the d. B E G I
discharge. The nurse is knowledgeable 61. This is known as the shortening and
that this is a normal manifestation if it thinning of the cervical canal during
lasts for a period of how many days? labor and delivery.
a. 1-3 days a. Engagement
b. 3-10 days b. Effacement
c. 10-14 weeks c. Station
d. 4 weeks to 6 weeks d. Dilatation
59. Uterine involution: Nurse Nondevilla 62. A manifestation for decreased heart
is knowledgeable if she documents that rate or deceleration would indicate that
uterus of a postpartal woman recedes the vagal nerve compression
under the pubic area after how many stimulating the Parasympathetic
days? Nervous System, that this nerve is
a. 5 days affected during a contraction, hence
b. 8 days lowering the fetal heart rate. What type
c. 10 days of deceleration does this belong in
d. 14 days periodic changes in FHR?
INP RBE
a. Late deceleration
b. Variable deceleration
c. Early deceleration
d. Sinusoidal Pattern
63. Mrs. Teopiz, a pregnant woman on
oxytocin, verbalized that “it seems my
baby isn’t well inside.” Immediately
nurse Shiela assessed the contractions
and fetal heart tone and stopped the
oxytocin. Findings shows that the paper
strip is showing Late Decelerations
indicating uteroplacental insufficiency
leading to hypoxia. What should the
nurse do next?
a. Place the patient in lateral
or side lying position
b. Provide oxygen as
prescribed
c. Intravenous fluids
d. Report findings and status
to the Physician
e. Document findings and
interventions and evaluation
a. D E B A C
b. D B A C E
c. A B C D E
d. B A C D E
64. A pregnant woman happens to come
to a birthing home experiencing labor
contractions and believed that they are
true signs of labor. She realizes after
being assessed and educated by the
nurse that they are false contractions.
Although the woman has been advised
to stay in the hospital for admission.
What nursing diagnosis is applicable for
this situation? (5pts)
a. Pain related to labor contractions
b. Anxiety related to process of labor and
birth
c. Health seeking behaviors related to
management of discomfort of labor
d. Situational low self-esteem related to
inability to use prepared childbirth
method
65. It is the softening of the cerix. This
is called as?
a. Hegar’s sign
b. Goodell’s sign
c. Chadwick’s sign
d. None of the above
66. Is a color change in the vagina from
pink to purple because of increased
formation of blood vessels and blood
flow.
a. Hegar’s sign
b. Goodell’s sign
c. Chadwick’s sign
d. All of the above
67. Lauren Maxwell’s doctor told her she
had a positive Chadwick’s sign. When
she asks the nurse what this means, the
best answer would be which of the
following?
a. “Your abdomen feels soft and tender,
a normal finding.”
b. “Your uterus has tipped forward, a
potential complication.”
c. “Your cervical mucus feels sticky, just
as it should feel.”
d. “Your vagina looks dark in color, a
typical pregnancy sign.”
68. Which among the following is NOT
true about Braxton Hicks Contraction?
a. These are manifestation of true labor
b. Can cause true discomfort
c. Also known as false labor
d. It is a problem sign of pregnancy
69. Psychological changes: The woman
and her partner both spend time
recording from the surprise of learning
they are pregnant and concentrate on
what it feels to be pregnant. A common
reaction is ambivalence
a. First trimester task: Accepting the
pregnancy
b. Second trimester task: Accepting the
fetus
c. Third trimester task: Preparing for the
baby and end of pregnancy
d. None of the above
INP RBE
70. What psychological change when
the woman and her partner move
through emotions such as narcissism
and introversion as they concentrate on
what it will feel like to be parent. Role
playing and increased dreaming are
common?
a. First trimester task: Accepting the
pregnancy
b. Second trimester task: Accepting the
fetus
c. Third trimester task: Preparing for the
baby and end of pregnancy
d. None of the above
71. The woman and her partner
prepares clothing and sleep
arrangements for the baby but also
grow impatient as they ready
themselves for birth.
a. First trimester task: Accepting the
pregnancy
b. Second trimester task: Accepting the
fetus
c. Third trimester task: Preparing for the
baby and end of pregnancy
d. None of the above
72. Your patient is complaining of
muscle cramps while undergoing
hemodialysis. Which intervention is
effective in relieving muscle cramps?
a. Increase the rate of dialysis
b. Infuse normal saline solution
c. Administer a 5% dextrose solution
d. Encourage active ROM exercises
73. Following delivery of the newborn,
which nursing intervention should be
carried out immediately?
a. Weigh the infant
b. Warm the infant
c. Bathe the infant
d. Inoculate the infant
74. The nurse is taking care of the
patient with chronic kidney disease.
Which of the following meal trays would
be the best for this patient?
a. Whole grain roll with baked chicken
and pea soup and milk
b. Sandwich with smoked salmon
lunchmeat, green beans, and banana
pudding
c. Baked ham, mashed potatoes, tomato
soup and peanut butter cookies
d. Low-sodium chicken noodle soup,
apple slices, white-wheat roll and rice
75. A client with acute renal failure
develops severe hyperkalemia. What
would the nurse anticipate to be used to
treat this imbalance?
a. Furosemide (Lasix)
b. Amphojel (aluminum hydroxide)
c. 50% glucose and regular insulin
d. Epoetin (Procrit)
76. A client with chronic renal failure
has been prescribed calcium carbonate.
What is the rationale for this particular
medication?
a. Diminishes incidence of gastric ulcer
b. Alleviates constipation
c. Binds with phosphorus to lower
concentration
d. Increase tubular reabsorption of
sodium
77. A client with chronic kidney failure
has an internal venous access site for
hemodialysis on her left forearm. What
action will the nurse take to protect this
access site?
a. Irrigate with heparin and NS q8 hrs
b. Apply warm moist packs to the area
after hemodialysis
c. Do not use the left arm to take blood
pressure readings
d. Keep the arm elevated above the level
of the heart
78. A nurse is assessing the patency of
a client’s left arm arteriovenous fistula
prior to initiating hemodialysis. Which
finding indicates that the fistula is
patent?
a. Palpation of a thrill over the fistula
INP RBE
b. Presence of a radial pulse in the left
wrist.
c. Absence of a bruit on auscultation of
the fistula
d. Capillary refill less than 3 seconds in
the nail beds of the fingers of the left
hand
79. A client with chronic renal failure
has completed a hemodialysis
treatment. The nurse would use which
of the following standard indicators to
evaluate the client’s status after
dialysis?
a. Vital signs and weight
b. Potassium level and weight
c. Vital signs and BUN
d. BUN and creatinine levels
80. A patient with diabetes mellitus and
renal failure begins hemodialysis. Which
diet is best on days between dialysis
treatments?
a. Low-protein diet with unlimited
amounts of water
b. Low-protein diet with a prescribed
amount of water
c. No problem in the diet and use of a
salt substitute
d. No restrictions
81. when assessing a mother 12 hours
following the delivery of a baby, where
should the nurse expect to palpate the
fundus?
a. 2 cm below the umbilicus
b. At the umbilicus
c. 1 cm below the umbilicus
d. Halfway between the umbilicus and
the symphysis pubis
82. What is the name of the vaginal
discharge that occurs immediately
following delivery?
a. Lochia serosa
b. Lochia rubra
c. Lochia palatine
d. Lochia alba
83. What is the first secretion produced
by the breast?
a. Prolactin
b. Colostrum
c. False milk
d. Whey
84. What should be included in a
teaching plan regarding breast
engorgement?
a. It typically occurs on the first
postpartum day
b. It is usually first observed in the
axillary region
c. It occurs only in women who are not
breastfeeding
d. It occurs near the nipple on the third
postpartum day
85. When is breast engorgement most
likely to occur?
a. When the infant’s mouth surrounds
the areola when feeding
b. When the breast tissue becomes
congested
c. When the breast is emptied
completely at each feeding
d. When the infant’s mouth grasps the
nipple firmly
86. Which statement would be a correct
description of colostrum?
a. Slightly yellow and low in protein
b. Slightly yellow and provides antibodies
c. Creamy and high in fat and protein
d. Colorless and high in fats and
carbohydrates
87. The new mother has decided not to
breastfeed the baby. How should the
nurse correctly instruct the mother to
suppress her milk supply?
a. Pump the breasts to remove milk
b. Apply warm, moist compresses
c. Restrict oral fluids
d. Apply a firm bra and ice packs
88. During the immediate postpartum
period, the mother has a temperature of
100.2’F, pulse 52, respirations 18, BP
138/84. What should the nurse do?
a. Report the temperature as abnormal
b. Continue to monitor every 15 minutes
INP RBE
c. Report the pulse as abnormal
d. Nothing as the vital signs are normal
89. Within the first hour following a
vaginal delivery, the nurse assesses the
mother and finds the fundus is firm and
there is a trickle of bright red blood.
What should be the nurse's reaction to
the assessment?
a. This is a normal occurrence.
b. This is abnormal and should be
reported.
c. The patient should be administered a
blood thinner.
d. The patient should be restricted to
bed rest.
90. What is the appropriate way to
assess the fundus of the postpartum
patient?
a. Using the side of one hand moving
down from the umbilicus
b. Using one hand over the lower
segment of the uterus
c. Using one hand pushing upward from
the lower uterus
d. Using one hand on the lower uterine
segment while the other hand locates
the fundus of the uterus
91. The postpartum mother with a third
degree laceration tells the nurse she is
afraid to have a bowel movement
because of her painful episiotomy. What
should the nurse do?
a. Offer a suppository or enema
b. Encourage ambulation
c. Offer stool softeners as prescribed
d. Offer pain medication before
defecating
92. A new mother had spinal anesthesia
during a cesarean delivery. She now has
a desire to void and can wiggle her toes.
What should be the nurse’s response
when the mother asks to go the
bathroom?
a. Assess her blood pressure
b. Obtain a wheelchair
c. Palpate her bladder
d. Put slippers on her feet
93. A mother delivered her baby at
midnight and it is now 9am. She wants
to sleep and asks the nurse to take care
of the baby. What is this considered?
a. Fatigue from labor
b. Normal “taking in” response
c. Abnormal “taking in” response
d. Risk for altered maternal-infant
bonding
94. Which of the following would be
considered a normal assessment finding
in a 1-day postpartum patient?
a. Pinkish to brown lochia
b. Voiding frequency 50mL to 75mL of
urine
c. Complaining of “after pains”
d. Fundus 1 cm above the umbilicus
95. A new Native American mother tells
the nurse that when she goes home, her
mother-in-law will be caring for the
baby while she rests. The nurse has
concerns. What should the nurse do?
a. Explain the importance of ambulating
to recover
b. Explain the importance of maternal-
infant bonding
c. Explore ways to blend this with safe
health teaching
d. Encourage this cultural behavior
96. The nurse is caring for a 54-year-old
unconscious female patient who has
just been admitted to the post
anesthesia care unit after abdominal
hysterectomy. How should the nurse
position the patient?
a. Left lateral position with head
supported on a pillow
b. Prone position with a pillow supporting
the abdomen
c. Supine position with head of bed
elevated 30 degrees
d. Semi-fowler’s position with the head
turned to the right
97. The nurse is providing discharge
teaching to a 51-year-old female patient
INP RBE

who has had a laparoscopic a. Administering adequate analgesics to

cholecystectomy at an ambulatory promote relief or control of pain
surgery center. Which statement, if b. Asking the patient to demonstrate the
made by the patient, indicates an postoperative exercises every 1 hour
understanding of the discharge c. Giving the patient positive feedback
instructions? when the activities are performed
a. “I will have someone stay with me for correctly
24 hours in case I feel dizzy.” d. Warning the patient about possible
b. “I should wait for the pain to be complications if the activities are not
severe before taking the medication.” performed
c. “Because I did not have general
anesthesia, I will be able to drive
home.”
d. “It is expected after this surgery to
have a temperature up to 102.4’F.”
98. The nurse is working on a surgical
floor and is preparing to receive a
postoperative patient from the post-
anesthesia care unit (PACU). What
should the nurse’s initial action be upon
the patient’s arrival?
a. Assess the patient’s pain
b. Assess the patient’s vital signs
c. Check the rate of the IV infusion
d. Check the physician’s postoperative
orders
99. When assessing a patient’s surgical
dressing on the first postoperative day,
the nurse notes new, bright-red
drainage about 5cm in diameter. In
response to this finding, what should
the nurse do first?
a. Recheck in 1 hour for increased
drainage
b. Notify the surgeon of a potential
hemorrhage
c. Assess the patient’s blood pressure
and heart rate
d. Remove the dressing and assess the
surgical incision
100. In planning postoperative
interventions to promote repositioning,
ambulation, coughing, and deep
breathing, which action should the
nurse recognize will best enable the
patient to achieve the desired outcome?