TOPZRANK REVIEW ACADEMY * NLE* NCLEX * CGFNS * HAD * PROMETRICS * DHA * MIDWIFERY “LET * RAD TECH * CRIMINOLOGY * DENTISTRY * PHARMACY RECALLS EXAMINATION 10 NURSING PRACTICE I COMMUNITY HEALTH NURSING NOV 2023 Phil (GENERAL INSTRUCTIONS: 4. This test questionnaire contains 100 test questions 2. Shade only one (1) box for each question on your answer sheetsi—iwo or more boxes shaded will invalid your answer. 3. AVOID ERASURES. 4. Detach one (1) answer sheet from the bottom 6f your Examing ‘Narse Licenstire Examination Review ID/Answer Sheet Set. 5. Write the subject ttle "NURSING PRACTICE I" on the box provided Situation: Nursing Organizations has been established to enhance growth of the profession as well as its members. 1. Established in 1896, This is the national professional organization of the United states of America. ALANA, 3. ICN PNA, D. CNA 2. Anastacia Giron Tupas presided in the founding of the PNA. on: |. September 2, 1922 3. September 2, 1927 C. October 2, 1902 D. October 2, 1922 3. Nurses in the Philippine government also felt the need to organize themselves, this leads to the creation of: |. National League of Government Nurses. 8. National League of Flipino Government Nurses C. National League of Philippine Government Nurses D. Philippe Government Nurses Association. Situation: A public health nurse is aiving orientation to three beginning nurses who are hired by the local government unit under the Nurse Deployment Programs. 4. Mc Reyes, 2 community health nuisejis assessing the rnutrional staius cf @ croup of ederly residents in a resdential cate facity. He finds that many of them have poor appetite and diffaity eating. What would be tis most appropriate intervention? A. Recommending a comnts liquid meal replacement forall residents 8, Providing individualized meal plans based on thei dietary preferences and restictons.. C. Referring all residents to. a nutritionist for assessment and counseling. D. Consuting with a speech therapist foF/eveluation and management of swallowing difficulties. 5, “Public health services are given free of charge,” Is this statement true or false? A. The statement is te; it is thélresponsibity of government to provide basic services. 8. The statement is false; people pay indirectly (oF public health services. C. The statement may be true or false, depending on the specific sevice required. D. The statement may be true or fase, depending on polices of the government concerned. 6. According to C.EWinslom, which of the folowing is the goal of Public Health? [A Fer people to attain ther birtvights of heath and longevity 8, For promotion of heath and prevention of disease For people to have access to basic heath services 0. Far people to be organized in their healt efforts 7. We say tiat a Filipino has attained longevity when he is able to reach the average lifespan of Flipines. What other statistics ‘may be used to determine attainment of longevity? ‘A. Age-speafic mortality rate B. Proportionate mortality rate CC. Swaroop’s index D. Case fatalty rate 8. Which of the foliowing is the most prominent feature of Pblic health nursing? ‘Ac Ttinvolves providing home care to sick people who afe not confined in the hospital. B. Services are provided free of charge to people within the catchment area, . The pubic health nurse functions a part of a team providing a public health nursing services. . Public health nursing focuses on preventive, not curative, services. Situation: A new public heath nurse intends to give health education through seminars and group discussion in her barangay. 9. Which disease was dedlered through, residential Proclamation No. 4 as a target_for- eradication in the Philippines? ‘A. Poliomyelitis B. Measles C Rabies D. Neonatal tetanus 10. The public healtn nurse s responsible for presenting the municipal health statstics using oraphs and tables. To compare the frequencysof the leading causes of ‘mortality in the ‘municipality, which gaph will you prepare? ‘Aline 8. Bar C.Pie D. Scatterlagram 11, Whit Step in community organizing involves’ spotting for potential leaders in the community? ‘Integration 8. Community ofjanization C.Communty study 1. Core group formation 2 In which step are plans formulated for solving community problems? ‘A. Moblization 8. Community organization C. Follon-up/extension D. Core group formation 13. The public health nurse takes an active role in community pattcgation. What is. the primary goal of community organizing? ‘A To educate the people regarding commurity health problems 8. To mobilze the people to resolve commurity health problems 1 | PogeC. To minimize the community's resources in dealing with heath problems D. To maximize the community's resources in dealing with health problems 14. An indicator of success in community organizing is Win people are able to ‘A. Participate in community actities forthe solution ofa community problem 3. Implanent adivtes for the solution of the community problem C. Plan activites for the solution of thé Community problem D. Identity the heath problem as a common concern 15. Tertiary prevention Is needed in which stage ofthe natural history of cisease? 1. Pre-pathogenesis 8, Pathogeness| €. Prodromal D, Terminal 16. Administering BCG vaccine to @ newborn belongs t6|What level of prevention? ‘A Primary 8. Secondary . Intermediate D. Tetiary 17, On the other hand, a woman undergoing Pap-smear test ordered by her OB-Gyne is___ preventon. 1A Peary 8, Secondary C. Imermediate D. Tetiary 18, Which type of famiy-nurse contact will provide you with the best opportunity to observe family dynamics? |. Ginic consultation 8. Group conference Home vist ©. Written communication 19. The typology of family nursing problems is used in the statement of nursing diagnosis in the care of femilies. The youngest child ofthe de los Reyes family has been diagnosed as mentaly retarded. Tis is Classified as @ ‘A Health threat 8, Heath deficit C. Foreseeable crisis D, Stress point 20, The dé los Reyes couple have a 6-year old child entering schoo for the frst ime. The De los Reyes family hae a |. Health threat 3 Health defiat C. Foreseeable crisis 0, Stress point 21, Which ofthe following is an advantage of a home visi? |. Tt allows the nurse to provide nursing care to a greater number of people. 8. It provides an_ opportunity to! @opfirst_ hand appraisal of the hone stuation.. CItallons sharing of experences amona people wth similer health problems. D. Tt develops the familys initiative in provicing for health needs ofits members. 22. Which Is CONTRARY to the prindples in planning a home visit? ‘A Alhome vist should have a purpose or objective. 8. The plan should revolve around. family heath needs. C. Ahore visit should be conducted in the manner prescribed by the RHU. D. Manning of continuing care should imoWve a responsible family member. 23, The PHN bag is an important too in providing nursing care duritg a home vit. The most important princple of tag technique states that it |. Should save time and effort. 8, Stould minmize if not totally prevent the spread of infection. C. Should not overshadow concern for the patient and his emily D. May be done in a vatiety of ways depending on the home situation, ete. 24, To maintain the cleanliness of the bag and its contents, hich ofthe following must the nurse do? ‘A. Wash his/her hands before and after providing nursing care tothe femily members. B. In the care of family members, as much as possible, use only artcles taken from the bag. Put on anvapron to protect her uniform and fold it With the right side Out before putting it back into the bag . At the end of the vist, fold the ling on which the ba Was placed, ensuring that the contaminated side ison the outside 25, The public health nurSélconducts a study on the main ‘aces of the tigh mortality rate due to heart disease in the Thunicipality where she works. Which branch of epidemiology does the nurse practice inthis situation? ‘A Descriptive B. Analytical C. Therapeutic: D.Psychiatric 26. Which of the folowirg is an enidemiologic function of the nurse during an epidemic? ‘A. Conducting assessment of stspected clients in ‘order to detect the communiceble disease B. Montoring the condition of the cases'affected by the communicabie disease C. Partcipating in the investigation to determine the souree ofthe epdemc D. Teaching the commurity on prevertive measures against the dseese Situation: Numerous actions aimed at lowering hazards or thveats to health are included under preventon. 27, Alof the folowingjnursing interventions are cortect when Using the Z-track method of drug injection except 'A. Prepare te injection site wih lcoho B. Use a needle that's a least 1" long Aspiate for blood before injection D. Rub the site vigorously after the injection to promote Absorption 28, The correct method for determining the vastus lateralis site for LM. injection sto: A. Locate the upper aspect of the upper outer ‘qlbdrant of the buttock about 5 to 8 cm below the ac crest B. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the am C Palpate a 1” crcular area anterior to the umbilicus D. Divide the areasbetween the oreater femoral trochanter. andthe leteral femoral condyle into thirds, andysdlect the middle third on the anterior of the thigh PBrThe mid-deltod injection site is seldom used for 1.M injections because it: 'A. Can accommedate only 1 mi oF less of medication B. Bruises too easly ‘C.Gan be used only when tne patientsVing down D. Does not readily parenteral medication 30. The approprate needle sie for insulin injection is: ‘R.18G, 1.1/2" leng B.22G, 1" long €.226, 112" lng D. 256, 5/8" tong 31. The approprate needle gale for intradermal injection i A. 206. 8.226 ©2356 0.266 32, Parenteral peniaitin can be administered as an ‘AIM injection or an IV sclution B.IV or an intradermal injection C.Intredermal or subcutaneous injaction LIM or a subcutaneous injecton 33. The physician erders gr 10 of asprin for @ patient. The equivalent dose in miligrams is A.0.6 mg 8.10 mg C60 mg D. 600mg 2 | Pose34, The physician orders an IV solution of dextrose 5% in water at 100mI/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml? A. 5 gtt/minute 8, 13 gtt/minute © 25 gtty/minute . 50 att/minute Situation: ‘Barangay Santo Tomas Health Center regularly conducts “Operation Timbang” to assess the nutritional status of children. 35, The sex of the children included ln his study will be ‘lassfied as male and feriale, This measurement us: a. Interval ». Ordinal & Ratio 4. Nominal 36, Age belongs to whet level of fheasurement? a. Ratio b. Interval © Ordinal 4. Nominal 37, The nutritional status of chidren is determined by weight and age. Weight is an example of what level of measurement? a. Ordinal ®. Ratio c Interval 4. Nominal 38. The educational level of the parents is also recorded with, the possible choices given as: '» Elementary level ‘» Elementary graduate ‘© High school level The above set of choices is an example of what vel of measurement? 2. Ratio b. Interval Nominal 4. Ordinal 39.Which "of the folowing condtions may require fluid restriction? A. Fever 8, Chronic Obstructive Pulmonary Disease C. Renal Feilure 0. Dehydration 40, All of the following are common signs Bidsymptoms of phlebitis except: |. Pain or discomfort atthe IV insertion site 8. Edema and warmth at the IV insertion ite C. Ared streak exiting the IV insertion site D. Frank bleeding atthe insertion site 41. The test way of determning whether a patient nae léarned ‘o instill ear medication property is for the nurse to: ‘A Ask the patent i he/she has used ear crops before 3. Have the patient repeat the nurses instructions using her own words ©. Demonstrate the procedure to the patiitt'and encourage to ask questions D. Ask the patent to demonstrate the procedure 42.Which of ‘the following types of medications canbe administered via gastrostomy tube? 1A. Any oral medications 8, Capsules whole contents are dissolve inwater C. Ertenc-coated tablets that are thoroughly dissolved i water D. Most tablets designed for oral use, except for extended-duration compounds 43.A patient who develops hives afte receiving an antiiotic is exhibiting drug: '. Tolerance 8. Idosynerasy C. Synerasm 0. Alergy 44, Food forifietion is one of the strategies to prevent micronutient defciency conditions. RA. 8976 mandates fortification of certain food items. Which of the following Is among these focd items? ‘A Sugar B. Bread C. Margarine Diiied. mi 45:The nurse explains to.a patient that 2 cough: ‘A. Is 2 protective’ response to clear the respiratory tract of iritants 8. Is prmarly a voluntary action C115 induced by the administration of an enttussive drug D. Can be inhibited by "spinting” the abdomen {46,An infected patient has his and begins shivering. The best hursiigintevention stor ‘A. Apply iced alcohol sponges B, Provide increased cool iquids ‘C Provide additional bedcothes . Provide increased ventiation sitdatins jou will start working as @ commurity health nurse ina Farflung barangay of Mindoro. ‘47, The pathognomonic sign of measles 1s Koplk’s spot. You roy see Kepi’s spot by nspecting the ‘A. Nasal mucosa B. Buccal mucosa C. Skin on the adornen D. Skin on the antecubital surface 48, Among the following diseases, which is sieborne? ‘A Viral conjunctivitis 8. Acute polomyetis C.Diptthera D. Measles 49;;Among)chikren}a9ed 2 months to 3 years, the most prevalent form of meningitis is caused by which ‘microorganism? ‘A. Hemophils influenzae B. Motilvius C. Steptococcus pneumoniae D. Neisseria meringiides 50. The use of larvivorous fish in malaria control is the baste for which strategy of malaria control? ‘A Stream seeding B,Stream caring Destruction of breeding places D. Zooprophivaxss 51. Mosquito-borne diseases are prevented. mastly with the Use of mosquito control measures. Which of the following is NOT appropriate for malaria conta? ‘A. Use of chemically treated mosquito nets 8. Seeding of breeding places with arva-eating fish (C. Destructon of breeding places of the mosquito vector D. Use of mosquito-@paling soaps, such as those with basil or dtrenella Situation: Student Nurse Mia is going to have her first duty rolation at Sroy.Pule Heelth Center. They are assigned by their lnical instructor to provide health teaching to the mothers who will have their children vaccineted that day. 52. A motherigéked about what vaccines can already be given Loshe® S-Week old son. The correct response of Nurse Mic ‘would be: ‘A*He should already have his first dose of 8CG, Hep , and OPVaccines.” Bo"Given his age, he is only eligible for BCG, Hep B, ‘and pentavalent vaccines.” “He should already have tis first doses of Pentavalent, OP\, and PCV." . "He has not yet reached the minimum age for the ‘other vaccines, only BCG and Hep 8.” ‘52. The nurse i¢ assisting the students on the preparation of the vaccines. As she was observing them them, she will intervene when: ‘A. The student prepared 2 1.5 mL Rotavirus vaccine. B. The student prepared “a 0.05 mL Pentavalent vaccine, C. The student prepared 2 0.5 mL MMR vaccine. D. The student prepared 2 drops of OPV. 3 | Poge54, To strengthen the fight and prevention against infant and child mortality, the government authored an act for mandatory basic immunization services for Filipino children and infants. This is alzo called: A. RA 10152 3. RA 8975 C. RA 10028 5. £051 55. You are preparing to administer an IPV to 2 14 week old Infart. Which of the following is the correct route. for you to A. Intradermal 8, Subcutaneous . Intramuscular D. The infant is too young to receive an IPV. dose 56. For infants, the nurse must Inow that this site is the choice for intramuscular injections: A. Vastus lateralis 8, Deltoid . Ventrogluteal . Rectus femoris Situation: Public health nurses are vital for the maintenance of {006 health and wellbeing in the local community. One of their responsibilities is making sure the people are equipped with knowledge on how to stay healthy. 57. Tatay Pio visited the healthcare center asking about herbal medicine, specifically for lowering cholesterol level. Which herbal plant would you tell him to prepare? |. Tsaang Gutat 8, Sambong Yerba Buena . Bawang 58. ling Mary is complaining about the expenses for the maintenance medications of his Type II diabetic husband. She asked if there are any herbal plants that can help with her problem. You would suggest her to prepare: |. Ulasimang bato 8. Ampalaya . Teaang Guat D. Yerba Buena 59. What are the main indication/s in using Bayabes as a: herbal plant? |. For lowering uric acid 8, For diuresis and antiperspirant CC. For cleansing wounds and mouth infections ©. For lowering LDL 60, Which of the following cofdtions would benefit mast from AAkapulko? A. Diarrhea 8, Toothache C. Athlete's Foot D. Tension headache 61. A friend esked you whether there is herbal medicine for pain. Which response would be correct? |. “You can prepare Yerba Buena, its very RebTubror. pain reliet.” 8. “Tsaang Gubat is What we recommend for pain relief” "You should try Niyug-niyugan)Vitshas great ‘analgesic properties.” . "Im sorry, but there's no herbal medicine that can help relieve pein.” Situation: Public Health Nurse Karen is preparing for a talk with the barangay officials to discuss the increasing ‘number of residents with communicable diseases, 62. She mentioned that she has assessed a patient with early signs of Leprasy. Which of the following would be corsidered an eary sign/symptom? A Madaresis 8, Sinking of nose bridge ©. Gynecomastia. D. Pain and redness ofthe eves 63, What Is the duration of treatment for Paucitacilary treatment of Leprasy? A.3-4 months 8, 5.8 months C.6-9 months D.9-12 months 64. The drugs included in Paudbacilary Leprosy treatment are: ‘A. Rifampicin & Fthambutol B. Isoniazid & Dapsone C. Ofloxacin & Ethambutol DiDapsone & Rirampicin 165. Which of the following vaccnes can contribute to the protection against Leprosy? ‘A Varicella vaecne B. BCG vaccne CLHIB vaccine . None of the above 66, All mentioned below are affected by Leprosy except: A. Skin B, Pleural space C Testes Mucous membrane 67. Th disease Is a0 called Snat Fever, which has long been sone ofthe important tropical diseases in our coun "A. Schistosomiass B. Malaria CBacilary Dysentery .Filarasis 68, The mode of transmission for Schistosomiasis is: ‘A. Being coughed at by an infected person 8. Having intercourse with an infected person C. Swimming in a contaminated fresh water . Being injacted with a non-sterile needle 69, The drug of choice against Schstosomiasis i: ‘A. Zidorudine 8. Penicilin C. Clotimoxazole D. Prazquantel 70. The nurse is assessing a patient wth Leptospiross. This is rmoinly caused by a: ‘AVirus B. Bacteria C. Funci D. Flatworm 71. The mother of the patient with Leptospiress asked you wity the symptoms have only appeared now when her child has walked through the flood “amost @ month ago” What would be a correct response? 2, “The incubation period can range from 7-19 days, which is why the syrotoms only have appeared now.” b. “only takes less than a week forthe symptoms of Leptospirosis to occu” c."I thnk you meaner’ than a month, since the incubation period of Leptospirosis is 28-36 days.” d.°Ate you sure it has been almost 2 month? The incubation period is just 3 days.” Silat: One of the crucial components of the nursing Profession is the Nursing Ethiés. The ethical issue appears Simulteneously with the tequrement for making moral and truthful decsiofmaking, 72. The purpose of having code of ethics for nurses is: 2. Define the limtation of nursing practice. . To assist the public understand the professional bear thet is anticpated from nurses «. Indicate nursing action recommended for specific medical circumstances d. To outline thesresporsibities and duties of the health professionals, nurses, and patients 73, Ethical dllermas exist because of: ‘2. The choices available do not seem to be indisputable right or wrong Decision making s ime-boundea c. Decision is based on the intellectual capacity of the healtheare provider d. A dients legal rights and the nurse's duty to practice professionalism coexist. 74, If a nurse violates the Code of Ethics, there is @ big possiblity of his/her license being revoked. Who revokes the license? a. PRC b.BON ©. 00H 4. PNA 4 | Pose75, According to Lawrence Kohlberg, a subjective feeling about hat is right or wrong is said to be: 2. Morality ». Religion «. Beliefs 4. Bioethics 76. When patients cannot make decisions for themselves, which ethical principles will the nurse use her basis on? A. justice and beneficence 8, beneficence and nonmaleficence . fidelity and nonmatefcence D. fidelity and justice Situation: IMCI is an integrated approach thet focuses on the health and well-heing of the child. IMCT aims to reduce Preventable mortality, minimize illness and disability, and. promote healthy growth and development. ofichidren under five years of age. 77. Alyssa, a 6-month old infant was brought by her mother to’ the health center because of diarrhea reaching 2 times a day. Her skin goes back slowly after a skin pinch and her eyes are sunken, Using the IMCI guidelines, you will cassify this infant in which category? a. No signs of dehydration . Some dehydration Severe dehydration d. The data is insufficient. 78, Kris manages the diarrhea of her 3 year old child with the use of Gresol She asked you "What wil I do if she vorits this?’ As a nurse you wil tll her to: ‘a. Bring the child to the nearest hospital to be assessed by a pediatrician. ». Let the child eat his/her favorite snack. «. Bring the child to the health center for assessment by the physician. 4. Let the child rest for 10 minutes then continue giving Oresol more slowly. 79, Kiefes, a 4-month old infant was brought by her mather to the health center because of a cough. His respiratory rate is 42/minute. Using the Integrated Management of Child Illness (IMC) guidelines of assessment, his breathing is considered a. Fast ®. Slow Normal 4. Insignificant 80, In Integrated Management of Childheod Diness, the nurse 's aware that the severe condtions generally require urgent referral to a hospital. Which of the following severe conditions DOES NOT always require urgent referral to a hospital? ‘a. Syncope ». Severe dehydration Severe pneumoria 4. Severe febrie disease 81, am brought her 4 year old son to théhealth center because of cough and colds. Following the IMCI assessment {uide, which of the following is e danger sign that would signal you to refer the child to the nearest hospital immediately? ‘2. Inability to drink ®. High grade fever Signs of severe dehydration 4. Cough for more than 30 days Situation: Being active in research as a student, you decided to apply in the research team of the hospital you're applying to, 82, Which of the following communicate the results of the research to the readers, They facilitate the description of the data. A. Hypothesis 8. Research problem . Independent variable . Tables and Graphs 83, Which of the following is not true about a Pure Experimental research? ‘A. There is a control group 8. There fs an experimental group C. Selection of subjects in the control group is, randomized D. The experimental group ie formed in a riterion-based selection 84. You are to perform a study about how nurses perform surgical asepsis during Philipine-Amercan War. A design best for this study is ‘A Historical B, Phenomenological ‘Cicase stuay D. Ethnoareohic 85, The sampling methOd)that.cives equal chance to all «4bjects inthe population to get picked is: ‘A. Random By Accidental Quota D. Case study 86, A nurse researcher wants 1 déternine some of the problems that are experienced by asthmatic cents when using ‘2 nebulizer The investigator Went into 2 respiratory ward ‘where he personally knows several asthmatic clients having problem with their nebulizer The type of sampling dane by the inyestigator is called: ‘A. Probability B. Snowball C. Purposive Dilncidental 87. Nurse Nicole 1s already in her data) gathering part of the study. Which of the following criteria of a good instrument refers to the ablity of the instrument to yiéd the same results Upon its repeated administration? 2 Validty b. Spectfcty €. Senstivity 4. Reliability 88, Hary knows thet he has to protect the rights of human research Subjects: Whicl of the following actions of Harry ‘ensures anonymity? '2. Keeping the identities ofthe subjects confidential b. Obtzin informed consent from the familes of the respondent . Provide equal treatment to all the subjects of the study. . Release findngs only to the participants of the study 89, The leeder of the study knows that certain patients who are in a spetialzed research setting tend to respond psycholagically to the conditions of the study. This referred to as a. Cause and effect b. Hawhorne effect Halo effect 4. Horns effect 90. Nurse Nice Is aware that the Board of Nursing has q.asi-jidicil power. An example of this power is 2 The Board can issue rules and regulations that will ‘govern the practce of nursing b. The Board can investigate violations of the nursing law and code of ethics ‘c. The Board can vist a schoo! applying for a permit in collaboration with CHED, dd. The Board prepares the board examinations Situation: 2s 2 nurse, one of your jobs is to reduce patents risk in harboring infections. ‘91, Which element in the crcular chain of infection can be eliminated by preserving skin Integy? 2 Host b. Resevoir Mode of transmission 4d. Portal of entry 92, Which of the felowng vill probably result in @ break in ster technique for respiratory isoation? 2. Opening the patients window to the ottside envirorment ». Turning on the patent’ room ventilator €. Opening the door ofthe patient’ room leading into the hospital corrdor 4 Faling to Wear gloves when dlsing the door of @ patient 93. Which of the fllowing patients is at a greater risk for contracting leukopenia? 5 | Pogea. A patient with leukopenia 8. A patient receiving broad-spectrum antibiotics A patient complening of headache 4. Anewiy diagnosed dabetic patient 94, Sterile technique is always used whenever: 2 Stic isolation Is required b. Endorsement and transfer of patient Is performed .lvasive procedures are performed 4. Protectve iolation is necessary 95. Which of the folowing consttutes a break..injstéfile technique while preparing asterle field fora dressing change? a. Using sterile forceps, rather than sterile gloves, to nande a stele item. b. Touching the outside wrapper of sterilized materia without sterile gloves. Placing a stelle abject on the edge of the stelle field 4. Refrainng from reactifig over the sterile ela 96. A natural body defense that plays an active rolein preventing infection I 2. Yawning b. Body hair Hiecuping 4. Rapid Eye movement Situation: informed consent is taken to assure thatthe dlent's autonomy is respected. AS 2 nurse, you should know the prindiples and your responsibilty in securing the informed consent. 97. Performing procedure on a dlient in the absence of an informed consent can lead to which of the following charges? a. Fraud D. Battery Harassment 4. Breach of confidentiality 98. Which ofthe following is the essence of informed consent? |. It should have a durable power of attorney 3. It should have coverage from an insurance company . It should respect the client's freedom from coercion D. It should disclose previous diagnosis, prognosis and alternative treatments available for the client 99. The main responsbilty of the nurse when the physidan obtains the informed consent is: A, Explain the procedure, alternatives, prognosis and, diagnosis, 8. Listen to the physician's explanation C. Make sure thet the»dlient fully understood the structions, the consent was given voluntary, the signature is authentic and the clentis competent when receiving the consent, D. Make sure thet the client fully understood thé instructions, the consent was given voluntaly, the signature iS authentic and the client is competent when giving the consent, 1100. Autonomy is said to be the bioethical principle respected. If the nurse made sure. that the clieit received enough information when the physician obtained the consent, asked and verifies if the client understood the pracedure and snforms the physician if the client have some questions with regards to the diagnosis, proceaure, altematives and prognosis) The nurse is playing which role? 'a. Mather surrogate 0. Care provider Gent advocate 4. Collaberator 6 | Pose© NLE* NCLEX * CGENS “AAD METRICS * DI RECALLS EXAI NURSING (CARE OF HEALTHY / AT ANK... = petistRY * EVIIEW ACADEMY NATION 10 ECE IT MOTHER AND CHILD NOV 2023 Philippine Nurse Licensure Examination Review (GENERAL INSTRUCTIONS: 1. This test questionnaire contains 100 test questions 2. Shade only one (1) box for each question on your answer: 3. AVOID ERASURES. (er more Bates shaded will invalid your answer. 4. Detach one (1) ansner sheet from the bottom of your Examince ID/Ansner Sheet Set 5. Write the subject title "NURSING PRACTICE IT” on the box pro 1. What change does a nurse expect In a clent's hematologic system during the second trimester of pregnaiicy? a. An increase in hematocrit . An increase in blood volume c. A decrease in sedimentation rate 4. A decrease in white blood cells 2. Acdliet in the active phase ofthe first stage of labor begins to tremble, becomes very tense curing coreractons, andis quite irritable. She frequently states, "I cannot stand this a minute longer.” What does this behavior indicate to the nurse caring for her? a, There was no preparation for labor. . She should receive an analgesic for pain. c. She is entering the transition phese of labor. 4. Hypertonic uterine contractions are developing 3. A nurse is caring for a primigravida during tabor. What does the nurse observe that indicates births about to take place? |. Bloody discharge from the vacina increases. 8. Perineum begins to bulge with each contraction, . lient becomes iitatle and stops fallowing instructions D.Contractions occur more frequenty, are stonger, and lst longer 4. For what complication should a nurse monitor a client when an oxytocin (Pitocin) infusions used to induce labor? a. Intense pain b. Uterine tetany Hypoglycemia 4. Umbilical cord prolapse 5. During the postpartum period it is expected for women to have an inceased cardiac output with tachycardia. This knowledge should motvate @ nurse who is earing foF client with cardiac problems to monitor fr: a. an irregular pulse. b._ respiratory distress. ‘&bypovolemic shock 4. an increase in vaginal beeding. 6. A nurse anticipates that newboms of mothers who have diabetes often have tremors, periods of apnes, cyanosis, and: poor sucking abilty. With what complication af these sions assoriated? 2. Hypoalycemia >. Hypercalcemia c. Cental nervous system edema 4. Congenital depression ofthe islets of Langerhans 7. What is the mest important facter for a nurse to consider when selecting nursing measures to help parent-child relationstips during the immediate postpartum period? a. Physical status of the infant . Duration and eificuty of the labor c. Anesthesia during the labor process 4. Health and errotional status during the pregnancy 8. ATfothe is concerned that her newoom may Be exposed to cable dSeases hen she goes home. When teaching "the mother ways to decreasethe sk of infection, what type of immunity should the nurse explain was transferred to her baby through the placenta? a. Active natural . Passive natural Active artical 4. Passive artical 9. A cient is rooming: with her newborn Anurse observes the infant ying quiety inthe bassinet with eyes opened wide. What action should the nurse take in response to the infant's behavior? 2. Brighten the light in the room. Wrap and then tur the infantto the sie. Encourage the mother to talk to her baby. 4. Begin the physical and behavioral assessments. 10. What is 2 nuse's primary crcal observation when performing an assessment for determining an Apgar score? a. Heart rate 'b. Respiratory rate Presence of meconium Evaluation of Mero reflex 11. A parent and 3-month-od infant are visting the welLbaby clinic fora routine examination: What should the nurse include in the accident prevention teaching plan? A. _Remove small objects from the flocr. Bill Gover electric outlets with safety plugs: Remove toxc stances from low areas. DD. Test the temperate of water before bthino. 2. Ina nosy room a sleeping newborn italy startles and has 29id mvements but soon goes back to sleep. What is themost eee action in response to ths behavior? ‘A. Accept the infant's behavior. . Assess the_lnfant’s vital signs. _C.Test the infant's abilty to hear. 1D. Stimulate the infant's respirations: 13. The nusse fs caring for-a\7-fear-old female on the schoo!- ‘202 Ut. Her mother iS concerned that she may have some developmental delays. Which of the following statements would ‘to the nurse that the child is not developmentaly on for her age: ‘A. The child is able to follow a four-to-ve-step command, B. The child started weiting the bed on this admission to the hospital C. The child has an imaginary friend named Kely. D. The child enjoys playing board games with her sister. 14, The nurse caring for an 8-year-old boy is trying to encourage developmental growth. What activity can the nurse provide for the chid to encourage his sense of industry? 1. Allow the child to choose what time to take his medication.2. Provide the child with the homework his teacher has sentin 3. Allow the child to assist with his bath 4 Allow the child to help with his dressing change, 15. The schoo! nurse is preparing a dscussion on nation with the fourth-grade dass. Based on the chiens’ developmental level, what information should she indude in her presentation? 1. Arreview ofthe numberof calories that a fourth-grade child should consume ina day. 2. review ofa lit ofhigh-calore foods that all fourth- graders shoul avoid. 3. review of how to read fod labels so eildren know which focds are good for them, 4. A review of nutritious foods with basic scent information about how they affect the body orgens and systems. Suation: Nuse Nico is assigned inthe pediatric ward. There, ne encountered pediatic cases and many curious mothers. 16, A Seared boy has been hosptalized fllowing a bicye injury. What should the nurse recommend tothe chid's parents to prevert future injury? 1. Their son should wear safety equipment while riding bicydes. 2. The son should read educational material on bicyele safety 3. Ther son should watch a video on bicycle safety. 4. Their son should ride sbi in the presence of aduts 17, The school nurse has seen several students inthe health office. For wich of the folowing students should the nuse suggest 2 follow-up exam? 2.4 14-year-old gi who has not experienced menarche ».A7-year-old boy who has grown 2 inches in a year -A 10-year-old gil who has gained 11 pounds in a year 4. An &-year-olé boy who has lost four decdvous teeth in the past year 18. A child who has @ BMI of 34 vist the school nurse. Which of the folowing factors does the nurse recognize that the child may be experiencing? 2. Inereased bullying by peers bi Increased sel-esteem ¢. Increased resiliency 4. Increased metivaton to lose weight 19, Which i the fist intervention that should be recommended ‘0 a pregnant worian complaining of hemohaid pain? a. Stereid-based creams Diet modfications c. Surgery 4. Oral medications 20. A pregrant clert presents with vaginal bleeding and ‘nereasing cramping, Her exam reveals that the cervical 0s i open. Which term shoud the nurse expec to see inthe client’ chart notation to most accurately deseribe the dient’ condition? a. Ectopic pregnancy . Complete abortion c. Imminent abortion 4. Incomplete abortion 21. A nurse is cating for @ pregnant woman who states she smokes two packs per day (PPD) of cigarettes. She states che has smoked in other pregnancies and has never had eny problems What isthe nurse's best response? 2. "Tam glad to hear your other pregnancies went well Smoling can cause a variety of problems in pregnancies and it would be best if you could quit smoking with this pregrancy." *Yourneed to stop smoking forthe baby's sake.” cc. “Smoking can lead to having a large baby which can make it difficult for delivery. You may even need 2 cesarean section.” 1d. “Smoking less would eliminate the risk for your baby.’ 22. A flitseic caring for a clant who has been in the second stage of labor forithe\last 12 hours. The nurse should monitor for which cardiovascular chafige that occurs during labor? 2. An increase in maternal heart rate IBA decrease in cardiac output Anincf8ase in peripheral vascular resistance d. A decrease in the uterine artery blood flew during contractions BByPA,nurse is assisting in the delivery of a)term newborn, Immediately after delivery of the placenta, the nurse palpates the uterine fundus and finds that itis frm end located halfway between the client's umbilicus’ and. symphysis pubis. Which faction should the nurse take based on the assessment findngs? a. Tifimediately begin to massage the uterus b, Document the findings ¢._Assess for bladder distension d. Monitor theclient closely for incfeased vaginal bleeding 24, While assisting with the vaginal delivery of 2 fulterm newborn, a nurse observes that, in spite of the fact that the cent did not have an episiotomy or a perineal laceration, her pperineum and labia are edematous. To promote comfort ané decrease the edema, which intervention is most appropriate? ‘a. Applying an ice pack to the perineum b. Teaching the client to relax her buttocks before siting ina chair Applying a warm pack d. Providing the client with a plastic donut cushion to be used when sitting 25. Apostpartum dent, who is 24 hours post-vaginal birth ané breastfeeding, acke a nurse when she can begin exercising to regain her prepregnancy body shape. Which response by the ‘hurse is correct? ‘@._ “Simple abdominal and pelvic exercises can begin right now.” b. "You. will need to wait until after your 6-week postpartum checkup.” “Once your lochiasiHaS stopped you can begin exercising." 06H should not exercise while you are breastfeeding.” 26. A primiparous clent, who is bottle feeding her infant, asks a nurse when she can expect tostart having her menstrual cycle ‘again, Which responce by the nurse is most accurate? ‘2._Mastwomen who bottle feed their infants can expect their periods to return within 6 to 10 weeks after birth.” b. "Your period should return few days after your lochia! discharge stops." c. "Youelllintice a change in your vaginal discharge from pink to white; once that happens your period should retum within a weeks" d. Bottle feeding. will delay the return of a normal menstrual eyele until 6 months post birth.” 27. Whillé Working ina perinatal clinic, e nurse receives a phone {al from a dient who is 20 days postpartum. The dient tells the fnurse she has been having heavy, bright red bleeding since Jeaving the hospital 18 days ago. She is concerned and wonders What se should do. Which instruction to the client is correct? ‘2. Come to the cline immediately b. Decrease physical activity until the bleeding stops c. Stop being concerned because this is expected after beth . Call again next week if the bleeding hes not stopped by then 28. The husbond of ¢ postpartum client, who has been diagnosed with postpartum depression (PPD), is concerned and 2 | Poeasks a nurse what kind of treatment his wife will equi. The nurse's response should be based on the knowledge that the collaborative plan of care for PPD indudes which of the following? a. Antidepressant medications and psychotherapy . Psychotherapy alone ¢. Removal of the infant fromthe home 4. Hypnotic agents and psychotherapy 29, The father ofa 12-hour-old newborn calls a nurse his, wife's hospital room. Heis agitated and reportsto the nurse that. his babys hands and feet are blue. The nurse confirms acrocyanosis and intervenes by: a. immediately stimulating the infart to cry. . explaining to the father that this s an expected finding ina newton. c_ assessing the newborn's tempereture 1d. assessing the newborn's cardiac status. 30. While assessing a full-term newborn, 2 nurse ndtés molding 1 the infant's head. Considering this assessment finding, which information should the nurse expect to seeon the mother's labor and delivery documentation? a. Vaginal breech birth . Planned easarean section, no labor ¢. 16-hour labor 4. Precipitous delivery after a 30-minute labor 31, The nurse evaluates that a mother understands information provided about her newborn's mila when the mother says: a. “Iwill put lotion on my infant’s nose twice a day.” >. “I understand these rasad white spots wil dear up without treatment.” ¢. “Trealize the baby will need surgery to remove these skin lesions.” “Lwil apply alcohol twice a day to the lesions until they disappear.” 32. While caring fer a 30-year-old, single Femsle who delivered a term newborn, a nurse determines that the best way to assess, the impact of the newborn on the client's ifestyle would be to: 2. observe how the client interacts with her hospital visitors . review the client's prenatal record. c. ask the dient what plans she has made for newborn care at home. observe the relationship betWeéen the client and her newborn’ father. 33, While caring fora small for gestational age newborn (SGA), a nurse notes slight tremors of the extremities, a high-pitched cry, and an exaggerated Moro reflex. In response to these assessment findings, what should be the nurse's first action? a, Assess the infant's blood sugar level . Document the findings in the infent’s medial record ¢. Immediately inform the health-care provider of the symptoms 4. Assess the infant's temperature. 34, A nurse is planning the care of a 2-hour-old infant at 38 weeks gestation whose mother has type 1 diabetes meltus. The nurse wrtes the following NANDA diagnosis: "Altered Nutrition: less than body requirements” and appropriately adds» which “related to” staterrent? 3. Decreased amounts of rad blood cells secondary to low erythropoietin levels >. Decreased amounts of total body fat secondary to decreased growth hormone c. Increased glucose metabolism secondary to hyperinsulinemia Increased amounts of body water 35, When assessing an infant undergoing phototherapy for hyperbilrubinemia, a nurse notes maculopapular rash over the infart’s buttocks and back In response to this assessment finding, what action should the rurse take next? 2. Document the resultsin the newborn's medical record. b. Call the health-care provider immediately to report thi finding c._ Discontinue the phototherapy immediately. 4.) Assess the infant's temperature Situation: Asa nurse itis very important to be knowledgeable ‘ict only on what are the ndral signs, but ako on the abnormal signs. A meticulous eye and quick decision making skills makes the diference especial in handling dificult cases. 36. IF nurse iStoncerned that a newborn may have congenital hydrocephalus, which assassment finding is noted? ‘2. Bulging anterior fontanel bins Head crcumference equal to the chést circumference €.Anatrowed posterior fontanel 4d. Low-set ears 37. While caring for a client With Severe preeclampsie who has been raceving intravenous magnesium sulfate for 26 hours, 2 nurse evalates that the medication is effective when noting: 2. anincreasein blood pressure. 'b.anincrease in urine eutput. ca decrease in pltelet count, 4. anincrease in hematocrit 38. L. After teaching 2 greup of parents of preschoolers attending a wel-chid dinic about oral hygiene and tooth brushing, the nurse determines that the teaching has been successful when the parents state that chidren can begin to brush their teeth without help at which ofthe folowing ages? a. 3 years b. 5 years. 7 years d. 9 years 39, After having blood sample drawn, a 5-year old child insists that the site be covered with a bardage. When the parent tries to remove the bandage before leaving the office, the chilé screanrs that al the blood will come out. The nurse encourages the parent to leave the bandage in place and tells the parent that the chid: ‘a. Fears another procedure. b. Does not understand body integrity. cc. Isexpressing pain. 4. Isaattempting to regain control 40. The mother of a 4-year-old'@xpresses concern that her child ‘may be hyperactivesShe describes the child 2s alvays in mation, constantly éFopping and spilling things. Which of the following ations would be appropriate at this time? @. Determine whether there have been any changes at home. b._Bplaif that thisis not unusua behavior. 1G Bnolore the possbilty that the child is being abused, d. Suggest that the child be seen by a pedatric eurolagist.. 1. A nurse isvasséssing the growth and development of a 10- year-old. What isthe expected behavior ofthis child? ‘2. Enjoys physical demonstrations of affection. ,_Isselfish and insensitive to the welfare of others. ‘c. Is uncooperative in play and school. 10 minutes. Which of the following assessments should be avoided? 2. Maternal vital sign ». Fetal heart rate Contraction monitoring 4. Cervical dletion 77. A pregnant client inthe Fst wimester cals the nurse at a health care dinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the clent? a. "Come to the dinic immediately.” b. “The vaginal discharge may be bothersome, but is a normal occurrence.” Report to the emergency department at the maternity center immediately.” 4d. “Use tampons if the dscharge is bothersome, but be sure to change the tampons every 2 hours.” 78. During labor a client who has been receiving epidural anesthesia has a sudden episode of severe nausea, and her skin becomes pale and clammy. What is the nurse's immediate reaction? 2. Turn the lient on her side. ®. Notify the health care provider. c. Check the vaginal area for bieeding 4. Monitor the fetal heart rate every three minutes. 79, A nurse observes a laboring clent’s amniotic fluid af decides that it is the expected. color. What descrigtion of amniotic fluid supports this conclusion? a. Clear, dark amber, and contains shreds Of mucus 8. Straw-colored, clear, and contains ite white specks c._ Milly, greenish yellow, and contains shreds of mucus 4. Greenish yellow, cloudy, ‘and. contains litle white specks 80. A nurse ic assigned to an adolescent who gave birth 12 hours ago. She cortinualy talks cn the phone to her friends and does not respond when her new baby cres. What is the best immediate intervention? a. Calling social service fora consult . Calling the psychiatric team for an intervention Calling her mother and having her speak with the client 4. Modeling appropriate behavors that encourage Infant bonding 81, What isthe best nursing intervention to minimize perineal edema after an epsiotomy? a. Applying ie packs . Offering warm sitz baths c. Administering aspirin pm 4. Elevating the hips on a pillow 32. A nurse teaches a postpartum client how to care for her episiotomy to prevent infection. Which behavior indicates that the teaching was effective? ‘2. The perineal pad is changed twice daily. bilShe washes her hands whenever a perineal pad ie changed. ‘G She rinses her pefineum with weter after using an analgesic spray. {dieThe perineum is cleansed from the afus toward the symphysis pubis 33. A dlient in labor begine to experience contractions 2 to 3 minutes apart that last about 45 seconds, Between contractions thelnurse identifies 2 fetal heart rate of 90 beats/min on the Jnternal fetal monitor. What is the next nursing action? Notify the health care provider. ‘Resume continuous fetal heart moritoring, Continue to moritor the maternal vital signe. ‘Décument the fetal heart rate as an expected response to contractions. 24, A nurse examines a client who had a cesarean bith, It is 3 days since the birth and the dient is about to be discharged, Where does the nurse expect the fundus to be located? ‘2.1 fingerbreadth below the umbilicus b. 2 fingerbreedths below the umbilicus . 3 fingerbreedths below the umbilicus 4. 4 fingerbreadths below the urbilicus 35. Aclient on the postpartum unit asks the nurse why the fhurses are always encouraging her to walk. What should the ‘nurse consider when forming a responce in language the client will understand? ‘a. _Respirations are enhanced b. Bladder tonicity increased. Abdominal musces are strengthened, d. Peripheral vasomotor activity is promoted. Situation 5: Despite numerous eheath teachings, High-risk pregnancies are inevitable. Different cases of high-risk ‘pregnancies always keep the Labor and Delivery Unit of JTA Hospital. 36. A client is receiving magresium suifate therapy for severe preeclampsia. What intial sign of toxicity should alertthe nurse tointervene? ‘a. Hyperactive sensoriu b. Increase imespratory rate ‘c._ Lack of the knee-jerk reflex 1d. Development of a cardiac dysrhythinia 37, Adientat 9 weeks’ gestation asks the nursein the prenatal nie #f she can have her chorionic vill sampling (CVS) done at this visit. AtjWhiat week gestation should the nurse respond is the best time for this test? 8. Siweeks and less than 10 weeks b. 10 weeks and.lessithan 12 weeks . 12 week and less than 14 weeks d. 14 weeks and less than 16 weeks 38. A nurse is assessing a client with’a tentative diagnosis of hhydatidform mole. Whichedinical finding should the nurse anticipate? ‘ae Hypotension b. Decreased fetal heart rate Unusual uterine enlargement 1d. Painless, heavy vagiral bleeding '39, Sonography of a primigravida who s at 15 weeks’ gestation reveals a twin pregnancy. The nurse reviews with the client the risks of a rrultiple pregnancy that were explained by the health care provider. Which condition does the client identify that Indicates the need for further inetruction about complications associated with a multiple gestation? ‘a. Preterm birth b. Down syndrome c. Twin to twin transfusion apc 6 | Poe4. Gestational hypertension 40. A nurse is reviewing the obstetric history of a client who had an abruptio placentae. What prenatal condition does the nurse expect the cient to have had? a. Cardiac disease b. Hyperthyroidism . Gestational hypertension 4. Cephalopelvie disproportion 41. A dlient arrives at the hospital at 38 weeks’ gestation with profuse vaginal bleeding, She states that it occUrred suddenly without any contractions. Which condition may the cfent be experiencing that requires immediate notification of the health care provider? a. Placenta previa b. Placenta accreta c. Ruptured uterus 4d. Concealed abruptio 42. When is it most important for a female client: to know that. a fetus may be structurally damaged by the ingestion of drugs? a. During early adolescence . Throughout the entire pregnancy c. When planning to become pregnant 4. At the beginning of the first trimester 43. A client at 10 weeks’ gestation calls the clinic and tells a nurse that she has morning sickness end cannot cortrol it. What should the nurse suggest to promote rele”? a. “Eat dry crackers before arisng.” b. “Increase fat intake before bedtime.” c. "Drink high-carbohydrate fude with meal” 4. “Have two small meals a day with a snack at noon.” 44. A client tells a nurse in the prenatal clinic that she has vaginal staining but no pain. Her histery reveals amenonthea for the last 2 months and pregnancy confirmation after her first ‘missed period. She is admitted to the high-risk unit because she may be having a spontanecus abortion. What type of abortion 's suspected? a. Missed >. Inevitable c. Threatened 4. Incomplete 45. A nurse assessing 2 pregnant cient during the third trimester. What clinical findings an expected response to the pregnancy? a. Tachycardia b. Dyspnea at rest c. Progressive dependént edema 4. Shortness of breath on exertion Situation 6: Part of the responsibilities of an OB)Ward. Nurse is to give proper health teachings to the mother and her significant, other on how to take care of ther newborn. 46. During a client's first visit to the prenatal clinic, @ nurse discusses a pregnancy diet. The client states that her mother told her she should restrict her salt intake. What isthe nurse's best response? a. "Your mether is corrétti'You, stould use less salt to prevent swing “Because you need salt to maintain’ Body water balance, tis not restricted. Just eat a well-balanced dict.” Salt is an essential nutrient that is raturaly reduced by the body's estrogen. There is no reason to restrict salt in your det.” 4. "We no longer recommend that salt intake be as restricted as much as in the past However, you shouldn't add sat to your food.” 47. & pregnant client uses a computer continuously during her working hours. This has implications for her plan of care during pregnaney. What should a nurse recommend? a. “Try to wek sound every few hours during the workday.” b. “Ask for time in the morning and afternoon to elevate your legs.” @NprTat_your boss that you cannot work beyond the second trimester.” ‘6. “Ask for time in|the»morning and afternoon to get something to eat.” 48)/Aipreanant clients being prepered for a peWic examination. She states that She'salnays tred end fees sick to her stomach, especially In the morning. What isthe nurse's best response? 2, “Tall me about how you feéithe ret ofthe cay.” DbepLet’s discuss ways to resolve these common problems.” “Perhaps éll/shoulé ask your health care provider about it” 4._ “There is 90. need to worry about these expacted problems.” 49, What is the bést\advice a nurse can give to a pregnant woman in her Fist tenester? 2. “Cut down on drugs, alcoho, sid cgarettes.” b. “Avoid drugs, and refrain from smoking and ingesting alcohol” ._“Avold'smoking, limit alechol consumption, end do not take aspirin” 4. “Take only prescription drugs, especially in the second and third trimesters.” 50. What information concerning the ctildbearing process should the nurse teach a client during the first trimestar of pregnancy? 2. Labor and birth b. Signs and symptoms of complications Role trenstion into parenthood and its acceptance . ‘Physical and emotional changes resulting from pregnancy Station: There is a rotation in the hospital for trainee nurses where Nurse Betty Is working, Nurse Betty is assigred in the labor and delivery unit. The amniotic fluid of a client has a greenish tint) The nurse Interprets this to be the result of which ofthe folowing? a. Lanugo bb. Hydramrio Meconiur d.Vernix 52 client has delivered althild at 23 weeks gestation, The nurse would cxpect the newborn to exhibit which of the findings?, am Bones are fully developed b. Eyes are developed end open €._Lanugo is beginning to disappear d. —_Lungsiafelcompletely mature. 553. A dient in labor at 38 weeks gestation was admitted to the labor and delivery unit. Asithe dient was walking around the hallway, sho toldithé nurse that her water broke. Which of the folowing Should the nurse do first? @ Check the color of the armiotic fluid. b. Escort the clientto the labor room and assess FHR. [_Heve the clent le on the bed and check vital signs. d. Escort the client to the labor room and notify the physician, 54, A nurse is teaching a postpartum cfent about cord cate for the newborn, Which statement by the clent indicates a need for further teaching? a. “Twill secure the diaper over the cord to protect it.” b. “Ican expect the cord to turn black in afew days.” “Twill give my newborn sponge baths until the cord falls off.” 7 | Poed, “T-shouldlet the cord fail by itself.” 55, The nurse should make which statement toa pregnant client found to have gynecoid pehis? a. “Your type of pelvis has a narrow putic arch.” b. "Your type of pelvis is the most favorable for labor and birth.” c. “Your type of pelvis is @'wide pebis, but ithas a short diameter.” 4. “Youwill need a cesarean section because this'tVpe of pelvis is not favorable for a vaginal delivery." Situation 2: Nurse Augustine is handling patients who are high- risk during their pregnancy. 56. The nurse is assisting with a vaginal delivery of a fulltefn infart. Which assassment finding of the newborn is most Important for the nurse to follow-up? a. Flat bluish discolored area on the buttocks b. Localized soft tissue edema of the scalp c ‘Small amount whitsh substence in axilla d. __Tuftof hair at the base of the spine 57. A nurse ie carng for a client who ie about to undergo an emergency cesarean birth for severe preeclampsia at 26.3 weeks gestation. The dient is admitted after 3 days of a severe headache and a 10-pound weight gain. Her blood pressure is 180/110 mm Hg, and she has a moderate abruption. The woman states, “It's my fault! IF [would have called earlier, they could have stopped it and I wouldn't be having my baby delivered now” What is the nurse's best response? a. “This is not your fault. You are here now, and we are going to take care of you.” b. “Earlier intervention might have deemed a better outcome, but you can't think of that now.” « “Your baby is going to be fine.” 4. “Your health and well-being are what is important, you ‘ees to think of yourseff and not the baby right now. 58. A pregnant client ie seen for a regular prenatal vsit and talls the nurse that she is experiencing lrreguar contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action 's appropriate? a. Contact the primary health care provider. b. —Inetruct the client to maintain bed rest for the remainder of the pregnancy, c Inform the client that these cofitractions are common, and may occur throughout the pregnancy. d. Call the maternity unit and inform them that the client: will be acmitted in a preterm labor condition 59, The nurse's performing a postpartum assesment 12 hours after the prolonged vaginal delvery of a term/infant, Which assessment findings should be reported to the health care provider? 2. Complaints of discomfort during fundal palpation b Foul-smeling lochia e Oral temperature of 37.7 € d. White ood cell of 20,000/mm3 60, When assessing a dientat 12 weeks of gestation, the nurse recommends that she and her husband concider attending childbirth preparation classes. When is the best timefor. the couple to attend these classes? A. AtAG weeks of gestation B, At20 weeks of gestation C. At24 weeks of gestation D. At 30 weeks of gestation 61. In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant's fontanels to dose. Which statement is accurate regarding the timing of closure of an infant's fontanels that should be included in this teaching plan? |A. The anterior fontane! doses at 2 to 4 months and the Posterior fontanel by the end of the first week. 8. The anterior fortanel closes at 5 to 7 months and the posterior fontanel by the and of the second week. . The anterior fontanel doses at 8 to 11 months and the Posterior fontanel by the end ofthe first month. D. Thel@ateror fortanel closes at 12 to 18 months and the posterior fontandl by the end ofthe second mont. 62. When preparing 2 daS5ion.newtorn care for expectant patents, wich ie correct forthe nurse to teach concerning the rnewom infant born at term gestation? ‘A Mile arered lars made by forceps and wil disappear within 710 10 days. B. Meconium isthe frst stool and if Usually yelow gold in coor. CiVernixis a white cheesy substance, predominantly located in the skin folds. 1. Pseudostrabismis found.in newboms is treated by minor suger. 63. Arurse racevesa shit change report for a newbern whois 12hous pest-vegina delvery. In developing a plan of care, the nurse should gine the highest priorty to which finding? 1. Cyanosis ofthe hands and fect 8. Skin color that ight jaundiced .Tiny white papules onthe nase oF chin . Red patches on the cheeks and trunk 64, A new mother who has just had her first Baby says to the nurse, “I saw the baby in the recovery room. She sure has ¢ funny-Looking head." Which response by the nurse is best? A “This isnot an urusuelly shaped head, especialy for 2 fist baby.” 8. "Te may look od, but newborn babies are often born with heads tke that." "Thetis normal. The head will turnto around shape within 70 10 days" D. "Your pais was too small, so the head tad to adjust t the bith canal.” 65, An expectant father tlle the nurse he fears that Hs wife "ie losing her mind." He states that she is constant rubbing her abdomen and talking to the baby and that she actualy talks to tho baby as if t can understand her. Which recommendation should the nurse make to this expectant father? A. Suggest thet his wife seek professional counsel to dea with her symptoms. 8. Expian that his wife isvediiting ambvalence about the pregnancy. C. Ack hint reper similar abnormal betaviers at the next prenatal vist. D. Resssure Hm that_normallfaternaltetal bonding is occurring. Situation 32INUBS Tyler isa newiy-hired nurse. He has always beem very interested in taking care of newborn babies. 66, Pror to discharging’@l/24-hour-old newborn, the nurse ‘assesses her.respiratory status. Which of the following woulé the nurse expect to assess? 1A) Respiratory rate 45, irregular B) Costa breathing pattem ©) Nasal axing, rate 65 ) Cracklés on auscultation (67, When explaining how a newbom adapts to extrauterine life, the nurse would descibe which body systems as undergoing the smost rapid changes? ‘A) Gastrointestinal and hepatic 8) Urinary and hematologic © Respiratory and cardiovascular D) Neurological and integumentary 668. Which anticipatory guidance action by the nurse makes the role transition to parenthood easier? a. Helps the new parents identify resources b. Recommends employing babysitters frequently «. Tells the parents about the realities of parenthood 8 | Poe4. Offers a home phone number and tells parents to calli they havea question 69, Twerty minutes after birth, @ baby begins to mave tis head from side to side, making eye contact with the mother, and! pushes Ne tongue out several times. The nurse interprets this as: |) Agood time to initiate breastfeeding 3) The period of decreased responsiveness preceding slop ©) The need tobe alert for gagaing and vomiting ©) Eviderce that the newber is beccming chilled 70. A naw mother is changing the diaper of her 20-hour-old newborn and asks why the stool is almost black. Which response. by the nurse would be most appropriate? A) "must be something you ate during your pregiianc.” 8) "This is meconium stool, normal for a newborn.” ©) "Ti take a sample and check it for possible bleeding.” ) "This is unusual and I nead te report this." 71, Which ofthe folowing would alert the rurse tothe possibity of respiratory distress in @ newborn? A) Symmetrical chest movements 8) Periode breathing ©) Respirations of 40 breaths/minute ) Steralrtractions 72. When counseling a mother about the immunologic properties of breast mil, the nurse would emphasize breast mk 35 a majer source of which immunoglobulin? A) oa 8) IgG OM 0) lee 73, k postpartum adolescert mather conf des to the nurse that she hopes her baby wil be good and sleep through the night What should the nurse plan to teach the cient to do? a. Talk softly and cudile her baby when crying occurs b. Keep her baby awake for longer periods during the day c Ensure sleep by adding cereal to her baby's bedtime bottle 4 Put a coft and brightly colored toy next to her baby at bedtime 74, A pregnant client is making her first Antepartum visi. She has a two year old gon born at 40 weeks, a 5 year old daughter born at 38 weeks, and 7 year old twin daughters born at 35 weeks. She had 2 spontaneous abortion 3 years ago at 10 weeks. Using the GTPAL format, the nurse should identify that the clients: A) G4 73 P2.ALL4 8) G5T2P2At La ©) G5 T2PLALL4 D) G4 TPA ALLA 75, The client tells the nurse that her lost menstrual period started on May 8 and ended on Nay 13: Using Nagel's rule, the nurse determines her EDD to be which of the following? a. February 20 b. February 1 January 20 , February 15 Situation: Nurse Tim and the rest of the labor and delivery Unit \s preparing forthe day's work. Asurge of pregnant women have arrived at the very first hour oftheir shift. 76. A multigravida at 37 weeks’ gestation arrives at the emergency room with painless, bright red bleeding and mild contractions every 7 to 10 minutes. Which of the following assessments should be avoided? 2. Materral vital sign . Fetal heart rate c. Contraction moritoring 4, Cervical dilation 72. A pregnant client in the frst tiimester calls the nurse at 2 health care clinic and reports that she has noticed a thin, oiorless vaginal drainage. The nurse should make which Statement to the client? "Came to the clinic immediately.” “The vaginaldischarge may be bothersome, but is 2 ‘normal occurrence.” <.__ "Report to the emergency department at the maternity coiteFimmediataly.” d. “Use tetmpons if the discharge Is bothersome, bit be ‘tre to change the tampons every 2 hours.” 78. During labor a client who faS!been receiving epidural jamiéSthesia has 2 sudden episode of severe nausea, and her skin becomes pale and clammy. What is the nurse's immediate reaction? a ‘Turn the client on her side, bo _ Notify the health care provider. € _Gfckthe vaginal area for bleeding. d.___Monitor the fetal heart rate every three minutes. 79. A nurse observes a laboring client's amniotic fluid ane decides that Tt is the expected color, What description of ‘amniotic fluid supports this conclusion? 2. lear, dark amber, and contains shreds of mucus b. —_Straw-colored, car, and contains Ite white specks Milky, creerish yellow, and contains shreds of mucus, . Greenish allow, cloudy, and contains litle white specks 80. A nurse is assigned to an adolescent who gave birth 12 hous 390: She Continually talks on the phone to her fiends ané does not respond when her new baby cries. What is the best immediate intervention? Calling socal service for a coneult b. Calling the psychiatric team for an intervention © Calling her mother and having her speak with the client d. __Medeling appropriate behaviors that encourage infant bonding 81. What is the best nursing intervention to minimize perineal ‘edema after an episiotomy? a. ‘Applying ice packs b. Offering warm sitz baths Administering aspirin pra, d. Elevating the higs ona pillow 82. A nurse teaches’a postpartum client how to care for her episiotomy to prevert infection. Which behavior indicates that the teaching was effective? a. _The perineal pad is changed twice dally. b, She washes her hands whenever a perineal pad is changed, co She rinses her perineum with weter after using an analgesic spray. 4. The perineum is(¢eansed from the anus toward the 'ymphysis pubis 33, =A lent in labor begins to xccrience contactions 2to 3 minutes apart that lat about 45 seconds, Between contractions the nurse identiies a fetalieaft rate of 90 beats/min on the internal fetal monitor. What isthe next nursing action? ._o Notify the health care provider. BI) Resume continuous fetal heart moritoring, € —_Gantinue to moritor the maternal vital signs. Document the fetal heart rate as an expected response to contractions, 84, A nurse examines a cient who had a cesarean bith. It is 3 days since the birth and the dient is about to be discharged, Where does the nurse expect the fundus to be located? a 1 fingerbresdth below the umbilicus b. 2 fingerbreadths below the umbilicus c. 3 fingerbreadths below the umbilicus d. 4 fingerbresdths below the umbilicus 9 | Poe85. A client on the postpartum unit asks the nurse vihy the nurses are alvaye encouraging her to walk. What should the rurse consider when forming a response in language the client will understand? A Respirations are enhanced. b. Bladder tonicity is increased. c Abdominal muscles are strengthened. 4 Peripheral vasomotor activity is promoted. Situation 5: Despite numerous ehealth teachings, highvtisk pregnances are inevitable. Different..cases of High-tsk pregnances always keep the Labor and Delivery Unit of ITA Hospital 86. A client is receiving magnesium sulfate therapy for sevaFe Preeclampsia. What intial sign of toxicity should’alert the nurse to intervene? a. Hyperactive sensorium b. Increase in respiratory rate c Lack ofthe knee-jerk reflex a Development of a cardiac dysrhy—fintia 87, A dient at 9 weeks’ gestation asks the nurse in the prenetal clinic if she can have her chorionic vii sampling (CVS) done at thie visit. At what week gestation should the nurse respond is the best time for this test? a. B weeks and less than 10 weeks b. 10 weeks and less than 12 weeks c 12 weeks and less than 14 weeks a 14 weeks and less than 16 weeks 88. A nurse ie assessing a client with a tentative diagnosis of hydatidiform mole. Which clinical finding should the nurse anticipate? a Hypotension . Decreased fetal heart rate c Unusual uterine enlargement 4 Painless, heavy vaginal bleoding 89, Sonography of a primigravida who is at 15 weeks’ gestation reveals a twin pregnancy. The nurse reviews with the dent the ricks of a multiple pregnancy that were explained by the health care provider. Which condition does the client identfy that indicates the need for further instruction about complications associated with a multiple gestation? a. Preterm birth b Down syndrome e Twin to twin tranefusion . Gestational hypertension 90. A nurse is reviewing the obstetric history of a client who had an abruptio placentae. What prenatal condition does the nurse expect the cient to have had? a. Cardiac disease b. Hyperthyroidism c Gestational hypertension dd. Cephalopelvic disproportion 91, A dliont arrives at the hospital at 38 weeks’ gestation with profuse vaginal bleeding: She states that it occurred suddenly’ without any contractions. Which condition may the clent be experiencing that requires immediate notification of the health care provider? a. Placenta previa b. Placenta accreta c Ruptured uterus d. Concealed abruptio 92. When is it most important for a female clint to know that a fetus may be structurally damaged by the ingestion of drugs? a. During early adolescence b. Throughout the entire pregrancy c When planning to become pregnant d. tthe beginning of the first trimester 93. A dient at 10 weeks’ gestation calls the clinic and tells 2 ‘nurse that che has morning sickness and cannot contvalit. What should the nurse suggest to promote relief? Bip “Eat dry crackers before arising.” b. MIncreave fat intake before bedtime.” & “Drink high-carbohydrate fluids with meals.” d. "Have two small meals a day with a snack at noon,’ 04. A client tells @ nurse in the prefatal clinic that she has Yaginalstalning but no pain, Her history reveals emenorthea for the last 2 mortisjand pregnancy confirmation after her first ‘missed period. She ie admitted to the high-risk urit because she may be having a spontaneous abortion, What type of abortion Is Suspected? a Missed b. Inevitable c. ‘Tiweatened ie Incomplete 95. A AUFSSIis.assessing a pregnant dlient during the thiré trimester. What clinical finding is an expected response to the pregnancy? a. Tachycardia b. Dyspnea at rest Progressive dependent edsma d. Shortness of breath on exertion Situation 6: Part of the responsibilties of an OB Ward Nurse is to give proper health teachings to the mother and her significant Cother on how to take care of their newborn. 96. During @ lent first visit to the prenatal clinic, a nurse discusses a pregnancy diet. The cient states that her mother told her she should restrict her salt intake. What is the nurse's best response? “Your mother is correct. You should use less salt to prevent swelling, b. *Bacause you need salt to mantain body water balance, itis not restricted. Just eat a well-balanced ciet.”" “Salt isan essential nutrient that is naturally reduced by the body's estrogen. There is no reason to restrict salt in your diet.” d. “Welno longer recommend that salt-intake be as restricted as much as in the past. However, you shouldn't adé salt to your food.” 97. A pregnant dlent{USes a computer continuously during her ‘working hours. This has implications for her plan of care during pprégnancy. What should a nurse recommend? @ “Try to wek ound every few hours during the workday.’ . “Ask time in the morning and afternoon to elevate your legs.” “Tall your boss that you cannot work beyond the second trirrester.” ‘d.—“Askeforitime in the morning and afternoon to’ get something to eat.” '98, A pregnant client is being prepared for a pelvic examination, She states that she is always'tied end feels sick to herstomach, ‘especially in the morning. What is the nurse's best response? 2._eg@*Tall me about how you feel the rest of the day.” Bl) “Let's discuss ways to resolve these common probleme. c about it.” d. “There is no need to worry about these expected problems.” 99, What is the best advice a nurse can give to a pregnant woman in her fist trimester? Perhaps you should ask your health care provider a. “Cut down on drugs, alcohol, and cigarettes.” b. “Avoid drugs, ard refrain from smoking and ingesting alcohol.” 20 | Pagec “Avoid smoking, limit alcohol corsumption, and do not take aspirin.” d. “Take only prescription drugs, especialy in the second and third trimesters.” 100. What information concerning the childbearing process should the nurse teach a client during the first trimester of Pregnancy? 2. Labor and birth b. Signs and symptoms of complications c. Role transtion into parenthood and its Beceptance 4. Physical and emotional changes resulting from Pregnancy 11 | PageTOPS * NLE* NCLEX * CGFNS * HAD * PROMETRICS * DHA *! RECALLS EXA\ NURSING P| CARE OF CLIENTS WITH PHYSIOLOGIC NOV 2023 Philippine Nurse. GENERAL INSTRUCTIONS: 1. This test questicnnaie contains 100 test questions 2. Shade only one (1) box for each question on your answer s 3. AVOID ERASURES. 4. Detach one (1) answer sheet from the bottom of your Examines ec tile “NURSING PRACTICE I" on the box provide 5..Wite the subj Situation: Nurse James is assigned in the medical-surgical ward. He is dealing with a clent who has Diverticults. 1. The dient diagnosed with diverticulitis is complaining of severe pain in the left lower quadrant and has an oral temperature of 100.6 F Which intervention should the nurse implement first? |A. Notify the health-care provider 8, Document the findings in the chart: . Acminister an oral artipyretic, D. Assess the dent's abdomen. 2. The nurse is teaching the client diagnosed with diverticulosis. Which instruction should the nurse Include in the teaching session? |A. Discuss the Importance of crinkiig 1,000 mL of water daily. 8, Irstruct the client to exercise at least three (3) times a week. . Teach the cient about eating a low-residue diet, . Explain the need to have daily bowel movements. 3. The client is admitted to the medical unt with a diagnosis of acute diverticultis. Which healticare provides order should the nurse question? |. Insert a nasogastric tube. 3 Start an IV with DSW at 125 mL/hr . Put the client on a clear liquid diet. D. Place the client on bedrest withibethroom privileges. 4. The nurse Is dscussng the therapeutic det forthe client diagnosed with dvertiuloss. Which meal indicates the client understands the discharge teaching? ‘A Fred fish, mashed potatoes, and iced tea. 8. Ham sandwich, applesauce, and whole milk. C. Chicken salad on whole-wheat bre2d and water. D. Lettuce, tomato, and cucumber salad and coffee. 5. The. client is ‘two (2) hours post colonoscopy. Which assessment data warrant intermediate intervention by. the ree? AA The client has @30ft, nontender abdomen, 8, The dient has a loose, wetery stool. The cent has hyperactive bowel sounds. D. The client's pulse is 104 and BP is 98/60. 6. The nurse is preparing to adminster the initial dose of af aminoglycoside anibiatic to the client agnosed with acute divertcultis, Which intervertion shoud the nurse implement? ‘A Obtain a serum trough level. 8, Ak about crug aleries. . Monito: the peak level D. Assess the vital signs 7, The clent diagnosed with acite dverticults is complaining of severe abdominal pain, On assessment, the nuree finds 2 hard, rigid abdomen and T 102A8F. Which intervention should the nurse implement? A. Notify the health-care provider. 8, Prepare to administer a Fee's enema, ANK WEW ACADEMY RAD TECH * CRIMINOLOGY * DENTISTRY * PHARMACY TION 10 (CE III ‘CHOSOCIAL ALTERATIONS (PART A) amination Review ‘more boxes shaded will invalid your answer. ‘Sheet Sot C- Administer an antipyretic suppostory. . Continue to monitor the client closely. 8. The nurse is working in an outpatient clinic. Which tient is most likely to have a diagnosis of diverticulosis? ‘A.A 60-year-old male with a sedentary ifestyle, B.A 72-year-old female with multiple ctildbirths. CA 63-year-old female with hemorrhoids. D. A 40-year-cld male with a family history of diverticulosis 9. The. cient.with acute diverticulitis has a nasogastric tube ‘draining green liquid bile. Which interventicn should the nurse implement? ‘A. Document the findings as normal B. Access the client’ bowel counds, C. Determine the client's last bowel movement. D. Insest the N/G tube at least two (2) more inches. 10. The nurse is teaching a dass on diverticuloss. Which interventiors should the nurse discuss when tezching ways to prevent an acute exacerbation of diverticulosis? Select all that apply. A.Eot a high-fiber diet. B, Decrease fluid intake. C-Walk 30 minutes a day. D. Take an antadd every two (2) hous. Situation: Nurse Tal is a highly-experianced Med-Surg nurse. Her patient that needssher utmost care at the roment is diagnosed with iver failure, lent has had a liver biopsy. Which postprocedure ‘should the nurse implement “K, Instuct the dient to void immediately. i B. Keepithe client NPO for eight (8) hours. ‘C Place the client on the right side. 'D. Monitor blood urea nitrogen (BUN) and creatinine level. client diagnosed Wwith endstage Iver failure is sdmitted with hepatic encephalopathy. Which _ dietary Should be implemented by the nurse to address this ? ‘A Restict sodium intake to 2 o/day. ~B. Limit oral fluids to 1,500 mL/day. C. Decrease the dail fat intake. 1D. Reduce protein intake to 60 to 80 a/day. lent diagnosed with end-stage renal failure and i is scheduled for 2 paracentesis. Which client teaching the nurse discuss with the dient? ‘A. Explain the procedure will be done in the operating room. B. Instruct the dient a Foley catheter wil have to be inserted C. Tell the client vital signs will be taken frequently after the procedure. D. Provide instructions on holding the breath when the HCP inserts the catheter 1 | Poge14, The client diagnosed with ler falure is experiencing prurtus secondary to severe jaundice. Which action by the Student rurse warrants intervention by the nurse? [A The stidert nurse f assisting the client to take a hot, soapy shower. 8. The ‘Student nurse apples an emolféfit to the dlient’ legs ard back. . The studert nurse puts mittens en both hands of the cient D, The student nurse pats the cient’ skin dry with a dean towel 15, The nurse identfies the client problem “excess fluid volume” for the dient in Iver fallure. Which short-term goal ‘woul be most appropriate fr this problem? [A The cent will not gain more than two (2) kaa Gay. 2, The client will have no increace in abdominal girth. . The cient’ vital signs wil remain within normal nts, D, The dent wil receive a law-sadium det. 16, The lent in. end-stage liver falure has. vitamin. K deficency. Which interventions should the nurse implement? Selec all that apply ‘Av Avoid rectal temperatures. 8. Use only a soft toothbrush. C. Monitor the pateet count. D. Use small-gauge needles E. Assess for asters, 17, Which gastrointestinal assasement data chould the nurse expect to find when assessing the client in end-stage liver falure? A. Hypoalouminemia and muscle wasting. 3 Olgomenarrhea and decreased body hai. C. Cay-ccored stools and hemorhoids. D, Dyspnea and caput medusae. 18, Which assessment question is priority forthe nurse to ak the dient diagnosed with end-stage lve fallure secondary to alcotolic cirrhosis? |A.*How many years have you been clnking aleohol?” 3 “Have you completed an advance directve?" "When did you have your last aleahole dink?” D, "What foods did you eat at your last meal?” 19, The dienthas end-stage live fellure secondary to alcoholic cirhosis. Which complication indicates the clent at risk for developing hepatic encephalopathy? A. Gastrcntestnal bleeding 3 Hypoabbuminemia, C.Splenomegaly. D. Hyperaldosterorism. 20, The client is dlagnased with end-stage Aver favre. The client asks the nurse, “Why is my doctor decreasing the doses of my medications?” Which statement Is the nurse best response? A. ‘You are werried because your doctor has decreased the dosage” 8, “You really should ask your doctoe Tam sure there & a good reason” €. “You may have an overdose of the medications because your Iver s damaged.” D, "The hale of the medications is altered because the lve is damaged. Stuation: Pancreatits Is one of the common dseases encountered in the Med-Surg Ward. Nurses can expect to care ‘or patients with pancreatitis in inpatient settings 21, The dient is admitted to the medical depaitnent with a Giagnosic of rule-out (R/O) acute pancreatic. | Which, laboratory values should the nurse monitor to confirm this diagnosis? ‘A. Creatinine and (BUN). 8, Troponin ard (CK-MB). C. Serum amyiase and lipase D. Serum bilirubin and calcium. 22. Which client problem has priority for the client diagnosed with acute pancreatitis? | Risk for fluid volume deficit. 8, Alteration in comfort. C. Imbalanced nutrition: ess than body requirements. D. Knowledge defict. 23, The nurse & preparing to administer am. mediation to clients. Which medication should the nurse question before administering? ’A. Panereatic enzymes tothe client who hos finshed breakfast. 8, The pain medicaton, morphine, tothe dent who has a respiratory rate of 20. CThe loop dirt to the dient who has a serum potassium level of 3.9 mE. D. The beta blacker to the clent who has an zpcal pilse of68 bpm. 24, The lent is dagnosed with acite pancreas. Which healthcare providers’ admiting order shoud the nurse suestion? ‘A Bedrest with bathroom privieges. B Initite 1V therapy of DSW at 125 mU/he CC. Weigh the lent day. D. Lowfat, low-carbehydrate det 125... The nurse 1S completing discharge teaching to the client tiaGosed with acute pancreatitis. Which instructon should the nurse discs With the cent? ‘Instruct the clent :o decrease alcohal intake Explain the need to avad al stress C.3, Discus the importance of stooping smoking. D. Teach the conect way to take pancreatic enzymes. 26, The male cient diagnosed with chronic pancreatitis calls and reports to the cline nurse he has been having a lt of gas," along with frothy and very foulsmling sted, Which intervention should the nurse implement? ’8. Explain this fs common for droric pencreatitis. 8. Ask the cent to bring in a stol specimen to the clinic (C)Arrangelaniappointment with the HCP for today. D, Discuss the need to decrease fet in the det so this won't happen. 27. The nurse. is discussing complications of chronic Dancreatits with a client dagnosed with the disease. Vhich Complication should the nurse discuss with the clent? A. Diabetes insipidus (DI) B. Crohn's dseace. .Narentic addiction. Di Peroni. 28. The dient is in immediate postprocedure endoscopic retrograde crolaniopancreatogram. (ERCP). Which intervention shoud the nurse implement? ‘A Asses for recal bleeding, B. Increase fd intake C. Assess gag refx 0. Keepin supine poston. 29. The client diagnosed with aaite pancreatitis is in pain. Which poston should the nurse asist the dient to assume to help decrease the pain? 'A. Recommend lying in the prone postion with leas extended. B.Maintain a tripod position over the bedside table. CC Place in sde-yng postion witninees flexed D, Encourage 2 supe positon with 2 pillow under the knees. 30. The cient wit acute exacerbation of chronic pancreatitis has a nasogastric (N/G) tube. Which intervertions Should the nurse implement? Selec all tet app. ‘A. Montor the clent’s bowel sounds. B. Monitor the cen’ food intake. Assess the dent’ intravenous ste. D. Provide cal and nasal care IE Montor the cent’ blood glucose. 31. The nurse is acmitting a client diagnosed with primary arena cortex nsuficency (Addisons disease). Which cincal manifestations shoud the nurse exoect to assess? ’A Moon face, buffalo hump, and hyperglycemia B Hirsitcm, fever, and ietabity C Bronze pigmentation, hypotension, and aroresia. D.Techycaria, bulging eyes, end goiter 32._ The nurse i plenning the cae ofa client diagnosed with ‘cdison's dsease. Which intervention should be ncluded? 'A. Administer steroid medications. 8 Pace the chent on fluid resticton C. Provide frequent stimulation. D. Consult physical therapy for gai trairing 2 | Pose