Professional Documents
Culture Documents
1. A 10 year old who has sustained a head injury is brought to the emergency department by his mother.
A diagnosis of a mild concussion is made. At the time of discharge, nurse Ron should instruct the mother
to:
C. Arrange for a follow up visit with the child’s primary care provider in one week.
C. Check for any change in responsiveness every two hours until the follow-up visit.
2. A male client has suffered a motor accident and is now suffering from hypovolemic shock. Nurse
Helen should frequency assess the client’s vital signs during the compensatory stage of shock, because:
D. Tell the client the food has been x-rayed by the staff and is safe
4. One day the mother of a young adult confides to nurse Frida that she is very troubled by he child’s
emotional illness. The nurse’s most therapeutic initial response would be:
B. “It would be helpful if you become involved in volunteer work at this time”
C. “I recognize it’s hard to deal with this, but try to remember that this too shall pass”
D. “Joining a support group of parents who are coping with this problem can be quite helpful.
5. To check for wound hemorrhage after a client has had a surgery for the removal of a tumor in the
neck, nurse grace should:
D. Press gently around the incision to express accumulated blood from the wound
6. A 16-year-old primigravida arrives at the labor and birthing unit in her 38th week of gestation and
states that she is labor. To verify that the client is in true labor nurse Trina should:
7. As part of the diagnostic workup for pulmonic stenosis, a child has cardiac catheterization. Nurse
Julius is aware that children with pulmonic stenosis have increased pressure:
8. An obese client asks nurse Julius how to lose weight. Before answering, the nurse should remember
that long-term weight loss occurs best when:
9. As a very anxious female client is talking to the nurse May, she starts crying. She appears to be upset
that she cannot control her crying. The most appropriate response by the nurse would be:
C. “You look upset; lets talk about why you are crying.”
10. A patient has partial-thickness burns to both legs and portions of his trunk. Which of the following
I.V. fluids is given first?
A. Albumin
B. D5W
11. During the first 48 hours after a severe burn of 40% of the clients body surface, the nurse’s
assessment should include observations for water intoxication. Associated adaptations include:
A. Sooty-colored sputum
12. After a muscle biopsy, nurse Willy should teach the client to:
13. Before a client whose left hand has been amputated can be fitted for a prosthesis, nurse Joy is aware
that:
14. Nurse Cathy applies a fetal monitor to the abdomen of a client in active labor. When the client has
contractions, the nurse notes a 15 beat per minute deceleration of the fetal heart rate below the
baseline lasting 15 seconds. Nurse Cathy should:
D. Assess the client’s lower extremities for the presence of pitting edema
16. Nurse Bea recognizes that a pacemaker is indicated when a client is experiencing:
A. Angina
B. Chest pain
C. Heart block
D. Tachycardia
17. When administering pancrelipase (Pancreases capsules) to child with cystic fibrosis, nurse Faith
knows they should be given:
18. A preterm neonate is receiving oxygen by an overhead hood. During the time the infant is under the
hood, it would be appropriate for nurse Gian to:
19. A client’s sputum smears for acid fast bacilli (AFB) are positive, and transmission-based airborne
precautions are ordered. Nurse Kyle should instruct visitors to:
20. A client with a head injury has a fixed, dilated right pupil; responds only to painful stimuli; and
exhibits decorticate posturing. Nurse Kate should recognize that these are signs of:
A. Meningeal irritation
B. Subdural hemorrhage
C. Medullary compression
21. After a lateral crushing chest injury, obvious right-sided paradoxic motion of the client’s chest
demonstrates multiple rib fraactures, resulting in a flail chest. The complication the nurse should
carefully observe for would be:
A. Mediastinal shift
B. Tracheal laceration
C. Open pneumothorax
D. Pericardial tamponade
22. When planning care for a client at 30-weeks gestation, admitted to the hospital after vaginal
bleeding secondary to placenta previa, the nurse’s primary objective would be:
A. Provide a calm, quiet environment
D. Ensure that the client has regular cervical examinations assess for labor
23. When planning discharge teaching for a young female client who has had a pneumothorax, it is
important that the nurse include the signs and symptoms of a pneumothorax and teach the client to
seek medical assistance if she experiences:
B. Episodes of palpitation
24. After a laryngectomy, the most important equipment to place at the client’s bedside would be:
A. Suction equipment
B. Humidified oxygen
C. A nonelectric call bell
D. A cold-stream vaporizer
25. Nurse Oliver interviews a young female client with anorexia nervosa to obtain information for the
nursing history. The client’s history is likely to reveal a:
26. Nurse Bea should plan to assist a client with an obsessive-compulsive disorder to control the use of
ritualistic behavior by:
C. Getting the client involved with activities that will provide distraction
D. Suggesting that the client perform menial tasks to expiate feelings of guilt
27. A 2 ½ year old child undergoes a ventriculoperitoneal shunt revision. Before discharge, nurse John,
knowing the expected developmental behaviors for this age group, should tell the parents to call the
physician if the child:
D. Frequently starts arguments with playmates by claiming all toys are “mine”
28. A urinary tract infection is a potential danger with an indwelling catheter. Nurse Gina can best plan
to avoid this complication by:
29. A client has sustained a fractured right femur in a fall on stairs. Nurse Troy with the emergency
response team assess for signs of circulatory impairment by:
A. Turning the client to side lying position
30. To assess orientation to place in a client suspected of having dementia of the alzheimers type, nurse
Chris should ask:
31. Nurse Mary assesses a postpartum client who had an abruption placentae and suspects that
disseminated intravascular coagulation (DIC) is occurring when assessments demonstrate:
A. A boggy uterus
32. When a client on labor experiences the urge to push a 9cm dilation, the breathing pattern that nurse
Rhea should instruct the client to use is the:
A. Expulsion pattern
D. blowing pattern
33. Nurse Ronald should explain that the most beneficial between-meal snack for a client who is
recovering from the full-thickness burns would be a:
A. flexed extremities
35. The laboratory calls to state that a client’s lithium level is 1.9 mEq/L after 10 days of lithium therapy.
Nurse Reese should:
A. Notify the physician of the findings because the level is dangerously high
B. Monitor the client closely because the level of lithium in the blood is slightly elevated
C. Continue to administer the medication as ordered because the level is within the therapeutic range
D. Report the findings to the physician so the dosage can be increased because the level is below
therapeutic range
36. A client has a regular 30-day menstrual cycles. When teaching about the rhythm method, Which the
client and her husband have chosen to use for family planning, nurse Dianne should emphasize that the
client’s most fertile days are:
A. Days 9 to 11
B. Days 12 to 14
C. Days 15 to 17
D. Days 18 to 20
C. Assure that informed consent has been obtained from the client
38. While a client is on intravenous magnesium sulfate therapy for preeclampsia, it is essential for nurse
Amy to monitor the client’s deep tendon reflexes to:
39. A preschooler is admitted to the hospital with a diagnosis of acute glomerulonephritis. The child’s
history reveals a 5-pound weight gain in one week and peritoneal edema. For the most accurate
information on the status of the child’s edema, nursing intervention should include:
40. Nurse Mickey is administering dexamethasome (Decadron) for the early management of a client’s
cerebral edema. This treatment is effective because:
41. During newborn nursing assessment, a positive Ortolani’s sign would be indicated by:
A. A unilateral droop of hip
42. When caring for a dying client who is in the denial stage of grief, the best nursing approach would be
to:
43. To decrease the symptoms of gastroesophageal reflux disease (GERD), the physician orders dietary
and medication management. Nurse Helen should teach the client that the meal alteration that would
be most appropriate would be:
44. After a mastectomy or hysterectomy, clients may feel incomplete as women. The statement that
should alert nurse Gina to this feeling would be:
45. A client with obstruction of the common bile duct may show a prolonged bleeding and clotting time
because:
A. Hyperactive reflexes
47. When assessing a newborn suspected of having Down syndrome, nurse Rey would expect to
observe:
48. A 10 year old girl is admitted to the pediatric unit for recurrent pain and swelling of her joints,
particularly her knees and ankles. Her diagnosis is juvenile rheumatoid arthritis. Nurse Janah recognizes
that besides joint inflammation, a unique manifestation of the rheumatoid process involves the:
A. Ears
B. Eyes
C. Liver
D. Brain
49. A disturbed client is scheduled to begin group therapy. The client refuses to attend. Nurse Lolit
should:
D. Insist that the client join the group to help the socialization process
50. Because a severely depressed client has not responded to any of the antidepressant medications,
the psychiatrist decides to try electroconvulsive therapy (ECT). Before the treatment the nurse should:
D. Provide a simple explanation of the procedure and continue to reassure the client
51. Nurse Vicky is aware that teaching about colostomy care is understood when the client states, “I will
contact my physician and report ____”:
52. The client’s history that alerts nurse Henry to assess closely for signs of postpartum infection would
be:
54. During a group therapy session, one of the clients ask a male client with the diagnosis of antisocial
personality disorder why he is in the hospital. Considering this client’s type of personality disorder, the
nurse might expect him to respond:
55. A child visits the clinic for a 6-week checkup after a tonsillectomy and adenoidectomy. In addition to
assessing hearing, the nurse should include an assessment of the child’s:
56. A client is diagnosed with cancer of the jaw. A course of radiation therapy is to be followed by
surgery. The client is concerned about the side effects related to the radiation treaments. Nurse Ria
should explain that the major side effects that will experienced is:
A. Fatigue
B. Alopecia
C. Vomiting
D. Leucopenia
57. Nurse Katrina prepares an older-adult client for sleep, actions are taken to help reduce the likelihood
of a fall during the night. Targeting the most frequent cause of falls, the nurse should:
58. When evaluating a growth and development of a 6 month old infant, nurse Patty would expect the
infant to be able to:
C. Crawl, transfer toy from one hand to the other, display of fear of strangers
59. A breastfeeding mother asks the nurse what she can do to ease the discomfort caused by a cracked
nipple. Nurse Tina should instruct the client to:
C. Use a breast shield to keep the baby from direct contact with the nipple
D. Feed the baby on the unaffected breast first until the affected breast heals
60. Nurse Sandy observes that there is blood coming from the client’s ear after head injury. Nurse Sandy
should:
A. Turn the client to the unaffected side
61. Nurse Gio plans a long term care for parents of children with sickle-cell anemia, which includes
periodic group conferences. Some of the discussions should be directed towards:
D. Airing their feelings regarding the transmission of the disease to the child
62. The central problem the nurse might face with a disturbed schizophrenic client is the client’s:
A. Suspicious feelings
B. Continuous pacing
C. Relationship with the family
63. When planning care with a client during the postoperative recovery period following an abdominal
hysterectomy and bilateral salpingo-oophorectomy, nurse Frida should include the explanation that:
64. An adolescent client with anorexia nervosa refuses to eat, stating, “I’ll get too fat.” Nurse Andrea can
best respond to this behavior initially by:
A. Not talking about the fact that the client is not eating
D. Pointing out to the client that death can occur with malnutrition.
65. A pain scale is used to assess the degree of pain. The client rates the pain as an 8 on a scale of 10
before medication and a 7 on a scale of 10 after being medicated. Nurse Glenda determines that the:
D. Client needs more education about the use of the pain scale
66. To enhance a neonate’s behavioral development, therapeutic nursing measures should include:
A. Keeping the baby awake for longer periods of time before each feeding
B. Assisting the parents to stimulate their baby through touch, sound, and sight.
C. Encouraging parental contact for at least one 15-minute period every four hours.
D. Touching and talking to the baby at least hourly, beginning within two to four hours after birth
67. Before formulating a plan of care for a 6 year old boy with attention deficit hyperactivity disorder
(ADHD), nurse Kyla is aware that the initial aim of therapy is to help the client to:
68. Nurse Wally knows that the most important aspect of the preoperative care for a child with Wilms’
tumor would be:
69. At 11:00 pm the count of hydrocodone (Vicodin) is incorrect. After several minutes of searching the
medication cart and medication administration records, no explanation can be found. The primary nurse
should notify the:
B. Hospital administrator
70. When caring for the a client with a pneumothorax, who has a chest tube in place, nurse Kate should
plan to:
B. Empty and measure the drainage in the collection chamber each shift
C. Apply clamps below the insertion site when ever getting the client out of bed
D. Encourage coughing, deep breathing, and range of motion to the arm on the affected side
71. According to C.E.Winslow, which of the following is the goal of Public Health?
C. Swaroop’s index
73. Which of the following is the most prominent feature of public health nursing?
A. It involves providing home care to sick people who are not confined in the hospital
B. Services are provided free of charge to people within the catchment area.
C. The public health nurse functions as part of a team providing a public health nursing services.
75. Nurse Pauline determines whether resources were maximized in implementing Ligtas Tigdas, she is
evaluating:
A. Effectiveness
B. Efficiency
C. Adequacy
D. Appropriateness
76. Lissa is a B.S.N. graduate. She want to become a Public Health Nurse. Where will she apply?
A. Department of Health
77. As an epidemiologist, Nurse Celeste is responsible for reporting cases of notifiable diseases. What
law mandates reporting of cases of notifiable diseases?
A. Act 3573
B. R.A. 3753
C. R.A. 1054
D. R.A. 1082
78. Nurse Fay is aware that isolation of a child with measles belongs to what level of prevention?
A. Primary
B. Secondary
C. Intermediate
D. Tertiary
79. Nurse Gina is aware that the following is an advantage of a home visit?
80. The PHN bag is an important tool in providing nursing care during a home visit. The most important
principle of bag technique states that it:
C. Should not overshadow concern for the patient and his family.
81. Nurse Willy reads about Path Goal theory. Which of the following behaviors is manifested by the
leader who uses this theory?
B. Challenges the staff to take individual accountability for their own practice
82. Nurse Cathy learns that some leaders are transactional leaders. Which of the following does NOT
characterize a transactional leader?
A. Focuses on management tasks
B. Is a caretaker
84. Which of the following is the best guarantee that the patient’s priority needs are met?
85. Nurse Tony stresses the need for all the employees to follow orders and instructions from him and
not from anyone else. Which of the following principles does he refer to?
A. Scalar chain
B. Discipline
C. Unity of command
D. Order
86. Nurse Joey discusses the goal of the department. Which of the following statements is a goal?
D. Possesses innate charisma that makes others feel good in his presence.
88. Nurse Mae tells one of the staff, “I don’t have time to discuss the matter with you now. See me in my
office later” when the latter asks if they can talk about an issue. Which of the following conflict
resolution strategies did she use?
A. Smoothing
B. Compromise
C. Avoidance
D. Restriction
89. Nurse Bea plans of assigning competent people to fill the roles designed in the hierarchy. Which
process refers to this?
A. Staffing
B. Scheduling
C. Recruitment
D. Induction
90. Nurse Linda tries to design an organizational structure that allows communication to flow in all
directions and involve workers in decision making. Which form of organizational structure is this?
A. Centralized
B. Decentralized
C. Matrix
D. Informal
91. When documenting information in a client’s medical record, the nurse should:
B. use a #2 pencil.
92. Which of the following factors are major components of a client’s general background drug history?
A. Hand washing
D. Colostomy irrigation
94. The nurse is performing wound care using surgical asepsis. Which of the following practices violates
surgical asepsis?
D. Opening the outermost flap of a sterile package away from the body
95. On admission, a client has the following arterial blood gas (ABG) values: PaO2, 50 mm Hg; PaCO2, 70
mm Hg; pH, 7.20; HCO3–, 28 mEq/L. Based on these values,
the nurse should formulate which nursing diagnosis for this client?
D. Metabolic acidosis
96. The use of larvivorous fish in malaria control is the basis for which strategy of malaria control?
A. Stream seeding
B. Stream clearing
C. Destruction of breeding places
D. Zooprophylaxis
97. In Integrated Management of Childhood Illness, severe conditions generally require urgent referral
to a hospital. Which of the following severe conditions DOES NOT always require urgent referral to a
hospital?
A. Mastoiditis
B. Severe dehydration
C. Severe pneumonia
98. A mother brought her daughter, 4 years old, to the RHU because of cough and colds. Following the
IMCI assessment guide, which of the following is a danger sign that indicates the need for urgent referral
to a hospital?
A. Inability to drink
A. Sugar
B. Bread
C. Margarine
D. Filled milk
100. The major sign of iron deficiency anemia is pallor. What part is best examined for pallor?
A. Palms
B. Nailbeds
1. C. Check for any change in responsiveness every two hours until the follow-up visit
Signs of an epidural hematoma in children usually do not appear for 24 hours or more hours; a follow-up
visit usually is arranged for one to two days after the injury.
The early compensation of shock is cardiovascular and is seen in changes in pulse, BP, and pulse
pressure; blood is shunted to vital centers, particularly heart and brain.
The client’s comfort, safety, and nutritional status are the priorities; the client may feel comfortable to
eat if the food has been sealed before reaching the mental health facility.
4. D. “Joining a support group of parents who are coping with this problem can be quite helpful.
Taking with others in similar circumstances provides support and allows for sharing of experiences.
5. B. Observe the dressing at the back of the neck for the presence of blood
Pulmonic stenosis increases resistance to blood flow, causing right ventricular hypertrophy; with right
ventricular failure there is an increase in pressure on the right side of the heart.
A new dietary regimen, with a balance of foods from the food pyramid, must be established and
continued for weight reduction to occur and be maintained.
9. B. “It is ok to cry; I’ll just stay with you for now”
Lactated Ringer’s solution replaces lost sodium and corrects metabolic acidosis, both of which
commonly occur following a burn. Albumin is used as adjunct therapy, not primary fluid replacement.
Dextrose isn’t given to burn patients during the first 24 hours because it can cause pseudodiabetes. The
patient is hyperkalemic from the potassium shift from the intracellular space to the plasma, so
potassium would be detrimental.
Excess extracellular fluid moves into cells (water intoxication); intracellular fluid excess in sensitive brain
cells causes altered mental status; other signs include anorexia nervosa, nausea, vomiting, twitching,
sleepiness, and convulsions.
As long as the client has no nausea or vomiting, there are no dietary restriction.
Shrinkage of the residual limb, resulting from reduction of subcutaneous fat and interstitial fluid, must
occur for an adequate fit between the limb and the prosthesis.
Stimulation of the sympathetic nervous system is an initial response to mild hypoxia that accompanies
partial cord compression (umbilical vein) during contractions; changing the maternal position can
alleviate the compression.
15. A. Perform a finger stick to test the client’s blood glucose level
The client has signs of diabetes, which may result from steroid therapy, testing the blood glucose level is
a method of screening for diabetes, thus gathering more data.
This is the primary indication for a pacemaker because there is an interfere with the electrical
conduction system of the heart.
Pancreases capsules must be taken with food and snacks because it acts on the nutrients and readies
them for absorption.
Oxygen has cooling effect, and the baby should be kept warm so that metabolic activity and oxygen
demands are not increased.
19. C. Wear an Ultra-Filter mask when they are in the client’s room
Tubercle bacilli are transmitted through air currents; therefore personal protective equipment such as
an Ultra-Filter mask is necessary.
Cerebral compression affects pyramidal tracts, resulting in decorticate rigidity and cranial nerve injury,
which cause pupil dilation.
Mediastinal structures move toward the uninjured lung, reducing oxygenation and venous return.
Stimulation of the cervix or uterus may cause bleeding or hemorrhage and should be avoided.
23. C. Severe shortness of breath
This could indicate a recurrence of the pneumothorax as one side of the lung is inadequate to meet the
oxygen demands of the body.
Respiratory complications can occur because of edema of the glottis or injury to the recurrent laryngeal
nerve.
Clients with anorexia nervosa have a disturbed self image and always see themselves as fat and needing
further reducing.
Persons with high anxiety levels develop various behaviors to relieve their anxiety; by reducing anxiety,
the need for these obsessive-compulsive action is reduced.
27. C. Becomes fussy when frustrated and displays a shortened attention span
Shortened attention span and fussy behavior may indicate a change in intracranial pressure and/or
shunt malfunction.
Promoting hydration maintains urine production at a higher rate, which flushes the bladder and
prevents urinary stasis and possible infection.
“Where are you?” is the best question to elicit information about the client’s orientation to place
because it encourages a response that can be assessed.
This indicates a fibrinogenemia; massive clotting in the area of the separation has resulted in a lowered
circulating fibrinogen.
Clients should use a blowing pattern to overcome the premature urge to push.
Of the selections offered, this is the highest in calories and protein, which are needed for increased basal
metabolic rate and for tissue repair.
Central cyanosis (blue lips and face) indicates lowered oxygenation of the blood, caused by either
decreased lung expansion or right to left shunting of blood.
35. A. Notify the physician of the findings because the level is dangerously high
Levels close to 2 mEq/L are dangerously close to the toxic level; immediate action must be taken.
36. C. Days 15 to 17
Ovulation occurs approximately 14 days before the next menses, about the 16th day in 30 day cycle; the
15th to 17th days would be the best time to avoid sexual intercourse.
37. C. Assure that informed consent has been obtained from the client
An invasive procedure such as amniocentesis requires informed consent.
Respiratory distress or arrest may occur when the serum level of magnesium sulfate reaches 12 to 15
mg/dl; deep tendon reflexes disappear when the serum level is 10 to 12 mg/dl; the drug is withheld in
the absence of deep tendon reflexes; the therapeutic serum level is 5 to 8 mg/dl.
Weight monitoring is the most useful means of assessing fluid balance and changes in the edematous
state; 1 liter of fluid weighs about 2.2 pounds.
With specific manipulation, an audible click may be heard of felt as he femoral head slips into the
acetabulum.
This does not remove client’s only way of coping, and it permits future movement through the grieving
process when the client is ready.
The volume of food in the stomach should be kept small to limit pressure on the cardiac sphincter.
Vitamin K, a fat soluble vitamin, is not absorbed from the GI tract in the absence of bile; bile enters the
duodenum via the common bile duct.
Impulse conduction of skeletal muscle is impaired with decreased potassium levels, muscular weakness
and cramps may occur with hypokalemia.
48. B. Eyes
Rheumatoid arthritis can cause inflammation of the iris and ciliary body of the eyes which may lead to
blindness.
This is all the nurse can do until trust is established; facing the client to attend will disrupt the group.
50. D. Provide a simple explanation of the procedure and continue to reassure the client
The nurse should offer support and use clear, simple terms to allay client’s anxiety.
51. D. If I have difficulty in inserting the irrigating tube into the stoma”
This occurs with stenosis of the stoma; forcing insertion of the tube could cause injury.
The client is incapable of accepting responsibility for self-created problems and blames society for the
behavior.
Swelling can obstruct nasal breathing, interfering with the senses of taste and smell.
56. A. Fatigue
Fatigue is a major problem caused by an increase in waste products because of catabolic processes.
Statistics indicate that the most frequent cause of falls by hospitalized clients is getting up or attempting
to get up to the bathroom unassisted.
58. D. Turn completely over, sit momentarily without support, reach to be picked up
59. D. Feed the baby on the unaffected breast first until the affected breast heals
The most vigorous sucking will occur during the first few minutes of breastfeeding when the infant
would be on the unaffected breast; later suckling is less traumatic.
60. D. Place sterile cotton loosely in the external ear of the client
61. D. Airing their feelings regarding the transmission of the disease to the child
Discussion with parents who have children with similar problems helps to reduce some of their
discomfort and guilt.
The nurse must deal with these feelings and establish basic trust to promote a therapeutic milieu.
When a bilateral oophorectomy is performed, both ovaries are excised, eliminating ovarian hormones
and initiating response.
64. D. Pointing out to the client that death can occur with malnutrition.
The client expects the nurse to focus on eating, but the emphasis should be placed on feelings rather
than actions.
The expected effect should be more than a one point decrease in the pain level.
66. B. Assisting the parents to stimulate their baby through touch, sound, and sight.
Stimuli are provided via all the senses; since the infant’s behavioral development is enhanced through
parent-infant interactions, these interactions should be encouraged.
Because the tumor is of renal origin, the rennin angiotensin mechanism can be involved, and blood
pressure monitoring is important.
Controlled substance issues for a particular nursing unit are the responsibility of that unit’s nurse
manager.
70. D. Encourage coughing, deep breathing, and range of motion to the arm on the affected side
All these interventions promote aeration of the re-expanding lung and maintenance of function in the
arm and shoulder on the affected side.
According to Winslow, all public health efforts are for people to realize their birthrights of health and
longevity.
Swaroop’s index is the percentage of the deaths aged 50 years or older. Its inverse represents the
percentage of untimely deaths (those who died younger than 50 years).
The catchment area in PHN consists of a residential community, many of whom are well individuals who
have greater need for preventive rather than curative services.
75. B. Efficiency
Efficiency is determining whether the goals were attained at the least possible cost.
R.A. 7160 devolved basic health services to local government units (LGU’s ). The public health nurse is an
employee of the LGU.
Act 3573, the Law on Reporting of Communicable Diseases, enacted in 1929, mandated the reporting of
diseases listed in the law to the nearest health station.
78. A. Primary
The purpose of isolating a client with a communicable disease is to protect those who are not sick
(specific disease prevention).
Choice A is not correct since a home visit requires that the nurse spend so much time with the family.
Choice C is an advantage of a group conference, while choice D is true of a clinic consultation.
Bag technique is performed before and after handling a client in the home to prevent transmission of
infection to and from the client.
81. A. Bag technique is performed before and after handling a client in the home to prevent
transmission of infection to and from the client.
Path Goal theory according to House and associates rewards good performance so that others would do
the same.
Inspires others with a vision is characteristic of a transformational leader. He is focused more on the
day-to-day operations of the department/unit.
When the functional method is used, the psychological and sociological needs of the patients are
neglected; the patients are regarded as ‘tasks to be done”
The best source of information about the priority needs of the patient is the patient himself. Hence
using a nursing care plan based on his expressed priority needs would ensure meeting his needs
effectively.
The principle of unity of command means that employees should receive orders coming from only one
manager and not from two managers. This averts the possibility of sowing confusion among the
members of the organization.
Goal is a desired result towards which efforts are directed. Options AB, C and D are all objectives which
are aimed at specific end.
88. C. Avoidance
This strategy shuns discussing the issue head-on and prefers to postpone it to a later time. In effect the
problem remains unsolved and both parties are in a lose-lose situation.
89. A. Staffing
Staffing is a management function involving putting the best people to accomplish tasks and activities to
attain the goals of the organization.
90. B. Decentralized
Decentralized structures allow the staff to make decisions on matters pertaining to their practice and
communicate in downward, upward, lateral and diagonal flow.
91. D. end each entry with the nurse’s signature and title.
The end of each entry should include the nurse’s signature and title; the signature holds the nurse
accountable for the recorded information. Erasing errors in documentation on a legal document such as
a client’s chart isn’t permitted by law. Because a client’s medical record is considered a legal document,
the nurse should make all entries in ink. The nurse is accountable for the information recorded and
therefore shouldn’t leave any blank lines in which another health care worker could make additions.
General background data consist of such components as allergies, medical history, habits,
socioeconomic status, lifestyle, beliefs, and sensory deficits. Urine output, gastric reflex, and bowel
habits are significant only if a disease affecting these functions is present.
Caregivers must use surgical asepsis when performing wound care or any procedure in which a sterile
body cavity is entered or skin integrity is broken. To achieve surgical asepsis, objects must be rendered
or kept free of all pathogens. Inserting an I.V. cannula requires surgical asepsis because it disrupts skin
integrity and involves entry into a sterile cavity (a vein). The other options are used to ensure medical
asepsis or clean technique to prevent the spread of infection. The GI tract isn’t sterile; therefore,
irrigating a nasogastric tube or a colostomy requires only clean technique.
94. B. Pouring solution onto a sterile field cloth
Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the
cloth can carry microorganisms to the sterile field via capillary action. The other options are practices
that help ensure surgical asepsis.
The client has a below-normal value for the partial pressure of arterial oxygen (PaO2) and an above-
normal value for the partial pressure of arterial carbon dioxide (PaCO2), supporting the nursing
diagnosis of Impaired gas exchange. ABG values can’t indicate a diagnosis of Fluid volume deficit (or
excess) or Risk for deficient fluid volume. Metabolic acidosis is a medical, not nursing, diagnosis; in any
event, these ABG values indicate respiratory, not metabolic, acidosis.
Stream seeding is done by putting tilapia fry in streams or other bodies of water identified as breeding
places of the Anopheles mosquito.
The order of priority in the management of severe dehydration is as follows: intravenous fluid therapy,
referral to a facility where IV fluids can be initiated within 30 minutes, Oresol/nasogastric tube,
Oresol/orem. When the foregoing measures are not possible or effective, tehn urgent referral to the
hospital is done.
A sick child aged 2 months to 5 years must be referred urgently to a hospital if he/she has one or more
of the following signs: not able to feed or drink, vomits everything, convulsions, abnormally sleepy or
difficult to awaken.
99. A. Sugar
R.A. 8976 mandates fortification of rice, wheat flour, sugar and cooking oil with Vitamin A, iron and/or
iodine.
100. A. Palms
The anatomic characteristics of the palms allow a reliable and convenient basis for examination for
pallor