MIDTERM

EXAM 1
1. A client asks the nurse what a third degree laceration is. She was informed that she
had one. The nurse explains that this is:

A. that extended their anal sphincter

B. through the skin and into the muscles
C. that involves anterior rectal wall
D. that extends through the perineal muscle.
2. Betina 30 weeks AOG discharged with a diagnosis of placenta previa. The nurse
knows that the client understands her care at home when she says:

A. I am happy to note that we can have sex occasionally when I have no bleeding.
B. I am afraid I might have an operation when my due comes
C. I will have to remain in bed until my due date comes
D. I may go back to work since I stay only at the office.
3. The uterus has already risen out of the pelvis and is experiencing farther into the
abdominal area at about the:

A. 8th week of pregnancy

B. 10th week of pregnancy
C. 12th week of pregnancy
D. 18th week of pregnancy
4. Which of the following urinary symptoms does the pregnant woman most
frequently experience during the first trimester:

A. frequency
B. dysuria
C. incontinence
D. burning
5. Mrs. Jimenez went to the health center for pre-natal check-up. the student nurse
took her weight and revealed 142 lbs. She asked the student nurse how much should
she gain weight in her pregnancy.

A. 20-30 lbs
B. 25-35 lbs
C. 30- 40 lbs
D. 10-15 lbs
6. The nurse is preparing Mrs. Jordan for cesarean delivery. Which of the following
key concept should the nurse consider when implementing nursing care?
 A. Explain the surgery, expected outcome and kind of anesthetics.
B. Modify preoperative teaching to meet the needs of either a planned or
emergency cesarean birth.
C. Arrange for a staff member of the anesthesia department to explain what to
expect post-operatively.
D. Instruct the mother’s support person to remain in the family lounge until after
the delivery.

7. Bettine Gonzales is hospitalized for the treatment of severe preecplampsia.

Which of the following represents an unusual finding for this condition?

A. generalized edema
B. proteinuria 4+
C. blood pressure of 160/110
D. convulsions
8. Nurse Geli explains to the client who is 33 weeks pregnant and is experiencing
vaginal bleeding that coitus:

A. Need to be modified in any way by either partner

B. Is permitted if penile penetration is not deep.
C. Should be restricted because it may stimulate uterine activity.
D. Is safe as long as she is in side-lying position.
9. Mrs. Precilla Abuel, a 32 year old mulripara is admitted to labor and delivery. Her
last 3 pregnancies in short stage one of labor. The nurses decide to observe her
closely. The physician determines that Mrs. Abuel’s cervix is dilated to 6 cm. Mrs.
Abuel states that she is extremely uncomfortable. To lessen Mrs. Abuel’s discomfort,
the nurse can advise her to:

A. lie face down

B. not drink fluids
C. practice holding breaths between contractions
D. assume Sim’s position
10. Which is true regarding the fontanels of the newborn?

A. The anterior is large in shape when compared to the posterior fontanel.

B. The anterior is triangular shaped; the posterior is diamond shaped.
C. The anterior is bulging; the posterior appears sunken.
D. The posterior closes at 18 months; the anterior closes at 8 to 12 months.
11. Mrs. Quijones gave birth by spontaneous delivery to a full term baby boy. After a
minute after birth, he is crying and moving actively. His birth weight is 6.8 lbs. What
do you expect baby Quijones to weigh at 6 months?
 A. 13 -14 lbs
B. 16 -17 lbs
C. 22 -23 lbs
D. 27 -28 lbs
12. During the first hours following delivery, the post partum client is given IVF with
oxytocin added to them. The nurse understands the primary reason for this is:

A. To facilitate elimination
B. To promote uterine contraction
C. To promote analgesia
D. To prevent infection

13. Nurse Luis is assessing the newborn’s heart rate. Which of the following would be
considered normal if the newborn is sleeping?

A. 80 beats per minute

B. 100 beats per minute
C. 120 beats per minute
D. 140 beats per minute
14. The infant with Down Syndrome should go through which of the Erikson’s
developmental stages first?

A. Initiative vs. Self doubt

B. Industry vs. Inferiority
C. Autonomy vs. Shame and doubt
D. Trust vs. Mistrust
15. The child with phenylketonuria (PKU) must maintain a low phenylalanine diet to
prevent which of the following complications?

A. Irreversible brain damage

B. Kidney failure
C. Blindness
D. Neutropenia
16. Which age group is with imaginative minds and creates imaginary friends?

A. Toddler
B. Preschool
C. School
D. Adolescence
17. Which of the following situations would alert you to a potentially developmental
problem with a child?
 A. Pointing to body parts at 15 months of age.
B. Using gesture to communicate at 18 months.
C. Cooing at 3 months.
D. Saying “mama” or “dada” for the first time at 18 months of age.
18. Isabelle, a 2 year old girl loves to move around and oftentimes manifests
negativism and temper tantrums. What is the best way to deal with her behavior?

A. Tell her that she would not be loved by others is she behaves that way..
B. Withholding giving her toys until she behaves properly.
C. Ignore her behavior as long as she does not hurt herself and others.
D. Ask her what she wants and give it to pacify her.
19. Baby boy Villanueva, 4 months old, was seen at the pediatric clinic for his
scheduled check-up. By this period, baby Villanueva has already increased his height
by how many inches?

A. 3 inches
B. 4 inches
C. 5 inches
D. 6 inches
20. Alice, 10 years old was brought to the ER because of Asthma. She was
immediately put under aerosol administration of Terbutaline. After sometime, you
observe that the child does not show any relief from the treatment given. Upon
assessment, you noticed that both the heart and respiratory rate are still elevated and
the child shows difficulty of exhaling. You suspect:

A. Bronchiectasis
B. Atelectasis
C. Epiglotitis
D. Status Asthmaticus
21. Nurse Jonas assesses a 2 year old boy with a tentative diagnosis of
nephroblastoma. Symptoms the nurse observes that suggest this problem include:

A. Lymphedema and nerve palsy

B. Hearing loss and ataxia
C. Headaches and vomiting
D. Abdominal mass and weakness
22. Which of the following danger sings should be reported immediately during the
antepartum period?

A. blurred vision
B. nasal stuffiness
 C. breast tenderness
D. constipation
23. Nurse Jacob is assessing a 15 month old child with acute otitis media. Which of
the following symptoms would the nurse anticipate finding?

A. periorbital edema, absent light reflex and translucent tympanic membrane

B. irritability, purulent drainage in middle ear, nasal congestion and cough
C. diarrhea, retracted tympanic membrane and enlarged parotid gland
D. Vomiting, pulling at ears and pearly white tympanic membrane
24. Which of the following is the most appropriate intervention to reduce stress in a
preterm infant at 33 weeks gestation?

A. Sensory stimulation including several senses at a time

B. tactile stimulation until signs of over stimulation develop
C. An attitude of extension when prone or side lying
D. Kangaroo care
25. The parent of a client with albinism would need to be taught which preventive
healthcare measure by the nurse:

A. Ulcerative colitis diet

B. Use of a high-SPF sunblock
C. Hair loss monitoring
D. Monitor for growth retardation

EXAM 2

1. Nurse Bella explains to a 28 year old pregnant woman undergoing a non-stress test
that the test is a way of evaluating the condition of the fetus by comparing the fetal
heart rate with:

A. Fetal lie
B. Fetal movement
C. Maternal blood pressure
D. Maternal uterine contractions
2. During a 2 hour childbirth focusing on labor and delivery process for primigravida.
The nurse describes the second maneuver that the fetus goes through during labor
progress when the head is the presenting part as which of the following:

A. Flexion
 B. Internal rotation
C. Descent
D. External rotation
3. Mrs. Jovel Diaz went to the hospital to have her serum blood test for alpha-
fetoprotein. The nurse informed her about the result of the elevation of serum AFP.
The patient asked her what was the test for:

A. Congenital Adrenal Hyperplasia

B. PKU
C. Down Syndrome
D. Neural tube defects
4. Fetal heart rate can be auscultated with a fetoscope as early as:

A. 5 weeks of gestation
B. 10 weeks of gestation
C. 15 weeks of gestation
D. 20 weeks of gestation
5. Mrs. Bendivin states that she is experiencing aching swollen, leg veins. The nurse
would explain that this is most probably the result of which of the following:

A. Thrombophlebitis
B. PIH
C. Pressure on blood vessels from the enlarging uterus
D. The force of gravity pulling down on the uterus
6. Mrs. Ella Santoros is a 25 year old primigravida who has Rheumatic heart disease
lesion. Her pregnancy has just been diagnosed. Her heart disease has not caused her to
limit physical activity in the past. Her cardiac disease and functional capacity
classification is:

A. Class I
B. Class II
C. Class III
D. class IV
7. The client asks the nurse, “When will this soft spot at the top of the head of my
baby will close?” The nurse should instruct the mother that the neonate’s anterior
fontanel will normally close by age:

A. 2-3 months
B. 6-8 months
C. 10-12 months
D. 12-18 months
8. When a mother bleeds and the uterus is relaxed, soft and non-tender, you can
account the cause to:

A. Atony of the uterus

B. Presence of uterine scar
C. Laceration of the birth canal
D. Presence of retained placenta fragments
9. Mrs. Pichie Gonzales’s LMP began April 4, 2010. Her EDD should be which of the
following:

A. February 11, 2011

B. January 11, 20111
C. December 12, 2010
D. Nowember 14, 2010
10. Which of the following prenatal laboratory test values would the nurse consider as
significant?

A. Hematocrit 33.5%
B. WBC 8,000/mm3
C. Rubella titer less than 1:8
D. One hour glucose challenge test 110 g/dL

11. Aling Patricia is a patient with preeclampsia. You advise her about her
condition, which would tell you that she has not really understood your
instructions?

A. “I will restrict my fat in my diet.”

B. “I will limit my activities and rest more frequently throughout the day.”
C. “I will avoid salty foods in my diet.”
D. “I will come more regularly for check-up.”

12. Mrs. Grace Evangelista is admitted with severe preeclampsia. What type of room
should the nurse select this patient?

A. A room next to the elevator.

B. The room farthest from the nursing station.
C. The quietest room on the floor.
D. The labor suite.
13. During a prenatal check-up, the nurse explains to a client who is Rh negative that
RhoGAM will be given:

A. Weekly during the 8th month because this is her third pregnancy.
 B. During the second trimester, if amniocentesis indicates a problem.
C. To her infant immediately after delivery if the Coomb’s test is positive.
D. Within 72 hours after delivery if infant is found to be Rh positive.
14. A baby boy was born at 8:50pm. At 8:55pm, the heart rate was 99 bpm. She has a
weak cry, irregular respiration. She was moving all extremities and only her hands
and feet were still slightly blue. The nurse should enter the APGAR score as:

A. 5
B. 6
C. 7
D. 8
15. Billy is a 4 year old boy who has an IQ of 140 which means:

A. average normal
B. very superior
C. above average
D. genius
16. A newborn is brought to the nursery. Upon assessment, the nurse finds that the
child has short palpebral fissures, thinned upper lip. Based on this data, the nurse
suspects that the newborn is MOST likely showing the effects of:

A. Chronic toxoplasmosis
B. Lead poisoning
C. Congenital anomalies
D. Fetal alcohol syndrome
17. A priority nursing intervention for the infant with cleft lip is which of the
following:

A. Monitoring for adequate nutritional intake

B. Teaching high-risk newborn care
C. Assessing for respiratory distress
D. Preventing injury
18. Nurse Jacob is assessing a 12 year old who has hemophilia A. Which of the
following assessment findings would the nurse anticipate?

A. an excess of RBC
B. an excess of WBC
C. a deficiency of clotting factor VIII
D. a deficiency of clotting factor IX
19. Celine, a mother of a 2 year old tells the nurse that her child “cries and has a fit
when I have to leave him with a sitter or someone else.” Which of the following
statements would be the nurse’s most accurate analysis of the mother’s comment?

A. The child has not experienced limit-setting or structure.

B. The child is expressing a physical need, such as hunger.
C. The mother has nurtured overdependence in the child.
D. The mother is describing her child’s separation anxiety.
20. Mylene Lopez, a 16 year old girl with scoliosis has recently received an invitation
to a pool party. She asks the nurse how she can disguise her impairment when dressed
in a bathing suit. Which nursing diagnosis can be justified by Mylene’s statement?

A. Anxiety
B. Body image disturbance
C. Ineffective individual coping
D. Social isolation
21. The foul-smelling, frothy characteristic of the stool in cystic fibrosis results from
the presence of large amounts of which of the following:

A. sodium and chloride

B. undigested fat
C. semi-digested carbohydrates
D. lipase, trypsin and amylase
22. Which of the following would be a disadvantage of breast feeding?

A. involution occurs rapidly

B. the incidence of allergies increases due to maternal antibodies
C. the father may resent the infant’s demands on the mother’s body
D. there is a greater chance of error during preparation
23. A client is noted to have lymphedema, webbed neck and low posterior hairline.
Which of the following diagnoses is most appropriate?

A. Turner’s syndrome
B. Down’s syndrome
C. Marfan’s syndrome
D. Klinefelter’s syndrome
24. A 4 year old boy most likely perceives death in which way:

A. An insignificant event unless taught otherwise

B. Punishment for something the individual did
C. Something that just happens to older people
 D. Temporary separation from the loved one.
25. Catherine Diaz is a 14 year old patient on a hematology unit who is being treated
for sickle cell crisis. During a crisis such as that seen in sickle cell anemia,
aldosterone release is stimulated. In what way might this influence Catherine’s fluid
and electrolyte balance?

A. sodium loss, water loss and potassium retention

B. sodium loss, water los and potassium loss
C. sodium retention, water loss and potassium retention
D. sodium retention, water retention and potassium loss

EXAM 3

1. A pregnant woman who is at term is admitted to the birthing unit in active labor.
The client has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with
hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her
contractions. Which of the following is the most important aspect of nursing
intervention at this time?

A. Timing and recording length of contractions.

B. Monitoring.
C. Preparing for an emergency cesarean birth.
D. Checking the perineum for bulging.
2. A client who hallucinates is not in touch with reality. It is important for the nurse
to:

A. Isolate the client from other patients.

B. Maintain a safe environment.
C. Orient the client to time, place, and person.
D. Establish a trusting relationship.
3. The nurse is caring to a child client who has had a tonsillectomy. The child
complains of having dryness of the throat. Which of the following would the nurse
give to the child?

A. Cola with ice

B. Yellow noncitrus Jello
C. Cool cherry Kool-Aid
D. A glass of milk
4. The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year-
old client. The nurse caring to the client provides instructions that the nasal spray
must be used exactly as directed to prevent the development of:

A. Increased nasal congestion.

B. Nasal polyps.
C. Bleeding tendencies.
D. Tinnitus and diplopia.
5. A client with tuberculosis is to be admitted in the hospital. The nurse who will be
assigned to care for the client must institute appropriate precautions. The nurse
should:

A. Place the client in a private room.

B. Wear an N 95 respirator when caring for the client.
C. Put on a gown every time when entering the room.
D. Don a surgical mask with a face shield when entering the room.
6. Which of the following is the most frequent cause of noncompliance to the medical
treatment of open-angle glaucoma?

A. The frequent nausea and vomiting accompanying use of miotic drug.

B. Loss of mobility due to severe driving restrictions.
C. Decreased light and near-vision accommodation due to miotic effects of
pilocarpine.
D. The painful and insidious progression of this type of glaucoma.
7. In the morning shift, the nurse is making rounds in the nursing care units. The nurse
enters in a client’s room and notes that the client’s tube has become disconnected
from the Pleurovac. What would be the initial nursing action?

A. Apply pressure directly over the incision site.

B. Clamp the chest tube near the incision site.
C. Clamp the chest tube closer to the drainage system.
D. Reconnect the chest tube to the Pleurovac.
8. Which of the following complications during a breech birth the nurse needs to be
alarmed?

A. Abruption placenta.
B. Caput succedaneum.
C. Pathological hyperbilirubinemia.
D. Umbilical cord prolapse.
9. The nurse is caring to a client diagnosed with severe depression. Which of the
following nursing approach is important in depression?
 A. Protect the client against harm to others.
B. Provide the client with motor outlets for aggressive, hostile feelings.
C. Reduce interpersonal contacts.
D. Deemphasizing preoccupation with elimination, nourishment, and sleep.
10. A 3-month-old client is in the pediatric unit. During assessment, the nurse is
suspecting that the baby may have hypothyroidism when mother states that her baby
does not:

A. Sit up.
B. Pick up and hold a rattle.
C. Roll over.
D. Hold the head up.
11. The physician calls the nursing unit to leave an order. The senior nurse had
conversation with the other staff. The newly hired nurse answers the phone so that the
senior nurses may continue their conversation. The new nurse does not knowthe
physician or the client to whom the order pertains. The nurse should:

A. Ask the physician to call back after the nurse has read the hospital policy
manual.
B. Take the telephone order.
C. Refuse to take the telephone order.
D. Ask the charge nurse or one of the other senior staff nurses to take the
telephone order.
12. The staff nurse on the labor and delivery unit is assigned to care to a primigravida
in transition complicated by hypertension. A new pregnant woman in active labor is
admitted in the same unit. The nurse manager assigned the same nurse to the second
client. The nurse feels that the client with hypertension requires one-to-one care. What
would be the initial actionof the nurse?

A. Accept the new assignment and complete an incident report describing a

shortage of nursing staff.
B. Report the incident to the nursing supervisor and request to be floated.
C. Report the nursing assessment of the client in transitional labor to the nurse
manager and discuss misgivings about the new assignment.
D. Accept the new assignment and provide the best care.
13. A newborn infant with Down syndrome is to be discharged today. The nurse is
preparing to give the discharge teaching regarding the proper care at home. The nurse
would anticipate that the mother is probably at the:

A. 40 years of age.
B. 20 years of age.
 C. 35 years of age.
D. 20 years of age.
14. The emergency department has shortage of staff. The nurse manager informs the
staff nurse in the critical care unit that she has to float to the emergency department.
What should the staff nurse expect under these conditions?

A. The float staff nurse will be informed of the situation before the shift begins.
B. The staff nurse will be able to negotiate the assignments in the emergency
department.
C. Cross training will be available for the staff nurse.
D. Client assignments will be equally divided among the nurses.
15. The nurse is assigned to care for a child client admitted in the pediatrics unit. The
client is receiving digoxin. Which of the following questions will be asked by the
nurse to the parents of the child in order to assess the client’s risk for digoxin toxicity?

A. “Has he been exposed to any childhood communicable diseases in the past 2-3
weeks?”
B. “Has he been taking diuretics at home?”
C. “Do any of his brothers and sisters have history of cardiac problems?”
D. “Has he been going to school regularly?”
16. The nurse noticed that the signed consent form has an error. The form states,
“Amputation of the right leg” instead of the left leg that is to be amputated. The nurse
has administered already the preoperative medications. What should the nurse do?

A. Call the physician to reschedule the surgery.

B. Call the nearest relative to come in to sign a new form.
C. Cross out the error and initial the form.
D. Have the client sign another form.
17. The nurse in the nursing care unit checks the fluctuation in the water-seal
compartment of a closed chest drainage system. The fluctuation has stopped, the nurse
would:

A. Vigorously strip the tube to dislodge a clot.

B. Raise the apparatus above the chest to move fluid.
C. Increase wall suction above 20 cm H2O pressure.
D. Ask the client to cough and take a deep breath.
18. The pediatric nurse in the neonatal unit was informed that the baby that is brought
to the mother in the hospital room is wrong. The nurse determines that two babies
were placed in the wrong cribs. The most appropriate nursing action would be to:
 A. Determine who is responsible for the mistake and terminate his or her
employment.
B. Record the event in an incident/variance report and notify the nursing
supervisor.
C. Reassure both mothers, report to the charge nurse, and do not record.
D. Record detailed notes of the event on the mother’s medical record.
19. Before the administration of digoxin, the nurse completes an assessment to a
toddler client for signs and symptoms of digoxin toxicity. Which of the following is
the earliest and most significant sign of digoxin toxicity?

A. Tinnitus
B. Nausea and vomiting
C. Vision problem
D. Slowing in the heart rate
20. Which of the following treatment modality is appropriate for a client with
paranoid tendency?

A. Activity therapy.
B. Individual therapy.
C. Group therapy.
D. Family therapy.
21. The client with rheumatoid arthritis is for discharge. In preparing the client for
discharge on prednisone therapy, the nurse should advise the client to:

A. Wear sunglasses if exposed to bright light for an extended period of time.

B. Take oral preparations of prednisone before meals.
C. Have periodic complete blood counts while on the medication.
D. Never stop or change the amount of the medication without medical advice.
22. A pregnant client tells the nurse that she is worried about having urinary
frequency. What will be the most appropriate nursing response?

A. “Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you
have frequency associated with fever, pain on voiding, or blood in the urine,
call your doctor/nurse-midwife.
B. “Placental progesterone causes irritability of the bladder sphincter. Your
symptoms will go away after the baby comes.”
C. “Pregnant women urinate frequently to get rid of fetal wastes. Limit fluids to
1L/daily.”
D. “Frequency is due to bladder irritation from concentrate urine and is normal in
pregnancy. Increase your daily fluid intake to 3L.”
23. Which of the following will help the nurse determine that the expression of
hostility is useful?

A. Expression of anger dissipates the energy.

B. Energy from anger is used to accomplish what needs to be done.
C. Expression intimidates others.
D. Degree of hostility is less than the provocation.
24. The nurse is providing an orientation regarding case management to the nursing
students. Which characteristics should the nurse include in the discussion in
understanding case management?

A. Main objective is a written plan that combines discipline-specific processes

used to measure outcomes of care.
B. Main purpose is to identify expected client, family and staff performance
against the timeline for clients with the same diagnosis.
C. Main focus is comprehensive coordination of client care, avoid unnecessary
duplication of services, improve resource utilization and decrease cost.
D. Primary goal is to understand why predicted outcomes have not been met and
the correction of identified problems.
25. The physician orders a dose of IV phenytoin to a child client. In preparing in the
administration of the drug, which nursing action is not correct?

A. Infuse the phenytoin into a smaller vein to prevent purple glove syndrome.
B. Check the phenytoin solution to be sure it is clear or light yellow in color, never
cloudy.
C. Plan to give phenytoin over 30-60 minutes, using an in-line filter.
D. Flush the IV tubing with normal saline before starting phenytoin.
26. The pregnant woman visits the clinic for check –up. Which assessment findings
will help the nurse determine that the client is in 8-week gestation?

A. Leopold maneuvers.
B. Fundal height.
C. Positive radioimmunoassay test (RIA test).
D. Auscultation of fetal heart tones.
27. Which of the following nursing intervention is essential for the client who had
pneumonectomy?

A. Medicate for pain only when needed.

B. Connect the chest tube to water-seal drainage.
C. Notify the physician if the chest drainage exceeds 100mL/hr.
D. Encourage deep breathing and coughing.
28. The nurse is providing a health teaching to a group of parents regarding
Chlamydia trachomatis. The nurse is correct in the statement, “Chlamydia trachomatis
is not only an intracellular bacterium that causes neonatal conjunctivitis, but it also
can cause:

A. Discoloration of baby and adult teeth.

B. Pneumonia in the newborn.
C. Snuffles and rhagades in the newborn.
D. Central hearing defects in infancy.
29. The nurse is assigned to care to a 17-year-old male client with a history of
substance abuse. The client asks the nurse, “Have you ever tried or used drugs?” The
most correct response of the nurse would be:

A. “Yes, once I tried grass.”

B. “No, I don’t think so.”
C. “Why do you want to know that?”
D. “How will my answer help you?”
30. Which of the following describes a health care team with the principles of
participative leadership?

A. Each member of the team can independently make decisions regarding the
client’s care without necessarily consulting the other members.
B. The physician makes most of the decisions regarding the client’s care.
C. The team uses the expertise of its members to influence the decisions regarding
the client’s care.
D. Nurses decide nursing care; physicians decide medical and other treatment for
the client.
31. A nurse is giving a health teaching to a woman who wants to breastfeed her
newborn baby. Which hormone, normally secreted during the postpartum period,
influences both the milk ejection reflex and uterine involution?

A. Oxytocin.
B. Estrogen.
C. Progesterone.
D. Relaxin.
32. One staff nurse is assigned to a group of 5 patients for the 12-hour shift. The nurse
is responsible for the overall planning, giving and evaluating care during the entire
shift. After the shift, same responsibility will be endorsed to the next nurse in charge.
This describes nursing care delivered via the:

A. Primary nursing method.

 B. Case method.
C. Functional method.
D. Team method.
33. The ambulance team calls the emergency department that they are going to bring a
client who sustained burns in a house fire. While waiting for the ambulance, the nurse
will anticipate emergency care to include assessment for:

A. Gas exchange impairment.

B. Hypoglycemia.
C. Hyperthermia.
D. Fluid volume excess.
34. Most couples are using “natural” family planning methods. Most accidental
pregnancies in couples preferred to use this method have been related to unprotected
intercourse before ovulation. Which of the following factor explains why pregnancy
may be achieved by unprotected intercourse during the preovulatory period?

A. Ovum viability.
B. Tubal motility.
C. Spermatozoal viability.
D. Secretory endometrium.
35. An older adult client wakes up at 2 o’clock in the morning and comes to the
nurse’s station saying, “I am having difficulty in sleeping.” What is the best nursing
response to the client?

A. “I’ll give you a sleeping pill to help you get more sleep now.”
B. “Perhaps you’d like to sit here at the nurse’s station for a while.”
C. “Would you like me to show you where the bathroom is?”
D. “What woke you up?”
36. The nurse is taking care of a multipara who is at 42 weeks of gestation and in
active labor, her membranes ruptured spontaneously 2 hours ago. While auscultating
for the point of maximum intensity of fetal heart tones before applying an external
fetal monitor, the nurse counts 100 beats per minute. The immediate nursing action is
to:

A. Start oxygen by mask to reduce fetal distress.

B. Examine the woman for signs of a prolapsed cord.
C. Turn the woman on her left side to increase placental perfusion.
D. Take the woman’s radial pulse while still auscultating the FHR.
37. The nurse must instruct a client with glaucoma to avoid taking over-the-counter
medications like:
 A. Antihistamines.
B. NSAIDs.
C. Antacids.
D. Salicylates.
38. A male client is brought to the emergency department due to motor vehicle
accident. While monitoring the client, the nurse suspects increasing intracranial
pressure when:

A. Client is oriented when aroused from sleep, and goes back to sleep
immediately.
B. Blood pressure is decreased from 160/90 to 110/70.
C. Client refuses dinner because of anorexia.
D. Pulse is increased from 88-96 with occasional skipped beat.
39. The nurse is conducting a lecture to a class of nursing students about advance
directives to preoperative clients. Which of the following statement by the nurse js
correct?

A. “The spouse, but not the rest of the family, may override the advance
directive.”
B. “An advance directive is required for a “do not resuscitate” order.”
C. “A durable power of attorney, a form of advance directive, may only be held by
a blood relative.”
D. “The advance directive may be enforced even in the face of opposition by the
spouse.”
40. A client diagnosed with schizophrenia is shouting and banging on the door leading
to the outside, saying, “I need to go to an appointment.” What is the appropriate
nursing intervention?

A. Tell the client that he cannot bang on the door.

B. Ignore this behavior.
C. Escort the client going back into the room.
D. Ask the client to move away from the door.
41. Which of the following action is an accurate tracheal suctioning technique?

A. 25 seconds of continuous suction during catheter insertion.

B. 20 seconds of continuous suction during catheter insertion.
C. 10 seconds of intermittent suction during catheter withdrawal.
D. 15 seconds of intermittent suction during catheter withdrawal.
42. The client’s jaw and cheekbone is sutured and wired. The nurse anticipates that
the most important thing that must be ready at the bedside is:
 A. Suture set.
B. Tracheostomy set.
C. Suction equipment.
D. Wire cutters.
43. A mother is in the third stage of labor. Which of the following signs will help the
nurse determine the signs of placental separation?

A. The uterus becomes globular.

B. The umbilical cord is shortened.
C. The fundus appears at the introitus.
D. Mucoid discharge is increased.
44. After therapy with the thrombolytic alteplase (t-PA), what observation will the
nurse report to the physician?

A. 3+ peripheral pulses.
B. Change in level of consciousness and headache.
C. Occasional dysrhythmias.
D. Heart rate of 100/bpm.
45. A client who undergone left nephrectomy has a large flank incision. Which of the
following nursing action will facilitate deep breathing and coughing?

A. Push fluid administration to loosen respiratory secretions.

B. Have the client lie on the unaffected side.
C. Maintain the client in high Fowler’s position.
D. Coordinate breathing and coughing exercise with administration of analgesics.
46. The community nurse is teaching the group of mothers about the cervical mucus
method of natural family planning. Which characteristics are typical of the cervical
mucus during the “fertile” period of the menstrual cycle?

A. Absence of ferning.
B. Thin, clear, good spinnbarkeit.
C. Thick, cloudy.
D. Yellow and sticky.
47. A client with ruptured appendix had surgery an hour ago and is transferred to the
nursing care unit. The nurse placed the client in a semi-Fowler’s position primarily to:

A. Facilitate movement and reduce complications from immobility.

B. Fully aerate the lungs.
C. Splint the wound.
D. Promote drainage and prevent subdiaphragmatic abscesses.
48. Which of the following will best describe a management function?
 A. Writing a letter to the editor of a nursing journal.
B. Negotiating labor contracts.
C. Directing and evaluating nursing staff members.
D. Explaining medication side effects to a client.
49. The parents of an infant client ask the nurse to teach them how to administer
Cortisporin eye drops. The nurse is correct in advising the parents to place the drops:

A. In the middle of the lower conjunctival sac of the infant’s eye.

B. Directly onto the infant’s sclera.
C. In the outer canthus of the infant’s eye.
D. In the inner canthus of the infant’s eye.
50. The nurse is assessing on the client who is admitted due to vehicle accident.
Which of the following findings will help the nurse that there is internal bleeding?

A. Frank blood on the clothing.

B. Thirst and restlessness.
C. Abdominal pain.
D. Confusion and altered of consciousness.
51. The nurse is completing an assessment to a newborn baby boy. The nurse observes
that the skin of the newborn is dry and flaking and there are several areas of an
apparent macular rash. The nurse charts this as:

A. Icterus neonatorum
B. Multiple hemangiomas
C. Erythema toxicum
D. Milia
52. The client is brought to the emergency department because of serious vehicle
accident. After an hour, the client has been declared brain dead. The nurse who has
been with the client must now talk to the family about organ donation. Which of the
following consideration is necessary?

A. Include as many family members as possible.

B. Take the family to the chapel.
C. Discuss life support systems.
D. Clarify the family’s understanding of brain death.
53. The nurse is teaching exercises that are good for pregnant women increasing tone
and fitness and decreasing lower backache. Which of the following should the nurse
exclude in the exercise program?

A. Stand with legs apart and touch hands to floor three times per day.
B. Ten minutes of walking per day with an emphasis on good posture.
 C. Ten minutes of swimming or leg kicking in pool per day.
D. Pelvic rock exercise and squats three times a day.
54. A client with obsessive-compulsive behavior is admitted in the psychiatric unit.
The nurse taking care of the client knows that the primary treatment goal is to:

A. Provide distraction.
B. Support but limit the behavior.
C. Prohibit the behavior.
D. Point out the behavior.
55. After ileostomy, the nurse expects that the drainage appliance will be applied to
the stoma:

A. When the client is able to begin self-care procedures.

B. 24 hours later, when the swelling subsided.
C. In the operating room after the ileostomy procedure.
D. After the ileostomy begins to function.
56. A female client who has a 28-day menstrual cycle asks the community health
nurse when she get pregnant during her cycle. What will be the best nursing response?

A. It is impossible to determine the fertile period reliably. So it is best to assume

that a woman is always fertile.
B. In a 28-day cycle, ovulation occurs at or about day 14. The egg lives for about
24 hours and the sperm live for about 72 hours. The fertile period would be
approximately between day 11 and day 15.
C. In a 28- day cycle, ovulation occurs at or about day 14. The egg lives for about
72 hours and the sperm live for about 24 hours. The fertile period would be
approximately between day 13 and 17.
D. In a 28-day cycle, ovulation occurs 8 days before the next period or at about
day 20. The fertile period is between day 20 and the beginning of the next
period.
57. Which of the following statement describes the role of a nurse as a client
advocate?

A. A nurse may override clients’ wishes for their own good.

B. A nurse has the moral obligation to prevent harm and do well for clients.
C. A nurse helps clients gain greater independence and self-determination.
D. A nurse measures the risk and benefits of various health situations while
factoring in cost.
58. A community health nurse is providing a health teaching to a woman infected with
herpes simplex 2. Which of the following health teaching must the nurse include to
reduce the chances of transmission of herpes simplex 2?
 A. “Abstain from intercourse until lesions heal.”
B. “Therapy is curative.”
C. “Penicillin is the drug of choice for treatment.”
D. “The organism is associated with later development of hydatidiform mole.
59. The nurse in the psychiatric ward informed the male client that he will be
attending the 9:00 AM group therapy sessions. The client tells the nurse that he must
wash his hands from 9:00 to 9:30 AM each day and therefore he cannot attend. Which
concept does the nursing staff need to keep in mind in planning nursing intervention
for this client?

A. Depression underlines ritualistic behavior.

B. Fear and tensions are often expressed in disguised form through symbolic
processes.
C. Ritualistic behavior makes others uncomfortable.
D. Unmet needs are discharged through ritualistic behavior.
60. The nurse assesses the health condition of the female client. The client tells the
nurse that she discovered a lump in the breast last year and hesitated to seek medical
advice. The nurse understands that, women who tend to delay seeking medical advice
after discovering the disease are displaying what common defense mechanism?

A. Intellectualization.
B. Suppression.
C. Repression.
D. Denial.
61. Which of the following situations cannot be delegated by the registered nurse to
the nursing assistant?

A. A postoperative client who is stable needs to ambulate.

B. Client in soft restraint who is very agitated and crying.
C. A confused elderly woman who needs assistance with eating.
D. Routine temperature check that must be done for a client at end of shift.
62. In the admission care unit, which of the following client would the nurse give
immediate attention?

A. A client who is 3 days postoperative with left calf pain.

B. A client who is postoperative hip pinning who is complaining of pain.
C. New admitted client with chest pain.
D. A client with diabetes who has a glucoscan reading of 180.
63. A couple seeks medical advice in the community health care unit. A couple has
been unable to conceive; the man is being evaluated for possible problems. The
physician ordered semen analysis. Which of the following instructions is correct
regarding collection of a sperm specimen?

A. Collect a specimen at the clinic, place in iced container, and give to laboratory
personnel immediately.
B. Collect specimen after 48-72 hours of abstinence and bring to clinic within 2
hours.
C. Collect specimen in the morning after 24 hours of abstinence and bring to clinic
immediately.
D. Collect specimen at night, refrigerate, and bring to clinic the next morning.
64. The physician ordered Betamethasone to a pregnant woman at 34 weeks of
gestation with sign of preterm labor. The nurse expects that the drug will:

A. Treat infection.
B. Suppress labor contraction.
C. Stimulate the production of surfactant.
D. Reduce the risk of hypertension.
65. A tracheostomy cuff is to be deflated, which of the following nursing intervention
should be implemented before starting the procedures?

A. Suction the trachea and mouth.

B. Have the obdurator available.
C. Encourage deep breathing and coughing.
D. Do a pulse oximetry reading.
66. A client is diagnosed with Tuberculosis and respiratory isolation is initiated. This
means that:

A. Gloves are worn when handling the client’s tissue, excretions, and linen.
B. Both client and attending nurse must wear masks at all times.
C. Nurse and visitors must wear masks until chemotherapy is begun. Client is
instructed in cough and tissue techniques.
D. Full isolation; that is, caps and gowns are required during the period of
contagion.
67. A client with lung cancer is admitted in the nursing care unit. The husband wants
to know the condition of his wife. How should the nurse respond to the husband?

A. Find out what information he already has.

B. Suggest that he discuss it with his wife.
C. Refer him to the doctor.
D. Refer him to the nurse in charge.
68. A hospitalized client cannot find his handkerchief and accuses other cient in the
room and the nurse of stealing them. Which is the most therapeutic approach to this
client?

A. Divert the client’s attention.

B. Listen without reinforcing the client’s belief.
C. Inject humor to defuse the intensity.
D. Logically point out that the client is jumping to conclusions.

Hint - Story
Lead - Question proper

69. After a cystectomy and formation of an ileal conduit, the nurse provides
instruction regarding prevention of leakage of the pouch and backflow of the
urine. The nurse is correct to include in the instruction to empty the urine pouch:

A. Every 3-4 hours.

B. Every hour.
C. Twice a day.
D. Once before bedtime.
70. Which telephone call from a student’s mother should the school nurse take care of
at once?

A. A telephone call notifying the school nurse that the child’ pediatrician has
informed the mother that the child will need cardiac repair surgery within the
next few weeks.
B. A telephone call notifying the school nurse that the child’s pediatrician has
informed the mother that the child has head lice.
C. A telephone call notifying the school nurse that a child has a temperature of
102ºF and a rash covering the trunk and upper extremities of the body.
D. A telephone call notifying the school nurse that a child underwent an
emergency appendectomy during the previous night.

71. Which of the following signs and symptoms that require immediate attention
and may indicate most serious complications during pregnancy?

A. Severe abdominal pain or fluid discharge from the vagina.

 B. Excessive saliva, “bumps around the areolae, and increased vaginal mucus.
C. Fatigue, nausea, and urinary frequency at any time during pregnancy.
D. Ankle edema, enlarging varicosities, and heartburn.

72. The nurse is assessing the newborn boy. Apgar scores are 7 and 9. The newborn
becomes slightly cyanotic. What is the initial nursing action?

A. Elevate his head to promote gravity drainage of secretions.

B. Wrap him in another blanket, to reduce heat loss.
C. Stimulate him to cry,, to increase oxygenation.
D. Aspirate his mouth and nose with bulb syringe.
73. The nurse is formulating a plan of care to a client with a somatoform disorder. The
nurse needs to have knowledge of which psychodynamic principle?

A. The symptoms of a somatoform disorder are an attempt to adjust to painful life

situations or to cope with conflicting sexual, aggressive, or dependent feelings.
B. The major fundamental mechanism is regression.
C. The client’s symptoms are imaginary and the suffering is faked.
D. An extensive, prolonged study of the symptoms will be reassuring to the client,
who seeks sympathy, attention and love.
74. An infant is brought to the health care clinic for three immunizations at the same
time. The nurse knows that hepatitis B, DPT, and Haemophilus influenzae type B
immunizations should:

A. Be drawn in the same syringe and given in one injection.

B. Be mixed and inject in the same sites.
C. Not be mixed and the nurse must give three injections in three sites.
D. Be mixed and the nurse must give the injection in three sites.
75. A female client with cancer has radium implants. The nurse wants to maintain the
implants in the correct position. The nurse should position the client:

A. Flat in bed.
B. On the side only.
C. With the foot of the bed elevated.
D. With the head elevated 45-degrees (semi-Fowler’s).
76. The nurse wants to know if the mother of a toddler understands the instructions
regarding the administration of syrup of ipecac. Which of the following statement will
help the nurse to know that the mother needs additional teaching?

A. “I’ll give the medicine if my child gets into some toilet bowl cleaner.”
B. “I’ll give the medicine if my child gets into some aspirin.”
 C. “I’ll give the medicine if my child gets into some plant bulbs.”
D. “I’ll give the medicine if my child gets into some vitamin pills.”
77. To assess if the cranial nerve VII of the client was damaged, which changes would
not be expected?

A. Drooling and drooping of the mouth.

B. Inability to open eyelids on operative side.
C. Sagging of the face on the operative side.
D. Inability to close eyelid on operative side.
78. The community health nurse makes a home visit to a family. During the visit, the
nurse observes that the mother is beating her child. What is the priority nursing
intervention in this situation?

A. Assess the child’s injuries.

B. Report the incident to protective agencies.
C. Refer the family to appropriate support group.
D. Assist the family to identify stressors and use of other coping mechanisms to
prevent further incidents.
79. The nurse in the neonatal care unit is supervising the actions of a certified nursing
assistant in giving care to the newborns. The nursing assistant mistakenly gives a
formula feeding to a newborn that is on water feeding only. The nurse is responsible
for the mistake of the nursing assistant:

A. Always, as a representative of the institution.

B. Always, because nurses who supervise less-trained individuals are responsible
for their mistakes.
C. If the nurse failed to determine whether the nursing assistant was competent to
take care of the client.
D. Only if the nurse agreed that the newborn could be fed formula.
80. The nurse is assigned to care for a client with urinary calculi. Fluid intake of
2L/day is encouraged to the client. the primary reason for this is to:

A. Reduce the size of existing stones.

B. Prevent crystalline irritation to the ureter.
C. Reduce the size of existing stones
D. Increase the hydrostatic pressure in the urinary tract.
81. The nurse is counseling a couple in their mid 30’s who have been unable to
conceive for about 6 months. They are concerned that one or both of them may be
infertile. What is the best advice the nurse could give to the couple?
 A. “it is no unusual to take 6-12 months to get pregnant, especially when the
partners are in their mid-30s. Eat well, exercise, and avoid stress.”
B. “Start planning adoption. Many couples get pregnant when they are trying to
adopt.”
C. “Consult a fertility specialist and start testing before you get any older.”
D. “Have sex as often as you can, especially around the time of ovulation, to
increase your chances of pregnancy.”
82. The nurse is caring for a cient who Is a retired nurse. A 24-hour urine collection
for Creatinine clearance is to be done. The client tells the nurse, “I can’t remember
what this test is for.” The best response by the nurse is:

A. “It provides a way to see if you are passing any protein in your urine.”
B. “It tells how well the kidneys filter wastes from the blood.”
C. “It tells if your renal insufficiency has affected your heart.”
D. “The test measures the number of particles the kidney filters.”
83. The nurse observes the female client in the psychiatric ward that she is having a
hard time sleeping at night. The nurse asks the client about it and the client says, “I
can’t sleep at night because of fear of dying.” What is the best initial nursing
response?

A. “It must be frightening for you to feel that way. Tell me more about it.”
B. “Don’t worry, you won’t die. You are just here for some test.”
C. “Why are you afraid of dying?”
D. “Try to sleep. You need the rest before tomorrow’s test.”
84. In the hospital lobby, the registered nurse overhears a two staff members
discussing about the health condition of her client. What would be the appropriate
action for the registered nurse to take?

A. Join in the conversation, giving her input about the case.

B. Ignore them, because they have the right to discuss anything they want to.
C. Tell them it is not appropriate to discuss such things.
D. Report this incident to the nursing supervisor.
85. The client has had a right-sided cerebrovascular accident. In transferring the client
from the wheelchair to bed, in what position should a client be placed to facilitate safe
transfer?

A. Weakened (L) side of the cient next to bed.

B. Weakened (R) side of the client next to bed.
C. Weakened (L) side of the client away from bed.
D. Weakened (R) side of the cient away from bed.
86. The child client has undergone hip surgery and is in a spica cast. Which of the
following toy should be avoided to be in the child’s bed?

A. A toy gun.
B. A stuffed animal.
C. A ball.
D. Legos.
87. The LPN/LVN asks the registered nurse why oxytocin (Pitocin), 10 units (IV or
IM) must be given to a client after birth fo the fetus. The nurse is correct to explain
that oxytocin:

A. Minimizes discomfort from “afterpains.”

B. Suppresses lactation.
C. Promotes lactation.
D. Maintains uterine tone.
88. The nurse in the nursing care unit is aware that one of the medical staff displays
unlikely behaviors like confusion, agitation, lethargy and unkempt appearance. This
behavior has been reported to the nurse manager several times, but no changes
observed. The nurse should:

A. Continue to report observations of unusual behavior until the problem is

resolved.
B. Consider that the obligation to protect the patient from harm has been met by
the prior reports and do nothing further.
C. Discuss the situation with friends who are also nurses to get ideas .
D. Approach the partner of this medical staff member with these concerns.
89. The physician ordered tetracycline PO qid to a child client who weights 20kg. The
recommended PO tetracycline dose is 25-50 mg/kg/day. What is the maximum single
dose that can be safely administered to this child?

A. 1 g
B. 500 mg
C. 250 mg
D. 125 mg
90. The nurse is completing an obstetric history of a woman in labor. Which event in
the obstetric history will help the nurse suspects dysfunctional labor in the current
pregnancy?

A. Total time of ruptured membranes was 24 hours with the second birth.
B. First labor lasting 24 hours.
C. Uterine fibroid noted at time of cesarean delivery.
 D. Second birth by cesarean for face presentation.
91. The nurse is planning to talk to the client with an antisocial personality disorder.
What would be the most therapeutic approach?

A. Provide external controls.

B. Reinforce the client’s self-concept.
C. Give the client opportunities to test reality.
D. Gratify the client’s inner needs.
92. The nurse is teaching a group of women about fertility awareness, the nurse
should emphasize that basal body temperature:

A. Can be done with a mercury thermometer but no a digital one.

B. The average temperature taken each morning.
C. Should be recorded each morning before any activity.
D. Has a lower degree of accuracy in predicting ovulation than the cervical mucus
test.
93. The nursing applicant has given the chance to ask questions during a job interview
at a local hospital. What should be the most important question to ask that can
increase chances of securing a job offer?

A. Begin with questions about client care assignments, advancement opportunities,

and continuing education.
B. Decline to ask questions, because that is the responsibility of the interviewer.
C. Ask as many questions about the facility as possible.
D. Clarify information regarding salary, benefits, and working hours first, because
this will help in deciding whether or not to take the job.
94. The nurse advised the pregnant woman that smoking and alcohol should be
avoided during pregnancy. The nurse takes into account that the developing fetus is
most vulnerable to environment teratogens that cause malformation during:

A. The entire pregnancy.

B. The third trimester.
C. The first trimester.
D. The second trimester.
95. A male client tells the nurse that there is a big bug in his bed. The most therapeutic
nursing response would be:

A. Silence.
B. “Where’s the bug? I’ll kill it for you.”
C. “I don’t see a bug in your bed, but you seem afraid.”
D. “You must be seeing things.”
96. A pregnant client in late pregnancy is complaining of groin pain that seems worse
on the right side. Which of the following is the most likely cause of it?

A. Beginning of labor.
B. Bladder infection.
C. Constipation.
D. Tension on the round ligament.
97. The nurse is conducting a lecture to a group of volunteer nurses. The nurse is
correct in imparting the idea that the Good Samaritan law protects the nurse from a
suit for malpractice when:

A. The nurse stops to render emergency aid and leaves before the ambulance
arrives.
B. The nurse acts in an emergency at his or her place of employment.
C. The nurse refuses to stop for an emergency outside of the scope of
employment.
D. The nurse is grossly negligent at the scene of an emergency.
98. A woman is hospitalized with mild preeclampsia. The nurse is formulating a plan
of care for this client, which nursing care is least likely to be done?

A. Deep-tendon reflexes once per shift.

B. Vital signs and FHR and rhythm q4h while awake.
C. Absolute bed rest.
D. Daily weight.
99. While feeding a newborn with an unrepaired cardiac defect, the nurse keeps on
assessing the condition of the client. The nurse notes that the newborn’s respiration is
72 breaths per minute. What would be the initial nursing action?

A. Burp the newborn.

B. Stop the feeding.
C. Continue the feeding.
D. Notify the physician.
100. A client who undergone appendectomy 3 days ago is scheduled for discharge
today. The nurse notes that the client is restless, picking at bedclothes and saying, “I
am late on my appointment,” and calling the nurse by the wrong name. The nurse
suspects:

A. Panic reaction.
B. Medication overdose.
C. Toxic reaction to an antibiotic.
D. Delirium tremens.