This action might not be possible to undo. Are you sure you want to continue?
Which of the following nursing actions will facilitate obtaining the specimen? a. b. c. d. Limiting fluid Having the client take deep breaths Asking the client to spit into the collection container Asking the client to obtain the specimen after eating
2. Nurse Joy is caring for a client after a bronchoscopy and biopsy. Which of the following signs, if noticed in the client, should be reported immediately to the physician? a. b. c. d. Dry cough Hermaturia Bronchospasm Blood-streaked sputum
3. A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: a. b. c. d. 1 minute 5 seconds 10 seconds 30 seconds
4. A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which if the following is the appropriate nursing intervention? a. b. c. d. Continue to suction Notify the physician immediately Stop the procedure and reoxygenate the client Ensure that the suction is limited to 15 seconds
5. A male adult client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? a. b. c. d. Dyspnea Bradypnea Bradycardia Decreased respirations
6. A slightly obese female client with a history of allergy-induced asthma, hypertension, and mitral valve prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history and performs a thorough physical examination, paying special attention to the cardiovascular and respiratory systems. When percussing the client‟s chest wall, the nurse expects to elicit: a. b. Resonant sounds. Hyperresonant sounds.
Dull sounds. Flat sounds.
7. A male client who weighs 175 lb (79.4 kg) is receiving aminophylline (Aminophyllin) (400 mg in 500 ml) at 50 ml/hour. The theophylline level is reported as 6 mcg/ml. The nurse calls the physician who instructs the nurse to change the dosage to 0.45 mg/kg/hour. The nurse should: a. b. c. d. Question the order because it‟s too low. Question the order because it‟s too high. Set the pump at 45 ml/hour. Stop the infusion and have the laboratory repeat the theophylline measurement.
8. The nurse is teaching a male client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching? a. b. c. d. Make inhalation longer than exhalation. Exhale through an open mouth. Use diaphragmatic breathing. Use chest breathing.
9. Which phrase is used to describe the volume of air inspired and expired with a normal breath? a. b. c. d. Total lung capacity Forced vital capacity Tidal volume Residual volume
10. A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations? a. b. c. d. Simple mask Non-rebreather mask Face tent Nasal cannula
11. A female client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs? a. b. c. d. Impaired color discrimination Increased urinary frequency Decreased hearing acuity Increased appetite
12. A male client is asking the nurse a question regarding the Mantoux test for tuberculosis. The nurse should base her response on the fact that the:
a. Area of redness is measured in 3 days and determines whether tuberculosis is present. b. Skin test doesn‟t differentiate between active and dormant tuberculosis infection. c. Presence of a wheal at the injection site in 2 days indicates active tuberculosis. d. Test stimulates a reddened response in some clients and requires a second test in 3 months.
13. A female adult client has a tracheostomy but doesn‟t require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for: a. b. c. d. 15 to 60 seconds. 5 to 20 minutes. 30 to 40 minutes. 45 to 60 minutes.
14. Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? a. b. c. d. The system is functioning normally The client has a pneumothorax. The system has an air leak. The chest tube is obstructed.
15. A black client with asthma seeks emergency care for acute respiratory distress. Because of this client‟s dark skin, the nurse should assess for cyanosis by inspecting the: a. b. c. d. Lips. Mucous membranes. Nail beds. Earlobes.
16. For a male client with an endotracheal (ET) tube, which nursing action is most essential? a. b. c. d. Auscultating the lungs for bilateral breath sounds Turning the client from side to side every 2 hours Monitoring serial blood gas values every 4 hours Providing frequent oral hygiene
17. The nurse assesses a male client‟s respiratory status. Which observation indicates that the client is experiencing difficulty breathing? a. b. c. d. Diaphragmatic breathing Use of accessory muscles Pursed-lip breathing Controlled breathing
18. A female client is undergoing a complete physical examination as a requirement for college. When checking the client‟s respiratory status, the nurse observes respiratory excursion to help assess: a. b. c. d. Lung vibrations. Vocal sounds. Breath sounds. Chest movements.
19. A male client comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client‟s history and physical findings, the physician suspects legionnaires‟ disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What is the drug of choice for treating legionnaires‟ disease? a. b. c. d. Erythromycin (Erythrocin) Rifampin (Rifadin) Amantadine (Symmetrel) Amphotericin B (Fungizone)
20. A male client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can‟t produce an effective cough, the nurse should monitor closely for: a. b. c. d. Pleural effusion. Pulmonary edema. Atelectasis. Oxygen toxicity.
21. The nurse in charge is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide? a. b. It helps prevent early airway collapse. It increases inspiratory muscle strength.
It decreases use of accessory breathing muscles. It prolongs the inspiratory phase of respiration.
22. After receiving an oral dose of codeine for an intractable cough, the male client asks the nurse, “How long will it take for this drug to work?” How should the nurse respond? a. b. c. d. In 30 minutes In 1 hour In 2.5 hours In 4 hours
23. A male client suffers adult respiratory distress syndrome as a consequence of shock. The client‟s condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? a. b. c. d. Kinking of the ventilator tubing A disconnected ventilator tube An ET cuff leak A change in the oxygen concentration without resetting the oxygen level alarm
24. A female client with chronic obstructive pulmonary disease (COPD) takes anhydrous theophylline, 200 mg P.O. every 8 hours. During a routine clinic visit, the client asks the nurse how the drug works. What is the mechanism of action of anhydrous theophylline in treating a nonreversible obstructive airway disease such as COPD? a. It makes the central respiratory center more sensitive to carbon dioxide and stimulates the respiratory drive. b. It inhibits the enzyme phosphodiesterase, decreasing degradation of cyclic adenosine monophosphate, a bronchodilator. c. It stimulates adenosine receptors, causing bronchodilation. d. It alters diaphragm movement, increasing chest expansion and enhancing the lung‟s capacity for gas exchange.
25. A male client with pneumococcal pneumonia is admitted to an acute care facility. The client in the next room is being treated for mycoplasmal pneumonia. Despite the different causes of the various types of pneumonia, all of them share which feature? a. b. c. d. Inflamed lung tissue Sudden onset Responsiveness to penicillin. Elevated white blood cell (WBC) count
26. A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? a. b. c. d. pH, 5.0; PaCO2 30 mm Hg pH, 7.40; PaCO2 35 mm Hg pH, 7.35; PaCO2 40 mm Hg pH, 7.25; PaCO2 50 mm Hg
27. A male client admitted to an acute care facility with pneumonia is receiving supplemental oxygen, 2 L/minute via nasal cannula. The client‟s history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. Because of these history findings, the nurse closely monitors the oxygen flow and the client‟s respiratory status. Which complication may arise if the client receives a high oxygen concentration? a. b. c. d. Apnea Anginal pain Respiratory alkalosis Metabolic acidosis
28. At 11 p.m., a male client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He‟s anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client‟s arterial blood oxygen saturation is 86% and he‟s still wheezing. The nurse should plan to administer: a. b. c. d. Alprazolam (Xanax). Propranolol (Inderal) Morphine. Albuterol (Proventil).
29. After undergoing a thoracotomy, a male client is receiving epidural analgesia. Which assessment finding indicates that the client has developed the most serious complication of epidural analgesia? a. b. c. d. Heightened alertness Increased heart rate Numbness and tingling of the extremities Respiratory depression
30. The nurse in charge formulates a nursing diagnosis of Activity intolerance related to inadequate oxygenation and dyspnea for a client with chronic bronchitis. To minimize this problem, the nurse instructs the client to avoid conditions that increase oxygen demands. Such conditions include: a. b. c. d. Drinking more than 1,500 ml of fluid daily. Being overweight. Eating a high-protein snack at bedtime. Eating more than three large meals a day.
A male client who takes theophylline for chronic obstructive pulmonary disease is seen in the urgent care center for respiratory distress. Once the client is stabilized, the nurse begins discharge teaching. The nurse would be especially vigilant to include information about complying with medication therapy if the client‟s baseline theophylline level was: a. 10 mcg/mL b. 12 mcg/mL c. 15 mcg/mL d. 18mcg/mL 2. Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate? a. Do nothing, because this is an expected finding. b. Immediately clamp the chest tube and notify the physician. c. Check for an air leak because the bubbling should be intermittent. d. Increase the suction pressure so that bubbling becomes vigorous. 3. A nurse has assisted a physician with the insertion of a chest tube. The nurse monitors the adult client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate? a. Inform the physician. b. Continue to monitor the client. c. Reinforce the occlusive dressing. d. Encourage the client to deep-breathe. 4. The nurse caring for a male client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to: a. Call the physician. b. Place the tube in a bottle of sterile water. c. Immediately replace the chest tube system. d. Place the sterile dressing over the disconnection site. 5. Nurse Paul is assisting a physician with the removal of a chest tube. The nurse should
instruct the client to: a. Exhale slowly. b. Stay very still. c. Inhale and exhale quickly. d. Perform the Valsalva maneuver. 6. While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to: a. Call the physician to reinsert the tube. b. Grasp the retention sutures to spread the opening. c. Call the respiratory therapy department to reinsert the tracheotomy. d. Cover the tracheostomy site with a sterile dressing to prevent infection. 7. A nurse is caring for a male client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client? a. Stridor b. Occasional pink-tinged sputum c. A few basilar lung crackles on the right d. Respiratory rate of 24 breaths/min 8. An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? a. A low respiratory b. Diminished breathe sounds c. The presence of a barrel chest d. A sucking sound at the site of injury 9. A nurse is caring for a male client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client? a. Hypocapnia b. A hyperinflated chest noted on the chest x-ray c. Increase oxygen saturation with exercise d. A widened diaphragm noted on the chest x-ray 10. A community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is: a. Dyspnea b. Chest pain
c. A bloody, productive cough d. A cough with the expectoration of mucoid sputum 11. A nurse performs an admission assessment on a female client with a diagnosis of tuberculosis. The nurse reviews the results of which diagnostic test that will confirm this diagnosis? a. Bronchoscopy b. Sputum culture c. Chest x-ray d. Tuberculin skin test 12. The nursing instructor asks a nursing student to describe the route of transmission of tuberculosis. The instructor concludes that the student understands this information if the student states that the tuberculosis is transmitted by: a. Hand and mouth b. The airborne route c. The fecal-oral route d. Blood and body fluids 13. A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed: a. 1 L/min b. 2 L/min c. 6 L/min d. 10 L/min 14. A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: a. Promote oxygen intake. b. Strengthen the diaphragm. c. Strengthen the intercostal muscles. d. Promote carbon dioxide elimination. 15. Nurse Hannah is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate obtaining the specimen? a. Limiting fluids b. Having the clients take three deep breaths c. Asking the client to split into the collection container d. Asking the client to obtain the specimen after eating
16. A nurse is caring for a female client after a bronchoscope and biopsy. Which of the following signs, if noted in the client, should be reported immediately to the physicians? a. Dry cough b. Hematuria c. Bronchospasm d. Blood-streaked sputum 17. A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: a. 1 minute b. 5 seconds c. 10 seconds d. 30 seconds 18. A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which of the following is the appropriate nursing intervention? a. Continue to suction. b. Notify the physician immediately. c. Stop the procedure and reoxygenate the client. d. Ensure that the suction is limited to 15 seconds. 19. An unconscious male client is admitted to an emergency room. Arterial blood gas measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, a normal oxygen level, and an elevated potassium level. These results indicate the presence of: a. Metabolic acidosis b. Respiratory acidosis c. Overcompensated respiratory acidosis d. Combined respiratory and metabolic acidosis 20. A female client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? a. Dyspnea b. Bradypnea c. Bradycardia d. Decreased respiratory 21. A nurse teaches a male client about the use of a respiratory inhaler. Which action by the
client indicates a need for further teaching? a. Inhales the mist and quickly exhales b. Removes the cap and shakes the inhaler well before use c. Presses the canister down with the finger as he breathes in d. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed 22. A female client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of the following nursing interventions for this client? a. Administering atropine intravenously b. Administering small doses of midazolam (Versed) c. Encouraging additional fluids for the next 24 hours d. Ensuring the return of the gag reflex before offering food or fluids 23. A nurse is assessing the respiratory status of a male client who has suffered a fractured rib. The nurse would expect to note which of the following? a. Slow deep respirations b. Rapid deep respirations c. Paradoxical respirations d. Pain, especially with inspiration 24. A female client with chest injury has suffered flail chest. A nurse assesses the client for which most distinctive sign of flail chest? a. Cyanosis b. Hypotension c. Paradoxical chest movement d. Dyspnea, especially on exhalation 25. A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of: a. Right pneumothorax b. Pulmonary embolism c. Displaced endotracheal tube d. Acute respiratory distress syndrome 26. A nurse is teaching a male client with chronic respiratory failure how to use a metereddose inhaler correctly. The nurse instructs the client to: a. Inhale quickly b. Inhale through the nose
c. Hold the breath after inhalation d. Take two inhalations during one breath 27. A nurse is assessing a female client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome? a. Bilateral wheezing b. Inspiratory crackles c. Intercostal retractions d. Increased respiratory rate 28. A nurse is taking pulmonary artery catheter measurements of a male client with acute respiratory distress syndrome. The pulmonary capillary wedge pressure reading is 12mm Hg. The nurse interprets that this readings is: a. High and expected b. Low and unexpected c. Normal and expected d. Uncertain and unexpected 29. A nurse is assessing a male client with chronic airflow limitations and notes that the client has a “barrel chest.” The nurse interprets that this client has which of the following forms of chronic airflow limitations? a. Emphysema b. Bronchial asthma c. Chronic obstructive bronchitis d. Bronchial asthma and bronchitis 30. A nurse is caring for a female client diagnosed with tuberculosis. Which assessment, if made by the nurse, is inconsistent with the usual clinical presentation of tuberculosis and may indicate the development of a concurrent problem? a. Cough b. High-grade fever c. Chills and night sweats d. Anorexia and weight loss
1. The registered nurse is planning to delegate tasks to unlicensed assistive personnel (UAP). Which of the following task could the registered nurse safely assigned to a UAP? A) Monitor the I&O of a comatose toddler client with salicylate poisoning B) Perform a complete bed bath on a 2-year-old with multiple injuries from a serious fall C) Check the IV of a preschooler with Kawasaki disease D) Give an outmeal bath to an infant with eczema
2. A nurse manager assigned a registered nurse from telemetry unit to the pediatrics unit. There were three patients assigned to the RN. Which of the following patients should not be assigned to the floated nurse? A) A 9-year-old child diagnosed with rheumatic fever B) A young infant after pyloromyotomy C) A 4-year-old with VSD following cardiac catheterization D) A 5-month-old with Kawasaki disease 3. A nurse in charge in the pediatric unit is absent. The nurse manager decided to assign the nurse in the obstetrics unit to the pediatrics unit. Which of the following patients could the nurse manager safely assign to the float nurse? A) A child who had multiple injuries from a serious vehicle accident B) A child diagnosed with Kawasaki disease and with cardiac complications C) A child who has had a nephrectomy for Wilm‟s tumor D) A child receiving an IV chelating therapy for lead poisoning 4. The registered nurse is planning to delegate task to a certified nursing assistant. Which of the following clients should not be assigned to a CAN? A) A client diagnosed with diabetes and who has an infected toe B) A client who had a CVA in the past two months C) A client with Chronic renal failure D) A client with chronic venous insufficiency 5. The nurse in the medication unit passes the medications for all the clients on the nursing unit. The head nurse is making rounds with the physician and coordinates clients‟ activities with other departments. The nurse assistant changes the bed lines and answers call lights. A second nurse is assigned for changing wound dressings; a licensed practitioner nurse takes vital signs and bathes theclients. This illustrates of what method of nursing care? A) Case management method B) Primary nursing method C) Team method D) Functional method 6. A registered nurse has been assigned to six clients on the 12-hour shift. The RN is responsible for every aspect of care such as formulating the care of plan, intervention and evaluating the care during her shift. At the end of her shift, the RN will pass this same task to the next RN in charge. This nursing care illustrates of what kind of method? A) primary nursing method B) case method C) team method D) functional method
7. A newly hired nurse on an adult medicine unit with 3 months experience was asked to float to pediatrics. The nurse hesitates to perform pediatric skills and receive an interesting assignment that feels overwhelming. The nurse should: A) resign on the spot from the nursing position and apply for a position that does not require floating B) Inform the nursing supervisor and the charge nurse on the pediatric floor about the nurse‟s lack of skill and feelings of hesitations and request assistance C) Ask several other nurses how they feel about pediatrics and find someone else who is willing to accept the assignment D) Refuse the assignment and leave the unit requesting a vacation a day 8. An experienced nurse who voluntarily trained a less experienced nurse with the intention of enhancing the skills and knowledge and promoting professional advancement to the nurse is called a: A) mentor B) team leader C) case manager D) change agent 9. The pediatrics unit is understaffed and the nurse manager informs the nurses in the obstetrics unit that she is going to assign one nurse to float in the pediatric units. Which statement by the designated float nurse may put her job at risk? A) “I do not get along with one of the nurses on the pediatrics unit” B) “I have a vacation day coming and would like to take that now” C) “I do not feel competent to go and work on that area” D) “ I am afraid I will get the most serious clients in the unit” 10. The newly hired staff nurse has been working on a medical unit for 3 weeks. The nurse manager has posted the team leader assignments for the following week. The new staff knows that a major responsibility of the team leader is to: A) Provide care to the most acutely ill client on the team B) Know the condition and needs of all the patients on the team C) Document the assessments completed by the team members D) Supervise direct care by nursing assistants 11. A 15-year-old girl just gave birth to a baby boy who needs emergency surgery. The nurse prepared the consent form and it should be signed by: A) The Physician B) The Registered Nurse caring for the client C) The 15-year-old mother of the baby boy D) The mother of the girl
12. A nurse caring to a client with Alzheimer‟s disease overheard a family member say to the client, “if you pee one more time, I won‟t give you any more food and drinks”. What initial action is best for the nurse to take? A) Take no action because it is the family member saying that to the client B) Talk to the family member and explain that what she/he has said is not appropriate for the client C) Give the family member the number for an Elder Abuse Hot line D) Document what the family member has said 13. Which is true about informed consent? A) A nurse may accept responsibility signing a consent form if the client is unable B) Obtaining consent is not the responsibility of the physician C) A physician will not subject himself to liability if he withholds any facts that are necessary to form the basis of an intelligent consent D) If the nurse witnesses a consent for surgery, the nurse is, in effect, indicating that the signature is that of the purported person and that the person‟s condition is as indicated at the time of signing 14. A mother in labor told the nurse that she was expecting that her baby has no chance to survive and expects that the baby will be born dead. The mother accepts the fate of the baby and informs the nurse that when the baby is born and requires resuscitation, the mother refuses any treatment to her baby and expresses hostility toward the nurse while the pediatric team is taking care of the baby. The nurse is legally obligated to: A) Notify the pediatric team that the mother has refused resuscitation and any treatment for the baby and take the baby to the mother B) Get a court order making the baby a ward of the court C) Record the statement of the mother, notify the pediatric team, and observe carefully for signs of impaired bonding and neglect as a reasonable suspicion of child abuse D) Do nothing except record the mother‟s statement in the medical record 15. The hospitalized client with a chronic cough is scheduled for bronchoscopy. The nurse is tasks to bring the informed consent document into the client‟s room for a signature. The client asks the nurse for details of the procedure and demands an explanation why the process of informed consent is necessary. The nurse responds that informed consent means: A) The patient releases the physician from all responsibility for the procedure. B) The immediate family may make decision against the patient‟s will. C) The physician must give the client or surrogates enough information to make health care judgments consistent with their values and goals. D) The patient agrees to a procedure ordered by the physician even if the client does not understand what the outcome will be.
16. A hospitalized client with severe necrotizing ulcer of the lower leg is schedule for an amputation. The client tells the nurse that he will not sign the consent form and he does not want any surgery or treatment because of religious beliefs about reincarnation. What is the role of the RN? A) call a family meeting B) discuss the religious beliefs with the physician C) encourage the client to have the surgery D) inform the client of other options 17. While in the hospital lobby, the RN overhears the three staff discussing the health condition of her client. What would be the appropriate nursing action for the RN to take? A) Tell them it is not appropriate to discuss the condition of the client B) Ignore them, because it is their right to discuss anything they want to C) Join in the conversation, giving them supportive input about the case of the client D) Report this incident to the nursing supervisor 18. A staff nurse has had a serious issue with her colleague. In this situation, it is best to: A) Discuss this with the supervisor B) Not discuss the issue with anyone. It will probably resolve itself C) Try to discuss with the colleague about the issue and resolve it when both are calmer D) Tell other members of the network what the team member did 19. The nurse is caring to a client who just gave birth to a healthy baby boy. The nurse may not disclose confidential information when: A) The nurse discusses the condition of the client in a clinical conference with other nurses B) The client asks the nurse to discuss the her condition with the family C) The father of a woman who just delivered a baby is on the phone to find out the sex of the baby D) A researcher from an institutionally approved research study reviews the medical record of a patient 20. A 17-year-old married client is scheduled for surgery. The nurse taking care of the client realizes that consent has not been signed after preoperative medications were given. What should the nurse do? A) Call the surgeon B) Ask the spouse to sign the consent C) Obtain a consent from the client as soon as possible D) Get a verbal consent from the parents of the client 21. A 12-year-old client is admitted to the hospital. The physician ordered Dilantin to the client. In administering IV phenytoin (Dilantin) to a child, the nurse would be most correct
in mixing it with: A) Normal Saline B) Heparinized normal saline C) 5% dextrose in water D) Lactated Ringer‟s solution 22. The nurse is caring to a client who is hypotensive. Following a large hematemesis, how should the nurse position the client? A) Feet and legs elevated 20 degrees, trunk horizontal, head on small pillow B) Low Fowler‟s with knees gatched at 30 degrees C) Supine with the head turned to the left D) Bed sloped at a 45 degree angle with the head lowest and the legs highest 23. The client is brought to the emergency department after a serious accident. What would be the initial nursing action of the nurse to the client? A) assess the level of consciousness and circulation B) check respirations, circulation, neurological response C) align the spine, check pupils, check for hemorrhage D) check respiration, stabilize spine, check circulation 24. A nurse is assigned to care to a client with Parkinson‟s disease. What interventions are important if the nurse wants to improve nutrition and promote effective swallowing of the client? A) Eat solid food B) Give liquids with meals C) Feed the client D) Sit in an upright position to eat 25. During tracheal suctioning, the nurse should implement safety measures. Which of the following should the nurse implements? A) limit suction pressure to 150-180 mmHg B) suction for 15-20 seconds C) wear eye goggles D) remove the inner cannula 26. The nurse is conducting a discharge instructions to a client diagnosed with diabetes. What sign of hypoglycemia should be taught to a client? A) warm, flushed skin B) hunger and thirst C) increase urinary output D) palpitation and weakness
27. A client admitted to the hospital and diagnosed with Addison‟s disease. What would be the appropriate nursing action to the client? A) administering insulin-replacement therapy B) providing a low-sodium diet C) restricting fluids to 1500 ml/day D) reducing physical and emotional stress 28. The nurse is to perform tracheal suctioning. During tracheal suctioning, which nursing action is essential to prevent hypoxemia? A) aucultating the lungs to determine the baseline data to assess the effectiveness of suctioning B) removing oral and nasal secretions C) encouraging the patient to deep breathe and cough to facilitate removal of upper-airway secretions D) administering 100% oxygen to reduce the effects of airway obstruction during suctioning. 29. An infant is admitted and diagnosed with pneumonia and suspicious-looking red marks on the swollen face resembling a handprint. The nurse does further assessment to the client. How would the nurse document the finding? A) Facial edema with ecchymosis and handprint mark: crackles and wheezes B) Facial edema, with red marks; crackles in the lung C) Facial edema with ecchymosis that looks like a handprint D) Red bruise mark and ecchymosis on face 30. On the evening shift, the triage nurse evaluates several clients who were brought to the emergency department. Which in the following clients should receive highest priority? A) an elderly woman complaining of a loss of appetite and fatigue for the past week B) A football player limping and complaining of pain and swelling in the right ankle C) A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his jaw D) A mother with a 5-year-old boy who says her son has been complaining of nausea and vomited once since noon 31. A 80-year-old female client is brought to the emergency department by her caregiver, on the nurse‟s assessment; the following are the manifestations of the client: anorexia, cachexia and multiple bruises. What would be the best nursing intervention? A) check the laboratory data for serum albumin, hematocrit, and hemoglobin B) talk to the client about the caregiver and support system C) complete a police report on elder abuse D) complete a gastrointestinal and neurological assessment
32. The night shift nurse is making rounds. When the nurse enters a client‟s room, the client is on the floor next to the bed. What would be the initial action of the nurse? A) chart that the patient fell B) call the physician C) chart that the client was found on the floor next to the bed D) fill out an incident report 33. The nurse on the night shift is about to administer medication to a preschooler client and notes that the child has no ID bracelet. The best way for the nurse to identify the client is to ask: A) The adult visiting, “The child‟s name is ____________________?” B) The child, “Is your name____________?” C) Another staff nurse to identify this child D) The other children in the room what the child‟s name is 34. The nurse caring to a client has completed the assessment. Which of the following will be considered to be the most accurate charting of a lump felt in the right breast? A) “abnormally felt area in the right breast, drainage noted” B) “hard nodular mass in right breast nipple” C) “firm mass at five „ clock, outer quadrant, 1cm from right nipple‟ D) “mass in the right breast 4cmx1cm 35. The physician instructed the nurse that intravenous pyelogram will be done to the client. The client asks the nurse what is the purpose of the procedure. The appropriate nursing response is to: A) outline the kidney vasculature B) determine the size, shape, and placement of the kidneys C) test renal tubular function and the patency of the urinary tract D) measure renal blood flow 36. A client visits the clinic for screening of scoliosis. The nurse should ask the client to: A) bend all the way over and touch the toes B) stand up as straight and tall as possible C) bend over at a 90-degree angle from the waist D) bend over at a 45-degree angle from the waist 37. A client with tuberculosis is admitted in the hospital for 2 weeks. When a client‟s family members come to visit, they would be adhering to respiratory isolation precautions when they:
A) wash their hands when leaving B) put on gowns, gloves and masks C) avoid contact with the client‟s roommate D) keep the client‟s room door open 38. An infant is brought to the emergency department and diagnosed with pyloric stenosis. The parents of the client ask the nurse, “Why does my baby continue to vomit?” Which of the following would be the best nursing response of the nurse? A) “Your baby eats too rapidly and overfills the stomach, which causes vomiting B) “Your baby can‟t empty the formula that is in the stomach into the bowel” C) “The vomiting is due to the nausea that accompanies pyloric stenosis” D) “Your baby needs to be burped more thoroughly after feeding” 39. A 70-year-old client with suspected tuberculosis is brought to the geriatric care facilities. An intradermal tuberculosis test is schedule to be done. The client asks the nurse what is the purpose of the test. Which of the following would be the best rationale for this? A) reactivation of an old tuberculosis infection B) increased incidence of new cases of tuberculosis in persons over 65 years old C) greater exposure to diverse health care workers D) respiratory problems are characteristic in this population 40. The nurse is making a health teaching to the parents of the client. In teaching parents how to measure the area of induration in response to a PPD test, the nurse would be most accurate in advising the parents to measure: A) both the areas that look red and feel raised B) The entire area that feels itchy to the child C) Only the area that looks reddened D) Only the area that feels raised 41. A community health nurse is schedule to do home visit. She visits to an elderly person living alone. Which of the following observation would be a concern? A) Picture windows B) Unwashed dishes in the sink C) Clear and shiny floors D) Brightly lit rooms 42. After a birth, the physician cut the cord of the baby, and before the baby is given to the mother, what would be the initial nursing action of the nurse? A) examine the infant for any observable abnormalities B) confirm identification of the infant and apply bracelet to mother and infant C) instill prophylactic medication in the infant‟s eyes D) wrap the infant in a prewarmed blanket and cover the head
43. A 2-year-old client is admitted to the hospital with severe eczema lesions on the scalp, face, neck and arms. The client is scratching the affected areas. What would be the best nursing intervention to prevent the client from scratching the affected areas? A) elbow restraints to the arms B) Mittens to the hands C) Clove-hitch restraints to the hands D) A posey jacket to the torso 44. The parents of the hospitalized client ask the nurse how their baby might have gotten pyloric stenosis. The appropriate nursing response would be: A) There is no way to determine this preoperatively B) Their baby was born with this condition C) Their baby developed this condition during the first few weeks of life D) Their baby acquired it due to a formula allergy 45. A male client comes to the clinic for check-up. In doing a physical assessment, the nurse should report to the physician the most common symptom of gonorrhea, which is: A) pruritus B) pus in the urine C) WBC in the urine D) Dysuria 46. Which of the following would be the most important goal in the nursing care of an infant client with eczema? A) preventing infection B) maintaining the comfort level C) providing for adequate nutrition D) decreasing the itching 47. The nurse is making a discharge instruction to a client receiving chemotherapy. The client is at risk for bone marrow depression. The nurse gives instructions to the client about how to prevent infection at home. Which of the following health teaching would be included? A) “Get a weekly WBC count” B) “Do not share a bathroom with children or pregnant woman” C) “Avoid contact with others while receiving chemotherapy” D) “Do frequent hand washing and maintain good hygiene” 48. The nurse is assigned to care the client with infectious disease. The best antimicrobial
agent for the nurse to use in handwashing is: A) Isopropyl alcohol B) Hexachlorophene (Phisohex) C) Soap and water D) Chlorhexidine gluconate (CHG) (Hibiclens) 49. The mother of the client tells the nurse, “ I‟m not going to have my baby get any immunization”. What would be the best nursing response to the mother? A) “You and I need to review your rationale for this decision” B) “Your baby will not be able to attend day care without immunizations” C) “Your decision can be viewed as a form of child abuse and neglect” D) “You are needlessly placing other people at risk for communicable diseases” 50. The nurse is teaching the client about breast self-examination. Which observation should the client be taught to recognize when doing the examination for detection of breast cancer? A) tender, movable lump B) pain on breast self-examination C) round, well-defined lump D) dimpling of the breast tissue 1. The student nurse is assigned to take the vital signs of the clients in the pediatric ward. The student nurse reports to the staff nurse that the parent of a toddler who is 2 days postoperative after a cleft palate repair has given the toddler a pacifier. What would be the best immediate action of the nurse? A) Notify the pediatrician of this finding B) Reassure the student that this is an acceptable action on the parent‟s part C) Discuss this action with the parents D) Ask the student nurse to remove the pacifier from the toddler‟s mouth 2. The nurse is providing a health teaching to the mother of an 8-year-old child with cystic fibrosis. Which of the following statement if made by the mother would indicate to the nurse the need for further teaching about the medication regimen of the child? A) “My child might need an extra capsule if the meal is high in fat” B) “I‟ll give the enzyme capsule before every snack” C) “I‟ll give the enzyme capsule before every meal” D) “My child hates to take pills, so I‟ll mix the capsule into a cup of hot chocolate 3. The mother brought her child to the clinic for follow-up check up. The mother tells the nurse that 14 days after starting an oral iron supplement, her child‟s stools are black. Which of the following is the best nursing response to the mother? A) “I will notify the physician, who will probably decrease the dosage slightly” B) “This is a normal side effect and means the medication is working”
C) “You sound quite concerned. Would you like to talk about this further?” D) “I will need a specimen to check the stool for possible bleeding” 4. An 8-year-old boy with asthma is brought to the clinic for check up. The mother asks the nurse if the treatment given to her son is effective. What would be the appropriate response of the nurse? A) I will review first the child‟s height on a growth chart to know if the treatment is working B) I will review first the child‟s weight on a growth chart to know if the treatment is working C) I will review first the number of prescriptions refills the child has required over the last 6 months to give you an accurate answer D) I will review first the number of times the child has seen the pediatrician during the last 6 months to give you an accurate answer 5. The nurse is caring to a child client who is receiving tetracycline. The nurse is aware that in taking this medication, it is very important to: A) Administer the drug between meals B) Monitor the child‟s hearing C) Give the drug through a straw D) Keep the child out of the sunlight 6. A 14 day-old infant with a cyanotic heart defects and mild congestive heart failure is brought to the emergency department. During assessment, the nurse checks the apical pulse rate of the infant. The apical pulse rate is 130 beats per minute. Which of the following is the appropriate nursing action? A) Retake the apical pulse in 15 minutes B) Retake the apical pulse in 30 minutes C) Notify the pediatrician immediately D) Administer the medication as scheduled 7. The physician prescribed gentamicin (Garamycin) to a child who is also receiving chemotherapy. Before administering the drug, the nurse should check the results of the child‟s: A) CBC and platelet count B) Auditory tests C) Renal Function tests D) Abdominal and chest x-rays 8. Which of the following is the suited size of the needle would the nurse select to administer the IM injection to a preschool child? A) 18 G, 1-1/2 inch B) 25 G, 5/8 inch
C) 21 G, 1 inch D) 18 G, 1inch 9. A 9-year-old boy is admitted to the hospital. The boy is being treated with salicylates for the migratory polyarthritis accompanying the diagnosis of rheumatic fever. Which of the following activities performed by the child would give a best sign that the medication is effective? A) Listening to story of his mother B) Listening to the music in the radio C) Playing mini piano D) Watching movie in the dvd mini player 10. The physician decided to schedule the 4-year-old client for repair of left undescended testicle. The Injection of a hormone, HCG finds it less successful for treatment. To administer a pentobarbital sodium (Nembutal) suppository preoperatively to this client, in which position should the nurse place him? A) Supine with foot of bed elevated B) Prone with legs abducted C) Sitting with foot of bed elevated D) Side-lying with upper leg flexed 11. The nurse is caring to a 24-month-old child diagnosed with congenital heart defect. The physician prescribed digoxin (Lanoxin) to the client. Before the administration of the drug, the nurse checks the apical pulse rate to be 110 beats per minute and regular. What would be the next nursing action? A) Check the other vital signs and level of consciousness B) Withhold the digoxin and notify the physician C) Give the digoxin as prescribed D) Check the apical and radial simultaneously, and if they are the same, give the digoxin. 12. An 8-year-old client with cystic fibrosis is admitted to the hospital and will undergo a chest physiotherapy treatment. The therapy should be properly coordinated by the nurse with the respiratory therapy department so that treatments occur during: A) After meals B) Between meals C) After medication D) Around the child‟s play schedule 13. The nurse is providing health teaching about the breastfeeding and family planning to the client who gave birth to a healthy baby girl. Which of the following statement would alert the nurse that the client needs further teaching?
A) “I understand that the hormones for breastfeeding may affect when my periods come” B) “Breastfeeding causes my womb to tighten and bleed less after birth” C) “I may not have periods while I am breastfeeding, so I don‟t need family planning” D) “I can get pregnant as early as one month after my baby was born” 14. A toddler is brought to the hospital because of severe diarrhea and vomiting. The nurse assigned to the client enters the client‟s room and finds out that the client is using a soiled blanket brought in from home. The nurse attempts to remove the blanket and replace it with a new and clean blanket. The toddler refuses to give the soiled blanket. The nurse realizes that the best explanation for the toddler‟s behavior is: A) The toddler did not bond well with the maternal figure B) The blanket is an important transitional object C) The toddler is anxious about the hospital experience D) The toddler is resistive to nursing interventions 15. The nurse has knowledge about the developmental task of the child. In caring a 3-yearold-client, the nurse knows that the suited developmental task of this child is to: A) Learn to play with other children B) Able to trust others C) Express all needs through speaking D) Explore and manipulate the environment 16. A mother who gave birth to her second daughter is so concerned about her 2-year old daughter. She tells the nurse, “I am afraid that my 2-year-old daughter may not accept her newly born sister”. It is appropriate to the nurse to response that: A) The older daughter be given more responsibility and assure her “that she is a big girl now, and doesn‟t need Mommy as much” B) The older daughter not have interaction with the baby at the hospital, because she may harm her new sibling C) The older daughter stay with her grandmother for a few days until the parents and new baby are settled at home D) The mother spend time alone with her older daughter when the baby is sleeping 17. A 2-year-old client with cystic fibrosis is confined to bed and is not allowed to go to the playroom. Which of the following is an appropriate toy would the nurse select for the child: A) Puzzle B) Musical automobile C) Arranging stickers in the album D) Pounding board and hammer 18. Which of the following clients is at high risk for developmental problem?
A) A toddler with acute Glomerulonephritis on antihypertensive and antibiotics B) A 5-year-old with asthma on cromolyn sodium C) A preschooler with tonsillitis D) A 2 1/2 –year old boy with cystic fibrosis 19. Which of the following would be the best divesionary activity for the nurse to select for a 2 weeks hospitalized 3-year-old girl? A) Crayons and coloring books B) doll C) xylophone toy D) puzzles 20. A nurse is providing safety instructions to the parents of the 11-month-old child. Which of the following will the nurse includes in the instructions? A) Plugging all electrical outlets in the house B) Installing a gate at the top and bottom of any stairs in the home C) Purchasing an infant car seat as soon as possible D) Begin to teach the child not to place small objects in the mouth 21. An 8-year-old girl is in second grade and the parents decided to enroll her to a new school. While the child is focusing on adjusting to new environment and peers, her grades suffer. The child‟s father severely punishes the child and forces her daughter to study after school. The father does not allow also her daughter to play with other children. These data indicate to the nurse that this child is deprived of forming which normal phase of development? A) Heterosexual relationships B) A love relationship with the father C) A dependency relationship with the father D) Close relationship with peers 22. A 5-year-old boy client is scheduled for hernia surgery. The nurse is preparing to do preoperative teaching with the child. The nurse should knows that the 5-year-old would: A) Expect a simple yet logical explanation regarding the surgery B) Asks many questions regarding the condition and the procedure C) Worry over the impending surgery D) Be uninterested in the upcoming surgery 23. The nine-year-old client is admitted in the hospital for almost 1 week and is on bed rest. The child complains of being bored and it seems tiresome to stay on bed and doing nothing. What activity selected by the nurse would the child most likely find stimulating? A) Watching a video B) Putting together a puzzle
C) Assembling handouts with the nurse for an upcoming staff development meeting D) Listening to a compact disc 24. The parent of a 16-year-old boy tells the nurse that his son is driving a motorbike very fast and with one hand. “It is making me crazy!” What would be the best explanation of the nurse to the behavior of the boy? A) The adolescent might have an unconscious death wish B) The adolescent feels indestructible C) The adolescent lacks life experience to realize how dangerous the behavior is D) The adolescent has found a way to act out hostility toward the parent 25. An 8-month-old infant is admitted to the hospital due to diarrhea. The nurse caring for the client tells the mother to stay beside the infant while making assessment. Which of the following developmental milestones the infant has reached? A) Has a three-word vocabulary B) Interacts with other infants C) Stands alone D) Recognizes but is fearful of strangers 26. The community nurse is conducting a health teaching in the group of married women. When teaching a woman about fertility awareness, the nurse should emphasize that the basal body temperature: A) Should be recorded each morning before any activity B) Is the average temperature taken each morning C) Can be done with a mercury thermometer but not a digital one D) Has a lower degree of accuracy in predicting ovulation than the cervical mucus test 27. The community nurse is providing an instruction to the clients in the health center about the use of diaphragm for family planning. To evaluate the understanding of the woman, the nurse asks her to demonstrate the use of the diaphragm. Which of following statement indicates a need for further health teaching? A) “I should check the diaphragm carefully for holes every time I use it.” B) “The diaphragm must be left in place for at least 6 hours after intercourse.” C) “I really need to use the diaphragm and jelly most during the middle of my menstrual cycle D) “I may need a different size diaphragm if I gain or lose more than 20 pounds” 28. The client visits the clinic for prenatal check-up. While waiting for the physician, the nurse decided to conduct health teaching to the client. The nurse informed the client that primigravida mother should go to the hospital when which patter is evident? A) Contractions are 2-3 minutes apart, lasting 90 seconds, and membranes have ruptured B) Contractions are 5-10 minutes apart, lasting 30 seconds, and are felt as strong
menstrual cramps C) Contractions are 3-5 minutes apart, accompanied by rectal pressure and bloody show D) Contractions are 5 minutes apart, lasting 60 seconds, and increasing in intensity 29. A nurse is planning a home visit program to a new mother who is 2 weeks postpartum and breastfeeding, the nurse includes in her health teaching about the resumption of fertility, contraception and sexual activity. Which of the following statement indicates that the mother has understood the teaching? A) “Because breastfeeding speeds the healing process after birth, I can have sex right away and not worry about infection” B) “Because I am breastfeeding and my hormones are decreased, I may need to use a vaginal lubricant when I have sex” C) “After birth, you have to have a period before you can get pregnant again‟ D) “Breastfeeding protects me from pregnancy because it keeps my hormones down, so I don‟t need any contraception until I stop breastfeeding” 30. A community nurse enters the home of the client for follow-up visit. Which of the following is the most appropriate area to place the nursing bag of the nurse when conducting a home visit? A) cushioned footstool B) bedside wood table C) kitchen countertop D) living room sofa 31. The nurse in the health center is making an assessment to the infant client. The nurse notes some rashes and small fluid-filled bumps in the skin. The nurse suspects that the infant has eczema. Which of the following is the most important nursing goal: A) Preventing infection B) Providing for adequate nutrition C) Decreasing the itching D) Maintaining the comfort level 32. The nurse in the health center is providing immunization to the children. The nurse is carefully assessing the condition of the children before giving the vaccines. Which of the following would the nurse note to withhold the infant‟s scheduled immunizations? A) a dry cough B) a skin rash C) a low-grade fever D) a runny nose 33. A mother brought her child in the health center for hepatitis B vaccination in a series. The mother informs the nurse that the child missed an appointment last month to have the third hepatitis B vaccination. Which of the following statements is the appropriate nursing
response to the mother? A) “I will examine the child for symptoms of hepatitis B” B) “Your child will start the series again” C) “Your child will get the next dose as soon as possible” D) “Your child will have a hepatitis titer done to determine if immunization has taken place.” 34. The community health nurse implemented a new program about effective breast cancer screening technique for the female personnel of the health department of Valenzuela. Which of the following technique should the nurse consider to be of the lowest priority? A) Yearly breast exam by a trained professional B) Detailed health history to identify women at risk C) Screening mammogram every year for women over age 50 D) Screening mammogram every 1-2 years for women over age of 40. 35. Which of the following technique is considered an aseptic practice during the home visit of the community health nurse? A) Wrapping used dressing in a plastic bag before placing them in the nursing bag B) Washing hands before removing equipment from the nursing bag C) Using the client‟s soap and cloth towel for hand washing D) Placing the contaminated needles and syringes in a labeled container inside the nursing bag 36. The nurse is planning to conduct a home visit in a small community. Which of the following is the most important factor when planning the best time for a home care visit? A) Purpose of the home visit B) Preference of the patient‟s family C) Location of the patient‟s home D) Length of time of the visit will take 37. The nurse assigned in the health center is counseling a 30-year-old client requesting oral contraceptives. The client tells the nurse that she has an active yeast infection that has recurred several times in the past year. Which statement by the nurse is inaccurate concerning health promotion actions to prevent recurring yeast infection? A) “During treatment for yeast, avoid vaginal intercourse for one week” B) “Wear loose-fitting cotton underwear” C) “Avoid eating large amounts of sugar or sugar-bingeing” D) “Douche once a day with a mild vinegar and water solution” 38. During immunization week in the health center, the parent of a 6-month-old infant asks the health nurse, “Why is our baby going to receive so many immunizations over a long time period?” The best nursing response would be:
A) “The number of immunizations your baby will receive shows how many pediatric communicable and infectious diseases can now be prevented.” B) “You need to ask the physician” C) “The number of immunizations your baby will receive is determined by your baby‟s health history and age” D) “It is easier on your baby to receive several immunizations rather than one at a time” 39. The community health nurse is conducting a health teaching about nutrition to a group of pregnant women who are anemic and are lactose intolerant. Which of the following foods should the nurse especially encourage during the third trimester? A) Cheese, yogurt, and fish for protein and calcium needs plus prenatal vitamins and iron supplements B) Prenatal iron and calcium supplements plus a regular adult diet C) Red beans, green leafy vegetables, and fish for iron and calcium needs plus prenatal vitamins and iron supplements D) Red meat, milk and eggs for iron and calcium needs plus prenatal vitamins and iron supplements 40. A woman with active tuberculosis (TB) and has visited the health center for regular therapy for five months wants to become pregnant. The nurse knows that further information is necessary when the woman states: A) “Spontaneous abortion may occur in one out of five women who are infected” B) “Pulmonary TB may jeopardize my pregnancy” C) “I know that I may not be able to have close contact with my baby until contagious is no longer a problem D) “I can get pregnant after I have been free of TB for 6 months” 41. The Department of Health is alarmed that almost 33 million people suffer from food poisoning every year. Salmonella enteritis is responsible for almost 4 million cases of food poisoning. One of the major goals is to promote proper food preparation. The community health nurse is tasks to conduct health teaching about the prevention of food poisoning to a group of mother everyday. The nurse can help identify signs and symptoms of specific organisms to help patients get appropriate treatment. Typical symptoms of salmonella include: A) Nausea, vomiting and paralysis B) Bloody diarrhea C) Diarrhea and abdominal cramps D) Nausea, vomiting and headache 42. A community health nurse makes a home visit to an elderly person living alone in a small house. Which of the following observation would be a great concern? A) Big mirror in a wall B) Scattered and unwashed dishes in the sink
C) Shiny floors with scattered rugs D) Brightly lit rooms 43. The health nurse is conducting health teaching about “safe” sex to a group of high school students. Which of the following statement about the use of condoms should the nurse avoid making? A) “Condoms should be used because they can prevent infection and because they may prevent pregnancy” B) “Condoms should be used even if you have recently tested negative for HIV” C) “Condoms should be used every time you have sex because condoms prevent all forms of sexually transmitted diseases” D) “Condoms should be used every time you have sex even if you are taking the pill because condoms can prevent the spread of HIV and gonorrhea” 44. The department of health is promoting the breastfeeding program to all newly mothers. The nurse is formulating a plan of care to a woman who gave birth to a baby girl. The nursing care plan for a breast-feeding mother takes into account that breast-feeding is contraindicated when the woman: A) Is pregnant B) Has genital herpes infection C) Develops mastitis D) Has inverted nipples 45. The City health department conducted a medical mission in Barangay Marulas. Majority of the children in the Barangay Marulas were diagnosed with pinworms. The community health nurse should anticipate that the children‟s chief complaint would be: A) Lack of appetite B) Severe itching of the scalp C) Perianal itching D) Severe abdominal pain 46. The mother brought her daughter to the health center. The child has head lice. The nurse anticipates that the nursing diagnosis most closely correlated with this is: A) Fluid volume deficit related to vomiting B) Altered body image related to alopecia C) Altered comfort related to itching D) Diversional activity deficit related to hospitalization 47. The mother brings a child to the health care clinic because of severe headache and vomiting. During the assessment of the health care nurse, the temperature of the child is 40 degree Celsius, and the nurse notes the presence of nuchal rigidity. The nurse is suspecting that the child might be suffering from bacterial meningitis. The nurse continues to assess the child for the presence of Kernig‟s sign. Which finding would indicate the presence of this
sign? A) Flexion of the hips when the neck is flexed from a lying position B) Calf pain when the foot is dorsiflexed C) Inability of the child to extend the legs fully when lying supine D) Pain when the chin is pulled down to the chest 48. A community health nurse makes a home visit to a child with an infectious and communicable disease. In planning care for the child, the nurse must determine that the primary goal is that the: A) Child will experience mild discomfort B) Child will experience only minor complications C) Child will not spread the infection to others D) Public health department will be notified 49. The mother brings her daughter to the health care clinic. The child was diagnosed with conjunctivitis. The nurse provides health teaching to the mother about the proper care of her daughter while at home. Which statement by the mother indicates a need for additional information? A) “I do not need to be concerned about the spreading of this infection to others in my family” B) “I should apply warm compresses before instilling antibiotic drops if purulent discharge is present in my daughter‟s eye” C) “I can use an ophthalmic analgesic ointment at nighttime if I have eye discomfort” D) “I should perform a saline eye irrigation before instilling, the antibiotic drops into my daughter‟s eye if purulent discharge is present" 50. A community health nurse is caring for a group of flood victims in Marikina area. In planning for the potential needs of this group, which is the most immediate concern? A) Finding affordable housing for the group B) Peer support through structured groups C) Setting up a 24-hour crisis center and hotline D) Meeting the basic needs to ensure that adequate food, shelter and clothing are available
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