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PNLE Mock Exam

Feb 20, 2025484 min read96609 words

1,150 questions covering all the major areas of the Philippine Nursing Licensure Exam. Sources vary. Formatting was done personally.

Fundamentals of Nursing

ParameterMetadata
DomainFundamentals of Nursing
Topics
Items150 multiple-choice questions
Answer StatusAnswer Key, Rationalized

The nurse in-charge in labor and delivery unit administered a dose of terbutaline to a client without checking the client’s pulse. The standard that would be used to determine if the nurse was negligent is:

  1. The physician’s orders.
  2. The action of a clinical nurse specialist who is recognized expert in the field.
  3. The statement in the drug literature about administration of terbutaline.
  4. The actions of a reasonably prudent nurse with similar education and experience.

Nurse Trish is caring for a female client with a history of GI bleeding, sickle cell disease, and a platelet count of 22,000/μl. The female client is dehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hr. The client complains of severe bone pain and is scheduled to receive a dose of morphine sulfate. In administering the medication, Nurse Trish should avoid which route?

  1. I.V
  2. I.M
  3. Oral
  4. S.C

Dr. Garcia writes the following order for the client who has been recently admitted “Digoxin .125 mg P.O. once daily.” To prevent a dosage error, how should the nurse document this order onto the medication administration record?

  1. “Digoxin .1250 mg P.O. once daily”
  2. “Digoxin 0.1250 mg P.O. once daily”
  3. “Digoxin 0.125 mg P.O. once daily”
  4. “Digoxin .125 mg P.O. once daily”

A newly admitted female client was diagnosed with deep vein thrombosis. Which nursing diagnosis should receive the highest priority?

  1. Ineffective peripheral tissue perfusion related to venous congestion.
  2. Risk for injury related to edema.
  3. Excess fluid volume related to peripheral vascular disease.
  4. Impaired gas exchange related to increased blood flow.

Nurse Betty is assigned to the following clients. The client that the nurse would see first after endorsement?

  1. A 34 year-old post-operative appendectomy client of five hours who is complaining of pain.
  2. A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
  3. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.
  4. A 63 year-old post operative’s abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid.

Nurse Gail places a client in a four-point restraint following orders from the physician. The client care plan should include:

  1. Assess temperature frequently.
  2. Provide diversional activities.
  3. Check circulation every 15-30 minutes.
  4. Socialize with other patients once a shift.

A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse In-charge knows the purpose of this therapy is to:

  1. Prevent stress ulcer
  2. Block prostaglandin synthesis
  3. Facilitate protein synthesis.
  4. Enhance gas exchange

The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take?

  1. Increase the I.V. fluid infusion rate
  2. Irrigate the indwelling urinary catheter
  3. Notify the physician
  4. Continue to monitor and record hourly urine output

Tony, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by Tony suggests that ice application has been effective?

  1. “My ankle looks less swollen now”.
  2. “My ankle feels warm”.
  3. “My ankle appears redder now”.
  4. “I need something stronger for pain relief”

The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?

  1. Hypernatremia
  2. Hyperkalemia
  3. Hypokalemia
  4. Hypervolemia

She finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors will she exhibit most likely?

  1. Have condescending trust and confidence in their subordinates.
  2. Gives economic and ego awards.
  3. Communicates downward to staffs.
  4. Allows decision making among subordinates.

Nurse Amy is aware that the following is true about functional nursing

  1. Provides continuous, coordinated and comprehensive nursing services.
  2. One-to-one nurse patient ratio.
  3. Emphasize the use of group collaboration.
  4. Concentrates on tasks and activities.

Which type of medication order might read “Vitamin K 10 mg I.M. daily × 3 days?”

  1. Single order
  2. Standard written order
  3. Standing order
  4. Stat order

A female client with a fecal impaction frequently exhibits which clinical manifestation?

  1. Increased appetite
  2. Loss of urge to defecate
  3. Hard, brown, formed stools
  4. Liquid or semi-liquid stools

Nurse Linda prepares to perform an otoscopic examination on a female client. For proper visualization, the nurse should position the client’s ear by:

  1. Pulling the lobule down and back
  2. Pulling the helix up and forward
  3. Pulling the helix up and back
  4. Pulling the lobule down and forward

Which instruction should nurse Tom give to a male client who is having external radiation therapy:

  1. Protect the irritated skin from sunlight.
  2. Eat 3 to 4 hours before treatment.
  3. Wash the skin over regularly.
  4. Apply lotion or oil to the radiated area when it is red or sore.

In assisting a female client for immediate surgery, the nurse In-charge is aware that she should:

  1. Encourage the client to void following preoperative medication.
  2. Explore the client’s fears and anxieties about the surgery.
  3. Assist the client in removing dentures and nail polish.
  4. Encourage the client to drink water prior to surgery.

A male client is admitted and diagnosed with acute pancreatitis after a holiday celebration of excessive food and alcohol. Which assessment finding reflects this diagnosis?

  1. Blood pressure above normal range.
  2. Presence of crackles in both lung fields.
  3. Hyperactive bowel sounds
  4. Sudden onset of continuous epigastric and back pain.

Which dietary guidelines are important for nurse Oliver to implement in caring for the client with burns?

  1. Provide high-fiber, high-fat diet
  2. Provide high-protein, high-carbohydrate diet.
  3. Monitor intake to prevent weight gain.
  4. Provide ice chips or water intake.

Nurse Hazel will administer a unit of whole blood, which priority information should the nurse have about the client?

  1. Blood pressure and pulse rate.
  2. Height and weight.
  3. Calcium and potassium levels
  4. Hgb and Hct levels.

Nurse Michelle witnesses a female client sustain a fall and suspects that the leg may be broken. The nurse takes which priority action?

  1. Takes a set of vital signs.
  2. Call the radiology department for X-ray.
  3. Reassure the client that everything will be alright.
  4. Immobilize the leg before moving the client.

A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladder cancer. The nurse in-charge would take which priority action in the care of this client?

  1. Place client on reverse isolation.
  2. Admit the client into a private room.
  3. Encourage the client to take frequent rest periods.
  4. Encourage family and friends to visit.

A newly admitted female client was diagnosed with agranulocytosis. The nurse formulates which priority nursing diagnosis?

  1. Constipation
  2. Diarrhea
  3. Risk for infection
  4. Deficient knowledge

A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embolism. What is the priority action by the nurse?

  1. Notify the physician.
  2. Place the client on the left side in the Trendelenburg position.
  3. Place the client in high-Fowlers position.
  4. Stop the total parenteral nutrition.

Nurse May attends an educational conference on leadership styles. The nurse is sitting with a nurse employed at a large trauma center who states that the leadership style at the trauma center is task-oriented and directive. The nurse determines that the leadership style used at the trauma center is:

  1. Autocratic.
  2. Laissez-faire.
  3. Democratic.
  4. Situational

The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse in-charge is going to hang a 500 cc bag. KCl is supplied 20 mEq/10 cc. How many cc’s of KCl will be added to the IV solution?

  1. .5 cc
  2. 5 cc
  3. 1.5 cc
  4. 2.5 cc

A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV drip factor is 60. The IV rate that will deliver this amount is:

  1. 50 cc/hour
  2. 55 cc/hour
  3. 24 cc/hour
  4. 66 cc/hour

The nurse is aware that the most important nursing action when a client returns from surgery is:

  1. Assess the IV for type of fluid and rate of flow.
  2. Assess the client for presence of pain.
  3. Assess the Foley catheter for patency and urine output
  4. Assess the dressing for drainage.

Which of the following vital sign assessments that may indicate cardiogenic shock after myocardial infarction?

  1. BP – 80/60, Pulse – 110 irregular
  2. BP – 90/50, Pulse – 50 regular
  3. BP – 130/80, Pulse – 100 regular
  4. BP – 180/100, Pulse – 90 irregular

Which is the most appropriate nursing action in obtaining a blood pressure measurement?

  1. Take the proper equipment, place the client in a comfortable position, and record the appropriate information in the client’s chart.
  2. Measure the client’s arm, if you are not sure of the size of cuff to use.
  3. Have the client recline or sit comfortably in a chair with the forearm at the level of the heart.
  4. Document the measurement, which extremity was used, and the position that the client was in during the measurement.

Asking the questions to determine if the person understands the health teaching provided by the nurse would be included during which step of the nursing process?

  1. Assessment
  2. Evaluation
  3. Implementation
  4. Planning and goals

Which of the following item is considered the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person’s needs?

  1. Diagnostic test results
  2. Biographical date
  3. History of present illness
  4. Physical examination

In preventing the development of an external rotation deformity of the hip in a client who must remain in bed for any period of time, the most appropriate nursing action would be to use:

  1. Trochanter roll extending from the crest of the ileum to the mid-thigh.
  2. Pillows under the lower legs.
  3. Footboard
  4. Hip-abductor pillow

Which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue?

  1. Stage I
  2. Stage II
  3. Stage III
  4. Stage IV

When the method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulations, the wound healing is termed

  1. Second intention healing
  2. Primary intention healing
  3. Third intention healing
  4. First intention healing

An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver learns that the client lives alone and hasn’t been eating or drinking. When assessing him for dehydration, nurse Oliver would expect to find:

  1. Hypothermia
  2. Hypertension
  3. Distended neck veins
  4. Tachycardia

The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as needed, to control a client’s postoperative pain. The package insert is “Meperidine, 100 mg/ml.” How many milliliters of meperidine should the client receive?

  1. 0.75 mL
  2. 0.6 mL
  3. 0.5 mL
  4. 0.25 mL

A male client with diabetes mellitus is receiving insulin. Which statement correctly describes an insulin unit?

  1. It’s a common measurement in the metric system.
  2. It’s the basis for solids in the avoirdupois system.
  3. It’s the smallest measurement in the apothecary system.
  4. It’s a measure of effect, not a standard measure of weight or quantity.

Nurse Oliver measures a client’s temperature at 102° F. What is the equivalent Centigrade temperature?

  1. 40.1°C
  2. 38.9°C
  3. 48°C
  4. 38°C

The nurse is assessing a 48-year-old client who has come to the physician’s office for his annual physical exam. One of the first physical signs of aging is:

  1. Accepting limitations while developing assets.
  2. Increasing loss of muscle tone.
  3. Failing eyesight, especially close vision.
  4. Having more frequent aches and pains.

The physician inserts a chest tube into a female client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse in-charge can prevent chest tube air leaks by:

  1. Checking and taping all connections.
  2. Checking patency of the chest tube.
  3. Keeping the head of the bed slightly elevated.
  4. Keeping the chest drainage system below the level of the chest.

Nurse Trish must verify the client’s identity before administering medication. She is aware that the safest way to verify identity is to:

  1. Check the client’s identification band.
  2. Ask the client to state his name.
  3. State the client’s name out loud and wait a client to repeat it.
  4. Check the room number and the client’s name on the bed.

The physician orders dextrose 5 % in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops/ml. Nurse John should run the I.V. infusion at a rate of:

  1. 30 drops/minute
  2. 32 drops/minute
  3. 20 drops/minute
  4. 18 drops/minute

If a central venous catheter becomes disconnected accidentally, what should the nurse in-charge do immediately?

  1. Clamp the catheter
  2. Call another nurse
  3. Call the physician
  4. Apply a dry sterile dressing to the site.

A female client was recently admitted. She has fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, Nurse Hazel inspects the client’s abdomen and notice that it is slightly concave. Additional assessment should proceed in which order:

  1. Palpation, auscultation, and percussion.
  2. Percussion, palpation, and auscultation.
  3. Palpation, percussion, and auscultation.
  4. Auscultation, percussion, and palpation.

Nurse Betty is assessing tactile fremitus in a client with pneumonia. For this examination, nurse Betty should use the:

  1. Fingertips
  2. Finger pads
  3. Dorsal surface of the hand
  4. Ulnar surface of the hand

Which type of evaluation occurs continuously throughout the teaching and learning process?

  1. Summative
  2. Informative
  3. Formative
  4. Retrospective

A 45 year old client, has no family history of breast cancer or other risk factors for this disease. Nurse John should instruct her to have mammogram how often?

  1. Twice per year
  2. Once per year
  3. Every 2 years
  4. Once, to establish baseline

A male client has the following arterial blood gas values: pH 7.30; PaO₂ 89 mmHg; PaCO₂ 50 mmHg; and HCO₃ 26mEq/L. Based on these values, Nurse Patricia should expect which condition?

  1. Respiratory acidosis
  2. Respiratory alkalosis
  3. Metabolic acidosis
  4. Metabolic alkalosis

Nurse Len refers a female client with terminal cancer to a local hospice. What is the goal of this referral?

  1. To help the client find appropriate treatment options.
  2. To provide support for the client and family in coping with terminal illness.
  3. To ensure that the client gets counseling regarding health care costs.
  4. To teach the client and family about cancer and its treatment.

When caring for a male client with a 3-cm stage I pressure ulcer on the coccyx, which of the following actions can the nurse institute independently?

  1. Massaging the area with an astringent every 2 hours.
  2. Applying an antibiotic cream to the area three times per day.
  3. Using normal saline solution to clean the ulcer and applying a protective dressing as necessary.
  4. Using a povidone-iodine wash on the ulceration three times per day.

Nurse Oliver must apply an elastic bandage to a client’s ankle and calf. He should apply the bandage beginning at the client’s:

  1. Knee
  2. Ankle
  3. Lower thigh
  4. Foot

A 10 year old child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk to this child?

  1. Hypernatremia
  2. Hypokalemia
  3. Hyperphosphatemia
  4. Hypercalcemia

Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly admitted client. Immediately afterward, the client may experience:

  1. Throbbing headache or dizziness
  2. Nervousness or paresthesia.
  3. Drowsiness or blurred vision.
  4. Tinnitus or diplopia.

Nurse Michelle hears the alarm sound on the telemetry monitor. The nurse quickly looks at the monitor and notes that a client is in a ventricular tachycardia. The nurse rushes to the client’s room. Upon reaching the client’s bedside, the nurse would take which action first?

  1. Prepare for cardioversion
  2. Prepare to defibrillate the client
  3. Call a code
  4. Check the client’s level of consciousness

Nurse Hazel is preparing to ambulate a female client. The best and the safest position for the nurse in assisting the client is to stand:

  1. On the unaffected side of the client.
  2. On the affected side of the client.
  3. In front of the client.
  4. Behind the client.

Nurse Janah is monitoring the ongoing care given to the potential organ donor who has been diagnosed with brain death. The nurse determines that the standard of care had been maintained if which of the following data is observed?

  1. Urine output: 45 ml/hr
  2. Capillary refill: 5 seconds
  3. Serum pH: 7.32
  4. Blood pressure: 90/48 mmHg

Nurse Amy has an order to obtain a urinalysis from a male client with an indwelling urinary catheter. The nurse avoids which of the following, which contaminate the specimen?

  1. Wiping the port with an alcohol swab before inserting the syringe.
  2. Aspirating a sample from the port on the drainage bag.
  3. Clamping the tubing of the drainage bag.
  4. Obtaining the specimen from the urinary drainage bag.

Nurse Meredith is in the process of giving a client a bed bath. In the middle of the procedure, the unit secretary calls the nurse on the intercom to tell the nurse that there is an emergency phone call. The appropriate nursing action is to:

  1. Immediately walk out of the client’s room and answer the phone call.
  2. Cover the client, place the call light within reach, and answer the phone call.
  3. Finish the bed bath before answering the phone call.
  4. Leave the client’s door open so the client can be monitored and the nurse can answer the phone call.

Nurse Janah is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. Nurse Janah plans to implement which intervention to obtain the specimen?

  1. Ask the client to expectorate a small amount of sputum into the emesis basin.
  2. Ask the client to obtain the specimen after breakfast.
  3. Use a sterile plastic container for obtaining the specimen.
  4. Provide tissues for expectoration and obtaining the specimen.

Nurse Ron is observing a male client using a walker. The nurse determines that the client is using the walker correctly if the client:

  1. Puts all the four points of the walker flat on the floor, puts weight on the hand pieces, and then walks into it.
  2. Puts weight on the hand pieces, moves the walker forward, and then walks into it.
  3. Puts weight on the hand pieces, slides the walker forward, and then walks into it.
  4. Walks into the walker, puts weight on the hand pieces, and then puts all four points of the walker flat on the floor.

Nurse Amy has documented an entry regarding client care in the client’s medical record. When checking the entry, the nurse realizes that incorrect information was documented. How does the nurse correct this error?

  1. Erases the error and writes in the correct information.
  2. Uses correction fluid to cover up the incorrect information and writes in the correct information.
  3. Draws one line to cross out the incorrect information and then initials the change.
  4. Covers up the incorrect information completely using a black pen and writes in the correct information

Nurse Ron is assisting with transferring a client from the operating room table to a stretcher. To provide safety to the client, the nurse should:

  1. Moves the client rapidly from the table to the stretcher.
  2. Uncovers the client completely before transferring to the stretcher.
  3. Secures the client safety belts after transferring to the stretcher.
  4. Instructs the client to move self from the table to the stretcher.

Nurse Myrna is providing instructions to a nursing assistant assigned to give a bed bath to a client who is on contact precautions. Nurse Myrna instructs the nursing assistant to use which of the following protective items when giving bed bath?

  1. Gown and goggles
  2. Gown and gloves
  3. Gloves and shoe protectors
  4. Gloves and goggles

Nurse Oliver is caring for a client with impaired mobility that occurred as a result of a stroke. The client has right sided arm and leg weakness. The nurse would suggest that the client use which of the following assistive devices that would provide the best stability for ambulating?

  1. Crutches
  2. Single straight-legged cane
  3. Quad cane
  4. Walker

A male client with a right pleural effusion noted on a chest X-ray is being prepared for thoracentesis. The client experiences severe dizziness when sitting upright. To provide a safe environment, the nurse assists the client to which position for the procedure?

  1. Prone with head turned toward the side supported by a pillow.
  2. Sims’ position with the head of the bed flat.
  3. Right side-lying with the head of the bed elevated 45 degrees.
  4. Left side-lying with the head of the bed elevated 45 degrees.

Nurse John develops methods for data gathering. Which of the following criteria of a good instrument refers to the ability of the instrument to yield the same results upon its repeated administration?

  1. Validity
  2. Specificity
  3. Sensitivity
  4. Reliability

Harry knows that he has to protect the rights of human research subjects. Which of the following actions of Harry ensures anonymity?

  1. Keep the identities of the subject secret
  2. Obtain informed consent
  3. Provide equal treatment to all the subjects of the study.
  4. Release findings only to the participants of the study

Patient’s refusal to divulge information is a limitation because it is beyond the control of Tifanny”. What type of research is appropriate for this study?

  1. Descriptive- correlational
  2. Experiment
  3. Quasi-experiment
  4. Historical

Nurse Ronald is aware that the best tool for data gathering is?

  1. Interview schedule
  2. Questionnaire
  3. Use of laboratory data
  4. Observation

Monica is aware that there are times when only manipulation of study variables is possible and the elements of control or randomization are not attendant. Which type of research is referred to this?

  1. Field study
  2. Quasi-experiment
  3. Solomon-Four group design
  4. Post-test only design

Cherry notes down ideas that were derived from the description of an investigation written by the person who conducted it. Which type of reference source refers to this?

  1. Footnote
  2. Bibliography
  3. Primary source
  4. Endnotes

When Nurse Trish is providing care to his patient, she must remember that her duty is bound not to do doing any action that will cause the patient harm. This is the meaning of the bioethical principle:

  1. Non-maleficence
  2. Beneficence
  3. Justice
  4. Solidarity

When a nurse in-charge causes an injury to a female patient and the injury caused becomes the proof of the negligent act, the presence of the injury is said to exemplify the principle of:

  1. Force majeure
  2. Respondeat superior
  3. Res ipsa loquitor
  4. Holdover doctrine

Nurse Myrna is aware that the Board of Nursing has quasi-judicial power. An example of this power is:

  1. The Board can issue rules and regulations that will govern the practice of nursing
  2. The Board can investigate violations of the nursing law and code of ethics
  3. The Board can visit a school applying for a permit in collaboration with CHED
  4. The Board prepares the board examinations

When the license of nurse Krina is revoked, it means that she:

  1. Is no longer allowed to practice the profession for the rest of her life
  2. Will never have her/his license re-issued since it has been revoked
  3. May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173
  4. Will remain unable to practice professional nursing

Ronald plans to conduct a research on the use of a new method of pain assessment scale. Which of the following is the second step in the conceptualizing phase of the research process?

  1. Formulating the research hypothesis
  2. Review related literature
  3. Formulating and delimiting the research problem
  4. Design the theoretical and conceptual framework

The leader of the study knows that certain patients who are in a specialized research setting tend to respond psychologically to the conditions of the study. This referred to as :

  1. Cause and effect
  2. Hawthorne effect
  3. Halo effect
  4. Horns effect

Mary finally decides to use judgment sampling on her research. Which of the following actions of is correct?

  1. Plans to include whoever is there during his study.
  2. Determines the different nationality of patients frequently admitted and decides to get representations samples from each.
  3. Assigns numbers for each of the patients, place these in a fishbowl and draw 10 from it.
  4. Decides to get 20 samples from the admitted patients

The nursing theorist who developed transcultural nursing theory is:

  1. Florence Nightingale
  2. Madeleine Leininger
  3. Albert Moore
  4. Sr. Callista Roy

Marion is aware that the sampling method that gives equal chance to all units in the population to get picked is:

  1. Random
  2. Accidental
  3. Quota
  4. Judgment

John plans to use a Likert Scale to his study to determine the:

  1. Degree of agreement and disagreement
  2. Compliance to expected standards
  3. Level of satisfaction
  4. Degree of acceptance

Which of the following theory addresses the four modes of adaptation?

  1. Madeleine Leininger
  2. Sr. Callista Roy
  3. Florence Nightingale
  4. Jean Watson

Ms. Garcia is responsible to the number of personnel reporting to her. This principle refers to:

  1. Span of control
  2. Unity of command
  3. Downward communication
  4. Leader

Ensuring that there is an informed consent on the part of the patient before a surgery is done, illustrates the bioethical principle of:

  1. Beneficence
  2. Autonomy
  3. Veracity
  4. Non-maleficence

Nurse Reese is teaching a female client with peripheral vascular disease about foot care; Nurse Reese should include which instruction?

  1. Avoid wearing cotton socks.
  2. Avoid using a nail clipper to cut toenails.
  3. Avoid wearing canvas shoes.
  4. Avoid using cornstarch on feet.

A client is admitted with multiple pressure ulcers. When developing the client’s diet plan, the nurse should include:

  1. Fresh orange slices
  2. Steamed broccoli
  3. Ice cream
  4. Ground beef patties

The nurse prepares to administer a cleansing enema. What is the most common client position used for this procedure?

  1. Lithotomy
  2. Supine
  3. Prone
  4. Sims’ left lateral

Nurse Marian is preparing to administer a blood transfusion. Which action should the nurse take first?

  1. Arrange for typing and cross matching of the client’s blood.
  2. Compare the client’s identification wristband with the tag on the unit of blood.
  3. Start an I.V. infusion of normal saline solution.
  4. Measure the client’s vital signs.

A 65 years old male client requests his medication at 9 p.m. instead of 10 p.m. so that he can go to sleep earlier. Which type of nursing intervention is required?

  1. Independent
  2. Dependent
  3. Interdependent
  4. Intradependent

A female client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The Nurse Betty notes that the client’s leg is pain-free, without redness or edema. The nurse’s actions reflect which step of the nursing process?

  1. Assessment
  2. Diagnosis
  3. Implementation
  4. Evaluation

Nursing care for a female client includes removing elastic stockings once per day. The Nurse Betty is aware that the rationale for this intervention?

  1. To increase blood flow to the heart
  2. To observe the lower extremities
  3. To allow the leg muscles to stretch and relax
  4. To permit veins in the legs to fill with blood.

Which nursing intervention takes highest priority when caring for a newly admitted client who’s receiving a blood transfusion?

  1. Instructing the client to report any itching, swelling, or dyspnea.
  2. Informing the client that the transfusion usually take 1 ½ to 2 hours.
  3. Documenting blood administration in the client care record.
  4. Assessing the client’s vital signs when the transfusion ends.

A male client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?

  1. Give the feedings at room temperature.
  2. Decrease the rate of feedings and the concentration of the formula.
  3. Place the client in semi-Fowler’s position while feeding.
  4. Change the feeding container every 12 hours.

Nurse Patricia is reconstituting a powdered medication in a vial. After adding the solution to the powder, she nurse should:

  1. Do nothing.
  2. Invert the vial and let it stand for 3 to 5 minutes.
  3. Shake the vial vigorously.
  4. Roll the vial gently between the palms.

Which intervention should the nurse Trish use when administering oxygen by face mask to a female client?

  1. Secure the elastic band tightly around the client’s head.
  2. Assist the client to the semi-Fowler position if possible.
  3. Apply the face mask from the client’s chin up over the nose.
  4. Loosen the connectors between the oxygen equipment and humidifier.

The maximum transfusion time for a unit of packed red blood cells (RBCs) is:

  1. 6 hours
  2. 4 hours
  3. 3 hours
  4. 2 hours

Nurse Monique is monitoring the effectiveness of a client’s drug therapy. When should the nurse Monique obtain a blood sample to measure the trough drug level?

  1. 1 hour before administering the next dose.
  2. Immediately before administering the next dose.
  3. Immediately after administering the next dose.
  4. 30 minutes after administering the next dose.

Nurse May is aware that the main advantage of using a floor stock system is:

  1. The nurse can implement medication orders quickly.
  2. The nurse receives input from the pharmacist.
  3. The system minimizes transcription errors.
  4. The system reinforces accurate calculations.

Nurse Oliver is assessing a client’s abdomen. Which finding should the nurse report as abnormal?

  1. Dullness over the liver.
  2. Bowel sounds occurring every 10 seconds.
  3. Shifting dullness over the abdomen.
  4. Vascular sounds heard over the renal arteries.

Which element in the circular chain of infection can be eliminated by preserving skin integrity?

  1. Host
  2. Reservoir
  3. Mode of transmission
  4. Portal of entry

Which of the following will probably result in a break in sterile technique for respiratory isolation?

  1. Opening the patient’s window to the outside environment
  2. Turning on the patient’s room ventilator
  3. Opening the door of the patient’s room leading into the hospital corridor
  4. Failing to wear gloves when administering a bed bath

Which of the following patients is at greater risk for contracting an infection?

  1. A patient with leukopenia
  2. A patient receiving broad-spectrum antibiotics
  3. A postoperative patient who has undergone orthopedic surgery
  4. A newly diagnosed diabetic patient

Effective hand washing requires the use of:

  1. Soap or detergent to promote emulsification
  2. Hot water to destroy bacteria
  3. A disinfectant to increase surface tension
  4. All of the above

After routine patient contact, hand washing should last at least:

  1. 30 seconds
  2. 1 minute
  3. 2 minute
  4. 3 minutes

Which of the following procedures always requires surgical asepsis?

  1. Vaginal instillation of conjugated estrogen
  2. Urinary catheterization
  3. Nasogastric tube insertion
  4. Colostomy irrigation

Sterile technique is used whenever:

  1. Strict isolation is required
  2. Terminal disinfection is performed
  3. Invasive procedures are performed
  4. Protective isolation is necessary

Which of the following constitutes a break in sterile technique while preparing a sterile field for a dressing change?

  1. Using sterile forceps, rather than sterile gloves, to handle a sterile item
  2. Touching the outside wrapper of sterilized material without sterile gloves
  3. Placing a sterile object on the edge of the sterile field
  4. Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a sterile container

A natural body defense that plays an active role in preventing infection is:

  1. Yawning
  2. Body hair
  3. Hiccupping
  4. Rapid eye movements

All of the following statement are true about donning sterile gloves except:

  1. The first glove should be picked up by grasping the inside of the cuff.
  2. The second glove should be picked up by inserting the gloved fingers under the cuff outside the glove.
  3. The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wrist
  4. The inside of the glove is considered sterile

When removing a contaminated gown, the nurse should be careful that the first thing she touches is the:

  1. Waist tie and neck tie at the back of the gown
  2. Waist tie in front of the gown
  3. Cuffs of the gown
  4. Inside of the gown

Which of the following nursing interventions is considered the most effective form or universal precautions?

  1. Cap all used needles before removing them from their syringes
  2. Discard all used uncapped needles and syringes in an impenetrable protective container
  3. Wear gloves when administering IM injections
  4. Follow enteric precautions

All of the following measures are recommended to prevent pressure ulcers except:

  1. Massaging the reddened are with lotion
  2. Using a water or air mattress
  3. Adhering to a schedule for positioning and turning
  4. Providing meticulous skin care

Which of the following blood tests should be performed before a blood transfusion?

  1. Prothrombin and coagulation time
  2. Blood typing and cross-matching
  3. Bleeding and clotting time
  4. Complete blood count (CBC) and electrolyte levels.

The primary purpose of a platelet count is to evaluate the:

  1. Potential for clot formation
  2. Potential for bleeding
  3. Presence of an antigen-antibody response
  4. Presence of cardiac enzymes

Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?

  1. 4,500/mm³
  2. 7,000/mm³
  3. 10,000/mm³
  4. 25,000/mm³

After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping and muscle weakness. These symptoms probably indicate that the patient is experiencing:

  1. Hypokalemia
  2. Hyperkalemia
  3. Anorexia
  4. Dysphagia

Which of the following statements about chest X-ray is false?

  1. No contradictions exist for this test
  2. Before the procedure, the patient should remove all jewelry, metallic objects, and buttons above the waist
  3. A signed consent is not required
  4. Eating, drinking, and medications are allowed before this test

The most appropriate time for the nurse to obtain a sputum specimen for culture is:

  1. Early in the morning
  2. After the patient eats a light breakfast
  3. After aerosol therapy
  4. After chest physiotherapy

A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient’s skin. The most appropriate nursing action would be to:

  1. Withhold the moderation and notify the physician
  2. Administer the medication and notify the physician
  3. Administer the medication with an antihistamine
  4. Apply corn starch soaks to the rash

All of the following nursing interventions are correct when using the Z- track method of drug injection except:

  1. Prepare the injection site with alcohol
  2. Use a needle that’s a least 1” long
  3. Aspirate for blood before injection
  4. Rub the site vigorously after the injection to promote absorption

The correct method for determining the vastus lateralis site for I.M. injection is to:

  1. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac crest
  2. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm
  3. Palpate a 1” circular area anterior to the umbilicus
  4. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds, and select the middle third on the anterior of the thigh

The mid-deltoid injection site is seldom used for I.M. injections because it:

  1. Can accommodate only 1 ml or less of medication
  2. Bruises too easily
  3. Can be used only when the patient is lying down
  4. Does not readily parenteral medication

The appropriate needle size for insulin injection is:

  1. 18G, 1 ½” long
  2. 22G, 1” long
  3. 22G, 1 ½” long
  4. 25G, 5/8” long

The appropriate needle gauge for intradermal injection is:

  1. 20G
  2. 22G
  3. 25G
  4. 26G

Parenteral penicillin can be administered as an:

  1. IM injection or an IV solution
  2. IV or an intradermal injection
  3. Intradermal or subcutaneous injection
  4. IM or a subcutaneous injection

The physician orders gr 10 of aspirin for a patient. The equivalent dose in milligrams is:

  1. 0.6 mg
  2. 10 mg
  3. 60 mg
  4. 600 mg

The physician orders an IV solution of dextrose 5% in water at 100ml/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml?

  1. 5 gtt/minute
  2. 13 gtt/minute
  3. 25 gtt/minute
  4. 50 gtt/minute

Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion?

  1. Hemoglobinuria
  2. Chest pain
  3. Urticaria
  4. Distended neck veins

Which of the following conditions may require fluid restriction?

  1. Fever
  2. Chronic Obstructive Pulmonary Disease
  3. Renal Failure
  4. Dehydration

All of the following are common signs and symptoms of phlebitis except:

  1. Pain or discomfort at the IV insertion site
  2. Edema and warmth at the IV insertion site
  3. A red streak exiting the IV insertion site
  4. Frank bleeding at the insertion site

The best way of determining whether a patient has learned to instill ear medication properly is for the nurse to:

  1. Ask the patient if he/she has used ear drops before
  2. Have the patient repeat the nurse’s instructions using her own words
  3. Demonstrate the procedure to the patient and encourage to ask questions
  4. Ask the patient to demonstrate the procedure

Which of the following types of medications can be administered via gastrostomy tube?

  1. Any oral medications
  2. Capsules whole contents are dissolve in water
  3. Enteric-coated tablets that are thoroughly dissolved in water
  4. Most tablets designed for oral use, except for extended-duration compounds

A patient who develops hives after receiving an antibiotic is exhibiting drug:

  1. Tolerance
  2. Idiosyncrasy
  3. Synergism
  4. Allergy

A patient has returned to his room after femoral arteriography. All of the following are appropriate nursing interventions except:

  1. Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours
  2. Check the pressure dressing for sanguineous drainage
  3. Assess vital signs every 15 minutes for 2 hours
  4. Order a hemoglobin and hematocrit count 1 hour after the arteriography

The nurse explains to a patient that a cough:

  1. Is a protective response to clear the respiratory tract of irritants
  2. Is primarily a voluntary action
  3. Is induced by the administration of an antitussive drug
  4. Can be inhibited by “splinting” the abdomen

An infected patient has chills and begins shivering. The best nursing intervention is to:

  1. Apply iced alcohol sponges
  2. Provide increased cool liquids
  3. Provide additional bedclothes
  4. Provide increased ventilation

A clinical nurse specialist is a nurse who has:

  1. Been certified by the National League for Nursing
  2. Received credentials from the Philippine Nurses’ Association
  3. Graduated from an associate degree program and is a registered professional nurse
  4. Completed a master’s degree in the prescribed clinical area and is a registered professional nurse.

The purpose of increasing urine acidity through dietary means is to:

  1. Decrease burning sensations
  2. Change the urine’s color
  3. Change the urine’s concentration
  4. Inhibit the growth of microorganisms

Clay colored stools indicate:

  1. Upper GI bleeding
  2. Impending constipation
  3. An effect of medication
  4. Bile obstruction

In which step of the nursing process would the nurse ask a patient if the medication she administered relieved his pain?

  1. Assessment
  2. Analysis
  3. Planning
  4. Evaluation

All of the following are good sources of vitamin A except:

  1. White potatoes
  2. Carrots
  3. Apricots
  4. Egg yolks

Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in place?

  1. Maintain the drainage tubing and collection bag level with the patient’s bladder
  2. Irrigate the patient with 1% Neosporin solution three times a daily
  3. Clamp the catheter for 1 hour every 4 hours to maintain the bladder’s elasticity
  4. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity

The ELISA test is used to:

  1. Screen blood donors for antibodies to human immunodeficiency virus (HIV)
  2. Test blood to be used for transfusion for HIV antibodies
  3. Aid in diagnosing a patient with AIDS
  4. All of the above

The two blood vessels most commonly used for TPN infusion are the:

  1. Subclavian and jugular veins
  2. Brachial and subclavian veins
  3. Femoral and subclavian veins
  4. Brachial and femoral veins

Effective skin disinfection before a surgical procedure includes which of the following methods?

  1. Shaving the site on the day before surgery
  2. Applying a topical antiseptic to the skin on the evening before surgery
  3. Having the patient take a tub bath on the morning of surgery
  4. Having the patient shower with an antiseptic soap on the evening before and the morning of surgery

When transferring a patient from a bed to a chair, the nurse should use which muscles to avoid back injury?

  1. Abdominal muscles
  2. Back muscles
  3. Leg muscles
  4. Upper arm muscles

Thrombophlebitis typically develops in patients with which of the following conditions?

  1. Increases partial thromboplastin time
  2. Acute pulsus paradoxus
  3. An impaired or traumatized blood vessel wall
  4. Chronic Obstructive Pulmonary Disease (COPD)

In a recumbent, immobilized patient, lung ventilation can become altered, leading to such respiratory complications as:

  1. Respiratory acidosis, ateclectasis, and hypostatic pneumonia
  2. Appneustic breathing, atypical pneumonia and respiratory alkalosis
  3. Cheyne-Strokes respirations and spontaneous pneumothorax
  4. Kussmail’s respirations and hypoventilation

Immobility impairs bladder elimination, resulting in such disorders as

  1. Increased urine acidity and relaxation of the perineal muscles, causing incontinence
  2. Urine retention, bladder distention, and infection
  3. Diuresis, natriuresis, and decreased urine specific gravity
  4. Decreased calcium and phosphate levels in the urine

CHN-MCN

ParameterMetadata
DomainCommunity Health Nursing-Maternal and Child Nursing
Topics
Items200 multiple-choice questions
Answer StatusAnswer Key, Rationalized

May arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. She also tells the nurse that a home pregnancy test was positive but she began to have mild cramps and is now having moderate vaginal bleeding. During the physical examination of the client, the nurse notes that May has a dilated cervix. The nurse determines that May is experiencing which type of abortion?

  1. Inevitable
  2. Incomplete
  3. Threatened
  4. Septic

Nurse Reese is reviewing the record of a pregnant client for her first prenatal visit. Which of the following data, if noted on the client’s record, would alert the nurse that the client is at risk for a spontaneous abortion?

  1. Age 36 years
  2. History of syphilis
  3. History of genital herpes
  4. History of diabetes mellitus

Nurse Hazel is preparing to care for a client who is newly admitted to the hospital with a possible diagnosis of ectopic pregnancy. Nurse Hazel develops a plan of care for the client and determines that which of the following nursing actions is the priority?

  1. Monitoring weight
  2. Assessing for edema
  3. Monitoring apical pulse
  4. Monitoring temperature

Nurse Oliver is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy requires:

  1. Decreased caloric intake
  2. Increased caloric intake
  3. Decreased Insulin
  4. Increase Insulin

Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware that one of the following is unassociated with this condition?

  1. Excessive fetal activity.
  2. Larger than normal uterus for gestational age.
  3. Vaginal bleeding
  4. Elevated levels of human chorionic gonadotropin.

A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is:

  1. Urinary output 90 cc in 2 hours.
  2. Absent patellar reflexes.
  3. Rapid respiratory rate above 40/min.
  4. Rapid rise in blood pressure.

During vaginal examination of Janah who is in labor, the presenting part is at station plus two. Nurse, correctly interprets it as:

  1. Presenting part is 2 cm above the plane of the ischial spines.
  2. Biparietal diameter is at the level of the ischial spines.
  3. Presenting part in 2 cm below the plane of the ischial spines.
  4. Biparietal diameter is 2 cm above the ischial spines.

A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is:

  1. Contractions every 1 ½ minutes lasting 70-80 seconds.
  2. Maternal temperature 101.2
  3. Early decelerations in the fetal heart rate.
  4. Fetal heart rate baseline 140-160 bpm.

Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). A nursing action that must be initiated as the plan of care throughout injection of the drug is:

  1. Ventilator assistance
  2. CVP readings
  3. EKG tracings
  4. Continuous CPR

A trial for vaginal delivery after an earlier caesarean, would likely to be given to a gravida, who had:

  1. First low transverse cesarean was for active herpes type 2 infections; vaginal culture at 39 weeks pregnancy was positive.
  2. First and second caesareans were for cephalopelvic disproportion.
  3. First caesarean through a classic incision as a result of severe fetal distress.
  4. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation.

Nurse Ryan is aware that the best initial approach when trying to take a crying toddler’s temperature is:

  1. Talk to the mother first and then to the toddler.
  2. Bring extra help so it can be done quickly.
  3. Encourage the mother to hold the child.
  4. Ignore the crying and screaming.

Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the nurse do to prevent trauma to operative site?

  1. Avoid touching the suture line, even when cleaning.
  2. Place the baby in prone position.
  3. Give the baby a pacifier.
  4. Place the infant’s arms in soft elbow restraints.

Which action should nurse Marian include in the care plan for a 2 month old with heart failure?

  1. Feed the infant when he cries.
  2. Allow the infant to rest before feeding.
  3. Bathe the infant and administer medications before feeding.
  4. Weigh and bathe the infant before feeding.

Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5 months. The nurse should advise her to include which foods in her infant’s diet?

  1. Skim milk and baby food.
  2. Whole milk and baby food.
  3. Iron-rich formula only.
  4. Iron-rich formula and baby food.

Mommy Linda is playing with her infant, who is sitting securely alone on the floor of the clinic. The mother hides a toy behind her back and the infant looks for it. The nurse is aware that estimated age of the infant would be:

  1. 6 months
  2. 4 months
  3. 8 months
  4. 10 months

Which of the following is the most prominent feature of public health nursing?

  1. It involves providing home care to sick people who are not confined in the hospital.
  2. Services are provided free of charge to people within the catchments area.
  3. The public health nurse functions as part of a team providing a public health nursing services.
  4. Public health nursing focuses on preventive, not curative, services.

When the nurse determines whether resources were maximized in implementing Ligtas Tigdas, she is evaluating

  1. Effectiveness
  2. Efficiency
  3. Adequacy
  4. Appropriateness

Vangie is a new B.S.N. graduate. She wants to become a Public Health Nurse. Where should she apply?

  1. Department of Health
  2. Provincial Health Office
  3. Regional Health Office
  4. Rural Health Unit

Tony is aware the Chairman of the Municipal Health Board is:

  1. Mayor
  2. Municipal Health Officer
  3. Public Health Nurse
  4. Any qualified physician

Myra is the public health nurse in a municipality with a total population of about 20,000. There are 3 rural health midwives among the RHU personnel. How many more midwife items will the RHU need?

  1. 1
  2. 2
  3. 3
  4. The RHU does not need any more midwife item.

According to Freeman and Heinrich, community health nursing is a developmental service. Which of the following best illustrates this statement?

  1. The community health nurse continuously develops himself personally and professionally.
  2. Health education and community organizing are necessary in providing community health services.
  3. Community health nursing is intended primarily for health promotion and prevention and treatment of disease.
  4. The goal of community health nursing is to provide nursing services to people in their own places of residence.

Nurse Tina is aware that the disease declared through Presidential Proclamation No. 4 as a target for eradication in the Philippines is?

  1. Poliomyelitis
  2. Measles
  3. Rabies
  4. Neonatal tetanus

May knows that the step in community organizing that involves training of potential leaders in the community is:

  1. Integration
  2. Community organization
  3. Community study
  4. Core group formation

Beth a public health nurse takes an active role in community participation. What is the primary goal of community organizing?

  1. To educate the people regarding community health problems
  2. To mobilize the people to resolve community health problems
  3. To maximize the community’s resources in dealing with health problems.
  4. To maximize the community’s resources in dealing with health problems.

Tertiary prevention is needed in which stage of the natural history of disease?

  1. Pre-pathogenesis
  2. Pathogenesis
  3. Prodromal
  4. Terminal

The nurse is caring for a primigravid client in the labor and delivery area. Which condition would place the client at risk for disseminated intravascular coagulation (DIC)?

  1. Intrauterine fetal death.
  2. Placenta accreta.
  3. Dysfunctional labor.
  4. Premature rupture of the membranes.

A fullterm client is in labor. Nurse Betty is aware that the fetal heart rate would be:

  1. 80 to 100 beats/minute
  2. 100 to 120 beats/minute
  3. 120 to 160 beats/minute
  4. 160 to 180 beats/minute

The skin in the diaper area of a 7 month old infant is excoriated and red. Nurse Hazel should instruct the mother to:

  1. Change the diaper more often.
  2. Apply talc powder with diaper changes.
  3. Wash the area vigorously with each diaper change.
  4. Decrease the infant’s fluid intake to decrease saturating diapers.

Nurse Carla knows that the common cardiac anomalies in children with Down Syndrome (tri-somy 21) is:

  1. Atrial septal defect
  2. Pulmonic stenosis
  3. Ventricular septal defect
  4. Endocardial cushion defect

Malou was diagnosed with severe preeclampsia is now receiving I.V. magnesium sulfate. The adverse effects associated with magnesium sulfate is:

  1. Anemia
  2. Decreased urine output
  3. Hyperreflexia
  4. Increased respiratory rate

A 23 year old client is having her menstrual period every 2 weeks that last for 1 week. This type of menstrual pattern is bets defined by:

  1. Menorrhagia
  2. Metrorrhagia
  3. Dyspareunia
  4. Amenorrhea

Jannah is admitted to the labor and delivery unit. The critical laboratory result for this client would be:

  1. Oxygen saturation
  2. Iron binding capacity
  3. Blood typing
  4. Serum Calcium

Nurse Gina is aware that the most common condition found during the second-trimester of pregnancy is:

  1. Metabolic alkalosis
  2. Respiratory acidosis
  3. Mastitis
  4. Physiologic anemia

Nurse Lynette is working in the triage area of an emergency department. She sees that several pediatric clients arrive simultaneously. The client who needs to be treated first is:

  1. A crying 5 year old child with a laceration on his scalp.
  2. A 4 year old child with a barking coughs and flushed appearance.
  3. A 3 year old child with Down syndrome who is pale and asleep in his mother’s arms.
  4. A 2 year old infant with stridorous breath sounds, sitting up in his mother’s arms and drooling.

Maureen in her third trimester arrives at the emergency room with painless vaginal bleeding. Which of the following conditions is suspected?

  1. Placenta previa
  2. Abruptio placentae
  3. Premature labor
  4. Sexually transmitted disease

A young child named Richard is suspected of having pinworms. The community nurse collects a stool specimen to confirm the diagnosis. The nurse should schedule the collection of this specimen for:

  1. Just before bedtime
  2. After the child has been bathe
  3. Any time during the day
  4. Early in the morning

In doing a child’s admission assessment, Nurse Betty should be alert to note which signs or symptoms of chronic lead poisoning?

  1. Irritability and seizures
  2. Dehydration and diarrhea
  3. Bradycardia and hypotension
  4. Petechiae and hematuria

To evaluate a woman’s understanding about the use of diaphragm for family planning, Nurse Trish asks her to explain how she will use the appliance. Which response indicates a need for further health teaching?

  1. “I should check the diaphragm carefully for holes every time I use it”
  2. “I may need a different size of diaphragm if I gain or lose weight more than 20 pounds”
  3. “The diaphragm must be left in place for atleast 6 hours after intercourse”
  4. “I really need to use the diaphragm and jelly most during the middle of my menstrual cycle”.

Hypoxia is a common complication of laryngotracheobronchitis. Nurse Oliver should frequently assess a child with laryngotracheobronchitis for:

  1. Drooling
  2. Muffled voice
  3. Restlessness
  4. Low-grade fever

How should Nurse Michelle guide a child who is blind to walk to the playroom?

  1. Without touching the child, talk continuously as the child walks down the hall.
  2. Walk one step ahead, with the child’s hand on the nurse’s elbow.
  3. Walk slightly behind, gently guiding the child forward.
  4. Walk next to the child, holding the child’s hand.

When assessing a newborn diagnosed with ductus arteriosus, Nurse Olivia should expect that the child most likely would have an:

  1. Loud, machinery-like murmur.
  2. Bluish color to the lips.
  3. Decreased BP reading in the upper extremities
  4. Increased BP reading in the upper extremities.

The reason nurse May keeps the neonate in a neutral thermal environment is that when a newborn becomes too cool, the neonate requires:

  1. Less oxygen, and the newborn’s metabolic rate increases.
  2. More oxygen, and the newborn’s metabolic rate decreases.
  3. More oxygen, and the newborn’s metabolic rate increases.
  4. Less oxygen, and the newborn’s metabolic rate decreases.

Before adding potassium to an infant’s I.V. line, Nurse Ron must be sure to assess whether this infant has:

  1. Stable blood pressure
  2. Patant fontanelles
  3. Moro’s reflex
  4. Voided

Nurse Carla should know that the most common causative factor of dermatitis in infants and younger children is:

  1. Baby oil
  2. Baby lotion
  3. Laundry detergent
  4. Powder with cornstarch

During tube feeding, how far above an infant’s stomach should the nurse hold the syringe with formula?

  1. 6 inches
  2. 12 inches
  3. 18 inches
  4. 24 inches

In a mothers’ class, Nurse Lhynnete discussed childhood diseases such as chicken pox. Which of the following statements about chicken pox is correct?

  1. The older one gets, the more susceptible he becomes to the complications of chicken pox.
  2. A single attack of chicken pox will prevent future episodes, including conditions such as shingles.
  3. To prevent an outbreak in the community, quarantine may be imposed by health authorities.
  4. Chicken pox vaccine is best given when there is an impending outbreak in the community.

Barangay Pinoy had an outbreak of German measles. To prevent congenital rubella, what is the BEST advice that you can give to women in the first trimester of pregnancy in the barangay Pinoy?

  1. Advise them on the signs of German measles.
  2. Avoid crowded places, such as markets and movie houses.
  3. Consult at the health center where rubella vaccine may be given.
  4. Consult a physician who may give them rubella immunoglobulin.

Myrna a public health nurse knows that to determine possible sources of sexually transmitted infections, the BEST method that may be undertaken is:

  1. Contact tracing
  2. Community survey
  3. Mass screening tests
  4. Interview of suspects

A 33-year old female client came for consultation at the health center with the chief complaint of fever for a week. Accompanying symptoms were muscle pains and body malaise. A week after the start of fever, the client noted yellowish discoloration of his sclera. History showed that he waded in flood waters about 2 weeks before the onset of symptoms. Based on her history, which disease condition will you suspect?

  1. Hepatitis A
  2. Hepatitis B
  3. Tetanus
  4. Leptospirosis

Mickey a 3-year old client was brought to the health center with the chief complaint of severe diarrhea and the passage of “rice water” stools. The client is most probably suffering from which condition?

  1. Giardiasis
  2. Cholera
  3. Amebiasis
  4. Dysentery

The most prevalent form of meningitis among children aged 2 months to 3 years is caused by which microorganism?

  1. Hemophilus influenzae
  2. Morbillivirus
  3. Steptococcus pneumoniae
  4. Neisseria meningitidis

The student nurse is aware that the pathognomonic sign of measles is Koplik’s spot and you may see Koplik’s spot by inspecting the:

  1. Nasal mucosa
  2. Buccal mucosa
  3. Skin on the abdomen
  4. Skin on neck

Angel was diagnosed as having Dengue fever. You will say that there is slow capillary refill when the color of the nailbed that you pressed does not return within how many seconds?

  1. 3 seconds
  2. 6 seconds
  3. 9 seconds
  4. 10 seconds

In Integrated Management of Childhood Illness, the nurse is aware that the severe conditions generally require urgent referral to a hospital. Which of the following severe conditions DOES NOT always require urgent referral to a hospital?

  1. Mastoiditis
  2. Severe dehydration
  3. Severe pneumonia
  4. Severe febrile disease

Myrna a public health nurse will conduct outreach immunization in a barangay Masay with a population of about 1500. The estimated number of infants in the barangay would be:

  1. 45 infants
  2. 50 infants
  3. 55 infants
  4. 65 infants

The community nurse is aware that the biological used in Expanded Program on Immunization (EPI) should NOT be stored in the freezer?

  1. DPT
  2. Oral polio vaccine
  3. Measles vaccine
  4. MMR

It is the most effective way of controlling schistosomiasis in an endemic area?

  1. Use of molluscicides
  2. Building of foot bridges
  3. Proper use of sanitary toilets
  4. Use of protective footwear, such as rubber boots

Several clients is newly admitted and diagnosed with leprosy. Which of the following clients should be classified as a case of multibacillary leprosy?

  1. 3 skin lesions, negative slit skin smear
  2. 3 skin lesions, positive slit skin smear
  3. 5 skin lesions, negative slit skin smear
  4. 5 skin lesions, positive slit skin smear

Nurses are aware that diagnosis of leprosy is highly dependent on recognition of symptoms. Which of the following is an early sign of leprosy?

  1. Macular lesions
  2. Inability to close eyelids
  3. Thickened painful nerves
  4. Sinking of the nosebridge

Marie brought her 10 month old infant for consultation because of fever, started 4 days prior to consultation. In determining malaria risk, what will you do?

  1. Perform a tourniquet test.
  2. Ask where the family resides.
  3. Get a specimen for blood smear.
  4. Ask if the fever is present every day.

Susie brought her 4 years old daughter to the RHU because of cough and colds. Following the IMCI assessment guide, which of the following is a danger sign that indicates the need for urgent referral to a hospital?

  1. Inability to drink
  2. High grade fever
  3. Signs of severe dehydration
  4. Cough for more than 30 days

Jimmy a 2-year old child revealed “baggy pants”. As a nurse, using the IMCI guidelines, how will you manage Jimmy?

  1. Refer the child urgently to a hospital for confinement.
  2. Coordinate with the social worker to enroll the child in a feeding program.
  3. Make a teaching plan for the mother, focusing on menu planning for her child.
  4. Assess and treat the child for health problems like infections and intestinal parasitism.

Gina is using Oresol in the management of diarrhea of her 3-year old child. She asked you what to do if her child vomits. As a nurse you will tell her to:

  1. Bring the child to the nearest hospital for further assessment.
  2. Bring the child to the health center for intravenous fluid therapy.
  3. Bring the child to the health center for assessment by the physician.
  4. Let the child rest for 10 minutes then continue giving Oresol more slowly.

Nikki a 5-month old infant was brought by his mother to the health center because of diarrhea for 4 to 5 times a day. Her skin goes back slowly after a skin pinch and her eyes are sunken. Using the IMCI guidelines, you will classify this infant in which category?

  1. No signs of dehydration
  2. Some dehydration
  3. Severe dehydration
  4. The data is insufficient.

Chris a 4-month old infant was brought by her mother to the health center because of cough. His respiratory rate is 42/minute. Using the Integrated Management of Child Illness (IMCI) guidelines of assessment, his breathing is considered as:

  1. Fast
  2. Slow
  3. Normal
  4. Insignificant

Maylene had just received her 4th dose of tetanus toxoid. She is aware that her baby will have protection against tetanus for

  1. 1 year
  2. 3 years
  3. 5 years
  4. Lifetime

Nurse Ron is aware that unused BCG should be discarded after how many hours of reconstitution?

  1. 2 hours
  2. 4 hours
  3. 8 hours
  4. At the end of the day

The nurse explains to a breastfeeding mother that breast milk is sufficient for all of the baby’s nutrient needs only up to:

  1. 5 months
  2. 6 months
  3. 1 year
  4. 2 years

Nurse Ron is aware that the gestational age of a conceptus that is considered viable (able to live outside the womb) is:

  1. 8 weeks
  2. 12 weeks
  3. 24 weeks
  4. 32 weeks

When teaching parents of a neonate the proper position for the neonate’s sleep, the nurse Patricia stresses the importance of placing the neonate on his back to reduce the risk of which of the following?

  1. Aspiration
  2. Sudden infant death syndrome (SIDS)
  3. Suffocation
  4. Gastroesophageal reflux (GER)

Which finding might be seen in baby James a neonate suspected of having an infection?

  1. Flushed cheeks
  2. Increased temperature
  3. Decreased temperature
  4. Increased activity level

Baby Jenny who is small-for-gestation is at increased risk during the transitional period for which complication?

  1. Anemia probably due to chronic fetal hyposia
  2. Hyperthermia due to decreased glycogen stores
  3. Hyperglycemia due to decreased glycogen stores
  4. Polycythemia probably due to chronic fetal hypoxia

Marjorie has just given birth at 42 weeks’ gestation. When the nurse assessing the neonate, which physical finding is expected?

  1. A sleepy, lethargic baby
  2. Lanugo covering the body
  3. Desquamation of the epidermis
  4. Vernix caseosa covering the body

After reviewing the Myrna’s maternal history of magnesium sulfate during labor, which condition would nurse Richard anticipate as a potential problem in the neonate?

  1. Hypoglycemia
  2. Jitteriness
  3. Respiratory depression
  4. Tachycardia

Which symptom would indicate the Baby Alexandra was adapting appropriately to extra-uterine life without difficulty?

  1. Nasal flaring
  2. Light audible grunting
  3. Respiratory rate 40 to 60 breaths/minute
  4. Respiratory rate 60 to 80 breaths/minute

When teaching umbilical cord care for Jennifer a new mother, the nurse Jenny would include which information?

  1. Apply peroxide to the cord with each diaper change
  2. Cover the cord with petroleum jelly after bathing
  3. Keep the cord dry and open to air
  4. Wash the cord with soap and water each day during a tub bath.

Nurse John is performing an assessment on a neonate. Which of the following findings is considered common in the healthy neonate?

  1. Simian crease
  2. Conjunctival hemorrhage
  3. Cystic hygroma
  4. Bulging fontanelle

Dr. Esteves decides to artificially rupture the membranes of a mother who is on labor. Following this procedure, the nurse Hazel checks the fetal heart tones for which the following reasons?

  1. To determine fetal well-being.
  2. To assess for prolapsed cord
  3. To assess fetal position
  4. To prepare for an imminent delivery.

Which of the following would be least likely to indicate anticipated bonding behaviors by new parents?

  1. The parents’ willingness to touch and hold the new born.
  2. The parent’s expression of interest about the size of the new born.
  3. The parents’ indication that they want to see the newborn.
  4. The parents’ interactions with each other.

Following a precipitous delivery, examination of the client’s vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client?

  1. Applying cold to limit edema during the first 12 to 24 hours.
  2. Instructing the client to use two or more peripads to cushion the area.
  3. Instructing the client on the use of sitz baths if ordered.
  4. Instructing the client about the importance of perineal (kegel) exercises.

A pregnant woman accompanied by her husband, seeks admission to the labor and delivery area. She states that she’s in labor and says she attended the facility clinic for prenatal care. Which question should the nurse Oliver ask her first?

  1. “Do you have any chronic illnesses?”
  2. “Do you have any allergies?”
  3. “What is your expected due date?”
  4. “Who will be with you during labor?”

A neonate begins to gag and turns a dusky color. What should the nurse do first?

  1. Calm the neonate.
  2. Notify the physician.
  3. Provide oxygen via face mask as ordered
  4. Aspirate the neonate’s nose and mouth with a bulb syringe.

When a client states that her “water broke,” which of the following actions would be inappropriate for the nurse to do?

  1. Observing the pooling of straw-colored fluid.
  2. Checking vaginal discharge with nitrazine paper.
  3. Conducting a bedside ultrasound for an amniotic fluid index.
  4. Observing for flakes of vernix in the vaginal discharge.

A baby girl is born 8 weeks premature. At birth, she has no spontaneous respirations but is successfully resuscitated. Within several hours she develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. She’s diagnosed with respiratory distress syndrome, intubated, and placed on a ventilator. Which nursing action should be included in the baby’s plan of care to prevent retinopathy of prematurity?

  1. Cover his eyes while receiving oxygen.
  2. Keep her body temperature low.
  3. Monitor partial pressure of oxygen (Pao2) levels.
  4. Humidify the oxygen.

Which of the following is normal newborn calorie intake?

  1. 110 to 130 calories per kg.
  2. 30 to 40 calories per lb of body weight.
  3. At least 2 ml per feeding
  4. 90 to 100 calories per kg

Nurse John is knowledgeable that usually individual twins will grow appropriately and at the same rate as singletons until how many weeks?

  1. 16 to 18 weeks
  2. 18 to 22 weeks
  3. 30 to 32 weeks
  4. 38 to 40 weeks

Which of the following classifications applies to monozygotic twins for whom the cleavage of the fertilized ovum occurs more than 13 days after fertilization?

  1. Conjoined twins
  2. Diamniotic dichorionic twins
  3. Diamniotic monochorionic twin
  4. Monoamniotic monochorionic twins

Tyra experienced painless vaginal bleeding has just been diagnosed as having a placenta previa. Which of the following procedures is usually performed to diagnose placenta previa?

  1. Amniocentesis
  2. Digital or speculum examination
  3. External fetal monitoring
  4. Ultrasound

Nurse Arnold knows that the following changes in respiratory functioning during pregnancy is considered normal:

  1. Increased tidal volume
  2. Increased expiratory volume
  3. Decreased inspiratory capacity
  4. Decreased oxygen consumption

Emily has gestational diabetes and it is usually managed by which of the following therapy?

  1. Diet
  2. Long-acting insulin
  3. Oral hypoglycemic
  4. Oral hypoglycemic drug and insulin

Magnesium sulfate is given to Jemma with preeclampsia to prevent which of the following condition?

  1. Hemorrhage
  2. Hypertension
  3. Hypomagnesemia
  4. Seizure

Cammile with sickle cell anemia has an increased risk for having a sickle cell crisis during pregnancy. Aggressive management of a sickle cell crisis includes which of the following measures?

  1. Antihypertensive agents
  2. Diuretic agents
  3. I.V. fluids
  4. Acetaminophen (Tylenol) for pain

Which of the following drugs is the antidote for magnesium toxicity?

  1. Calcium gluconate (Kalcinate)
  2. Hydralazine (Apresoline)
  3. Naloxone (Narcan)
  4. Rho (D) immune globulin (RhoGAM)

Marlyn is screened for tuberculosis during her first prenatal visit. An intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is given. She is considered to have a positive test for which of the following results?

  1. An indurated wheal under 10 mm in diameter appears in 6 to 12 hours.
  2. An indurated wheal over 10 mm in diameter appears in 48 to 72 hours.
  3. A flat circumcised area under 10 mm in diameter appears in 6 to 12 hours.
  4. A flat circumcised area over 10 mm in diameter appears in 48 to 72 hours.

Dianne, 24 year-old is 27 weeks’ pregnant arrives at her physician’s office with complaints of fever, nausea, vomiting, malaise, unilateral flank pain, and costovertebral angle tenderness. Which of the following diagnoses is most likely?

  1. Asymptomatic bacteriuria
  2. Bacterial vaginosis
  3. Pyelonephritis
  4. Urinary tract infection (UTI)

Rh isoimmunization in a pregnant client develops during which of the following conditions?

  1. Rh-positive maternal blood crosses into fetal blood, stimulating fetal antibodies.
  2. Rh-positive fetal blood crosses into maternal blood, stimulating maternal antibodies.
  3. Rh-negative fetal blood crosses into maternal blood, stimulating maternal antibodies.
  4. Rh-negative maternal blood crosses into fetal blood, stimulating fetal antibodies.

To promote comfort during labor, the nurse John advises a client to assume certain positions and avoid others. Which position may cause maternal hypotension and fetal hypoxia?

  1. Lateral position
  2. Squatting position
  3. Supine position
  4. Standing position

Celeste who used heroin during her pregnancy delivers a neonate. When assessing the neonate, the nurse Lhynnette expects to find:

  1. Lethargy 2 days after birth.
  2. Irritability and poor sucking.
  3. A flattened nose, small eyes, and thin lips.
  4. Congenital defects such as limb anomalies.

The uterus returns to the pelvic cavity in which of the following time frames?

  1. 7th to 9th day postpartum.
  2. 2 weeks postpartum.
  3. End of 6th week postpartum.
  4. When the lochia changes to alba.

Maureen, a primigravida client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin (Pitocin) augmentation. The nurse who’s caring for her should stay alert for:

  1. Uterine inversion
  2. Uterine atony
  3. Uterine involution
  4. Uterine discomfort

For the client who is using oral contraceptives, the nurse informs the client about the need to take the pill at the same time each day to accomplish which of the following?

  1. Decrease the incidence of nausea
  2. Maintain hormonal levels
  3. Reduce side effects
  4. Prevent drug interactions

When teaching a client about contraception. Which of the following would the nurse include as the most effective method for preventing sexually transmitted infections?

  1. Spermicides
  2. Diaphragm
  3. Condoms
  4. Vasectomy

When preparing a woman who is 2 days postpartum for discharge, recommendations for which of the following contraceptive methods would be avoided?

  1. Diaphragm
  2. Female condom
  3. Oral contraceptives
  4. Rhythm method

For which of the following clients would the nurse expect that an intrauterine device would not be recommended?

  1. Woman over age 35
  2. Nulliparous woman
  3. Promiscuous young adult
  4. Postpartum client

A client in her third trimester tells the nurse, “I’m constipated all the time!” Which of the following should the nurse recommend?

  1. Daily enemas
  2. Laxatives
  3. Increased fiber intake
  4. Decreased fluid intake

Which of the following would the nurse use as the basis for the teaching plan when caring for a pregnant teenager concerned about gaining too much weight during pregnancy?

  1. 10 pounds per trimester
  2. 1 pound per week for 40 weeks
  3. ½ pound per week for 40 weeks
  4. A total gain of 25 to 30 pounds

The client tells the nurse that her last menstrual period started on January 14 and ended on January 20. Using Nagele’s rule, the nurse determines her EDD to be which of the following?

  1. September 27
  2. October 21
  3. November 7
  4. December 27

When taking an obstetrical history on a pregnant client who states, “I had a son born at 38 weeks gestation, a daughter born at 30 weeks gestation and I lost a baby at about 8 weeks,” the nurse should record her obstetrical history as which of the following?

  1. G2 T2 P0 A0 L2
  2. G3 T1 P1 A0 L2
  3. G3 T2 P0 A0 L2
  4. G4 T1 P1 A1 L2

When preparing to listen to the fetal heart rate at 12 weeks’ gestation, the nurse would use which of the following?

  1. Stethoscope placed midline at the umbilicus
  2. Doppler placed midline at the suprapubic region
  3. Fetoscope placed midway between the umbilicus and the xiphoid process
  4. External electronic fetal monitor placed at the umbilicus

When developing a plan of care for a client newly diagnosed with gestational diabetes, which of the following instructions would be the priority?

  1. Dietary intake
  2. Medication
  3. Exercise
  4. Glucose monitoring

A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of the following would be the priority when assessing the client?

  1. Glucosuria
  2. Depression
  3. Hand/face edema
  4. Dietary intake

A client 12 weeks’ pregnant come to the emergency department with abdominal cramping and moderate vaginal bleeding. Speculum examination reveals 2 to 3 cms cervical dilation. The nurse would document these findings as which of the following?

  1. Threatened abortion
  2. Imminent abortion
  3. Complete abortion
  4. Missed abortion

Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy?

  1. Risk for infection
  2. Pain
  3. Knowledge Deficit
  4. Anticipatory Grieving

Before assessing the postpartum client’s uterus for firmness and position in relation to the umbilicus and midline, which of the following should the nurse do first?

  1. Assess the vital signs
  2. Administer analgesia
  3. Ambulate her in the hall
  4. Assist her to urinate

Which of the following should the nurse do when a primipara who is lactating tells the nurse that she has sore nipples?

  1. Tell her to breast feed more frequently
  2. Administer a narcotic before breast feeding
  3. Encourage her to wear a nursing brassiere
  4. Use soap and water to clean the nipples

The nurse assesses the vital signs of a client, 4 hours’ postpartum that are as follows: BP 90/60; temperature 100.4ºF; pulse 100 weak, thready; R 20 per minute. Which of the following should the nurse do first?

  1. Report the temperature to the physician
  2. Recheck the blood pressure with another cuff
  3. Assess the uterus for firmness and position
  4. Determine the amount of lochia

The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Which of the following assessments would warrant notification of the physician?

  1. A dark red discharge on a 2-day postpartum client
  2. A pink to brownish discharge on a client who is 5 days postpartum
  3. Almost colorless to creamy discharge on a client 2 weeks after delivery
  4. A bright red discharge 5 days after delivery

A postpartum client has a temperature of 101.4ºF, with a uterus that is tender when palpated, remains unusually large, and not descending as normally expected. Which of the following should the nurse assess next?

  1. Lochia
  2. Breasts
  3. Incision
  4. Urine

Which of the following is the priority focus of nursing practice with the current early postpartum discharge?

  1. Promoting comfort and restoration of health
  2. Exploring the emotional status of the family
  3. Facilitating safe and effective self-and newborn care
  4. Teaching about the importance of family planning

Which of the following actions would be least effective in maintaining a neutral thermal environment for the newborn?

  1. Placing infant under radiant warmer after bathing
  2. Covering the scale with a warmed blanket prior to weighing
  3. Placing crib close to nursery window for family viewing
  4. Covering the infant’s head with a knit stockinette

A newborn who has an asymmetrical Moro reflex response should be further assessed for which of the following?

  1. Talipes equinovarus
  2. Fractured clavicle
  3. Congenital hypothyroidism
  4. Increased intracranial pressure

During the first 4 hours after a male circumcision, assessing for which of the following is the priority?

  1. Infection
  2. Hemorrhage
  3. Discomfort
  4. Dehydration

The mother asks the nurse. “What’s wrong with my son’s breasts? Why are they so enlarged?” Whish of the following would be the best response by the nurse?

  1. “The breast tissue is inflamed from the trauma experienced with birth”
  2. “A decrease in material hormones present before birth causes enlargement,”
  3. “You should discuss this with your doctor. It could be a malignancy”
  4. “The tissue has hypertrophied while the baby was in the uterus”

Immediately after birth the nurse notes the following on a male newborn: respirations 78; apical hearth rate 160 BPM, nostril flaring; mild intercostal retractions; and grunting at the end of expiration. Which of the following should the nurse do?

  1. Call the assessment data to the physician’s attention
  2. Start oxygen per nasal cannula at 2 L/min.
  3. Suction the infant’s mouth and nares
  4. Recognize this as normal first period of reactivity

The nurse hears a mother telling a friend on the telephone about umbilical cord care. Which of the following statements by the mother indicates effective teaching?

  1. “Daily soap and water cleansing is best”
  2. ‘Alcohol helps it dry and kills germs”
  3. “An antibiotic ointment applied daily prevents infection”
  4. “He can have a tub bath each day”

A newborn weighing 3000 grams and feeding every 4 hours needs 120 calories/kg of body weight every 24 hours for proper growth and development. How many ounces of 20 cal/oz formula should this newborn receive at each feeding to meet nutritional needs?

  1. 2 ounces
  2. 3 ounces
  3. 4 ounces
  4. 6 ounces

The postterm neonate with meconium-stained amniotic fluid needs care designed to especially monitor for which of the following?

  1. Respiratory problems
  2. Gastrointestinal problems
  3. Integumentary problems
  4. Elimination problems

When measuring a client’s fundal height, which of the following techniques denotes the correct method of measurement used by the nurse?

  1. From the xiphoid process to the umbilicus
  2. From the symphysis pubis to the xiphoid process
  3. From the symphysis pubis to the fundus
  4. From the fundus to the umbilicus

A client with severe preeclampsia is admitted with of BP 160/110, proteinuria, and severe pitting edema. Which of the following would be most important to include in the client’s plan of care?

  1. Daily weights
  2. Seizure precautions
  3. Right lateral positioning
  4. Stress reduction

A postpartum primipara asks the nurse, “When can we have sexual intercourse again?” Which of the following would be the nurse’s best response?

  1. “Anytime you both want to.”
  2. “As soon as choose a contraceptive method.”
  3. “When the discharge has stopped and the incision is healed.”
  4. “After your 6 weeks examination.”

When preparing to administer the vitamin K injection to a neonate, the nurse would select which of the following sites as appropriate for the injection?

  1. Deltoid muscle
  2. Anterior femoris muscle
  3. Vastus lateralis muscle
  4. Gluteus maximus muscle

When performing a pelvic examination, the nurse observes a red swollen area on the right side of the vaginal orifice. The nurse would document this as enlargement of which of the following?

  1. Clitoris
  2. Parotid gland
  3. Skene’s gland
  4. Bartholin’s gland

To differentiate as a female, the hormonal stimulation of the embryo that must occur involves which of the following?

  1. Increase in maternal estrogen secretion
  2. Decrease in maternal androgen secretion
  3. Secretion of androgen by the fetal gonad
  4. Secretion of estrogen by the fetal gonad

A client at 8 weeks’ gestation calls complaining of slight nausea in the morning hours. Which of the following client interventions should the nurse question?

  1. Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of water
  2. Eating a few low-sodium crackers before getting out of bed
  3. Avoiding the intake of liquids in the morning hours
  4. Eating six small meals a day instead of thee large meals

The nurse documents positive ballottement in the client’s prenatal record. The nurse understands that this indicates which of the following?

  1. Palpable contractions on the abdomen
  2. Passive movement of the unengaged fetus
  3. Fetal kicking felt by the client
  4. Enlargement and softening of the uterus

During a pelvic exam the nurse notes a purple-blue tinge of the cervix. The nurse documents this as which of the following?

  1. Braxton-Hicks sign
  2. Chadwick’s sign
  3. Goodell’s sign
  4. McDonald’s sign

During a prenatal class, the nurse explains the rationale for breathing techniques during preparation for labor based on the understanding that breathing techniques are most important in achieving which of the following?

  1. Eliminate pain and give the expectant parents something to do
  2. Reduce the risk of fetal distress by increasing uteroplacental perfusion
  3. Facilitate relaxation, possibly reducing the perception of pain
  4. Eliminate pain so that less analgesia and anesthesia are needed

After 4 hours of active labor, the nurse notes that the contractions of a primigravida client are not strong enough to dilate the cervix. Which of the following would the nurse anticipate doing?

  1. Obtaining an order to begin IV oxytocin infusion
  2. Administering a light sedative to allow the patient to rest for several hour
  3. Preparing for a cesarean section for failure to progress
  4. Increasing the encouragement to the patient when pushing begins

A multigravida at 38 weeks’ gestation is admitted with painless, bright red bleeding and mild contractions every 7 to 10 minutes. Which of the following assessments should be avoided?

  1. Maternal vital sign
  2. Fetal heart rate
  3. Contraction monitoring
  4. Cervical dilation

Which of the following would be the nurse’s most appropriate response to a client who asks why she must have a cesarean delivery if she has a complete placenta previa?

  1. “You will have to ask your physician when he returns.”
  2. “You need a cesarean to prevent hemorrhage.”
  3. “The placenta is covering most of your cervix.”
  4. “The placenta is covering the opening of the uterus and blocking your baby.”

The nurse understands that the fetal head is in which of the following positions with a face presentation?

  1. Completely flexed
  2. Completely extended
  3. Partially extended
  4. Partially flexed

With a fetus in the left-anterior breech presentation, the nurse would expect the fetal heart rate would be most audible in which of the following areas?

  1. Above the maternal umbilicus and to the right of midline
  2. In the lower-left maternal abdominal quadrant
  3. In the lower-right maternal abdominal quadrant
  4. Above the maternal umbilicus and to the left of midline

The amniotic fluid of a client has a greenish tint. The nurse interprets this to be the result of which of the following?

  1. Lanugo
  2. Hydramnio
  3. Meconium
  4. Vernix

A patient is in labor and has just been told she has a breech presentation. The nurse should be particularly alert for which of the following?

  1. Quickening
  2. Ophthalmia neonatorum
  3. Pica
  4. Prolapsed umbilical cord

When describing dizygotic twins to a couple, on which of the following would the nurse base the explanation?

  1. Two ova fertilized by separate sperm
  2. Sharing of a common placenta
  3. Each ova with the same genotype
  4. Sharing of a common chorion

Which of the following refers to the single cell that reproduces itself after conception?

  1. Chromosome
  2. Blastocyst
  3. Zygote
  4. Trophoblast

In the late 1950s, consumers and health care professionals began challenging the routine use of analgesics and anesthetics during childbirth. Which of the following was an outgrowth of this concept?

  1. Labor, delivery, recovery, postpartum (LDRP)
  2. Nurse-midwifery
  3. Clinical nurse specialist
  4. Prepared childbirth

A client has a midpelvic contracture from a previous pelvic injury due to a motor vehicle accident as a teenager. The nurse is aware that this could prevent a fetus from passing through or around which structure during childbirth?

  1. Symphysis pubis
  2. Sacral promontory
  3. Ischial spines
  4. Pubic arch

When teaching a group of adolescents about variations in the length of the menstrual cycle, the nurse understands that the underlying mechanism is due to variations in which of the following phases?

  1. Menstrual phase
  2. Proliferative phase
  3. Secretory phase
  4. Ischemic phase

When teaching a group of adolescents about male hormone production, which of the following would the nurse include as being produced by the Leydig cells?

  1. Follicle-stimulating hormone
  2. Testosterone
  3. Luteinizing hormone
  4. Gonadotropin releasing hormone

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?

  1. Notify the pediatrician of this finding
  2. Reassure the student that this is an acceptable action on the parent’s part
  3. Discuss this action with the parents
  4. Ask the student nurse to remove the pacifier from the toddler’s mouth

The nurse is providing a health teaching to the mother of an 8-year-old child with cystic fbrosis. 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?

  1. “My child might need an extra capsule if the meal is high in fat”
  2. “I’ll give the enzyme capsule before every snack”
  3. “I’ll give the enzyme capsule before every meal”
  4. “My child hates to take pills, so I’ll mix the capsule into a cup of hot chocolate

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?

  1. “I will notify the physician, who will probably decrease the dosage slightly”
  2. “This is a normal side effect and means the medication is working”
  3. “You sound quite concerned. Would you like to talk about this further?”
  4. “I will need a specimen to check the stool for possible bleeding”

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?

  1. I will review first the child’s height on a growth chart to know if the treatment is working
  2. I will review first the child’s weight on a growth chart to know if the treatment is working
  3. I will review first the number of prescriptions refills the child has required over the last 6 months to give you an accurate answer
  4. 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

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:

  1. Administer the drug between meals
  2. Monitor the child’s hearing
  3. Give the drug through a straw
  4. Keep the child out of the sunlight

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?

  1. Retake the apical pulse in 15 minutes
  2. Retake the apical pulse in 30 minutes
  3. Notify the pediatrician immediately
  4. Administer the medication as scheduled

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:

  1. CBC and platelet count
  2. Auditory tests
  3. Renal Function tests
  4. Abdominal and chest x-rays

Which of the following is the suited size of the needle would the nurse select to administer the IM injection to a preschool child?

  1. 18 G, 1-1/2 inch
  2. 25 G, 5/8 inch
  3. 21 G, 1 inch
  4. 18 G, 1inch

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?

  1. Listening to story of his mother
  2. Listening to the music in the radio
  3. Playing mini piano
  4. Watching movie in the dvd mini player

The physician decided to schedule the 4-year-old client for repair of left undescended testicle. The Injection of a hormone, HCG fnds it less successful for treatment. To administer a pentobarbital sodium (Nembutal) suppository preoperatively to this client, in which position should the nurse place him?

  1. Supine with foot of bed elevated
  2. Prone with legs abducted
  3. Sitting with foot of bed elevated
  4. Side-lying with upper leg fexed

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?

  1. Check the other vital signs and level of consciousness
  2. Withhold the digoxin and notify the physician
  3. Give the digoxin as prescribed
  4. Check the apical and radial simultaneously, and if they are the same, give the digoxin.

An 8-year-old client with cystic fbrosis 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:

  1. After meals
  2. Between meals
  3. After medication
  4. Around the child’s play schedule

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?

  1. “I understand that the hormones for breastfeeding may affect when my periods come”
  2. “Breastfeeding causes my womb to tighten and bleed less after birth”
  3. “I may not have periods while I am breastfeeding, so I don’t need family planning”
  4. “I can get pregnant as early as one month after my baby was born”

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 fnds 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:

  1. The toddler did not bond well with the maternal fgure
  2. The blanket is an important transitional object
  3. The toddler is anxious about the hospital experience
  4. The toddler is resistive to nursing interventions

The nurse has knowledge about the developmental task of the child. In caring a 3-year-old-client, the nurse knows that the suited developmental task of this child is to:

  1. Learn to play with other children
  2. Able to trust others
  3. Express all needs through speaking
  4. Explore and manipulate the environment

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:

  1. The older daughter be given more responsibility and assure her “that she is a big girl now, and doesn’t need Mommy as much”
  2. The older daughter not have interaction with the baby at the hospital, because she may harm her new sibling
  3. The older daughter stay with her grandmother for a few days until the parents and new baby are settled at home
  4. The mother spend time alone with her older daughter when the baby is sleeping

A 2-year-old client with cystic fbrosis is confned 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:

  1. Puzzle
  2. Musical automobile
  3. Arranging stickers in the album
  4. Pounding board and hammer

Which of the following clients is at high risk for developmental problem?

  1. A toddler with acute Glomerulonephritis on antihypertensive and antibiotics
  2. A 5-year-old with asthma on cromolyn sodium
  3. A preschooler with tonsillitis
  4. A 2 1/2 –year old boy with cystic fbrosis

Which of the following would be the best divesionary activity for the nurse to select for a 2 weeks hospitalized 3-year-old girl?

  1. Crayons and coloring books
  2. doll
  3. xylophone toy
  4. puzzles

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?

  1. Plugging all electrical outlets in the house
  2. Installing a gate at the top and bottom of any stairs in the home
  3. Purchasing an infant car seat as soon as possible
  4. Begin to teach the child not to place small objects in the mouth

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?

  1. Heterosexual relationships
  2. A love relationship with the father
  3. A dependency relationship with the father
  4. Close relationship with peers

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:

  1. Expect a simple yet logical explanation regarding the surgery
  2. Asks many questions regarding the condition and the procedure
  3. Worry over the impending surgery
  4. Be uninterested in the upcoming surgery

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 fnd stimulating?

  1. Watching a video
  2. Putting together a puzzle
  3. Assembling handouts with the nurse for an upcoming staff development meeting
  4. Listening to a compact disc

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?

  1. The adolescent might have an unconscious death wish
  2. The adolescent feels indestructible
  3. The adolescent lacks life experience to realize how dangerous the behavior is
  4. The adolescent has found a way to act out hostility toward the parent

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?

  1. Has a three-word vocabulary
  2. Interacts with other infants
  3. Stands alone
  4. Recognizes but is fearful of strangers

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:

  1. Should be recorded each morning before any activity
  2. Is the average temperature taken each morning
  3. Can be done with a mercury thermometer but not a digital one
  4. Has a lower degree of accuracy in predicting ovulation than the cervical mucus test

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?

  1. “I should check the diaphragm carefully for holes every time I use it.”
  2. “The diaphragm must be left in place for at least 6 hours after intercourse.”
  3. “I really need to use the diaphragm and jelly most during the middle of my menstrual cycle
  4. “I may need a different size diaphragm if I gain or lose more than 20 pounds”

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?

  1. Contractions are 2-3 minutes apart, lasting 90 seconds, and membranes have ruptured
  2. Contractions are 5-10 minutes apart, lasting 30 seconds, and are felt as strong menstrual cramps
  3. Contractions are 3-5 minutes apart, accompanied by rectal pressure and bloody show
  4. Contractions are 5 minutes apart, lasting 60 seconds, and increasing in intensity

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?

  1. “Because breastfeeding speeds the healing process after birth, I can have sex right away and not worry about infection”
  2. “Because I am breastfeeding and my hormones are decreased, I may need to use a vaginal lubricant when I have sex”
  3. “After birth, you have to have a period before you can get pregnant again’
  4. “Breastfeeding protects me from pregnancy because it keeps my hormones down, so I don’t need any contraception until I stop breastfeeding”

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?

  1. cushioned footstool
  2. bedside wood table
  3. kitchen countertop
  4. living room sofa

The nurse in the health center is making an assessment to the infant client. The nurse notes some rashes and small fuid-flled bumps in the skin. The nurse suspects that the infant has eczema. Which of the following is the most important nursing goal:

  1. Preventing infection
  2. Providing for adequate nutrition
  3. Decreasing the itching
  4. Maintaining the comfort level

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?

  1. a dry cough
  2. a skin rash
  3. a low-grade fever
  4. a runny nose

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?

  1. “I will examine the child for symptoms of hepatitis B”
  2. “Your child will start the series again”
  3. “Your child will get the next dose as soon as possible”
  4. “Your child will have a hepatitis titer done to determine if immunization has taken place.”

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?

  1. Yearly breast exam by a trained professional
  2. Detailed health history to identify women at risk
  3. Screening mammogram every year for women over age 50
  4. Screening mammogram every 1-2 years for women over age of 40.

Which of the following technique is considered an aseptic practice during the home visit of the community health nurse?

  1. Wrapping used dressing in a plastic bag before placing them in the nursing bag
  2. Washing hands before removing equipment from the nursing bag
  3. Using the client’s soap and cloth towel for hand washing
  4. Placing the contaminated needles and syringes in a labeled container inside the nursing bag

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?

  1. Purpose of the home visit
  2. Preference of the patient’s family
  3. Location of the patient’s home
  4. Length of time of the visit will take

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?

  1. “During treatment for yeast, avoid vaginal intercourse for one week”
  2. “Wear loose-ftting cotton underwear”
  3. “Avoid eating large amounts of sugar or sugar-bingeing”
  4. “Douche once a day with a mild vinegar and water solution”

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:

  1. “The number of immunizations your baby will receive shows how many pediatric communicable and infectious diseases can now be prevented.”
  2. “You need to ask the physician”
  3. “The number of immunizations your baby will receive is determined by your baby’s health history and age”
  4. “It is easier on your baby to receive several immunizations rather than one at a time”

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?

  1. Cheese, yogurt, and fsh for protein and calcium needs plus prenatal vitamins and iron supplements
  2. Prenatal iron and calcium supplements plus a regular adult diet
  3. Red beans, green leafy vegetables, and fsh for iron and calcium needs plus prenatal vitamins and iron supplements
  4. Red meat, milk and eggs for iron and calcium needs plus prenatal vitamins and iron supplements

A woman with active tuberculosis (TB) and has visited the health center for regular therapy for fve months wants to become pregnant. The nurse knows that further information is necessary when the woman states:

  1. “Spontaneous abortion may occur in one out of fve women who are infected”
  2. “Pulmonary TB may jeopardize my pregnancy”
  3. “I know that I may not be able to have close contact with my baby until contagious is no longer a problem
  4. “I can get pregnant after I have been free of TB for 6 months”

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 specifc organisms to help patients get appropriate treatment. Typical symptoms of salmonella include:

  1. Nausea, vomiting and paralysis
  2. Bloody diarrhea
  3. Diarrhea and abdominal cramps
  4. Nausea, vomiting and headache

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?

  1. Big mirror in a wall
  2. Scattered and unwashed dishes in the sink
  3. Shiny foors with scattered rugs
  4. Brightly lit rooms

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?

  1. “Condoms should be used because they can prevent infection and because they may prevent pregnancy”
  2. “Condoms should be used even if you have recently tested negative for HIV”
  3. “Condoms should be used every time you have sex because condoms prevent all forms of sexually transmitted diseases”
  4. “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”

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:

  1. Is pregnant
  2. Has genital herpes infection
  3. Develops mastitis
  4. Has inverted nipples

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:

  1. Lack of appetite
  2. Severe itching of the scalp
  3. Perianal itching
  4. Severe abdominal pain

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:

  1. Fluid volume defcit related to vomiting
  2. Altered body image related to alopecia
  3. Altered comfort related to itching
  4. Diversional activity defcit related to hospitalization

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 fnding would indicate the presence of this sign?

  1. Flexion of the hips when the neck is fexed from a lying position
  2. Calf pain when the foot is dorsifexed
  3. Inability of the child to extend the legs fully when lying supine
  4. Pain when the chin is pulled down to the chest

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:

  1. Child will experience mild discomfort
  2. Child will experience only minor complications
  3. Child will not spread the infection to others
  4. Public health department will be notifed

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?

  1. “I do not need to be concerned about the spreading of this infection to others in my family”
  2. “I should apply warm compresses before instilling antibiotic drops if purulent discharge is present in my daughter’s eye”
  3. “I can use an ophthalmic analgesic ointment at nighttime if I have eye discomfort”
  4. “I should perform a saline eye irrigation before instilling, the antibiotic drops into my daughter’s eye if purulent discharge is present”

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?

  1. Finding affordable housing for the group
  2. Peer support through structured groups
  3. Setting up a 24-hour crisis center and hotline
  4. Meeting the basic needs to ensure that adequate food, shelter and clothing are available

Medical-Surgical Nursing

ParameterMetadata
DomainMedical-Surgical Nursing
Topics
Items350 multiple-choice questions
Answer StatusAnswer Key, Rationalized

Nurse Michelle should know that the drainage is normal 4 days after a sigmoid colostomy when the stool is:

  1. Green liquid
  2. Solid formed
  3. Loose, bloody
  4. Semi-formed

Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia?

  1. On the client’s right side
  2. On the client’s left side
  3. Directly in front of the client
  4. Where the client like

A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse?

  1. Check respiration, circulation, neurological response.
  2. Align the spine, check pupils, and check for hemorrhage.
  3. Check respirations, stabilize spine, and check circulation.
  4. Assess level of consciousness and circulation.

In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and relieves angina by:

  1. Increasing contractility and slowing heart rate.
  2. Increasing AV conduction and heart rate.
  3. Decreasing contractility and oxygen consumption.
  4. Decreasing venous return through vasodilation.

Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action?

  1. Call for help and note the time.
  2. Clear the airway
  3. Give two sharp thumps to the precordium, and check the pulse.
  4. Administer two quick blows.

Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse should:

  1. Plan care so the client can receive 8 hours of uninterrupted sleep each night.
  2. Monitor vital signs every 2 hours.
  3. Make sure that the client takes food and medications at prescribed intervals.
  4. Provide milk every 2 to 3 hours.

A male client was on warfarin (Coumadin) before admission, and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?

  1. Stop the I.V. infusion of heparin and notify the physician.
  2. Continue treatment as ordered.
  3. Expect the warfarin to increase the PTT.
  4. Increase the dosage, because the level is lower than normal.

A client undergone ileostomy, when should the drainage appliance be applied to the stoma?

  1. 24 hours later, when edema has subsided.
  2. In the operating room.
  3. After the ileostomy begin to function.
  4. When the client is able to begin self-care procedures.

A client undergone spinal anesthetic, it will be important that the nurse immediately position the client in:

  1. On the side, to prevent obstruction of airway by tongue.
  2. Flat on back.
  3. On the back, with knees flexed 15 degrees.
  4. Flat on the stomach, with the head turned to the side.

While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure?

  1. Blood pressure is decreased from 160/90 to 110/70.
  2. Pulse is increased from 87 to 95, with an occasional skipped beat.
  3. The client is oriented when aroused from sleep, and goes back to sleep immediately.
  4. The client refuses dinner because of anorexia.

Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first?

  1. Altered mental status and dehydration
  2. Fever and chills
  3. Hemoptysis and Dyspnea
  4. Pleuritic chest pain and cough

A male client has active tuberculosis (TB). Which of the following symptoms will be exhibit?

  1. Chest and lower back pain
  2. Chills, fever, night sweats, and hemoptysis
  3. Fever of more than 104°F (40°C) and nausea
  4. Headache and photophobia

Mark, a 7-year-old client is brought to the emergency department. He’s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has a nonproductive cough. He recently had a cold. Form this history; the client may have which of the following conditions?

  1. Acute asthma
  2. Bronchial pneumonia
  3. Chronic obstructive pulmonary disease (COPD)
  4. Emphysema

Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have which of the following reactions?

  1. Asthma attack
  2. Respiratory arrest
  3. Seizure
  4. Wake up on his own

A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging?

  1. Increased elastic recoil of the lungs
  2. Increased number of functional capillaries in the alveoli
  3. Decreased residual volume
  4. Decreased vital capacity

Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to administration of this medication?

  1. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter.
  2. Increase in systemic blood pressure.
  3. Presence of premature ventricular contractions (PVCs) on a cardiac monitor.
  4. Increase in intracranial pressure (ICP).

Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to:

  1. Report incidents of diarrhea.
  2. Avoid foods high in vitamin K
  3. Use a straight razor when shaving.
  4. Take aspirin to pain relief.

Nurse Lhynnette is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by:

  1. Leaving the hair intact
  2. Shaving the area
  3. Clipping the hair in the area
  4. Removing the hair with a depilatory.

Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication:

  1. Bone fracture
  2. Loss of estrogen
  3. Negative calcium balance
  4. Dowager’s hump

Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose of performing the examination is to discover:

  1. Cancerous lumps
  2. Areas of thickness or fullness
  3. Changes from previous examinations.
  4. Fibrocystic masses

When caring for a female client who is being treated for hyperthyroidism, it is important to:

  1. Provide extra blankets and clothing to keep the client warm.
  2. Monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy.
  3. Balance the client’s periods of activity and rest.
  4. Encourage the client to be active to prevent constipation.

Nurse Kris is teaching a client with history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:

  1. Avoid focusing on his weight.
  2. Increase his activity level.
  3. Follow a regular diet.
  4. Continue leading a high-stress lifestyle.

Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client following a:

  1. Laminectomy
  2. Thoracotomy
  3. Hemorrhoidectomy
  4. Cystectomy.

A 55-year old client underwent cataract removal with intraocular lens implant. Nurse Oliver is giving the client discharge instructions. These instructions should include which of the following?

  1. Avoid lifting objects weighing more than 5 lb (2.25 kg).
  2. Lie on your abdomen when in bed
  3. Keep rooms brightly lit.
  4. Avoiding straining during bowel movement or bending at the waist.

George should be taught about testicular examinations during:

  1. When sexual activity starts
  2. After age 69
  3. After age 40
  4. Before age 20.

A male client undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. Nurse Trish first response is to:

  1. Call the physician
  2. Place a saline-soaked sterile dressing on the wound.
  3. Take a blood pressure and pulse.
  4. Pull the dehiscence closed.

Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During routine assessment, the nurse notices Cheyne- Strokes respirations. Cheyne-strokes respirations are:

  1. A progressively deeper breaths followed by shallower breaths with apneic periods.
  2. Rapid, deep breathing with abrupt pauses between each breath.
  3. Rapid, deep breathing and irregular breathing without pauses.
  4. Shallow breathing with an increased respiratory rate.

Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:

  1. Tracheal
  2. Fine crackles
  3. Coarse crackles
  4. Friction rubs

The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing and breath sounds aren’t audible. The reason for this change is that:

  1. The attack is over.
  2. The airways are so swollen that no air cannot get through.
  3. The swelling has decreased.
  4. Crackles have replaced wheezes.

Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should:

  1. Place the client on his back remove dangerous objects, and insert a bite block.
  2. Place the client on his side, remove dangerous objects, and insert a bite block.
  3. Place the client o his back, remove dangerous objects, and hold down his arms.
  4. Place the client on his side, remove dangerous objects, and protect his head.

After insertion of a cheat tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for?

  1. Infection of the lung.
  2. Kinked or obstructed chest tube
  3. Excessive water in the water-seal chamber
  4. Excessive chest tube drainage

Nurse Maureen is talking to a male client; the client begins choking on his lunch. He’s coughing forcefully. The nurse should:

  1. Stand him up and perform the abdominal thrust maneuver from behind.
  2. Lay him down, straddle him, and perform the abdominal thrust maneuver.
  3. Leave him to get assistance
  4. Stay with him but not intervene at this time.

Nurse Ron is taking a health history of an 84 year old client. Which information will be most useful to the nurse for planning care?

  1. General health for the last 10 years.
  2. Current health promotion activities.
  3. Family history of diseases.
  4. Marital status.

When performing oral care on a comatose client, Nurse Krina should:

  1. Apply lemon glycerin to the client’s lips at least every 2 hours.
  2. Brush the teeth with client lying supine.
  3. Place the client in a side lying position, with the head of the bed lowered.
  4. Clean the client’s mouth with hydrogen peroxide.

A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status. He’s being hydrated with L.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103°F (39.4°C) a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client may have which of the following conditions?

  1. Adult respiratory distress syndrome (ARDS)
  2. Myocardial infarction (MI)
  3. Pneumonia
  4. Tuberculosis

Nurse Oliver is working in an outpatient clinic. He has been alerted that there is an outbreak of tuberculosis (TB). Which of the following clients entering the clinic today most likely to have TB?

  1. A 16-year-old female high school student
  2. A 33-year-old day-care worker
  3. A 43-yesr-old homeless man with a history of alcoholism
  4. A 54-year-old businessman

Virgie with a positive Mantoux test result will be sent for a chest X-ray. The nurse is aware that which of the following reasons this is done?

  1. To confirm the diagnosis
  2. To determine if a repeat skin test is needed
  3. To determine the extent of lesions
  4. To determine if this is a primary or secondary infection

Kennedy with acute asthma showing inspiratory and expiratory wheezes and a decreased forced expiratory volume should be treated with which of the following classes of medication right away?

  1. Beta-adrenergic blockers
  2. Bronchodilators
  3. Inhaled steroids
  4. Oral steroids

Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum, peripheral edema and cyanotic nail beds. Based on this information, he most likely has which of the following conditions?

  1. Adult respiratory distress syndrome (ARDS)
  2. Asthma
  3. Chronic obstructive bronchitis
  4. Emphysema

Situation

Francis, age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia.

The treatment for patients with leukemia is bone marrow transplantation. Which statement about bone marrow transplantation is not correct?

  1. The patient is under local anesthesia during the procedure
  2. The aspirated bone marrow is mixed with heparin.
  3. The aspiration site is the posterior or anterior iliac crest.
  4. The recipient receives cyclophosphamide (Cytoxan) for 4 consecutive days before the procedure.

After several days of admission, Francis becomes disoriented and complains of frequent headaches. The nurse in-charge first action would be:

  1. Call the physician
  2. Document the patient’s status in his charts.
  3. Prepare oxygen treatment
  4. Raise the side rails

During routine care, Francis asks the nurse, “How can I be anemic if this disease causes increased my white blood cell production?” The nurse in-charge best response would be that the increased number of white blood cells (WBC) is:

  1. Crowd red blood cells
  2. Are not responsible for the anemia.
  3. Uses nutrients from other cells
  4. Have an abnormally short life span of cells.

Diagnostic assessment of Francis would probably not reveal:

  1. Predominance of lymphoblasts
  2. Leukocytosis
  3. Abnormal blast cells in the bone marrow
  4. Elevated thrombocyte counts

Robert, a 57-year-old client with acute arterial occlusion of the left leg undergoes an emergency embolectomy. Six hours later, the nurse isn’t able to obtain pulses in his left foot using Doppler ultrasound. The nurse immediately notifies the physician, and asks her to prepare the client for surgery. As the nurse enters the client’s room to prepare him, he states that he won’t have any more surgery. Which of the following is the best initial response by the nurse?

  1. Explain the risks of not having the surgery
  2. Notifying the physician immediately
  3. Notifying the nursing supervisor
  4. Recording the client’s refusal in the nurses’ notes

During the endorsement, which of the following clients should the on-duty nurse assess first?

  1. The 58-year-old client who was admitted 2 days ago with heart failure, blood pressure of 126/76 mm Hg, and a respiratory rate of 22 breaths/ minute.
  2. The 89-year-old client with end-stage right-sided heart failure, blood pressure of 78/50 mm Hg, and a “do not resuscitate” order
  3. The 62-year-old client who was admitted 1 day ago with thrombophlebitis and is receiving L.V. heparin
  4. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem)

Honey, a 23-year old client complains of substernal chest pain and states that her heart feels like “it’s racing out of the chest”. She reports no history of cardiac disorders. The nurse attaches her to a cardiac monitor and notes sinus tachycardia with a rate of 136beats/minutes. Breath sounds are clear and the respiratory rate is 26 breaths/minutes. Which of the following drugs should the nurse question the client about using?

  1. Barbiturates
  2. Opioids
  3. Cocaine
  4. Benzodiazepines

A 51-year-old female client tells the nurse in-charge that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client’s lump is cancerous?

  1. Eversion of the right nipple and mobile mass
  2. Nonmobile mass with irregular edges
  3. Mobile mass that is soft and easily delineated
  4. Nonpalpable right axillary lymph nodes

A 35-year-old client with vaginal cancer asks the nurse, “What is the usual treatment for this type of cancer?” Which treatment should the nurse name?

  1. Surgery
  2. Chemotherapy
  3. Radiation
  4. Immunotherapy

Cristina undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean?

  1. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis
  2. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
  3. Can’t assess tumor or regional lymph nodes and no evidence of metastasis
  4. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis

Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?

  1. “Keep the stoma uncovered.”
  2. “Keep the stoma dry.”
  3. “Have a family member perform stoma care initially until you get used to the procedure.”
  4. “Keep the stoma moist.”

A 37-year-old client with uterine cancer asks the nurse, “Which is the most common type of cancer in women?” The nurse replies that it’s breast cancer. Which type of cancer causes the most deaths in women?

  1. Breast cancer
  2. Lung cancer
  3. Brain cancer
  4. Colon and rectal cancer

Antonio with lung cancer develops Horner’s syndrome when the tumor invades the ribs and affects the sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse should note:

  1. miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
  2. chest pain, dyspnea, cough, weight loss, and fever.
  3. arm and shoulder pain and atrophy of arm and hand muscles, both on the affected side.
  4. hoarseness and dysphagia.

Vic asks the nurse what PSA is. The nurse should reply that it stands for:

  1. prostate-specific antigen, which is used to screen for prostate cancer.
  2. protein serum antigen, which is used to determine protein levels.
  3. pneumococcal strep antigen, which is a bacteria that causes pneumonia.
  4. Papanicolaou-specific antigen, which is used to screen for cervical cancer.

What is the most important postoperative instruction that nurse Kate must give a client who has just returned from the operating room after receiving a subarachnoid block?

  1. “Avoid drinking liquids until the gag reflex returns.”
  2. “Avoid eating milk products for 24 hours.”
  3. “Notify a nurse if you experience blood in your urine.”
  4. “Remain supine for the time specified by the physician.”

A male client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis?

  1. Stool Hematest
  2. Carcinoembryonic antigen (CEA)
  3. Sigmoidoscopy
  4. Abdominal computed tomography (CT) scan

During a breast examination, which finding most strongly suggests that the Luz has breast cancer?

  1. Slight asymmetry of the breasts.
  2. A fixed nodular mass with dimpling of the overlying skin
  3. Bloody discharge from the nipple
  4. Multiple firm, round, freely movable masses that change with the menstrual cycle

A female client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis sites for cancer cells?

  1. Liver
  2. Colon
  3. Reproductive tract
  4. White blood cells (WBCs)

Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?

  1. The client lies still.
  2. The client asks questions.
  3. The client hears thumping sounds.
  4. The client wears a watch and wedding band.

Nurse Cecile is teaching a female client about preventing osteoporosis. Which of the following teaching points is correct?

  1. Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss.
  2. To avoid fractures, the client should avoid strenuous exercise.
  3. The recommended daily allowance of calcium may be found in a wide variety of foods.
  4. Obtaining the recommended daily allowance of calcium requires taking a calcium supplement.

Before Jacob undergoes arthroscopy, the nurse reviews the assessment findings for contraindications for this procedure. Which finding is a contraindication?

  1. Joint pain
  2. Joint deformity
  3. Joint flexion of less than 50%
  4. Joint stiffness

Mr. Rodriguez is admitted with severe pain in the knees. Which form of arthritis is characterized by urate deposits and joint pain, usually in the feet and legs, and occurs primarily in men over age 30?

  1. Septic arthritis
  2. Traumatic arthritis
  3. Intermittent arthritis
  4. Gouty arthritis

A heparin infusion at 1,500 unit/hour is ordered for a 64-year-old client with stroke in evolution. The infusion contains 25,000 units of heparin in 500 ml of saline solution. How many milliliters per hour should be given?

  1. 15 ml/hour
  2. 30 ml/hour
  3. 45 ml/hour
  4. 50 ml/hour

A 76-year-old male client had a thromboembolic right stroke; his left arm is swollen. Which of the following conditions may cause swelling after a stroke?

  1. Elbow contracture secondary to spasticity
  2. Loss of muscle contraction decreasing venous return
  3. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side
  4. Hypoalbuminemia due to protein escaping from an inflamed glomerulus

Heberden’s nodes are a common sign of osteoarthritis. Which of the following statement is correct about this deformity?

  1. It appears only in men
  2. It appears on the distal interphalangeal joint
  3. It appears on the proximal interphalangeal joint
  4. It appears on the dorsolateral aspect of the interphalangeal joint.

Which of the following statements explains the main difference between rheumatoid arthritis and osteoarthritis?

  1. Osteoarthritis is gender-specific, rheumatoid arthritis isn’t
  2. Osteoarthritis is a localized disease rheumatoid arthritis is systemic
  3. Osteoarthritis is a systemic disease, rheumatoid arthritis is localized
  4. Osteoarthritis has dislocations and subluxations, rheumatoid arthritis doesn’t

Mrs. Cruz uses a cane for assistance in walking. Which of the following statements is true about a cane or other assistive devices?

  1. A walker is a better choice than a cane.
  2. The cane should be used on the affected side
  3. The cane should be used on the unaffected side
  4. A client with osteoarthritis should be encouraged to ambulate without the cane

A male client with type 1 diabetes is scheduled to receive 30 U of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client:

  1. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).
  2. 21 U regular insulin and 9 U NPH.
  3. 10 U regular insulin and 20 U NPH.
  4. 20 U regular insulin and 10 U NPH.

Nurse Len should expect to administer which medication to a client with gout?

  1. aspirin
  2. furosemide (Lasix)
  3. colchicines
  4. calcium gluconate (Kalcinate)

Mr. Domingo with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client’s hypertension is caused by excessive hormone secretion from which of the following glands?

  1. Adrenal cortex
  2. Pancreas
  3. Adrenal medulla
  4. Parathyroid

For a diabetic male client with a foot ulcer, the doctor orders bed rest, a wet-to-dry dressing change every shift, and blood glucose monitoring before meals and bedtime. Why are wet-to-dry dressings used for this client?

  1. They contain exudate and provide a moist wound environment.
  2. They protect the wound from mechanical trauma and promote healing.
  3. They debride the wound and promote healing by secondary intention.
  4. They prevent the entrance of microorganisms and minimize wound discomfort.

Nurse Zeny is caring for a client in acute addisonian crisis. Which laboratory data would the nurse expect to find?

  1. Hyperkalemia
  2. Reduced blood urea nitrogen (BUN)
  3. Hypernatremia
  4. Hyperglycemia

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?

  1. Infusing I.V. fluids rapidly as ordered
  2. Encouraging increased oral intake
  3. Restricting fluids
  4. Administering glucose-containing I.V. fluids as ordered

A female client tells nurse Nikki that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client’s efforts, the nurse should check:

  1. urine glucose level.
  2. fasting blood glucose level.
  3. serum fructosamine level.
  4. glycosylated hemoglobin level.

Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to a diabetic client at 7 a.m. At what time would the nurse expect the client to be most at risk for a hypoglycemic reaction?

  1. 10:00 am
  2. Noon
  3. 4:00 pm
  4. 10:00 pm

The adrenal cortex is responsible for producing which substances?

  1. Glucocorticoids and androgens
  2. Catecholamines and epinephrine
  3. Mineralocorticoids and catecholamines
  4. Norepinephrine and epinephrine

On the third day after a partial thyroidectomy, Proserfina exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?

  1. Hypocalcemia
  2. Hyponatremia
  3. Hyperkalemia
  4. Hypermagnesemia

Which laboratory test value is elevated in clients who smoke and can’t be used as a general indicator of cancer?

  1. Acid phosphatase level
  2. Serum calcitonin level
  3. Alkaline phosphatase level
  4. Carcinoembryonic antigen level

Francis with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron-deficiency anemia?

  1. Nights sweats, weight loss, and diarrhea
  2. Dyspnea, tachycardia, and pallor
  3. Nausea, vomiting, and anorexia
  4. Itching, rash, and jaundice

In teaching a female client who is HIV-positive about pregnancy, the nurse would know more teaching is necessary when the client says:

  1. The baby can get the virus from my placenta.”
  2. “I’m planning on starting on birth control pills.”
  3. “Not everyone who has the virus gives birth to a baby who has the virus.”
  4. “I’ll need to have a C-section if I become pregnant and have a baby.”

When preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction?

  1. “Put on disposable gloves before bathing.”
  2. “Sterilize all plates and utensils in boiling water.”
  3. “Avoid eating foods from serving dishes shared by other family members.”

Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?

  1. Pallor, bradycardia, and reduced pulse pressure
  2. Pallor, tachycardia, and a sore tongue
  3. Sore tongue, dyspnea, and weight gain
  4. Angina, double vision, and anorexia

After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina suspects the client is experiencing anaphylactic shock. What should the nurse do first?

  1. Page an anesthesiologist immediately and prepare to intubate the client.
  2. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.
  3. Administer the antidote for penicillin, as prescribed, and continue to monitor the client’s vital signs.
  4. Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered.

Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:

  1. weight gain.
  2. fine motor tremors.
  3. respiratory acidosis.
  4. bilateral hearing loss.

A 23-year-old client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that adaptive immunity is provided by which type of white blood cell?

  1. Neutrophil
  2. Basophil
  3. Monocyte
  4. Lymphocyte

In an individual with Sjögren’s syndrome, nursing care should focus on:

  1. moisture replacement.
  2. electrolyte balance.
  3. nutritional supplementation.
  4. arrhythmia management.

During chemotherapy for lymphocytic leukemia, Mathew develops abdominal pain, fever, and “horse barn” smelling diarrhea. It would be most important for the nurse to advise the physician to order:

  1. enzyme-linked immunosuppressant assay (ELISA) test.
  2. electrolyte panel and hemogram.
  3. stool for Clostridium difficile test.
  4. flat plate X-ray of the abdomen.

A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:

  1. E-rosette immunofluorescence.
  2. quantification of T-lymphocytes.
  3. enzyme-linked immunosorbent assay (ELISA).
  4. Western blot test with ELISA.

A complete blood count is commonly performed before a Joe goes into surgery. What does this test seek to identify?

  1. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels
  2. Low levels of urine constituents normally excreted in the urine
  3. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
  4. Electrolyte imbalance that could affect the blood’s ability to coagulate properly

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?

  1. Platelet count, prothrombin time, and partial thromboplastin time
  2. Platelet count, blood glucose levels, and white blood cell (WBC) count
  3. Thrombin time, calcium levels, and potassium levels
  4. Fibrinogen level, WBC, and platelet count

When taking a dietary history from a newly admitted female client, Nurse Len should remember that which of the following foods is a common allergen?

  1. Bread
  2. Carrots
  3. Orange
  4. Strawberries

Nurse John is caring for clients in the outpatient clinic. Which of the following phone calls should the nurse return first?

  1. A client with hepatitis A who states, “My arms and legs are itching.”
  2. A client with cast on the right leg who states, “I have a funny feeling in my right leg.”
  3. A client with osteomyelitis of the spine who states, “I am so nauseous that I can’t eat.”
  4. A client with rheumatoid arthritis who states, “I am having trouble sleeping.”

Nurse Sarah is caring for clients on the surgical floor and has just received report from the previous shift. Which of the following clients should the nurse see first?

  1. A 35-year-old admitted three hours ago with a gunshot wound; 1.5 cm area of dark drainage noted on the dressing.
  2. A 43-year-old who had a mastectomy two days ago; 23 ml of serosanguinous fluid noted in the Jackson-Pratt drain.
  3. A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous eight hours.
  4. A 62-year-old who had an abdominal-perineal resection three days ago; client complaints of chills.

Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for treatment of Grave’s disease. The nurse would be most concerned if which of the following was observed?

  1. Blood pressure 138/82, respirations 16, oral temperature 99°F.
  2. The client supports his head and neck when turning his head to the right.
  3. The client spontaneously flexes his wrist when the blood pressure is obtained.
  4. The client is drowsy and complains of sore throat.

Julius is admitted with complaints of severe pain in the lower right quadrant of the abdomen. To assist with pain relief, the nurse should take which of the following actions?

  1. Encourage the client to change positions frequently in bed.
  2. Administer Demerol 50 mg IM q 4 hours and PRN.
  3. Apply warmth to the abdomen with a heating pad.
  4. Use comfort measures and pillows to position the client.

Nurse Tina prepares a client for peritoneal dialysis. Which of the following actions should the nurse take first?

  1. Assess for a bruit and a thrill.
  2. Warm the dialysate solution.
  3. Position the client on the left side.
  4. Insert a Foley catheter

Nurse Jannah teaches an elderly client with right-sided weakness how to use cane. Which of the following behaviors, if demonstrated by the client to the nurse, indicates that the teaching was effective?

  1. The client holds the cane with his right hand, moves the can forward followed by the right leg, and then moves the left leg.
  2. The client holds the cane with his right hand, moves the cane forward followed by his left leg, and then moves the right leg.
  3. The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg.
  4. The client holds the cane with his left hand, moves the cane forward followed by his left leg, and then moves the right leg.

An elderly client is admitted to the nursing home setting. The client is occasionally confused and her gait is often unsteady. Which of the following actions, if taken by the nurse, is most appropriate?

  1. Ask the woman’s family to provide personal items such as photos or mementos.
  2. Select a room with a bed by the door so the woman can look down the hall.
  3. Suggest the woman eat her meals in the room with her roommate.
  4. Encourage the woman to ambulate in the halls twice a day.

Nurse Evangeline teaches an elderly client how to use a standard aluminum walker. Which of the following behaviors, if demonstrated by the client, indicates that the nurse’s teaching was effective?

  1. The client slowly pushes the walker forward 12 inches, then takes small steps forward while leaning on the walker.
  2. The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward.
  3. The client supports his weight on the walker while advancing it forward, then takes small steps while balancing on the walker.
  4. The client slides the walker 18 inches forward, then takes small steps while holding onto the walker for balance.

Nurse Deric is supervising a group of elderly clients in a residential home setting. The nurse knows that the elderly are at greater risk of developing sensory deprivation for what reason?

  1. Increased sensitivity to the side effects of medications.
  2. Decreased visual, auditory, and gustatory abilities.
  3. Isolation from their families and familiar surroundings.
  4. Decrease musculoskeletal function and mobility.

A male client with emphysema becomes restless and confused. What step should nurse Jasmine take next?

  1. Encourage the client to perform pursed lip breathing.
  2. Check the client’s temperature.
  3. Assess the client’s potassium level.
  4. Increase the client’s oxygen flow rate.

Randy has undergone kidney transplant, what assessment would prompt Nurse Katrina to suspect organ rejection?

  1. Sudden weight loss
  2. Polyuria
  3. Hypertension
  4. Shock

The immediate objective of nursing care for an overweight, mildly hypertensive male client with ureteral colic and hematuria is to decrease:

  1. Pain
  2. Weight
  3. Hematuria
  4. Hypertension

Matilda, with hyperthyroidism is to receive Lugol’s iodine solution before a subtotal thyroidectomy is performed. The nurse is aware that this medication is given to:

  1. Decrease the total basal metabolic rate.
  2. Maintain the function of the parathyroid glands.
  3. Block the formation of thyroxine by the thyroid gland.
  4. Decrease the size and vascularity of the thyroid gland.

Ricardo, was diagnosed with type I diabetes. The nurse is aware that acute hypoglycemia also can develop in the client who is diagnosed with:

  1. Liver disease
  2. Hypertension
  3. Type 2 diabetes
  4. Hyperthyroidism

Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby should monitor the client for the systemic side effect of:

  1. Ascites
  2. Nystagmus
  3. Leukopenia
  4. Polycythemia

Norma, with recent colostomy expresses concern about the inability to control the passage of gas. Nurse Oliver should suggest that the client plan to:

  1. Eliminate foods high in cellulose.
  2. Decrease fluid intake at meal times.
  3. Avoid foods that in the past caused flatus.
  4. Adhere to a bland diet prior to social events.

Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, “I should:

  1. Lie on my left side while instilling the irrigating solution.”
  2. Keep the irrigating container less than 18 inches above the stoma.”
  3. Instill a minimum of 1200 ml of irrigating solution to stimulate evacuation of the bowel.”
  4. Insert the irrigating catheter deeper into the stoma if cramping occurs during the procedure.”

Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and electrolyte imbalances. The client is somewhat confused and complains of nausea and muscle weakness. As part of the prescribed therapy to correct this electrolyte imbalance, the nurse would expect to:

  1. Administer Kayexalate
  2. Restrict foods high in protein
  3. Increase oral intake of cheese and milk.
  4. Administer large amounts of normal saline via I.V.

Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:

  1. 18 gtt/min
  2. 28 gtt/min
  3. 32 gtt/min
  4. 36 gtt/min

Terence suffered from burn injury. Using the rule of nines, which has the largest percent of burns?

  1. Face and neck
  2. Right upper arm and penis
  3. Right thigh and penis
  4. Upper trunk

Herbert, a 45 year old construction engineer is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:

  1. Reactive pupils
  2. A depressed fontanel
  3. Bleeding from ears
  4. An elevated temperature

Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?

  1. take the pulse rate once a day, in the morning upon awakening
  2. May be allowed to use electrical appliances
  3. Have regular follow up care
  4. May engage in contact sports

The nurse is ware that the most relevant knowledge about oxygen administration to a male client with COPD is

  1. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
  2. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.
  3. Oxygen is administered best using a non-rebreathing mask
  4. Blood gases are monitored using a pulse oximeter.

Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Tonny is placed in Fowler’s position on either his right side or on his back. The nurse is aware that this position:

  1. Reduce incisional pain.
  2. Facilitate ventilation of the left lung.
  3. Equalize pressure in the pleural space.
  4. Increase venous return

Kristine is scheduled for a bronchoscopy. When teaching Kristine what to expect afterward, the nurse’s highest priority of information would be:

  1. Food and fluids will be withheld for at least 2 hours.
  2. Warm saline gargles will be done q 2h.
  3. Coughing and deep-breathing exercises will be done q2h.
  4. Only ice chips and cold liquids will be allowed initially.

Nurse Tristan is caring for a male client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:

  1. hypernatremia.
  2. hypokalemia.
  3. hyperkalemia.
  4. hypercalcemia.

Ms. X has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?

  1. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.
  2. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.
  3. The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse.
  4. The human papillomavirus (HPV), which causes condylomata acuminata, can’t be transmitted during oral sex.

Maritess was recently diagnosed with a genitourinary problem and is being examined in the emergency department. When palpating her kidneys, the nurse should keep which anatomical fact in mind?

  1. The left kidney usually is slightly higher than the right one.
  2. The kidneys are situated just above the adrenal glands.
  3. The average kidney is approximately 5 cm (2”) long and 2 to 3 cm (¾” to 1-1/8”) wide.
  4. The kidneys lie between the 10th and 12th thoracic vertebrae.

Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The nurse is aware that the diagnostic test are consistent with CRF if the result is:

  1. Increased pH with decreased hydrogen ions.
  2. Increased serum levels of potassium, magnesium, and calcium.
  3. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/ dl.
  4. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%.

Katrina has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, Katrina asks what dysplasia means. Which definition should the nurse provide?

  1. Presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin.
  2. Increase in the number of normal cells in a normal arrangement in a tissue or an organ.
  3. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t found.
  4. Alteration in the size, shape, and organization of differentiated cells.

During a routine checkup, Nurse Mariane assesses a male client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related cancer?

  1. Squamous cell carcinoma
  2. Multiple myeloma
  3. Leukemia
  4. Kaposi’s sarcoma

Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist’s instructions. Why does the client require special positioning for this type of anesthesia?

  1. To prevent confusion
  2. To prevent seizures
  3. To prevent cerebrospinal fluid (CSF) leakage
  4. To prevent cardiac arrhythmias

A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

  1. Auscultate bowel sounds.
  2. Palpate the abdomen.
  3. Change the client’s position.
  4. Insert a rectal tube.

Wilfredo with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse Patricia position the client for this test initially?

  1. Lying on the right side with legs straight
  2. Lying on the left side with knees bent
  3. Prone with the torso elevated
  4. Bent over with hands touching the floor

A male client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, Nurse Oliver notes that the client’s stoma appears dusky. How should the nurse interpret this finding?

  1. Blood supply to the stoma has been interrupted.
  2. This is a normal finding 1 day after surgery.
  3. The ostomy bag should be adjusted.
  4. An intestinal obstruction has occurred.

Anthony suffers burns on the legs, which nursing intervention helps prevent contractures?

  1. Applying knee splints
  2. Elevating the foot of the bed
  3. Hyperextending the client’s palms
  4. Performing shoulder range-of-motion exercises

Nurse Ron is assessing a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?

  1. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
  2. Urine output of 20 ml/hour.
  3. White pulmonary secretions.
  4. Rectal temperature of 100.6° F (38° C).

Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, Nurse Celia should:

  1. Turn him frequently.
  2. Perform passive range-of-motion (ROM) exercises.
  3. Reduce the client’s fluid intake.
  4. Encourage the client to use a footboard.

Nurse Maria plans to administer dexamethasone cream to a female client who has dermatitis over the anterior chest. How should the nurse apply this topical agent?

  1. With a circular motion, to enhance absorption.
  2. With an upward motion, to increase blood supply to the affected area
  3. In long, even, outward, and downward strokes in the direction of hair growth
  4. In long, even, outward, and upward strokes in the direction opposite hair growth

Nurse Kate is aware that one of the following classes of medication protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation is:

  1. Beta -adrenergic blockers
  2. Calcium channel blocker
  3. Narcotics
  4. Nitrates

A male client has jugular distention. On what position should the nurse place the head of the bed to obtain the most accurate reading of jugular vein distention?

  1. High Fowler’s
  2. Raised 10 degrees
  3. Raised 30 degrees
  4. Supine position

The nurse is aware that one of the following classes of medications maximizes cardiac performance in clients with heart failure by increasing ventricular contractility?

  1. Beta-adrenergic blockers
  2. Calcium channel blocker
  3. Diuretics
  4. Inotropic agents

A male client has a reduced serum high-density lipoprotein (HDL) level and an elevated low-density lipoprotein (LDL) level. Which of the following dietary modifications is not appropriate for this client?

  1. Fiber intake of 25 to 30 g daily
  2. Less than 30% of calories from fat
  3. Cholesterol intake of less than 300 mg daily
  4. Less than 10% of calories from saturated fat

A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with an acute myocardial infarction. Which of the following actions would breach the client confidentiality?

  1. The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client to that unit
  2. The CCU nurse notifies the on-call physician about a change in the client’s condition
  3. The emergency department nurse calls up the latest electrocardiogram results to check the client’s progress.
  4. At the client’s request, the CCU nurse updates the client’s wife on his condition

A male client arriving in the emergency department is receiving cardiopulmonary resuscitation from paramedics who are giving ventilations through an endotracheal (ET) tube that they placed in the client’s home. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of beats/minute with a palpable pulse. Which of the following actions should the nurse take first?

  1. Start an L.V. line and administer amiodarone (Cardarone), 300 mg L.V. over 10 minutes.
  2. Check endotracheal tube placement.
  3. Obtain an arterial blood gas (ABG) sample.
  4. Administer atropine, 1 mg L.V.

After cardiac surgery, a client’s blood pressure measures 126/80 mm Hg. Nurse Katrina determines that mean arterial pressure (MAP) is which of the following?

  1. 46 mm Hg
  2. 80 mm Hg
  3. 95 mm Hg
  4. 90 mm Hg

A female client arrives at the emergency department with chest and stomach pain and a report of black tarry stool for several months. Which of the following order should the nurse Oliver anticipate?

  1. Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase levels
  2. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split product values.
  3. Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic panel.
  4. Electroencephalogram, alkaline phosphatase and aspartate aminotransferase levels, basic serum metabolic panel

Macario had coronary artery bypass graft (CABG) surgery 3 days ago. Which of the following conditions is suspected by the nurse when a decrease in platelet count from 230,000 ul to 5,000 ul is noted?

  1. Pancytopenia
  2. Idiopathic thrombocytopemic purpura (ITP)
  3. Disseminated intravascular coagulation (DIC)
  4. Heparin-associated thrombosis and thrombocytopenia (HATT)

Which of the following drugs would be ordered by the physician to improve the platelet count in a male client with idiopathic thrombocytopenic purpura (ITP)?

  1. Acetylsalicylic acid (ASA)
  2. Corticosteroids
  3. Methotrezate
  4. Vitamin K

A female client is scheduled to receive a heart valve replacement with a porcine valve. Which of the following types of transplant is this?

  1. Allogeneic
  2. Autologous
  3. Syngeneic
  4. Xenogeneic

Marco falls off his bicycle and injuries his ankle. Which of the following actions shows the initial response to the injury in the extrinsic pathway?

  1. Release of Calcium
  2. Release of tissue thromboplastin
  3. Conversion of factors XII to factor XIIa
  4. Conversion of factor VIII to factor VIIIa

Instructions for a client with systemic lupus erythematosus (SLE) would include information about which of the following blood dyscrasias?

  1. Dressler’s syndrome
  2. Polycythemia
  3. Essential thrombocytopenia
  4. Von Willebrand’s disease

The nurse is aware that the following symptom is most commonly an early indication of stage 1 Hodgkin’s disease?

  1. Pericarditis
  2. Night sweat
  3. Splenomegaly
  4. Persistent hypothermia

Francis with leukemia has neutropenia. Which of the following functions must frequently assessed?

  1. Blood pressure
  2. Bowel sounds
  3. Heart sounds
  4. Breath sounds

The nurse knows that neurologic complications of multiple myeloma (MM) usually involve which of the following body system?

  1. Brain
  2. Muscle spasm
  3. Renal dysfunction
  4. Myocardial irritability

Nurse Patricia is aware that the average length of time from human immunodeficiency virus (HIV) infection to the development of acquired immunodeficiency syndrome (AIDS)?

  1. Less than 5 years
  2. 5 to 7 years
  3. 10 years
  4. More than 10 years

An 18-year-old male client admitted with heat stroke begins to show signs of disseminated intravascular coagulation (DIC). Which of the following laboratory findings is most consistent with DIC?

  1. Low platelet count
  2. Elevated fibrinogen levels
  3. Low levels of fibrin degradation products
  4. Reduced prothrombin time

Mario comes to the clinic complaining of fever, drenching night sweats, and unexplained weight loss over the past 3 months. Physical examination reveals a single enlarged supraclavicular lymph node. Which of the following is the most probable diagnosis?

  1. Influenza
  2. Sickle cell anemia
  3. Leukemia
  4. Hodgkin’s disease

A male client with a gunshot wound requires an emergency blood transfusion. His blood type is AB negative. Which blood type would be the safest for him to receive?

  1. AB Rh-positive
  2. A Rh-positive
  3. A Rh-negative
  4. O Rh-positive

Situation

Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.

Stacy is discharged from the hospital following her chemotherapy treatments. Which statement of Stacy’s mother indicated that she understands when she will contact the physician?

  1. “I should contact the physician if Stacy has difficulty in sleeping”.
  2. “I will call my doctor if Stacy has persistent vomiting and diarrhea”.
  3. “My physician should be called if Stacy is irritable and unhappy”.
  4. “Should Stacy have continued hair loss, I need to call the doctor”.

Stacy’s mother states to the nurse that it is hard to see Stacy with no hair. The best response for the nurse is:

  1. “Stacy looks very nice wearing a hat”.
  2. “You should not worry about her hair, just be glad that she is alive”.
  3. “Yes it is upsetting. But try to cover up your feelings when you are with her or else she may be upset”.
  4. “This is only temporary; Stacy will re-grow new hair in 3-6 months, but may be different in texture”.

Stacy has beginning stomatitis. To promote oral hygiene and comfort, the nurse in-charge should:

  1. Provide frequent mouthwash with normal saline.
  2. Apply viscous Lidocaine to oral ulcers as needed.
  3. Use lemon glycerine swabs every 2 hours.
  4. Rinse mouth with Hydrogen Peroxide.

During the administration of chemotherapy agents, Nurse Oliver observed that the IV site is red and swollen, when the IV is touched Stacy shouts in pain. The first nursing action to take is:

  1. Notify the physician
  2. Flush the IV line with saline solution
  3. Immediately discontinue the infusion
  4. Apply an ice pack to the site, followed by warm compress.

The term “blue bloater” refers to a male client which of the following conditions?

  1. Adult respiratory distress syndrome (ARDS)
  2. Asthma
  3. Chronic obstructive bronchitis
  4. Emphysema

The term “pink puffer” refers to the female client with which of the following conditions?

  1. Adult respiratory distress syndrome (ARDS)
  2. Asthma
  3. Chronic obstructive bronchitis
  4. Emphysema

Jose is in danger of respiratory arrest following the administration of a narcotic analgesic. An arterial blood gas value is obtained. Nurse Oliver would expect the paco2 to be which of the following values?

  1. 15 mm Hg
  2. 30 mm Hg
  3. 40 mm Hg
  4. 80 mm Hg

Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result represents which of the following conditions?

  1. Metabolic acidosis
  2. Metabolic alkalosis
  3. Respiratory acidosis
  4. Respiratory alkalosis

Norma has started a new drug for hypertension. Thirty minutes after she takes the drug, she develops chest tightness and becomes short of breath and tachypneic. She has a decreased level of consciousness. These signs indicate which of the following conditions?

  1. Asthma attack
  2. Pulmonary embolism
  3. Respiratory failure
  4. Rheumatoid arthritis

Situation

Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:

Which laboratory test indicates liver cirrhosis?

  1. Decreased red blood cell count
  2. Decreased serum acid phosphate level
  3. Elevated white blood cell count
  4. Elevated serum aminotransferase

The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at increased risk for excessive bleeding primarily because of:

  1. Impaired clotting mechanism
  2. Varix formation
  3. Inadequate nutrition
  4. Trauma of invasive procedure

Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation is most common with this condition?

  1. Increased urine output
  2. Altered level of consciousness
  3. Decreased tendon reflex
  4. Hypotension

When Mr. Gonzales regained consciousness, the physician orders 50 ml of Lactose p.o. every 2 hours. Mr. Gozales develops diarrhea. The nurse best action would be:

  1. “I’ll see if your physician is in the hospital”.
  2. “Maybe you’re reacting to the drug; I will withhold the next dose”.
  3. “I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day”.
  4. “Frequently, bowel movements are needed to reduce sodium level”.

Which of the following groups of symptoms indicates a ruptured abdominal aortic aneurysm?

  1. Lower back pain, increased blood pressure, decreased red blood cell (RBC) count, increased white blood (WBC) count.
  2. Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count.
  3. Severe lower back pain, decreased blood pressure, decreased RBC count, decreased RBC count, decreased WBC count.
  4. Intermitted lower back pain, decreased blood pressure, decreased RBC count, increased WBC count.

After undergoing a cardiac catheterization, Tracy has a large puddle of blood under his buttocks. Which of the following steps should the nurse take first?

  1. Call for help.
  2. Obtain vital signs
  3. Ask the client to “lift up”
  4. Apply gloves and assess the groin site

Which of the following treatment is a suitable surgical intervention for a client with unstable angina?

  1. Cardiac catheterization
  2. Echocardiogram
  3. Nitroglycerin
  4. Percutaneous transluminal coronary angioplasty (PTCA)

The nurse is aware that the following terms used to describe reduced cardiac output and perfusion impairment due to ineffective pumping of the heart is:

  1. Anaphylactic shock
  2. Cardiogenic shock
  3. Distributive shock
  4. Myocardial infarction (MI)

A client with hypertension asks the nurse which factors can cause blood pressure to drop to normal levels?

  1. Kidneys’ excretion to sodium only.
  2. Kidneys’ retention of sodium and water
  3. Kidneys’ excretion of sodium and water
  4. Kidneys’ retention of sodium and excretion of water

Nurse Rose is aware that the statement that best explains why furosemide (Lasix) is administered to treat hypertension is:

  1. It dilates peripheral blood vessels.
  2. It decreases sympathetic cardioacceleration.
  3. It inhibits the angiotensin-coverting enzymes
  4. It inhibits reabsorption of sodium and water in the loop of Henle.

Nurse Nikki knows that laboratory results supports the diagnosis of systemic lupus erythematosus (SLE) is:

  1. Elavated serum complement level
  2. Thrombocytosis, elevated sedimentation rate
  3. Pancytopenia, elevated antinuclear antibody (ANA) titer
  4. Leukocysis, elevated blood urea nitrogen (BUN) and creatinine levels

Arnold, a 19-year-old client with a mild concussion is discharged from the emergency department. Before discharge, he complains of a headache. When offered acetaminophen, his mother tells the nurse the headache is severe and she would like her son to have something stronger. Which of the following responses by the nurse is appropriate?

  1. “Your son had a mild concussion, acetaminophen is strong enough.”
  2. “Aspirin is avoided because of the danger of Reye’s syndrome in children or young adults.”
  3. “Narcotics are avoided after a head injury because they may hide a worsening condition.”
  4. Stronger medications may lead to vomiting, which increases the intracarnial pressure (ICP).”

When evaluating an arterial blood gas from a male client with a subdural hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following responses best describes the result?

  1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP)
  2. Emergent; the client is poorly oxygenated
  3. Normal
  4. Significant; the client has alveolar hypoventilation

When prioritizing care, which of the following clients should the nurse Olivia assess first?

  1. A 17-year-old client’s 24-hours postappendectomy
  2. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome
  3. A 50-year-old client 3 days postmyocardial infarction
  4. A 50-year-old client with diverticulitis

JP has been diagnosed with gout and wants to know why colchicine is used in the treatment of gout. Which of the following actions of colchicines explains why it’s effective for gout?

  1. Replaces estrogen
  2. Decreases infection
  3. Decreases inflammation
  4. Decreases bone demineralization

Norma asks for information about osteoarthritis. Which of the following statements about osteoarthritis is correct?

  1. Osteoarthritis is rarely debilitating
  2. Osteoarthritis is a rare form of arthritis
  3. Osteoarthritis is the most common form of arthritis
  4. Osteoarthritis afflicts people over 60

Ruby is receiving thyroid replacement therapy develops the flu and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication will put the client at risk for developing which of the following life-threatening complications?

  1. Exophthalmos
  2. Thyroid storm
  3. Myxedema coma
  4. Tibial myxedema

Nurse Sugar is assessing a client with Cushing’s syndrome. Which observation should the nurse report to the physician immediately?

  1. Pitting edema of the legs
  2. An irregular apical pulse
  3. Dry mucous membranes
  4. Frequent urination

Cyrill with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client’s urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes insipidus?

  1. Above-normal urine and serum osmolality levels
  2. Below-normal urine and serum osmolality levels
  3. Above-normal urine osmolality level, below-normal serum osmolality level
  4. Below-normal urine osmolality level, above-normal serum osmolality level

Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which of the following statements indicates that the client understands her condition and how to control it?

  1. “I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual.”
  2. “If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar.”
  3. “I will have to monitor my blood glucose level closely and notify the physician if it’s constantly elevated.”
  4. “If I begin to feel especially hungry and thirsty, I’ll eat a snack high in carbohydrates.”

A 66-year-old client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse would suspect which of the following disorders?

  1. Diabetes mellitus
  2. Diabetes insipidus
  3. Hypoparathyroidism
  4. Hyperparathyroidism

Nurse Lourdes is teaching a client recovering from Addisonian crisis about the need to take fludrocortisone acetate and hydrocortisone at home. Which statement by the client indicates an understanding of the instructions?

  1. “I’ll take my hydrocortisone in the late afternoon, before dinner.”
  2. “I’ll take all of my hydrocortisone in the morning, right after I wake up.”
  3. “I’ll take two-thirds of the dose when I wake up and one-third in the late afternoon.”
  4. “I’ll take the entire dose at bedtime.”

Which of the following laboratory test results would suggest to the nurse Len that a client has a corticotropin-secreting pituitary adenoma?

  1. High corticotropin and low cortisol levels
  2. Low corticotropin and high cortisol levels
  3. High corticotropin and high cortisol levels
  4. Low corticotropin and low cortisol levels

A male client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. Preoperatively, the nurse should assess for potential complications by doing which of the following?

  1. Testing for ketones in the urine
  2. Testing urine specific gravity
  3. Checking temperature every 4 hours
  4. Performing capillary glucose testing every 4 hours

Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Nurse Mariner should expect the dose’s:

  1. Onset to be at 2 p.m. and its peak to be at 3 p.m.
  2. Onset to be at 2:15 p.m. and its peak to be at 3 p.m.
  3. Onset to be at 2:30 p.m. and its peak to be at 4 p.m.
  4. Onset to be at 4 p.m. and its peak to be at 6 p.m.

The physician orders laboratory tests to confirm hyperthyroidism in a female client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis?

  1. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test
  2. A decreased TSH level
  3. An increase in the TSH level after 30 minutes during the TSH stimulation test
  4. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay

Rico with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?

  1. “Inject insulin into healthy tissue with large blood vessels and nerves.”
  2. “Rotate injection sites within the same anatomic region, not among different regions.”
  3. “Administer insulin into areas of scar tissue or hypotrophy whenever possible.”
  4. “Administer insulin into sites above muscles that you plan to exercise heavily later that day.”

Nurse Sarah expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?

  1. Elevated serum acetone level
  2. Serum ketone bodies
  3. Serum alkalosis
  4. Below-normal serum potassium level

For a client with Graves’ disease, which nursing intervention promotes comfort?

  1. Restricting intake of oral fluids
  2. Placing extra blankets on the client’s bed
  3. Limiting intake of high-carbohydrate foods
  4. Maintaining room temperature in the low-normal range

Patrick is treated in the emergency department for a Colles’ fracture sustained during a fall. What is a Colles’ fracture?

  1. Fracture of the distal radius
  2. Fracture of the olecranon
  3. Fracture of the humerus
  4. Fracture of the carpal scaphoid

Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the development of this disorder?

  1. Calcium and sodium
  2. Calcium and phosphorous
  3. Phosphorous and potassium
  4. Potassium and sodium

Johnny a firefighter was involved in extinguishing a house fire and is being treated to smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. He most likely has developed which of the following conditions?

  1. Adult respiratory distress syndrome (ARDS)
  2. Atelectasis
  3. Bronchitis
  4. Pneumonia

A 67-year-old client develops acute shortness of breath and progressive hypoxia requiring right femur. The hypoxia was probably caused by which of the following conditions?

  1. Asthma attack
  2. Atelectasis
  3. Bronchitis
  4. Fat embolism

A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this?

  1. Acute asthma
  2. Chronic bronchitis
  3. Pneumonia
  4. Spontaneous pneumothorax

A 62-year-old male client was in a motor vehicle accident as an unrestrained driver. He’s now in the emergency department complaining of difficulty of breathing and chest pain. On auscultation of his lung field, no breath sounds are present in the upper lobe. This client may have which of the following conditions?

  1. Bronchitis
  2. Pneumonia
  3. Pneumothorax
  4. Tuberculosis (TB)

If a client requires a pneumonectomy, what fills the area of the thoracic cavity?

  1. The space remains filled with air only
  2. The surgeon fills the space with a gel
  3. Serous fluids fills the space and consolidates the region
  4. The tissue from the other lung grows over to the other side

Hemoptysis may be present in the client with a pulmonary embolism because of which of the following reasons?

  1. Alveolar damage in the infracted area
  2. Involvement of major blood vessels in the occluded area
  3. Loss of lung parenchyma
  4. Loss of lung tissue

Aldo with a massive pulmonary embolism will have an arterial blood gas analysis performed to determine the extent of hypoxia. The acid-base disorder that may be present is?

  1. Metabolic acidosis
  2. Metabolic alkalosis
  3. Respiratory acidosis
  4. Respiratory alkalosis

After a motor vehicle accident, Armand an 22-year-old client is admitted with a pneumothorax. The surgeon inserts a chest tube and attaches it to a chest drainage system. Bubbling soon appears in the water seal chamber. Which of the following is the most likely cause of the bubbling?

  1. Air leak
  2. Adequate suction
  3. Inadequate suction
  4. Kinked chest tube

Nurse Michelle calculates the IV flow rate for a postoperative client. The client receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should regulate the client’s IV to deliver how many drops per minute?

  1. 18
  2. 21
  3. 35
  4. 40

Mickey, a 6-year-old child with a congenital heart disorder is admitted with congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount should the nurse administer to the child?

  1. 1.2 ml
  2. 2.4 ml
  3. 3.5 ml
  4. 4.2 ml

Nurse Alexandra teaches a client about elastic stockings. Which of the following statements, if made by the client, indicates to the nurse that the teaching was successful?

  1. “I will wear the stockings until the physician tells me to remove them.”
  2. “I should wear the stockings even when I am sleep.”
  3. “Every four hours I should remove the stockings for a half hour.”
  4. “I should put on the stockings before getting out of bed in the morning.”

Marco who was diagnosed with brain tumor was scheduled for craniotomy. In preventing the development of cerebral edema after surgery, the nurse should expect the use of:

  1. Diuretics
  2. Antihypertensive
  3. Steroids
  4. Anticonvulsants

Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse Hazel should:

  1. Increase the flow of normal saline
  2. Assess the pain further
  3. Notify the blood bank
  4. Obtain vital signs.

Nurse Maureen knows that the positive diagnosis for HIV infection is made based on which of the following:

  1. A history of high risk sexual behaviors.
  2. Positive ELISA and western blot tests
  3. Identification of an associated opportunistic infection
  4. Evidence of extreme weight loss and high fever

Nurse Maureen is aware that a client who has been diagnosed with chronic renal failure recognizes an adequate amount of high-biologic-value protein when the food the client selected from the menu was:

  1. Raw carrots
  2. Apple juice
  3. Whole wheat bread
  4. Cottage cheese

Kenneth who has diagnosed with uremic syndrome has the potential to develop complications. Which among the following complications should the nurse anticipates:

  1. Flapping hand tremors
  2. An elevated hematocrit level
  3. Hypotension
  4. Hypokalemia

A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant assessment would be:

  1. Flank pain radiating in the groin
  2. Distention of the lower abdomen
  3. Perineal edema
  4. Urethral discharge

A client has undergone with penile implant. After 24 hrs of surgery, the client’s scrotum was edematous and painful. The nurse should:

  1. Assist the client with sitz bath
  2. Apply war soaks in the scrotum
  3. Elevate the scrotum using a soft support
  4. Prepare for a possible incision and drainage.

Nurse hazel receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?

  1. Liver disease
  2. Myocardial damage
  3. Hypertension
  4. Cancer

Nurse Maureen would expect the client with mitral stenosis would demonstrate symptoms associated with congestion in the:

  1. Right atrium
  2. Superior vena cava
  3. Aorta
  4. Pulmonary

A client has been diagnosed with hypertension. The nurse priority nursing diagnosis would be:

  1. Ineffective health maintenance
  2. Impaired skin integrity
  3. Deficient fluid volume
  4. Pain

Nurse Hazel teaches the client with angina about common expected side effects of nitroglycerin including:

  1. High blood pressure
  2. Stomach cramps
  3. Headache
  4. Shortness of breath

The following are lipid abnormalities. Which of the following is a risk factor for the development of atherosclerosis and PVD?

  1. High levels of low density lipid (LDL) cholesterol
  2. High levels of high density lipid (HDL) cholesterol
  3. Low concentration triglycerides
  4. Low levels of LDL cholesterol.

Which of the following represents a significant risk immediately after surgery for repair of aortic aneurysm?

  1. Potential wound infection
  2. Potential ineffective coping
  3. Potential electrolyte balance
  4. Potential alteration in renal perfusion

Nurse Josie should instruct the client to eat which of the following foods to obtain the best supply of Vitamin B12?

  1. Dairy products
  2. Vegetables
  3. Grains
  4. Broccoli

Karen has been diagnosed with aplastic anemia. The nurse monitors for changes in which of the following physiologic functions?

  1. Bowel function
  2. Peripheral sensation
  3. Bleeding tendencies
  4. Intake and out put

Lydia is scheduled for elective splenectomy. Before the clients goes to surgery, the nurse in charge final assessment would be:

  1. Signed consent
  2. Vital signs
  3. Name band
  4. Empty bladder

What is the peak age range in acquiring acute lymphocytic leukemia (ALL)?

  1. 4 to 12 years.
  2. 20 to 30 years
  3. 40 to 50 years
  4. 60 60 70 years

Marie with acute lymphocytic leukemia suffers from nausea and headache. These clinical manifestations may indicate all of the following except

  1. Effects of radiation
  2. Chemotherapy side effects
  3. Meningeal irritation
  4. Gastric distension

A client has been diagnosed with Disseminated Intravascular Coagulation (DIC). Which of the following is contraindicated with the client?

  1. Administering Heparin
  2. Administering Coumadin
  3. Treating the underlying cause
  4. Replacing depleted blood products

Which of the following findings is the best indication that fluid replacement for the client with hypovolemic shock is adequate?

  1. Urine output greater than 30ml/hr
  2. Respiratory rate of 21 breaths/minute
  3. Diastolic blood pressure greater than 90 mmhg
  4. Systolic blood pressure greater than 110 mmhg

Which of the following signs and symptoms would Nurse Maureen include in teaching plan as an early manifestation of laryngeal cancer?

  1. Stomatitis
  2. Airway obstruction
  3. Hoarseness
  4. Dysphagia

Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse understands that this therapy is effective because it:

  1. Promotes the removal of antibodies that impair the transmission of impulses
  2. Stimulates the production of acetylcholine at the neuromuscular junction.
  3. Decreases the production of autoantibodies that attack the acetylcholine receptors.
  4. Inhibits the breakdown of acetylcholine at the neuromuscular junction.

A female client is receiving IV Mannitol. An assessment specific to safe administration of the said drug is:

  1. Vital signs q4h
  2. Weighing daily
  3. Urine output hourly
  4. Level of consciousness q4h

Patricia a 20 year old college student with diabetes mellitus requests additional information about the advantages of using a pen like insulin delivery devices. The nurse explains that the advantages of these devices over syringes include:

  1. Accurate dose delivery
  2. Shorter injection time
  3. Lower cost with reusable insulin cartridges
  4. Use of smaller gauge needle.

A male client’s left tibia is fractures in an automobile accident, and a cast is applied. To assess for damage to major blood vessels from the fracture tibia, the nurse in charge should monitor the client for:

  1. Swelling of the left thigh
  2. Increased skin temperature of the foot
  3. Prolonged reperfusion of the toes after blanching
  4. Increased blood pressure

After a long leg cast is removed, the male client should:

  1. Cleanse the leg by scrubbing with a brisk motion
  2. Put leg through full range of motion twice daily
  3. Report any discomfort or stiffness to the physician
  4. Elevate the leg when sitting for long periods of time.

While performing a physical assessment of a male client with gout of the great toe, NurseVivian should assess for additional tophi (urate deposits) on the:

  1. Buttocks
  2. Ears
  3. Face
  4. Abdomen

Nurse Katrina would recognize that the demonstration of crutch walking with tripod gait was understood when the client places weight on the:

  1. Palms of the hands and axillary regions
  2. Palms of the hand
  3. Axillary regions
  4. Feet, which are set apart

Mang Jose with rheumatoid arthritis states, “the only time I am without pain is when I lie in bed perfectly still”. During the convalescent stage, the nurse in charge with Mang Jose should encourage:

  1. Active joint flexion and extension
  2. Continued immobility until pain subsides
  3. Range of motion exercises twice daily
  4. Flexion exercises three times daily

A male client has undergone spinal surgery, the nurse should:

  1. Observe the client’s bowel movement and voiding patterns
  2. Log-roll the client to prone position
  3. Assess the client’s feet for sensation and circulation
  4. Encourage client to drink plenty of fluids

Marina with acute renal failure moves into the diuretic phase after one week of therapy. During this phase the client must be assessed for signs of developing:

  1. Hypovolemia
  2. Renal failure
  3. Metabolic acidosis
  4. Hyperkalemia

Nurse Judith obtains a specimen of clear nasal drainage from a client with a head injury. Which of the following tests differentiates mucus from cerebrospinal fluid (CSF)?

  1. Protein
  2. Specific gravity
  3. Glucose
  4. Microorganism

A 22 year old client suffered from his first tonic-clonic seizure. Upon awakening the client asks the nurse, “What caused me to have a seizure? Which of the following would the nurse include in the primary cause of tonic-clonic seizures in adults more the 20 years?

  1. Electrolyte imbalance
  2. Head trauma
  3. Epilepsy
  4. Congenital defect

What is the priority nursing assessment in the first 24 hours after admission of the client with thrombotic CVA?

  1. Pupil size and papillary response
  2. Cholesterol level
  3. Echocardiogram
  4. Bowel sounds

Nurse Linda is preparing a client with multiple sclerosis for discharge from the hospital to home. Which of the following instruction is most appropriate?

  1. “Practice using the mechanical aids that you will need when future disabilities arise”.
  2. “Follow good health habits to change the course of the disease”.
  3. “Keep active, use stress reduction strategies, and avoid fatigue.
  4. “You will need to accept the necessity for a quiet and inactive lifestyle”.

The nurse is aware the early indicator of hypoxia in the unconscious client is:

  1. Cyanosis
  2. Increased respirations
  3. Hypertension
  4. Restlessness

A client is experiencing spinal shock. Nurse Myrna should expect the function of the bladder to be which of the following?

  1. Normal
  2. Atonic
  3. Spastic
  4. Uncontrolled

Which of the following stage the carcinogen is irreversible?

  1. Progression stage
  2. Initiation stage
  3. Regression stage
  4. Promotion stage

Among the following components thorough pain assessment, which is the most significant?

  1. Effect
  2. Cause
  3. Causing factors
  4. Intensity

A 65 year old female is experiencing flare up of pruritus. Which of the client’s action could aggravate the cause of flare ups?

  1. Sleeping in cool and humidified environment
  2. Daily baths with fragrant soap
  3. Using clothes made from 100% cotton
  4. Increasing fluid intake

Atropine sulfate (Atropine) is contraindicated in all but one of the following client?

  1. A client with high blood
  2. A client with bowel obstruction
  3. A client with glaucoma
  4. A client with U.T.I

Among the following clients, which among them is high risk for potential hazards from the surgical experience?

  1. 67-year-old client
  2. 49-year-old client
  3. 33-year-old client
  4. 15-year-old client

Nurse Jon assesses vital signs on a client undergone epidural anesthesia. Which of the following would the nurse assess next?

  1. Headache
  2. Bladder distension
  3. Dizziness
  4. Ability to move legs

Nurse Katrina should anticipate that all of the following drugs may be used in the attempt to control the symptoms of Meniere’s disease except:

  1. Antiemetics
  2. Diuretics
  3. Antihistamines
  4. Glucocorticoids

Which of the following complications associated with tracheostomy tube?

  1. Increased cardiac output
  2. Acute respiratory distress syndrome (ARDS)
  3. Increased blood pressure
  4. Damage to laryngeal nerves

Nurse Faith should recognize that fluid shift in a client with burn injury results from increase in the:

  1. Total volume of circulating whole blood
  2. Total volume of intravascular plasma
  3. Permeability of capillary walls
  4. Permeability of kidney tubules

An 83-year-old woman has several ecchymotic areas on her right arm. The bruises are probably caused by:

  1. Increased capillary fragility and permeability
  2. Increased blood supply to the skin
  3. Self-inflicted injury
  4. Elder abuse

Nurse Anna is aware that early adaptation of client with renal carcinoma is:

  1. Nausea and vomiting
  2. Flank pain
  3. Weight gain
  4. Intermittent hematuria

A male client with tuberculosis asks Nurse Brian how long the chemotherapy must be continued. Nurse Brian’s accurate reply would be:

  1. 1 to 3 weeks
  2. 6 to 12 months
  3. 3 to 5 months
  4. 3 years and more

A client has undergone laryngectomy. The immediate nursing priority would be:

  1. Keep trachea free of secretions
  2. Monitor for signs of infection
  3. Provide emotional support
  4. Promote means of communication

The nurse is going to replace the Pleur-O-Vac attached to the client with a small, persistent left upper lobe pneumothorax with a Heimlich Flutter Valve. Which of the following is the best rationale for this?

  1. Promote air and pleural drainage
  2. Prevent kinking of the tube
  3. Eliminate the need for a dressing
  4. Eliminate the need for a water-seal drainage

The client with acute pancreatitis and fluid volume deficit is transferred from the ward to the ICU. Which of the following will alert the nurse?

  1. Decreased pain in the fetal position
  2. Urine output of 35 mL/hr
  3. CVP of 12 mmHg
  4. Cardiac output of 5L/min

The nurse in the morning shift is making rounds in the ward. The nurse enters the client’s room and found the client in discomfort condition. The client complains of stiffness in the joints. To reduce the early morning stiffness of the joints of the client,the nurse can encourage the client to:

  1. Sleep with a hot pad
  2. Take to aspirins before arising, and wait 15 minutes before attempting locomotion
  3. Take a hot tub bath or shower in the morning
  4. Put joints through passive ROM before trying to move them actively

The nurse is planning of care to a client with peptic ulcer disease. To avoid the worsening condition of the client, the nurse should carefully plan the diet of the client. Which of the following will be included in the diet regime of the client?

  1. Eating mainly bland food and milk or dairy products
  2. Reducing intake of high-fber foods
  3. Eating small, frequent meals and a bedtime snack
  4. Eliminating intake of alcohol and coffee

The physician has given instruction to the nurse that the client can be ambulated on crutches, with no weight bearing on the affected limb. The nurse is aware that the appropriate crutch gait for the nurse to teach the client would be:

  1. Tripod gait
  2. Two-point gait
  3. Four-point gait
  4. Three-point gait

The client is transferred to the nursing care unit from the operating room after a transurethral resection of the prostate. The client is complaining of pain in the abdomen area. The nurse suspects of bladder spasms, which of the following is the best nursing action to minimize the pain felt by the client?

  1. Advising the client not to urinate around catheter
  2. Intermittent catheter irrigation with saline
  3. Giving prescribed narcotics every 4 hour
  4. Repositioning catheter to relieve pressure

A client is diagnosed with peptic ulcer. The nurse caring for the client expects the physician to order which diet?

  1. NPO
  2. Small feedings of bland food
  3. A regular diet given frequently in small amounts
  4. Frequent feedings of clear liquids

The nurse is going to insert a Miller-Abbott tube to the client. Before insertion of the tube, the balloon is tested for patency and capacity and then defated. Which of the following nursing measure will ease the insertion to the tube?

  1. Positioning the client in Semi-Fowler’s position
  2. Administering a sedative to reduce anxiety
  3. Chilling the tube before insertion
  4. Warming the tube before insertion

The physician ordered a low-sodium diet to the client. Which of the following food will the nurse avoid to give to the client?

  1. Orange juice.
  2. Whole milk.
  3. Ginger ale.
  4. Black coffee.

Mr. Bean, a 70-year-old client is admitted in the hospital for almost one month. The nurse understands that prolonged immobilization could lead to decubitus ulcers. Which of the following would be the least appropriate nursing intervention in the prevention of decubitus?

  1. Giving backrubs with alcohol
  2. Use of a bed cradle
  3. Frequent assessment of the skin
  4. Encouraging a high-protein diet

The physician prescribed digoxin 0.125 mg PO qd to a client and instructed the nurse that the client is on high-potassium diet. High potassium foods are recommended in the diet of a client taking digitalis preparations because a low serum potassium has which of the following effects?

  1. Potentiates the action of digoxin
  2. Promotes calcium retention
  3. Promotes sodium excretion
  4. Puts the client at risk for digitalis toxicity

The nurse is caring for a client who is transferred from the operating room for pneumonectomy. The nurse knows that immediately following pneumonectomy; the client should be in what position?

  1. Supine on the unaffected side
  2. Low-Fowler’s on the back
  3. Semi-Fowler’s on the affected side
  4. Semi-Fowler’s on the unaffected side

A client is placed on digoxin, high potassium foods are recommended in the diet of the client. Which of the following foods willthe nurse give to the client?

  1. Whole grain cereal, orange juice, and apricots
  2. Turkey, green bean, and Italian bread
  3. Cottage cheese, cooked broccoli, and roast beef
  4. Fish, green beans and cherry pie

The nurse is assigned to care to a client who undergone thyroidectomy. What nursing intervention is important during the immediate postoperative period following a thyroidectomy?

  1. Assess extremities for weakness and faccidity
  2. Support the head and neck during position changes
  3. Position the client in high Fowler’s
  4. Medicate for restlessness and anxiety

What would be the recommended diet the nurse will implement to a client with burns of the head, face, neck and anterior chest?

  1. Serve a high-protein, high-carbohydrate diet
  2. Encourage full liquid diet
  3. Serve a high-fat diet, high-fber diet
  4. Monitor intake to prevent weight gain

A client with multiple fractures of both lower extremities is admitted for 3 days ago and is on skeletal traction. The client is complaining of having difculty in bowel movement. Which of the following would be the most appropriate nursing intervention?

  1. Administer an enema
  2. Perform range-of-motion exercise to all extremities
  3. Ensure maximum fuid intake (3000ml/day)
  4. Put the client on the bedpan every 2 hours

John is diagnosed with Addison’s disease and admitted in the hospital. What would be the appropriate nursing care for John?

  1. Reducing physical and emotional stress
  2. Providing a low-sodium diet
  3. Restricting fuids to 1500ml/day
  4. Administering insulin-replacement therapy

Mr. Smith is scheduled for an above-the-knee amputation. After the surgery he was transferred to the nursing care unit. The nurse assigned to him knows that 72 hours after the procedure the client should be positioned properly to prevent contractures. Which of the following is the best position to the client?

  1. Side-lying, alternating left and right sides
  2. Sitting in a reclining chair twice a day
  3. Lying on abdomen several times daily
  4. Supine with stump elevated at least 30 degrees

A client is scheduled to have an inguinal herniorraphy in the outpatient surgical department. The nurse is providing health teaching about post surgical care to the client. Which of the following statement if made by the client would refect the need for more teaching?

  1. “I should call the physician if I have a cough or cold before surgery”
  2. “I will be able to drive soon after surgery”
  3. “I will not be able to do any heavy lifting for 3-6 weeks after surgery”
  4. “I should support my incision if I have to cough or turn”

Ms Jones is brought to the emergency room and is complaining of muscle spasms, numbness, tremors and weakness in the arms and legs. The client was diagnosed with multiple sclerosis. The nurse assigned to Ms. Jones is aware that she has to prevent fatigue to the client to alleviate the discomfort. Which of the following teaching is necessary to prevent fatigue?

  1. Avoid extremes in temperature
  2. Install safety devices in the home
  3. Attend support group meetings
  4. Avoid physical exercise

Mr. Stewart is in sickle cell crisis and complaining pain in the joints and difculty of breathing. On the assessment of the nurse, his temperature is 38.1 ºC. The physician ordered Morphine sulfate via patient-controlled analgesia (PCA), and oxygen at 4L/min. A priority nursing diagnosis to Mr. Stewart is risk for infection. A nursing intervention to assist in preventing infection is:

  1. Using standard precautions and medical asepsis
  2. Enforcing a “no visitors” rule
  3. Using moist heat on painful joints
  4. Monitoring a vital signs every 2 hour

Mrs. Maupin is a professor in a prestigious university for 30 years. After lecture, she experience blurring of vision and tiredness. Mrs. Maupin is brought to the emergency department. On assessment, the nurse notes that the blood pressure of the client is 139/90. Mrs. Maupin has been diagnosed with essential hypertension and placed on medication to control her BP. Which potential nursing diagnosis will be a priority for discharge teaching?

  1. Sleep Pattern disturbance
  2. Impaired physical mobility
  3. Noncompliance
  4. Fluid volume excess

Following a needle biopsy of the kidney, which assessment is an indication that the client is bleeding?

  1. Slow, irregular pulse
  2. Dull, abdominal discomfort
  3. Urinary frequency
  4. Throbbing headache

A client with acute bronchitis is admitted in the hospital. The nurse assigned to the client is making a plan of care regarding expectoration of thick sputum. Which nursing action is most effective?

  1. Place the client in a lateral position every 2 hour
  2. Splint the patient’s chest with pillows when coughing
  3. Use humifed oxygen
  4. Offer fuids at regular intervals

The nurse is going to assess the bowel sound of the client. For accurate assessment of the bowel sound, the nurse should listen for at least:

  1. 5 minutes
  2. 60 seconds
  3. 30 seconds
  4. 2 minutes

The nurse encourages the client to wear compression stockings. What is the rationale behind in using compression stockings?

  1. Compression stockings promote venous return
  2. Compression stockings divert blood to major vessels
  3. Compression stockings decreases workload on the heart
  4. Compression stockings improve arterial circulation

Mr. Whitman is a stroke client and is having difculty in swallowing. Which is the best nursing intervention is most likely to assist the client?

  1. Placing food in the unaffected side of the mouth
  2. Increasing fber in the diet
  3. Asking the patient to speak slowly
  4. Increasing fuid intake

Following nephrectomy, the nurse closely monitors the urinary output of the client. Which assessment fnding is an early indicator of fuid retention in the postoperative period?

  1. Periorbital edema
  2. Increased specifc gravity of urine
  3. A urinary output of 50mL/hr
  4. Daily weight gain of 2 lb or more

A nurse is completing an assessment to a client with cirrhosis. Which of the following nursing assessment is important to notify the physician?

  1. Expanding ecchymosis
  2. Ascites and serum albumin of 3.2 g/dl
  3. Slurred speech
  4. Hematocrit of 37% and hemoglobin of 12g/dl

Mr. Park is 32-year-old, a badminton player and has a type 1 diabetes mellitus. After the game, the client complains of becoming diaphoretic and light-headedness. The client asks the nurse how to avoid this reaction. The nurse will recommend to:

  1. Allow plenty of time after the insulin injection and before beginning the match
  2. Eat a carbohydrate snack before and during the badminton match
  3. Drink plenty of fuids before, during, and after bed time
  4. Take insulin just before starting the badminton match

A client is rushed to the emergency room due to serious vehicle accident. The nurse is suspecting of head injury. Which of the following assessment fndings would the nurse report to the physician?

  1. CVP of 5mmHa
  2. Glasgow Coma Scale score of 13
  3. Polyuria and dilute urinary output
  4. Insomnia

Mrs. Moore, 62-year-old, with diabetes is in the emergency department. She stepped on a sharp sea shells while walking barefoot along the beach. Mrs. Moore did not notice that the object pierced the skin until later that evening. What problem does the client most probably have?

  1. Nephropathy
  2. Macroangiopathy
  3. Carpal tunnel syndrome
  4. Peripheral neuropathy

A client with gangrenous foot has undergone a below-knee amputation. The nurse in the nursing care unit knows that the priority nursing intervention in the immediate post operative care of this client is:

  1. Elevate the stump on a pillow for the first 24 hours
  2. Encourage use of trapeze
  3. Position the client prone periodically
  4. Apply a cone-shaped dressing

A client with a diagnosis of gastric ulcer is complaining of syncope and vertigo. What would be the initial nursing intervention by the nurse?

  1. Monitor the client’s vital signs
  2. Keep the client on bed rest
  3. Keep the patient on bed rest
  4. Give a stat dose of Sucralfate (Carafate)

After a right lower lobectomy on a 55-year-old client, which action should the nurse initiate when the client is transferred from the post anesthesia care unit?

  1. Notify the family to report the client’s condition
  2. Immediately administer the narcotic as ordered
  3. Keep client on right side supported by pillows
  4. Encourage coughing and deep breathing every 2 hours

The nurse is providing a discharge instruction about the prevention of urinary stasis to a client with frequent bladder infection. Which of the following will the nurse include in the instruction?

  1. Drink 3-4 quarts of fuid every day
  2. Empty the bladder every 2-4 hours while awake
  3. Encourage the use of coffee, tea, and colas for their diuretic effect
  4. Teach Kegel exercises to control bladder fow

A male client visits the clinic for check-up. The client tells the nurse that there is a yellow discharge from his penis. He also experiences a burning sensation when urinating. The nurse is suspecting of gonorrhea. What teaching is necessary for this client?

  1. Sex partner of 3 months ago must be treated
  2. Women with gonorrhea are symptomatic
  3. Use a condom for sexual activity
  4. Sex partner needs to be evaluated

A client with AIDS is admitted in the hospital. He is receiving intravenous therapy. While the nurse is assessing the IV site, the client becomes confused and restless and the intravenous catheter becomes disconnected and minimal amount of the client’s blood spills onto the foor. Which action will the nurse take to remove the blood spill?

  1. Promptly clean with a 1:10 solution of household bleach and water
  2. Promptly clean up the blood spill with full-strength antimicrobial cleaning solution
  3. Immediately mop the foor with boiling water
  4. Allow the blood to dry before cleaning to decrease the possibility of cross-contamination

Before surgery, the physician ordered pentobarbital sodium (Nembutal) for the client to sleep. The night before the scheduled surgery, the nurse gave the pre-medication. One hour later the client is still unable to sleep. The nurse review the client’s chart and note the physician’s prescription with an order to repeat. What should the nurse do next?

  1. Rub the client’s back until relaxed
  2. Prepare a glass of warm milk
  3. Give the second dose of pentobarbital sodium
  4. Explore the client’s feelings about surgery

The nurse on the night shift is making rounds in the nursing care unit. The nurse is about to enter to the client’s room when a ventilator alarm sounds, what is the first action the nurse should do?

  1. Assess the lung sounds
  2. Suction the client right away
  3. Look at the client
  4. Turn and position the client

What effective precautions should the nurse use to control the transmission of methicillin-resistant Staphylococcus aureus (MRSA)?

  1. Use gloves and handwashing before and after client contact
  2. Do nasal cultures on healthcare providers
  3. Place the client on total isolation
  4. Use mask and gown during care of the MRSA client

The postoperative gastrectomy client is scheduled for discharge. The client asks the nurse, “When I will be allowed to eat three meals a day like the rest of my family?”. The appropriate nursing response is:

  1. “You will probably have to eat six meals a day for the rest of your life.”
  2. “Eating six meals a day can be a bother, can’t it?”
  3. “Some clients can tolerate three meals a day by the time they leave the hospital. Maybe it will be a little longer for you.”
  4. “ It varies from client to client, but generally in 6-12 months most clients can return to their previous meal patterns”

A male client with cirrhosis is complaining of belly pain, itchiness and his breasts are getting larger and also the abdomen. The client is so upset because of the discomfort and asks the nurse why his breast and abdomen are getting larger. Which of the following is the appropriate nursing response?

  1. “How much of a difference have you noticed”
  2. “It’s part of the swelling your body is experiencing”
  3. “It’s probably because you have been less physically active”
  4. “Your liver is not destroying estrogen hormones that all men produce”

A client is diagnosed with detached retina and scheduled for surgery. Preoperative teaching of the nurse to the client includes:

  1. No eye pain is expected postoperatively
  2. Semi-fowler’s position will be used to reduce pressure in the eye.
  3. Eye patches may be used postoperatively
  4. Return of normal vision is expected following surgery

A 70-year-old client is brought to the emergency department with a caregiver. The client has manifestations of anorexia, wasting of muscles and multiple bruises. What nursing interventions would the nurse implement?

  1. Talk to the client about the caregiver and support system
  2. Complete a gastrointestinal and neurological assessment
  3. Check the lab data for serum albumin, hematocrit and hemoglobin
  4. Complete a police report on elder abuse

A nurse is providing a discharge instruction to the client about the self-catheterization at home. Which of the following instructions would the nurse include?

  1. Wash the catheter with soap and water after each use
  2. Lubricate the catheter with Vaseline
  3. Perform the Valsalva maneuver to promote insertion
  4. Replace the catheter with a new one every 24 hour

The nurse in the nursing care unit is assigned to care to a client who is Immunocompromised. The client tells the nurse that his chest is painful and the blisters are itchy. What would be the nursing intervention to this client?

  1. Call the physician
  2. Give a prn pain medication
  3. Clarify if the client is on a new medication
  4. Use gown and gloves while assessing the lesions

A client is admitted and has been diagnosed with bacterial (meningococcal) meningitis. The infection control registered nurse visits the staff nurse caring to the client. What statement made by the nurse refects an understanding of the management of this client?

  1. speech pattern may be altered
  2. Respiratory isolation is necessary for 24 hours after antibiotics are started
  3. Perform skin culture on the macular popular rash
  4. Expect abnormal general muscle contractions

A 18-year-old male client had sustained a head injury from a motorbike accident. It is uncertain whether the client may have minimal but permanent disability. The family is concerned regarding the client’s difculty accepting the possibility of long term effects. Which nursing diagnosis is best for this situation?

  1. Nutrition, less than body requirements
  2. Injury, potential for sensory-perceptual alterations
  3. Impaired mobility, related to muscle weakness
  4. Anticipatory grieving, due to the loss of independence

A client with AIDS is scheduled for discharge. The client tells the nurse that one of his hobbies at home is gardening. What will be the discharge instruction of the nurse to the client knowing that the client is prone to toxoplasmosis?

  1. Wash all vegetables before cooking
  2. Wear gloves when gardening
  3. Wear a mask when travelling to foreign countries
  4. Avoid contact with cats and birds

Following spinal injury, the nurse should encourage the client to drink fluids to avoid:

  1. Urinary tract infection.
  2. Fluid and electrolyte imbalance.
  3. Dehydration.
  4. Skin breakdown.

The client is transferred from the operating room to recovery room after an open-heart surgery. The nurse assigned is taking the vital signs of the client. The nurse notifed the physician when the temperature of the client rises to 38.8ºC or 102ºF because elevated temperatures:

  1. May be a forerunner of hemorrhage.
  2. Are related to diaphoresis and possible chilling.
  3. May indicate cerebral edema.
  4. Increase the cardiac output.

After radiation therapy for cancer of the prostate, the client experienced irritation in the bladder. Which of the following sign of bladder irritability is correct?

  1. Hematuria
  2. Dysuria
  3. Polyuria
  4. Dribbling

A client is diagnosed with a brain tumor in the occipital lobe. Which of the following will the client most likely experience?

  1. Visual hallucinations.
  2. Receptive aphasia.
  3. Hemiparesis.
  4. Personality changes.

A client with Addison’s disease has a blood pressure of 65/60. The nurse understands that decreased blood pressure of the client with Addison’s disease involves a disturbance in the production of:

  1. Androgens
  2. Glucocorticoids
  3. Mineralocorticoids
  4. Estrogen

The nurse is planning to teach the client about a spontaneous pneumothorax. The nurse would base the teaching on the understanding that:

  1. Inspired air will move from the lung into the pleural space.
  2. There is greater negative pressure within the chest cavity.
  3. The heart and great vessels shift to the affected side.
  4. The other lung will collapse if not treated immediately.

During an assessment, the nurse recognizes that the client has an increased risk for developing cancer of the tongue. Which of the following health history will be a concern?

  1. Heavy consumption of alcohol.
  2. Frequent gum chewing.
  3. Nail biting.
  4. Poor dental habits.

The client in the orthopedic unit asks the nurse the reason behind why compact bone is stronger than cancellous bone. Which of the following is the correct response of the nurse?

  1. Compact bone is stronger than cancellous bone because of its greater size.
  2. Compact bone is stronger than cancellous bone because of its greater weight.
  3. Compact bone is stronger than cancellous bone because of its greater volume.
  4. Compact bone is stronger than cancellous bone because of its greater density.

The nurse is reviewing the laboratory results of the client. In reviewing the results of the RBC count, the nurse understands that the higher the red blood cell count, the :

  1. Greater the blood viscosity.
  2. Higher the blood pH.
  3. Less it contributes to immunity.
  4. Lower the hematocrit.

The physician advised the client with Hemiparesis to use a cane. The client asks the nurse why cane will be needed. The nurse explains to the client that cane is advised specifcally to:

  1. Aid in controlling involuntary muscle movements.
  2. Relieve pressure on weight-bearing joints.
  3. Maintain balance and improve stability.
  4. Prevent further injury to weakened muscles.

The nurse is conducting a discharge teaching regarding the prevention of further problems to a client who undergone surgery for carpal tunnel syndrome of the right hand. Which of the following instruction will the nurse includes?

  1. Learn to type using your left hand only.
  2. Avoid typing in a long period of time.
  3. Avoid carrying heavy things using the right hand.
  4. Do manual stretching exercise during breaks.

A female client is admitted because of recurrent urinary tract infections. The client asks the nurse why she is prone to this disease. The nurse states that the client is most susceptible because of:

  1. Continuity of the mucous membrane.
  2. Inadequate fuid intake.
  3. The length of the urethra.
  4. Poor hygienic practices.

A 55-year-old client is admitted with chest pain that radiates to the neck, jaw and shoulders that occurs at rest, with high body temperature, weak with generalized sweating and with decreased blood pressure. A myocardial infarction is diagnosed. The nurse knows that the most accurate explanation for one of these presenting adaptations is:

  1. Catecholamines released at the site of the infarction causes intermittent localized pain.
  2. Parasympathetic refexes from the infarcted myocardium causes diaphoresis.
  3. Constriction of central and peripheral blood vessels causes a decrease in blood pressure.
  4. Infammation in the myocardium causes a rise in the systemic body temperature.

Following an amputation of a lower limb to a male client, the nurse provides an instruction on how to prevent a hip fexion contracture. The nurse should instruct the client to:.

  1. Perform quadriceps muscle setting exercises twice a day.
  2. Sit in a chair for 30 minutes three times a day.
  3. Lie on the abdomen 30 minutes every four hours.
  4. Turn from side to side every 2 hours.

The physician scheduled the client with rheumatoid arthritis for the injection of hydrocortisone into the knee joint. The client asks the nurse why there is a need for this injection. The nurse explains that the most important reason for doing this is to:

  1. Lubricate the joint.
  2. Prevent ankylosis of the joint.
  3. Reduce infammation.
  4. Provide physiotherapy.

The nurse is assigned to care for a 57-year-old female client who had a cataract surgery an hour ago. The nurse should:

  1. Advise the client to refrain from vigorous brushing of teeth and hair.
  2. Instruct the client to avoid driving for 2 weeks.
  3. Encourage eye exercises to strengthen the ocular musculature.
  4. Teach the client coughing and deep-breathing techniques.

A client with AIDS develops bacterial pneumonia is admitted in the emergency department. The client’s arterial blood gases is drawn and the result is PaO2 80mmHg. then arterial blood gases are drawn again and the level is reduced from 80 mmHg to 65 mmHg. The nurse should;

  1. Have arterial blood gases performed again to check for accuracy.
  2. Increase the oxygen fow rate.
  3. Notify the physician.
  4. Decrease the tension of oxygen in the plasma.

An 18-year-old college student is brought to the emergency department due to serious motor vehicle accident. Right above-knee-amputation is done. Upon awakening from surgery the client tells the nurse, “What happened to me? I cannot remember anything?” Which of the following would be the appropriate initial nursing response?

  1. “You sound concerned; You’ll probably remember more as you wake up.”
  2. “Tell me what you think happened.”
  3. “You were in a car accident this morning.”
  4. “An amputation of your right leg was necessary because of an accident.”

A 38-year-old client with severe hypertension is hospitalized. The physician prescribed a Captopril (Capoten) and Alprazolam (Xanax) for treatment. The client tells the nurse that there is something wrong with the medication and nursing care. The nurse recognizes this behavior is probably a manifestation of the client’s:

  1. Reaction to hypertensive medications.
  2. Denial of illness.
  3. Response to cerebral anoxia.
  4. Fear of the health problem.

Before discharge, the nurse scheduled the client who had a colostomy for colorectal cancer for discharge instruction about resuming activities. The nurse should plan to help the client understands that:

  1. After surgery, changes in activities must be made to accommodate for the physiologic changes caused by the operation.
  2. Most sports activities, except for swimming, can be resumed based on the client’s overall physical condition.
  3. With counseling and medical guidance, a near normal lifestyle, including complete sexual function is possible.
  4. Activities of daily living should be resumed as quickly as possible to avoid depression and further dependency.

A client is scheduled for bariatric surgery. Preoperative teaching is done. Which of the following statement would alert the nurse that further teaching to the client is necessary?

  1. “I will be limiting my intake to 600 to 800 calories a day once I start eating again.”
  2. “I’m going to have a fgure like a model in about a year.”
  3. “I need to eat more high-protein foods.”
  4. “I will be going to be out of bed and sitting in a chair the first day after surgery.”.

The client who had transverse colostomy asks the nurse about the possible effect of the surgery on future sexual relationship. What would be the best nursing response?

  1. The surgery will temporarily decrease the client’s sexual impulses.
  2. Sexual relationships must be curtailed for several weeks.
  3. The partner should be told about the surgery before any sexual activity.
  4. The client will be able to resume normal sexual relationships.

A 75-year-old male client tells the nurse that his wife has osteoporosis and asks what chances he had of getting also osteoporosis like his wife. Which of the following is the correct response of the nurse?

  1. “This is only a problem for women.”
  2. “You are not at risk because of your small frame.”
  3. “You might think about having a bone density test,”
  4. “Exercise is a good way to prevent this problem.”

An older adult client with acute pain is admitted in the hospital. The nurse understands that in managing acute pain of the client during the first 24 hours, the nurse should ensure that:

  1. Ordered PRN analgesics are administered on a scheduled basis.
  2. Patient controlled analgesia is avoided in this population.
  3. Pain medication is ordered via the intramuscular route.
  4. An order for meperidine (Demerol) is secured for pain relief.

A nurse is caring to an older adult with presbycusis. In formulating nursing care plan for this client, the nurse should expect that hearing loss of the client that is caused by aging to have:

  1. Overgrowth of the epithelial auditory lining.
  2. Copious, moist cerumen.
  3. Difculty hearing women’s voices.
  4. Tears in the tympanic membrane.

The nurse is reviewing the client’s chart about the ordered medication. The nurse must observe for signs of hyperkalemia when administering:

  1. Furosemide (Lasix)
  2. Hydrochlorothiazide (HydroDIURIL)
  3. Metolazone (Zaroxolyn)
  4. Spironolactone (Aldactone)

The physician prescribed Albuterol (Proventil) to the client with severe asthma. After the administration of the medication the nurse should monitor the client for:

  1. Palpitation
  2. Visual disturbance
  3. Decreased pulse rate
  4. Lethargy

A client is receiving diltiazem (Cardizem). What should the nurse include in a teaching plan aimed at reducing the side effects of this medication?

  1. Take the drug with an antacid.
  2. Lie down after meals.
  3. Avoid dairy products in diet.
  4. Change positions slowly.

A client is receiving simvastatin (Zocor). The nurse is aware that this medication is effective when there is decrease in:

  1. The triglycerides
  2. The INR
  3. Chest pain
  4. Blood pressure

A client is taking nitroglycerine tablets, the nurse should teach the client the importance of:

  1. Increasing the number of tablets if dizziness or hypertension occurs.
  2. Limiting the number of tablets to 4 per day.
  3. Making certain the medication is stored in a dark container.
  4. Discontinuing the medication if a headache develops.

The physician prescribes Ibuprofen (Motrin) and hydroxychloroquine sulfate (Plaquenil) for a 58-year-old male client with arthritis. The nurse provides information about toxicity of the hydroxychloroquine. The nurse can determine if the information is clearly understood if the client states:

  1. “I will contact the physician immediately if I develop blurred vision.”
  2. “I will contact the physician immediately if I develop urinary retention.”
  3. “I will contact the physician immediately if I develop swallowing difculty.”
  4. “I will contact the physician immediately if I develop feelings of irritability.”

The client with an acute myocardial infarction is hospitalized for almost one week. The client experiences nausea and loss of appetite. The nurse caring for the client recognizes that these symptoms may indicate the:

  1. Adverse effects of spironolactone (Aldactone)
  2. Adverse effects of digoxin (Lanoxin)
  3. Therapeutic effects of propranolol (Indiral)
  4. Therapeutic effects of furosemide (Lasix)

A client with a partial occlusion of the left common carotid artery is scheduled for discharge. The client is still receiving Coumadin. The nurse provided a discharge instruction to the client regarding adverse effects of Coumadin. The nurse should tell the client to consult with the physician if:

  1. Swelling of the ankles increases.
  2. Blood appears in the urine.
  3. Increased transient Ischemic attacks occur.
  4. The ability to concentrate diminishes.

Levodopa is ordered for a client with Parkinson’s disease. Before starting the medication, the nurse should know that:

  1. Levodopa is inadequately absorbed if given with meals.
  2. Levodopa may cause the side effects of orthostatic hypotension.
  3. Levodopa must be monitored by weekly laboratory tests.
  4. Levodopa causes an initial euphoria followed by depression.

In making a diagnosis of myasthenia gravis Edrophonium HCI (Tensilon) is used. The nurse knows that this drug will cause a temporary increase in:

  1. Muscle strength
  2. Symptoms
  3. Blood pressure
  4. Consciousness

The nurse can determine the effectiveness of carbamazepine (Tegretol) in the management of trigeminal neuralgia by monitoring the client’s:

  1. Seizure activity
  2. Liver function
  3. Cardiac output
  4. Pain relief

Administration of potassium iodide solution is ordered to the client who will undergo a subtotal thyroidectomy. The nurse understands that this medication is given to:

  1. Ablate the cells of the thyroid gland that produce T4.
  2. Decrease the total basal metabolic rate.
  3. Decrease the size and vascularity of the thyroid.
  4. Maintain function of the parathyroid gland.

A client with Addison’s disease is scheduled for discharge. Before the discharge, the physician prescribes hydrocortisone and fudrocortisone. The nurse expects the hydrocortisone to:

  1. Increase amounts of angiotensin II to raise the client’s blood pressure.
  2. Control excessive loss of potassium salts.
  3. Prevent hypoglycemia and permit the client to respond to stress.
  4. Decrease cardiac dysrhythmias and dyspnea.

A client with diabetes insipidus is taking Desmopressin acetate (DDAVP). To determine if the drug is effective, the nurse should monitor the client’s:

  1. Arterial blood pH
  2. Pulse rate
  3. Serum glucose
  4. Intake and output

A client with recurrent urinary tract infections is to be discharged. The client will be taking nitrofurantoin (Macrobid) 50 mg po every evening at home. The nurse provides discharge instructions to the client. Which of the following instructions will be correct?

  1. Strain urine for crystals and stones
  2. Increase fuid intake.
  3. Stop the drug if the urinary output increases
  4. Maintain the exact time schedule for drug taking.

A client with cancer of the lung is receiving chemotherapy. The physician orders antibiotic therapy for the client. The nurse understands that chemotherapy destroys rapidly growing leukocytes in the:

  1. Bone marrow
  2. Liver
  3. Lymph nodes
  4. Blood

The physician reduced the client’s Dexamethasone (Decadron) dosage gradually and to continue a lower maintenance dosage. The client asks the nurse about the change of dosage. The nurse explains to the client that the purpose of gradual dosage reduction is to allow:

  1. Return of cortisone production by the adrenal glands.
  2. Production of antibodies by the immune system
  3. Building of glycogen and protein stores in liver and muscle
  4. Time to observe for return of increases intracranial pressure

The nurse is assigned to care for a client with diarrhea. Excessive fuid loss is expected. The nurse is aware that fuid defcit can most accurately be assessed by:

  1. The presence of dry skin
  2. A change in body weight
  3. An altered general appearance
  4. A decrease in blood pressure

Which of the following is the most important electrolyte of intracellular fuid?

  1. Potassium
  2. Sodium
  3. Chloride
  4. Calcium

Which of the following client has a high risk for developing hyperkalemia?

  1. Crohn’s disease
  2. End-Stage renal disease
  3. Cushing’s syndrome
  4. Chronic heart failure

The nurse is reviewing the laboratory result of the client. The client’s serum potassium level is 5.8 mEq/L. Which of the following is the initial nursing action?

  1. Call the cardiac arrest team to alert them
  2. Call the laboratory and repeat the test
  3. Take the client’s vital signs and notify the physician
  4. Obtain an ECG strip and have lidocaine available

Potassium chloride, 20 mEq, is ordered and to be added in the IV solution of a client in a diabetic ketoacidosis. The primary reason for administering this drug is:

  1. Replacement of excessive losses
  2. Treatment of hyperpnea
  3. Prevention of flaccid paralysis
  4. Treatment of cardiac dysrhythmias

A female client is brought to the emergency unit. The client is complaining of abdominal cramps. On assessment, client is experiencing anorexia and weight is reduced. The physician’s diagnosis is colitis. Which of the following symptoms of fluid and electrolyte imbalance should the nurse report immediately?

  1. Skin rash, diarrhea, and diplopia
  2. Development of tetany with muscles spasms
  3. Extreme muscle weakness and tachycardia
  4. Nausea, vomiting, and leg and stomach cramps.

The client is to receive an IV piggyback medication. When preparing the medication the nurse should be aware that it is very important to:

  1. Use strict sterile technique
  2. Use exactly 100 mL of fluid to mix the medication
  3. Change the needle just before adding the medication
  4. Rotate the bag after adding the medication

The nurse is reviewing the laboratory result of the client. An arterial blood gas report indicates the client’s pH is 7.20, PCO₂ 35 mmHg and HCO₃- is 19 mEq/L. The results are consistent with:

  1. Metabolic acidosis
  2. Metabolic alkalosis
  3. Respiratory acidosis
  4. Respiratory alkalosis

Psychiatric Nursing

ParameterMetadata
DomainPsychiatric Nursing
Topics
Items200 multiple-choice questions
Answer StatusAnswer Key, Rationalized

Mr. Marquez reports of losing his job, not being able to sleep at night, and feeling upset with his wife. Nurse John responds to the client, “You may want to talk about your employment situation in group today.” The Nurse is using which therapeutic technique?

  1. Observations
  2. Restating
  3. Exploring
  4. Focusing

Tony refuses his evening dose of Haloperidol (Haldol), then becomes extremely agitated in the dayroom while other clients are watching television. He begins cursing and throwing furniture. Nurse Oliver first action is to:

  1. Check the client’s medical record for an order for an as-needed I.M. dose of medication for agitation.
  2. Place the client in full leather restraints.
  3. Call the attending physician and report the behavior.
  4. Remove all other clients from the dayroom.

Tina who is manic, but not yet on medication, comes to the drug treatment center. The nurse would not let this client join the group session because:

  1. The client is disruptive.
  2. The client is harmful to self.
  3. The client is harmful to others.
  4. The client needs to be on medication first.

Dervid, an adolescent boy was admitted for substance abuse and hallucinations. The client’s mother asks Nurse Armando to talk with his husband when he arrives at the hospital. The mother says that she is afraid of what the father might say to the boy. The most appropriate nursing intervention would be to:

  1. Inform the mother that she and the father can work through this problem themselves.
  2. Refer the mother to the hospital social worker.
  3. Agree to talk with the mother and the father together.
  4. Suggest that the father and son work things out.

What is Nurse John likely to note in a male client being admitted for alcohol withdrawal?

  1. Perceptual disorders.
  2. Impending coma.
  3. Recent alcohol intake.
  4. Depression with mutism.

Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that it “doesn’t help” and refuses to take it. What should the nurse say or do?

  1. Withhold the drug.
  2. Record the client’s response.
  3. Encourage the client to tell the doctor.
  4. Suggest that it takes a while before seeing the results.

Dervid, an adolescent has a history of truancy from school, running away from home and “borrowing” other people’s things without their permission. The adolescent denies stealing, rationalizing instead that as long as no one was using the items, it was all right to borrow them. It is important for the nurse to understand the psychodynamically, this behavior may be largely attributed to a developmental defect related to the:

  1. Id
  2. Ego
  3. Superego
  4. Oedipal complex

In preparing a female client for electroconvulsive therapy (ECT), Nurse Michelle knows that succinylcoline (Anectine) will be administered for which therapeutic effect?

  1. Short-acting anesthesia
  2. Decreased oral and respiratory secretions.
  3. Skeletal muscle paralysis.
  4. Analgesia.

Nurse Gina is aware that the dietary implications for a client in manic phase of bipolar disorder is:

  1. Serve the client a bowl of soup, buttered French bread, and apple slices.
  2. Increase calories, decrease fat, and decrease protein.
  3. Give the client pieces of cut-up steak, carrots, and an apple.
  4. Increase calories, carbohydrates, and protein.

What parental behavior toward a child during an admission procedure should cause Nurse Ron to suspect child abuse?

  1. Flat affect
  2. Expressing guilt
  3. Acting overly solicitous toward the child.
  4. Ignoring the child.

Nurse Lynnette notices that a female client with obsessive-compulsive disorder washes her hands for long periods each day. How should the nurse respond to this compulsive behavior?

  1. By designating times during which the client can focus on the behavior.
  2. By urging the client to reduce the frequency of the behavior as rapidly as possible.
  3. By calling attention to or attempting to prevent the behavior.
  4. By discouraging the client from verbalizing anxieties.

After seeking help at an outpatient mental health clinic, Ruby who was raped while walking her dog is diagnosed with posttraumatic stress disorder (PTSD). Three months later, Ruby returns to the clinic, complaining of fear, loss of control, and helpless feelings. Which nursing intervention is most appropriate for Ruby?

  1. Recommending a high-protein, low-fat diet.
  2. Giving sleep medication, as prescribed, to restore a normal sleep- wake cycle.
  3. Allowing the client time to heal.
  4. Exploring the meaning of the traumatic event with the client.

Meryl, age 19, is highly dependent on her parents and fears leaving home to go away to college. Shortly before the semester starts, she complains that her legs are paralyzed and is rushed to the emergency department. When physical examination rules out a physical cause for her paralysis, the physician admits her to the psychiatric unit where she is diagnosed with conversion disorder. Meryl asks the nurse, “Why has this happened to me?” What is the nurse’s best response?

  1. “You’ve developed this paralysis so you can stay with your parents. You must deal with this conflict if you want to walk again.”
  2. “It must be awful not to be able to move your legs. You may feel better if you realize the problem is psychological, not physical.”
  3. “Your problem is real but there is no physical basis for it. We’ll work on what is going on in your life to find out why it’s happened.”
  4. “It isn’t uncommon for someone with your personality to develop a conversion disorder during times of stress.”

Nurse Krina knows that the following drugs have been known to be effective in treating obsessive-compulsive disorder (OCD):

  1. benztropine (Cogentin) and diphenhydramine (Benadryl).
  2. chlordiazepoxide (Librium) and diazepam (Valium)
  3. fluvoxamine (Luvox) and clomipramine (Anafranil)
  4. divalproex (Depakote) and lithium (Lithobid)

Alfred was newly diagnosed with anxiety disorder. The physician prescribed buspirone (BuSpar). The nurse is aware that the teaching instructions for newly prescribed buspirone should include which of the following?

  1. A warning about the drugs delayed therapeutic effect, which is from 14 to 30 days.
  2. A warning about the incidence of neuroleptic malignant syndrome (NMS).
  3. A reminder of the need to schedule blood work in 1 week to check blood levels of the drug.
  4. A warning that immediate sedation can occur with a resultant drop in pulse.

Richard with agoraphobia has been symptom-free for 4 months. Classic signs and symptoms of phobias include:

  1. Insomnia and an inability to concentrate.
  2. Severe anxiety and fear.
  3. Depression and weight loss.
  4. Withdrawal and failure to distinguish reality from fantasy.

Which medications have been found to help reduce or eliminate panic attacks?

  1. Antidepressants
  2. Anticholinergics
  3. Antipsychotics
  4. Mood stabilizers

A client seeks care because she feels depressed and has gained weight. To treat her atypical depression, the physician prescribes tranylcypromine sulfate (Parnate), 10 mg by mouth twice per day. When this drug is used to treat atypical depression, what is its onset of action?

  1. 1 to 2 days
  2. 3 to 5 days
  3. 6 to 8 days
  4. 10 to 14 days

A 65 years old client is in the first stage of Alzheimer’s disease. Nurse Patricia should plan to focus this client’s care on:

  1. Offering nourishing finger foods to help maintain the client’s nutritional status.
  2. Providing emotional support and individual counseling.
  3. Monitoring the client to prevent minor illnesses from turning into major problems.
  4. Suggesting new activities for the client and family to do together.

The nurse is assessing a client who has just been admitted to the emergency department. Which signs would suggest an overdose of an antianxiety agent?

  1. Combativeness, sweating, and confusion
  2. Agitation, hyperactivity, and grandiose ideation
  3. Emotional lability, euphoria, and impaired memory
  4. Suspiciousness, dilated pupils, and increased blood pressure

The nurse is caring for a client diagnosed with antisocial personality disorder. The client has a history of fighting, cruelty to animals, and stealing. Which of the following traits would the nurse be most likely to uncover during assessment?

  1. History of gainful employment
  2. Frequent expression of guilt regarding antisocial behavior
  3. Demonstrated ability to maintain close, stable relationships
  4. A low tolerance for frustration

Nurse Amy is providing care for a male client undergoing opiate withdrawal. Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:

  1. Barbiturates
  2. Amphetamines
  3. Methadone
  4. Benzodiazepines

Nurse Cristina is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as:

  1. Delusions
  2. Hallucinations
  3. Loose associations
  4. Neologisms

Nurse Marco is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan?

  1. Restricts visits with the family and friends until the client begins to eat.
  2. Provide privacy during meals.
  3. Set up a strict eating plan for the client.
  4. Encourage the client to exercise, which will reduce her anxiety.

Tim is admitted with a diagnosis of delusions of grandeur. The nurse is aware that this diagnosis reflects a belief that one is:

  1. Highly important or famous.
  2. Being persecuted
  3. Connected to events unrelated to oneself
  4. Responsible for the evil in the world.

Nurse Jen is caring for a male client with manic depression. The plan of care for a client in a manic state would include:

  1. Offering a high-calorie meals and strongly encouraging the client to finish all food.
  2. Insisting that the client remain active through the day so that he’ll sleep at night.
  3. Allowing the client to exhibit hyperactive, demanding, manipulative behavior without setting limits.
  4. Listening attentively with a neutral attitude and avoiding power struggles.

Ramon is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but that he can control his use if he chooses. Which coping mechanism is he using?

  1. Withdrawal
  2. Logical thinking
  3. Repression
  4. Denial

Richard is admitted with a diagnosis of schizotypal personality disorder. hich signs would this client exhibit during social situations?

  1. Aggressive behavior
  2. Paranoid thoughts
  3. Emotional affect
  4. Independence needs

Nurse Mickey is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:

  1. Avoid shopping for large amounts of food.
  2. Control eating impulses.
  3. Identify anxiety-causing situations
  4. Eat only three meals per day.

Rudolf is admitted for an overdose of amphetamines. When assessing the client, the nurse should expect to see:

  1. Tension and irritability
  2. Slow pulse
  3. Hypotension
  4. Constipation

Nicolas is experiencing hallucinations tells the nurse, “The voices are telling me I’m no good.” The client asks if the nurse hears the voices. The most appropriate response by the nurse would be:

  1. “It is the voice of your conscience, which only you can control.”
  2. “No, I do not hear your voices, but I believe you can hear them”.
  3. “The voices are coming from within you and only you can hear them.”
  4. “Oh, the voices are a symptom of your illness; don’t pay any attention to them.”

The nurse is aware that the side effect of electroconvulsive therapy that a client may experience:

  1. Loss of appetite
  2. Postural hypotension
  3. Confusion for a time after treatment
  4. Complete loss of memory for a time

A dying male client gradually moves toward resolution of feelings regarding impending death. Basing care on the theory of Kubler-Ross, Nurse Trish plans to use nonverbal interventions when assessment reveals that the client is in the:

  1. Anger stage
  2. Denial stage
  3. Bargaining stage
  4. Acceptance stage

The outcome that is unrelated to a crisis state is:

  1. Learning more constructive coping skills
  2. Decompensation to a lower level of functioning.
  3. Adaptation and a return to a prior level of functioning.
  4. A higher level of anxiety continuing for more than 3 months.

Miranda a psychiatric client is to be discharged with orders for haloperidol (haldol) therapy. When developing a teaching plan for discharge, the nurse should include cautioning the client against:

  1. Driving at night
  2. Staying in the sun
  3. Ingesting wines and cheeses
  4. Taking medications containing aspirin

Jen a nursing student is anxious about the upcoming board examination but is able to study intently and does not become distracted by a roommate’s talking and loud music. The student’s ability to ignore distractions and to focus on studying demonstrates:

  1. Mild-level anxiety
  2. Panic-level anxiety
  3. Severe-level anxiety
  4. Moderate-level anxiety

When assessing a premorbid personality characteristic of a client with a major depression, it would be unusual for the nurse to find that this client demonstrated:

  1. Rigidity
  2. Stubbornness
  3. Diverse interest
  4. Over meticulousness

Nurse Krina recognizes that the suicidal risk for depressed client is greatest:

  1. As their depression begins to improve
  2. When their depression is most severe
  3. Before any type of treatment is started
  4. As they lose interest in the environment

Nurse Kate would expect that a client with vascular dementis would experience:

  1. Loss of remote memory related to anoxia
  2. Loss of abstract thinking related to emotional state
  3. Inability to concentrate related to decreased stimuli
  4. Disturbance in recalling recent events related to cerebral hypoxia.

Josefina is to be discharged on a regimen of lithium carbonate. In the teaching plan for discharge the nurse should include:

  1. Advising the client to watch the diet carefully
  2. Suggesting that the client take the pills with milk
  3. Reminding the client that a CBC must be done once a month.
  4. Encouraging the client to have blood levels checked as ordered.

The psychiatrist orders lithium carbonate 600 mg p.o t.i.d for a female client. Nurse Katrina would be aware that the teachings about the side effects of this drug were understood when the client state, “I will call my doctor immediately if I notice any:

  1. Sensitivity to bright light or sun
  2. Fine hand tremors or slurred speech
  3. Sexual dysfunction or breast enlargement
  4. Inability to urinate or difficulty when urinating

Nurse Mylene recognizes that the most important factor necessary for the establishment of trust in a critical care area is:

  1. Privacy
  2. Respect
  3. Empathy
  4. Presence

When establishing an initial nurse-client relationship, Nurse Hazel should explore with the client the:

  1. Client’s perception of the presenting problem.
  2. Occurrence of fantasies the client may experience.
  3. Details of any ritualistic acts carried out by the client
  4. Client’s feelings when external; controls are instituted.

Tranylcypromine sulfate (Parnate) is prescribed for a depressed client who has not responded to the tricyclic antidepressants. After teaching the client about the medication, Nurse Marian evaluates that learning has occurred when the client states, “I will avoid:

  1. Citrus fruit, tuna, and yellow vegetables.”
  2. Chocolate milk, aged cheese, and yogurt’”
  3. Green leafy vegetables, chicken, and milk.”
  4. Whole grains, red meats, and carbonated soda.”

Nurse John is a aware that most crisis situations should resolve in about:

  1. 1 to 2 weeks
  2. 4 to 6 weeks
  3. 4 to 6 months
  4. 6 to 12 months

Nurse Judy knows that statistics show that in adolescent suicide behavior:

  1. Females use more dramatic methods than males
  2. Males account for more attempts than do females
  3. Females talk more about suicide before attempting it
  4. Males are more likely to use lethal methods than are females

Dervid with paranoid schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be most appropriate?

  1. “Your behavior won’t be tolerated. Go to your room immediately.”
  2. “You’re just doing this to get back at me for making you come to therapy.”
  3. “Your cursing is interrupting the activity. Take time out in your room for 10 minutes.”
  4. “I’m disappointed in you. You can’t control yourself even for a few minutes.”

Nurse Maureen knows that the nonantipsychotic medication used to treat some clients with schizoaffective disorder is:

  1. phenelzine (Nardil)
  2. chlordiazepoxide (Librium)
  3. lithium carbonate (Lithane)
  4. imipramine (Tofranil)

Which information is most important for the nurse Trinity to include in a teaching plan for a male schizophrenic client taking clozapine (Clozaril)?

  1. Monthly blood tests will be necessary.
  2. Report a sore throat or fever to the physician immediately.
  3. Blood pressure must be monitored for hypertension.
  4. Stop the medication when symptoms subside.

Ricky with chronic schizophrenia takes neuroleptic medication is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. These findings suggest which life- threatening reaction:

  1. Tardive dyskinesia.
  2. Dystonia.
  3. Neuroleptic malignant syndrome.
  4. Akathisia.

Which nursing intervention would be most appropriate if a male client develop orthostatic hypotension while taking amitriptyline (Elavil)?

  1. Consulting with the physician about substituting a different type of antidepressant.
  2. Advising the client to sit up for 1 minute before getting out of bed.
  3. Instructing the client to double the dosage until the problem resolves.
  4. Informing the client that this adverse reaction should disappear within 1 week.

Mr. Cruz visits the physician’s office to seek treatment for depression, feelings of hopelessness, poor appetite, insomnia, fatigue, low self- esteem, poor concentration, and difficulty making decisions. The client states that these symptoms began at least 2 years ago. Based on this report, the nurse Tyfany suspects:

  1. Cyclothymic disorder.
  2. Atypical affective disorder.
  3. Major depression.
  4. Dysthymic disorder.

After taking an overdose of phenobarbital (Barbita), Mario is admitted to the emergency department. Dr. Trinidad prescribes activated charcoal (Charcocaps) to be administered by mouth immediately. Before administering the dose, the nurse verifies the dosage ordered. What is the usual minimum dose of activated charcoal?

  1. 5 g mixed in 250 ml of water
  2. 15 g mixed in 500 ml of water
  3. 30 g mixed in 250 ml of water
  4. 60 g mixed in 500 ml of water

What herbal medication for depression, widely used in Europe, is now being prescribed in the United States?

  1. Ginkgo biloba
  2. Echinacea
  3. St. John’s wort
  4. Ephedra

Cely with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication?

  1. Clcium
  2. Sodium
  3. Chloride
  4. Potassium

Nurse Josefina is caring for a client who has been diagnosed with delirium. Which statement about delirium is true?

  1. It’s characterized by an acute onset and lasts about 1 month.
  2. It’s characterized by a slowly evolving onset and lasts about 1 week.
  3. It’s characterized by a slowly evolving onset and lasts about 1 month.
  4. It’s characterized by an acute onset and lasts hours to a number of days.

Edward, a 66 year old client with slight memory impairment and poor concentration is diagnosed with primary degenerative dementia of the Alzheimer’s type. Early signs of this dementia include subtle personality changes and withdrawal from social interactions. To assess for progression to the middle stage of Alzheimer’s disease, the nurse should observe the client for:

  1. Occasional irritable outbursts.
  2. Impaired communication.
  3. Lack of spontaneity.
  4. Inability to perform self-care activities.

Isabel with a diagnosis of depression is started on imipramine (Tofranil), 75 mg by mouth at bedtime. The nurse should tell the client that:

  1. This medication may be habit forming and will be discontinued as soon as the client feels better.
  2. This medication has no serious adverse effects.
  3. The client should avoid eating such foods as aged cheeses, yogurt, and chicken livers while taking the medication.
  4. This medication may initially cause tiredness, which should become less bothersome over time.

Kathleen is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client’s physical health, the nurse should plan to:

  1. Severely restrict the client’s physical activities.
  2. Weigh the client daily, after the evening meal.
  3. Monitor vital signs, serum electrolyte levels, and acid-base balance.
  4. Instruct the client to keep an accurate record of food and fluid intake.

Celia with a history of polysubstance abuse is admitted to the facility. She complains of nausea and vomiting 24 hours after admission. The nurse assesses the client and notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through which of the following withdrawals?

  1. Alcohol withdrawal
  2. Cannibis withdrawal
  3. Cocaine withdrawal
  4. Opioid withdrawal

Mr. Garcia, an attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm’s employee assistance program. Nurse Beatriz knows that the client’s behavior most likely represents the use of which defense mechanism?

  1. Regression
  2. Projection
  3. Reaction-formation
  4. Intellectualization

Nurse Anne is caring for a client who has been treated long term with antipsychotic medication. During the assessment, Nurse Anne checks the client for tardive dyskinesia. If tardive dyskinesia is present, Nurse Anne would most likely observe:

  1. Abnormal movements and involuntary movements of the mouth, tongue, and face.
  2. Abnormal breathing through the nostrils accompanied by a “thrill.”
  3. Severe headache, flushing, tremors, and ataxia.
  4. Severe hypertension, migraine headache,

Dennis has a lithium level of 2.4 mEq/L. The nurse immediately would assess the client for which of the following signs or symptoms?

  1. Weakness
  2. Diarrhea
  3. Blurred vision
  4. Fecal incontinence

Nurse Jannah is monitoring a male client who has been placed inrestraints because of violent behavior. Nurse determines that it will be safe to remove the restraints when:

  1. The client verbalizes the reasons for the violent behavior.
  2. The client apologizes and tells the nurse that it will never happen again.
  3. No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints.
  4. The administered medication has taken effect.

Nurse Irish is aware that Ritalin is the drug of choice for a child with ADHD. The side effects of the following may be noted by the nurse:

  1. Increased attention span and concentration
  2. Increase in appetite
  3. Sleepiness and lethargy
  4. Bradycardia and diarrhea

Kitty, a 9 year old child has very limited vocabulary and interaction skills. She has an I.Q. of 45. She is diagnosed to have Mental retardation of this classification:

  1. Profound
  2. Mild
  3. Moderate
  4. Severe

The therapeutic approach in the care of Armand an autistic child include the following EXCEPT:

  1. Engage in diversionary activities when acting -out
  2. Provide an atmosphere of acceptance
  3. Provide safety measures
  4. Rearrange the environment to activate the child

Jeremy is brought to the emergency room by friends who state that he took something an hour ago. He is actively hallucinating, agitated, with irritated nasal septum.

  1. Heroin
  2. Cocaine
  3. LSD
  4. Marijuana

Nurse Pauline is aware that Dementia unlike delirium is characterized by:

  1. Slurred speech
  2. Insidious onset
  3. Clouding of consciousness
  4. Sensory perceptual change

A 35 year old female has intense fear of riding an elevator. She claims “ As if I will die inside.” The client is suffering from:

  1. Agoraphobia
  2. Social phobia
  3. Claustrophobia
  4. Xenophobia

Nurse Myrna develops a counter-transference reaction. This is evidenced by:

  1. Revealing personal information to the client
  2. Focusing on the feelings of the client.
  3. Confronting the client about discrepancies in verbal or non-verbal behavior
  4. The client feels angry towards the nurse who resembles his mother.

Tristan is on Lithium has suffered from diarrhea and vomiting. What should the nurse in-charge do first:

  1. Recognize this as a drug interaction
  2. Give the client Cogentin
  3. Reassure the client that these are common side effects of lithium therapy
  4. Hold the next dose and obtain an order for a stat serum lithium level

Nurse Sarah ensures a therapeutic environment for all the client. Which of the following best describes a therapeutic milieu?

  1. A therapy that rewards adaptive behavior
  2. A cognitive approach to change behavior
  3. A living, learning or working environment.
  4. A permissive and congenial environment

Anthony is very hostile toward one of the staff for no apparent reason. He is manifesting:

  1. Splitting
  2. Transference
  3. Countertransference
  4. Resistance

Marielle, 17 years old was sexually attacked while on her way home from school. She is brought to the hospital by her mother. Rape is an example of which type of crisis:

  1. Situational
  2. Adventitious
  3. Developmental
  4. Internal

Nurse Greta is aware that the following is classified as an Axis I disorder by the Diagnosis and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR) is:

  1. Obesity
  2. Borderline personality disorder
  3. Major depression
  4. Hypertension

Katrina, a newly admitted is extremely hostile toward a staff member she has just met, without apparent reason. According to Freudian theory, the nurse should suspect that the client is experiencing which of the following phenomena?

  1. Intellectualization
  2. Transference
  3. Triangulation
  4. Splitting

An 83year-old male client is in extended care facility is anxious most of the time and frequently complains of a number of vague symptoms that interfere with his ability to eat. These symptoms indicate which of the following disorders?

  1. Conversion disorder
  2. Hypochondriasis
  3. Severe anxiety
  4. Sublimation

Charina, a college student who frequently visited the health center during the past year with multiple vague complaints of GI symptoms before course examinations. Although physical causes have been eliminated, the student continues to express her belief that she has a serious illness. These symptoms are typically of which of the following disorders?

  1. Conversion disorder
  2. Depersonalization
  3. Hypochondriasis
  4. Somatization disorder

Nurse Daisy is aware that the following pharmacologic agents are sedative- hypnotic medication is used to induce sleep for a client experiencing a sleep disorder is:

  1. Triazolam (Halcion)
  2. Paroxetine (Paxil)
  3. Fluoxetine (Prozac)
  4. Risperidone (Risperdal)

Aldo, with a somatoform pain disorder may obtain secondary gain. Which of the following statement refers to a secondary gain?

  1. It brings some stability to the family
  2. It decreases the preoccupation with the physical illness
  3. It enables the client to avoid some unpleasant activity
  4. It promotes emotional support or attention for the client

Dervid is diagnosed with panic disorder with agoraphobia is talking with the nurse in-charge about the progress made in treatment. Which of the following statements indicates a positive client response?

  1. “I went to the mall with my friends last Saturday”
  2. “I’m hyperventilating only when I have a panic attack”
  3. “Today I decided that I can stop taking my medication”
  4. “Last night I decided to eat more than a bowl of cereal”

The effectiveness of monoamine oxidase (MAO) inhibitor drug therapy in a client with posttraumatic stress disorder can be demonstrated by which of the following client self –reports?

  1. “I’m sleeping better and don’t have nightmares”
  2. “I’m not losing my temper as much”
  3. “I’ve lost my craving for alcohol”
  4. I’ve lost my phobia for water”

Mark, with a diagnosis of generalized anxiety disorder wants to stop taking his lorazepam (Ativan). Which of the following important facts should nurse Betty discuss with the client about discontinuing the medication?

  1. Stopping the drug may cause depression
  2. Stopping the drug increases cognitive abilities
  3. Stopping the drug decreases sleeping difficulties
  4. Stopping the drug can cause withdrawal symptoms

Jennifer, an adolescent who is depressed and reported by his parents as having difficulty in school is brought to the community mental health center to be evaluated. Which of the following other health problems would the nurse suspect?

  1. Anxiety disorder
  2. Behavioral difficulties
  3. Cognitive impairment
  4. Labile moods

Ricardo, an outpatient in psychiatric facility is diagnosed with dysthymic disorder. Which of the following statement about dysthymic disorder is true?

  1. It involves a mood range from moderate depression to hypomania
  2. It involves a single manic depression
  3. It’s a form of depression that occurs in the fall and winter
  4. It’s a mood disorder similar to major depression but of mild to moderate severity

The nurse is aware that the following ways in vascular dementia different from Alzheimer’s disease is:

  1. Vascular dementia has more abrupt onset
  2. The duration of vascular dementia is usually brief
  3. Personality change is common in vascular dementia
  4. The inability to perform motor activities occurs in vascular dementia

Loretta, a newly admitted client was diagnosed with delirium and has history of hypertension and anxiety. She had been taking digoxin, furosemide (Lasix), and diazepam (Valium) for anxiety. This client’s impairment may be related to which of the following conditions?

  1. Infection
  2. Metabolic acidosis
  3. Drug intoxication
  4. Hepatic encephalopathy

Nurse Ron enters a client’s room, the client says, “They’re crawling on my sheets! Get them off my bed!” Which of the following assessment is the most accurate?

  1. The client is experiencing aphasia
  2. The client is experiencing dysarthria
  3. The client is experiencing a flight of ideas
  4. The client is experiencing visual hallucination

Which of the following descriptions of a client’s experience and behavior can be assessed as an illusion?

  1. The client tries to hit the nurse when vital signs must be taken
  2. The client says, “I keep hearing a voice telling me to run away”
  3. The client becomes anxious whenever the nurse leaves the bedside
  4. The client looks at the shadow on a wall and tells the nurse she sees frightening faces on the wall.

During conversation of Nurse John with a client, he observes that the client shift from one topic to the next on a regular basis. Which of the following terms describes this disorder?

  1. Flight of ideas
  2. Concrete thinking
  3. Ideas of reference
  4. Loose association

Francis tells the nurse that her coworkers are sabotaging the computer. When the nurse asks questions, the client becomes argumentative. This behavior shows personality traits associated with which of the following personality disorder?

  1. Antisocial
  2. Histrionic
  3. Paranoid
  4. Schizotypal

Which of the following interventions is important for a Cely experiencing with paranoid personality disorder taking olanzapine (Zyprexa)?

  1. Explain effects of serotonin syndrome
  2. Teach the client to watch for extrapyramidal adverse reaction
  3. Explain that the drug is less affective if the client smokes
  4. Discuss the need to report paradoxical effects such as euphoria

Nurse Alexandra notices other clients on the unit avoiding a client diagnosed with antisocial personality disorder. When discussing appropriate behavior in group therapy, which of the following comments is expected about this client by his peers?

  1. Lack of honesty
  2. Belief in superstition
  3. Show of temper tantrums
  4. Constant need for attention

Tommy, with dependent personality disorder is working to increase his self- esteem. Which of the following statements by the Tommy shows teaching was successful?

  1. “I’m not going to look just at the negative things about myself”
  2. “I’m most concerned about my level of competence and progress”
  3. “I’m not as envious of the things other people have as I used to be”
  4. “I find I can’t stop myself from taking over things other should be doing”

Norma, a 42-year-old client with a diagnosis of chronic undifferentiated schizophrenia lives in a rooming house that has a weekly nursing clinic. She scratches while she tells the nurse she feels creatures eating away at her skin. Which of the following interventions should be done first?

  1. Talk about his hallucinations and fears
  2. Refer him for anticholinergic adverse reactions
  3. Assess for possible physical problems such as rash
  4. Call his physician to get his medication increased to control his psychosis

Ivy, who is on the psychiatric unit is copying and imitating the movements of her primary nurse. During recovery, she says, “I thought the nurse was my mirror. I felt connected only when I saw my nurse.” This behavior is known by which of the following terms?

  1. Modeling
  2. Echopraxia
  3. Ego-syntonicity
  4. Ritualism

Jun approaches the nurse and tells that he hears a voice telling him that he’s evil and deserves to die. Which of the following terms describes the client’s perception?

  1. Delusion
  2. Disorganized speech
  3. Hallucination
  4. Idea of reference

Mike is admitted to a psychiatric unit with a diagnosis of undifferentiated schizophrenia. Which of the following defense mechanisms is probably used by mike?

  1. Projection
  2. Rationalization
  3. Regression
  4. Repression

Rocky has started taking haloperidol (Haldol). Which of the following instructions is most appropriate for Ricky before taking haloperidol?

  1. Should report feelings of restlessness or agitation at once
  2. Use a sunscreen outdoors on a year-round basis
  3. Be aware you’ll feel increased energy taking this drug
  4. This drug will indirectly control essential hypertension

A 17-year-old client has a record of being absent in the class without permission, and “borrowing” other people’s things without asking permission. The client denies stealing; rationalizing instead that as long as no one was using the items, there is no problem to use it by other people. It is important for the nurse to understand that psychodynamically, the behavior of the client may be largely attributed to a development defect related to the:

  1. Oedipal complex
  2. Superego
  3. Id
  4. Ego

A client tells the nurse, “Yesterday, I was planning to kill myself.” What is the best nursing response to this cient?

  1. “What are you going to do this time?”
  2. Say nothing. Wait for the client’s next comment
  3. “You seem upset. I am going to be here with you; perhaps you will want to talk about it”
  4. “Have you felt this way before?”

In crisis intervention therapy, which of the following principle that the nurse will use to plan her/his goals?

  1. Crises are related to deep, underlying problems
  2. Crises seldom occur in normal people’s lives
  3. Crises may go on indefnitely.
  4. Crises usually resolved in 4-6 weeks.

The nurse enters the room of the male client and found out that the client urinates on the foor. The client hides when the nurse is about to talk to him. Which of the following is the best nursing intervention?

  1. Place restriction on the client’s activities when his behavior occurs.
  2. Ask the client to clean the soiled foor.
  3. Take the client to the bathroom at regular intervals.
  4. Limit fuid intake.

A young lady with a diagnosis of schizophrenic reaction is admitted to the psychiatric unit. In the past two months, the client has poor appetite, experienced difculty in sleeping, was mute for long periods of time, just stayed in her room, grinning and pointing at things. What would be the initial nursing action on admitting the client to the unit?

  1. Assure the client that “ You will be well cared for.”
  2. Introduce the client to some of the other clients.
  3. Ask “Do you know where you are?”
  4. Take the client to the assigned room.

A 16-year-old girl was diagnosed with anorexia. What would be the first assessment of the nurse?

  1. What food she likes.
  2. Her desired weight.
  3. Her body image.
  4. What causes her behavior.

On an adolescent unit, a nurse caring to a client was informed that her client’s closest roommate dies at night. What would be the most appropriate nursing action?

  1. Do not bring it up unless the client asks.
  2. Tell the client that her roommate went home.
  3. Tell the client, if asked, “You should ask the doctor.”
  4. Tell the client that her closest roommate died.

A woman gave birth to an unhealthy infant, and with some body defects. The nurse should expect the woman’s initial reactions to include:

  1. Depression
  2. Withdrawal
  3. Apathy
  4. Anger

A client in the psychiatric unit is shouting out loud and tells the nurse, “Please, help me. They are coming to get me.” What would be the appropriate nursing response?

  1. “ I won’t let anyone get you.”
  2. “Who are they?”
  3. “I don’t see anyone coming.”
  4. “You look frightened.”

A client who is severely obese tells the nurse, “My therapist told me that I eat a lot because I didn’t get any attention and love from my mother. What does the therapist mean?” What is the best nursing response?

  1. “What do you think is the connection between your not getting enough love and overeating?”
  2. “Tell me what you think the therapist means.”
  3. “You need to ask your therapist.”
  4. “ We are here to deal with your diet, not with your psychological problems.”

After the discussion about the procedure the physician scheduled the client for mastectomy. The client tells the nurse, “If my breasts will be removed, I’m afraid my husband will not love me anymore and maybe he will never touch me.” What should the nurse’s response?

  1. “I doubt that he feels that way.”
  2. “What makes you feel that way?”
  3. “Have you discussed your feelings with your husband?”
  4. Ask the husband, in front of the wife, how he feels about this.

The child is brought to the hospital by the parents. During assessment of the nurse, what parental behavior toward a child should alert the nurse to suspect child abuse?

  1. Ignoring the child.
  2. Flat affect.
  3. Expressions of guilt.
  4. Acting overly solicitous toward the child

A nurse is caring to a client with manic disorder in the psychiatric ward. On the morning shift, the nurse is talking with the client who is now exhibiting a manic episode with fight of ideas. The nurse primarily needs to:

  1. Focus on the feelings conveyed rather than the thoughts expressed.
  2. Speak loudly and rapidly to keep the client’s attention, because the client is easily distracted.
  3. Allow the client to talk freely.
  4. Encourage the client to complete one thought at a time.

The nurse is caring to an autistic child. Which of the following play behavior would the nurse expect to see in a child?

  1. competitive play
  2. nonverbal play
  3. cooperative play
  4. solitary play

The client is telling the nurse in the psychiatric ward, “I hate them.” Which of the following is the most appropriate nursing response to the client?

  1. “Tell me about your hate.”
  2. “I will stay with you as long as you feel this way.”
  3. “For whom do you have these feelings?”
  4. “I understand how you can feel this way.”

The mother visits her son with major depression in the psychiatric unit. After the conversation of the client and the mother, the nurse asks the mother how it is talking to her son. The mother tells the nurse that it was a stressful time. During an interview with the client, the client says, “we had a marvelous visit.” Which of the following coping mechanism can be described to thestatement of the client?

  1. Identifcation.
  2. Rationalization.
  3. Denial.
  4. Compensation.

A male client is quiet when the physician told him that he has stage IV cancer and has 4 months to live. The nurse determines that this reaction may be an example of:

  1. Indifference
  2. Denial
  3. Resignation
  4. Anger

A nurse is caring to a female client with fve young children. The family member told the client that her ex-husband has died 2 days ago. The reaction of the client is stunned silence, followed by anger that the ex-husband left no insurance money for their young children. The nurse should understand that:

  1. The children and the injustice done to them by their father’s death are the woman’s main concern.
  2. To explain the woman’s reaction, the nurse needs more information about the relationship and breakup.
  3. The woman is not reacting normally to the news.
  4. The woman is experiencing a normal bereavement reaction.

A client who is manic comes to the outpatient department. The nurse is assigning an activity for the client. What activity is best for the nurse to encourage for a client in a manic phase?

  1. Solitary activity, such as walking with the nurse, to decrease stimulation.
  2. Competitive activity, such as bingo, to increase the client’s self-esteem.
  3. Group activity, such as basketball, to decrease isolation.
  4. Intellectual activity, such as scrabble, to increase concentration.

The nurse is about to administer Imipramine HCI (Tofranil) to the client, the client says, “Why should I take this?” The doctor started me on this 10days ago; it didn’t help me at all.” Which of the following is the best nursing response:

  1. “What were you expecting to happen?”
  2. “It usually takes 2-3 weeks to be effective.”
  3. “Do you want to refuse this medication? You have the right.”
  4. “That’s a long time wait when you feel so depressed.”

Which of the following drugs the nurse should choose to administer to a client to prevent pseudoparkinsonism?

  1. Isocarboxazid (Marplan)
  2. Chlorpromazine HCI (Thorazine)
  3. Trihexyphenidyl HCI (Artane)
  4. Trifuoperazine HCI (Stelazine)

The nurse is caring to an 80-year-old client with dementia? What is the most important psychosocial need for this client?

  1. Focus on the there-and-then rather the here-and-now.
  2. Limit in the number of visitors, to minimize confusion.
  3. Variety in their daily life, to decrease depression.
  4. A structured environment, to minimize regressive behaviors.

A client tells the nurse, “I don’t want to eat any meals offered in this hospital because the food is poisoned.” The nurse is aware that the client is expressing an example of:

  1. Delusion.
  2. Hallucination.
  3. Negativism.
  4. Illusion.

A client is admitted in the hospital. On assessment, the nurse found out that the client had several suicidal attempts. Which of the following is the most important nursing action?

  1. Ignore the client as long as he or she is talking about suicide, because suicide attempt is unlikely.
  2. Administer medication.
  3. Relax vigilance when the client seems to be recovering from depression.
  4. Maintain constant awareness of the client’s whereabouts.

The nurse suspects that the client is suffering from depression. During assessment, what are the most characteristic signs and symptoms of depression the nurse would note?

  1. Constipation, increased appetite.
  2. Anorexia, insomnia.
  3. Diarrhea, anger.
  4. Verbosity, increased social interaction.

The client in the psychiatric unit states that, “The goodas are coming! I must be ready.” In response to this neologism, the nurse’s initial response is to:

  1. Acknowledge that the word has some special meaning for the client.
  2. Try to interpret what the client means.
  3. Divert the client’s attention to an aspect of reality.
  4. State that what the client is saying has not been understood and then divert attention to something that is really bound.

A male client diagnosed with depression tells the nurse, “I don’t want to look weak and I don’t even cry because my wife and my kids can’t bear it.” The nurse understands that this is an example of:

  1. Repression.
  2. Suppression.
  3. Undoing.
  4. Rationalization.

A female client tells the nurse that she is afraid to go out from her room because she thinks that the other client might kill her. The nurse is aware that this behavior is related to:

  1. Hallucination.
  2. Ideas of reference.
  3. Delusion of persecution.
  4. Illusion.

A female client is taking Imipramine HCI (Tofranil) for almost 1 week and shows less awareness of the physical body. What problem would the nurse be most concerned?

  1. Nausea.
  2. Gait disturbances.
  3. Bowel movements.
  4. Voiding.

A 6-year-old client dies in the nursing unit. The parents want to see the child. What is the most appropriate nursing action?

  1. Give the parents time alone with the body.
  2. Ask the physician for permission.
  3. Complete the postmortem care and quietly accompany the family to the child’s room.
  4. Suggest the parents to wait until the funeral service to say “good-bye.”

A 20-year-old female client is diagnosed with anxiety disorder. The physician prescribed Flouxetine (Prozac). What is the most important side effects should a nurse be concerned?

  1. Tremor, drowsiness.
  2. Seizures, suicidal tendencies.
  3. Visual disturbance, headache.
  4. Excessive diaphoresis, diarrhea.

A nurse is assigned to activate a client who is withdrawn, hears voices and negativistic. What would be the best nursing approach?

  1. Mention that the “voices” would want the client to participate.
  2. Demand that the client must join a group activity.
  3. Give the client a long explanation of the benefts of activity.
  4. Tell the client that the nurse needs a partner for an activity.

A nurse is going to give a rectal suppository as a preoperative medication to a 4-year-old boy. The boy is very anxious and frightened. Which of the following statement by the nurse would be most appropriate to gain the child’s cooperation?

  1. “Be a big kid! Everyone’s waiting for you.”
  2. “Lie still now and I’ll let you have one of your presents before you even have your operation.”
  3. “Take a nice, big, deep breath and then let me hear you count to fve.”
  4. “You look so scared. Want to know a secret? This won’t hurt a bit!”

A depressed client is on an MAO inhibitor? What should the nurse watch out for?

  1. Hypertensive crisis.
  2. Diet restrictions.
  3. Taking medication with meals.
  4. Exposure to sunlight.

A 16-year-old girl is admitted for treatment of a fracture. The client shares to the nurse caring to her that her step-father has made sexual advances to her. She got the chance to tell it to her mother but refuses to believe. What is the most therapeutic action of the nurse would be:

  1. Tell the client to work it out with her father.
  2. Tell the client to discuss it with her mother.
  3. Ask the father about it.
  4. Ask the mother what she thinks.

A client with a diagnosis of paranoid disorder is admitted in the psychiatric hospital. The client tells the nurse, “the FBI is following me. These people are plotting against me.” With this statement the nurse will need to:

  1. Acknowledge that this is the client’s belief but not the nurse’s belief.
  2. Ask how that makes the client feel.
  3. Show the client that no one is behind.
  4. Use logic to help the client doubt this belief.

A nurse is completing the routine physical examination to a healthy 16-year-old male client. The client shares to the nurse that he feels like killing his girlfriend because he found out that her girlfriend had another boyfriend. He then laughs, and asks the nurse to keep this a secret just between the two of them. The nurse reviews his chart and notes that there is no previously history of violence or psychiatric illness. Which of the following would be the best action of the nurse to take at this time?

  1. Suggest the teen meet with a counselor to discuss his feelings about his girlfriend.
  2. Tell the teen that his feelings are normal, and recommend that he fnd another girlfriend to take his mind off the problem.
  3. Recall the teenage boys often say things they really do not mean and ignore the comment.
  4. Regard the comment seriously and notify the teen’s primary health care provider and parents

Which of the following person will be at highest risk for suicide?

  1. A student at exam time
  2. A married woman, age 40, with 6 children.
  3. A person who is an alcoholic.
  4. A person who made a previous suicide attempt.

A male client is repetitively doing the handwashing every time he touches things. It is important for a nurse to understand that the client’s behavior is probably an attempt to:

  1. Seek attention from the staff.
  2. Control unacceptable impulses or feelings.
  3. Do what the voices the patient hears tell him or her to do.
  4. Punish himself or herself for guilt feeling.

In a mental health settings, the basic goal of nursing is to:

  1. Advance the science of psychiatry by initiating research and gathering data for current statistics on emotional illness.
  2. Plan activity programs for clients.
  3. Understand various types of family therapy and psychological tests and how to interpret them.
  4. Maintain a therapeutic environment.

A 3-year-old boy is brought to the emergency department. After an hour, the boy dies of respiratory failure. The mother of the boy becomes upset, shouting and abusive, saying to the nurse, “If it had been your son, they would have done more to save it. “What should the nurse say or do?

  1. Touch her and tell her exactly what was done for her baby.
  2. Allow the mother to continue her present behavior while sitting quietly with her.
  3. “No, all clients are given the same good care.”
  4. “Yes, you’re probably right. Your son did not get better care.”

The nurse is interacting to a client with an antisocial personality disorder. What would be the most therapeutic approach of the nurse to an antisocial behavior?

  1. Gratify the client’s inner needs.
  2. Give the client opportunities to test reality.
  3. Provide external controls.
  4. Reinforce the client’s self-concept.

A 55-year-old male client tells the nurse that he needs his glasses and hearing aid with him in the recovery room after the surgery, or he will be upset for not granting his request. What is the appropriate nursing response?

  1. “Do you get upset and confused often?”
  2. “You won’t need your glasses or hearing aid. The nurses will take care of you.”
  3. “I understand. You will be able to cooperate best if you know what is going on, so I will fnd out how I can arrange to have your glasses and hearing aid available to you in the recovery room.”
  4. I understand you might be more cooperative if you have your aid and glasses, but that is just not possible. Rules, you know.”

The male client had fght with his roommates in the psychiatric unit. The client agitated client is placed in isolation for seclusion. The nurse knows it is essential that:

  1. A staff member has frequent contacts with the client.
  2. Restraints are applied.
  3. The client is allowed to come out after 4 hours.
  4. All the furniture is removed form the isolation room.

A medical representative comes to the hospital unit for the promotion of a new product. A female client, admitted for hysterical behavior, is found embracing him. What should the nurse say?

  1. “Have you considered birth control?”
  2. “This isn’t the purpose of either of you being here.”
  3. “I see you’ve made a new friend.”
  4. “Think about what you are doing.”

A client with dementia is for discharge. The nurse is providing a discharge instruction to the family member regarding safety measures at home. What suggestion can the nurse make to the family members?

  1. Avoid stairs without banisters.
  2. Use restraints while the client is in bed to keep him or her from wandering off during the night.
  3. Use restraints while the client is sitting in a chair to keep him or her from wandering off during the day.
  4. Provide a night-light and a big clock.

A 30-year-old married woman comes to the hospital for treatment of fractures. The woman tells the nurse that she was physically abused by her husband. The woman receives a call from her husband telling her to get home and things will be different. He felt sorry of what he did. What can the nurse advise her?

  1. “Do you think so?”
  2. “It’s not likely.”
  3. “What will be different?”
  4. “I hope so, for your sake.”

A female client was diagnosed with breast cancer. It is found to be stage IV, and a modifed mastectomy is performed. After the procedure, what behaviors could the nurse expects the client to display?

  1. Denial of the possibility of carcinoma.
  2. Signs of grief reaction.
  3. Relief that the operation is over.
  4. Signs of deep depression.

A client is withdrawn and does not want to interact to anybody even to the nurse. What is the best initial nursing approach to encourage communication with this client?

  1. Use simple questions that call for a response.
  2. Encourage discussion of feelings.
  3. Look through a photo album together.
  4. Bring up neutral topics.

Which of the following nursing approach is most important in a client with depression?

  1. Deemphasizing preoccupation with elimination, nourishment, and sleep.
  2. Protecting against harm to others.
  3. Providing motor outlets for aggressive, hostile feelings.
  4. Reducing interpersonal contacts.

Marco approached Nurse Trish asking for advice on how to deal with his alcohol addiction. Nurse Trish should tell the client that the only effective treatment for alcoholism is:

  1. Psychotherapy
  2. Alcoholics anonymous (A.A.)
  3. Total abstinence
  4. Aversion Therapy

Nurse Hazel is caring for a male client who experience false sensory perceptions with no basis in reality. This perception is known as:

  1. Hallucinations
  2. Delusions
  3. Loose associations
  4. Neologisms

Nurse Monet is caring for a female client who has suicidal tendency. When accompanying the client to the restroom, Nurse Monet should…

  1. Give her privacy
  2. Allow her to urinate
  3. Open the window and allow her to get some fresh air
  4. Observe her

Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. Which action should the nurse include in the plan?

  1. Provide privacy during meals
  2. Set-up a strict eating plan for the client
  3. Encourage client to exercise to reduce anxiety
  4. Restrict visits with the family

A client is experiencing anxiety attack. The most appropriate nursing intervention should include?

  1. Turning on the television
  2. Leaving the client alone
  3. Staying with the client and speaking in short sentences
  4. Ask the client to play with other clients

A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects a belief that one is:

  1. Being Killed
  2. Highly famous and important
  3. Responsible for evil world
  4. Connected to client unrelated to oneself

A 20 year old client was diagnosed with dependent personality disorder. Which behavior is not most likely to be evidence of ineffective individual coping?

  1. Recurrent self-destructive behavior
  2. Avoiding relationship
  3. Showing interest in solitary activities
  4. Inability to make choices and decision without advise

A male client is diagnosed with schizotypal personality disorder. Which signs would this client exhibit during social situation?

  1. Paranoid thoughts
  2. Emotional affect
  3. Independence need
  4. Aggressive behavior

Nurse Claire is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is?

  1. Encourage to avoid foods
  2. Identify anxiety causing situations
  3. Eat only three meals a day
  4. Avoid shopping plenty of groceries

Nurse Tony was caring for a 41 year old female client. Which behavior by the client indicates adult cognitive development?

  1. Generates new levels of awareness
  2. Assumes responsibility for her actions
  3. Has maximum ability to solve problems and learn new skills
  4. Her perception are based on reality

A neuromuscular blocking agent is administered to a client before ECT therapy. The Nurse should carefully observe the client for?

  1. Respiratory difficulties
  2. Nausea and vomiting
  3. Dizziness
  4. Seizures

A 75 year old client is admitted to the hospital with the diagnosis of dementia of the Alzheimer’s type and depression. The symptom that is unrelated to depression would be?

  1. Apathetic response to the environment
  2. “I don’t know” answer to questions
  3. Shallow of labile effect
  4. Neglect of personal hygiene

Nurse Trish is working in a mental health facility; the nurse priority nursing intervention for a newly admitted client with bulimia nervosa would be to?

  1. Teach client to measure I & O
  2. Involve client in planning daily meal
  3. Observe client during meals
  4. Monitor client continuously

Nurse Patricia is aware that the major health complication associated with intractable anorexia nervosa would be?

  1. Cardiac dysrhythmias resulting to cardiac arrest
  2. Glucose intolerance resulting in protracted hypoglycemia
  3. Endocrine imbalance causing cold amenorrhea
  4. Decreased metabolism causing cold intolerance

Nurse Anna can minimize agitation in a disturbed client by?

  1. Increasing stimulation
  2. Limiting unnecessary interaction
  3. Increasing appropriate sensory perception
  4. Ensuring constant client and staff contact

A 39 year old mother with obsessive-compulsive disorder has become immobilized by her elaborate hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C. disorder is often:

  1. Problems with being too conscientious
  2. Problems with anger and remorse
  3. Feelings of guilt and inadequacy
  4. Feeling of unworthiness and hopelessness

Mario is complaining to other clients about not being allowed by staff to keep food in his room. Which of the following interventions would be most appropriate?

  1. Allowing a snack to be kept in his room
  2. Reprimanding the client
  3. Ignoring the clients behavior
  4. Setting limits on the behavior

Conney with borderline personality disorder who is to be discharge soon threatens to “do something” to herself if discharged. Which of the following actions by the nurse would be most important?

  1. Ask a family member to stay with the client at home temporarily
  2. Discuss the meaning of the client’s statement with her
  3. Request an immediate extension for the client
  4. Ignore the clients statement because it’s a sign of manipulation

Joey a client with antisocial personality disorder belches loudly. A staff member asks Joey, “Do you know why people find you repulsive?” this statement most likely would elicit which of the following client reaction?

  1. Depensiveness
  2. Embarrassment
  3. Shame
  4. Remorsefulness

Which of the following approaches would be most appropriate to use with a client suffering from narcissistic personality disorder when discrepancies exist between what the client states and what actually exist?

  1. Rationalization
  2. Supportive confrontation
  3. Limit setting
  4. Consistency

Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis and hyperactivity. Blood pressure is 190/87 mmhg and pulse is 92 bpm. Which of the medications would the nurse expect to administer?

  1. Naloxone (Narcan)
  2. Benzlropine (Cogentin)
  3. Lorazepam (Ativan)
  4. Haloperidol (Haldol)

Which of the following foods would the nurse Trish eliminate from the diet of a client in alcohol withdrawal?

  1. Milk
  2. Orange Juice
  3. Soda
  4. Regular Coffee

Which of the following would Nurse Hazel expect to assess for a client who is exhibiting late signs of heroin withdrawal?

  1. Yawning & diaphoresis
  2. Restlessness & Irritability
  3. Constipation & steatorrhea
  4. Vomiting and Diarrhea

To establish open and trusting relationship with a female client who has been hospitalized with severe anxiety, the nurse in charge should?

  1. Encourage the staff to have frequent interaction with the client
  2. Share an activity with the client
  3. Give client feedback about behavior
  4. Respect client’s need for personal space

Nurse Monette recognizes that the focus of environmental (MILIEU) therapy is to:

  1. Manipulate the environment to bring about positive changes in behavior
  2. Allow the client’s freedom to determine whether or not they will be involved in activities
  3. Role play life events to meet individual needs
  4. Use natural remedies rather than drugs to control behavior

Nurse Trish would expect a child with a diagnosis of reactive attachment disorder to:

  1. Have more positive relation with the father than the mother
  2. Cling to mother & cry on separation
  3. Be able to develop only superficial relation with the others
  4. Have been physically abuse

When teaching parents about childhood depression Nurse Trina should say?

  1. It may appear acting out behavior
  2. Does not respond to conventional treatment
  3. Is short in duration & resolves easily
  4. Looks almost identical to adult depression

Nurse Perry is aware that language development in autistic child resembles:

  1. Scanning speech
  2. Speech lag
  3. Shuttering
  4. Echolalia

A 60 year old female client who lives alone tells the nurse at the community health center “I really don’t need anyone to talk to”. The TV is my best friend. The nurse recognizes that the client is using the defense mechanism known as?

  1. Displacement
  2. Projection
  3. Sublimation
  4. Denial

When working with a male client suffering phobia about black cats, Nurse Trish should anticipate that a problem for this client would be?

  1. Anxiety when discussing phobia
  2. Anger toward the feared object
  3. Denying that the phobia exist
  4. Distortion of reality when completing daily routines

Linda is pacing the floor and appears extremely anxious. The duty nurse approaches in an attempt to alleviate Linda’s anxiety. The most therapeutic question by the nurse would be?

  1. Would you like to watch TV?
  2. Would you like me to talk with you?
  3. Are you feeling upset now?
  4. Ignore the client

Nurse Penny is aware that the symptoms that distinguish post traumatic stress disorder from other anxiety disorder would be:

  1. Avoidance of situation & certain activities that resemble the stress
  2. Depression and a blunted affect when discussing the traumatic situation
  3. Lack of interest in family & others
  4. Re-experiencing the trauma in dreams or flashback

Nurse Benjie is communicating with a male client with substance-induced persisting dementia; the client cannot remember facts and fills in the gaps with imaginary information. Nurse Benjie is aware that this is typical of?

  1. Flight of ideas
  2. Associative looseness
  3. Confabulation
  4. Concretism

Nurse Joey is aware that the signs & symptoms that would be most specific for diagnosis anorexia are?

  1. Excessive weight loss, amenorrhea & abdominal distension
  2. Slow pulse, 10% weight loss & alopecia
  3. Compulsive behavior, excessive fears & nausea
  4. Excessive activity, memory lapses & an increased pulse

A characteristic that would suggest to Nurse Anne that an adolescent may have bulimia would be:

  1. Frequent regurgitation & re-swallowing of food
  2. Previous history of gastritis
  3. Badly stained teeth
  4. Positive body image

Nurse Monette is aware that extremely depressed clients seem to do best in settings where they have:

  1. Multiple stimuli
  2. Routine Activities
  3. Minimal decision making
  4. Varied Activities

To further assess a client’s suicidal potential, Nurse Katrina should be especially alert to the client expression of:

  1. Frustration & fear of death
  2. Anger & resentment
  3. Anxiety & loneliness
  4. Helplessness & hopelessness

A nursing care plan for a male client with bipolar I disorder should include:

  1. Providing a structured environment
  2. Designing activities that will require the client to maintain contact with reality
  3. Engaging the client in conversing about current affairs
  4. Touching the client provide assurance

When planning care for a female client using ritualistic behavior, Nurse Gina must recognize that the ritual:

  1. Helps the client focus on the inability to deal with reality
  2. Helps the client control the anxiety
  3. Is under the client’s conscious control
  4. Is used by the client primarily for secondary gains

A 32 year old male graduate student, who has become increasingly withdrawn and neglectful of his work and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed assessment, a diagnosis of schizophrenia is made. It is unlikely that the client will demonstrate:

  1. Low self esteem
  2. Concrete thinking
  3. Effective self boundaries
  4. Weak ego

A 23 year old client has been admitted with a diagnosis of schizophrenia says to the nurse “Yes, its march, March is little woman”. That’s literal you know”. These statement illustrate:

  1. Neologisms
  2. Echolalia
  3. Flight of ideas
  4. Loosening of association

A long term goal for a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs would be to help the client develop:

  1. Insight into his behavior
  2. Better self control
  3. Feeling of self worth
  4. Faith in his wife

A male client who is experiencing disordered thinking about food being poisoned is admitted to the mental health unit. The nurse uses which communication technique to encourage the client to eat dinner?

  1. Focusing on self-disclosure of own food preference
  2. Using open ended question and silence
  3. Offering opinion about the need to eat
  4. Verbalizing reasons that the client may not choose to eat

Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina enters the client’s room, the client is found lying on the bed with a body pulled into a fetal position. Nurse Nina should?

  1. Ask the client direct questions to encourage talking
  2. Rake the client into the dayroom to be with other clients
  3. Sit beside the client in silence and occasionally ask open-ended question
  4. Leave the client alone and continue with providing care to the other clients

Nurse Tina is caring for a client with delirium and states that “look at the spiders on the wall”. What should the nurse respond to the client?

  1. “You’re having hallucination, there are no spiders in this room at all”
  2. “I can see the spiders on the wall, but they are not going to hurt you”
  3. “Would you like me to kill the spiders”
  4. “I know you are frightened, but I do not see spiders on the wall”

Nurse Jonel is providing information to a community group about violence in the family. Which statement by a group member would indicate a need to provide additional information?

  1. “Abuse occurs more in low-income families”
  2. “Abuser Are often jealous or self-centered”
  3. “Abuser use fear and intimidation”
  4. “Abuser usually have poor self-esteem”

During electroconvulsive therapy (ECT) the client receives oxygen by mask via positive pressure ventilation. The nurse assisting with this procedure knows that positive pressure ventilation is necessary because?

  1. Anesthesia is administered during the procedure
  2. Decrease oxygen to the brain increases confusion and disorientation
  3. Grand mal seizure activity depresses respirations
  4. Muscle relaxations given to prevent injury during seizure activity depress respirations.

When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of the discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care requiring evaluation? 1.The client eliminates all anxiety from daily situations

  1. The client ignores feelings of anxiety
  2. The client identifies anxiety producing situations
  3. The client maintains contact with a crisis counselor

Nurse Tina is caring for a client with depression who has not responded to antidepressant medication. The nurse anticipates that what treatment procedure may be prescribed?

  1. Neuroleptic medication
  2. Short term seclusion
  3. Psychosurgery
  4. Electroconvulsive therapy

Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of prescribed antipsychotic medication. The most important piece of information the nurse in charge should obtain initially is the:

  1. Length of time on the med.
  2. Name of the ingested medication & the amount ingested
  3. Reason for the suicide attempt
  4. Name of the nearest relative & their phone number

Comprehensive

ParameterMetadata
DomainMixed
Topics
Items250 multiple-choice questions
Answer StatusAnswer Key, Rationalized

A 10-year-old who has sustained a head injury is brought to the emergency department by his mother. A diagnosis of a mild concussion is made. At the time of discharge, nurse Ron should instruct the mother to:

  1. Withhold food and fluids for 24 hours.
  2. Allow him to play outdoors with his friends.
  3. Arrange for a follow up visit with the child’s primary care provider in one week.
  4. Check for any change in responsiveness every two hours until the follow-up visit.

A male client has suffered a motor accident and is now suffering from hypovolemic shock. Nurse Helen should frequency assess the client’s vital signs during the compensatory stage of shock, because:

  1. Arteriolar constriction occurs
  2. The cardiac workload decreases
  3. Decreased contractility of the heart occurs
  4. The parasympathetic nervous system is triggered

A paranoid male client with schizophrenia is losing weight, reluctant to eat, and voicing concerns about being poisoned. The best intervention by nurse Dina would be to:

  1. Allow the client to open canned or pre-packaged food
  2. Restrict the client to his room until 2 lbs are gained
  3. Have a staff member personally taste all of the client’s food
  4. Tell the client the food has been x-rayed by the staff and is safe

One day the mother of a young adult confides to nurse Frida that she is very troubled by he child’s emotional illness. The nurse’s most therapeutic initial response would be:

  1. “You may be able to lessen your feelings of guilt by seeking counseling”
  2. “It would be helpful if you become involved in volunteer work at this time”
  3. “I recognize it’s hard to deal with this, but try to remember that this too shall pass”
  4. “Joining a support group of parents who are coping with this problem can be quite helpful.

To check for wound hemorrhage after a client has had a surgery for the removal of a tumor in the neck, nurse grace should:

  1. Loosen an edge of the dressing and lift it to see the wound
  2. Observe the dressing at the back of the neck for the presence of blood
  3. Outline the blood as it appears on the dressing to observe any progression
  4. Press gently around the incision to express accumulated blood from the wound

A 16-year-old primigravida arrives at the labor and birthing unit in her 38th week of gestation and states that she is labor. To verify that the client is in true labor nurse Trina should:

  1. Obtain sides for a fern test
  2. Time any uterine contractions
  3. Prepare her for a pelvic examination
  4. Apply nitrazine paper to moist vaginal tissue

As part of the diagnostic workup for pulmonic stenosis, a child has cardiac catheterization. Nurse Julius is aware that children with pulmonic stenosis have increased pressure:

  1. In the pulmonary vein
  2. In the pulmonary artery
  3. On the left side of the heart
  4. On the right side of the heart

An obese client asks nurse Julius how to lose weight. Before answering, the nurse should remember that long-term weight loss occurs best when:

  1. Eating patterns are altered
  2. Fats are limited in the diet
  3. Carbohydrates are regulated
  4. Exercise is a major component

As a very anxious female client is talking to the nurse May, she starts crying. She appears to be upset that she cannot control her crying. The most appropriate response by the nurse would be:

  1. “Is talking about your problem upsetting you?”
  2. “It is Ok to cry; I’ll just stay with you for now”
  3. “You look upset; lets talk about why you are crying.”
  4. “Sometimes it helps to get it out of your system.”

A patient has partial-thickness burns to both legs and portions of his trunk. Which of the following I.V. fluids is given first?

  1. Albumin
  2. D5W
  3. Lactated Ringer’s solution
  4. 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml

During the first 48 hours after a severe burn of 40% of the clients body surface, the nurse’s assessment should include observations for water intoxication. Associated adaptations include:

  1. Sooty-colored sputum
  2. Frothy pink-tinged sputum
  3. Twitching and disorientation
  4. Urine output below 30ml per hour

After a muscle biopsy, nurse Willy should teach the client to:

  1. Change the dressing as needed
  2. Resume the usual diet as soon as desired
  3. Bathe or shower according to preference
  4. Expect a rise in body temperature for 48 hours

Before a client whose left hand has been amputated can be fitted for a prosthesis, nurse Joy is aware that:

  1. Arm and shoulder muscles must be developed
  2. Shrinkage of the residual limb must be completed
  3. Dexterity in the other extremity must be achieved
  4. Full adjustment to the altered body image must have occurred

Nurse Cathy applies a fetal monitor to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beat per minute deceleration of the fetal heart rate below the baseline lasting 15 seconds. Nurse Cathy should:

  1. Change the maternal position
  2. Prepare for an immediate birth
  3. Call the physician immediately
  4. Obtain the client’s blood pressure

A male client receiving prolonged steroid therapy complains of always being thirsty and urinating frequently. The best initial action by the nurse would be to:

  1. Perform a finger stick to test the client’s blood glucose level
  2. Have the physician assess the client for an enlarged prostate
  3. Obtain a urine specimen from the client for screening purposes
  4. Assess the client’s lower extremities for the presence of pitting edema

Nurse Bea recognizes that a pacemaker is indicated when a client is experiencing:

  1. Angina
  2. Chest pain
  3. Heart block
  4. Tachycardia

When administering pancrelipase (Pancreases capsules) to child with cystic fibrosis, nurse Faith knows they should be given:

  1. With meals and snacks
  2. Every three hours while awake
  3. On awakening, following meals, and at bedtime
  4. After each bowel movement and after postural draianage

A preterm neonate is receiving oxygen by an overhead hood. During the time the infant is under the hood, it would be appropriate for nurse Gian to:

  1. Hydrate the infant q15 min
  2. Put a hat on the infant’s head
  3. Keep the oxygen concentration consistent
  4. Remove the infant q15 min for stimulation

A client’s sputum smears for acid fast bacilli (AFB) are positive, and transmission-based airborne precautions are ordered. Nurse Kyle should instruct visitors to:

  1. Limit contact with non-exposed family members
  2. Avoid contact with any objects present in the client’s room
  3. Wear an Ultra-Filter mask when they are in the client’s room
  4. Put on a gown and gloves before going into the client’s room

A client with a head injury has a fixed, dilated right pupil; responds only to painful stimuli; and exhibits decorticate posturing. Nurse Kate should recognize that these are signs of:

  1. Meningeal irritation
  2. Subdural hemorrhage
  3. Medullary compression
  4. Cerebral cortex compression

After a lateral crushing chest injury, obvious right-sided paradoxic motion of the client’s chest demonstrates multiple rib fraactures, resulting in a flail chest. The complication the nurse should carefully observe for would be:

  1. Mediastinal shift
  2. Tracheal laceration
  3. Open pneumothorax
  4. Pericardial tamponade

When planning care for a client at 30-weeks gestation, admitted to the hospital after vaginal bleeding secondary to placenta previa, the nurse’s primary objective would be:

  1. Provide a calm, quiet environment
  2. Prepare the client for an immediate cesarean birth
  3. Prevent situations that may stimulate the cervix or uterus
  4. Ensure that the client has regular cervical examinations assess for labor

When planning discharge teaching for a young female client who has had a pneumothorax, it is important that the nurse include the signs and symptoms of a pneumothorax and teach the client to seek medical assistance if she experiences:

  1. Substernal chest pain
  2. Episodes of palpitation
  3. Severe shortness of breath
  4. Dizziness when standing up

After a laryngectomy, the most important equipment to place at the client’s bedside would be:

  1. Suction equipment
  2. Humidified oxygen
  3. A nonelectric call bell
  4. A cold-stream vaporizer

Nurse Oliver interviews a young female client with anorexia nervosa to obtain information for the nursing history. The client’s history is likely to reveal a:

  1. Strong desire to improve her body image
  2. Close, supportive mother-daughter relationship
  3. Satisfaction with and desire to maintain her present weight
  4. Low level of achievement in school, with little concerns for grades

Nurse Bea should plan to assist a client with an obsessive-compulsive disorder to control the use of ritualistic behavior by:

  1. Providing repetitive activities that require little thought
  2. Attempting to reduce or limit situations that increase anxiety
  3. Getting the client involved with activities that will provide distraction
  4. Suggesting that the client perform menial tasks to expiate feelings of guilt

A 2 ½ year old child undergoes a ventriculoperitoneal shunt revision. Before discharge, nurse John, knowing the expected developmental behaviors for this age group, should tell the parents to call the physician if the child:

  1. Tries to copy all the father’s mannerisms
  2. Talks incessantly regardless of the presence of others
  3. Becomes fussy when frustrated and displays a shortened attention span
  4. Frequently starts arguments with playmates by claiming all toys are “mine”

A urinary tract infection is a potential danger with an indwelling catheter. Nurse Gina can best plan to avoid this complication by:

  1. Assessing urine specific gravity
  2. Maintaining the ordered hydration
  3. Collecting a weekly urine specimen
  4. Emptying the drainage bag frequently

A client has sustained a fractured right femur in a fall on stairs. Nurse Troy with the emergency response team assess for signs of circulatory impairment by:

  1. Turning the client to side lying position
  2. Asking the client to cough and deep breathe
  3. Taking the client’s pedal pulse in the affected limb
  4. Instructing the client to wiggle the toes of the right foot

To assess orientation to place in a client suspected of having dementia of the alzheimers type, nurse Chris should ask:

  1. “Where are you?”
  2. “Who brought you here?”
  3. “Do you know where you are?”
  4. “How long have you been there?”

Nurse Mary assesses a postpartum client who had an abruption placentae and suspects that disseminated intravascular coagulation (DIC) is occurring when assessments demonstrate:

  1. A boggy uterus
  2. Multiple vaginal clots
  3. Hypotension and tachycardia
  4. Bleeding from the venipuncture site

When a client on labor experiences the urge to push a 9cm dilation, the breathing pattern that nurse Rhea should instruct the client to use is the:

  1. Expulsion pattern
  2. Slow paced pattern
  3. Shallow chest pattern
  4. blowing pattern

Nurse Ronald should explain that the most beneficial between-meal snack for a client who is recovering from the full-thickness burns would be a:

  1. Cheeseburger and a malted
  2. Piece of blueberry pie and milk
  3. Bacon and tomato sandwich and tea
  4. Chicken salad sandwich and soft drink

Nurse Wilma recognizes that failure of a newborn to make the appropriate adaptation to extrauterine life would be indicated by:

  1. flexed extremities
  2. Cyanotic lips and face
  3. A heart rate of 130 beats per minute
  4. A respiratory rate of 40 breath per minute

The laboratory calls to state that a client’s lithium level is 1.9 mEq/L after 10 days of lithium therapy. Nurse Reese should:

  1. Notify the physician of the findings because the level is dangerously high
  2. Monitor the client closely because the level of lithium in the blood is slightly elevated
  3. Continue to administer the medication as ordered because the level is within the therapeutic range
  4. Report the findings to the physician so the dosage can be increased because the level is below therapeutic range

A client has a regular 30-day menstrual cycles. When teaching about the rhythm method, Which the client and her husband have chosen to use for family planning, nurse Dianne should emphasize that the client’s most fertile days are:

  1. Days 9 to 11
  2. Days 12 to 14
  3. Days 15 to 17
  4. Days 18 to 20

Before an amniocentesis, nurse Alexandra should:

  1. Initiate the intravenous therapy as ordered by the physiscian
  2. Inform the client that the procedure could precipitate an infection
  3. Assure that informed consent has been obtained from the client
  4. Perform a vaginal examination on the client to assess cervical dilation

While a client is on intravenous magnesium sulfate therapy for preeclampsia, it is essential for nurse Amy to monitor the client’s deep tendon reflexes to:

  1. Determine her level of consciousness
  2. Evaluate the mobility of the extremities
  3. Determine her response to painful stimuli
  4. Prevent development of respiratory distress

A preschooler is admitted to the hospital with a diagnosis of acute glomerulonephritis. The child’s history reveals a 5-pound weight gain in one week and peritoneal edema. For the most accurate information on the status of the child’s edema, nursing intervention should include:

  1. Obtaining the child’s daily weight
  2. Doing a visual inspection of the child
  3. Measuring the child’s intake and output
  4. Monitoring the child’s electrolyte values

Nurse Mickey is administering dexamethasome (Decadron) for the early management of a client’s cerebral edema. This treatment is effective because:

  1. Acts as hyperosmotic diuretic
  2. Increases tissue resistance to infection
  3. Reduces the inflammatory response of tissues
  4. Decreases the information of cerebrospinal fluid

During newborn nursing assessment, a positive Ortolani’s sign would be indicated by:

  1. A unilateral droop of hip
  2. A broadening of the perineum
  3. An apparent shortening of one leg
  4. An audible click on hip manipulation

When caring for a dying client who is in the denial stage of grief, the best nursing approach would be to:

  1. Agree and encourage the client’s denial
  2. Allow the denial but be available to discuss death
  3. Reassure the client that everything will be OK
  4. Leave the client alone to confront the feelings of impending loss

To decrease the symptoms of gastroesophageal reflux disease (GERD), the physician orders dietary and medication management. Nurse Helen should teach the client that the meal alteration that would be most appropriate would be:

  1. Ingest foods while they are hot
  2. Divide food into four to six meals a day
  3. Eat the last of three meals daily by 8pm
  4. Suck a peppermint candy after each meal

After a mastectomy or hysterectomy, clients may feel incomplete as women. The statement that should alert nurse Gina to this feeling would be:

  1. “I can’t wait to see all my friends again”
  2. “I feel washed out; there isn’t much left”
  3. “I can’t wait to get home to see my grandchild”
  4. “My husband plans for me to recuperate at our daughter’s home”

A client with obstruction of the common bile duct may show a prolonged bleeding and clotting time because:

  1. Vitamin K is not absorbed
  2. The ionized calcium levels falls
  3. The extrinsic factor is not absorbed
  4. Bilirubin accumulates in the plasma

Realizing that the hypokalemia is a side effect of steroid therapy, nurse Monette should monitor a client taking steroid medication for:

  1. Hyperactive reflexes
  2. An increased pulse rate
  3. Nausea, vomiting, and diarrhea
  4. Leg weakness with muscle cramps

When assessing a newborn suspected of having Down syndrome, nurse Rey would expect to observe:

  1. long thin fingers
  2. Large, protruding ears
  3. Hypertonic neck muscles
  4. Simian lines on the hands

A 10 year old girl is admitted to the pediatric unit for recurrent pain and swelling of her joints, particularly her knees and ankles. Her diagnosis is juvenile rheumatoid arthritis. Nurse Janah recognizes that besides joint inflammation, a unique manifestation of the rheumatoid process involves the:

  1. Ears
  2. Eyes
  3. Liver
  4. Brain

A disturbed client is scheduled to begin group therapy. The client refuses to attend. Nurse Lolit should:

  1. Accept the client’s decision without discussion
  2. Have another client to ask the client to consider
  3. Tell the client that attendance at the meeting is required
  4. Insist that the client join the group to help the socialization process

Because a severely depressed client has not responded to any of the antidepressant medications, the psychiatrist decides to try electroconvulsive therapy (ECT). Before the treatment the nurse should:

  1. Have the client speak with other clients receiving ECT
  2. Give the client a detailed explanation of the entire procedure
  3. Limit the client’s intake to a light breakfast on the days of the treatment
  4. Provide a simple explanation of the procedure and continue to reassure the client

Nurse Vicky is aware that teaching about colostomy care is understood when the client states, “I will contact my physician and report ____”:

  1. If I notice a loss of sensation to touch in the stoma tissue”
  2. When mucus is passed from the stoma between irrigations”
  3. The expulsion of flatus while the irrigating fluid is running out”
  4. If I have difficulty in inserting the irrigating tube into the stoma”

The client’s history that alerts nurse Henry to assess closely for signs of postpartum infection would be:

  1. Three spontaneous abortions
  2. negative maternal blood type
  3. Blood loss of 850 ml after a vaginal birth
  4. Maternal temperature of 99.9° F 12 hours after delivery

A client is experiencing stomatitis as a result of chemotherapy. An appropriate nursing intervention related to this condition would be to:

  1. Provide frequent saline mouthwashes
  2. Use karaya powder to decrease irritation
  3. Increase fluid intake to compensate for the diarrhea
  4. Provide meticulous skin care of the abdomen with Betadine

During a group therapy session, one of the clients ask a male client with the diagnosis of antisocial personality disorder why he is in the hospital. Considering this client’s type of personality disorder, the nurse might expect him to respond:

  1. “I need a lot of help with my troubles”
  2. “Society makes people react in old ways”
  3. “I decided that it’s time I own up to my problems”
  4. “My life needs straightening out and this might help”

A child visits the clinic for a 6-week checkup after a tonsillectomy and adenoidectomy. In addition to assessing hearing, the nurse should include an assessment of the child’s:

  1. Taste and smell
  2. Taste and speech
  3. Swallowing and smell
  4. Swallowing and speech

A client is diagnosed with cancer of the jaw. A course of radiation therapy is to be followed by surgery. The client is concerned about the side effects related to the radiation treaments. Nurse Ria should explain that the major side effects that will experienced is:

  1. Fatigue
  2. Alopecia
  3. Vomiting
  4. Leucopenia

Nurse Katrina prepares an older-adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. Targeting the most frequent cause of falls, the nurse should:

  1. Offer the client assistance to the bathroom
  2. Move the bedside table closer to the client’s bed
  3. Encourage the client to take an available sedative
  4. Assist the client to telephone the spouse to say “goodnight”

When evaluating a growth and development of a 6 month old infant, nurse Patty would expect the infant to be able to:

  1. Sit alone, display pincer grasp, wave bye bye
  2. Pull self to a standing position, release a toy by choice, play peek-a-boo
  3. Crawl, transfer toy from one hand to the other, display of fear of strangers
  4. Turn completely over, sit momentarily without support, reach to be picked up

A breastfeeding mother asks the nurse what she can do to ease the discomfort caused by a cracked nipple. Nurse Tina should instruct the client to:

  1. Manually express milk and feed it to the baby in a bottle
  2. Stop breastfeeding for two days to allow the nipple to heal
  3. Use a breast shield to keep the baby from direct contact with the nipple
  4. Feed the baby on the unaffected breast first until the affected breast heals

Nurse Sandy observes that there is blood coming from the client’s ear after head injury. Nurse Sandy should:

  1. Turn the client to the unaffected side
  2. Cleanse the client’s ear with sterile gauze
  3. Test the drainage from the client’s ear with Dextrostix
  4. Place sterile cotton loosely in the external ear of the client

Nurse Gio plans a long term care for parents of children with sickle-cell anemia, which includes periodic group conferences. Some of the discussions should be directed towards:

  1. Finding special school facilities for the child
  2. Making plans for moving to a more therapeutic climate
  3. Choosing a means of birth control to avoid future pregnancies
  4. Airing their feelings regarding the transmission of the disease to the child

The central problem the nurse might face with a disturbed schizophrenic client is the client’s:

  1. Suspicious feelings
  2. Continuous pacing
  3. Relationship with the family
  4. Concern about working with others

When planning care with a client during the postoperative recovery period following an abdominal hysterectomy and bilateral salpingo-oophorectomy, nurse Frida should include the explanation that:

  1. Surgical menopause will occur
  2. Urinary retention is a common problem
  3. Weight gain is expected, and dietary plan are needed
  4. Depression is normal and should be expected

An adolescent client with anorexia nervosa refuses to eat, stating, “I’ll get too fat.” Nurse Andrea can best respond to this behavior initially by:

  1. Not talking about the fact that the client is not eating
  2. Stopping all of the client’s privileges until food is eaten
  3. Telling the client that tube feeding will eventually be necessary
  4. Pointing out to the client that death can occur with malnutrition.

A pain scale is used to assess the degree of pain. The client rates the pain as an 8 on a scale of 10 before medication and a 7 on a scale of 10 after being medicated. Nurse Glenda determines that the:

  1. Client has a low pain tolerance
  2. Medication is not adequately effective
  3. Medication has sufficiently decreased the pain level
  4. Client needs more education about the use of the pain scale

To enhance a neonate’s behavioral development, therapeutic nursing measures should include:

  1. Keeping the baby awake for longer periods of time before each feeding
  2. Assisting the parents to stimulate their baby through touch, sound, and sight.
  3. Encouraging parental contact for at least one 15-minute period every four hours.
  4. Touching and talking to the baby at least hourly, beginning within two to four hours after birth

Before formulating a plan of care for a 6 year old boy with attention deficit hyperactivity disorder (ADHD), nurse Kyla is aware that the initial aim of therapy is to help the client to:

  1. Develop language skills
  2. Avoid his own regressive behavior
  3. Mainstream into a regular class in school
  4. Recognize himself as an independent person of worth

Nurse Wally knows that the most important aspect of the preoperative care for a child with Wilms’ tumor would be:

  1. Checking the size of the child’s liver
  2. Monitoring the child’s blood pressure
  3. Maintaining the child in a prone position
  4. Collecting the child’s urine for culture and sensitivity

At 11:00 pm the count of hydrocodone (Vicodin) is incorrect. After several minutes of searching the medication cart and medication administration records, no explanation can be found. The primary nurse should notify the:

  1. Nursing unit manager
  2. Hospital administrator
  3. Quality control manager
  4. Physician ordering the medication

When caring for the a client with a pneumothorax, who has a chest tube in place, nurse Kate should plan to:

  1. Administer cough suppressants at appropriate intervals as ordered
  2. Empty and measure the drainage in the collection chamber each shift
  3. Apply clamps below the insertion site when ever getting the client out of bed
  4. Encourage coughing, deep breathing, and range of motion to the arm on the affected side

According to C.E.Winslow, which of the following is the goal of Public Health?

  1. For people to attain their birthrights of health and longevity
  2. For promotion of health and prevention of disease
  3. For people to have access to basic health services
  4. For people to be organized in their health efforts

What other statistic may be used to determine attainment of longevity?

  1. Age-specific mortality rate
  2. Proportionate mortality rate
  3. Swaroop’s index
  4. Case fatality rate

Which of the following is the most prominent feature of public health nursing?

  1. It involves providing home care to sick people who are not confined in the hospital
  2. Services are provided free of charge to people within the catchment area.
  3. The public health nurse functions as part of a team providing a public health nursing services.
  4. Public health nursing focuses on preventive, not curative, services.

Which of the following is the mission of the Department of Health?

  1. Health for all Filipinos
  2. Ensure the accessibility and quality of health care
  3. Improve the general health status of the population
  4. Health in the hands of the Filipino people by the year 2020

Nurse Pauline determines whether resources were maximized in implementing Ligtas Tigdas, she is evaluating:

  1. Effectiveness
  2. Efficiency
  3. Adequacy
  4. Appropriateness

Lissa is a B.S.N. graduate. She want to become a Public Health Nurse. Where will she apply?

  1. Department of Health
  2. Provincial Health Office
  3. Regional Health Office
  4. Rural Health Unit

As an epidemiologist, Nurse Celeste is responsible for reporting cases of notifiable diseases. What law mandates reporting of cases of notifiable diseases?

  1. Act 3573
  2. R.A. 3753
  3. R.A. 1054
  4. R.A. 1082

Nurse Fay is aware that isolation of a child with measles belongs to what level of prevention?

  1. Primary
  2. Secondary
  3. Intermediate
  4. Tertiary

Nurse Gina is aware that the following is an advantage of a home visit?

  1. It allows the nurse to provide nursing care to a greater number of people.
  2. It provides an opportunity to do first hand appraisal of the home situation.
  3. It allows sharing of experiences among people with similar health problems.
  4. It develops the family’s initiative in providing for health needs of its members.

The PHN bag is an important tool in providing nursing care during a home visit. The most important principle of bag technique states that it:

  1. Should save time and effort.
  2. Should minimize if not totally prevent the spread of infection.
  3. Should not overshadow concern for the patient and his family.
  4. May be done in a variety of ways depending on the home situation, etc.

Nurse Willy reads about Path Goal theory. Which of the following behaviors is manifested by the leader who uses this theory?

  1. Recognizes staff for going beyond expectations by giving them citations
  2. Challenges the staff to take individual accountability for their own practice
  3. Admonishes staff for being laggards
  4. Reminds staff about the sanctions for non performance

Nurse Cathy learns that some leaders are transactional leaders. Which of the following does NOT characterize a transactional leader?

  1. Focuses on management tasks
  2. Is a caretaker
  3. Uses trade-offs to meet goals
  4. Inspires others with vision

Functional nursing has some advantages, which one is an EXCEPTION?

  1. Psychological and sociological needs are emphasized.
  2. Great control of work activities.
  3. Most economical way of delivering nursing services.
  4. Workers feel secure in dependent role

Which of the following is the best guarantee that the patient’s priority needs are met?

  1. Checking with the relative of the patient
  2. Preparing a nursing care plan in collaboration with the patient
  3. Consulting with the physician
  4. Coordinating with other members of the team

Nurse Tony stresses the need for all the employees to follow orders and instructions from him and not from anyone else. Which of the following principles does he refer to?

  1. Scalar chain
  2. Discipline
  3. Unity of command
  4. Order

Nurse Joey discusses the goal of the department. Which of the following statements is a goal?

  1. Increase the patient satisfaction rate
  2. Eliminate the incidence of delayed administration of medications
  3. Establish rapport with patients
  4. Reduce response time to two minutes

Nurse Lou considers shifting to transformational leadership. Which of the following statements best describes this type of leadership?

  1. Uses visioning as the essence of leadership
  2. Serves the followers rather than being served
  3. Maintains full trust and confidence in the subordinates
  4. Possesses innate charisma that makes others feel good in his presence.

Nurse Mae tells one of the staff, “I don’t have time to discuss the matter with you now. See me in my office later” when the latter asks if they can talk about an issue. Which of the following conflict resolution strategies did she use?

  1. Smoothing
  2. Compromise
  3. Avoidance
  4. Restriction

Nurse Bea plans of assigning competent people to fill the roles designed in the hierarchy. Which process refers to this?

  1. Staffing
  2. Scheduling
  3. Recruitment
  4. Induction

Nurse Linda tries to design an organizational structure that allows communication to flow in all directions and involve workers in decision making. Which form of organizational structure is this?

  1. Centralized
  2. Decentralized
  3. Matrix
  4. Informal

When documenting information in a client’s medical record, the nurse should:

  1. erase any errors.
  2. use a #2 pencil.
  3. leave one line blank before each new entry.
  4. end each entry with the nurse’s signature and title.

Which of the following factors are major components of a client’s general background drug history?

  1. Allergies and socioeconomic status
  2. Urine output and allergies
  3. Gastric reflex and age
  4. Bowel habits and allergies

Which procedure or practice requires surgical asepsis?

  1. Hand washing
  2. Nasogastric tube irrigation
  3. I.V. cannula insertion
  4. Colostomy irrigation

The nurse is performing wound care using surgical asepsis. Which of the following practices violates surgical asepsis?

  1. Holding sterile objects above the waist
  2. Pouring solution onto a sterile field cloth
  3. Considering a 1″ (2.5-cm) edge around the sterile field contaminated
  4. Opening the outermost flap of a sterile package away from the body

On admission, a client has the following arterial blood gas (ABG) values: PaO2, 50 mm Hg; PaCO2, 70 mm Hg; pH, 7.20; HCO3–, 28 mEq/L. Based on these values, the nurse should formulate which nursing diagnosis for this client?

  1. Risk for deficient fluid volume
  2. Deficient fluid volume
  3. Impaired gas exchange
  4. Metabolic acidosis

The use of larvivorous fish in malaria control is the basis for which strategy of malaria control?

  1. Stream seeding
  2. Stream clearing
  3. Destruction of breeding places
  4. Zooprophylaxis

In Integrated Management of Childhood Illness, severe conditions generally require urgent referral to a hospital. Which of the following severe conditions DOES NOT always require urgent referral to a hospital?

  1. Mastoiditis
  2. Severe dehydration
  3. Severe pneumonia
  4. Severe febrile disease

A mother brought her daughter, 4 years old, to the RHU because of cough and colds. Following the IMCI assessment guide, which of the following is a danger sign that indicates the need for urgent referral to a hospital?

  1. Inability to drink
  2. High grade fever
  3. Signs of severe dehydration
  4. Cough for more than 30 days

Food fortification is one of the strategies to prevent micronutrient deficiency conditions. R.A. 8976 mandates fortification of certain food items. Which of the following is among these food items?

  1. Sugar
  2. Bread
  3. Margarine
  4. Filled milk

The major sign of iron deficiency anemia is pallor. What part is best examined for pallor?

  1. Palms
  2. Nailbeds
  3. Around the lips
  4. Lower conjunctival sac

A woman in a child bearing age receives a rubella vaccination. Nurse Joy would give her which of the following instructions?

  1. Refrain from eating eggs or egg products for 24 hours
  2. Avoid having sexual intercourse
  3. Don’t get pregnant at least 3 months
  4. Avoid exposure to sun

Jonas who is diagnosed with encephalitis is under the treatment of Mannitol. Which of the following patient outcomes indicate to Nurse Ronald that the treatment of Mannitol has been effective for a patient that has increased intracranial pressure?

  1. Increased urinary output
  2. Decreased RR
  3. Slowed papillary response
  4. Decreased level of consciousness

Mary asked Nurse Maureen about the incubation period of rabies. Which statement by the Nurse Maureen is appropriate?

  1. Incubation period is 6 months
  2. Incubation period is 1 week
  3. Incubation period is 1 month
  4. Incubation period varies depending on the site of the bite

Which of the following should Nurse Cherry do first in taking care of a male client with rabies?

  1. Encourage the patient to take a bath
  2. Cover IV bottle with brown paper bag
  3. Place the patient near the comfort room
  4. Place the patient near the door

Which of the following is the screening test for dengue hemorrhagic fever?

  1. Complete blood count
  2. ELISA
  3. Rumpel-leeds test
  4. Sedimentation rate

Mr. Dela Rosa is suspected to have malaria after a business trip in Palawan. The most important diagnostic test in malaria is:

  1. WBC count
  2. Urinalysis
  3. ELISA
  4. Peripheral blood smear

The Nurse supervisor is planning for patient’s assignment for the AM shift. The nurse supervisor avoids assigning which of the following staff members to a client with herpes zoster?

  1. Nurse who never had chicken pox
  2. Nurse who never had roseola
  3. Nurse who never had german measles
  4. Nurse who never had mumps

Clarissa is 7 weeks pregnant. Further examination revealed that she is susceptible to rubella. When would be the most appropriate for her to receive rubella immunization?

  1. At once
  2. During 2nd trimester
  3. During 3rd trimester
  4. After the delivery of the baby

A female child with rubella should be isolated from a:

  1. 21 year old male cousin living in the same house
  2. 18 year old sister who recently got married
  3. 11 year old sister who had rubeola during childhood
  4. 4 year old girl who lives next door

What is the primary prevention of leprosy?

  1. Nutrition
  2. Vitamins
  3. BCG vaccination
  4. DPT vaccination

A bacteria which causes diphtheria is also known as?

  1. Amoeba
  2. Cholera
  3. Klebs-loeffler bacillus
  4. Spirochete

Nurse Ron performed mantoux skin test today (Monday) to a male adult client. Which statement by the client indicates that he understood the instruction well?

  1. I will come back later
  2. I will come back next month
  3. I will come back on Friday
  4. I will come back on Wednesday, same time, to read the result

A male client had undergone Mantoux skin test. Nurse Ronald notes an 8mm area of indurations at the site of the skin test. The nurse interprets the result as:

  1. Negative
  2. Uncertain and needs to be repeated
  3. Positive
  4. Inconclusive

Tony will start a 6 month therapy with Isoniazid (INH). Nurse Trish plans to teach the client to:

  1. Use alcohol moderately
  2. Avoid vitamin supplements while o therapy
  3. Incomplete intake of dairy products
  4. May be discontinued if symptoms subsides

Which is the primary characteristic lesion of syphilis?

  1. Sore eyes
  2. Sore throat
  3. Chancroid
  4. Chancre

What is the fast breathing of Jana who is 3 weeks old?

  1. 60 breaths per minute
  2. 40 breaths per minute
  3. 10 breaths per minute
  4. 20 breaths per minute

Which of the following signs and symptoms indicate some dehydration?

  1. Drinks eagerly
  2. Restless and irritable
  3. Unconscious
  4. A and B

What is the first line for dysentery?

  1. Amoxicillin
  2. Tetracycline
  3. Cefalexin
  4. Co-trimoxazole

In home made oresol, what is the ratio of salt and sugar if you want to prepare with 1 liter of water?

  1. 1 tbsp. salt and 8 tbsp. sugar
  2. 1 tbsp. salt and 8 tsp. sugar
  3. 1 tsp. salt and 8 tsp. sugar
  4. 8 tsp. salt and 8 tsp. sugar

Gentian Violet is used for:

  1. Wound
  2. Umbilical infections
  3. Ear infections
  4. Burn

Which of the following is a live attenuated bacterial vaccine?

  1. BCG
  2. OPV
  3. Measles
  4. None of the above

EPI is based on?

  1. Basic health services
  2. Scope of community affected
  3. Epidemiological situation
  4. Research studies

TT3 provides how many percentage of protection against tetanus?

  1. 100
  2. 99
  3. 80
  4. 90

Temperature of refrigerator to maintain potency of measles and OPV vaccine is:

  1. -2 0C to -8 0C
  2. -15 0C to -25 0C
  3. +15 0C to +25 0C
  4. +2 0C to +8 0C

Diptheria vaccine is a:

  1. Bacterial toxin
  2. Killed bacteria
  3. Live attenuated
  4. Plasma derivatives

Budgeting is under in which part of management process?

  1. Directing
  2. Controlling
  3. Organizing
  4. Planning

Time table showing planned work days and shifts of nursing personnel is:

  1. Staffing
  2. Schedule
  3. Scheduling
  4. Planning

A force within an individual that influences the strength of behavior?

  1. Motivation
  2. Envy
  3. Reward
  4. Self-esteem

“To be the leading hospital in the Philippines” is best illustrate in:

  1. Mission
  2. Philosophy
  3. Vision
  4. Objective

It is the professionally desired norms against which a staff performance will be compared?

  1. Job descriptions
  2. Survey
  3. Flow chart
  4. Standards

Reprimanding a staff nurse for work that is done incorrectly is an example of what type of reinforcement?

  1. Feedback
  2. Positive reinforcement
  3. Performance appraisal
  4. Negative reinforcement

Questions that are answerable only by choosing an option from a set of given alternatives are known as?

  1. Survey
  2. Close ended
  3. Questionnaire
  4. Demographic

A researcher that makes a generalization based on observations of an individual’s behavior is said to be which type of reasoning:

  1. Inductive
  2. Logical
  3. Illogical
  4. Deductive

The balance of a research’s benefit vs. its risks to the subject is:

  1. Analysis
  2. Risk-benefit ratio
  3. Percentile
  4. Maximum risk

An individual/object that belongs to a general population is a/an:

  1. Element
  2. Subject
  3. Respondent
  4. Author

An illustration that shows how the members of an organization are connected:

  1. Flowchart
  2. Bar graph
  3. Organizational chart
  4. Line graph

The first college of nursing that was established in the Philippines is:

  1. Fatima University
  2. Far Eastern University
  3. University of the East
  4. University of Sto. Tomas

Florence nightingale is born on:

  1. France
  2. Britain
  3. U.S
  4. Italy

Objective data is also called:

  1. Covert
  2. Overt
  3. Inference
  4. Evaluation

An example of subjective data is:

  1. Size of wounds
  2. VS
  3. Lethargy
  4. The statement of patient “My hand is painful”

What is the best position in palpating the breast?

  1. Trendelenburg
  2. Side lying
  3. Supine
  4. Lithotomy

When is the best time in performing breast self examination?

  1. 7 days after menstrual period
  2. 7 days before menstrual period
  3. 5 days after menstrual period
  4. 5 days before menstrual period

Which of the following should be given the highest priority before performing physical examination to a patient?

  1. Preparation of the room
  2. Preparation of the patient
  3. Preparation of the nurse
  4. Preparation of environment

It is a flip over card usually kept in portable file at nursing station.

  1. Nursing care plan
  2. Medicine and treatment record
  3. Kardex
  4. TPR sheet

Jose has undergone thoracentesis. The nurse in charge is aware that the best position for Jose is:

  1. Semi fowlers
  2. Low fowlers
  3. Side lying, unaffected side
  4. Side lying, affected side

The degree of patients abdominal distension may be determined by:

  1. Auscultation
  2. Palpation
  3. Inspection
  4. Percussion

A male client is addicted with hallucinogen. Which physiologic effect should the nurse expect?

  1. Bradyprea
  2. Bradycardia
  3. Constricted pupils
  4. Dilated pupils

Tristan a 4 year old boy has suffered from full thickness burns of the face, chest and neck. What will be the priority nursing diagnosis?

  1. Ineffective airway clearance related to edema
  2. Impaired mobility related to pain
  3. Impaired urinary elimination related to fluid loss
  4. Risk for infection related to epidermal disruption

In assessing a client’s incision 1 day after the surgery, Nurse Betty expect to see which of the following as signs of a local inflammatory response?

  1. Greenish discharge
  2. Brown exudates at incision edges
  3. Pallor around sutures
  4. Redness and warmth

Nurse Ronald is aware that the amiotic fluid in the third trimester weighs approximately:

  1. 2 kilograms
  2. 1 kilograms
  3. 100 grams
  4. 1.5 kilograms

After delivery of a baby girl. Nurse Gina examines the umbilical cord and expects to find a cord to:

  1. Two arteries and two veins
  2. One artery and one vein
  3. Two arteries and one vein
  4. One artery and two veins

Myrna a pregnant client reports that her last menstrual cycle is July 11, her expected date of birth is

  1. November 4
  2. November 11
  3. April 4
  4. April 18

Which of the following is not a good source of iron?

  1. Butter
  2. Pechay
  3. Grains
  4. Beef

Maureen is admitted with a diagnosis of ectopic pregnancy. Which of the following would you anticipate?

  1. NPO
  2. Bed rest
  3. Immediate surgery
  4. Enema

Gina a postpartum client is diagnosed with endometritis. Which position would you expect to place her based on this diagnosis?

  1. Supine
  2. Left side lying
  3. Trendelinburg
  4. Semi-fowlers

Nurse Hazel knows that Myrna understands her condition well when she remarks that urinary frequency is caused by:

  1. Pressure caused by the ascending uterus
  2. Water intake of 3L a day
  3. Effect of cold weather
  4. Increase intake of fruits and vegetables

How many ml of blood is loss during the first 24 hours post delivery of Myrna?

  1. 100
  2. 500
  3. 200
  4. 400

Which of the following hormones stimulates the secretion of milk?

  1. Progesterone
  2. Prolactin
  3. Oxytocin
  4. Estrogen

Nurse Carla is aware that Myla’s second stage of labor is beginning when the following assessment is noted:

  1. Bay of water is broken
  2. Contractions are regular
  3. Cervix is completely dilated
  4. Presence of bloody show

The leaking fluid is tested with nitrazine paper. Nurse Kelly confirms that the client’s membrane have ruptures when the paper turns into a:

  1. Pink
  2. Violet
  3. Green
  4. Blue

After amniotomy, the priority nursing action is:

  1. Document the color and consistency of amniotic fluid
  2. Listen the fetal heart tone
  3. Position the mother in her left side
  4. Let the mother rest

Which is the most frequent reason for postpartum hemorrhage?

  1. Perineal lacerations
  2. Frequent internal examination (IE)
  3. CS
  4. Uterine atomy

On 2nd postpartum day, which height would you expect to find the fundus in a woman who has had a caesarian birth?

  1. 1 finger above umbilicus
  2. 2 fingers above umbilicus
  3. 2 fingers below umbilicus
  4. 1 finger below umbilicus

Which of the following criteria allows Nurse Kris to perform home deliveries?

  1. Normal findings during assessment
  2. Previous CS
  3. Diabetes history
  4. Hypertensive history

Nurse Carla is aware that one of the following vaccines is done by intramuscular (IM) injection?

  1. Measles
  2. OPV
  3. BCG
  4. Tetanus toxoid

Asin law is on which legal basis:

  1. RA 8860
  2. RA 2777
  3. RI 8172
  4. RR 6610

Nurse John is aware that the herbal medicine appropriate for urolithiasis is:

  1. Akapulco
  2. Sambong
  3. Tsaang gubat
  4. Bayabas

Community/Public health bag is defined as:

  1. An essential and indispensable equipment of the community health nurse during home visit
  2. It contains drugs and equipment used by the community health nurse
  3. Is a requirement in the health center and for home visit
  4. It is a tool used by the community health nurse in rendering effective procedures during home visit

TT4 provides how many percentage of protection against tetanus?

  1. 70
  2. 80
  3. 90
  4. 99

Third postpartum visit must be done by public health nurse:

  1. Within 24 hours after delivery
  2. After 2-4 weeks
  3. Within 1 week
  4. After 2 months

Nurse Candy is aware that the family planning method that may give 98% protection to another pregnancy to women

  1. Pills
  2. Tubal ligation
  3. Lactational Amenorrhea method (LAM)
  4. IUD

Which of the following is not a part of IMCI case management process

  1. Counsel the mother
  2. Identify the illness
  3. Assess the child
  4. Treat the child

If a young child has pneumonia when should the mother bring him back for follow up?

  1. After 2 days
  2. In the afternoon
  3. After 4 days
  4. After 5 days

It is the certification recognition program that develop and promotes standard for health facilities:

  1. Formula
  2. Tutok gamutan
  3. Sentrong program movement
  4. Sentrong sigla movement

Baby Marie was born May 23, 1984. Nurse John will expect finger thumb opposition on:

  1. April 1985
  2. February 1985
  3. March 1985
  4. June 1985

Baby Reese is a 12 month old child. Nurse Oliver would anticipate how many teeth?

  1. 9
  2. 7
  3. 8
  4. 6

Which of the following is the primary antidote for Tylenol poisoning?

  1. Narcan
  2. Digoxin
  3. Acetylcysteine
  4. Flumazenil

A male child has an intelligence quotient of approximately 40. Which kind of environment and interdisciplinary program most likely to benefit this child would be best described as:

  1. Habit training
  2. Sheltered workshop
  3. Custodial
  4. Educational

Nurse Judy is aware that following condition would reflect presence of congenital G.I anomaly?

  1. Cord prolapse
  2. Polyhydramios
  3. Placenta previa
  4. Oligohydramios

Nurse Christine provides health teaching for the parents of a child diagnosed with celiac disease. Nurse Christine teaches the parents to include which of the following food items in the child’s diet:

  1. Rye toast
  2. Oatmeal
  3. White bread
  4. Rice

Nurse Randy is planning to administer oral medication to a 3 year old child. Nurse Randy is aware that the best way to proceed is by:

  1. “Would you like to drink your medicine?”
  2. “If you take your medicine now, I’ll give you lollipop”
  3. “See the other boy took his medicine? Now it’s your turn.”
  4. “Here’s your medicine. Would you like a mango or orange juice?”

At what age a child can brush her teeth without help?

  1. 6 years
  2. 7 years
  3. 5 years
  4. 8 years

Ribivarin (Virazole) is prescribed for a female hospitalized child with RSV. Nurse Judy prepare this medication via which route?

  1. Intra venous
  2. Oral
  3. Oxygen tent
  4. Subcutaneous

The present chairman of the Board of Nursing in the Philippines is:

  1. Maria Joanna Cervantes
  2. Carmencita Abaquin
  3. Leonor Rosero
  4. Primitiva Paquic

The obligation to maintain efficient ethical standards in the practice of nursing belong to this body:

  1. BON
  2. ANSAP
  3. PNA
  4. RN

A male nurse was found guilty of negligence. His license was revoked. Re-issuance of revoked certificates is after how many years?

  1. 1 year
  2. 2 years
  3. 3 years
  4. 4 years

Which of the following information cannot be seen in the PRC identification card?

  1. Registration Date
  2. License Number
  3. Date of Application
  4. Signature of PRC chairperson

Breastfeeding is being enforced by milk code or:

  1. EO 51
  2. R.A. 7600
  3. R.A. 6700
  4. P.D. 996

Self governance, ability to choose or carry out decision without undue pressure or coercion from anyone:

  1. Veracity
  2. Autonomy
  3. Fidelity
  4. Beneficence

A male patient complained because his scheduled surgery was cancelled because of earthquake. The hospital personnel may be excused because of:

  1. Governance
  2. Respondent superior
  3. Force majeure
  4. Res ipsa loquitor

Being on time, meeting deadlines and completing all scheduled duties is what virtue?

  1. Fidelity
  2. Autonomy
  3. Veracity
  4. Confidentiality

This quality is being demonstrated by Nurse Ron who raises the side rails of a confused and disoriented patient?

  1. Responsibility
  2. Resourcefulness
  3. Autonomy
  4. Prudence

Which of the following is formal continuing education?

  1. Conference
  2. Enrollment in graduate school
  3. Refresher course
  4. Seminar

The BSN curriculum prepares the graduates to become?

  1. Nurse generalist
  2. Nurse specialist
  3. Primary health nurse
  4. Clinical instructor

Disposal of medical records in government hospital/institutions must be done in close coordination with what agency?

  1. Department of Health
  2. Records Management Archives Office
  3. Metro Manila Development Authority
  4. Bureau of Internal Revenue

Nurse Jolina must see to it that the written consent of mentally ill patients must be taken from:

  1. Nurse
  2. Priest
  3. Family lawyer
  4. Parents/legal guardians

When Nurse Clarence respects the client’s self-disclosure, this is a gauge for the nurses’

  1. Respectfulness
  2. Loyalty
  3. Trustworthiness
  4. Professionalism

The Nurse is aware that the following tasks can be safely delegated by the nurse to a non-nurse health worker except:

  1. Taking vital signs
  2. Change IV infusions
  3. Transferring the client from bed to chair
  4. Irrigation of NGT

During the evening round Nurse Tina saw Mr. Toralba meditating and afterwards started singing prayerful hymns. What would be the best response of Nurse Tina?

  1. Call the attention of the client and encourage to sleep
  2. Report the incidence to head nurse
  3. Respect the client’s action
  4. Document the situation

In caring for a dying client, you should perform which of the following activities

  1. Do not resuscitate
  2. Assist client to perform ADL
  3. Encourage to exercise
  4. Assist client towards a peaceful death

The Nurse is aware that the ability to enter into the life of another person and perceive his current feelings and their meaning is known:

  1. Belongingness
  2. Genuineness
  3. Empathy
  4. Respect

The termination phase of the NPR is best described one of the following:

  1. Review progress of therapy and attainment of goals
  2. Exploring the client’s thoughts, feelings and concerns
  3. Identifying and solving patients problem
  4. Establishing rapport

During the process of cocaine withdrawal, the physician orders which of the following:

  1. Haloperidol (Haldol)
  2. Imipramine (Tofranil)
  3. Benztropine (Cogentin)
  4. Diazepam (Valium)

The nurse is aware that cocaine is classified as:

  1. Hallucinogen
  2. Psycho stimulant
  3. Anxiolytic
  4. Narcotic

In community health nursing, it is the most important risk factor in the development of mental illness?

  1. Separation of parents
  2. Political problems
  3. Poverty
  4. Sexual abuse

All of the following are characteristics of crisis except

  1. The client may become resistive and active in stopping the crisis
  2. It is self-limiting for 4-6 weeks
  3. It is unique in every individual
  4. It may also affect the family of the client

Freud states that temper tantrums is observed in which of the following:

  1. Oral
  2. Anal
  3. Phallic
  4. Latency

The nurse is aware that ego development begins during:

  1. Toddler period
  2. Preschool age
  3. School age
  4. Infancy

Situation: A 19 year old nursing student has lost 36 lbs for 4 weeks. Her parents brought her to the hospital for medical evaluation. The diagnosis was ANOREXIA NERVOSA. The Primary gain of a client with anorexia nervosa is:

  1. Weight loss
  2. Weight gain
  3. Reduce anxiety
  4. Attractive appearance

The nurse is aware that the primary nursing diagnosis for the client is:

  1. Altered nutrition : less than body requirement
  2. Altered nutrition : more than body requirement
  3. Impaired tissue integrity
  4. Risk for malnutrition

After 14 days in the hospital, which finding indicates that her condition in improving?

  1. She tells the nurse that she had no idea that she is thin
  2. She arrives earlier than scheduled time of group therapy
  3. She tells the nurse that she eat 3 times or more in a day
  4. She gained 4 lbs in two weeks

The nurse is aware that ataractics or psychic energizers are also known as:

  1. Anti manic
  2. Anti depressants
  3. Antipsychotics
  4. Anti anxiety

Known as mood elevators:

  1. Anti depressants
  2. Antipsychotics
  3. Anti manic
  4. Anti anxiety

The priority of care for a client with Alzheimer’s disease is

  1. Help client develop coping mechanism
  2. Encourage to learn new hobbies and interest
  3. Provide him stimulating environment
  4. Simplify the environment to eliminate the need to make chores

Autism is diagnosed at:

  1. Infancy
  2. 3 years old
  3. 5 years old
  4. School age

The common characteristic of autism child is:

  1. Impulsitivity
  2. Self destructiveness
  3. Hostility
  4. Withdrawal

The nurse is aware that the most common indication in using ECT is:

  1. Schizophrenia
  2. Bipolar
  3. Anorexia Nervosa
  4. Depression

A therapy that focuses on here and now principle to promote self-acceptance?

  1. Gestalt therapy
  2. Cognitive therapy
  3. Behavior therapy
  4. Personality therapy

A client has many irrational thoughts. The goal of therapy is to change her:

  1. Personality
  2. Communication
  3. Behavior
  4. Cognition

The appropriate nutrition for Bipolar I disorder, in manic phase is:

  1. Low fat, low sodium
  2. Low calorie, high fat
  3. Finger foods, high in calorie
  4. Small frequent feedings

Which of the following activity would be best for a depressed client?

  1. Chess
  2. Basketball
  3. Swimming
  4. Finger painting

The nurse is aware that clients with severe depression, possess which defense mechanism:

  1. Introjection
  2. Suppression
  3. Repression
  4. Projection

Nurse John is aware that self mutilation among Bipolar disorder patients is a means of:

  1. Overcoming fear of failure
  2. Overcoming feeling of insecurity
  3. Relieving depression
  4. Relieving anxiety

Which of the following may cause an increase in the cystitis symptoms?

  1. Water
  2. Orange juice
  3. Coffee
  4. Mango juice

In caring for clients with renal calculi, which is the priority nursing intervention?

  1. Record vital signs
  2. Strain urine
  3. Limit fluids
  4. Administer analgesics as prescribed

In patient with renal failure, the diet should be:

  1. Low protein, low sodium, low potassium
  2. Low protein, high potassium
  3. High carbohydrate, low protein
  4. High calcium, high protein

Which of the following cannot be corrected by dialysis?

  1. Hypernatremia
  2. Hyperkalemia
  3. Elevated creatinine
  4. Decreased hemoglobin

Tony with infection is receiving antibiotic therapy. Later the client complaints of ringing in the ears. This ototoxicity is damage to:

  1. 4th CN
  2. 8th CN
  3. 7th CN
  4. 9th CN

Nurse Emma provides teaching to a patient with recurrent urinary tract infection includes the following:

  1. Increase intake of tea, coffee and colas
  2. Void every 6 hours per day
  3. Void immediately after intercourse
  4. Take tub bath everyday

Which assessment finding indicates circulatory constriction in a male client with a newly applied long leg cast?

  1. Blanching or cyanosis of legs
  2. Complaints of pressure or tightness
  3. Inability to move toes
  4. Numbness of toes

During acute gout attack, the nurse administer which of the following drug:

  1. Prednisone (Deltasone)
  2. Colchicines
  3. Aspirin
  4. Allopurinol (Zyloprim)

Information in the patients chart is inadmissible in court as evidence when:

  1. The client objects to its use
  2. Handwriting is not legible
  3. It has too many unofficial abbreviations
  4. The clients parents refuses to use it

Nurse Karen is revising a client plan of care. During which step of the nursing process does such revision take place?

  1. Planning
  2. Implementation
  3. Diagnosing
  4. Evaluation

When examining a client with abdominal pain, Nurse Hazel should assess:

  1. Symptomatic quadrant either second or first
  2. The symptomatic quadrant last
  3. The symptomatic quadrant first
  4. Any quadrant

How long will nurse John obtain an accurate reading of temperature via oral route?

  1. 3 minutes
  2. 1 minute
  3. 8 minutes
  4. 15 minutes

The one filing the criminal care against an accused party is said to be the?

  1. Guilty
  2. Accused
  3. Plaintiff
  4. Witness

A male client has a standing DNR order. He then suddenly stopped breathing and you are at his bedside. You would:

  1. Call the physician
  2. Stay with the client and do nothing
  3. Call another nurse
  4. Call the family

The ANA recognized nursing informatics heralding its establishment as a new field in nursing during what year?

  1. 1994
  2. 1992
  3. 2000
  4. 2001

When is the first certification of nursing informatics given?

  1. 1990-1993
  2. 2001-2002
  3. 1994-1996
  4. 2005-2008

The nurse is assessing a female client with possible diagnosis of osteoarthritis. The most significant risk factor for osteoarthritis is:

  1. Obesity
  2. Race
  3. Job
  4. Age

A male client complains of vertigo. Nurse Bea anticipates that the client may have a problem with which portion of the ear?

  1. Tympanic membranes
  2. Inner ear
  3. Auricle
  4. External ear

When performing Weber’s test, Nurse Rosean expects that this client will hear

  1. On unaffected side
  2. Longer through bone than air conduction
  3. On affected side by bone conduction
  4. By neither bone or air conduction

Toy with a tentative diagnosis of myasthenia gravis is admitted for diagnostic make up. Myasthenia gravis can confirmed by:

  1. Kernig’s sign
  2. Brudzinski’s sign
  3. A positive sweat chloride test
  4. A positive edrophonium (Tensilon) test

A male client is hospitalized with Guillain-Barre Syndrome. Which assessment finding is the most significant?

  1. Even, unlabored respirations
  2. Soft, non distended abdomen
  3. Urine output of 50 ml/hr
  4. Warm skin

For a female client with suspected intracranial pressure (ICP), a most appropriate respiratory goal is:

  1. Maintain partial pressure of arterial oxygen (Pa O2) above 80mmHg
  2. Promote elimination of carbon dioxide
  3. Lower the PH
  4. Prevent respiratory alkalosis

Which nursing assessment would identify the earliest sign of ICP?

  1. Change in level of consciousness
  2. Temperature of over 103°F
  3. Widening pulse pressure
  4. Unequal pupils

The greatest danger of an uncorrected atrial fibrillation for a male patient will be which of the following:

  1. Pulmonary embolism
  2. Cardiac arrest
  3. Thrombus formation
  4. Myocardial infarction

Linda, A 30 year old post hysterectomy client has visited the health center. She inquired about BSE and asked the nurse when BSE should be performed. You answered that the BSE is best performed:

  1. 7 days after menstruation
  2. At the same day each month
  3. During menstruation
  4. Before menstruation

An infant is ordered to recieve 500 ml of D5NSS for 24 hours. The Intravenous drip is running at 60 gtts/min. How many drops per minute should the flow rate be?

  1. 60 gtts/min.
  2. 21 gtts/min
  3. 30 gtts/min
  4. 15 gtts/min

Mr. Gutierrez is to receive 1 liter of D5LR to run for 12 hours. The drop factor of the IV infusion set is 10 drops per minute. Approximately how many drops per minutes should the IV be regulated?

  1. 13-14 drops
  2. 17-18 drops
  3. 10-12 drops
  4. 15-16 drops

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