Codes I

CODES I 1
DISCLAIMER: This manuscript is a combination of actual past board examinations and high yield concepts. Answers are
well - research.

FUNDAMENTALS IN NURSING

Situation 1. The nursing process provides a framework for a nurse's responsibility and
accountability. It requires critical thinking.

1. The patient states, My chest hurts and my left arm feels numb. What is the type
and source of this data?
A. Subjective data from a primary source
B. Subjective data from a secondary source
C. Objective data from a primary source
D. Objective data from a secondary source

Answer: A
Rationale: Subjective data is apparent only to the person affected and cannot be
measured, seen, felt, or heard by the nurse. It may be called covert data. It
includes the patient's thoughts, beliefs, feelings, perceptions, and sensations. The
patient is always considered the primary source.
(Hogan et. al., Prentice Hall Reviews and Rationales Series for Nursing: Fundamentals
of Nursing)

2. The nurse is measuring the patient's urine output and straining the urine to assess
for stones. Which of the following should the nurse record as objective data?
A. The patient stated, I feel like I have passed a stone.
B. The patient's urine output was 550 mL
C. The patient is complaining of abdominal pain
D. The patient stated, I didn't see any stones in my urine.

Answer: B
Rationale: Measurable data is objective data.
of Nursing)

3. Which of the following demonstrates that the nurse is participating critical thinking?
A. The nurse admits she does not know how to do a procedure and requests
help
B. The nurse makes her point with clever and persuasive remarks to win an
argument
C. The nurse accepts without question the values acquired in nursing school
D. The nurse finds a quick and logical answer, even to complex questions

Answer: A
Rationale: Critical thinking is self-directed and supports what an individual knows and
makes clear what she does not know. It is important for nurses to recognize when
they lack the knowledge they need to provide safe care for a client. Nurses must
utilize their resources to acquire the knowledge and support they need to fulfill a
nursing responsibility safely.
(Hogan et. al., Prentice Hall Reviews and Rationales Series for Nursing:
Fundamentals of Nursing)

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4. What is the problem with the following outcome goal, Patient will state pain is less
than or equal to 3 on a 0 to 10 pain scale?
A. None, goal is written correctly
B. It is not measurable
C. No target time is given
D. Patient behavior is missing

Answer: C
Rationale: Outcome goals should be SMART (specific, measurable, appropriate,
realistic, and timely). There is no time estimate for goal attainment. Thus, option A
is incorrect.
of Nursing)

5. When evaluating an adult patient's blood pressure reading. The nurse considers the
patient's age. This is an example of which of the following?
A. Comparing data against standards
B. Clustering data
C. Determining gaps in the data
D. Differentiating cues and inferences

Answer: A
Rationale: Analysis of the client data (blood pressure reading) requires knowledge of
the normal blood pressure range for an adult. The nurse compares client data
against standards to identify significant cues. (Hogan et. al., Prentice Hall Reviews
and Rationales Series for Nursing: Fundamentals of Nursing)

Situation 2. Jason has a nursing diagnosis of ineffective airway clearance related to
excessive secretions and is at risk for infection because of retained secretions. Part of
Nurse Melais nursing care plan is to loosen and remove excessive secretions in the
airway.
11. Nurse Melai listens to Jasons bilateral sounds and finds that congestion is in
the upper lobes of the lungs. The appropriate position to drain the anterior and
posterior apical segment of the lungs when the nurse does percussion would be:
A. Patient lying on his back then flat on his abdomen on Trendelenburg
position
B. Patient seated upright in bed or on a chair then leaning forward in sitting
position then flat on his back and on his abdomen
C. Patient lying flat in his back and then flat on his abdomen
D. Patient lying on his right then left side on Trendelenburg position

Answer: B
Rationale: Chest physiotherapy is a dependent nursing function that uses principles of
percussion, vibration and postural drainage to drain thick tenacious bronchial
secretions. Percussion is done by clapping cupped hand over the affected lobe of
the lung. Positioning varies according to the area of affectation. Patients with

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posterior segment of the upper lobe affectation should be positioned in a sitting and
leaning forward position and flat on bed (dorsal recumbent) with pillow under the
buttocks for anterior segment of upper lobe affectation.

12. When documenting the outcome of Jasons treatment Nurse Melai should
include the following in her recording, except:
A. Color, amount, consistency of sputum
B. Character of breath sounds and respiratory rate before and after procedure
C. Amount of fluid intake of the patient before and after the procedure
D. Significant changes in vital signs

Answer: C
Rationale: Though patients receiving Chest Physiotherapy are encouraged to
increase oral fluid intake, this intervention is not too specific for documentation of
pertinent data related to the procedure.

13. When assessing Jason for chest percussion or chest vibration and postural
drainage, Nurse Melai would focus on the following, except:
A. Amount of fluid taken during the last meal before treatment
B. Respiratory rate, breath sounds and location of congestion
C. Teaching the patients relatives to perform the procedure
D. Doctors order regarding position restrictions and the patients tolerance for
lying flat

Answer: C
Rationale: Options A, B and D are all assessable, C is an intervention that is not
allowed. Chest Physiotherapy is a dependent nursing intervention that cannot be
just delegated to the patients relatives. Even for home/community based care or
long term care of patients; CPT is done during home visits by a home care nurse
and not delegated to the relatives.

14. Nurse Melai prepares Jason for postural drainage and percussion. Which of
the following is a special consideration when doing the procedure?
A. Respiratory rate of 16-20 per minute
B. Patient can tolerate sitting and lying positions
C. Patient has no sign of infection
D. Time of the last food and fluid intake of the patient

Answer: D
Rationale: The time of last food and fluid intake of the client is very important for
the nurse to assess. The best time to perform chest physiotherapy is 1 hour before
meals or 2-3 hours after meals to prevent food and fluid regurgitation or vomiting.

15. The purpose of chest percussion and vibration is to loosen secretions in the
lungs. The difference between the procedures is:
A. Percussion uses only one hand while vibration uses both hands
B. Percussion delivers cushioned blows to the chest with cupped palms while
vibration gently shakes secretion loose on the exhalation cycle

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C. In both percussion and vibration the hands are on top of each other and
hand action is in tune with the clients breathing rhythm
D. Percussion slaps the chest to loosen secretions while vibration shakes the
secretions with inhalation of air

Answer: B
Rationale: Option B is the correct comparison.
Situation 3. The vital signs are body temperature, pulse, respirations, and blood pressure.
These signs, which should be looked at in total, are checked to monitor the functions of
the body. They reflect changes in function that otherwise might not be observed.
11. For a patient with a previous blood pressure of 140/80 and pulse of 64,
approximately how long should the nurse take to release the blood pressure cuff in
order to obtain an accurate reading?
A. 10 to 20 seconds C. 30 to 45 seconds
B. 1 to 1.5 minutes D. 3 to 3.5 minutes

Answer: C
Rationale: If the cuff is inflated to about 30 mm Hg over the previous systolic
pressure, which would be 170. To ensure that the diastolic has been determined,
the cuff should be released slowly until the mid-60s mm Hg (and then completely)
for someone with a previous reading of 80. The cuff should be deflated at a rate of
2 to 3 mm per second. Thus, a range of 90 mm Hg will require 30 to 45 seconds.
(Kozier & Erb's Fundamentals of Nursing, 8
th
Edition)

12. A patient with pyrexia will most likely demonstrate:
A. Dyspnea C. Increased pulse rate
B. Precordial pain D. Elevated blood pressure

Answer: C
Rationale: The pulse increases to meet increased tissue demands for oxygen in the
febrile state.
(Mosby, 18
th
Edition)

13. Which of the following patients meet the criteria for selection of the apical
site for assessment of the pulse rather than a radial pulse?
A. A patient is in shock
B. The pulse changes with body position changes
C. A patient with an arrhythmia
D. It is less than 24 hours since a patient's surgical operation

Answer: C
Rationale: The apical rate would confirm the rate and determine the actual cardiac
rhythm for a client with an abnormal rhythm; a radial pulse would only reveal the
heart rate and suggest an arrhythmia.
th
Edition)

14. The absence of which pulse may not be a significant finding when a patient is
admitted to the hospital?
A. Pedal C. Apical

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B. Femoral D. Radial

Answer: A
Rationale: Because the pedal pulse cannot be detected in 10% to 20% of the
population, its absence is not necessarily a significant finding. However, the
presence or absence of the pedal pulse should be documented upon admission so
that changes can be identified during the hospital stay. (Kozier & Erb's
Fundamentals of Nursing, 8
th
Edition)

15. All of the following can cause tachycardia, except:
a. Sympathetic nervous system stimulation
b. Parasympathetic nervous system stimulation
c. Fever
d. Exercise
Answer: B
Rationale: Parasympathetic nervous system stimulation of the heart decreases the
heart rate as well as the force of contraction, rate of impulse conduction and blood
flow through the coronary vessels.
th
Edition)

Situation 4. Diagnostic and laboratory tests (commonly called lab tests) are tools that
provide information about the client. Frequently, tests are used to help confirm a
diagnosis, monitor an illness, and provide valuable information about the client's
response to treatment.
16. A patient is admitted to the hospital with complaints of nausea, vomiting,
diarrhea, and severe abdominal pain. Which of the following would immediately
alert the nurse that the patient has gastrointestinal tract bleeding?
A. Complete blood count C. Vital signs
B. Guaiac test D. Abdominal girth
Answer: B
Rationale: To assess for GI tract bleeding when frank blood is absent, the nurse has
two options: She can test for occult blood in vomitus, if present, or in stool - through
Guaiac (Hemoccult) test. (Kozier & Erb's Fundamentals of Nursing, 8
th
Edition)

17. Before scheduling a patient for endoscopic retrograde
cholangiopancreatography (ERCP), the nurse should assess the patient's:
A. Urine output C. Serum glucose
B. Bilirubin leve D. Blood pressure
Answer: B
Rationale: ERCP or endoscopic retrograde cholangiopancreatography involves the
insertion of a cannula into the pancreatic and common bile ducts during an
endoscopy. The test is not performed if the client's bilirubin is greater than 3 to 5
mg/dL because cannulization may cause edema, which would increase obstruction
of bile flow.
(Mosby, 18
th
Edition)

18. The laboratory tests that would indicate that the liver of a patient with
cirrhosis is compromised and neomycin enemas might be helpful would be:
A. Ammonia level C. Culture and sensitivity

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B. White blood count D. Alanine aminotransferase level

Answer: A
Rationale: Increased ammonia levels indicate that the liver is unable to detoxify
protein byproducts. Neomycin reduces the amount of ammonia-forming bacteria in
the intestines. (Mosby, 18
th
Edition)

19. The most important test used to determine whether a transplanted kidney is
working is:
A. Renal ultrasound C. White blood cell count
B. Serum creatinine level D. Twenty-four hour output

Answer: B
Rationale: Serum creatinine concentration measures the kidney's ability to excrete
metabolic wastes. Creatinine, a nitrogenous product of protein breakdown, is
elevated in renal insufficiency. (Mosby, 18
th
Edition)

20. The best blood test for the nurse to use to evaluate fluid loss resulting from
burns is the:
A. Blood urea nitrogen C. Hematocrit
B. Blood pH D. Sedimentation rate

Answer: C
Rationale: An increased hematocrit level indicates hemoconcentration secondary to
fluid loss.
Option A is incorrect because although blood urea nitrogen (BUN) may be used to
indicate dehydration from burns, interpretation can be complicated by other
conditions accompanying burns that also cause elevation of the BUN.
(Mosby, 18
th
Edition)

Situation 5. Nurse Flo is assigned to the triage area and while on duty, she assesses the
condition of Mr. Floremonte who came in with asthma. He has difficulty of breathing and
his respiratory rate is 40 breaths per minute. The nurse is asked to inject the patient
epinephrine 0.3mg subcutaneously.

21. The indication for epinephrine injection for Mr. Floremonte is to:
A. Reduce anaphylaxis
B. Relieve hypersensitivity to allergen
C. Relieve respiratory distress due to bronchial spasm
D. Restore the patients cardiac rhythm

Answer: C
Rationale: Epinephrine is a sympathomimetic that is frequently used in
emergencies to combat anaphylaxis, which is a life threatening allergic response. It
is a potent inotropic agent that causes the blood vessels to constrict; thus blood
pressure increases, and the bronchial tubes to dilate. Epinephrine increases cAMP
(cyclic adenosine monophosphate), a molecule responsible for maintaining
bronchodilation. Epinephrine is the drug of choice for the treatment of anaphylactic
shock.

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22. When preparing the epinephrine injection from an ampule, Nurse Flo initially:
A. Taps the ampule at the top to allow fluid to flow to the base of the ampule
B. Checks expiration date of the medication ampule
C. Removes the needle cap of syringe and pulls plunger to expel air
D. Breaks the neck of the ampule with a gauze around it

Answer: B
Rationale: Before preparing any medication for administration, it is a vital role of
the nurse to check the integrity of the drug and its container, including the expiry
date of the medication.
Doing option A before option B would make option A useless.

23. Mr. Floremonte is obese. When administering subcutaneous injection to an
obese patient, it is best for Nurse Flo to:
A. Inject needle at a 15 degree angle over the stretched skin of the patient
B. Pinch the skin and use an airlock technique
C. Pull skin of the patient down to administer drug in a Z-track
D. Spread the skin or pinch at the injection site and inject needle at a 45-90
degree angle

Answer: D
Rationale: Subcutaneous (SC) injections have systemic and sustained effects,
absorbed mainly through the capillaries, usually slower in onset that Intramuscular
(IM). SC route is used for small doses of non-irritating, water-soluble drugs.
Locations for SC injections are chosen for adequate fat-pad size and include the
abdomen, upper hips, upper back, lateral upper arms and upper thighs. Insert the
needle at an angle appropriate to body size 45 degrees (for those with little SC
tissue) to 90 degrees.

24. When preparing for a subcutaneous injection, the proper size of syringe and
needle would be:
A. Syringe 3-5mL and needle 21-23
B. Tuberculin syringe 1mL with needle gauge 26-27
C. Syringe 2mL and needle gauge 22
D. Syringe 1-3mL and needle gauge 25-27
Answer: D
Rationale: Since for SC injections, usually 0.5-1.5mL is injected, a 1-3mL syringe is
recommended with a needle gauge 25-27 with 1/2 to 5/8 inches of needle length.

25. The rationale for giving medications through the subcutaneous route is:
A. There are many alternative sites for SC injection
B. Absorption time of the medicine is slower
C. There are less pain receptors in this area
D. The medication can be injected while the patient is in any position

Answer: B
Rationale: Since the subcutaneous layer as vascularized as the muscle layer, the
medicine is not as rapidly absorbed as that in IM route. Absorption in the SC route

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occurs via the capillaries while in IM route, it can be through capillaries and main
blood vessels.

Situation 6. When positioning clients in bed, the nurse can do a number of things to
ensure proper alignment and promote client comfort and safety.
26. When Rosenda, age 21, is in the right side-lying position after the insertion of
a left hip prosthesis, Nurse Claudine ensures that the patient has an abduction
pillow placed between the thighs and that the entire length of the upper leg is
supported. The most important reason for this is to prevent:
A. Strain on the operative site
B. Thrombus formation in the leg
C. Flexion contractures of the hip joint
D. Skin surfaces from rubbing together

Answer: A
Rationale: The right side-lying position supports the operative site; the involved leg
must be maintained in alignment, avoiding adduction to prevent dislocation of the
prosthesis. (Mosby, 18
th
Edition)

27. The position that is indicated for Rosanna, age 23, after surgery for a
perforated appendix with localized peritonitis is the:
A. Sims' position C. Semi-Fowler's position
B. Trendelenburg position D. Dorsal recumbent position

Answer: C
Rationale: The semi-Fowler's position aids in drainage and prevents spread of
infection throughout the abdominal cavity. (Mosby, 18
th
Edition)

28. After surgery on the neck, Rosita, age 22, should be placed in a high-Fowler's
position to:
A. Avoid strain on the incision
B. Promote drainage of the wound
C. Provide stimulation for the patient
D. Reduce edema at the operative site
Answer: D
Rationale: The high-Fowler's position promotes fluid drainage by gravity, minimizing
edema. (Mosby, 18
th
Edition)

29. After a total hip replacement surgery, Nurse Claudine should avoid placing
Rosario, age 25, in the:
A. Supine position C. Orthopneic position
B. Lateral position D. Semi-Fowler's position
Answer: C
Rationale: The orthopneic position involves hip flexion greater than 90 degrees. This
puts stress on the operative site and could dislodge the prosthesis. (Mosby, 18
th

Edition)

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30. Rosemary, age 20, is to have gastric gavage. When the gavage tube is being
inserted, Nurse Claudine should place the patient in the:
A. Supine position C. High-Fowler's position
B. Mid-Fowler's position D. Trendelenburg position

Answer: C
Rationale: The high-Fowler's position promotes optimal entry into the esophagus
aided by gravity.(Mosby, 18
th
Edition)

Situation 7. Nurse Junelyn is assigned in the medical-surgical unit to provide basic nursing
care to a group of clients with nasogastric tube.
31. Nurse Junelyn is to irrigate a nasogastric tube every two hours. Which solution
should the nurse select to irrigate the tube?
A. Normal saline C. Ringer's lactate
B. Tap water D. Half-strength peroxide

Answer: A
Rationale: Normal saline is used to irrigate a nasogastric tube since it will not cause
a loss of sodium when it is removed by suction. Saline is an isotonic solution which
has the same osmotic pressure as that found across the semi-permeable
membrane within the cell. (NSNA NCLEX-RN Review, 4
th
Edition)

32. Mr. Beans, a 37-year-old client with a nasogastric tube connected to a low
continuous suction for abdominal decompression. Nurse Junelyn notes that gastric
fluid in the suction tubing is not moving and the patient's abdomen is becoming
distended. The nurse's best action is to:
A. Pull out the nasogastric tube and insert a new one
B. Irrigate the tube with 30 cc of water
C. Tell the client to take a few deep breaths
D. Turn the suction higher

Answer: B
Rationale: The most likely cause of the problem is that the nasogastric tube is
plugged with gastric contents or has adhered to the gastric mucosa and is no longer
draining. Irrigating the tube with 30 cc of water should clear any obstructions and
free the tube from the gastric mucosa.
(Davis's NCLEX-RN Success, 2
nd
Edition)

33. Mr. Borat, a 45-year-old male patient, has an order for a nasogastric tube.
Before inserting the tube, Nurse Junelyn measures the amount of tube needed. To
determine the amount of tube needed, the nurse should:
A. Measure from the forehead to the ear and from the ear to the umbilicus
B. Measure from the chin to the back of the throat and from the back of the
throat to the umbilicus
C. Measure from the mouth to the xiphoid process and add 2 inches
D. Measure from the tip of the patient's nose to his earlobe and from the
earlobe to the xiphoid process

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Answer: D
Rationale: The best way to determine the amount of tube needed to reach the
pylorus is to measure from the tip of the client's nose to his earlobe and from the
earlobe to the xiphoid process. (NSNA NCLEX-RN Review, 4
th
Edition)

34. When assessing Mr. Peas, a postoperative patient, Nurse Junelyn notes a
nasogastric tube to low constant suction, the absence of a bowel movement since
surgery, and no bowel sounds. The most appropriate plan of care based on these
findings is to:
A. Increase the patient's mobility and ensure he is receiving adequate pain
relief
B. Increase coughing, turning, and deep breathing exercises
C. Discontinue the nasogastric tube as the patient does not need it any more
D. Assess for bladder pain and distention

Answer: A
Rationale: Paralytic ileus can be related to immobility and inadequate pain
medication as well as bowel manipulation and the anesthetic used during surgery.
(NSNA NCLEX-RN Review, 4
th
Edition)

35. Nurse Junelyn is caring for Mr. Turnips who has a nasogastric tube attached to
low wall suction. The suction is not working. Which is the nurse least likely to note
when assessing the patient?
A. Patient vomits
B. Patient has a distended abdomen
C. There is no nasogastric output in the last two hours
D. Large amounts of nasogastric output

Answer: D
Rationale: If the nasogastric suction is not working, the nurse would not expect to
see large amounts of nasogastric output. (NSNA NCLEX-RN Review, 4
th
Edition)

Situation 8. Nurse Bro is assigned to a group of clients with chest tubes.
36. The physician inserts a chest tube to Mariel, a 24-year-old patient who has
been stabbed in the chest, and attaches it to a closed-drainage system. When
caring for the patient, Nurse Bro should:
A. Apply a thoracic binder to prevent tension on the tube
B. Observe for fluid fluctuations in the water seal chamber
C. Clamp the tubing securely to prevent a rapid decline in pressure
D. Administer morphine sulfate, because the patient will be agitated

Answer: B
Rationale: Fluctuations occur with normal inspiration and expiration until the lung is
fully expanded. If these fluctuations do not occur, the chest tube may be clogged or
kinked; coughing should be encouraged. (Mosby, 18
th
Edition)

37. Paul Jake, age 25, arrives in the postanesthesia care unit after a segmental
resection of the right lower lobe of the lung, with a chest tube drainage system in

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place. Nurse Bro caring for the client should:
A. Add 3 to 5 ml of sterile saline to the water seal chamber
B. Raise the drainage system to bed level to check its patency
C. Mark the time and the fluid level on the side of the drainage chamber
D. Secure the chest catheter to the wound dressing with a sterile safety pin

Answer: C
Rationale: The fluid level and time must be marked so that the amount of drainage
in the chest tube drainage system can be evaluated. (Mosby, 18
th
Edition)

38. Tibo, age 27, has a chest tube to a Pleur-evac

drainage system attached to
wall suction. An order to ambulate the patient has been received. To ambulate the
patient safely, Nurse Bro should:
A. Clamp the chest tube and carefully ambulate the patient a short distance
B. Question the order to ambulate the patient
C. Carefully ambulate the patient, keeping the Pleur-evac

lower than the
patient's chest
D. Disconnect the Pleur-evac

from the patient's chest tube, leave it attached
to the bed, ambulate the patient, and then reconnect the chest tube when
he is returned to bed

Answer: C
Rationale: The Pleur-evac

must not be raised above chest level because it can
cause back flow of the fluid into the pleural space precipitating collapse of the lung
or mediastinal shift. The Pleur-evac

must remain upright and the chest tube should
not have traction on it.
Option A is incorrect because the chest tube should not be clamped for ambulation.
Chest tubes should not be clamped unless an order to do so is present.
th
Edition)

39. Kathy, a 30-year-old client with a spontaneous pneumothorax, has had a
chest tube for 3 days. On morning rounds, the physician clamped the chest tube to
determine the patient's readiness to have the chest tube discontinued. Two hours
after having the chest tube clamped, the patient began to have difficulty breathing.
What action should Nurse Bro take first?
A. Notify the physician
B. Unclamp the chest tube
C. Assess the patient for subcutaneous emphysema
D. Place the patient on 2L nasal cannula oxygen

Answer: B
Rationale: The chest tube should be immediately unclamped. The client still has an
air leak that is causing a build up of air in the pleural space, collapsing part of the
lung, and causing breathing difficulty. The clamp must be removed from the chest
tube immediately to allow this air to escape and the lung to re-expand.
Option A is incorrect because the first priority is to remain with the client and
address the breathing difficulty by unclamping the chest tube clamp. The physician
should be notified as priority number 4 in this option sequence.
(Davis's NCLEX RN Success, 2
nd
Edition)

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40. Johan, a 29-year-old client who has had thoracic surgery, is admitted to the
postanesthesia care unit. After the chest catheters are attached to a closed
drainage system, Nurse Bro should:
A. Check that the fluid in the water seal compartment rises with expiration
B. Ensure the security of the connections from the patient to the drainage unit
C. Ensure that there is vigorous bubbling in the wet suction control
compartment
D. Empty the drainage container, measure and record the amount, and send a
sample for analysis every 24 hours

Answer: B
Rationale: The system must remain airtight (closed) to prevent collapse of the lung.
(Mosby, 18
th
Edition)

Situation 9. Gibo Posible is returned to the medical-surgical floor after tracheostomy
insertion. His respirations are regular and unlabored.

41. When performing tracheostomy care, Nurse Edu must:
A. Place the patient in the semi-Fowler's position
B. Maintain sterile technique during the procedure
C. Monitor the patient's temperature after the procedure
D. Use Betadine to clean the inner cannula when it is removed

Answer: B
Rationale: The tracheostomy site is a portal of entry for microorganisms. Sterile
technique must be used. (Mosby, 18
th
Edition)

42. Mr. Posible's tracheostomy is producing a small amount of thin, white
secretions. The stoma is pink with no drainage noted. Nurse Edu should expect to
provide tracheostomy care for the patient every:
A. Four hours C. 24 hours
B. Eight hours D. Hour

Answer: B
Rationale: Tracheostomy care should be provided once every eight hours.
th
Edition)

43. Nurse Edu is administering tracheostomy care to Mr. Posible. Which of the
following should be included in the procedure?
A. Soaking the outer cannula with saline solution
B. Performing the procedure utilizing medical asepsis
C. Soaking the inner cannula in half-strength hydrogen peroxide solution
D. Cutting a sterile gauze pad to place between the neck and the
tracheostomy tube

Answer: C
Rationale: The inner cannula is removed utilizing sterile gauze and is soaked in half-
strength hydrogen peroxide solution. Clean the inner cannula with a small brush or

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pipe cleaners. Rinse in sterile saline or water and replace after the outer cannula
has been suctioned. (NSNA NCLEX-RN Review, 4
th
Edition)

44. When suctioning Mr. Posible, with a tracheostomy, Nurse Edu must remember
to:
A. Use a new sterile catheter with each insertion
B. Initiate suction as the catheter is being withdrawn
C. Insert the catheter until the cough reflex is stimulated
D. Remove the inner cannula before inserting the suction catheter

Answer: B
Rationale: During suctioning of a client, negative pressure (suction) should not be
applied until the catheter is ready to be drawn out because, in addition to the
removal of secretions, oxygen is being depleted. (Mosby, 18
th
Edition)

45. Mr. Posible had a cuffed tracheostomy tube placed 4 weeks ago. The patient
is going to begin eating by mouth, with the tracheostomy tube in place. To prevent
aspiration, Nurse Edu will:
1. Raise the head of the bed to high-Fowler's position
2. Deflate the cuff on the tracheostomy tube
3. Suction the client before eating
4. Assess gag and swallow ability
5. Replace the tracheostomy tie
A. All except 2 C. All except 5
B. All except 3 D. All of the above

Answer: C
Rationale: Number 1 is correct because by raising the head of the bed, gravity helps
the client swallow and helps prevent aspiration.
Number 2 is correct because the cuff should initially be deflated to assess gag and
swallowing ability. In addition, some clients find it more difficult to swallow with the
cuff inflated. Thus, option A is incorrect.
Number 3 is correct because the client's airway should be patent, and secretions
removed before deflating the cuff. Thus, option B is incorrect
Number 4 is correct because assessing the client's gag and swallowing ability is
crucial before starting the client on PO food and fluids.
Numbers 5 is incorrect because it is not necessary to replace the tracheostomy ties
before the client eats, unless they are noted to be soiled or loose. Thus, making
option C the correct answer and option D incorrect. (Davis's NCLEX RN Success, 2
nd

Edition)

Situation 10. Noynoy Shananga, 58-year-old, is admitted to the medical-surgical unit of a
tertiary hospital with complains of alternating diarrhea and constipation, weight loss,
abdominal distention, and frank blood in the stool. Diagnostic tests reveal cancer of the
colon and creation of a colostomy was performed.
46. During a colostomy irrigation, if Mr. Shananga complains of abdominal

CODES I 14
well - research.
cramps, Nurse Mar Kit should:
A. Clamp the tubing and allow the patient to rest
B. Reassure the patient and continue the irrigation
C. Pinch the tubing so that less fluid enters the colon
D. Raise the irrigating container to complete the irrigation quickly

Answer: A
Rationale: Rapid instillation of fluid into the colon may cause abdominal cramps. By
clamping the tubing, the nurse allows the cramps to subside so the irrigation can be
continued.
Option B is incorrect because emotional support will not interrupt the physical
adaptation to abdominal. (Mosby, 18
th
Edition)

47. Mr. Shananga is concerned about the odor of the stool in the ostomy drainage
bag. Nurse Mar Kit teaches the patient to include which of the following foods in the
diet to reduce odor?
A. Cucumbers C. Yogurt
B. Broccoli D. Eggs

Answer: C
Rationale: The client should be taught to include deodorizing foods in the diet, such
as beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor, but is a
gas-forming food as well. (Saunders, 2
nd
Edition)

48. When discussing the regaining of bowel control with Mr. Shananga who has
had surgery for a colostomy, which is most important?
A. High-protein diet C. Managing fluid intake
B. Irrigation routine D. Soft, low-residue diet
Answer: B
Rationale: Colostomy irrigations done daily at the same time help establish a
regular pattern of bowel evacuation. (Mosby, 18
th
Edition)

49. Mr. Shananga tells Nurse Mar Kit that his wife does not let him change his
colostomy bag himself. Which response by the nurse indicates an understanding of
the situation?
A. Your wife's need to help you is a reality you should accept.
B. Do you think your wife might benefit from counseling?
C. You feel you need privacy when changing your colostomy?
D. Have you discussed the situation with your doctor?
Answer: C
Rationale: This type of communication technique, making an observation, enables
the nurse to acknowledge that something exists or has changed in some way. This
acknowledgement made by the nurse should open communication with the client.
th
Edition)

50. An adhesive-backed ostomy opening should be how much larger than the
stoma?
A. inch B. inch C.
1
/3 inch D.
1
/8 inch
Answer: D

CODES I 15
well - research.
Rationale: In general, the opening should be
1
/8 inch larger than the stoma itself. An
opening that fits too tightly can injure the stoma.
(Fundamentals of Nursing: Made Incredibly Easy!, 2007)

Situation 11. Nurse Loren is taking care of Mr. Money Billiards, a 35-year-old businessman
with acute renal failure, who is scheduled for hemodialysis.
51. Mr. Billiards is placed on hemodialysis three times a week. Which is an
attainable short-term goal for this patient when he is placed on hemodialysis?
A. Understanding the treatment and its implications
B. Independence in the care of the AV shunt
C. Self-monitoring during dialysis
D. Recording dialysate composition and temperature
Answer: A
Rationale: Prior to the start of dialysis, the client should fully comprehend its
meaning and the changes in lifestyle required. (NSNA NCLEX-RN Review, 4
th

Edition)

52. Mr. Billiards has an arteriovenous fistula. Which finding is expected when
assessing the fistula?
A. Ecchymotic area C. Pulselessness
B. Enlarged veins D. Redness
Answer: B
Rationale: The leaking of arterial blood into an AV fistula causes the veins to
enlarge so they are easier to access for hemodialysis. An AV fistula requires 4 to 6
weeks to mature before it can be used. Peritoneal dialysis or external shunts may
be used while the fistula is maturing. (NSNA NCLEX-RN Review, 4
th
Edition)

53. When caring for Mr. Billiards who has had an arteriovenous shunt inserted for
hemodialysis, Nurse Loren should:
A. Cover the entire cannula with an elastic bandage
B. Notify the physician if a bruit is heard in the cannula
C. Use surgical aseptic technique when giving shunt care
D. Take the blood pressure every 4 hours, using the arm that contains the
shunt

Answer: C
Rationale: Insertion of an arteriovenous shunt represents a break in the first line of
defense against infection, the skin. An infection of an arteriovenous shunt can be
avoided by strict aseptic (sterile) technique. (Mosby, 18
th
Edition)

54. Nurse Loren is monitoring Mr. Billiards who is undergoing hemodialysis. The
patient suddenly becomes cyanotic and complains of dyspnea and chest pain. His
blood pressure is 70/40 mm Hg and his pulse is weak and rapid. The nurse calls the
physician immediately because the signs and symptoms suggest which of the
following complications of dialysis?
A. Disequilibrium syndrome
B. Air embolism
C. Internal bleeding
D. Hemorrhage at the shunt

CODES I 16
well - research.

Answer: B
Rationale: Air embolism is a potentially fatal complication characterized by sudden
hypotension, dyspnea, chest pain, cyanosis, and weak, rapid pulse.
th
Edition)

55. Before discharge, Nurse Loren discusses care at home with Mr. Billiards and
his wife. The nurse recognizes that further teaching is required when the wife says:
A. I must touch the shunt several times a day to feel for the bruit.
B. I have to take his blood pressure every day in the arm with the fistula.
C. He will have to be very careful at night not to lie on the arm with the
fistula.
D. We really should check the fistula every day for signs of redness and
swelling.

Answer: B
Rationale: Taking the blood pressure in the affected arm could injure the fistula.
Option A is incorrect because the presence of a bruit indicates the circulation is not
obstructed by a thrombus. (Mosby, 18
th
Edition)

Situation 12. Nurse Jason is taking care of Mr. Freddie Ivler, 30 years old, with chronic
renal failure, who is scheduled for peritoneal dialysis.

56. The purpose of peritoneal dialysis is to:
A. Reestablish kidney function
B. Clean the peritoneal membrane
C. Provide fluid for intracellular spaces
D. Remove toxins and metabolic wastes

Answer: D
Rationale: Peritoneal dialysis uses the peritoneum as a selectively permeable
membrane for diffusion of toxins and wastes from the blood into the dialyzing
solution. (Mosby, 18
th
Edition)

57. When caring for Mr. Ivler who is receiving peritoneal dialysis, Nurse Jason
should:
A. Position the patient from side to side if fluid is not draining adequately
B. Notify the physician if there is a deficit of 200 ml in the drainage fluid
C. Maintain the patient in a flat, supine position during the entire procedure
D. Remove the cannula at the end of the procedure and apply a dry, sterile
dressing

Answer: A
Rationale: If fluid is not draining adequately, the client should be positioned from
side to side or with the head raised; or manual pressure should be applied to the
lower abdomen to facilitate drainage by using external pressure and gravity.
(Mosby, 18
th
Edition)

58. When assessing Mr. Ivler during peritoneal dialysis, Nurse Jason observes that

CODES I 17
well - research.
drainage of the dialysate from the peritoneal cavity has ceased before the required
amount has drained out. The nurse should assist the patient to:
A. Drink 8 oz of water C. Deep breathe and cough
B. Turn from side to side D. Periodically rotate the catheter

Answer: B
Rationale: Turning from side to side will change position of the catheter, thereby
freeing the drainage holes, which may be obstructed.(Mosby, 18
th
Edition)

59. Nurse Jason is completing the exchange by draining the dialysate and notices
the dialysate is opaque. The nurse best interprets this finding as:
A. The normal appearance of draining dialysate
B. A sign of infection
C. An indication of an impending lower back problem
D. A sign of a vascular access occlusion

Answer: B
Rationale: Peritonitis is usually caused by Staphylococcus. The first indication of
peritonitis is opaque or cloudy dialysate. (NSNA NCLEX-RN Review, 4
th
Edition)

60. Nurse Jason suspects a complication in Mr. Ivler who is receiving peritoneal
dialysis. Which of the following observations would support this evaluation?
A. Pain during the inflow of dialysate
B. Occasional diarrhea
C. Cloudy effluent
D. Clear or light yellow effluent

Answer: C
Rationale: The major complication of peritoneal dialysis is peritonitis. Cloudy or
opaque effluent is the earliest sign of peritonitis. Other signs of infection include
fever, rebound abdominal tenderness, malaise, nausea, and vomiting.
th
Edition)

Situation 13. Ms. Chica Go, a 40-year-old patient with esophageal cancer, is to receive
total parenteral nutrition. A right subclavian catheter is inserted by the physician.

61. Nurse Archipela knows that the primary reason for using a central line is that:
A. It prevents the development of phlebitis
B. There is less chance of this infusion infiltrating
C. It is more convenient so clients can use their hands
D. The large amount of blood helps to dilute the concentrated solution

Answer: D
Rationale: Unless diluted, the highly concentrated solution can cause hyperosmolar
diuresis. (Mosby, 18
th
Edition)

62. Nurse Archipela is preparing to change the total parenteral nutrition (TPN)
solution bag and tubing. The nurse asks Ms. Go to do which of the following most
essential action during the tubing changes?

CODES I 18
well - research.
A. Take a deep breath, hold it, and bear down
B. Exhale slowly and evenly
C. Turn the head to the right
D. Breathe normally

Answer: A
Rationale: The client should be asked to perform Valsalva maneuver during tubing
changes. This helps to avoid air embolism during tubing changes. The nurse asks
the client to take deep breath, hold it, and bear down.
(Silvestri, Saunders Comprehensive Review for the NCLEX-RN Examination, 3
rd

Edition)

63. Nurse Archipela is changing the central line dressing of Ms. Go who is
receiving total parenteral nutrition (TPN). The nurse notes that the catheter insertion
site appears reddened. The nurse next assesses which of the following?
A. Tightness of tubing connections
B. Clients temperature
C. Expiration date of the bag
D. Time of last dressing change
Answer: B
Rationale: Redness at the catheter insertion site is a possible indication of infection.
The nurse would next assess for other signs of infection. Of the options given, the
temperature is the next item to assess.
rd

Edition)

64. Ms. Go with total parenteral nutrition (TPN) infusing has disconnected the
tubing from the central line catheter. Nurse Archipela assesses the client and
suspects an air embolism. The nurse should immediately place the patient in which
of the following positions?
a. On the left side with the head higher than the feet
b. On the left side with the head lower than the feet
c. On the right side with the head higher than the feet
d. On the right side with the head lower than the feet
Answer: B
Rationale: When air embolism is suspected, the client should be placed in a left
side-lying position. The head should be lower than the feet. This position is used to
try to minimize the effect of the air traveling as a bolus to the lungs by trapping it in
the right side of the heart.
rd

Edition)

65. Ms. Go is being weaned from total parenteral nutrition (TPN) and is expected
to being taking solid food today. The ongoing solution rate has been 100 ml/hr.
Nurse Archipela anticipates that which of the following orders regarding the TPN
solution will accompany the diet order?
a. Discontinue the TPN
b. Continue current infusion rate orders for TPN
c. Decrease TPN rate to 50 ml/hr

CODES I 19
well - research.
d. Hang 1000 ml 0.9% normal saline
Answer: C
Rationale: When a client begins taking a diet after a period of receiving parenteral
nutrition, the TPN is decreased gradually. Total parenteral nutrition that is
discontinued abruptly (option A) can cause hypoglycemia. Clients often have
anorexia after being without food for some time, and the digestive tract also is not
used to producing the digestive enzymes that will be needed. Gradually decreasing
the infusion rate allows the client to remain adequately nourished during the
transition to a normal diet and prevents the occurrence of hypoglycemia. Even
before clients are started on a solid diet, they are given clear liquids followed by full
liquids to further ease the transition.
rd

Edition)

Situation 14. Using Maslows need theory, Airway, Breathing and Circulation are the
physiological needs vital to life. The nurses knowledge and ability to identify and
immediately intervene to meet these needs is important to save lives.
66. Which of these patients has a problem with transport of oxygen from the
lungs to the tissues?
A. Carol with a tumor in the brain
B. Patria with anemia
C. Jimson with fracture in the femur
D. Kenny with diarrhea
Answer: B
Rationale: A person with anemia may actually have decreased oxygen carriers (RBC
containing Hgb) in the blood. The RBC component of blood serves as the oxygen
carrying media that diffuses into it from the pulmonary capillaries.

67. You noted from the lab exams in the chart of Tado, a 25-year-old patient, that
he has reduced oxygen in the blood. This condition is called:
A. Cyanosis C. Hypoxemia
B. Hypoxia D. Anemia
Answer: C
Rationale: Hypoxemia is a state of reduced oxygen in the blood.

68. You will do nasopharyngeal suctioning on Hermes, 30 years old. Your guide
for the insertion of the tubing for an adult would be:
A. Tip of the nose to the base of the neck
B. The distance form the tip of the nose to the middle of the cheek
C. The distance from the tip of the nose to the earlobe
D. Eight to ten inches
Answer: C
Rationale: The guide for insertion of the tubing for an adult for nasopharyngeal
suctioning is: Measure the distance between the tip of the clients nose and the
earlobe, or about 13cm (5inches).

69. While doing nasopharyngeal suctioning on Hermes, the nurse can avoid
trauma to the area by:

CODES I 20
well - research.
A. Apply suction for at least 20-30 seconds each time to ensure that all
secretions are removed
B. Using gloves to prevent introduction of pathogens to the respiratory system
C. Applying no suction while inserting the catheter
D. Rotating the catheter as it is inserted with gentle suction
Answer: C
Rationale: Without applying suction, insert the premeasured catheter, or the
prescribed length into the naris, and advance it along the floor of the nasal cavity.

70. Cath, 21 years old, has difficulty of breathing when on her back and must sit
upright in bed in order to breathe effectively and comfortably. The nurse documents
this condition as:
A. Apnea C. Dyspnea
B. Orthopnea D. Tachypnea
Answer: B
Rationale: Orthopnea is an abnormal condition in which a person must sit of stand
to breathe deeply or comfortably, occurring in many disorders of the cardiac and
respiratory systems.

Situation 15. Nurse Jhang witnesses a vehicular accident near the hospital where she
works. She decides to get involved and help the victims of the accident.

71. Her priority nursing action would be to:
A. Assess damage to property
B. Assist in the police investigation since she is a witness
C. Report the incident immediately to the local police authorities
D. Assess the extent of injuries incurred by the victims of the accident
Answer: A
Rationale: Standard operating procedure in responding to disasters would be: 1
st
,
survey the scene if it is safe, 2
nd
, call for help, 3
rd
, begin primary survey, 4
th
begin
secondary survey. For multiple victims, do triage simultaneously with primary
survey.

72. Priority attention should be given to which of these patients?
A. Bryan who shows severe anxiety due to trauma of the accident
B. Anton who has chest injury, is pale and with difficulty of breathing
C. Chris who has laceration on the arms with mild bleeding
D. Joseph whose left ankle swelled and has some abrasions

Answer: B
Rationale: The use of ABC principle and Maslows Hierarchy of needs would indicate
that B is the best answer. Anxiety due to trauma is not a physiologic need which
requires greater priority. Having lacerations on the arms with mild bleeding and
having a swollen ankle and some abrasions may be a part of physiologic aspect, but
they are not as critical as a patient with chest injury, who is pale and has dyspnea.
Using the principle of ABC, airway deserves the greatest priority.

73. In the emergency room, Nurse Jhang is assigned to attend to the patient with
lacerations on the arms. While assessing the extent of the wound the nurse

CODES I 21
well - research.
observes that the wound is now starting to bleed profusely. The most immediate
nursing action would be to:
A. Apply antiseptic to prevent infection
B. Clean the wound vigorously of contaminants
C. Control and reduce the bleeding of the wound
D. Bandage the wound and elevate the arm
Answer: D
Rationale: According to the Red Cross guidelines for first-aid, management for
bleeding will involve the application of direct pressure only. The application of direct
pressure, elevation and pressure points is the old protocol in bleeding management.
Bandaging can cause pressure application and elevation of the affected part wound
will reduce blood flow to the area. This is the most appropriate intervention.
Option C is not an intervention but a nursing goal.

74. Nurse Jhang applies pressure dressing on the bleeding site. This intervention
is done to:
A. Reduce the need to change dressing frequently
B. Allow the pus to surface faster
C. Protect the wound from microorganisms in the air
D. Promote homeostasis
Answer: D
Rationale: For active bleeding in emergency situations, it is vital that the nurse or
the trained responder applies direct pressure over the bleeding site for the main
purpose of preventing further bleeding and even at times promote homeostasis. The
application of direct pressure over the bleeding site will not allow the pus to surface
faster nor will it protect the wound from microorganisms in the air. The reduction of
the need to change dressing is but just a secondary effect of the said intervention.

75. After the treatment, the patient is sent home and asked to come back for
follow-up care. Your responsibilities when the patient is to be discharged include the
following, except:
A. Encouraging the patient to go to the out patient clinic for follow up care
B. Accurate recording of treatment done and instructions given to the patient
C. Instructing the patient to see you after discharge for further assistance
D. Providing instructions regarding wound care

Answer: C
Rationale: Discharge includes obtaining order for discharge, planning continuity of
care, providing patient teaching, performing a final assessment, caring for personal
property, performing business functions, and documentation. Instructing the client
to see the nurse privately after discharge for further assistance is not a
responsibility.

Situation 16. Regardless of the prescribed solution, the nurse prepares the solution for
administration, performs a venipuncture, regulates the rate of administration, monitors
the infusion, and discontinues the administration when fluid balance is restored.

76. The physician is going to order a hypotonic intravenous solution for a patient
with cellular dehydration. Nurse Vince would expect which of the following fluids to

CODES I 22
well - research.
be administered?
A. 0.9% normal saline
B. 5% dextrose in normal saline
C. Lactated Ringer's
D. 0.45% sodium chloride

Answer: D
Rationale: 0.45% normal saline is a hypotonic solution that draws fluid from the
vascular compartment into the cells
(Hogan, Prentice Hall Reviews and Rationales Series for Nursing: Fundamentals of
Nursing)

77. IV orders for a 75-year-old patient include D5 NS with 20 mEq KCl at 75
cc/hr. At 6:00 A.M. a new bag of 1000 ml was hung. At 8:00 A.M. Nurse Vince sees
that only 200 ml remains. The first action by the nurse would be to:
A. Check the site for infiltration and elevate the extremity if needed
B. Order an infusion pump to provide better control of the rate
C. Slow the IV to keep open and check the patient for lung crackles
D. Assist the patient to the bathroom to void

Answer: C
Rationale: The first priority is to assess the effect on an elderly client from the rapid
infusion of 800 ml of fluid. The older adult is at greater risk for signs and symptoms
of volume overload (shortness of breath, crackles, and decreased oxygen
saturation) particularly with a history of heart failure.
(Davis's NCLEX RN Success, 2
nd
Edition)

78. Potassium chloride is to be added to an infant's intravenous fluids. Before
adding this electrolyte, Nurse Vince should determine that:
A. The infant has voided recently
B. Moro reflex is present
C. Respiratory rate is between 25 and 40
D. Mucous membrane is moist

Answer: A
Rationale: Before adding potassium chloride to any IV line, the nurse must check
that the client's kidneys are functioning to avoid potassium overload and
hyperkalemia. (Davis's NCLEX RN Success, 2
nd
Edition)

79. A patient admitted for decreased level of consciousness and dehydration is
receiving an IV of D5 NS with 40 mEq KCl/L infusing at 100 cc/hr. The patient's
potassium level is 5.9 mEq/L. Nurse Vince knows to:
A. Recheck the potassium level 6 hours after the blood is drawn in the
morning
B. Stop the IV, maintain the site, notify the physician about the lab level

CODES I 23
well - research.
C. Decrease the IV rate to 50 cc/hr and notify the physician when the
physician is on rounds
D. Assess the IV site and continue with the current order

Answer: B
Rationale: A normal potassium level is 3.5 to 5.5 mEq/L and the client has a high
potassium level of 5.9 mEq/L with potassium continuing to infuse in the IV fluid.
The nurse should stop the IV, maintain the IV site by flushing the IV with normal
saline or heparin per agency protocol, and notify the physician immediately for a
change in IV fluid order. (Davis's NCLEX RN Success, 2
nd
Edition)

80. When preparing an IV piggyback medication for a patient, Nurse Vince is
aware that it is essential to:
A. Use strict sterile technique
B. Rotate the bag after adding the medication
C. Use exactly 100 ml of fluid to mix the medication
D. Change the needle just before adding the medication

Answer: A
Rationale: Because IV solutions enter the body's internal environment, all solutions
and medications utilizing this route must be sterile to prevent the introduction of
microbes.
(Mosby, 18
th
Edition)

Situation 17. Blood is collected, stored, and checked for safety and compatibility before it
is administered as a transfusion.

81. Which nursing intervention is appropriate for Nurse Yuri to take when setting
up supplies for Toni, age 45, who requires a blood transfusion?
A. Add any needed IV medication in the blood bag within one half hour of
planned infusion
B. Obtain blood bag from laboratory and leave at room temperature for at
least one hour prior to infusion
C. Prime tubing of blood administration set with normal saline solution,
completely filling filter
D. Use a small-bore catheter to prevent rapid infusion of blood products that
may lead to a reaction

Answer: C
Rationale: The tubing is primed with normal saline solution (0.9% NS solution). If
the filter is not completely primed, debris will coagulate in the filter and the
transfusion will be slowed. In addition, saline is prepared to infuse in case a
transfusion reaction occurs.
NSNA NCLEX-RN Review, 4
th
Edition)

82. The physician orders 3 units of whole blood for Mr. Otol, age 51, who is in
hypovolemic shock after a gastrointestinal hemorrhage. When administering blood,
Nurse Yuri first verifies the type and cross-match and then routinely:
A. Warms the blood to body temperature to prevent chills

CODES I 24
well - research.
B. Uses an infusion pump to increase the accuracy of the infusion
C. Draws blood samples from the patient before and after each unit is
transfused
D. Runs the blood at a slower rate during the first 10 to 15 minutes of the
transfusion
Answer: D
Rationale: A slow rate provides time to recognize a transfusion reaction that is
developing before too much blood has been administered.
(Mosby, 18
th
Edition)

83. Princess, age 30, requires a blood transfusion. Her blood type is AB. To
prevent complications of blood incompatibilities, Nurse Yuri knows that this patient
may receive:
A. Type A or B blood only C. Type O blood only
B. Type AB blood only D. Either type A, B, AB, or O blood
Answer: D
Rationale: Persons with type AB blood, because they are universal blood recipients,
are able to receive either type A, B, AB, or O blood.
People with any blood type other than AB (type A, B and O blood), are restricted as
to the type of blood they can receive. (NSNA NCLEX-RN Review, 4
th
Edition)

84. Nurse Yuri is preparing to administer two units of packed red blood cells to
Bianca, age 34. The nurse should:
A. Prime the blood administration tubing with 3% saline solution
B. Administer the prescribed intravenous drugs through the blood
administration tubing to ensure proper distribution throughout the body
C. Understand that blood transfusion reactions usually do not occur until the
client has received 500 ml of the packed red blood cells
D. Use a special blood filter and an 18-gauge needle to administer the packed
red blood cells
Answer: D
Rationale: The large bore needle prevents lysis of the red blood cells. The special
blood filter prevents emboli or contaminated matter from flowing into the
bloodstream. (NSNA NCLEX-RN Review, 4
th
Edition)

85. Mariel, 50 years old, is receiving 5% dextrose in 0.45% saline. The physician
has ordered the patient receive one unit of packed red blood cells. Prior to hanging
the blood, Nurse Yuri will prime the blood tubing with which of the following
solutions?
A. 3% saline solution C. 0.9% sodium chloride
B. Lactated Ringer's D. 5% dextrose in 0.45% sodium chloride
Answer: C
Rationale: 0.9% sodium chloride (normal saline) is the only solution that can be
administered with blood or blood products.
Other solutions may cause the blood cells to clump or cause clotting. Thus, options
A, B and D are incorrect. (Hogan, Prentice Hall Reviews and Rationales Series for
Nursing: Fundamentals of Nursing)

CODES I 25
well - research.
Situation 18. When evaluating ABG results to determine acid-base balance, it is important
to use a systematic approach. Nurses need to assess each measurement individually, and
then look at the interrelationships to determine what type of acid-base imbalance may be
present.
86. Nurse Charitie understands that metabolic acidosis develops in kidney failure
as a result of:
A. Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate
B. Inability of the renal tubules to reabsorb water to dilute the acid contents of blood
C. Depression of respiratory rate by metabolic wastes causing carbon dioxide
retention
D. Impaired glomerular filtration causing retention of sodium and metabolic waste
products

Answer: A
Rationale: Bicarbonate buffering is limited, hydrogen ions accumulate, and acidosis
results. (Mosby, 18
th
Edition)

87. A patient's blood gases reflect diabetic acidosis. Nurse Charitie should expect:
A. Increased pH C. Increased PCO2
B. Decreased PO2 D. Decreased HCO3

Answer: D
Rationale: The bicarbonate-carbonic acid buffer system helps maintain the pH of
the body fluids; in metabolic acidosis there is a decrease in bicarbonate because of
an increase of metabolic acids.(Mosby, 18
th
Edition)

88. Nurse Charitie is interpreting the results of a blood gas analysis performed on
an adult patient. The values include pH of 7.35, PCO2 of 60, HCO3 of 35, and O2 of
60. Which interpretation is most accurate?
A. The patient is in metabolic acidosis
B. The patient is in compensated metabolic alkalosis
C. The patient is in respiratory alkalosis
D. The patient is in compensated respiratory acidosis

Answer: D
Rationale: A pH of 7.35 is on the acid side of normal. All of the other values are
abnormal so the client is compensated. The CO2 is sharply elevated and will lower
the pH. The HCO3 is also elevated and is responsible for bringing the pH up to the
normal range. An abnormal O2 suggests that the problem is a respiratory one.
th
Edition)

89. An adult woman is admitted with metabolic acidosis. Which set of arterial
blood gases should Nurse Charitie expect to find in a client with metabolic acidosis?
A. pH - 7.28; PCO2 - 55; HCO3 - 26
B. pH - 7.50; PCO2 - 40; HCO3 - 31
C. pH - 7.48; PCO2 - 30; HCO3 - 22
D. pH - 7.30; PCO2 - 36; HCO3 - 18
Answer: D

CODES I 26
well - research.
Rationale: The pH is below the normal range of 7.35 to 7.45. The PCO2 is within the
normal range of 35 to 45 mm Hg and the HCO3 is below the normal limits of 21 to
28 mEq/L. These values indicate a metabolic problem because the PCO2 is within
normal limits. And the problem is acidosis because the pH is below normal. This is
uncompensated metabolic acidosis because both the HCO3 level and the pH are
below normal.(NSNA NCLEX-RN Review, 4
th
Edition)

90. The patient's arterial blood gases on room air are: pH of 7.33; PO2 of 77; PCO2
of 50; and HCO3 of 23. Nurse Charitie instructs the patient to:
A. Try to breathe more slowly
B. Use the bedside inspirometer hourly when awake
C. Wear nasal cannula oxygen at 6 L/min
D. Increase fluid intake to flush the kidneys

Answer: B
Rationale: The blood gases indicate an uncompensated (normal HCO3; abnormal pH
and PCO2) respiratory (abnormal PCO2) acidosis (below normal pH). The client is
hypoventilating. To increase ventilation, the client should increase deep breathing
and activity levels to facilitate better O2/CO2 exchange. Instructing the client to use
the bedside inspirometer is an excellent tool for encouraging deep breathing and
giving the client a specific measured respiratory goal 10 times per hour when
awake. Walking should also be advised.(Davis's NCLEX RN Success, 2
nd
Edition)

Situation 19. Suctioning of the airway is the mechanical aspiration of mucous secretions
from the tracheobronchial tree by application of negative pressure. Appropriate nursing
care is needed in the performance of this procedure.

91. A nurse is performing oropharyngeal suctioning on an unconscious patient.
Which of the following actions is safe?
A. Insert the catheter approximately 20 cm while applying suction
B. Allow 20- to 30-second intervals between each suction, and limit suctioning
to a total of 15 minutes
C. Gently rotate the catheter while applying suction
D. Apply suction for 5 seconds while inserting the catheter and continue for
another 5 seconds before withdrawing

Answer: C
Rationale: Gentle rotation ensures that all surfaces are reached and prevents
trauma to any one area caused by prolonged suctioning.
(Hogan, Reviews and Rationales Series for Nursing: Fundamentals of Nursing)

92. An emergency tracheostomy is performed on a child with croup, and the child
is receiving humidified air via a tracheostomy collar. When caring for this child, the
nurse should suction the tracheostomy if the child:
A. Tells the nurse of difficulty in breathing
B. Becomes restless, diaphoretic, and cyanotic
C. Has severe substernal retractions and stridor
D. Becomes restless, pale, or the pulse increases

CODES I 27
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Answer: D
Rationale: These are some of the first signs of hypoxia; the airway must be kept
patent to promote oxygenation.(Mosby, 18
th
Edition)

93. The physician orders oropharyngeal suctioning as needed for a patient in a
coma. The nurse prepares to suction when assessment reveals:
A. Drainage of mucus and saliva from the mouth
B. The presence of a gurgling sound with each breath
C. Development of cyanosis in the nail beds of the fingers
D. The presence of a dry cough at increasingly frequent intervals

Answer: B
Rationale: The presence of secretions in the upper airway produces gurgling sounds
that interfere with the free flow of air with each breath.
. (Mosby, 18
th
Edition)

94. A nurse is suctioning fluids from a patient via a tracheostomy tube. When
suctioning, the nurse must limit the suctioning to a maximum of:
A. 5 seconds C. 30 seconds
B. 10 seconds D. 1 minute

Answer: B
Rationale: Hypoxemia can be caused by prolonged suctioning, which stimulates the
pacemaker cells within the heart. A vasovagal response may occur, causing
bradycardia. The nurse must preoxygenate the client before suctioning and limit the
suctioning pass to 10 seconds. (Silvestri, Saunders Comprehensive Review for the
NCLEX-RN Examination, 3
rd
Edition)

95. A patient with a pulmonary embolus is intubated and placed on mechanical
ventilation. When suctioning the endotracheal tube, the nurse should:
A. Apply suction while inserting the catheter
B. Hyperoxygenate with 100% oxygen before and after suctioning
C. Use short, jabbing movements of the catheter to loosen secretions
D. Suction two to three times in quick succession to remove secretions

Answer: B
Rationale: Suctioning also removes oxygen, which can cause cardiac dysrhythmias;
the nurse should try to prevent this by hyperoxygenating the client before and after
suctioning. (Mosby, 18
th
Edition)

Situation 20. Nursing is a science. It involves a wide spectrum of theoretical foundation
applied in current health care situation. The nurse must use these theories in order to
deliver quality health care.
96. Florence Nightingale was born in:
A. Italy, May 12, 1820 C. England, May 12, 1820
B. Italy, May 12, 1840 D. England, May 12, 1840

Answer: A

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Rationale: Florence Nightingale, the matriarch of modern nursing, was born on May
12, 1820. Her parents, Edward and Frances Nightingale, named their daughter after
her birthplace, Florence, Italy. Nightingales theory focused on the environment. She
believed that disease was a reparative process; disease was natures effort to
remedy a process of poisoning or decay, or a reaction against the conditions in
which a person is placed. In addition, her nursing principles remain applicable
today. The environmental aspects of her theory (ventilation, warmth, quiet, diet and
cleanliness) remain integral components of current nursing care. (Tomey, Nursing
Theorists and their Work, 5
th
Edition)

97. The theorist that describes nursing as a significant, therapeutic, interpersonal
process, which functions cooperatively with other human processes that make
health possible for individuals in communities is:
A. Hildegard Peplau C. Patricia Benner
B. Joyce Travelbee D. Ida Jean Orlando

Answer: A
Rationale: Hildegard Peplaus theory is on Interpersonal Relations. She describes
nursing as a significant, therapeutic, interpersonal process. It functions
cooperatively with other human processes that make health possible for individuals
in communities. (Tomey, Nursing Theorists and their Work, 5
th
Edition)

98. The theorist whose major theme is the idea of transcultural nursing and
caring is:
A. Jean Watson C. Virginia Henderson
B. Madeleine Leininger D. Ernestine Wiedenbach

Answer: B
Rationale: Madeleine Leininger is the founder of transcultural nursing and a leader
in transcultural nursing and human care theory.
(Tomey, Nursing Theorists and their Work, 5
th
Edition)

99. The theorist whose theory can be defined as the development of a science of
humankind, incorporating the concepts of energy fields, openness, pattern and
organization is:
A. Dorothy Johnson C. Martha Rogers
B. Imogene King D. Myra Levine

Answer: C
Rationale: Martha Rogers develop the Science of Unitary Human Beings. Rogerian
nursing focuses on concern with people and the world in which they live, a natural
fit for nursing care, as it encompasses people and their environments. The
integrality of people and their environments, operating from a pandimensional
universe of open systems, points to a new paradigm and initiate the identity of
nursing as a science. (Tomey, Nursing Theorists and their Work, 5
th
Edition)

100. The theorist who is the proponent of the Self Care Deficit theory of nursing is:
A. Betty Neuman C. Faye Glenn Abdellah
B. Dorothea Orem D. Sister Callista Roy

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Answer: B
Rationale: Dorothea Orem is the proponent of the Self Care Deficit theory of
nursing. (Tomey, Nursing Theorists and their Work, 5
th
Edition)

MATERNITY NURSING

Situation 1: Cora, 9 months pregnant, is admitted to the hospital with bleeding caused by
possible placenta previa. The laboratory technician takes blood samples and IV fluids are
begun.

6. A client with placenta previa is likely to present with:
a. Hard, tender uterus
b. Painless, bright-red vaginal bleeding after the 20
th
week of gestation
c. A sluggish fetus with weak heart sounds on auscultation
d. Bleeding during the first trimester
Answer: B
Rationale: With placenta previa, the client has painless, bright-red vaginal bleeding
after the 20
th
week of gestation that starts without warning and stops spontaneously.
Palpation reveals a soft, non-tender uterus, and auscultation reveals an active fetus
with good heart sounds. Also, bleeding commonly occurs during the third trimester.
(Straight As in Maternal-Neonatal Nursing, 2
nd
Edition)

7. Nursing care for Cora includes:
a. Withholding foods and fluids
b. Encouraging ambulation and supervision
c. Inspecting the hemorrhage
d. Avoiding all extraneous stimuli
Answer: C
Rationale: To prevent further maternal and fetal complication, clients must be
continuously observed for blood loss by the monitoring of external bleeding and the
counting and weighing of pads.

8. The nurse following the physicians order, begins administering oxygen by mask. The
clients apprehension is increasing and she asked the nurse what is happening. The
nurse tells her not to worry, that she is going to be all right and everything is under
control. The nurse statements are:
a. Correct, since only the physician should explain why treatment are being done
b. Proper, since the clients anxieties would be increased if she knew the dangers
c. Adequate, since all preparations are routine and need no explanation
d. Questionable, since the client has the right to know what treatment is being given
and why
Answer: D
Rationale: The client has the right to a complete and accurate explanation of
treatment.

9. If a vaginal examination is to be performed on Cora, the nurse should be prepared for
an immediate:

CODES I 30
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a. Induction of labor c. Forceps delivery
b. Cesarean delivery d. X-ray examination
Answer: B
Rationale: Vaginal exam might precipitate severe bleeding, which could be life
threatening to the mother and infant and necessitate immediate CS delivery.

10. The care of a client with placenta previa includes:
a. Vital signs at least once per shift
b. A tap-water enema before delivery
c. Observation and recording of the bleeding
d. Limited ambulation until the bleeding stops

Answer: C
Rationale: Observation and documentation of bleeding are independent nursing
functions and necessary for implementing safe care, because hemorrhage and shock
can be life-threatening.

Situation 2: Helen, age 20, is 37 weeks pregnant. She is admitted to the hospital with
preeclampsia, moderate vaginal bleeding, and sudden abdominal pain. The results of the
ultrasound indicate that abruptio placenta is present.

11. Based on these findings, the nurse would prepare the client for:
a. Complete bed rest for the remainder of the pregnancy
b. Delivery of the fetus
c. Strict monitoring of intake and output
d. The need for weekly monitoring of coagulation studies until the time of delivery

Answer: B
Rationale: The goal of management in abruptio placenta is to control the hemorrhage
and deliver the fetus a soon as possible. Delivery is the treatment of choice if the fetus
is at term gestation, or if bleeding is moderate to severe, and the mother or fetus is in
jeopardy. (Saunders, 3
rd
Edition)

12. On Helens admission to the unit the nurse should observe for:
a. Decrease in size of uterus, cessation of contractions, visible or concealed
hemorrhage
b. Firm and tender uterus, concealed or external hemorrhage, shock
c. Increase in size uterus, visible bleeding, no associated pain
d. Shock, decrease in size uterus, absence of external bleeding

Answer: B
Rationale: Signs of mild to moderate placental separation include uterine discomfort
and tenderness because of concealed bleeding. Visible bleeding maybe scant,
moderate or heavy

13. The nurse realizes that the abdominal pain associated with abruption placenta is
caused by:
a. Hemorrhagic shock
b. Inflammatory reactions

CODES I 31
well - research.
c. Blood in the uterine muscle
d. Concealed hemorrhage

Answer: D
Rationale: The blood can not escape from behind the placenta. Thus the abdomen
becomes board like and painful because of the entrapment.

14. Helen is given a unit of blood. The realizes that this is necessary, since the bleeding
following severe abruptio placenta is usually caused by:
a. Hypofibrinogenemia c. Thrombocytopenia
b. Hyperglobulinemia d. Polycythemia

Answer: A
Rationale: Clotting defects are common in moderate and severe abruption placentae
because of the loss of fibrinogen from severe internal bleeding.

15. A nurse is monitoring Helen for Disseminated Intravascular Coagulopathy. Which
assessment finding is least likely to be associated with DIC?
a. Swelling of the calf on one leg
b. Prolonged clotting times
c. Decreased platelet count
d. Petechiae, oozing from injection sites, and hematuria

Answer: A
Rationale: These signs are most likely associated with thrombophlebitis.

Situation3: Anne delivered a child two days ago. She is breastfeeding her child.
16. To show Anne how to help her have good attachment of the infant during breast
feeding. Which of the following statements should NOT be included?
a. Place the infant in your most convenient position
b. Touch the infants lips with her nipples
c. Wait until the infants mouth is widely open
d. Move the infant quickly onto her breast, aiming the infants lips well below the
nipple

Answer: A
Rationale: The infant should be positioned in such a way that the chin of the child is
touching the breast of the mother, for better latch-on technique.

17. Which of the following signs of good attachment should the nurse teach Anne?
a. The chin should touch the breast, the mouth is wide open while the lower lip is
turned inward, and more areola is visible above than below
b. The chin should touch the breast, the mouth is wide open while the lower lip turned
outward, and more areola visible above than below
c. The chin should touch the breast, the mouth is wide open while the lower lip turned
outward, and more areola visible below than above
d. The chin should touch the breast, the mouth is wide open while the lower lip turned
inward, and more areola is visible below than above

CODES I 32
well - research.
Answer: B
Rationale: Signs of good latch-on technique include: chin touching the breast, the
mouth is wide open; the lower lip turned outward; and more areola is visible above
than below the mouth.

18. Which of the following instructions can the nurse give to Anne?
a. Wear a good, well-supporting bra
b. Apply warm compresses to breast if too full
c. Apply cold compresses to breast if too full
d. Do not apply any soap to your nipples

Answer: A
Rationale: A well-fitting supportive bra with wide straps can be recommended for a
nursing mother. The nursing mother's bra should have front flaps over each breast for
easy access during nursing periods.

19. Anne is visited by the home health nurse two weeks after delivery. The woman is
febrile with flu-like symptoms. On assessment, the nurse notes a warm, reddened
painful area of the right breast. The best initial action of the nurse is to:
a. Contact the physician for an order of antibiotics
b. Advise the mother to stop breastfeeding and pumping
c. Assess the mother's feeding technique and knowledge of breast care
d. Obtain a sample of the breast milk for culture

Answer: A
Rationale: These symptoms are signs of infectious mastitis, usually caused by
Staphylococcus aureus. A 10-day course of antibiotics is needed.

20. Anne has received treatment for a warm, reddened, painful area in the breast as
well as cracked and fissured nipples. The client expresses the desire to continue
breastfeeding. The following are instructions that the nurse should include to prevent
recurrence of this condition EXCEPT:
a. Change the breast pads frequently
b. Expose the nipples to air for part of each day
c. Wash hands before handling the breast and breastfeeding
d. Make sure that the baby grasps the nipple only

Answer: D
Rationale: The baby should grasp both the nipple and areola.

Situation 4: Rita, 27 years old, is a gravida 1 in the active phase of labor. Fetal position is
LOA, and cervix is 4 cm dilated.
21. Rita wants to walk about in the labor room. Which of the following criteria will help
the nurse determine whether she should walk?
a. Whether membranes are intact
b. Frequency of contraction
c. Fetal position
d. Fetal station

CODES I 33
well - research.
Answer: D
Rationale: If the fetus is engaged (0 station, or +1 or more), cord prolapse will be
prevented whether her membranes have ruptured or not.

22. When planning comfort measures to help Rita in active labor to tolerate her pain,
the nurse must consider which of the following?
a. Early labor contractions are usually regular, coordinated, and very painful
b. If women are properly prepared, they will require no pain medication to manage
their pain
c. Pain medication given during the latent phase of labor is not likely to impair
contractions
d. The acceleration phase of labor can be a time of true discomfort and high anxiety

Answer: D
Rationale: During the acceleration/active phase of labor, contractions grow strong, last
longer and begin to cause true discomfort and high anxiety as she realizes that labor is
truly progressing and her life is about to change forever.

23. When her membranes rupture, the nurse should expect to see:
a. A large amount of bloody fluid
b. A moderate amount of clear to straw-colored fluid
c. A small amount of greenish fluid
d. A small segment of the umbilical cord

Answer: B
Rationale: With the baby in a vertex LOA presentation and no other indicators of fetal
distress, amniotic fluid has a clear to straw-colored appearance.

24. When her membranes rupture, the nurse's first action should be to:
a. Notify the physician because delivery is imminent
b. Measure the amount of fluid
c. Count the fetal heart rate
d. Perform a vaginal exam

Answer: C
Rationale: Immediately after rupture of membranes fetal heart tones should be
checked, and then checked again after the next contraction or after 5-10 minutes.

25. During the third stage of labor, the nurse may have which of the following
responsibilities?
a. Administer intramuscular Oxytocin to facilitate uterine contractility
b. Monitor for blood loss greater than 100 cc, which would indicate gross hemorrhage
c. Note if the placenta makes a Schultz presentation, which is a sign of gross
complication
d. Push down on the relaxed uterus to aid in the removal of the placenta

Answer: A
Rationale: Oxytocin causes uterine contraction, thus preventing hemorrhage.

CODES I 34
well - research.
Situation 5: A pregnant client has delayed her first prenatal visit. She visits the prenatal
clinic only after she starts to experience edema of the feet and hands. The nurse takes a
history and physical assessment to begin Mrs. Barton's care.
26. The client's response to one of the nurse's questions is, This is my third pregnancy.
I miscarried twice, the first time I was 8 weeks pregnant, and the last time I was 26
weeks pregnant. The nurse correctly records Mrs. Barton's pregnancy status as:
a. G2, P0, A1 c. G3, P0, A2
b. G2, P1, A1 d. G3, P1, A1

Answer: D
Rationale: G3 (total of 3 pregnancies: present pregnancy plus the two miscarriage); P1
(second miscarriage at 26 weeks AOG); A1 (first miscarriage at 8 weeks AOG). Gravida
pertains to the number of pregnancies regardless of the duration. Para pertains to the
number of pregnancies that lasted more than 20 weeks, regardless of the outcome.
Abortion pertains to the number of terminated pregnancies, not reaching the age of 20
weeks (age of viability).

27. During the examination, while client is lying in a lithotomy position, the client
complains of dizziness and nausea. What would be an appropriate nursing action to
relieve the client's discomfort?
a. Administering an antiemetic ordered by the physician
b. Offering small sips of ginger ale
c. Assisting to a side-lying position temporarily
d. Discontinuing the examination

Answer: C
Rationale: Lying supine for a prolonged period of time, with the legs in a lithotomy
position. The weight of the growing uterus presses the vena cava against the vertebrae,
obstructing blood flow to the lower extremities. This causes a decrease ion blood return
to the heart, and consequently decreased cardiac output and hypotension, manifesting
as nausea and dizziness, lightheadedness, faintness and palpitations. Assisting the
client in a side-lying position relieves pressure on the vena cava, thus improving blood
circulation.

28. Diplopia was noted during the assessment of Mrs. Barton. This condition is
described as:
a. Elevated pigmentation of the skin
b. Double vision
c. Facial edema
d. Gingivitis

Answer: B
Rationale: Diplopia is described as having double vision. Women with PIH commonly
report spots before their eyes, or having double vision.

29. The physician asks the nurse to make sure his pregnant patient's next appointment
is scheduled correctly. The patient is in her 33rd week. Her next appointment should be
in:

CODES I 35
well - research.
a. 1 month c. 2 weeks
b. 3 weeks d. 1 week

Answer: C
Rationale: First visit may be made as soon as the woman suspects she is pregnant.
Subsequent visits are as follows: monthly until the 8
th
month; every 2 weeks during the
8
th
month, and weekly during the 9
th
month. More frequent visits are scheduled if
problems arise. The client is 8 months pregnant (33 weeks), so the next visit will be
scheduled after 2 weeks.

30. Mrs. Barton reports that the last day of her last menstrual period was May 11,
2009. Her menstruation lasted for 5 days. Her expected date of delivery will be:
a. February 14, 2010 c. August 4, 2010
b. February 18, 2010 d. August 18, 2010

Answer: A
Rationale:
A. February 14, 2010
Her first day of LMP is May 7, 2009.
Use Naegel's rule: month-3; day+7; year+1
05 07 2009
-3 +7 +1
------------------------------
02 14 2010

Situation 6: Nene is a 26-year-old woman you admit to a birthing room. Shes been having
contractions 45 seconds long and 3 minutes apart for the last 6 hours. She tells you she
wants to have her baby natural without analgesia or anesthesia. Her husband is in the
army assigned overseas, so he is not with her. Although her sister lives only two blocks
from the birthing center, Nene doesnt want her called. She asks if she can talk to her
mother on the telephone. As you finish assessing contractions, she screams with pain and
shouts, Ginagawa ko na ang lahat ng makakaya ko! Kailan ba matatapos ang paghihirap
kong ito?
31. Nene did not recognize for over an hour that she was in labor. A sign of true labor is:
a. Sudden increased energy from epinephrine release
b. Nagging but constant pain in the lower back
c. Urinary urgency from increased bladder pressure
d. Show or release of the cervical mucus plug

Answer: D
Rationale: Signs of true labor involve uterine and cervical changes. As the cervix
softens and ripens, the mucus plug that filled the cervical canal during pregnancy
(operculum) is expelled. The exposed cervical capillaries seep blood as a result of
pressure exerted by the fetus. The blood, mixed with mucus, takes on a pink tinge and
is referred to as show or bloody show.

32. Nene asks which fetal position and presentation are ideal. Your best answer would
be:

CODES I 36
well - research.
a. Right occipitoanterior full flexion
b. Left transverse anterior in moderate flexion
c. Right occipitoposterior with no flexion
d. Left sacroanterior with flexion

Answer: A
Rationale: A fetus is born fastest from ROA/LOA position. Full flexion (chin touches the
sternum, arms are flexed and folded on the chest, thighs are flexed onto the abdomen,
and the calves are pressed against the posterior aspect of the thighs) allows the
smallest diameter of the skull to enter to the pelvis.

33. Nene is having long and hard uterine contraction. What length of contraction would
you report as abnormal?
a. Any length over 30 seconds
b. A contraction over 70 seconds in length
c. A contraction that peaks at 20 seconds
d. A contraction shorter than 60 seconds

Answer: B
Rationale: Uterine contractions lasting longer than 70 seconds should be reported,
because contractions of this length begin to compromise fetal well-being by interfering
with adequate uterine artery filling. (Pillitteri, Maternal and Child Health Nursing, 5
th

Edition)

34. You assess Nenes uterine contractions. In relation to the contraction, when does a
late deceleration begin?
a. 45 seconds after the contraction is over
b. 30 seconds after the start of a contraction
c. After every tenth or more contraction
d. After a typical contraction ends

Answer: B
Rationale: Late decelerations are those that are delayed until 30 to 45 seconds after
the onset of a contraction, and continue beyond the end of the contraction. This is an
ominous pattern in labor, because it suggests uteroplacental insufficiency. (Pillitteri,
Maternal and Child Health Nursing, 5
th
Edition)

35. Immediately after the membranes rupture, which of the following should the nurse
check?
a. Check the presence of infection
b. Assess for prolapsed umbilical cord
c. Check for maternal heart rate
d. Assess the color of the amniotic fluid

Answer: B
Rationale: When membranes rupture, amniotic fluid is allowed to escape. The nurse
should check for prolapse of the umbilical cord because there is a possibility that a
loop of cord will escape with the fluid, which can cu off the oxygen supply to the fetus.

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well - research.
Situation 7: Sexually Transmitted Diseases are important to identify during pregnancy
because of its potential effect on the pregnancy, fetus, or newborn. The following
questions pertain to STDs.

36. Frankie, a promiscuous woman in Manila, submits herself to the clinic for check-up.
She complains of vaginal irritation, redness and a thick cream cheese-like vaginal
discharge. As a nurse, you will suspect that Frankie is having a vaginal infection caused
by:
a. Gardnerella vaginalis
b. Candida albicans
c. Treponema pallidum
d. Herpes simplex virus type 2

Answer: B
Rationale: Vaginal infection with Candida albicans (Candidiasis) is characterized by
red and irritated vagina, pruritus, and thick vaginal discharge that resemble cream
cheese.

37. Cecil comes to the health center. Her doctor examines Cecils vaginal secretions
and finds out that she has Trichomoniasis infection. Trichomoniasis is diagnosed
through which of the following methods?
a. Vaginal secretions are examined in a wet slide that has been treated with
potassium hydroxide
b. Vaginal speculum is used to obtain secretions from the cervix
c. A litmus paper is used to test if the vaginal secretions are infected with
Trichomoniasis
d. Vaginal secretions are examined on a wet slide treated with zephiram solution

Answer: A
Rationale: Trichomoniais is diagnosed by examination of vaginal secretions on a wet
slide that has been treated with potassium hydroxide. (Pillitteri, Maternal and Child
Health Nursing, 5
th
Edition)

38. The drug of choice for a client with Trichomoniasis is:
a. Flagyl c. Monistat
b. Cotrimazole d. Zovira

Answer: A
Rationale: The drug of choice for Trichomoniasis a single-dose oral metronidazole
(Flagyl).

39. Jarisch-Herxheimer reaction maybe experienced by the client with syphilis after
therapy with benzathine penicillin G. The characteristic manifestation of Jarisch-
Herxheimer reaction are:
a. Rashes, itchiness, hives and pruritus
b. Confusion, drowsiness, and numbness of extremities
c. Sudden episode of hypotension, fever, tachycardia, and muscle aches
d. Episodes of nausea and vomiting, with bradypnea and bradycardia

CODES I 38
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Answer: C
Rationale: After therapy with benzathine penicillin G, a woman may experience sudden
episode of hypotension, fever, tachycardia and muscle aches, which is known as the
Jarisch-Herxheimer reaction. This occurs when large quantities of toxins are released
into the body as spirochetes die, due to antibiotic treatment. Typically the death of
these spirochetes and the associated release of endotoxins occur faster than the body
can remove the toxins via the natural detoxification process performed by the kidneys
and liver. The reaction lasts about 24 hours and then fades. (Pillitteri, Maternal and
Child Health Nursing, 5
th
Edition)

40. Cryocautery may be used in removing the lesions of a client with venereal warts.
The healing period after cryocautery may be completed in 4-6 weeks but may cause
some discomforts to the woman. What measures can alleviate these discomforts?
a. Kegels exercise
b. Cool air
c. Topical steroids
d. Sitz bath and lidocaine cream

Answer: D
Rationale: With cryocautery, edema at the site is evident immediately. Lesions become
gangrenous, and sloughing occurs in 7 days. Healing will be complete in 4 to 6 weeks
with only slight depigmentation at the site. Sitz baths hand lidocaine cream may be
soothing during the healing period. (Pillitteri, Maternal and Child Health Nursing, 5
th

Edition)

Situation 8: Nurse Gwen is an Independent Nurse Practitioner following-up referred clients
in their respective homes. She handles Leah's case, a postpartal mother.
41. Leah is developing constipation from being on bed rest. What measures would you
suggest she take to help prevent this?
a. Eat more frequent small meals instead of three large one daily
b. Walk for at least half an hour daily to stimulate peristalsis
c. Drink more milk, increased calcium intake prevents constipation
d. Drink eight full glasses of fluid such as water daily

Answer: D
Rationale: Increasing oral fluid intake relieves constipation.

42. Which of the following actions would alert Nurse Gwen that Leah is entering a
postpartal taking-hold phase?
a. She urges the baby to stay awake so that she can breast-feed him or her
b. She tells you she was in a lot of pain all during labor
c. She says that she has not selected a name for the baby as yet
d. She sleeps as if exhausted from the effort of labor

Answer: A
Rationale: Taking-hold phase usually happens by the third postpartum day.

43. At 6-week postpartum visit, what should Leah's fundic height be?
a. Inverted and palpable at the cervix

CODES I 39
well - research.
b. Six finger breadths below umbilicus
c. No longer palpable on her abdomen
d. One centimeter above the symphysis pubis

Answer: C
Rationale: Involution of the uterus occurs at a rate of 1 finger breadth (1 cm) per
postpartum day, until by the end of the second week postpartum it is already a pelvic
organ and cannot be palpated through the abdominal wall.
B. This is during the 6
th
postpartum day.

44. Leah wants to loose the weight she gained in pregnancy, so she is reluctant to
increase her caloric intake for breast-feeding. By how much should a lactating mother
increase her caloric intake during the first 6 months after birth?
a. 350 kcal/day c. 200 kcal/day
b. 500 kcal/day d. 1000 kcal/day

Answer: B
Rationale: A lactating mom should have an additional intake of 500 kcal/day.

45. When preparing recommendations for Leah, which of the following contraceptive
methods would be avoided?
a. Diaphragm c. Oral contraceptives
b. Female condom d. Rhythm method

Answer: A
Rationale:
A. The diaphragm must be fitted individually to ensure effectiveness. Because of the
changes to the reproductive structures during pregnancy and following delivery, the
diaphragm must be refitted, usually at the 6 weeks examination following childbirth or
after a weight loss of 15 lbs or more. In addition, for maximum effectiveness,
spermicidal jelly should be placed in the dome and around the rim. However,
spermicidal jelly should not be inserted into the vagina until involution is completed at
approximately 6 weeks.

Situation 9: Nette, a nurse palpates the abdomen of Mrs. Medina, a primigravida. She is
unsure of the date of her last menstrual period. Leopolds Maneuver is done. The
obstetrician said that she appears to be 20 weeks pregnant.
46. Nette explains this because the fundus is:
a. At the level of the umbilicus, and the fetal heart can be heard with a fetoscope
b. 18 cm, and the baby is just about to move
c. Is just over the symphysis, and fetal heart cannot be heard
d. 28 cm, and fetal heart can be heard with a Doppler

Answer: A
Rationale: According to Bartholomew's rule, fundus located at the umbilicus is
approximately 20 weeks AOG. Fetal heart can be heard using a fetoscope by 18 to 20
weeks AOG.

47. In doing Leopolds Maneuver palpation which among the following is NOT

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considered a good preparation:
a. The woman should lie in a supine position with her knees flexed slightly
b. The hands of the nurse should be cold so that abdominal muscles would contract
and tighten
c. Be certain that your hands are warm (by washing them in warm water first if
necessary)
d. The woman empties her bladder before palpation

Answer: B
Rationale: The hands of the nurse should be warm so that abdominal muscles will not
contract and tighten on palpation.

48. In her pregnancy, she experienced fatigue and drowsiness. This probably occurs
because:
a. Of high blood pressure
b. She is expressing pressure
c. The fetus utilizes her glucose stores and leaves her with a low blood glucose
d. Of the rapid growth of the fetus

Answer: C

49. The nurse assesses the woman at 20 weeks gestation and expects the woman to
report:
a. Spotting related to fetal implantation
b. Symptoms of diabetes as human placental lactogen is released
c. Feeling fetal kicks
d. Nausea and vomiting related HCG production

Answer: C
Rationale: Quickening is felt by 16 to 20 weeks AOG.

50. Mrs. Medina comes to you for check-up on June 2, her EDC is June 11. What do you
expect during assessment?
a. Fundic height of 2 fingers below xyphoid process, engaged
b. Cervix close, uneffaced, FH-midway between the umbilicus and symphysis pubis
c. Cervix open, fundic height 2 fingers below xyphoid process, floating
d. Fundic height at least at the level of the xyphoid process, engaged

Answer: A
Rational: Around this time, the fetus has already engaged (dropped into the maternal
true pelvis; otherwise known as lightening) as indicated by the fundus located 2 finger
breadths below the xiphoid process.

Situation 10: A professional nurse should know how to respond in these varied health
situations.
51. RhoGAM is given to Rh-negative women to prevent maternal sensitization from
occurring. The nurse is aware that in addition to pregnancy, Rh-negative women would
also receive this medication after which of the following?
a. Unsuccessful artificial insemination procedure

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b. Blood transfusion after hemorrhage
c. Therapeutic or spontaneous abortion
d. Head injury from a car accident

Answer: C
Rationale: Therapeutic or spontaneous abortion causes mixing of the fetal blood
(RH+) and maternal blood (Rh-). This could trigger the production of maternal
antibodies against the circulating Rh+ blood. The circulating antibodies in the maternal
blood will destroy future pregnancies with a Rh+ blood. Rhogam is given 72 hours post
delivery to prevent production of maternal antibodies.

52. The breathing technique that the mother should be instructed to use as the fetus'
head is crowning is:
a. Blowing c. Shallow
b. Slow chest d. Accelerated-decelerated

Answer: A
Rationale: Blowing forcefully through the mouth controls the strong urge to push and
allows for a more controlled birth of the head.

53. When providing prenatal education to a pregnant woman with asthma, which of the
following would be important for the nurse to do?
a. Demonstrate how to assess her blood glucose levels
b. Teach correct administration of subcutaneous bronchodilators
c. Ensure she seeks treatment for any acute exacerbation
d. Explain that she should avoid steroids during her pregnancy

Answer: D
Rationale: Steroids cause cleft lip/palate in newborns.

54. Which of the following conditions would cause an insulin-dependent diabetic client
the most difficulty during her pregnancy?
a. Rh incompatibility
b. Placenta Previa
c. Hyperemesis Gravidarum
d. Abruptio Placenta

Answer: C
Rationale: Both conditions predispose the mother to accumulating high levels of
ketone bodies in the blood.

55. 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?
a. 10 pounds per trimester
b. 1 pound per week for 40 weeks
c. pound per week for 40 weeks
d. A total gain of 25 to 30 pounds

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Answer: D
Rationale: To ensure adequate fetal growth and development during pregnancy, a
total weight gain 25 to 30 lbs (other books: 25 to 35 lbs) pounds is recommended: 1 lb
per month in the first trimester; and 1 lb per week in the last two trimesters.

Situation 11: Angel, 25 years old, is a 2-day postpartum client. She delivered a 6 lb 4 oz
baby boy.
56. Angel verbalizes her labor and delivery experience, does not appear confident about
holding the baby or changing diapers. The nurse identifies the client is in which phase
of the postpartum period?
a. Letting go c. Holding out
b. Taking in d. Taking hold

Answer: B
Rationale: The taking-in phase is the first postpartum phase. During this phase, the
mother feels overwhelmed by the responsibilities of the newborn care and is still
fatigued from delivery.

57. When checking Angel's fundus, the nurse observes that the fundus is above the
umbilicus and displaced to the right. The nurse evaluates that the client probably has:
a. A slow rate of involution
b. A full, overdistended bladder
c. Retained placental fragments
d. Overstretched uterine ligaments

Answer: B
Rationale: A distended bladder will displace the fundus upward and laterally.

58. During the postpartum period, Angel tells the nurse she is having leg cramps. The
nurse should suggest that she should increase her intake of:
a. Eggs and bacon c. Juices and water
b. Liver and onions d. Cheese and broccoli

Answer: D
Rationale: The leg cramps may be related to low calcium intake. Cheese and broccoli
both have high calcium content.

59. When performing discharge teaching for Angel, the nurse should inform her that:
a. The episiotomy sutures will be removed at the first postpartum checkup
b. She may not have any bowel movements for up to a week after the birth
c. She has to schedule a postpartum checkup as soon as her menses returns
d. The perineal tightening exercises started during pregnancy should be continued
indefinitely

Answer: D
Rationale: Kegels exercise can be resumed immediately and should be done for the
rest of her lie.

60. Which of the following statements would indicate to the nurse that Angel has begun

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to integrate her new baby into the family structure?
a. All the baby does is cry. He's not like my other child.
b. I wish he had curly hair like my husband
c. My parents wanted a granddaughter
d. When he yawns, he looks like just his brother

Answer: D
Rationale: Family identification of the newborn is an important part of attachment.
The first step in identification is done in terms of likeness to family members.

Situation12: Awareness of the complications that may accompany pregnancy is essential
in order to render apt nursing management.
61. In which of the following clients would the nurse suspect anemia?
a. Client in her first trimester with a hemoglobin level of 12 g/dL
b. Client in her second trimester with a hemoglobin level of 11 g/dL
c. Client in her third trimester with a hemoglobin level of 8 g/dL
d. Client in her first trimester with a hemoglobin level of 10.5 g/dL

Answer: C
Rationale: Anemia during pregnancy is described as a hemoglobin level of 10 g/dL or
less during the second and third trimesters. Thus, the nurse would suspect anemia in
the client in her third trimester with hemoglobin of 8 g/dL. Hemoglobin levels of 12
g/dL, 11 g/dL, and 10.5 g/dL are above the cut-off range for the diagnosis of anemia.
(Lippincotts Review Series: Maternal-Newborn Nursing, 4
th
Edition)

62. Which of the following would the nurse identify as a classic sign of PIH?
a. Edema of the feet and ankles
b. Edema of the hands and face
c. Weight gain of 1 lb/week
d. Early morning headache

Answer: B
Rationale: This is the classic sign of PIH.

63. Which of the following may happen if the uterus becomes overstimulated by
oxytocin during the induction of labor?
a. Weak contractions prolonged to more than 70 seconds
b. Tetanic contractions prolonged to more than 90 seconds
c. Increased pain with bright red vaginal bleeding
d. Increased restlessness and anxiety

Answer: B
Rationale: Hyperstimulation of the uterus such as with oxytocin during the induction of
labor may result in tetanic contractions prolonged to more than 90 seconds.

64. Which of the following best describes preterm labor?
a. Labor that begins after 20 weeks gestation and before 37 weeks gestation
b. Labor that begins after 15 weeks gestation and before 37 weeks gestation
c. Labor that begins after 24 weeks gestation and before 28 weeks gestation

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d. Labor that begins after 28 weeks gestation and before 40 weeks gestation

Answer: A
Rationale: Preterm labor is best described as labor that begins after 20 weeks
gestation and before 37 weeks gestation. (Lippincotts Review Series: Maternal-
Newborn Nursing, 4
th
Edition)

65. The nurse evaluates that the danger of a seizure in a woman with eclampsia
subsides:
a. After labor begins
b. After delivery occurs
c. 24 hours postpartum
d. 48 hours postpartum

Answer: D
Rationale: The danger of a seizure in a woman with eclampsia subsides when
postpartum diuresis has occurred, usually 48 hours after delivery. The risk for seizures
may remain for up to two weeks after delivery. (Mosbys Comprehensive Review of
Nursing for NCLEX-RN Examination, 18
th
Edition)

Situation 13: You are the nurse taking care of a client moving into the active phase of
labor.
66. The nurse should include which of the following as priority care?
a. Offer support by reviewing the short-pant form of breathing
b. Administer a narcotic analgesia
c. Allow the mother to walk around the unit
d. Watch for the rupture of the membrane

Answer: A
Rationale: By helping the client use the short pant form of breathing, the nurse can
help the client manage her contractions and reduce the need for narcotics and other
form of pain relief which can affect the fetal outcome.

67. A client is progressing through the 1
st
stage of labor. Which finding signals the 2nd
stage of labor?
a. Passage of the mucus plug
b. Bearing down reflex
c. Change in uterine shape
d. Gush of dark blood

Answer: B
Rationale: 2
nd
stage of labor is heralded by bearing down reflex with each contraction,
increased bloody show, severe rectal pressure and rupture of membrane if this hasnt
already occurred.

68. As the nurse assigned to a laboring woman, you are observing the FHR. Which of
the following findings would you consider abnormal for a client in active labor?
a. A rate of 160 with no significant changes through a contraction
b. A rate of 130 with accelerations to 150 with fetal movement

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c. A rate that varies between 120 and 130
d. A rate of 170 with a drop to 140 during a contraction.

Answer: D
Rationale: A rate of 170 is suggestive of fetal tachycardia. A drop to 140 during
contraction represents some periodic change, which is not normal finding.

69. The client is now 8 cm dilated. To support her during this phase of labor, you should:
a. Leave her alone most of the time
b. Offer her a back rub during contraction
c. Offer her sips of oral fluids
d. Provide her with warm blanket

Answer: B
Rationale: The counterpressure of a back rub during contraction may relive
discomfort.

70. During the 4
th
stage of labor, the client should be carefully assessed for:
a. Uterine atony
b. Complete cervical dilatation
c. Placental expulsion
d. Umbilical cord prolapse

Answer: A
Rationale: Uterine atony should be carefully assessed during the 4
th
stage of labor.
2
nd
stage Begins with complete cervical dilatation and ends with birth
3
rd
stage Begins immediately after birth and ends with expulsion of the placenta

Situation 14: As the fetus grows and hormone shift during pregnancy, physiologic
adaptations occur in every body system to accommodate the fetus.
71. The nurse suggests breast pumping to relieve clients breast engorgement. Which
instruction should the nurse provide?
a. Pump each breast 5 to 10 minutes every 3 to 4 hours round the clock
b. Pump each breast for at least 10 minutes every 3 to 4 hours, pump at night only if
awake
c. Pump each breast for no more than 10 minutes every 2 hours round the clock
d. Pump each breast for 10 minutes every 2 hours, skip one pumping at night

Answer: B
Rationale: To relieve engorgement, she should try to pump 10 min for 24 hrs. Pumping
every 3 to 4 hours allows milk to build up. Waking up at night just to pump interferes
with mothers rest.

72. Weng complains of constipation. The nurse should explain that constipation
frequently occurs during pregnancy because of:
a. Pressure of the growing uterus on the anus
b. Increased intake of milk as recommended during pregnancy
c. The slowing of peristalsis in the GIT
d. Changes in the metabolic rate

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Answer: C
Rationale: The growing uterus exerts pressure on the mesentary slowing peristalsis;
more water is reabsorbed, and constipation results.

73. Jane is concerned about the mask of pregnancy, the dark nipples and the dark line
from her navel to her pubis. The nurse explains that these adaptations are caused by
the hyperactivity of the:
a. Adrenal gland c. Ovaries
b. Thyroid gland d. Pituitary gland

Answer: D
Rationale: Pigmentation is caused by the anterior pituitary hormone, melanotropin,
which increases during pregnancy.

74. Jane complains of morning sickness. The nurse realizes that a predisposing factor
that causes morning sickness during the first trimester of pregnancy is the adaptation
to increased level of:
a. Estrogen c. Luteinizing hormone
b. Progesterone d. Chorionic gonadotropin

Answer: D
Rationale: Chorionic gonadotropin, secreted in large amount by the placenta during
gestation, and the metabolic changes associated with pregnancy can precipitate N/V
in early pregnancy.

75. During pregnancy, what happens to the heart from displacement of the diaphragm?
It moves:
a. Upward and to the left
b. Upward and to the right
c. Downward and to the left
d. Downward and to the right

Answer: A
Rationale: During pregnancy, the heart is displaced upward and to the left from
pressure of the pregnant uterus on the diaphragm. (Straight As in Maternal-Neonatal
Nursing, 2
nd
Edition)

Situation 15: The process of data gathering and analysis is ongoing. The nurse, therefore,
should focus on trimester-specific issues.
76. Fetal heart rate can be auscultated with a fetoscope as early as which of the
following?
a. 5 weeks gestation
b. 10 weeks gestation
c. 15 weeks gestation
d. 20 weeks gestation

Answer: D

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Rationale: The FHR can be auscultated with a fetoscope at about 20 weeks gestation.
FHR can be heard using a Doppler at 10-12 weeks gestation. FHR cannot be heard any
earlier than 10 weeks gestation. (Lippincotts Review Series: Maternal-Newborn
Nursing, 4
th
Edition)

77. An ultrasound is typically performed during the third trimester for which of the
following reasons?
a. To evaluate the fetus for possible congenital anomalies
b. To determine the fetal position and estimate fetal size
c. To confirm the suspicion of possible multiple gestation
d. To enhance prenatal testing and evaluation of pelvic mass

Answer: B
Rationale: Ultrasound is typically performed during the third trimester to determine
fetal position and estimate fetal size.

78. Quickening in primigravidas usually can be detected during which of the following
weeks of gestation?
a. 10 to 14 weeks
b. 15 to 17 weeks
c. 18 to 20 weeks
d. 20 to 22 weeks

Answer: C
Rationale: Quickening is typically described as a light fluttering feeling, can usually be
detected between 18 and 20 weeks gestation in primigravidas. However, in
multigravidas, fetal movement can be detected as early as 16 weeks gestation.
th
Edition)

79. At 12 weeks gestation, what fetal development would you expect to find?
a. Eyelids are open
b. Insulin is present in the pancreas
c. Vernix caseosa is copious
d. Subcutabneous fat increases

Answer: B
Rationale: At 12 weeks gestation, the pancreas secretes insulin.

80. During prenatal development, fetal weight gain is greatest in the:
a. First trimester
b. Third trimester
c. Second trimester
d. Implantation period

Answer: B
Rationale: This is the period in which the fetus stores deposits of fat.

Situation 16: The nurse bears responsibilities during the postpartum stage, wherein the
mother undergoes physical and psychological adjustment to the process of childbearing.

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81. While bottle feeding her neonate, a post partum client asks the nurse when she can
expect her menstrual period to return. How should the nurse respond?
a. In 1-2 weeks c. In 7-9 weeks
b. In 3-4 weeks d. In 10-12 weeks

Answer: C
Rationale: In non-lactating clients, menstruation typically resumes 7-9 weeks after
delivery. The average time before return of ovulation is about 10 weeks after delivery.

82. When assessing lochia serosa, which of the following would the nurse expect?
a. Creamy yellow color
b. Characteristic odor
c. Serosanguineous appearance
d. White to colorless

Answer: C
Rationale: Lochia serosa appears as pink and brownish, serosanguineous discharge
with a strong odor occurring from 3 to 10 days after delivery. Lochia alba is typically
almost colorless to creamy yellowish discharge occurring from 10 to 21 days after
delivery. Lochia rubra appears as dark red vaginal discharge with a characteristic odor,
occurring in the first 2 days after delivery. (Lippincotts Review Series: Maternal-
Newborn Nursing, 4
th
Edition)

83. Which behavior would the postpartum client demonstrate during the taking-in
phase?
a. Passive dependent role
b. Increased energy
c. Receptiveness to self-care education
d. Increased responsibility for neonate

Answer: A
Rationale: During the taking-in phase, the client typically demonstrates a passi2ve-
dependent role, directing energy toward herself, instead of the neonate.

84. Which statement about nutrition in the postpartum period is true?
a. The client should maintain a high-carbohydrate diet
b. The client should expect a decrease in thirst
c. The client should eat low-fiber food
d. The client should increase protein and caloric intake

Answer: D
Rationale: The client should increase protein and caloric intake not necessarily
increased carbohydrates.

85. The nurse working on the postpartum unit should encourage clients to ambulate
early to:
a. Promote respirations
b. Increase the tone of the bladder
c. Maintain tone of abdominal muscles

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d. Increase peripheral vasomotor activity

Answer: D
Rationale: There is extensive activation of the blood clotting factor after delivery. This,
together with immobility, trauma, or sepsis, encourages thromboembolization, which
can be limited through activity.

Situation 17: Nutrition is an important aspect during pregnancy. It has a direct bearing on
her health and on the fetal growth and development. Nurses can help guide pregnant
women in planning a good diet.
86. The nurse in the prenatal clinic should provide nutritional counseling to all newly
pregnant women because:
a. Most weight gain during pregnancy is fluid retention
b. Dietary allowances should not increase during pregnancy
c. Pregnant women must adhere to a specific pregnancy diet
d. Different sources of essential nutrients are favored by different cultural groups

Answer: D
Rationale: The nurse should become informed about the cultural eating patterns of
clients so that foods containing essential nutrients, which are part of these dietary
patterns, will be included.

87. Nutritional planning for a newly pregnant woman of average height weighing 145
pounds should include:
a. A decrease of 200 calories per day
b. An increase of 300 calories per day
c. An increase of 500 calories per day
d. A maintenance of her present caloric intake

Answer: B
Rationale: This is the recommended caloric increase for adult women to meet the
increased metabolic demands of pregnancy.

88. A primigravida woman in her 10th week of gestation is concerned because she has
read that nutrition during pregnancy is important for the growth and development of
the fetus. She wants to know something about the food she should eat. The nurse
should:
a. Instruct her to continue eating a normal diet
b. Assess what she eat by taking a diet history
c. Give her a list of food to help her better plan her meals
d. Emphasize the importance of limiting salt and highly seasoned food

Answer: B
Rationale: By taking a diet history, the nurse can assess the woman's level of
nutritional knowledge and gain clues for appropriate methods of counseling.

89. A client is concerned about gaining weight during pregnancy. The nurse explains
that the largest part of weight gain during pregnancy is because of:
a. The fetus

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b. Fluid retention
c. Metabolic alterations
d. Increased blood volume

Answer: A
Rationale: The average weight gain is 25 to 35 lbs. Of this, the fetus accounts for 7 to 8
lbs, or approximately 30% of weight gain.

90. A patient who is 20 weeks pregnant tells the nurse that her prenatal vitamin makes
her sick. Which is the best suggestion?
a. Take the vitamin with breakfast
b. Stop taking the vitamin for a few days and then resume
c. Take the vitamin at bedtime
d. Take the vitamin with milk between meals

Answer: C
Rationale: When prenatal vitamins cause a bit of nausea, it is suggested that patients
take the medication at bedtime so they may experience less nausea when they sleep.

Situation 18: A nurse is taking care of a client who is scheduled for cesarean delivery.
91. Which assessment finding would indicate a need to contact the physician?
a. Fetal heart rate of 180 bpm
b. WBC count of 12,000 cells/mm
3

c. Maternal pulse rate of 85 bpm
d. Hemoglobin of 11.0 g/dL

Answer: A
Rationale: A normal fetal heart rate is 120 to 160 bpm. A count of 180 bpm could
indicate fetal distress and would warrant physician notification.

92. A client in labor is transported to the delivery room and is prepared for a cesarean
delivery. The nurse places the client in the:
a. Trendelenburgs position with the legs in stirrups
b. Semi-fowler position with a pillow under the knees
c. Prone position with the legs separated and elevated
d. Supine position with a wedge under the right hip

Answer: D
Rationale: Vena cava and descending aorta compression by the pregnant uterus
impedes blood return from the lower trunk and extremities. This leads to decreasing
cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus.
The best position to prevent this would be side-lying with the uterus displaced off the
abdominal vessels.

93. A nurse prepares to auscultate the fetal heart rate by using a Doppler ultrasound
device. The nurse most accurately determines that the fetal heart sound are heard by:
a. Noting if the heart rate is greater than 140 bpm
b. Placing the diaphragm of the Doppler on the mothers abdomen
c. Performing Leopolds maneuver first to determine the location of the fetal heart

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d. Palpating the maternal radial pulse while listening to the fetal heart rate

Answer: D
Rationale: The nurse simultaneously should palpate the maternal radial or carotid
pulse and auscultate the fetal heart rate to differentiate the two. If the fetal and
maternal heart rates are similar, the nurse may mistake the maternal hear rate for the
FHR.

94. After delivery, the nurse is assessing the mother for signs and symptoms of
superficial venous thrombosis. Which of the following signs and symptoms would the
nurse note if superficial venous thrombosis were present?
a. Paleness of the calf area
b. Enlarged, hardened veins
c. Coolness of the calf area
d. Palpable dorsalis pedis pulses

Answer: B
Rationale: Thrombosis of superficial veins usually is accompanied by signs and
symptoms of inflammation. These include swelling of the involved extremity and
redness, tenderness and warmth. (Saunders, 3
rd
Edition)

95. A nurse has provided discharge instructions to a client who delivered healthy
newborn infant by cesarean delivery. Which statement if made by the client indicates a
need for further instructions?
a. I will notify the physician if I develop a fever.
b. I will lift nothing heavier than the newborn infant for at least 2 weeks.
c. I will begin abdominal exercises immediately.
d. I will turn on my side and push up with my arms to get out of bed.

Answer: C
Rationale: Abdominal exercise should not start immediately following abdominal
surgery, and the client should wait at least 3 to 4 weeks post-operatively to allow
healing of the incision. (Saunders, 3
rd
Edition)

Situation 19: The following questions pertain to care of womens reproductive health.
96. For women aged 19-39 years, recommended health screening diagnostic testing
includes which of the following?
a. Pap smear
b. Mammography
c. Cholesterol and lipid profile
d. Bone mineral density testing

Answer: A
Rationale: A Pap smear is recommended for women aged 19-39 years, as well as for
women aged 40 and older.

97. The nurse teaches the female patient who is premenopausal to perform breast self-
examination (BSE):
a. Any time during the month

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b. With the onset of menstruation
c. On day 5 to day 7, counting the first day of menses as day 1
d. On day 2 to day 4, counting the first day of menses as day 1

Answer: C
Rationale: BSE is best performed after menses, when less fluid is retained.

98. The nurse is caring for a 38-year-old unmarried woman. She is 38 weeks pregnant
and has two school-age children at home. She has gained 4 pounds in the last week
and she states her rings are tight and wont come off. Her significant other, who is
not the father of this baby or the other children, attends prenatal clinic with her to
provide support and share information. Based on the philosophy of family-centered
maternal-newborn nursing, the following principles apply to the care of this family
EXCEPT:
a. Pregnancy and childbirth are usually normal, healthy events in the family
b. Pregnancy and childbirth affect the entire family
c. Families are able to make decisions about care if given the proper information
d. Personal and cultural attitudes influence the meaning of pregnancy and birth in the
family

Answer: A
Rationale: The statement pregnancy and childbirth are usually normal, healthy events
within the family does not apply because the mother has a weight gain of 4 pounds,
which is excessive for this time of pregnancy, and states that her rings are tight and
wont come off. In this non-traditional family, the applicable philosophy of family-
centered maternal-newborn nursing includes the statements in B, C and D.
th
Edition)

99. Stage 3 of breast development, according to Tanner, occurs when:
a. Breast budding begins
b. The breast develops into a single contour
c. The areola (a darker tissue ring around the nipple) develops
d. The areola and nipple form a secondary mound on top of breast tissue

Answer: C
Rationale: Stage 3 further enlargement of breast tissue and the areola (a darker
tissue around the nipple)
A. Stage 2 Breast budding (the first sign of puberty in a female)
B. In stage 5 female demonstrates continued development of a larger breast with a
single contour.
D. In stage 4 the nipple and areola form a secondary mound on top of breast tissue
Note: Stage 1 describes the prepubertal breast (Brunner and Suddarth's Medical-
Surgical Nursing, 11
th
Edition)

100. In counseling the couple about the various Family Planning Methods, the nurse
identifies that the most important factor in choosing a contraceptive method is:
a. Financial expense
b. Compliance with cultural expectations
c. Non-contraceptive benefits

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d. Correct and consistent use

Answer: D
Rationale: To achieve the maximum effectiveness from a contraceptive, it must be
used correctly and consistently.

Situation 20: All maternal body systems are altered by pregnancy. The following questions
pertain to the signs and symptoms of pregnancy.

101. Cervical softening and uterine souffl are classified as which of the following?
a. Diagnostic signs c. Probable signs
b. Presumptive signs d. Positive signs

Answer: C
Rationale: Cervical softening (Goodell sign) and uterine souffl are two probable signs
of pregnancy. Probable signs are objective findings that strongly suggest pregnancy.

102. Which of the following would the nurse identify as a presumptive sign of pregnancy?
a. Hegars sign
b. Nausea and vomiting
c. Skin pigmentation changes
d. Positive serum pregnancy test

Answer: B
Rationale: Presumptive signs are subjective signs. Of the signs listed, only nausea and
vomiting are presumptive signs.

103. The nurse documents positive ballottement in the client's prenatal record. The nurse
understands that this indicates which of the following?
a. Contractions palpable on the abdomen
b. Passive movement of the unengaged fetus
c. Fetal kicking felt by the client
d. Enlargement and softening of the uterus

Answer: B
Rationale: Ballottement indicates passive movement of the unengaged fetus.
A. Ballottement is not a contraction.
C. This represents quickening.
D. This is known as the Piskacek's sign.

104. The client has completed an at-home pregnancy test with positive results. Which of
the following indicates the client understands the meaning of the test results?
a. I understand that this means I have ovulated in the past 24 hours.
b. I understand that this means I am not pregnant.
c. I understand that this means I might be pregnant.
d. I understand that this means I am pregnant.

Answer: C

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well - research.
Rationale: A positive at-home pregnancy test indicates the presence of growing
trophoblastic tissue and not necessarily a uterine pregnancy.

105. The client has come to the clinic because she suspects that she is pregnant. Which
of the following would be the most definitive way to confirm the diagnosis?
a. Client's report of amenorrhea for 3 months
b. Positive Hegar's sign
c. Pigmentation changes of the breast
d. Palpation of fetal movement by the care provider

Answer: D
Rationale: Palpation of fetal movement by the care provider is a positive sign of
pregnancy.

PEDIATRIC NURSING

Situation 1: Nurse Melai is taking care of a 12-year-old female hospitalized with a
suspected diagnosis of acute bacterial meningitis.
106. In performing the lumbar puncture, which safety measure would Nurse Melai
implement while CSF specimen is obtained?
a. Place the child in a sitting position with the head extended
b. Place the child in a side-lying position with the back closest to the edge of the bed
c. Do not wear gloves because the physician is collecting the specimen
d. Place one arm behind the childs neck and the other behind the knees
Answer: B
Rationale: This allows the physician to assess the site with ease. (Chernecky)

107. Nurse Melai reviews the results of the CSF analysis and determines that which of
the following results would confirm bacterial meningitis?
a. Cloudy CSF, protein, and glucose
b. Cloudy CSF, protein, and glucose
c. Clear CSF, protein, and glucose
d. Clear CSF, pressure, and protein
Answer: B
Rationale: In case of bacterial meningitis, findings usually include an elevated
pressure, turbid or cloudy CSF, elevated leukocytes, elevated protein, and decreased
glucose levels. (Saunders, 3
rd
Edition)

108. Based on the mode of transmission of this infection, which of the following would
be included in the plan of care?
a. No precautions are required as long as antibiotics have been started
b. Maintain enteric precautions
c. Maintain respiratory isolation precautions for at least 24 hours after the initiation of
antibiotics
d. Maintain neutropenic precautions
Answer: C
Rationale: For a child with meningitis, prescribed antibiotic is administered as soon as
it is ordered. The child is placed in respiratory isolation for at least 24 hours while
culture results are obtained and the antibiotics having an effect.

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(Saunders, 3
rd
Edition)

109. In planning a roommate for the child, Nurse Melai should realize that a child of this
developmental level will:
a. Prefer another girl her own age
b. Most likely seek out opportunities to socialize with teenagers
c. Enjoy being with either a girl or boy, as long as they are the same age
d. Feel helpful if given the opportunity to look after a slightly younger child
Answer: A
Rationale: Younger teenage girls in particular prefer the company of other young girls.
They have a definite preference for same sex, same-age companions.
(Davis NCLEX-RN Success, 2
nd
Edition)

110. As the child recovers from meningitis, for which long-term complication should
Nurse Melai watch carefully?
a. Encephalitis c. Learning disabilities
b. Hydrocephalus d. Mental retardation
Answer: B
Rationale: As healing of the pathways of the CSF occurs following an episode of
meningitis, scar tissue naturally forms. This may lead to non-communicating
hydrocephalus.
nd
Edition)

Situation 2: A child is admitted to the hospital with a history of vomiting and diarrhea for
two days. The admitting diagnosis is gastroenteritis and isotonic dehydration.
111. The nurse understands that isotonic dehydration:
a. Occurs when water and electrolytes are lost in about the same proportions as they
exist in the body
b. Occurs when the loss of electrolytes is greater than the loss of water
c. Occurs when the loss of water is greater than the loss of electrolytes
d. Causes the serum sodium level to rise above 150 mEq/L
Answer: A
Rationale: Isotonic dehydration occurs when water and electrolytes are lost in about
the same proportions as they exist in the body. In this type of dehydration, the serum
sodium levels remain normal (135 to 145 mEq/L).
(Saunders Comprehensive Review for the NCLEX-RN Examination, 3
rd
Edition)

112. What type of room assignment should the nurse make?
a. A room near the nurse's station so that he can be checked frequently and heard if
he vomits
b. A single room with a sink nears the doorway for isolation use
c. A double room with another toddler who also has vomiting and diarrhea
d. A bed in the pediatric intensive care unit, in case dehydration develops
Answer: B
Rationale: The child should be placed on enteric isolation until the lab reports no
contagious organisms in the stool. If the stool is infected, isolation is continued after
the antibiotics are completed until three consecutive daily stool specimens are
negative.
th
Edition)

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113. Which priority nursing intervention should be included when caring for a client
diagnosed with gastroenteritis?
a. Encouraging optimal nutritional intake
b. Alleviating abdominal pain and cramping
c. Administering an oral anti-emetic every 2 hours
d. Monitoring intake and output, and electrolyte levels
Answer: D
Rationale: With gastroenteritis, the client typically experiences vomiting and diarrhea,
which put the client at risk for fluid volume deficit and electrolyte imbalance. Close
monitoring of intake and output along with serum electrolyte levels is important to
prevent any imbalances and ensure prompt treatment if an imbalance occurs.
(Lippincott's Review Series: Medical-Surgical Nursing, 4
th
Edition)

114. The nurse is assessing the child for dehydration. The nurse determines that the child
is moderately dehydrated if which symptom is noted on assessment?
a. Flat fontanels
b. Moist mucous membranes
c. Pale skin color
d. Oliguria
Answer: D
Rationale: In moderate dehydration, oliguria would be present.
rd
Edition)

115. The nurse prepares to take the child's temperature and avoids which method of
measurement?
a. Tympanic c. Rectal
b. Axillary d. Electronic
Answer: C
Rationale: Rectal temperature measurements should be avoided if diarrhea is present.
Use of rectal temperature stimulates peristalsis and cause more diarrhea.
rd
Edition)

Situation 3: A nurse is working in the Holy Child ward. One of her patients is an infant
diagnosed with Cystic fibrosis.
116. The foul-smelling, frothy characteristics stool in cystic results from the presence of
large amounts of:
a. Undigested fat
b. Sodium and chloride
c. Semidigested carbohydrates
d. Lipase, trypsin and amylase
Answer: A
Rationale: Because of lack of the pancreatic enzyme lipase, fats remain unabsorbed
and are excreted in excessive amounts in the stool.
(Mosbys, 18
th
Edition)

117. The nurse, when planning care, recalls that chest percussion and postural drainage
for a toddler with cystic fibrosis are best done:
a. After suctioning

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b. Before aerosol therapy
c. One hour before meals
d. Immediately after meals
Answer: C
Rationale: This regimen will give the child an opportunity to rest before eating.
(Mosbys, 18
th
Edition)

118. Medications that will probably be used in the therapeutic regimen for a child with
cystic fibrosis include:
a. A steroid and an antimetabolite
b. Pancreatic enzymes and antibiotics
c. Aerosol mists, decongestants, and fat-soluble vitamins
d. Antibiotics, a multivitamin preparation, and cough drops
Answer: B
Rationale: Pancreatic enzymes are given as replacement because of the lack of their
production by the pancreas. Antibiotics are prescribed to control respiratory tract
infection.
(Mosbys, 18
th
Edition)

119. At a previous visit, the parents of an infant with cystic fibrosis received instruction in
administration of pancrelipase (Pancrease). At a follow up visit, which finding in the
infant suggests that the parents are not administering the pancreatic enzymes as
instructed?
a. Fatty stools c. Bloody stools
b. Bloody urine d. Glucose in urine
Answer: A
Rationale: Pancreatic enzymes normally aid in food digestion in the intestine. In a child
with cystic fibrosis, however, these natural enzymes cannot reach the intestine
because mucus blocks the pancreatic duct. Without these enzymes, undigested fats
and proteins produce fatty stools. Treatment with pancreatic enzymes should result in
stools of normal consistency. Noncompliance with the treatment produces fatty stools.

120. In young children with cystic fibrosis, frequent stool and tenacious mucus often
produce:
a. Anal fissures c. Rectal prolapse
b. Intussusception d. Meconium ileus
Answer: C
Rationale: Rectal prolapse is a common GI complication and results from wasting of
perirectal supporting tissues, secondary to malnutrition.
(Mosbys, 18
th
Edition)

Situation 4: The following cases pertain to different Gastrointestinal Disorders in children.
121. A toddler is brought to the emergency department with sudden onset of abdominal
pain, vomiting and stools that look like red currant jelly. To confirm intussusception,
the suspected cause of these findings, the nurse would expect the physician to order:
a. Barium enema
b. Suprapubic aspiration
c. NG Tube insertion
d. Indwelling urinary catheter insertion

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Answer: A
Rationale: A barium enema commonly is used to confirm and correct intussusception.
Performing a suprapubic aspiration or NG tube insertion or an indwelling catheter
insertion wouldnt help diagnose or treat this disorder.

122. The nurse documents that the infant with GERD should be maintained in which
position following feeding and at night in order to manage reflux?
a. 30-degree angle when supine
b. 60-degree angle when supine
c. Head-elevated prone position
d. 20-degree angle when supine
Answer: C
Rationale: The infant should be placed in the flat prone position or the head-elevated
prone position following feedings and at night.
rd
Edition)

123. A 5-year-old child has lactose intolerance. The nurse tells the mother that it is
necessary to provide which dietary supplement in the childs diet?
a. Zinc c. Calcium
b. Protein d. Fats
Answer: C
Rationale: Lactose intolerance is the inability to tolerate lactose, the sugar found in
dairy products. Removing milk from the diet can provide adequate relief from
symptoms. Additional dietary changes may be required to provide adequate source of
calcium, and in the infant, protein and calories. (Saunders Comprehensive Review for
the NCLEX-RN Examination, 3
rd
Edition)

124. A nurse reviews the record of 3-week-old infant and notes that the physician has
documented a diagnosis of suspected Hirschsprungs disease. The nurse reviews the
assessment finding documented in the record, knowing that which symptom most
likely led the mother to seek healthcare for the infant?
a. Diarrhea
b. Projectile vomiting
c. Regurgitation of feedings
d. Foul-smelling ribbon-like stools
Answer: D
Rationale: Chronic constipation beginning in the first month of life and resulting in
pellet-like of ribbon stools that are foul-smelling is a clinical manifestation of this
disorder. Delayed passage or absence of meconium stool in the neonatal period is the
cardinal sign. Bowel obstruction, especially in the neonatal period, abdominal pain and
distention, and failure to thrive are also clinical manifestations.
rd
Edition)

125. The nurse monitors the infant with suspected diagnosis of imperforate anus,
knowing that which of the following is a clinical manifestation associated with this
disorder?
a. Sausage-shaped mass palpated in the upper right abdominal quadrant
b. Bile-stained fecal emesis
c. Failure to pass meconium stool in the first 24 hours after birth

CODES I 59
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d. The passage of currant jelly-like stools
Answer: C
Rationale: During the newborn assessment, this defect should be identified easily on
sight. However, a rectal thermometer or tube may be necessary to determine patency
if meconium is not passed in the first 24 hours after birth. Other assessment findings
include absence or stenosis of the anal rectal canal, presence of an anal membrane,
and an external fistula to the perineum.
rd
Edition)

Situation 5: The following questions will assess your knowledge on basic life support
measures for infant and children.
126. The nurse performs cardiopulmonary resuscitation (CPR) for 1 minute on an infant
without calling for assistance. In reassessing the infant after 1 minute of CPR, the
nurse finds he still isnt breathing and has no pulse. The nurse should then:
a. Resume CPR beginning with breaths
b. Declare her efforts futile
c. Resume CPR beginning with chest compressions
d. Call for assistance
Answer: D
Rationale: After 1 minute of CPR, the nurse should call for assistance and then resume
efforts.

127. A 10-year-old child begins to choke and cough on a piece of candy. Which priority
nursing action should the nurse implement?
a. Provide abdominal thrusts
b. Give 5 back slaps, followed by 5 abdominal thrusts
c. Look in the mouth and perform a blind finger sweep
d. Allow a child to expel the candy by himself or herself
Answer: D
Rationale: If a child is choking, allow the victim to continue to cough if the cough is
forceful.
(Saunders, 3
rd
Edition)

128. A nurse is preparing to attempt to relieve an airway obstruction on a 3-year-old
conscious child. The nurse performs this maneuver by placing the hands between the:
a. Umbilicus and the groin
b. Groin and the abdomen
c. Umbilicus and the xiphoid process
d. Lower abdomen and the chest
Answer: C
Rationale: To perform the Heimlich maneuver on a child, the rescuer places the thumb
side of one fist against the victims abdomen in the midline slightly above the
umbilicus and well below the tip of the xiphoid process. (Saunders, 3
rd
Edition)

129. A nurse is performing CPR on an infant. When performing chest compressions, the
nurse understands that the compression rate is at least:
a. 60 times per minute
b. 80 times per minute
c. 100 times per minute

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d. 160 times per minute
Answer: C
Rationale: In an infant, the rate of chest compression is at least 100 times per minute.
(Saunders, 3
rd
Edition)

130. Which among the following is the most appropriate location to assess the pulse of
an infant under 1 year of age?
a. Brachial c. Popliteal
b. Carotid d. Radial
Answer: A
Rationale: To assess a pulse in an infant, check the pulse at the brachial artery.
(Saunders, 3
rd
Edition)

Situation 6: The first hours after birth represent a
critical adjustment period for the newborn. The nurse must provide direct care to the
newborn immediately after birth.
131. Which of the following would the nurse identify as goal of newborn care in the initial
postpartum period?
a. To facilitate development of a close parent-newborn relationship
b. To assist parents in developing healthy attitudes about childbearing practices
c. To identify actual or potential problems requiring immediate or emergency
attention
d. To provide the parents of the newborn with information about well-baby programs
Answer: C
Rationale: In the initial postpartum period, one of the goals of newborn care is to
identify actual and potential problems that might require immediate attention. Other
goals include establishing and maintaining an airway and supporting respirations,
maintaining warmth and preventing hypothermia, and ensuring safety and preventing
injury or infection.

132. Which of the following actions would be least effective in maintaining a neutral
environment for the newborn?
a. Placing an infant under a radiant warmer after bathing
b. Covering the scale with a warmed blanket prior to weighing
c. Placing crib close to the nursery window for family viewing
d. Covering the infant's head with a stockinette
Answer: C
Rationale: Heat loss by radiation occurs when the infant's crib is placed too near cold
walls or windows. Thus, placing the newborns crib close to the viewing window would
be least effective.

133. When preparing to administer the vitamin K to a neonate, the nurse would select
which of the following sites as appropriate for the injection?
a. Deltoid muscle
b. Anterior femoris muscle
c. Vastus lateralis muscle
d. Gluteus maximus muscle
Answer: C

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Rationale: The middle third of the vastus lateralis is the preferred injection site for
vitamin K administration because it is free of blood vessels and nerves, and is large
enough to absorb the medication.

134. The first period of reactivity in the newborn begins at birth. The following are
characteristics of this period EXCEPT:
a. This lasts for 30 minutes
b. Respirations are increased to 80/minute
c. Flaring of nares and grunting are common
d. Bowel sounds are present
Answer: D
Rationale: Bowel sounds are usually absent at this time.

135. A nurse providing care to a newborn would use knowledge of which of the following
concepts underlying adaptation of the newborn's immune system?
a. Iron stores from the mother are sufficient to carry the newborn through the 5
th

month of extrauterine life
b. Unconjugated bilirubin can leave the vascular system and permeate the other
extravascular tissues
c. The newborn is unable to limit invading organisms at their point of entry
d. Most newborns void in the first 24 hours after birth and 5 to 20 times thereafter
Answer: C
Rationale: The newborns cannot limit the invading organism at the port of entry.

Situation 7: Santino, a 3-year-old child is scheduled for a tonsillectomy.
136. A nurse is reviewing the laboratory results of Santino. The nurse determines that
which of the following laboratory values is most significant to review?
a. Prothrombin time c. Blood urea nitrogen
b. Sedimentation rate d. Creatinine
Answer: A
Rationale: Because the tonsillar area is so vascular, postoperative bleeding is a
concern. PT, PTT, platelet count, hg, hct, WBC, and urinalysis are performed
preoperatively. PT results would identify a potential for bleeding. (Saunders, 3
rd
Edition)

137. On the day of surgery, Santino will most likely be fearful of:
a. Intrusive procedure
b. Perceived abandonment
c. Premature death
d. Unfamiliar caregivers
Answer: A
Rationale: One of the greatest fears of preschoolers is fear of mutilation. Other options
are not developmentally appropriate responses for a preschooler.

138. A nurse panning care for Santino knows that which of the following would present
the highest risk of aspiration during surgery?
a. Difficulty in swallowing
b. The presence of loose teeth
c. Bleeding during surgery
d. Exudate in the throat area

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Answer: B
Rationale: In the preoperative period, the child should be observed for the presence of
loose teeth to decrease the risk of aspiration during surgery.
(Saunders, 3
rd
Edition)

139. After a tonsillectomy, the nurse documents on the plan of care to place Santino in
which most appropriate position?
a. Supine c. Side-lying
b. Trendelenburg's d. High Fowler's
Answer: C
Rationale: The child should be placed in a prone or side-lying position following
tonsillectomy to facilitate drainage. (Saunders, 3
rd
Edition)

140. After a tonsillectomy, the nurse suspects hemorrhage postoperatively when the
child:
a. Snores noisily
b. Becomes pale
c. Complains of thirst
d. Swallows frequently
Answer: D
Rationale: The seeping of blood from the operative site increases secretions, which the
child adapts to by swallowing frequently.
(Mosbys, 18
th
Edition)

Situation 8: A 2-week-old is diagnosed as having hypertrophic pyloric stenosis, and is
scheduled for corrective surgery.
141.When palpating the infant's abdomen, the nurse would expect to find:
a. An impacted and distended colon
b. Marked tenderness around the umbilicus
c. An olive-sized mass in the right upper quadrant
d. Rhythmic peristaltic waves in the lower abdomen
Answer: C
Rationale: The olive-like mass is caused by the thickened muscle of the pyloric
sphincter.

142.The nurse should carefully observe the infant for:
e. Quality of cry
f. Character of stool
g. Signs of dehydration
h. Coughing after feeding
Answer: C
Rationale: Hypertrophy of the pyloric sphincter, at the distal end of the stomach,
causes partial and then complete obstruction. Non-projectile vomiting progresses to
projectile vomiting which rapidly leads to dehydration.

143.After the corrective surgery, the nurse caring for an infant, who had been formula-
fed, notices that the post-operative orders are similar to those for the other infants
having undergone such surgery and include:
i. Thickened formula 24 hours after surgery

CODES I 63
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j. Withholding all feedings for the first 24 hours
k. Regular formula feeding 24 hours after the surgery
l. Additional glucose feeding as desired after the first 24 hours
Answer: C
Rationale: Initial feedings of glucose and electrolytes in water or breast milk are given
4 to 6 hours after surgery. When clear fluids are retained, usually within 24 hours,
formula feedings are begun.

144.When the corrective surgery for hypertrophic pyloric stenosis is completed, the
infant was returned in stable condition to the pediatric unit with an intravenous
infusion and a nasogastric tube in place. The priority nursing action should be to:
m. Apply adequate restraints
n. Administer a mild sedative
o. Assess the IV site for infiltration
p. Attach the nasogastric tube to wall suction
Answer: A
Rationale: Protecting the IV and nasogastric tube from becoming dislodged is a
priority.
B, C and D. These are not priority actions.

145.To reduce vomiting, the nurse should teach the mother that immediately after the
feeding the infant, she should:
q. Rock the baby for 20 minutes
r. Place the baby in an infant seat.
s. Place the baby flat on the right side
t. Keep the baby awake with sensory stimulation
Answer: B
Rationale: An elevated position allows gravity to aid in preventing vomiting.

Situation 9: Nurses must know the developmental milestones of children in order to
perform age-appropriate assessments.
141. Which behavior should the nurse expect a 3-year-old child to be capable of doing?
a. Going up the stairs on alternate feet
b. Pedaling a bicycle
c. Dressing without supervision
d. Tying shoelaces
Answer: A
Rationale: 3-year-olds should be able to coordinate the brain and gross motor activity
necessary to go up stairs using alternate feet.
nd
Edition)

142. The best way to perform a DDST on a 9-month-old is to:
a. Take the infant from the mother and ask her to wait in the childs room
b. Take the infant from the mother and ask her to come with them to the testing area
c. Briefly talk first with the mother, then take the infant to the testing area alone
d. Ask the infants mother to carry the child to testing area
Answer: D

CODES I 64
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Rationale: The parent should accompany the infant who is to have the DDST and that
the examiner should do everything possible to establish rapport with the parent and
the infant. (Davis NCLEX-RN Success, 2
nd
Edition)

143. At 7 months of age, an infant exhibits the following skills. The nurse should know
that the most recently acquired skill is the ability to:
a. Roll over
b. Sit up
c. Bear some weight on legs
d. Pick up objects with palmar grasp
Answer: B
Rationale: At 7 months of age, an infant may sit with some support or sit alone. Either
behavior is commonly acquired at this age.
nd
Edition)
144. In assessing the development of a 5-year-old, the nurse would not expect the child
to be able to:
a. Name primary colors
b. Count to 100
c. Know the days of the week
d. Give telephone number and address
Answer: B
Rationale: 5-year-olds may count up to 20 or 25, but seldom beyond this.
nd
Edition)

145. Which of the following activities should a 2-year-old child be able to do?
a. Build a tower of 8 cubes
b. Point out a picture
c. Wash and dry his hands
d. Remove a garment
Answer: D
Rationale: According to Denver II Developmental Screening Test, most 2 years old are
able to remove one garment.

Situation 10: Nurse Jean is working in the Orthopedic ward, wherein she encounters
various cases of fractures in children.
146. A 9-year-old child has a fractured tibia, and a full leg cast has been applied. Nurse
Jean should immediately notify the physician if assessment demonstrates:
a. A pedal pulse of 90
b. An increased urinary output
c. An inability to move the toes
d. A plaster cast that is still damp after 4 hours
Answer: C
Rationale: Cold toes, loss of sensation on toes, and pain, which indicate poor
circulation, should be reported to the physician immediately.
(Mosbys, 18
TH
Edition)

147. To hasten drying of the cast, Nurse Jean should include the following in the care
plan:
a. Using a blow dryer

CODES I 65
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b. Exposing the casted extremity
c. Covering the cast with a light sheet
d. Opening the window slightly to circulate air
Answer: B
Rationale: This is the safest way.
(Mosbys, 18
TH
Edition)

148. An 11-year-old child has just had the application of a cast for a fractured wrist. The
wrist and elbow are immobilized. When providing home care instructions before
discharge, Nurse Jean should include the fact that the:
a. Child can resume usual activities
b. Casted arm should be elevated while upright and resting
c. Physician should be notified if swelling of the fingers occurs
d. Shoulder on the affected side should remain immobilized in a splint
Answer: C
Rationale: Swelling may cause the cast to become too tight resulting in neurovascular
damage; permanent damage can occur in 6-8 hours.
(Mosbys, 18
TH
Edition)
149. After orthopedic surgery, a 15-year-old complains of pain and is given 15 mg of
codeine sulfate ad ordered every3 hours PRN. Two hours after having been given this
medication, the adolescent complain of severe pain. Nurse Jean should:
a. Report that the adolescent has an apparent idiosyncrasy to codeine
b. Tell the adolescent that additional medication cannot be given for 1 more hour
c. Request that the physician evaluate the adolescents need for additional mediation
d. Administer another dose of codeine within 30 minutes, because it is a relatively
safe drug
Answer: C
Rationale:
(Mosbys, 18
TH
Edition)

150. Nurse Jean takes care of an 8-year-old child with a diagnosis of a basilar skull
fracture. Nurse Jean reviews the physicians orders and contacts the physician to
question which order?
a. Clear liquid intake
b. Maintain a patent intravenous line
c. Daily weight
d. Suction as needed
Answer: D
Rationale: This is contraindicated; there is a high risk of secondary infection and a
probability of the catheter entering the brain through the fracture.
A. Child is maintained on NPO or restricted to clear liquids until it is determined that
vomiting will not occur.
B. This is necessary for fluids and medications.
C. Fluid balance is monitored closely by daily weight, and I&O measurement to detect
early signs of water retention, excessive dehydration, and states of hyper/hypotonicity.
(Saunders, 3rd Edition)

Situation 11: A nurse receives a telephone call from the admitting section and is told that
a 9-year-old girl with rheumatic fever will be arriving in the nursing unit for admission.

CODES I 66
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151. On admission, the nurse prepares to ask the mother which question to elicit
assessment information specific to the development of rheumatic fever?
a. Did the child have a sore throat or an unexplained fever within the last 2 months?
b. Has the child had any nausea or vomiting?
c. Has the child complained of headaches?
d. Has the child complained of back pain?
Answer: A
Rationale: Rheumatic fever characteristically presents 2 to 6 weeks after an untreated
or partially treated group A B-hemolytic streptococcal infection of the upper respiratory
tract. Initially, the nurse determines whether the child had a sore throat or an
unexplained fever within the past 2 months. (Saunders, 3
rd
Edition)

152. Which laboratory study would assist in confirming the diagnosis of rheumatic fever?
a. White blood cell count
b. Red blood cell count
c. Immunoglobulin
d. Antistreptolysin O titer
Answer: D
Rationale: A diagnosis of rheumatic fever is confirmed by the presence of two major
manifestations; or one major and two minor manifestations from the Jones criteria. In
addition, evidence of a recent streptococcal infection is confirmed by a positive
antistreptolysin O titer, streptozyme assay, or an anti-DNase B assay. (Davis, 2
nd

Edition)

153. Which findings will the nurse observe in this patient?
a. Macular rash that is pruritic
b. Decreased antistreptolysin O titer
c. Elevated C-reactive protein levels
d. Decreased erythrocyte sedimentation rate
Answer: C
Rationale:
A. Macular rash is non-pruritic. B, C and D are elevated. (Chernecky)

154. The child experiences the following signs or symptoms of rheumatic fever. The
nurse should plan any interventions based on the knowledge that the only one that
may result in permanent damage is:
a. Sydenham's chorea
b. Migratory polyarthritis
c. Carditis
d. Erythema marginatum
Answer: C
Rationale: Carditis can lead to permanent, irreversible cardiac damage, specifically,
mitral valve stenosis.
(Davis, 2
nd
Edition)

155. The best roommate for a 9-year-old girl with rheumatic fever would be:
a. An 8-year-old girl with impetigo
b. A 9-year-old girl with a tonsillectomy

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c. A 10-year-old girl with a concussion
d. An 11 year-old girl with a fractured elbow in skeletal traction
Answer: D
Rationale: A child with rheumatic fever will be in the hospital for a relatively longer
time and will be confirmed to bed most of the time. The ideal roommate would be
another child of the same sex and same developmental level who will also be in the
hospital for some time and confined to bed. The best choice is the young girl with the
fractured elbow, who will be in skeletal traction and also on bed rest.
A. The child with impetigo, caused by
(Davis, 2
nd
Edition)

Situation 12: A 3-year-old child has been hospitalized with nephrotic syndrome.
156. The nurse knows that the most common characteristic associated with nephrotic
syndrome is:
a. Generalized edema
b. Frank bright red blood in the urine
c. Increased urinary output
d. Hypertension
Answer: A
Rationale: Nephrotic syndrome is commonly characterized by periorbital and facial
edema that is most prominent in the morning; and leg, ankle, labial, or scrotal edema.
(Saunders, 3
rd
Edition)

157. The best way to detect fluid retention would be to:
a. Have the child urinate in a bedpan
b. Measure the childs abdominal girth daily
c. Weigh the child at the same time every day
d. Test the childs urine for hematuria and proteinuria
Answer: C
Rationale: Daily weights are an important direct way to assess fluid retention or loss.
A. This may not always happen and would not be accurate.
(Mosbys, 18
th
Edition)

158. The mother asks the nurse if the child will ever look thin again. The nurse most
appropriately responds by telling the mother:
a. Wearing loose-fitting clothing should help conceal the extra weight.
b. In most cases, medication and diet will control fluid retention.
c. Do you feel guilty because you didnt notice the weight gain?
d. When children are little, its expected theyll look a little chubby.
Answer: B
Rationale: The nurse must give the mother information that addresses the issue that is
the parents concern. Most children experience remission without treatment.
(Saunders, 3
rd
Edition)

159. The preschooler is started on prednisone. If the prednisone is having the expected
therapeutic effect, the nurse should expect that this child will:
a. Experience mood swings
b. Have sugar in the urine
c. Gain weight

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d. Feel better
Answer: D
Rationale: There is no known cure for nephrotic syndrome; treatment is aimed at
providing symptomatic relief. If prednisone has the expected therapeutic effect, the
preschooler should report feeling better.
(Davies, 2
nd
Edition)

160. The child is already in remission. What type of diet would the nurse plan to feed this
child?
a. High protein, low calorie
b. High calorie, low protein
c. Low sodium, low fat
d. Regular diet, no added salt
Answer: D
Rationale: The child who is in remission is allowed a regular diet; salt is restricted in
the form of no added salt at the table and excluding food with very high salt content.
(NSNA, 4
th
Edition)

Situation 13: You are working as a Pediatric Nurse in you own Child Health Nursing Clinic.
The following cases pertain to Assessment and Care of the Newborn at Risk conditions.
161. A mother of a 2-year-old daughter asks, At what age can I be able to take the blood
pressure of my daughter as a routine procedure since hypertension is common in the
family? The most appropriate response would be:
a. 2 years old c. 3 years old
b. 4 years old d. 6 years old
Answer: C
Rationale: Blood pressure should be included in the routine physical assessment of all
children older than 3 years old.

162. You typically gag children to inspect the back of their throat. When is it important
NOT to elicit a gag reflex?
a. When a girl has a geographic tongue
b. When a boy has a possible inguinal hernia
c. When a child has symptoms of epiglottitis
d. When children are under 5 years of age
Answer: C
Rationale: When the gag reflex is stimulated in a child with epiglottitis, it causes
complete obstruction of the glottis and respiratory failure. In children with symptoms of
epiglottitis, never attempt to visualize the epiglottis directly with a tongue blade unless
a means of providing an artificial airway is readily available.

163. Baby John was given a drug at birth to reverse the effects of a narcotic given to his
mother in labor. What drug is commonly used for this:
a. Naloxone (Narcan) c. Sodium Chloride
b. Morphine Sulfate d. Penicillin G
Answer: A
Rationale: This is the antidote to narcotic overdose.

164. Why are small-for-gestational-age newborns at risks for difficulty maintaining body

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temperature?
a. They do not have as many fat stores as other infants
b. They are more active than usual so throw off covers
c. Their skin is more susceptible to conduction of cold
d. They are preterm so are born relatively small in size
Answer: A
Rationale: SGA infants are less able to control body temperature than normal
newborns because they lack subcutaneous fat.

165. Baby John develops hyperbilirubinemia. What is a method used to treat
hyperbilirubinemia in a newborn?
a. Keeping infants in a warm and dark environment
b. Administration of cardiovascular stimulant
c. Gentle exercise to stop muscle breakdown
d. Early feeding to speed passage of meconium

Answer: D
Rationale: Early and frequent feeding treats hyperbilirubinemia because the colostrum
is a natural laxative and it helps promote passage of meconium and bile.

Situation 14: The following questions apply to Agua, an infant born with a unilateral cleft
lip.
166. A cleft lip predisposes an infant to infections primarily because of:
a. Poor nutrition from disturbed feedling
b. Poor circulation to the defective area
c. Waste products that accumulate along the defect
d. Mouth breathing, which dries the oropharyngeal mucous membranes
Answer: D
Rationale: Infants with a cleft lip breathe through their mouth, bypassing the natural
humidification provided by the nose. As a result, the mucous membranes become dry
and cracked and are easily infected.
(Mosbys, 18
th
Edition)

167. Feeding for Agua will probably be:
a. Limited to IV fluids
b. With a cross-cut nipple
c. Too difficult because of breathing problems
d. With a rubber-tipped syringe or medicine dropper
Answer: D
Rationale: Because an infant with a cleft lip and palate is unable to from the vacuum
needed for sucking, a rubber-tipped syringe or dropper is used.
(Mosbys, 18
th
Edition)

168. Agua has just returned to the nursing unit following a surgical repair of a cleft lip
located on the right side of the lip. The nurse places the infant in which most
appropriate position?
a. On the right side c. Prone
b. On the left side d. Supine
Answer: B

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Rationale: Post cleft lip repair, the infant should be positioned supine or on the side
lateral to the repair to prevent the contact of the suture lines with the bed linens.
Placing the infant on the left side rather than supine immediately after surgery is best
to prevent the risk of aspiration of the infant vomits. (Saunders, 3
rd
Edition)

169. The most critical factor in the immediate care of an infant after repair of cleft lip
would be the:
a. Prevention of vomiting
b. Maintenance of a patent airway
c. Administration if parenteral fluids
d. Administration of drugs to reduce oral secretions
Answer: B
Rationale: These children frequently have difficulty swallowing secretions as well as
difficulty breathing after surgery. (Mosbys, 18
th
Edition)

170. Nursing care for Agua after the surgical repair of a cleft lip should include:
a. Keeping the baby NPO
b. Keeping the infant from crying
c. Placing the infant in a semi-sitting position
d. Spoon-feeding for the first 2 days after surgery
Answer: B
Rationale: Crying should be prevented because it places tension on the suture line.
(Mosbys, 18
th
Edition)

Situation 15: The following questions pertain to provision of care involving toddlers.
171. A mother of a 3-year-old tells a clinic nurse that the child is rebelling constantly and
having temper tantrums. The nurse most appropriately tells the mother to:
a. Punish the child every time the child says no, to change the behavior
b. Allow the behavior because this is normal at this age period
c. Set limits on the childs behavior
d. Ignore the child when this behavior occurs
Answer: C
Rationale: According to Erikson, the child focuses on independence between ages 1
and 3 years. Gaining independence often means that the child ahs to rebel against
parents wishes. Saying things like no, and having temper tantrums are common
doing this period of development. Being consistent and setting limits on the childs
behavior are necessary elements. (Saunders, 3
rd
Edition)

172. The nurse observes a 2-year-old child at play and notes at this age a toddler:
a. Builds houses with blocks
b. Is extremely possessive of toys
c. Attempts to stay within the lines when coloring
d. Amuses self with a picture book for 15 minutes
Answer: B
Rationale: Common developmental norms of the toddler, who is struggling for
independence, are inability to share easily, egotism, egocentrism, and possessiveness.
(Mosbys, 18
th
Edition)

173. A mother asks when to take her 2-year-old to the dentist. For dental prophylaxis, the

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nurse encourages her to take the child:
a. Before starting school
b. Between 2 and 3 years of age
c. When the child begins to lose deciduous teeth
d. The next time another family member goes to the dentist
Answer: B
Rationale: The child should be taken to the dentist between 2 and 3 years of age, when
most of the 20 deciduous teeth have erupted.
(Mosbys, 18
th
Edition)

174. During a nap, a 3-year-old hospitalized boy wets the bed. The best approach by the
nurse would be to:
a. Tell him to help with remaking the bed
b. Change his clothes and make no issue of it
c. Change his bed putting a rubber sheet on it
d. Explain that big boys should try to call the nurse
Answer: B
Rationale: Bedwetting accidents are common in this age group, especially during
hospitalization when regression may occur. Therefore the best approach is to ignore
the event. (Mosbys, 18
th
Edition)

175. At 2 years of age, a child is readmitted to the hospital for additional surgery. The
most important factor in preparing the child for this experience is:
a. Gratification of the childs wishes
b. The childs previous hospital visits
c. Assurance of affection and security
d. Avoiding leaving the child with strangers
Answer: C
Rationale: The 2-year-old is still attached to and dependent on the parents. Fear of
separation is a great stress. (Mosbys, 18
th
Edition)

Situation 16: Basic knowledge of the normal behavior of varied age groups guides the
nurse in helping address the concerns of parents in rearing their children.
176. A maternity nurse is providing instructions to a new mother regarding the
psychosocial development theory, the nurse would instruct the mother to:
a. Allow the newborn infant to signal a need
b. Anticipate all of the needs of the newborn infant
c. Avoid the newborn infant during the first 10 minutes of crying
d. Attend to the newborn infant immediately when crying
Answer: A
Rationale: According to Erikson, the caregiver should not try to anticipate the newborn
infants need at all times but must allow the newborn infant to signal needs.
(Saunders, 3
rd
Edition)

177. The mother of an 8-year-chid tells the nurse that she is concerned about the child
that she is concerned about the child because the child seems to be more attentive to
friends than anything else. The most appropriate nursing response would be which of
the following?
a. You need to be concerned.

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b. You need to monitor the childs behavior closely.
c. At this age, the child is developing his own personality.
d. You need to provide more praise to the child to stop this behavior.
Answer: C
Rationale: According to Erikson, during school age years (6-12 years), the child begins
to move toward peers and friends and away from the parents for support. The child
also begins to develop special interests that reflect his/her own developing personality
instead of the parents. (Saunders, 3
rd
Edition)

178. The mother of a 4-year-old child calls the clinic nurse and expresses concern
because the child has been masturbating. The most appropriate response by the nurse
is which of the following?
a. The child is very young to begin this behavior and should be brought to the clinic.
b. This is not normal behavior, and the child should be seen by the physician
c. This is a normal behavior at this age.
d. Children usually begin this behavior at 8 years.
Answer: C
Rationale: According to Freuds psychosexual stages of development, between ages 3
and 6, the child is the phallic stage. At this time, the child devotes much energy to
examining his/her genitalia, masturbating, and expressing interest in sexual concerns.
(Saunders, 3
rd
Edition)

179. A mother of a 5-year-old child tells the nurse that the child scolds the floor or a table
if the child hurts herself on the object. According to Piagets theory of cognitive
development, this behavior is identified as:
a. Object permanence
b. Egocentric speech
c. Animism
d. Global organization
Answer: C
Rationale: Animism means that all inanimate objects are given living meaning.
(Saunders, 3rd Edition)

180. A clinic nurse is preparing to discuss the concepts of moral development with a
mother. The nurse understands that according to Kohlbergs theory of moral
development. In the pre-conventional level, moral development is thought to be
motivated by which of the following?
a. The parents behavior
b. Peer pressure
c. Social pressures
d. Punishment and reward
Answer: D
Rationale: In pre-conventional stage, morals are thought to be motivated by
punishment and reward. If the child is obedient and is not punished, then the child is
being moral. The child sees actions as good or bad. If the childs actions are good, the
child is praised. If the childs actions are bad, the child is punished. (Saunders, 3rd
Edition)

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Situation 17: The nurse is caring for 5-year-old child who is diagnosed with acute lymphoid
leukemia.
181. The child refuses to go
to sleep and is afraid that his parents will leave. The nurse recognizes that the child
suspects she is dying and is afraid. Which of the following questions about death is
most likely to be made by a 5-year-old child?
a. What does it feel like when you die?
b. Who will take care of me when I die?
c. What will my friends do when I die?
d. Why do children die if they are not old?
Answer: B
Rationale: The greatest fear of preschool children is being left alone and abandoned.
Preschool children still think as though they are alive and need to be taken cared of.

182. The child is receiving
induction therapy with vincristine and prednisone, and L-asparaginase. She presents
with paresthesia, alopecia and moon face. Which of the following diagnoses would be
most appropriate for this child?
a. High risk for injury
b. Impaired physical mobility
c. Body image disturbance
d. Altered nutrition: less than body requirements
Answer: C
Rationale: Her loss of hair and fat face will make her different from her friends.

183. The primary reason for
using prednisone in the treatment of acute lymphoid leukemia in children is that it is
able to:
a. Decrease inflammation
b. Reduce irradiation edema
c. Suppress mitosis in lymphocytes
d. Increase appetite and sense of well-being
Answer: A
Rationale: Prednisone is a synthetic glucocorticoid that has an active anti
inflammatory effect by stabilizing lysosomal membranes and thus inhibiting proteolytic
enzyme release.

184. Because of the toxicity
of vincristine (Oncovin), the nurse could expect:
a. Anemia and fever
b. Irreversible alopecia
c. Neurologic symptoms
d. Gastrointestinal symptoms
Answer: C
Rationale: Vincristine is highly neurotoxic, causing paresthesias, muscle weakness,
ptosis, diplopia, paralytic ileus, vocal cord paralysis, and loss of deep tendon reflex.

185. The childs absolute
neutrophil count is 500/mm
3
. In planning for her care, which of the following would be

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included in a nursing care plan?
a. Good handwashing by visitors and staff
b. Daily CBCs withdrawn
c. Daily physical therapy
d. Restriction of activity
Answer: A
Rationale: Because of the maintenance therapy and neutrophil count, this client may
have bone marrow suppression, which increases her risk for infection. Good
handwashing is essential to help prevent infection.

Situation 18: An estimated 1% to 3% of the population is mentally retarded. The following
questions pertain to mental retardation.
186. Mental retardation is
best described as:
a. A delay in normal growth and development caused by an inadequate environment
b. A lack of development of sensory abilities
c. A condition of subaverage intellectual functioning that originates during the
developmental period and is associated with impairment in adaptive behavior
d. A severe lag in neuromuscular development and motor abilities
Answer: C
Rationale: Mental Retardation is defined mental retardation as a condition of
subaverage intelligence that originates during the developmental period (before the
age of 18).

187. A mentally retarded
child has an IQ of 45, and can be trained in a sheltered workshop. What is the level of
mental retardation of the child?
a. Mild c. Severe
b. Moderate d. Profound
Answer: B
Rationale: A moderately retarded child has an IQ of 35-50, is trainable, and can learn
the activities of daily living, social skills, and can be trained to work in a sheltered
workshop.

188. A mother tells the
nurse that the pediatrician is concerned that her 4-year-old child exhibits
developmental delays. The mother expresses readiness to place her child in a
preschool program for retarded children. The nurse should:
a. Praise the mother for her acceptance and encourage her plan
b. Advise the mother to have the pediatrician help choose an appropriate program
c. Ask the mother for more specific information related to the developmental delays
d. Tell the mother that this is probably a premature action because developmental
delays often disappear
Answer: C
Rationale: More information is needed. Developmental delay suggests some
milestones for the age is not being met at the average time. It is not synonymous with
mental retardation.
A. This would be inappropriate as more information must be obtains.
B. Although the physician may help, it is not yet known if such a program is needed.

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D. The nurse does not know this without more information.

189. Studies of young
children institutionalized for some time indicate that they show signs of retarded
development. Least affected by this type retardation is the child's:
a. Sense of hearing
b. Ability to understand
c. Ability for self-expression
d. Neuromuscular development

Answer: A
Rationale: Hearing is a sense that is not greatly influenced by emotional response in
the young child.

190. Hydrocephalus, if
untreated, can cause mental retardation because:
a. Cerebrospinal fluid (CSF) dilutes blood supply, causing cells to atrophy
b. Hypertonic CSF disturbs normal plasma concentration, depriving nerve cells of vital
nutrients
c. Increasing head size necessitates more oxygen and nutrients than normal blood
flow can supply
d. Gradually increasing size of the ventricles presses the brain against the bony
cranium; anoxia and decreased blood supply result
Answer: D
Rationale: Cellular destruction occurs as the brain is pressed against the unyielding
skull. This occludes blood vessels and deprives the cells of oxygen.

Situation 19: The nurse is counseling 10-year-old child and her parents in the hospital
about the action of insulin and its effect in the blood glucose levels before meals and at
bedtime. The child has been instructed to take a split dose of regular and NPH insulin
twice a day. The goal is to keep all glucose levels between 80 and 150 mg/dL before
meals. The child has been instructed by the physician to change the insulin pattern
control.
191. Insulin causes the blood glucose to:
a. Increase
b. Decrease
c. Neither increase nor decrease
d. Increase, then decrease
Answer: B
Rationale: Insulin, which is produced by the beta cells, facilitates entry of glucose into
the cells, thus decreasing blood glucose levels.

192. A pre-bedtime glucose level of 50 would be considered too low. The clinical
symptoms would likely include which of the following?
a. Thirst c. Dehydration
b. Flushing d. Sweating
Answer: D
Rationale: Sweating is a sign of hypoglycemia.

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193. When a child begins to use an insulin pump, her parent must wake at 2:00 am and
test her for hypoglycemia. The reason the blood glucose may drop at this time may be
too little:
a. Food c. Fluid
b. Exercise d. Sodium
Answer: A
Rationale: An insulin ump is an automatic device that delivers insulin at a constant
rate. When pump therapy first begins, a parent must awake at 2:00 am and test the
child's glucose level, because the pump is delivering insulin and the child has not eaten
since bedtime, which predisposes the child to develop hypoglycemia.

194. The child has experienced Somogyi phenomenon. The following day, the physician
visits the child. The nurse should anticipate orders to:
a. Increase the regular insulin
b. Decrease the regular insulin
c. Increase the intake of protein at supper
d. Decrease the intake of protein at supper
Answer: B
Rationale: Insulin overuse and persistent hypoglycemia causes Somogyi phenomenon.
Somogyi phenomenon is a rebound hyperglycemic response, typically manifested with
nighttime hypoglycemia and early morning hyperglycemia. In order to manage this, the
physician has to decrease the regular insulin dosage.

195. The child is planning to play basketball at 3:00 in the afternoon. It would be best to:

a. Take no insulin that morning
b. Decrease regular insulin dosage in the morning
c. Decrease NPH insulin dosage in the morning
d. Increase the NPH insulin dosage in the morning
Answer: C
Rationale: NPH is intermediate-acting insulin. It takes effect 1-2 hours, and peaks at
4-12 hours after insulin administration. Decreasing the dosage of NPH insulin,
therefore, decreases absorption and utilization of glucose by active body cells around
mid to late afternoon, around which time the child is playing basketball, thus
preventing hypoglycemia.

Situation 20: The patient has the right to receive right dosage of the drug. Nurses
therefore should be accurate in doing drug calculations and conversions especially for
pediatric clients.
196. The adult dose is Dilantin 150 mg. How much should be given to a 6-year-old child?
a. 20 mg c. 75 mg
b. 50 mg d. 100 mg
Answer: B
Rationale: Use Young's formula:
(age in years / age in years + 12 ) x Adult dose
(6 / 6 + 12) x 150 mg = 50 mg

197. Average adult dose is 500 mg. How much should be given to a 30-lb child?
a. 100 mg c. 300 mg

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b. 250 mg d. 350 mg
Answer: A
Rationale: Use Clark's formula:
(weight in lbs / 150 ) x Adult dose
(30 / 150) x 500 mg = 100 mg

198. Average adult dose is 250 mg. How much should be given to a 12-month-old infant?
a. 20 mg c. 75 mg
b. 50 mg d. 100 mg
Answer: A
Rationale: Use Fried's formula:
(age in months / 150 ) x Adult dose
(12 / 150 ) x 250 mg = 20 mg

199. The nurse practitioner has ordered amoxicillin 145 mg PO TID for a 28-lb toddler. It
is supplied as a suspension of 250 mg/5 mL. The safe dosage is 35 mg/kg/24 hours.
Is this dose safe?
a. Yes c. Cannot be determined
b. No d. There is inadequate data
Answer: A
Rationale: Yes
28 lbs is equal to 12.7 kg.
35 mg x 12.7 kg = 444.5 mg/24 hours
444.5 / 3 = 148 mg/dose

200. An infant is hospitalized for dehydration. The child has just urinated and the
practitioner has changed the IV order to 5% dextrose in normal saline and 20 mEq/L
of potassium chloride. A 500 mL bag of 5% dextrose in normal saline is available.
The potassium chloride label reads 2 mEq/mL. How many millimeters of potassium
chloride should the nurse add to the 500 mL bag?
a. 2.5 mL c. 10 mL
b. 5 mL d. 15 mL
Answer: B
Rationale: Use the formula: (Desired Dose / Drug at Hand) x Vehicle or simply (D / H)
x V.
The desired dose is 20 mEq/L. For a 500 ml bag, only 10 mEq of potassium chloride is
needed.
(10 mEq / 2 mEq) x mL = 5 mL

The reason most goals are not achieved is that we spend our time doing second things
first.

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CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS PART C

SITUATION: In its most basic sense, trauma means injury to the body. In medicine, the
term typically refers to the most severe injuriesthose that threaten life and limb. Unlike
most emergency room patients, trauma patients require highly specialized care, including
surgery and blood transfusions. Time is a critical factortrauma treatment should be
given within the first hour (the so-called "golden hour") following injury.

1. A disaster is defined as:
a. Any event or situation that results in multiple casualties and/or deaths
b. A catastrophic and/or destructive event that disrupts normal functioning
c. An industrial accident or unplanned release of nuclear waste
d. An event that results in human casualties that overwhelm the available health care
resources

ANSWER: B
Disastera catastrophic and/or destructive event that disrupts normal functioning; it may
include any anticipated or unexpected event whose effects lead to significant destruction
and/or adverse consequences. Option A: Mass casualty incident or event (MCI) any event
or situation that results in multiple casualties and/or deaths.
Option C: Technological disastersindustrial accidents and unplanned release of nuclear
waste. Option D: Medical disasters catastrophic events that result in human casualties
that overwhelm the available health care resources
Reference: Perry Clinical Nursing Skills and Technique. 6th edition. Page 105
Barbara Blok. First Aid for the Emergency Medicine (2009). 900

2. Which of the following statements is not true regarding the role of nurses in Disaster
Response Plan:
a. Nurses can perform duties outside of his/her expertise.
b. Nurses can serve as a triage officer
c. Nurses may participate in crisis intervention and counselling of other staff members
d. None of the above

ANSWER: D
The role of the nurse during a disaster varies. The nurse may be asked to perform outside
his or her area of expertise and may take on responsibilities normally held by physicians
or advanced practice nurses. For example, a critical care nurse may intubate a patient or
even insert chest tubes. Wound debridement or suturing may be performed by staff
registered nurses. A nurse may serve as the triage officer. New settings and atypical roles
for nurses arise during a disaster: the nurse may provide shelter care in a temporary
housing area, or bereavement support and assistance with identification of deceased
loved ones. Individuals may require crisis intervention, or the nurse may participate in
counselling other staff members and in critical incident stress management.
Reference: Brunner. Medical Surgical Nursing. 11th edition. Page 2563

3. Which of the following statements best describes prioritization in disaster situations?
a. In disaster, decisions are based on the likelihood of survival and consumption of
available resources

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b. In disaster or non-disaster situations, priority is given to those who are most critically ill
c. Conditions with high mortality rate would be assigned as a priority in a disaster
d. In disaster situations priority is given to those who are most critically ill

ANSWER: A
In non-disaster situations, health care workers assign a high priority and allocate the most
resources to those who are the most critically ill. In a disaster, however, when health care
providers are faced with a large number of casualties, the fundamental principle guiding
resource allocation is to do the greatest good for the greatest number of people.
Decisions are based on the likelihood of survival and consumption of available resources.
Therefore, this same patient, and others with conditions associated with a high mortality
rate, would be assigned a low triage priority in a disaster situation, even if the person is
conscious.

4. In performing cardiopulmonary resuscitation, the primary goal of the nurse is to:
a. Return the heart to normal rhythm c. Maintain circulation to vital organs
b. Maintain acid-base balance d. Avoid fluid volume deficit

ANSWER: C
The goal of CPR is to maintain circulation to vital organs until more advanced forms of life
support can be initiated.
Reference: American Heart associations

5. Which of the four phases of emergency management is known as the sustained action
that reduces or eliminates long term risk to people and poverty from natural hazards and
their effects?
a. Mitigation b. Preparedness c. Recovery d. Response

ANSWER: A
The process of emergency management involves four phases which includes mitigation,
preparedness, response and recovery.
Mitigation efforts in this phase attempts to prevent hazards from occurring into
disasters altogether or to reduce the effects of disasters when they occur. The mitigation
phase differs from other phases because it focuses on the long-term measures for
eliminating or reducing the risk.
Preparedness in this phase, emergency managers develop plans of action for when the
disaster strikes. Common preparedness measures include communication plans, proper
maintenance and training of emergency services, response teams, evacuation plans, etc.
Response includes the mobilization of necessary emergency services and responders in
the disaster area. This includes core emergency services such as fire-fighters, police,
ambulance crews and special rescue teams.
Recovery the aim of this phase is to restore the affected area to its previous state. It is
concerned with the efforts concerned with actions that involve rebuilding destroyed
property, rebuilding infrastructure, re-employment and repair of other essential
infrastructures.
Reference: Veenema. Disaster Nursing and Emergency preparedness. 2
nd
edition. Page
140

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6. Upon arriving at a mass casualty scene, the health care providers will initiate triage by
doing which of the following first?
a. Assess b. Move c. Sort d. Send

ANSWER: B
The move phase also allows rescue workers to identify those individuals who can follow
commands but may not be able to walk.
Option A: The second step of the triage process, assess, allows rescue workers to focus
on the remaining victims who are presumed more critically injured.
Option C: During the assess triage process personnel actually begin the sort task.
Option D: The final step in the MASS triage system is send.
Rescue workers evacuate, transport, or release all living clients as soon as possible.
Reference: Perry Clinical Nursing Skills and Technique. 6th edition. Page 110

7. During the sort phase of triage, a client with a closed head injury with no altered level
of consciousness would be classified using the ID-me system as:
a. Green b. Yellow c. Red d. Black

ANSWER: B
Yellowclosed head injury without altered level of consciousness.
Greenabrasions, contusions, minor lacerations, no apparent injuries.
Redunconscious or unresponsive, altered mental status, severe breathing difficulty.
Blackvictims still alive but so badly injured as to have little chance of survival; victims
who have died.
Reference: Perry Clinical Nursing Skills and Technique. 6th edition. Page 110-111
: Brunner. Medical Surgical Nursing. 11th edition. Page 2562

8. A 40-year-old male patient who was at the site of a workplace explosion that is
considered a disaster area has suffered second- and third-degree burns to 65% of his
body, but he is conscious. This person would be triaged as:
a. Green b. Yellow c. Red d. Black

ANSWER: D
A 2nd/3rd degree burns in excess of 60% of body surface area is triaged as black. In
black category: Injuries are extensive and chances of survival are unlikely even with
definitive care. Persons in this group should be separated from other casualties, but not
abandoned. Comfort measures should be provided when possible.

9. A maintenance man falls from a ladder into the unit hall, striking his head on some
equipment. The man is unconscious and not breathing; the Code Team has already been
paged and is on its way. The nurse should:
a. Wait for the team to start CPR c. Give two rescue breaths after extending the
neck
b. Open airway with a jaw thrust d. Start chest compressions

ANSWER: B

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The jaw thrust, rather than neck extension, is used when a head or neck injury is
suspected. CPR should be initiated and then taken over by the Code Team when they
arrive.
Reference: Adrian Linton. Introduction to Medical Surgical Nursing. 4th edition. Page 226

10. Nurse Hannah is doing the CPR to an unconscious client. Nurse Hannah can cease
CPR when there is:
a. Spontaneous breathing and absence of dyspnea c. Heartbeat and
spontaneous breathing
b. Spontaneous breathing and absence of cyanosis d. Heartbeat and return of
consciousness

ANSWER: C
Cardiopulmonary resuscitation success refers to the lack of need for assisted respiration
and assisted blood circulation. These two criteria are met when the heartbeat and
spontaneous breathing are restored.
Reference: Adrian Linton. Introduction to Medical Surgical Nursing. 4th edition. Page 226

11. A patient enters the emergency department with a gunshot wound to the abdomen.
The most common hollow organ injured in this way is the:
a. Liver b. Small bowel c. Stomach d. Large bowel

ANSWER: B
Intra-abdominal injuries are categorized as penetrating or blunt trauma. Penetrating blunt
injuries (e.g gunshot wounds, stab wounds) are serious and usually require surgery.
Penetrating abdominal trauma results in a high incidence of injury to hollow organs,
particularly the small bowel. The liver is the most frequently injured solid organ.
Reference: Brunner. Medical and Surgical Nursing. 11
th
edition. Page 2529

12. A 45-year-old man is involved in a motor vehicle accident and sustains blunt trauma
to his abdomen. The patient must be:
a. Ambulated immediately to expel flatus c. Immobilized on a backboard
b. Placed in a Fowler's position d. Placed in a left lateral position

ANSWER: C
Blunt trauma to the abdomen may result form motor vehicle crashes, falls, blows, or
explosions. Blunt trauma is commonly associated with extra-abdominal injuries to the
chest, head or extremities. Patients with blunt trauma are a challenge because injuries
may be difficult to detect. The incidence of delayed and trauma-related complications is
greater than penetrating injuries. With blunt trauma, the patient is kept on a stretcher to
immobilize the spine. A backboard may be used for transporting the patient.
Reference: Brunner. Medical and Surgical Nursing. 11th edition. Page 2531-2532

13. Nurse Isabel is assessing a patient presenting to the emergency department with the
potential diagnosis of heat stroke. She is most likely to see which of the following
sign/symptom?
a. Anhidrosis b. Increased blood pressure c. Warm moist skin d. Decreased
heart rate

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ANSWER: B
Heat stroke causes thermal injury at the cellular level, resulting in widespread damage to
the heart, liver, kidney, and blood coagulation. Recent patient history reveals exposure to
elevated ambient temperature or excessive exercise during extreme heat. When
assessing the patient, the nurse notes the following symptoms: profound central nervous
system (CNS) dysfunction (manifested by confusion, delirium, bizarre behavior, coma);
elevated body temperature (40.6C [105F] or higher); hot, dry skin; and usually
anhidrosis (absence of sweating), tachypnea, hypotension, and tachycardia.

14. Which laboratory finding is expected of a patient who suffered heat stroke?
a. Elevated ALT/AST b. Hot and dry skin c. Normal ECG d. CNS
dysfunction

ANSWER: A
Marked elevation of AST/ALT is expected with peak in 2472 hours. Complete recovery is
expected. Options B and D though present, is not a laboratory finding but are symptoms.
ECG is monitored for dysrhythmias.
Barbara k. Blok. First Aid for the Emergency Medicine Boards (2009). Page 629

15. Which of the following is the most important step to restore oxygenation and
ventilation for the unresponsive, breathless submersion (near drowning) victim?
a. Attempt to drain water from breathing passages by performing the Heimlich maneuver
b. Begin chest compressions
c. Provide cervical spine stabilization because a diving accident may have occurred
d. Open the airway and begin rescue breathing as soon as possible even in the water

ANSWER: D
The first and most important treatment of the near-drowning victim is provision of
immediate mouth to mouth ventilation. Prompt initiation of rescue breathing has a
positive association with survival.
Answer A is incorrect because the drainage of water is unnecessary and will delay
provision of rescue breathing. The ACLS guidelines state there is no need to clear the
airway of aspirated water. Some victims aspirate nothing At most only a modest
amount of water is aspirated by the majority of drowning victims, and it is rapidly
absorbed. In addition the abdominal thrusts can cause injuries.
Answer B is incorrect because chest compressions should be performed only if there are
no signs of circulation after delivery of 2 breaths if the victim is unresponsive and not
breathing.
Answer C is incorrect because providing cervical spine stabilization will not restore
oxygenation and ventilation.

16. During CPR, when attempting to ventilate a client's lungs, the nurse notes that the
chest is not moving. What action should the nurse take first?
a. Use a laryngoscope to check for a foreign body lodged in the esophagus.
b. Reposition the head to validate that the head is in the proper position to open the
airway.
c. Turn the client to the side and administer three back blows.

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d. Perform a finger sweep of the mouth to remove any vomitus.

ANSWER: B
The most frequent cause of inadequate aeration of the client's lungs during CPR is
improper positioning of the head resulting in occlusion of the airway (B). A foreign body
can occlude the airway, but this is not common unless choking preceded the cardiac
emergency, and (A, C and D) should not be the nurse's first action.

17. The emergency department nurse is performing an assessment on a client who has
sustained circumferential burns of both legs. Which assessment would be the priority in
caring for this client?
a. Assessing peripheral pulses c. Assessing urine output
b. Assessing neurological status d. Assessing blood pressure

ANSWER: A
The client who receives circumferential burns to the extremities is at risk for altered
peripheral circulation. The priority assessment would be to check for peripheral pulses to
ensure that adequate circulation is present. Although the urine output, neurological
status, and BP would also be assessed, the priority with a circumferential burn is the
assessment for the presence of peripheral pulses.
Reference: Brunner and Suddarths Textbook of Medical Surgical Nursing by Smeltzer and
Bare 12th ed.

18. A 35-year-old male presents to the ED with a complaint of abdominal pain, nausea
and blurry vision. He has a history of alcohol abuse and reports ingesting something from
the copier shop earlier in the day. The nurse will most likely expect the client to receive
which initial treatment?
a. Administration of ethanol c. Assist in hemodialysis
b. Acidifying urine d. Administer oxygen as ordered

ANSWER: A
This patient has likely ingested methanol; Methanol is found in windshield wiper fluid,
antifreeze and photocopier fluid. Initial therapies include administration of fomepizole or
ethanol (via drip) to decreased formation of formic acid (the toxic metabolite) and urinary
alkalinization to increase its clearance. Consider hemodialysis in cases of severe
acidosis, visual changes or a serum level >50 mg/dL.
Reference: Barbara k. Blok. First Aid for the Emergency Medicine Boards (2009). Page
322

19. A client presents with circumferential burns to the chest and shortness of breath
following an electrical burn injury. The nurse identifies that the priority nursing diagnosis
for this injury would be:
a. Deficient fluid volume. c. Ineffective breathing pattern.
b. Risk for injury. d. Decreased cardiac output

ANSWER: C
Circumferential burns to the chest wall will decrease chest expansion and ventilation and
will compromise breathing.

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An ineffective breathing pattern is evident as a result of this injury. There is potential for
further tissue damage, decreased cardiac output, and fluid volume deficit caused by
hypoxia and edema formation for burn with third-spacing of fluids. However, breathing
and airway are priorities in this case.

SITUATION: Nurses in many types of practice settings encounter patients with altered
neurologic function. Disorders of the nervous system can occur at any time during the life
span and can vary from mild, self-limiting symptoms to devastating, life-threatening
disorders.

20. The nurse is planning care for a client who has a right hemispheric stroke. Which
nursing diagnosis should the nurse include in the plan of care?
a. Impaired physical mobility related to right-sided hemiplegia.
b. Risk for injury related to denial of deficits and impulsiveness.
c. Impaired verbal communication related to speech-language deficits.
d. Ineffective coping related to depression and distress about disability.

ANSWER: B
With right-brain damage, a client experience difficulty in judgment and spatial perception
and is more likely to be impulsive and move quickly, which places the client at risk for
falls (B). Although clients with right and left hemisphere damage may experience
impaired physical mobility, the client with right brain damage will manifest physical
impairments on the contralateral side of the body, not the same side (A). The client with a
left-brain injury may manifest right-sided hemiplegia with speech or language deficits (C).
A client with left-brain damage is more likely to be aware of the deficits and experience
grief related to physical impairment and depression (D).
Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition

21. Physical examination of a comatose client reveals decorticate posturing. Which
statement is accurate regarding
this client's status based upon this finding?
a. A cerebral infectious process is causing the posturing.
b. Severe dysfunction of the cerebral cortex has occurred.
c. There is a probable dysfunction of the midbrain.
d. The client is exhibiting signs of a brain tumor.

ANSWER: B
Decorticate posturing (adduction of arms at shoulders, flexion of arms on chest with
wrists flexed and hands fisted and extension and adduction of extremities) is seen with
severe dysfunction of the cerebral cortex (B). Option A is characteristic of meningitis.
Option C is characterized by decerebrate posturing (rigid extension and pronation of arms
and legs).
A client with (D) may exhibit decorticate posturing, depending on the position of the
tumor and the
condition of the client.

22. In developing a plan of care for a client with dementia, the nurse should remember
that confusion in the elderly

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a. Is to be expected, and progresses with age. c. Is a result of irreversible brain
pathology.
b. Often follows relocation to new surroundings. d. Can be prevented with
adequate sleep.

ANSWER: B
Relocation (B) often results in confusion among elderly clients--moving is stressful for
anyone. Option A is a
stereotypical judgment. Stress in the elderly often manifests itself as confusion, so (C) is
wrong. Adequate sleep is not a prevention (D) for confusion.
Reference: Brunner and Suddarths Medical Surgical Nursing 12
th
edition

23. An elderly male client who is unresponsive following a cerebral vascular accident
(CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best
client position for administration of the bolus tube feedings?
a. Prone b. Fowler's c. Sims' d. Supine

ANSWER: B
The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to
decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to
placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into
the stomach through an incision in the abdomen for long-term administration of nutrition
and hydration in the debilitated client. In (A and/or C), the client is placed on the
abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of
aspiration.

24. A client with Parkinson's disease is taking carbidopa-levodopa (Sinemet). Which
observation by the nurse should indicate that the desired outcome of the medication is
being achieved?
a. Decreased blood pressure.
b. Lessening of tremors.
c. Increased salivation.
d. Increased attention span.

ANSWER: B
Sinemet increases the amount of levodopa to the CNS (dopamine to the brain). Increased
amounts of dopamine improve the symptoms of Parkinson's, such as involuntary
movements, resting tremors (B), shuffling gait, etc.
Option A is a side effect of Sinemet. Decreased drooling would be a desired effect, not (C).
Sinemet does not affect (D).
Reference: Amy Karch. Focus on Nursing Pharmacology 3
rd
edition

25. A patient with Parkinsons disease would be at risk for falling as a result of:
a. Quick movements.
b. Unsteady, shuffling gait.
c. Hemiparesis.
d. Frequent loss of consciousness.

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ANSWER: B
The patient with Parkinsons disease has a very unsteady shuffling gait, as well as a very
slow response, which could cause the patient to fall.
Reference: Kozier and Erbs Fundamentals of Nursing: Concepts, Process and Practice.
8th edition

26. A client with multiple sclerosis has experienced an exacerbation of symptoms,
including paresthesias, diplopia, and nystagmus. Which instruction should the nurse
provide?
a. Stay out of direct sunlight. c. Schedule extra rest periods.
b. Restrict intake of high protein foods. d. Go to the emergency room immediately.

ANSWER: C
Exacerbations of the symptoms of MS occur most commonly as the result of fatigue and
stress. Extra rest periods should be scheduled (C) to reduce the symptoms. Options A, B,
and D are not necessary.
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edition

27. The Glasgow coma scale measures the level of consciousness. Which of the following
is the critical score which is generally accepted as indicating severe head injury?
a. 12 b. 9 c. 8 d. 3

ANSWER: C
A score of 8 and below is the critical score which is generally accepted as indicating
severe head injury. The lowest score is 3 (least responsive) where the client is already in a
deep coma.
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edition

28. The physician ordered an MRI for a client. As the nurse taking care of the client, she
knows that all of the
following are true of MRI, except:
a. The client must be placed on NPO four hours prior the test
b. All metal objects should be removed from the client
c. Sedation may be prescribed in some circumstances
d. It uses a powerful magnetic field to obtain images of different areas of the body

ANSWER: A
The client is not placed NPO prior to an MRI. This is usually done only in tests such as CT-
Scan if a contrast agent will be used. All the other options are correct. All metal objects
should be removed from the client and the nurse must ensure that no patient care
equipment that contains metal or metal parts enters the room where MRI is located.
Furthermore, sedation may be prescribed in some circumstances because the MRI is a
narrow tube and clients may experience claustrophobia.
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29. A client presents in the emergency room with symptoms of slurred speech, decreased
level of consciousness and flaccid paralysis. During assessment, she appears to be
drowsy. The attending physician observes that her pupils are fixed and her reflexes are

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absent. It was determined that she is showing signs of increased ICP. The nurse monitors
the client and found his ICP reading to be 60. What is the nurses best action?
a. Record the reading c. Notify the physician
b. Place the client in a supine position d. Turn the client and recheck the
reading

ANSWER: C
This is the nurses best action at this time. The normal ICP reading is 10-20mmHg and 60
mmHg is already too high. The physician should be notified immediately. Option A would
be the action if the ICP reading was normal.
Options B and D are incorrect.
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30. A cleint with ICP exhibits significant changes in mental status and vital signs and
continues to deteriorate. The nurse knows that this Cushings triad may happen along with
this deterioration and needs immediate intervention. Which of the following is not
associated with the Cushings triad?
a. HR 50 bpm b. BP 190/98 mmHg c. RR 11 cpm d. TEMP 38C

ANSWER: D
The Cushings triad includes bradycardia, hypertension and bradypnea and is a grave sign.
This requires intermediate intervention.
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edition

31. The nurse is teaching a client recently diagnosed with myasthenia gravis about the
disease. Which of the following is true about myasthenia gravis?
a. It is a genetic dysfunction c. There is involuntary muscle weakness that
escalates with rest
b. Men are affected more frequently d. The initial manifestation usually involves the
ocular muscles

ANSWER: D
Myasthenia gravis is an autoimmune (not genetic) disorder affecting the myoneural
junctions, affects more women than men, there is voluntary muscle weakness that
escalates with activity and the initial manifestation usually involves the ocular muscles
(e.g. diplopia and ptosis are common).
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32. A client is admitted to the hospital for diagnostic testing for possible myasthenia
gravis. The nurse prepares for intravenous administration of edrophonium chloride
(Tensilon). What is the expected outcome for this client following administration of this
pharmacologic agent?
a. Progressive difficulty with swallowing. c. Improvement in generalized fatigue.
b. Decreased respiratory effort. d. Decreased muscle weakness.

ANSWER: D
Administration of edrophonium chloride (Tensilon), a cholinergic agent, will temporarily
reduce muscle weakness (D), the most common complaint of newly-diagnosed clients
with myasthenia gravis. This medication is used to diagnose myasthenia gravis due to its

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short duration of action. This drug would temporarily reverse (A and B), not increase these
symptoms. (C) is not a typical complaint of clients with myasthenia gravis, but weakness
of specific muscles, especially after prolonged use, is a common symptom.
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33. In planning care for a client with advanced Parkinsons disease, which activity is most
likely to be effective in alleviating fatigue?
a. Getting him to bed on time c. Collaborating with him when scheduling
activities
b. Avoiding high-carbohydrate foods d. Providing for morning and afternoon naps while
he is in the hospital

ANSWER: C
Scheduling activities in collaboration with the client will allow him to proceed at his own
pace and maximize his strength. All activities, including naps, should be planned with the
client, as well as providing a high-carbohydrate diet to provide energy.
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edition
Reference: Norman Keltner. Psychiatric Nursing. 5
th
edition

SITUATION: PSYCHE
34. A group of eight psychiatric clients have been together in group therapy for 12
sessions. There has been an expression of warm feelings, self-disclosure, and an
awareness of events in the here and now. The group finds it difficult to deal with two
members who must now join the group. The nurse recognizes that group members are
experiencing which phase of group process?
a. Beginning phase b. Transition phase c. Middle phase d. Termination
phase

ANSWER: C
The cohesiveness is apparent in the group. Joining or leaving the group results in strong
emotions due to disruption of the sharing group. In the beginning phase, members are
getting to know each other, transition phase is not aphase in group process; termination
phase may bring various emotions, but not what is described.

35. A female client is hospitalized for depression. One evening after an argument with her
husband, she discusses with the evening nurse her intent to cut her wrists. Her husband
has threatened to divorce her and retain custody of the children. What is the most
appropriate initial action for the nurse to take?
a. Attempt to convince the client the need to address her husbands threat instead of
using self-destructive behavior
b. Place the client on suicide precautions, requiring close observation and one-to-one
monitoring by nursing staff
c. Recognize suicidal remarks as less serious because the client is in a safe environment
d. Tell the client that her husband will not divorce her if she wont attempt suicide.

ANSWER: C
Suicide attempts are more common on evenings, night shift or weekends when the unit
structure is lessened. The client feels threatened form her husbands actions and is
expressing tunnel vision in regards to her situation. The safety of the client is the first

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concern and all suicidal remarks and gestures must be taken seriously. Therapeutic
sessions will be held at a later time.
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36. The nurse is planning the care for a 32-year-old male client with acute depression.
Which nursing intervention best helps this client deal with his depression?
a. Ensure that the client's day is filled with group activities.
b. Assist the client in exploring feelings of shame, anger, and guilt.
c. Allow the client to initiate and determine activities of daily living.
d. Encourage the client to explore the rationale for his depression.

ANSWER: B
Depression is associated with feelings of shame, anger, and guilt. Exploring such feelings
is an important nursing intervention for the depressed client (B). If the client's day is filled
with group activities (A) he might not have the opportunity to explore these feelings.
Option C is a good intervention for the chronically depressed client who exhibits vegetative
signs of depression. Option D is essentially asking the client "why" he is depressed--avoid
"whys" disguised as "rationale."
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37. A nurse working on a mental health unit receives a community call from a person who
is tearful and states, "I just feel so nervous all of the time. I don't know what to do about
my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or
4 days." The nurse should initiate a referral based on which assessment?
a. Altered thought processes. c. Inadequate social support.
b. Moderate levels of anxiety. d. Altered health maintenance.

ANSWER: B
The nurse should initiate a referral based on anxiety levels (B) and feelings of nervousness
that interfere with sleep, appetite, and the inability to solve problems. The client does not
report symptoms of (A) or evidence of (C). There is not enough information to initiate a
referral based on (D).
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38. A male client is admitted to a mental health unit on Friday afternoon and is very upset
on Sunday because he has not had the opportunity to talk with the healthcare provider.
Which response is best for the nurse to provide this client?
a. Let me call and leave a message for your healthcare provider
b. The healthcare provider should be here on Monday morning
c. How can I help answer your questions?
d. What concerns do you have at this time?

ANSWER: A
It is best for the nurse to call the healthcare provider (A) because clients have the right to
information about their treatment. Suggesting that the healthcare provider will be
available the following day (B) does not provide immediate reassurance to the client. The
nurse can also implement offer to assist the client (C and D), but the highest priority
intervention is contacting the healthcare provider.

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39. A male client is admitted to the mental health unit because he was feeling depressed
about the loss of his wife and job. The client has a history of alcohol dependency and
admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100 F,
pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based
on which priority nursing diagnosis?
a. Risk for injury related to suicidal ideation. c. Knowledge deficit related to
ineffective coping.
b. Risk for injury related to alcohol detoxification. d. Health seeking behaviors related to
personal crisis.

ANSWER: B
The most important nursing diagnosis is related to alcohol detoxification (B) because the
client has elevated vital signs, a sign of alcohol detoxification. Maintaining client safety
related to (A) should be addressed after giving the client Ativan for elevated vital signs
secondary to alcohol withdrawal. Options C and D can be addressed when immediate
needs for safety are met.
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40. An adult is experiencing a panic attack. The nurse intervenes by escorting him to his
room, using short sentences, and conveying a calm demeanor. Which action by the client
indicates the nursing interventions are effective?
a. Releases his anxiety by punching his fist on a bedside table
b. States he wants to be alone to deal with his feelings
c. Expresses verbally his demands to the nurse
d. Makes connections between events and his anxious response

ANSWER: D
With reduced levels of anxiety, the clients perceptual field broadens, allowing the client to
focus on the cause of anxiety and to connect the cause with his anxious response. He is
able to learn from the experience. High levels of anxiety, as expressed in other choices,
prevent this from occurring.
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41. A young adult is involuntarily admitted to the psychiatric unit in a manic state. Upon
arrival on the unit he is unable to sit, he is very difficult to understand because of his rapid
rate of speech, and he refuses to eat or drink. What area of disturbance poses the
greatest physical danger to this client?
a. Activity b. Perceptual c. Sensory d. Social

ANSWER: A
The clients high activity level poses the most danger because it can lead to absence of
food, fluid, and rest with resultant dehydration, electrolyte imbalance, and physical
collapse.
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edition

42. A young woman with history of bipolar disorder is admitted to the psychiatric unit. She
is talking excitedly and walking rapidly around the unit. What intervention would most
likely be initiated during the initial period of hospitalization?
a. Encourage the client to participate in group and therapeutic activities

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b. Observe the client closely until she calms down
c. Place the client in four-point restraints for protection of self and others
d. Place the client in seclusion but maintain frequent one-to-one contact with her

ANSWER: D
Manic clients cannot calm down without assistance. Decreasing the level of sensory
stimulation is of paramount importance and provides the greatest therapeutic effect until
proper medication levels (often lithium) are established. Restraints would further agitate
the client.
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43. Which of the following is least likely to influence the potential for a client to comply
with lithium therapy after discharge?
a. The impact of lithium on the clients energy level and lifestyle
b. The need for consistent blood level monitoring
c. The potential side effects of lithium
d. What the clients friends think of his need to take medication

ANSWER: D
While the clients social network can influence the client in terms of compliance, the
influence is typically secondary to that of the other factors listed. Side effects of lithium
include fine tremor, drowsiness, diarrhea, polyuria, thirst, weight gain, and fatigue, which
can be disturbing to the client.
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edition

44. The nurse is caring for an elderly client who has been diagnosed as having
sundowners syndrome. The nurse asks the client and his family to list all the
medications, prescription and nonprescription, he is currently taking. What is the primary
reason for this action?
a. Multiple medications can lead to dementia
b. The medications can provide clues regarding his medical background
c. Ability to recall medications is a good assessment of the clients level of orientation
d. Medications taken by a client are part of every nursing assessment

ANSWER: A
Polypharmacy (concurrent use of several drugs) increases the potential for adverse side
effects, one being dementia. Sundowners syndrome involves behavior that are seen in
the late afternoon or early evening when the sun sets, which include disorientation,
emotional upset, or confusion.
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edition

45. A resident of a long-term care facility is taking lithium carbonate (Eskalith) to treat
bipolar disorder. Which instruction should the nurse provide to this client's caregivers?
a. Offer the morning dose of the medicine before breakfast.
b. Have the client chew the pill if it is difficult to swallow.
c. Encourage high energy fluid intake by providing sports drinks or sodas.
d. Report symptoms of hypothyroidism such as fatigue and constipation.

ANSWER: D

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Lithium carbonate (Eskalith) causes hypothyroidism in 1 to 4% of those clients receiving
the medication, so caregivers should assess for signs of hypothyroidism, including fatigue
and constipation (early signs) and myxedema or goiter (late symptoms) (D). Lithium
carbonate (Eskalith) should be offered with meals, not before (A), and should not be
chewed, crushed, or halved (B). Fluid intake should be encouraged to treat polydipsia
caused by this medication, but (C) should be avoided to reduce the occurrence of weight
gain and dental caries.

46. When should the nurse introduce information about the end of the nurse-client
relationship?
a. During the orientation phase c. At least one or two sessions before the last
meeting
b. As the goals of the relationship are reached d. When the client can tolerate it

ANSWER: A
Preparation for ending the nurse-client relationship should begin during the orientation
phase, when the limits of the relationship are established.
Option B - termination should also be discussed as goals are achieved and the
relationship nears an end.
Option C - although the nurse should remind the client that only one or two sessions are
left, the nurse must not wait until then to prepare the client for termination.
Option D - the client's ability to tolerate the end of a relationship shouldn't dictate its
timing. Because many clients have had negative experiences when ending relationships,
the nurse can use termination of the nurse-client relationship to prepare the client for and
work the client through positive termination experiences with others.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page 93

47. One tool that is useful in learning more about oneself is the Johari window which
creates a word portrait of a person in four areas and indicates how well the person
knows himself or herself and communicates with others. Which area evaluated the
qualities known only to oneself:
a. Quadrant 1 b. Quadrant 2 c. Quadrant 3 d. Quadrant 4

ANSWER: C
Quadrant 3: Hidden/ private self portrays to qualities known only to oneself.
Option A Open/public self portrays qualities one knows about oneself and others also
know.
Option B Blind/unaware self portrays qualities known only to otheres.
Option D Unknown portrays an empty quadrant to symbolize qualities as yet
undiscovered by oneself or others.

48. A client reports losing his job, not being able to sleep at night, and feeling upset with
his wife. The nurse responds to the client, "You may want to talk about your employment
situation in group today." The nurse is using which therapeutic technique?
a. Restating b. Making observations c. Exploring d. Focusing

ANSWER D:

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The nurse is using focusing by suggesting that the client discuss a specific issue. She
didn't restate the question, ask further questions (exploring), and didn't make an
observation.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page
111-115

49. Earlier today you said you were concerned that your son was still upset with you.
When I stopped by your room about an hour ago, you and your son seemed relaxed and
smiling as you spoke to each other. How did things go between the two of you? This is an
example of which therapeutic communication technique?
a. Consensual validation b. Encouraging comparison c. Accepting d.
General lead

ANSWER: A
Consensual validation is searching for mutual understanding. For verbal communication
to be meaningful, it is essential that the words being used have the same meaning for
both (all) participants. Sometimes words, phrases, or slang terms, have different
meanings and can be easily misunderstood.
Option B comparing ideas, experiences, or relationships brings out many recurring
themes. The client benefits from making the comparison because she or he might recall
past coping strategies that were effective or remember that he or she has survived a
similar situation. For example: Have you had similar experiences?, Was it something
like.?
Option C this response indicates the nurse has heard and followed the train of thought.
It does not indicate
agreement but is nonjudgmental. For example: Yes., I follow what you said. Nodding.
Option D indicates that nurse is listening and following what the client is saying without
taking away the initiative for the interaction. Go on, And then?

50. A true crisis state, involving a period of severe disorganization, is difficult to endure
emotionally and physically. The nurse recognizes that a client will only be able to tolerate
being in crisis for which of the following lengths of time?
a. 5 to 7 days b. 2 to 3 weeks c. 4 to 6 weeks d. 8 to 12 weeks

ANSWER: B
Generally, 4 to 6 weeks is viewed as the length of time a client can tolerate the severe
level of disturbance of a true crisis. In the first week or two, clients usually are still trying
to use their normal coping skills and support systems. After 6 weeks of continuous crisis,
a client is probably becoming so physically and emotionally drained that he or she has
sought or has been brought by others for medical or psychiatric use.
Isaac, A. (2001) Lippincotts Review Series Mental Health and Psychiatric Nursing 3rd
Edition. Page 215-220

51. The nurse would select which of the following approaches in order to best respond to
a client in crisis?
a. Behavioral approach c. Problem-solving approach
b. Nondirective approach d. Supportive approach

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ANSWER: C
The problem-solving method is used in a systematic manner as part of crisis intervention.
Option A and B - the behavioral approach or the nondirective approach would not be
selected as part of crisis
intervention.
Option D - although a supportive approach (eg. supporting client strengths) is part of crisis
intervention, the over-all method guiding the nurse is the problem-solving approach.
Edition. Page 215-220

52. What nursing intervention should be included prior to electroconvulsive therapy (ECT)?
a. Providing an opportunity for the client to ask questions and express concerns about ECT
b. Telling the client that it is not helpful to concentrate on the therapy
c. Reassuring the client that ECT is no worse than having a venipuncture
d. Telling the client she will recover completely as a result of ECT

ANSWER: A
The opportunity to ask questions helps to reduce anxiety and misinformation while
enlisting the client and familys support and cooperation in the treatment. The treatment
often results in significant reduction in depression but the results cannot be guaranteed.
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53. The nurse is discussing electroconvulsive therapy (ECT) with a client who asks how
long it will be before she feels better. How soon will the nurse state the beneficial effects
of ECT occur?
a. 1 week b. 3 weeks c. 4 weeks d. 6 weeks

ANSWER: A
Treatments are administered at intervals of 48 hours, with beneficial effects evident after
the first several treatments, which is within 1 week.
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54. Nursing assessment before electroconvulsive therapy (ECT) is aimed at establishing
parameters that reflect the clients mental and physical status. Which assessment is
excluded in the assessment before ECT therapy?
a. Activity level b. Bowel habits c. Pain tolerance d. Sleep habit

ANSWER: C
Pain is not associated with ECT, but activity level, bowel habits, and sleep habits and/or
depression provide insight into the clients physical and mental status.
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55. A newly admitted client with conversion disorder says he cannot move his legs. What
is the best nursing
response?
a. The physical tests and examinations state no physiological reason for your paralysis

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b. Let me help you out of the bed to the wheelchair. I will show you where the dining
room is. Dinner is served at 6:30 pm. Ill be telling you more about the typical routine
later
c. Ill plan to have your meals served to you in bed. Because of your physical problem you
will receive special
privileges
d. You are here to get an understanding of how your physical symptoms related to the
conflicts in your personal life. Maybe you should reflect on this awhile and Ill be back in
one hour to discuss it with you

ANSWER: B
Explanation of normal routine reduces anxiety and decreases secondary gain. It is too
early in the relationship to uncover the conflict underlying the conversion.
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56. A client with depression receives a prescription for amitriptyline (Elavil). Which
instruction should the nurse include in the client's teaching?
a. Do not ingest foods with tyramine. c. Obtain daily blood pressure readings.
b. Avoid the consumption of alcohol. d. Take with a glass of orange juice.

ANSWER: B
Tricyclic antidepressants (TCAs) such as amitriptyline can cause sedation and should not
be mixed with agents that depress the central nervous system, so the client should be
instructed to avoid alcohol (B). Tyramine rich foods (A) should be avoided when taking
mono-amine oxidase inhibitors. Blood pressure (C) should be monitored in a client taking
selective-serotonin reuptake inhibitors. Option D does not affect the absorption of
amitriptyline.
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57. A young woman is admitted to the psychiatric unit for treatment of bulimia. What is
the primary issue for the bulimia client?
a. Delusions b. Depersonalization c. Fear and suspicion of others d. Poor
impulse control
ANSWER: D
The bulimic clients awareness of the inappropriateness of the eating pattern coupled with
the clients inability to control eating activity indicates lack of impulse control. The other
choices describe paranoia or schizophrenia.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition

58. The nurse is assessing a client with bulimia. Which characteristic is least likely to be
evident in the history?
a. Repeated crash dieting c. Rigorous exercise regimens
b. Repeated weight fluctuations d. Self-induced vomiting

ANSWER: C
This activity is seen in anorexia nervosa. The others are commonly associated with
bulimia.
Reference: Norman Keltner. Psychiatric Nursing. 5th edition

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59. The nurse is assessing a 15-year-old female who's being admitted for treatment of
anorexia nervosa. Which symptom is the nurse most likely to find?
a. Heat intolerance b. Hypertension c. Hypertrophy of salivary glands d. Not
preoccupied with food

ANSWER: C
Frequent vomiting causes tenderness and swelling of the parotid glands.
Symptoms: Preoccupation with thoughts of food, Fear of gaining weight, amenorrhea,
cold intolerance, hypotension, hypothermia, bradycardia, hypertrophy of the salivary
glands and electrolyte imbalance.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition. Page
532-533

60. What should the nurse do when interviewing a child suspected of being sexually
abused?
a. Ask leading questions c. have a security guard present
b. Have the parents present d. Use the childs words to describe body parts

ANSWER: D
Using words the child uses to describe body parts ensure that the child understands what
is being said. The child should be asked to describe things in her own words, and in a
private interview so the child will feel free to express her feelings.
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61. What would be a short-term goal (to be met in 1 week following admission) planned
by a nurse for a delusional client?
a. Reduce the frequency and intensity of the delusional thinking
b. Verbalize why he uses delusions to deal with life
c. Communicate in only reality-oriented terms
d. Recognize his delusions as nonreality-based statements

ANSWER: A
Within 1 week, there may be minimal to moderate changes in thought process,
depending on the clients diagnosed mental illness. An appropriate goal is for the client to
feel less threatened and less anxious, lessening the requirement for delusional thought. If
the client is compliant with psychotropic medications, the client may respond positively by
decreased frequency and intensity of delusions after 1 week of medications. The other
choices are long-term goals.
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62. An adult client states, That TV news anchor is talking about me The nurse recognizes
the statement as what type of thought process?
a. Thought broadcasting
b. Delusion of reference
c. Thought insertion
d. Delusion of persecution

ANSWER: B

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A delusion of reference is a fixed false belief that events or people are directly related to
the individual person. The other choices are a disturbance in thought pattern or a belief
that others are attempting to harm a person.
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63. In planning care for a client with schizophrenia who has negative symptoms, the nurse
would anticipate a problem with:
a. Auditory hallucinations
b. Bizarre behaviors
c. Ideas of reference
d. Motivation for activities
ANSWER: D
In a client demonstrating negative symptoms of schizophrenia, avolition or the lack of
motivation for activities is a common problem.
Options A, B and C all the other symptoms listed are the positive symptoms of
schizophrenia.
Edition. Page 132,134

64. A client who has had auditory hallucinations for many years tells the nurse that the
voices prevent participation in the social skills training program of the community health
center. Which of the following would the nurse teach the client to do?
a. Analyze the content of the voices c. Take medication as prescribed
b. Participate when the voices cease d. Use thought stopping techniques

ANSWER: D
Clients with long-lasting auditory hallucinations can learn to use thought-stopping
measures to accomplish tasks.
Option A analyzing the content of the voices may be indicated when hallucinations first
occur to establish whether the voices are threatening to the individual or instructing the
client to harm others. Focusing on content at this point would reinforce the symptom.
Option B the voices have lasted many years, the client should participate despite the
voices.
Option C there is no indication that the client is not taking medication as prescribed.
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65. Based on non-compliance with the medication regimen, an adult client with a medical
diagnosis of substance abuse and schizophrenia was recently switched from oral
fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate). What is
most important to teach the client and family about this change in medication regimen?
a. Signs and symptoms of extrapyramidal effects (EPS).
b. Information about substance abuse and schizophrenia.
c. The effects of alcohol and drug interaction.
d. The availability of support groups for those with dual diagnoses.

ANSWER: C
Alcohol enhances the EPS side effects of Prolixin. The half-life of Prolixin PO is 8 hours,
whereas the half-life of the Prolixin Decanoate IM is 2 to 4 weeks. That means the side

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effects of drinking alcohol are far more severe when the client drinks alcohol after taking
the long-acting Prolixin Decanoate IM. Options A, B, and D provide valuable information
and should be included in the client/family teaching, but they do not have the priority of
(C).
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66. A client chronically complains of being unappreciated and misunderstood by others.
She is argumentative and sullen. She always blames others for her failure to complete
work assignments. She expresses feelings of envy toward people she perceives as more
fortunate. She voices exaggerated complaints of personal misfortune. The client most
likely suffers from which personality disorder?
a. Dependent personality c. Avoidant personality disorder
b. Passive-aggressive personality d. Obsessive-compulsive disorder

ANSWER: B
The client with passive-aggressive personality disorder displays a pervasive pattern of
negative attitudes, chronic complaints, and passive resistance to demands for adequate
social and occupational performance. The client with a dependent personality is unable to
make everyday decisions and allows others to make important decisions. In addition, the
client with a dependent personality often volunteers to do things that are unpleasant so
that others will like him. The avoidant personality displays a pervasive pattern of social
discomfort, fear of negative evaluation, and timidity. The obsessive-compulsive
personality displays a pervasive pattern of perfectionism and inflexibility.
Reference: Videbeck, S.L. (2006) Psychiatric Mental Health Nursing 3rd Edition.

67. Nurse Hannah knows that the client with obsessive-compulsive disorder who
constantly does repetitive cleaning is attempting to:
a. Decrease her anxiety level c. Control others
b. Focus attention on nonthreatening tasks d. Manipulate others

ANSWER: A
The primary reason for the compulsive activity is to decrease the anxiety caused by
obsessive thoughts. The client is not trying to focus her attention on tasks, control others,
or lessen interaction with others.
Reference: Vdebeck SL. 2008. Psychiatric Mental Health Nursing. 4th Ed. Wolter Kluwer /
Lippincott Williams and Wilkins. p.359.

68. The nurse is assessing a client who is believed to have a borderline personality
disorder. Which question is most important to include in this assessment?
a. At what age did you begin to exhibit symptoms? c. How often do you drink alcoholic
beverages?
b. Do you have a family history of borderline disorder? d. Do you frequently have
temper tantrums?

ANSWER: D
Those with a borderline personality disorder demonstrate intense outbursts of anger, so
(D) is the most important question to ask. (A, B, and C) provide worthwhile information,
but do not have the priority of (D) when assessing a client who is suspected of having a
borderline personality disorder.

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SITUATION: The problems associated with musculoskeletal structures are common and
affect all age groups.

69. A woman who has had rheumatoid arthritis for several years is admitted to the
hospital. Upon physical
examination of the client, what should the nurse expect to find?
a. Asymmetric joint involvement b. Heberdens nodes c. Obesity d. Small joint
involvement

ANSWER: D
Small joint involvement is common in rheumatoid arthritis. All of other symptoms are
seen in osteoarthritis but not rheumatoid arthritis.

70. An elderly is admitted to the orthopedic unit with a diagnosis of a right intracapsular
hip fracture. Bucks extension traction is employed prior to surgery. She complains of
numbness in the right foot. After the nurse notes the tapes are lengthwise on the opposite
sides of the limb, what would be the nurses best response?
a. How long has your foot been numb? c. Ill call your doctor later
b. I can adjust it for your comfort d. There is nothing wrong with the traction

ANSWER: A
Numbness is symptomatic of circulatory or nerve impairment to the extremity. (Assess) It
is important to know the length of time the client has been experiencing this sensation.
The physician needs to be notified immediately if neurovascular compromise is
suspected. Delay may result in permanent nerve and muscle damage or even necrosis.
The nurse is not allowed to adjust the traction.
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71. The nurse is caring for an elderly woman who has had a fractured hip repaired. In the
first few days following the surgical repair which of the following nursing measures will
best facilitate the resumption of activities for this client?
a. Arranging for wheelchair c. Assisting her to sit out of bed on a chair QID
b. Asking her family to visit d. Encouraging the use of an overhead trapeze

ANSWER: D
Exercise is important to keep the joints and muscles functioning and to prevent secondary
complications. Use of the overhead trapeze prevents hazards of immobility by permitting
movement in bed and strengthening of the upper extremities in preparation for
ambulation.

72. A 90-year old woman is preparing to transfer to continue recovery following repair of a
fractured hip. She begins to cry and says, When youre young these things dont happen.
Why did I break my hip at this age? Which response by the nurse indicates the best
understanding of risk factors for the elderly?
a. As you age you become less aware of your surroundings and careless about safety
b. Nothing works as well when we are older

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c. There are no known specific reasons why hip fractures occur more often in your age
group
d. Your age and sex are factors in the loss of minerals from your bones, making them
more likely to break

ANSWER: D
Elderly females are prone to hip fractures because the cessation of estrogen production
after menopause contributes to demineralization of bone. Other options are incorrect.
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73. Mr. Ortega is admitted to the Orthopedic Hospital. X-rays reveal a fractured tibia and a
cast is applied. Of the following, which nursing action would be most important after the
cast is in place?
a. Assessing for capillary refill c. Discussing cast care with the client
b. Arranging for physical therapy d. Helping the client to ambulate

ANSWER: A
Good capillary refill indicates that the cast has not caused a circulatory problem in the
extremity. Other options are correct but assessing circulation is a priority action.
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74. A client attends a class on osteoporosis. Which statement by the client needs further
teaching about the
relationship between exercise and maintenance of bones?
a. I will begin jogging b. I will begin jumping rope c. I will begin swimming d. I will
begin walking

ANSWER: C
Adequate dietary or supplemental calcium and vitamin D, regular weight-bearing exercise,
and modification of lifestyle, if necessary (eg, cessation of smoking, reduced use of
caffeine and alcohol), help to maintain bone mass. Diet, exercise, and physical activity are
the primary keys to developing high-density bones that are resistant to osteoporosis. It is
emphasized that all people continue to need sufficient calcium, vitamin D, sunshine, and
weight-bearing exercise to slow the progression of osteoporosis. Physical compression of
weight-bearing joints stimulates osteoblastic deposition of calcium. Swimming does not
involve weight bearing and physical compression of joints.
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75. An adult who has had a total hip replacement is learning how to walk with a standard
walker. Which description below tells the nurse that he is using the walker correctly?
a. One side of the walker is simultaneously advanced with the opposite foot; the process
is repeated on the other side
b. Each time he steps on his nonaffected side, the client advances the walker; when
moving his affected side, he steps into the walker and lifts his nonaffected foot
c. The client balances on both feet, most weight on his nonaffected side, and lifts the
walker forward; he then
balances on the walker and swings both feet forward into the walker
d. The client lifts the walker in front while balancing on both feet, then walks into the
walker, supporting his body weight on his hands while advancing his affected side

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ANSWER: D
The sequence for using a walker is balance on both feet, lift the walker and place in front
of you, walk into the walker (using it for support when standing on affected limb) and then
balance on both feet before repeating the sequence.
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76. A man has sprained his knee and the emergency nurse is fitting him with crutches. If
the man is measured while he is lying down, how does the nurse ensure correct crutch
length?
a. Measure the client from anterior axillary fold to sole of the foot and add 2 inches
b. Add 6 inches to the length of the clients foot and measure the distance from that point
to the clients axilla
c. Measure the clients axilla to his palm to get the length from the top of the crutch to the
hand piece. Measure form palm to sole to determine the length of lower part of crutch
d. Subtract 24 inches from the clients height to determine length of crutch from top to tip

ANSWER: A
Although measuring the client while he is lying down is not preferred method of fitting
crutches, this formula may used successfully.
Reference: Kozier and erbs Fundamentals of Nursing 8th edition

77. The nurse is teaching a client with a broken left ankle how to go up stairs when using
crutches. Which statement by the nurse is correct?
a. Place both crutches on the next step, stand on the right foot and place the left foot on
the step next to the crutches
b. Place the left crutch and right foot on the next step and push off with both arms then
lift the left foot up to the step
c. Place the right foot on the next step, then move the crutches and the left foot onto the
step
d. Place the right crutch and left foot on the next step; move the right crutch up onto the
step, then swing the right foot up

ANSWER: C
The unaffected limb is advanced to the next step, then the crutches and the affected limb
move to the next step (weight stays on crutches or foot of unaffected side). A handy
mnemonic for clients is, Up with the good leg, down with bad meaning the good leg is
used first when going up stairs, and the crutches and bad leg go to the new step first
when going down stairs.
Reference: Kozier and erbs Fundamentals of Nursing 8th edition

78. Which of the following findings would alert the nurse to notify the physician of a
serious complication for the client with cast on his leg?
a. Itching under the cast c. Ability of client to move toes without difficulty
b. Poor capillary refill of the toes d. Pain relieved by application of ice bag to cast

ANSWER: B

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Poor capillary refill ( a pinking up of the toes after the nailbeds are blanched by
compression, which takes more than 3 seconds) is indicative of a circulatory compromise.
In this situation, the likely cause is compartment syndrome: an increase of pressure
within the cast. Other signs and symptoms include pain unrelieved by usual modalities,
disproportional swelling, and inability to move digits.

79. A client whose left leg is in balanced suspension traction for a femur fracture needs to
moved to a new bed. What is the best way to do this safely?
a. All weights are removed from the ends of the traction ropes so the leg moves freely
before the move is attempted
b. The left leg is kept above the level of the heart
c. Sufficient time is given to the client to move himself to the new bed at his own rate of
tolerance
d. The line of pull is maintained on the left leg

ANSWER: D
A vertical transfer is permitted, as long as manual traction is applied to maintain the line
of pull, that is, the
direction of the traction, or pull, which balanced suspension device supplied.

80. Which statement by an adult with osteoarthritis indicates to the nurse that she
understands her therapeutic regimen?
a. I will wait until my pain is very bad before I take my pain medication, or else further on
in my disease, the
medication wont help at all
b. Jogging for a short distances is better for my arthritis than walking for longer
distances
c. It would probably be a good idea for me to lose the 30 pounds my doctor
recommended I lose
d. I should do all my house cleaning on one day, so I can rest for the remainder of the
week

ANSWER: C
Weight reduction can reduce stress on weight-bearing joints; because the clients
physician has recommended it, we can believe that she will benefit from weight loss.

81. In preparing a discharge teaching plan for the client with osteoarthritis, the nurse
would include which of the following?
a. Application of cold packs to affected joints to decrease swelling
b. Client education regarding self-administration of medications
c. Progressively increasing activity to point of muscle fatigue to build muscle bulk and
improve rate of metabolism
d. Teaching client that degenerative changes are progressive and that pain is natural
sequela of age

ANSWER: B

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Anti-inflammatory medications including salicylates and NSAID will be taken by the client
indefinitely. The client must understand the regimen; ways to monitor for (and when
possible, diminish) adverse effects must also be taught.
Option A: Application of heat is used.
Option C: It is a degenerative disease with pain as a natural sequela of the disease, not of
age.
Reference: Brunner and Suddarths Medical Surgical Nursing 12thedition

82. A 75-year-old male client asks the nurse about the chances of getting osteoporosis
like his wife. The nurse responds correctly by stating:
a. This is only a problem for women
b. Exercise is a good way to prevent this problem
c. You are not at risk because of your small frame
d. You might think about having bone density test

ANSWER: D
Osteoporosis is characterized by reduced bony density and a change in bone structure,
both of which increase susceptibility to fracture. Osteoporosis is a potential major health
problem of all older adults and is not restricted to women Exercise may decrease the
occurrence of, but will not prevent, osteoporosis. A regimen including weight-bearing
exercises is advised. A small frame is a risk factor of osteoporosis.
Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of
Medical-Surgical Nursing. 10th Edition, Vol. 2. Pages 2057-2058.

83. The nurse is caring for clients in the outpatient clinic. Which of the following phone
calls should the nurse return first?
a. A client with hepatitis A who states, My arms and legs are itching
b. A client with osteomyelitis of the spine who states, I am so nauseous that I cant eat
c. A client with a cast on the right leg who states, I have a funny feeling in my right leg
d. A client with rheumatoid arthritis who states, I am having trouble sleeping

ANSWER: C
It is important to meet clients needs. In the given situations, physical stability is nurses
first concern. The most unstable client should be contacted first. A client with cast that
has a funny feeling in his casted leg may indicate neurovascular compromise therefore it
requires immediate assessment.
Reference: Kozier and Erbs. Fundamentals of Nursing: Concepts, Process and Practice.
8th edition

84. Which intervention should the nurse plan to implement when caring for a client who
has just undergone a right above-the-knee amputation?
a. Maintain the residual limb on three pillows at all times.
b. Place a large tourniquet at the client's bedside.
c. Apply constant, direct pressure to the residual limb.
d. Do not allow the client to lie in the prone position.

ANSWER: B
A large tourniquet should be placed in plain sight at the client's bedside (B). If severe
bleeding occurs, the tourniquet should be readily available and applied to the residual

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limb to control hemorrhage. The residual limb should not be placed on a pillow (option A)
because a flexion contracture of the hip may result. Option C should be avoided because it
may compromise wound healing. Option D should be encouraged to stretch the flexor
muscles and to prevent flexion contracture of the hip.

SITUATION: Nurse Hannah is working at the EENT unit of the hospital.

85. A client admitted with glaucoma is being treated with miotic eye drops. Following
administration of the eye drops, the nurse will note:
a. Dilation of the pupils
b. Constriction of the pupils
c. Decreased scleral redness
d. Decreased corneal edema

ANSWER: B
Miotic eye drops are given to a client with glaucoma to cause pupillary constriction,
thereby lowering intra ocular pressure. Option A refers to the action of mydriatics, which
are used for clients with cataracts. Options C and D is also incorrect since miotics do not
diminish redness or decrease edema.

86. After administering pilocarpine, the client complains of blurred vision. Which nursing
action is most appropriate?
a. Immediately notify the physician
b. Administer antihistamine for allergic reaction
c. Suggesting that the client put on his glasses
d. Explaining that this is an expected side effect

ANSWER: D
Pilocarpine, a miotic drug used to treat glaucoma, achieves its effect by constricting the
pupil. Blurred vision lasting 1 to 2 hours after instilling the eyedrops is an expected side
effect. The client may also note difficulty adapting to the dark.
Option A - Because blurred vision is an expected side effect, the physician does not need
to be notified.
Option B - Likewise, the client doesn't need to be treated for an allergic reaction.
Option C - Wearing glasses won't alter this temporary adverse effect.
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87. The client asks Nurse Hannah when he can stop instilling the eye medication for his
chronic open-angle glaucoma. The most appropriate response by Nurse Hannah is?
a. You can stop using it when your vision improves
b. Use the eye medication when you experience the symptoms associated with the
disease
c. Stop using the medication after 2 consecutive eye examinations
d. You cannot stop using the medication

ANSWER: D
To control his increased intraocular pressure, the client will need to continue taking eye
medications for the rest of his life. Lifelong therapy is almost always necessary because

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glaucoma cannot be cured. Intraocular pressure will rise once medications are
discontinued.
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88. Which of the following is contraindicated for clients with glaucoma?
a. Pilocarpine b. Atropine c. Diamox d. Timolol

ANSWER: B
Options A, C and D are all medications used to treat glaucoma. Atropine is
contraindicated for clients with glaucoma because it closes the canal of Schlemm and
increases intraocular pressure.

89. Nurse Hannah assesses a client suspected of having retinal detachment. Signs and
symptoms to expect include:
a. Painless decrease in vision, veil over the visual field, and flashing lights
b. Veil over the visual field, increased intraocular pressure, and yellow-green halos around
visual images
c. Photophobia, yellow-green halos around visual images and blurred vision
d. Unilateral eye inflammation, cloudy cornea, and moderately dilated pupil.

ANSWER: A
A patient with retinal detachment has a painless decrease in vision and vision that is
cloudy or smoky with flashing lights. The patient may also indicate that a curtain or veil is
over the visual field. Intraocular pressure is normal or low. Photophobia, yellow-green
halos around visual images and blurred vision may occur with digoxin toxicity.
Unilateral eye inflammation, cloudy cornea, and a moderately dilated pupil thats not
reactive to light may occur with glaucoma.

90. When Nurse Hannah performs a neurologic assessment on a client, her pupils are
dilated and dont respond to light. The client most likely has:
a. Glaucoma b. Damage to the third cranial nerve c. Damage to the lumbar spine
d. Bells palsy

ANSWER: B
The third cranial nerve (oculomotor) is responsible for pupil constriction. When there is
damage to the nerve, the pupils remain dilated and dont respond to light. Glaucoma,
lumber spine injury, and Bells palsy wont affect pupil constriction.
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91. When assessing a client's interior eye structures with an ophthalmoscope, which
action should the nurse use?
a. Use a red-free filter.
b. Adjust the diopters.
c. Direct a wide-beam light.
d. Dilate the client's pupils.

ANSWER: B

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The diopter corresponds to the magnification power of the ophthalmoscope's lens, which
is adjusted to bring the retina into focus when a client's error of refraction, such as myopia
or hyperopia, causes a change in the eyeball shape. Option A produces a green beam for
examination of the optic disc for pallor and recognition of retinal hemorrhages. Option C is
used to examine the anterior eye. The application of an ophthalmic mydriatic (option D)
should be instilled prior to extended fundoscopic visualization.

92. An older adult client begins wearing binaural hearing aids due to presbycusis. Which
instruction should Nurse Hannah provide to assist the client in adapting to the new
hearing aids?
a. Begin wearing the aids in quiet environments to experiment with adjustments.
b. Wear the hearing aids for an hour a day at first, gradually increasing the time.
c. Keep the volume on low until the conditions with noises are audible.
d. Use one hearing aid until comfortable, then add the second aid.

ANSWER: A
Initially, the use of hearing aids should be restricted to quiet situations in the home (A). As
adjustments occur, the client should gradually be exposed to conditions with background
noise and the outdoors. Time restriction (B) is not necessary. Options C and D do not help
the client adjust as well as gradually introducing various sound conditions.

93. Nurse Hannah is preparing a teaching plan for a client with newly diagnosed
glaucoma and a history of allergic rhinitis. Which information is most important for Nurse
Hannah to provide the client about using over-the-counter (OTC) medications for allergies?
a. Notify your healthcare provider if there is an increase in heart rate.
b. Increase fluid intake while taking an antihistamine or decongestant.
c. Avoid allergy medications that contain pseudoephedrine or phenylephrine.
d. Ophthalmic lubricating drops may be used for eye dryness due to allergy medications.

ANSWER: C
OTC allergy medications may contain ephedrine, phenylephrine, or pseudoephedrine,
which can cause adrenergic side effects, such as increased intraocular pressure, so a
client with glaucoma should avoid using these OTC medications (C). A client with
hypertension should avoid using OTC medications containing ingredients that can
increase blood pressure and heart rate (A), but an increase in IOP is most important in a
client with glaucoma. (B and D) may provide symptomatic relief for other side effects,
such as dry mouth or eye dryness related to common agents used for allergic rhinits.

94. Nurse Hannah is about to give nutritional teaching to a client with Menieres disease.
The most suitable diet for this client is:
a. A diet high in protein c. A diet high in vitamins A, D, E and K
b. A diet low in sodium d. A diet restricted in carbohydrates/calories

ANSWER: B
Patients with Menieres disease can control their symptoms by adhering to a low sodium
diet (2000mg/day). The amount of sodium is one of the many factors that regulate the

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balance of fluid within the body. Sodium and fluid retention disrupts the balance between
endolymph and perilymph in the inner ear.

95. With aging, changes occur in the ear that lay lead to hearing loss. Which term is used
to describe progressive hearing loss associated with aging?
a. Otosclerosis b. Presbycusis c. Presbyopia d. Menieres disease

ANSWER: B
Presbycusis is the term used to describe progressive hearing loss associated with aging.
This type of hearing loss is the result of the damage to the ganglion cells of the cochlea
and decreased blood supply to the inner ear. Presbyopia is the term used to describe loss
of accommodative power of the lens due to aging.

96. Which of the following risk factors would Nurse Hannah assess for a client with
glaucoma?
a. Family history, increased IOP, age of 45-65
b. History of diabetes and age greater than 55
c. Female gender, cigarette smoking, age greater than 65
d. Myopia, history of diabetes, and sudden severe physical exertion

ANSWER: A
Glaucoma is more prevalent among people older than 45 years of age, and the incidence
increases with age. It is also more prevalent among men than women and in the African
American and Asian populations. Family history and increasing IOP is also a risk factor.
There is no cure for glaucoma, but research continues.
th
edition

97. Nurse Hannah has been planning for home care with the family of a client who will
undergo extracapsular lens extraction with an intraocular lens implant. Nurse Hannah
takes care to evaluate their understanding. Which behavior by the client and/or family
shows progress in understanding post-op home care instructions?
a. Using a chart showing various sleeping positions, the client points to a person lying on
the affected side
b. The family demonstrates that the eye should be cleaned with a washcloth, soap and
water
c. The client demonstrates medication instillation by carefully dropping the solution on the
cornea
d. The family shows the nurse the sunglasses they have purchased for the client to wear
post-op

ANSWER: D
To prevent accidental rubbing or poking of the eye, the patient wears a protective eye
patch for 24 hours after surgery, followed by eyeglasses worn during the day and a metal
shield worn at night for 1 to 4 weeks. The nurse instructs the patient and family in
applying and caring for the eye shield. Sunglasses should be worn while outdoors during
the day because the eye is sensitive to light. Option A: The patient should lie on the

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unaffected side. Option B: A clean, damp washcloth may be used to remove slight
morning eye discharge. Option C: The solution should be dropped on the conjunctiva.

98. Nurse Hannah cares for a client following surgery for removal of a cataract in her right
eye. The client complains of severe eye pain in her right eye. Nurse Hannah knows that
this symptom:
a. Is expected and should administer analgesic to the client
b. Is expected and should maintain the client on bed rest
c. Is expected. Hemorrhage is normal after surgery.
d. Is unexpected and may signify hemorrhage

ANSWER: D
Cataract is the change in the transparency of crystalline lens of eye which may be caused
by aging, trauma,
congenital, systemic disease. Signs and symptoms include blurred vision, decrease in
color perception, photophobia.
Treated by removal of lens under local anesthesia with sedation. Intraocular lens
implantation, eyeglasses, or contact lenses after surgery. Complications of surgery include
glaucoma, infection, bleeding, retinal detachment. Ruptured blood vessel or suture
causing hemorrhage or increased intraocular pressure; notify physician if restless,
increased pulse, drainage on dressing.

99. Which of the following should be immediately reported to the physician?
a. Change in color vision c. Increased lacrimation
b. Crusty yellow drainage on eyelashes d. Curtain-like shadow across visual field

ANSWER: D
A curtain-like shadow is a symptom of retinal detachment, which is an emergency
situation. Change in color vision is a symptom of cataract. Crusty drainage is associated
with many eye irritants, such as allergies, contact lenses, or foreign bodies.

100. Despite several eye surgeries, a 78-year-old client who lives alone has persistent
vision problems. The visiting nurse is discussing painting the house with the client. The
nurse suggests that the edge of the steps should be painted which color?
a. Black b. White c. Light green d. Medium yellow

ANSWER: D
Yellow is the easiest for a person with failing vision to see (D). Option A will be almost
impossible to see at night because the shadows of the steps will be too difficult to
determine, and would pose a safety hazard. Option B is very hard to see with a glare from
the sun and it could hurt the eyes in the daytime to look at them. Option C is a pastel color
and is difficult for elderly clients to see.

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COMMUNICABLE DISEASE NURSING

Situation 1. Specific defenses of the body involve the immune system. Nurses should be
knowledgeable on the importance of immunity in the prevention of communicable
diseases.
201. The nurse knows which of the following is true about immunity?
a. Antibody-mediated defense occurs through the T-cell system
b. Cellular immunity is mediated by antibodies produced by B-cells
c. Antibodies are produced by the B-cells
d. Humoral or circulating immunity is lost with AIDS
Answer: C
Rationale: Antibodies are produced by the B-cells and are part of the body's plasma
proteins. (Kozier & Erb's Fundamentals of Nursing, 8
th
Edition)

202. The nurse explains to a mother whose child just received a tetanus toxoid injection
that the toxoid confers which of the following immunity?
a. Lifelong passive immunity
b. Long-lasting active immunity
c. Lifelong active natural immunity
d. Lifelong active artificial immunity
Answer: B
Rationale: Toxoids and vaccines are considered artificial active immunity. The
administration of antigens (toxoids and vaccines) stimulates antibody production. The
duration of its effect lasts for many years, however, it is not lifelong (option C and D)
because the immunity must be reinforced by booster. It is not a passive (option A) and
natural (option C) immunity. (Kozier & Erb's Fundamentals of Nursing, 8
th
Edition)

203. A mother asked a nurse on the duration of the effectiveness of a natural passive
immunity. The nurse is correct when she tell the mother that the effect lasts for:
a. 2 to 3 weeks c. 6 months to 1 year
b. Permanent d. 2 to 5 years
Answer: C
Rationale: The effectiveness of a natural passive immunity lasts for 6 months to 1
year. (Kozier & Erb's Fundamentals of Nursing, 8
th
Edition)

204. When it is impossible to determine whether a patient has been immunized against
tetanus, the preparation of choice used to produced passive immunity for several
weeks with minimal danger of allergic reactions is:
a. DTP vaccine c. Tetanus antitoxin
b. Tetanus toxoid d. Tetanus immune globulin
Answer: D
Rationale: Tetanus immune globulin (TIG) provides antibodies against tetanus; it is
used if the patient has never received tetanus toxoid or has not received it for over 10
years. It confers passive immunity.

205. A patient who was exposed to hepatitis A is given gamma globulin to provide
passive immunity, which:
a. Increases production of short-lived antibodies
b. Provides antibodies that neutralize the antigen

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c. Accelerates antigen-antibody union at the hepatic sites
d. Stimulates the lymphatic system to produce large numbers of antibodies
Answer: B
Rationale: Gamma globulin, an immune globulin, contains most of the antibodies
circulating in the blood. When injected into an individual, it prevents a specific antigen
from entering a host cell. (Mosby's, 18
th
Edition)

Situation 2. Immunization is the process by which resistance to infectious disease is
induced or augmented.
206. A nursing student is assigned to administer immunizations to children in a clinic.
The nursing instructor asks the student about the contraindications in receiving an
immunization. The student responds correctly by telling the instructor that a
contraindication to receiving an immunization is if a child has:
a. A cold c. Mild diarrhea
b. Otitis media d. A severe febrile illness
Answer: D
Rationale: A severe febrile illness is a reason to delay immunization but only until child
has recovered from the acute stage of the illness.

207. A clinic nurse prepares to administer a measles, mumps, rubella (MMR) vaccine to
a 5-year-old child. The nurse administers this vaccine:
a. Intramuscularly in the anterolateral aspect of the thigh
b. Intramuscularly in the deltoid muscle
c. Subcutaneously in the outer aspect of the upper arm
d. Subcutaneously in the gluteal muscle
Answer: C
Rationale: The MMR vaccine is administered subcutaneously in the outer aspect of the
upper arm.

208. A mother brings her 6-month-old daughter to a well baby clinic for her regular
checkup. When discussing childhood immunizations, the nurse explains that routine
childhood immunizations protect against:
a. Calmette-Guerin bacillus, poliomyelitis, hepatitis A, measles
b. Measles, mumps, rubella, pertussis, herpes simplex
c. Diphtheria, measles, tetanus, mononucleosis
d. Poliomyelitis, pertussis, mumps, tetanus
Answer: D
Rationale: Routine childhood immunizations protect against Calmette-Guerin bacillus,
poliomyelitis, measles, mumps, rubella, diphtheria, pertussis, tetanus, and hepatitis B.

209. A rubella vaccine is prescribed to be administered to a 2 day postpartum patient.
The nurse preparing to administer the vaccine develops a list of the potential risks
associated with this vaccine. The nurse reviews the list with the patient and cautions
the patient to avoid:
a. Sunlight for 3 days
b. Scratching the injection site
c. Pregnancy for 2 to 3 months after the vaccination
d. Sexual intercourse for 2 to 3 months after the vaccination
Answer: C

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Rationale: Rubella vaccine is a live attenuated virus that evokes an antibody response
that provides immunity for 15 years. Because rubella is a live vaccine, it will act as the
virus and is potentially teratogenic in the organogenesis phase of fetal development.
The client needs to be informed about the potential effects that this vaccine may have
and the need to avoid becoming pregnant for a period of 2 to 3 months after receiving
the vaccine.

210. The mother of a child in well baby clinic asks the nurse which immunization
contains live virus?
a. MMR and OPV c. DPT and OPV
b. Hib and MMR d. DPT and Hib
Answer: A
Rationale: MMR and OPV contain live attenuated virus.

Situation 3. Whenever possible, the nurse implements strategies to prevent infection.
Integration of Infection Control measures with the Nursing Process is imperative in the
prevention of the further spread of infection.
16. The most effective nursing action for controlling the spread of infection includes
which of the following?
a. Thorough hand cleansing
b. Wearing gloves and masks when providing direct client care
c. Implementing appropriate isolation precautions
d. Administering broad-spectrum prophylactic antibiotics
Answer: A
Rationale: Since the hands are frequently in contact with clients and equipment, they
are the most obvious source of transmission. Regular and routine hand cleansing is the
most effective way to prevent movement of potentially infective materials. (Kozier &
Erb's Fundamentals in Nursing, 8
th
Edition)

17. Ms. Vibac is a chronic carrier of infection. To prevent the spread of the infection to
other patients or health care providers, the nurse emphasizes interventions that do
which of the following?
a. Eliminate the reservoir
b. Block the portal of exit from the reservoir
c. Block the portal of entry into the host
d. Decrease the susceptibility of the host
Answer: B
Rationale: Blocking the movement of the organism from the reservoir will succeed in
preventing the infection of any other persons. (Kozier & Erb's Fundamentals in
Nursing, 8
th
Edition)

18. When caring for a single patient during one shift, it is appropriate for the nurse to
reuse which of the following personal protective equipment?
a. Goggles c. Surgical mask
b. Gown d. Clean gloves
Answer: A
Rationale: Unless overly contaminated by material that has splashed in the nurse's
face and cannot be effectively rinsed off, goggles may be worn repeatedly. (Kozier &
Erb's Fundamentals in Nursing, 8
th
Edition)

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19. In caring for Mr. Bacte who is on contact precautions for a draining infected foot
ulcer, the nurse should perform which of the following?
a. Wear a mask during dressing changes
b. Provide disposable meal trays and silverware
c. Follow standard precautions in all interactions with the patient
d. Use surgical aseptic technique for all direct contact with the patient
Answer: C
Rationale: Standard Precautions include all aspects of contact precautions with the
exception of placing the client in a private room. (Kozier & Erb's Fundamentals in
Nursing, 8
th
Edition)

20. Regardless of the type of isolation precautions that a patient has been assigned,
which of the following actions by the nurse should be given the highest priority in terms
of infection control?
a. Using strict aseptic technique
b. Washing of hand before and after giving client care
c. Checking sterile supplies for expiration date
d. Changing intravenous tubing according to hospital policy
Answer: B
Rationale: Regardless of isolation precautions, the basic action by the nurse to prevent
infection is hand washing. All of the other options should also be followed but
handwashing establishes the first line of defense and is therefore the highest
importance.

Situation 4. Malaria continues to be a major health problem in the Philippines. It requires
sustained and systematic efforts toward prevention of transmission through vector
control, and early detection and treatment of malarial cases.
21. The nurse is reviewing the physical examination and laboratory tests of a client with
malaria. The nurse understands that an important finding on malaria is:
a. Polyuria c. Splenomegaly
b. Leukocytosis d. Erythrocytosis
Answer: C
Rationale: Malarial parasites invade the erythrocytes, subsequently dividing and
causing the cell to burst. The spleen enlarges from the sloughing of red blood cells.

22. When caring for a patient with malaria, the nurse should know that:
a. Seizure precautions must be followed
b. Blood transfusions usually are indicated
c. Isolation is necessary to prevent cross-infection
d. Nutrition should be provided between intestinal paroxysms
Answer: D
Rationale: Maintaining adequate nutritional and fluid balance is essential to life and
must be accomplished during periods when intestinal motility is not too excessive so
that absorption can occur.

23. When teaching a patient about drug therapy against Plasmodium falciparum, the
nurse should include the fact that:
a. The infection is controlled

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b. Immunity will prevent reinfestation
c. The infection can generally be eliminated
d. Transmission by the Anopheles mosquito can occur
Answer: C
Rationale: Quinine sulfate is used in malaria when the plasmodia are resistant to the
less toxic chloroquine. However, a new strain of Plasmodium, resistant to quinine,
must me be treated with combination of quinine (quick-acting), pyrimethamine, and
sulfonamide (slow-acting).

24. Blackwater fever occurs in some patients with malaria. Therefore, the nurse should
observe a patient with malaria for:
a. Diarrhea c. Low-grade fever
b. Dark red urine d. Coffee-ground emesis
Answer: B
Rationale: Plasmodium falciparum in persons with malaria can cause hemoglobinuria,
intravascular hemolysis, and renal failure as a result of destruction of RBCs.

25. The nurse explains to the patient that the best way to prevent malaria is to avoid:
a. Mosquito bites
b. Untreated water
c. Undercooked food
d. Overpopulated areas
Answer: A
Rationale: Malaria is caused by the protozoan Plasmodium falciparum, which is carried
by mosquitoes.

Situation 5. Dengue is a major health concern in the community. There had been a
sudden increase in the incidence of dengue as a result of poor environmental sanitation
and increase breeding places for mosquitoes.
21. In what stage of the acute febrile infection wherein tourniquet test, which may be
positive on the 3
rd
day, may become negative due to low or vasomotor collapse?
a. Febrile stage c. Invasive Stage
b. Hemorrhagic stage d. Convalescent stage
Answer: B
Rationale: The toxic or hemorrhagic stage occurs on the 4
th
to 7
th
days of infection.
During this stage there would be lowering of temperature, severe abdominal pain,
vomiting and frequent bleeding from gastrointestinal tract in the form of hematemesis
or melena. Unstable blood pressure, narrow pulse pressure and shock can also occur.
Death can occur in many cases. The tourniquet test, which may be positive on the 3
rd

day of infection, may become negative due to low or vasomotor collapse. (Public
Health Nursing in the Philippines)

22. During the first 3 days of infection, the following signs and symptoms are common,
except:
a. Abdominal pain and headache
b. Flushing which may be accompanied by vomiting
c. Lowering of temperature
d. Epistaxis and conjunctival infection
Answer: C

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Rationale: The febrile or invasive stage occurs on the first 4 days of the infection. This
stage starts abruptly as high fever (up to 105 F), abdominal pain and headache
(option A), which can also be accompanied by other symptoms such as chilliness, rash,
backache, and severe muscle ache; later flushing which may be accompanied by
nausea and vomiting (option B), conjunctival infection and epistaxis (option D).
In option C, lowering of temperature occurs during the toxic or hemorrhagic stage,
which occurs on the 4
th
to 7
th
days of infection. (Public Health Nursing in the
Philippines)

23. The nurse should frequently monitor a patient with dengue for developing signs and
symptoms of Dengue Shock Syndrome, which include all of the following, except:
a. Restlessness and cold clammy skin
b. Rapid weak pulse and narrowing of pulse pressure
c. Severe abdominal pain
d. Hypertension and massive hemorrhage
Answer: D
Rationale: Dengue shock syndrome (DSS), the most severe form of dengue fever,
includes all Dengue Hemorrhagic Fever (DHF) symptoms, as well as its own symptoms.
Initial signs of DSS include restlessness, cold clammy skin. (Public Health Nursing in
the Philippines)

24. Rumpel-Leede Capillary-Fragility test is a clinical diagnostic method performed to
determine possible dengue infection. Which of the following steps, done by the nurse,
would be considered incorrect?
a. A test is positive when 25 petechiae per 1 inch square are observed
b. Count the number of petechiae inside the box
c. Release the cuff and make an imaginary 2.5 cm square or 1 inch square just below
the cuff, at the antecubital fossa
d. Inflate the blood pressure cuff on the lower arm to a point midway between the
systolic and diastolic pressure for 5 minutes
Answer: D
Rationale: A tourniquet test (also known as a Rumpel-Leede Capillary-Fragility test or
simply a capillary fragility test) determines capillary fragility. It is a clinical diagnostic
method to determine a patients hemorrhagic tendency. It assesses fragility of
capillary walls and is used to identify thrombocytopenia (a reduced platelet count). It is
performed to determine possible dengue infection. The steps are as follows:
1. Inflate the blood pressure cuff on the upper arm to a point midway between the
systolic and diastolic pressure for 5 minutes.
2. Release the cuff and make an imaginary 2.5 cm square or 1 inch square just
below the cuff, at the antecubital fossa.
3. Count the number of petechiae inside the box.
4. A test is positive when 20 or more petechiae per 1 inch square are observed.
(Public Health Nursing in the Philippines)

25. Supportive and symptomatic treatment should be provided to patients with dengue.
This includes which of the following, except:
a. For fever and muscles pains give paracetamol
b. For headache give analgesics such as aspirin
c. Give ORS to replace fluid as in moderate dehydration at 75 ml/kg in 4-6 hours or up

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to 2-3 liters in adults
d. Includes intensive monitoring and follow-up
Answer: B
Rationale: Supportive and symptomatic treatment should be provided to patients with
dengue which includes:
1. For fever and muscle pains give paracetamol (option D). For headaches, give
analgesics. DONT give ASPIRIN.
2. Rapid replacement of body fluids is the most important treatment.
3. Includes intensive monitoring and follow-up (option B).
4. Give ORS to replace fluid as in moderate dehydration at 75 ml/kg in 4-6 hours or
up to 2-3 liters in adults (option C). (Public Health Nursing in the Philippines)

Situation 6. Nurse Granyels is taking care of patients diagnosed with chickenpox and
shingles.
26. Nurse Granyels reviews the health care record of Dyomanji, age 10, diagnosed with
varicella zoster. The following are findings the nurse expect to note as characteristic of
this disorder, except:
a. Slight fever
b. Centripetal rashes
c. Vesicular for 3-4 days and leaves granular scabs
d. Painful vesicular eruptions along the route of inflamed nerves
Answer: D
Rationale: Chickenpox (varicella zoster) is an acute infectious disease of sudden onset
with slight fever. (Public Health nursing in the Philippines)

27. Dyomanjis mother calls the nurse station to find out when her son can return to
school. What is the best response for Nurse Granyels to make?
a. All the lesions must be completely gone before contact with others is resumed
b. Within two to three weeks, the itching should be under control and good hand
washing established so that contact with others can be started
c. Dyomanji can return six days after the first lesions appear, because the crusts will
be formed
d. Dyomanji must first learn to cough with his mouth covered, put tissues in the trash,
and wash his hands after touching his nose and mouth
Answer: C
Rationale: Varicella zoster, the chickenpox virus, is found in the respiratory secretions
of infected persons and also in the skin lesions that are not scabbed over. Scabs are
not infectious. By six days after the rash first appears, all the lesions will be scabbed
over. (NSNA, NCLEX-RN Review, 4
th
Edition)

28. Mr. Clottey, age 50, is seen by the physician and suspects herpes zoster. Nurse
Granyels prepares the items needed to perform the diagnostic test to confirm this
diagnosis. Which item will the nurse obtain?
a. A Woods light
b. A culture swab and tube
c. A patch test kit
d. A biopsy kit

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Answer: B
Rationale: Herpes zoster (shingles) is caused by a reactivation of the varicella zoster
virus, the cause of the virus for chicken pox. With classic presentation of herpes zoster,
the clinical examination is diagnostic. A viral culture of the lesion provides the
definitive diagnosis.

29. What should Nurse Granyels expect to find during the initial assessment of Mr.
Clottey?
a. Rhinorrhea, small red lesions including some with vesicles that are widespread over
the face and body
b. A painful vesicular eruption following a nerve pathway
c. Blisters on the lips and in the corners of the mouth
d. Painful fluid-filled vesicles in the genital area
Answer: B
Rationale: Herpes zoster (shingles) produces painful vesicular eruptions along a nerve
pathway. (NSNA, NCLEX-RN Review, 4
th
Edition)

30. Which pharmacological therapy would Nurse Granyels expect to be prescribed to
treat Mr. Clotteys disorder?
a. Tetracycline hydrochloride (Achromycin)
b. Erythromycin base (E-mycin)
c. Acyclovir (Zovirax)
d. Indomethacin (Indocin)
Answer: C
Rationale: The goals of treatment for herpes zoster are to relieve pain, to prevent
infection and scarring, and to reduce the possibility of post-herpetic neuralgia. Oral
analgesics are prescribed to reduce the incidence of persistent pain. The lesions may
also be injected with corticosteroids. Acyclovir, if started early, may reduce the severity
of herpes zoster.

Situation 7. Nurse Damaso is taking care of Basilio, 17 months old, who is admitted to
the hospital with Rubeola. He has rashes, coryza, cough, conjunctivitis, temperature of
38C and white spots in his mouth.
36. Sources of infection in rubeola are secretions of the nose and throat of the
infectious person. Filterable virus of measles is transmitted through:
a. Water supply c. Food ingestion
b. Droplet d. Sexual contact
Answer: B
Rationale: Measles is spread through direct and indirect contact with droplets.
(Pillitteri, Maternal and Child Health Nursing, 5
th
Edition)

37. The characteristic signs of rubeola are which of the following group?
a. Rashes which spread from the face to the trunk and limbs, conjunctivitis, high fever
and tiny white spots in the mucosa inside the cheek
b. Skin eruptions which are abundant on covered areas of the body than on the
exposed areas
c. Vomiting, headache, fine petechial and morbilliform rashes and epistaxis
d. Severe backache and rashes which are more abundant on extremities than on the
trunk

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Answer: A
Rationale: The characteristic signs of measles are which of the following: Rashes which
spread from the face to the trunk and limbs ending in branny desquamation,
conjunctivitis (Stimson's sign), high fever and tiny white spots in the mucosa inside the
cheek (Koplik spots). (Public Health Nursing in the Philippines, 2007)

38. Nurse Damaso knows that the incubation period of rubeola is:
a. Varies from 3 days to 1 month or more, falling between 7-14days in high proportion
of cases
b. 12 to 26 days, usually 18 days
c. 2-3 weeks, commonly 13 to 17 days
d. 10 days from exposure to appearance of fever and about 14 days until rash appears
Answer: D
Rationale: The incubation period of Rubeola is 10 days from exposure to appearance
of fever and about 14 days until rash appears. (Public Health Nursing in the
Philippines, 2007)

39. Basilio's immunity from his mother lasted only 6 months. He was brought by his
mother because of spots in his buccal mucosa. What do you call these spots?
a. Rose spots
b. Pseudomembrane
c. Forscheimer's spots
d. Koplik spots
Answer: D
Rationale: Koplik spots are tiny grayish to whitish spots found in the buccal mucosa of
a client with Rubeola. (Public Health Nursing in the Philippines, 2007)

40. A nursing intervention that is important in caring for Basilio would include the
following, except:
a. Wearing face mask when administering nursing care to the child
b. Increase fluid intake of the child by drinking water frequently
c. Administer as prescribed antipyretics to reduce fever
d. Ensuring that the room is well lighted
Answer: D
Rationale: Clients with Rubeola has conjunctivitis (Stimson's sign), as a result an
important nursing intervention is to protect the eyes of the client from glare of strong
light as they are apt to be inflamed. Place the client in a dim-lighted room, not well
lighted. (Public Health Nursing in the Philippines, 2007)

Situation 8. A 45-year-old male, diabetic with chronic Hepatitis B, is admitted because of
pneumonia. Regular CBG monitoring was performed every 6 hours. While giving the
insulin subcutaneously, the nurse accidentally pricked her finger. The nurse previously
received only one dose of hepatitis B vaccine.
36. Which of the following should be done initially?
a. Check for her Hepatitis B status with HBsAg and Anti-HBs
b. Administer HBIg immediately
c. Administer both HBIg and the first dose of Hepatitis B vaccine
d. Administer both HBIg and the first dose of Hepatitis B vaccine, after collecting blood
samples to HBsAg reactivity

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Answer: A
Rationale: The patient's blood must initially be screened for presence of HBsAg and
Anti-HBs. A positive HBsAg confirms active replication of and infection with hepatitis B
virus. If this happens, active immunization (HBV vaccine) will no longer be given since it
does not provide protection to those already exposed to HBV. The presence of Anti-HBs
usually indicates development of immunity. Most people (more than 90%) who
contract HBV infection develop antibodies and recover spontaneously in 6 months. If
this happens, administering HBIg is no longer necessary.
Note: HBV vaccine is given IM in 3 doses: the first dose is given at birth, the second and
third doses are given 1 and 6 months after the first dose (Smeltzer, 2008). From
another source, the second and third doses are given 6 and 14 weeks after the first
dose (PHN book). Antibody response may be measured by an Anti-HBs level 1 to 3
months after completion of the basic course of vaccine.

37. Choose the correct statement about hepatitis B vaccine:
a. All persons at risk should receive active immunization
b. Evidence suggests that HIV may be harbored in the vaccine
c. Booster doses are recommended every 5 years
d. One dose in the dorsogluteal muscle is recommended
Answer: A
Rationale: All persons at risk should receive active immunization

38. The nurse taking care of the patient is correct in identifying which of the following
statements as true regarding Hepatitis B virus transmission?
a. Blood, saliva, semen, and vaginal secretions contain low Hepatitis B virus
b. Urine, feces, and sweat contain high Hepatitis B virus titers
c. After needle stick injury, the risk of the health care worker acquiring the hepatitis B
virus is greater from HBsAg patient, compared to the pricks of acquiring HIV from an
HIV+ patient
d. The risk of transmission after needle stick injury is increased of the source is
HBeAg+
Answer: D
Rationale: The presence of Hepatitis B early antigen (HBeAg) signifies that the client is
highly infectious.

39. A patient positive for HBeAg signifies that the patient:
a. Is highly infectious
b. Is not infectious
c. Has chronic hepatitis B virus infection
d. Has evidence of immunity to hepatitis B virus
Answer: A
Rationale: The presence of Hepatitis B early antigen (HBeAg) signifies that the client is
highly infectious. HBeAg is detected in the blood about 1 week after the appearance of
HBsAg.

40. The type of viral hepatitis that is linked to chronic hepatitis B is:
a. A b. C c. D d. E
Answer: C

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Rationale: The type D virus depends on the double-shelled type B virus to replicate. For
this reason, type D infection can't outlast a type B infection.

Situation 9. Salmon, 18 years old, is spending his Summer Vacation in Siquijor. A week
before the vacation ends, he developed fever, diarrhea and rose spots on his abdomen.
41. Based on Salmon's clinical findings, the nurse will suspect the patient to have
contacted which infection?
a. Amoebiasis c. Cholera
b. Dysentery d. Typhoid fever
Answer: D
Rationale: Typhoid fever is characterized by continued fever, anorexia (loss of appetite),
slow pulse, involvement of lymphoid tissues, especially ulceration of Peyer's patches,
enlargement of spleen, rose spots on trunk and abdomen and diarrhea. (Public Health
Nursing in the Philippines, 2007)

42. Salmon's condition is caused by a:
a. Bacteria c. Protozoa
b. Virus d. Fungi
Answer: A
Rationale: Typhoid fever is caused by Salmonella typhosa or typhoid bacillus, which is
a bacterium. (Public Health Nursing in the Philippines, 2007)

43. The characteristic signs and symptoms of the said condition in #41 are the
following, except:
1. Rose spots on trunk and abdomen
2. Continued fever
3. Bloody stool
4. Diarrhea
5. Intermittent fever
6. Slow pulse
7. Rice watery stool
8. Loss of appetite
a. 2, 4 and 8 c. 3, 5 and 7
b. 2, 7 and 8 d. 4, 6 and 7
Answer: C
Rationale: Typhoid fever is characterized by continued fever, anorexia (loss of appetite),
slow pulse, involvement of lymphoid tissues, especially ulceration of Peyer's patches,
enlargement of spleen, rose spots on trunk and abdomen and diarrhea.
(Public Health Nursing in the Philippines, 2007)

44. The nurse provided the family with health education to prevent transmission of
infection as the disease can be transmitted to family members through the following,
except:
a. Flies
b. Direct contact
c. Contaminated food and water
d. Airborne transmission
Answer: D

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Rationale: Typhoid fever can be transmitted through the following mode of
transmission: direct or indirect contact with patient or carrier; contaminated food and
water with flies as vectors; and improper food handling.
(Public Health Nursing in the Philippines, 2007)

45. As a preventive control measure for the said condition in #41, which of the following
must be discussed in the health education program for the public?
1. Sanitary disposal of human feces and maintenance of fly proof latrine
2. Use of repellants and insecticides
3. Removal of stagnant water in empty water drums and flower pots
4. Proper food handling and preparation
a. 1 and 4 c. 3 and 4
b. 2 and 3 d. 1 and 2
Answer: A
Rationale: Preventive control measures include sanitary disposal of human feces and
maintenance of fly proof latrine and proper food handling and preparation. (Public
Health Nursing in the Philippines, 2007)
Situation 10. Katayama fever is a significant tropical disease in our country, since it is not
only a public concern but a socio-economic problem. As the nurse working in a far-flung
health center, you must know how to address this health problem.
46. In order to confirm the diagnosis of Katayama fever, you advise a patient to have
which of these examinations?
a. X-ray of the abdomen
b. Urinalysis
c. CBC
d. Stool examination
Answer: D
Rationale: The male and female parasites live in blood vessels of intestines and liver,
but the eggs are laid in the terminal capillary vessels in the submucosa of the
intestines, and through the ulcerations reach the lumen of the intestines and pass out
with the feces. The presence of parasitic eggs in the stool confirms the diagnosis of
Schistosomiasis, otherwise known as Katayama fever.

47. You know that the mode of transmission of Katayama fever is:
a. Contact with affected stray animals
b. Use of sanitary toilets
c. Infected flies and rodent
d. Contact with water infected with cercariae
Answer: D
Rationale: Schistosoma cercariae (free swimming larval forms) can penetrate the skin
of persons who are wading, swimming, bathing or washing in contaminated water.

48. Which of the following is the drug of choice for Katayama fever?
a. Biltricide c. Chloramphenicol
b. Hetrazan d. Tetracycline
Answer: A
Rationale: Praziquantel (Biltricide) is the drug of choice for Schistosomiasis.

49. The following are preventive measures for Katayama fever, except:

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a. Use of safe water
b. Avoid bathing and washing in infested waters
c. Use of sanitary toilets
d. Elimination of breeding sites of mosquitoes
Answer: D
Rationale: This is a preventive measure for vector-borne diseases, such as Dengue
fever, Malaria, and Filariasis. Schistosomiasis is a water-borne disease.

50. Which of the following is not a complication of Katayama fever?
a. Liver cirrhosis and portal hypertension
b. Cor pulmonale, pulmonary hypertension
c. Meningitis and hepatomegaly
d. Ascitis and renal failure
Answer: C
Rationale: Meningitis is not a complication of Schistosomiasis.

Situation 11. Filariasis is endemic in some parts of the Philippines. The disease often
progresses to become chronic, debilitating and often unfamiliar to health workers.
51. Ej, a 36-year-old man, is brought by his wife to a doctors clinic to be tested for
filariasis. The most likely diagnostic test that he will undergo is:
a. Immunochromatographic test (ICT)
b. Nocturnal Blood Examination
c. Stool examination
d. Urinalysis
Answer: A
Rationale: The clinic provides services from 8am to 5pm. The ICT is an antigen test
that can be done in daytime.

52. The vector for Filariasis is:
a. Wuchereria bancrofti c. Anopheles
b. Aedes poecilus d. Aedes aegypti
Answer: B
Rationale: The vector for Filariasis is the mosquito Aedes poecilus.

53. A long incubation period characterizes Filariasis that typically ranges from:
a. 2-4 weeks c. 2-3 years
b. 4-6 weeks d. 8-16 months
Answer: D
Rationale: Incubation period ranges from 8-16 months.

54. Ej is in the acute stage of the disease. He will manifest which of the following
clinical findings?
a. Lymphangitis, lymphadenitis, epidydimitis
b. Hydrocele, lymphedema, elephantiasis
c. Orchitis, hydrocele, elephantiasis
d. Lymphadenitis, lymphedema and orchitis
Answer: A
Rationale: Lymphangitis, lymphadenitis, epidydimitis, funiculitis and orchitis are acute
clinical manifestations of Filariasis.

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55. Effective methods that the government would likely to pursue to eliminate filariasis
in the country are all of the following, except:
a. Pursue annual mass drug administration using two drugs in all endemic areas for at
least five consecutive years
b. Vaccination of all susceptible persons in high risk areas and high risk populations
c. Intensify health information and advocacy campaigns in its prevention, control and
elimination
d. Halt progression of disease through disability prevention
Answer: B
Rationale: There is no known vaccination for Filariasis. Diethylcarbamazine Citrate
(DEC) is given to patients with clinical manifestations and/or microfilariae.

Situation 12. Mrs. Churia brings her 4-year-old daughter, Trish, to the pediatrician because
she lost weight, is quite irritable, and has intense perianal pruritus that causes continuous
scratching. The mother suspects that her daughter has worms.
61. Basing on the chief complaints, the nurse is correct in identifying that more likely,
the child has:
a. Ascariasis
b. Enterobiasis
c. Trichuriasis
d. Hookworm infection
Answer: B
Rationale: Intense perianal itching is a characteristic of enterobiasis. Enterobius
vermicularis, or pinworms, live in the cecum. At night, female pinworms migrate down
the intestinal tract and out the anus to deposit eggs in the anal and perianal region.
The movement of the worms causes the anal area to itch, and the child awakens at
night crying and scratching.

62. Nurse Ria can assist in confirming Trishs suspected diagnosis by:
a. Asking the mother to collect stools for 3 consecutive days for culture
b. Instructing the mother how and when to do an anal transparent-tape test
c. Having the mother bring in the childs stools for visual examination for 3 days
d. Assisting the mother to schedule a hypersensitivity test of the childs blood serum
Answer: B
Rationale: Pinworms emerge nocturnally to lay eggs in the perianal area; eggs are
caught on transparent tape in the morning before toileting. (NSNA, NCLEX-RN Review,
4
th
Edition)

63. The most effective time to perform the diagnostic test is:
a. Just following a bowel movement
b. Immediately after meals
c. At bedtime before bathing
d. Early morning before rising
Answer: D
Rationale: The adult pinworm lives in the rectum or colon and emerges onto the
perirectal skin during the hours of sleep, depositing its eggs during this time. (NSNA,
NCLEX-RN Review, 4
th
Edition)

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64. Antihelminthic drugs used include:
a. Albendazole and Pyrantel
b. Metronidazole and Albendazole
c. Cotrimoxazole and Metronidazole
d. All of the above
Answer: A
Rationale: Antihelminthic drugs used in treating parasitic infections include:
Albendazole and Mebendazole (Vermox) that inhibits glucose and other nutrient
uptake of helminth; Pyrantel embonate (Antiminth) that paralyzes intestinal tract of
worm; and Thiabendazole (Mintezol) that interferes with parasitic metabolism. (NSNA
NCLEX-RN Review, 4
th
Edition)

65. Mebendazole (Vermox) is ordered for Trish. It is advisable that this drug also be
administered to:
a. The childs younger brother who is 1 year old
b. All members of the childs family who test positive
c. All people using the same toilet facilities as the child
d. The childs mother, father and siblings even if they are symptom-free
Answer: D
Rationale: All household members should be treated at the same time unless they are
younger than 2 years or pregnant. (NSNA, NCLEX-RN Review, 4
th
Edition)

Situation 13. During the rainy season, several areas in Metro Manila become flooded with
water. Leptospirosis is one infection that is common during this time of year.
61. Leptospirosis is also known by which of the following names?
a. Drip and Weeping Itch
b. Shigellosis and Lyssa
c. Catarrhal jaundice and Ragpicker disease
d. Spiroketal jaundice and Japanese Seven Days Fever
Answer: D
Rationale: Leptospirosis is also known with the following names: Weil's disease, Mud
fever, Trench fever, Flood fever, Spiroketal jaundice and Japanese Seven Days Fever
(option D). (Public Health Nursing in the Philippines, 2007)

62. How many days after infection with leptospires do the urine cultures become
positive?
a. Fourth week of illness
b. Third week of illness
c. Second week of illness
d. First week of illness
Answer: C
Rationale: Leptospirosis can be diagnosed by its clinical manifestations, culture of the
organism, and examination of blood and CSF during the first week of illness and urine
after the 10
th
day (second week of illness). (Public Health Nursing in the Philippines,
2007)

63. Leptospirosis in human rarely occurs through:

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a. Contact with contaminated human urine
b. Indirect contact with contaminated animal urine
c. Direct contact with contaminated animal urine
d. Contact with contaminated soil
Answer: A
Rationale: Leptospirosis can be transmitted through contact (direct or indirect) of the
skin, especially open wounds with water, moist soil or vegetation contaminated with
urine of infected host. Rat is the main host to Leptospirosis although pigs, cattles,
rabbits, hare, skunk, and other wild animals can also serve as reservoir. (Public Health
Nursing in the Philippines, 2007)

64. Incubation period of leptospirosis ranges form:
a. Fifteen to fifty days, depending on dose
b. A few hours to 7 days most cases occur within 48 hours of exposure
c. Usually 2-10 days, possibly 3 days or more
d. 7-19 days, with average of 10 days
Answer: D
Rationale: The incubation period of leptospirosis ranges from 7-19 days, with average
of 10 days. (Public Health Nursing in the Philippines, 2007)

65. A patient asked if it is possible to be infected while swimming in flood waters. The
nurse replied that:
a. You can protect yourself by applying 70% alcohol before swimming.
b. There is no danger during day time because leptospires die when exposed to
sunlight.
c. This is not possible as long as you have no open wounds while swimming.
d. Infection with leptospirosis is possible with swimming in flood water contaminated
with urine of animals having the infection.
Answer: D
Rationale: Infection with leptospirosis is possible with swimming in flood waters
contaminated with urine of animals having the infection.
Option C is incorrect because leptospirosis is possible even without any open wounds
while swimming because the spirochete bacteria (Leptospira interrogans) can enter
the mucous membranes of the eyes and mouth. (Public Health Nursing in the
Philippines, 2007)

Situation 14. A mother of a 4-year-old child arrives at a clinic and tells Nurse Tes that the
child has been scratching the skin continuously and has developed a rash.
66. Nurse Tes assesses the child and suspects the presence of scabies. The nurse bases
this suspicion on which finding noted on assessment of the childs skin?
a. Clusters of fluid-filled vesicles
b. Fine threadlike lines
c. Purple-colored lesions
d. Thick, honey-colored crusts
Answer: B
Rationale: Scabies appears as burrows or fine, grayish, thread-like lines. They may be
difficult to see if they are obscured by excoriation and inflammation. (Silvestri,
Saunders Comprehensive Review for the NCLEX-RN Examination, 3
rd
Edition)

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67. Nurse Tes can assist in confirming the childs diagnosis of scabies by:
a. Gram staining
b. Using a dark field illumination test
c. Scraping from its burrow with a hypodermic needle or curette, and then examined
under low power microscope or by hard lens
d. Microscopic slide of discharge; culture tests; examination

Answer: C
Rationale: To confirm the diagnosis of scabies, a sample is taken by scraping from its
burrow with a hypodermic needle or curette, and then examined under low power
microscope or by hard lens. (Public Health nursing in the Philippines)

68. The incubation period of scabies is which of the following?
a. It occurs within 12 hours from the original contact
b. It occurs within 24 hours from the original contact
c. It occurs within 36 hours from the original contact
d. It occurs within 48 hours from the original contact
Answer: B
Rationale: The incubation period of scabies occurs within 24 hours from the original
contact, which is the length of time required for itch mite to burrow on infected skin
and lay ova. (Public Health nursing in the Philippines)

69. Permethrin 5% (Elimite) is prescribed to the child. Nurse Tes instructs the mother
regarding the use of this treatment and tells the mother:
a. That the lotion should be applied to areas of the rash only
b. To apply the lotion and leave it on for 6 hours
c. To apply the lotion to cool, dry skin at least one half hour after bathing
d. To avoid clothing the child while the lotion is in place
Answer: C
Rationale: Permethrin 5% (Elimite) should not be applied until at least one half hour
after bathing and should be applied only to cool, dry skin. (Silvestri, Saunders
Comprehensive Review for the NCLEX-RN Examination, 3
rd
Edition)

70. Nurse Tes is reviewing the physicians orders. Lindane (Kwell, Scabene) has been
prescribed for the child. The nurse questions the order if which of the following is noted
in the childs record?
a. The child is 18 months old
b. The child has a history of frequent respiratory infections
c. A sibling is using Lindane for the treatment of scabies
d. The child is being bottle-fed
Answer: A
Rationale: Lindane is contraindicated for children younger than 2 years of age. These
children have more permeable skin, and high systemic absorption may occur, placing
the child at risk of central nervous system toxicity and seizures. Lindane also is used
with caution in children between the ages of 2 and 10. (Silvestri, Saunders
Comprehensive Review for the NCLEX-RN Examination, 3
rd
Edition)

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Situation 15. Mikaela Cotto, a school cafeteria worker, comes to the school clinic
complaining of severe scalp itching. Upon inspection, Nurse Rica finds nail marks on the
scalp and small, light-colored, round specks attached to the hair shafts close to the scalp.
71. These findings suggest that Mrs. Cotto suffers from:
a. Tinea capitis c. Scabies
b. Pediculosis capitis d. Impetigo
Answer: B
Rationale: The light-colored spots attached to the hair shafts are nits, which are the
eggs of head lice (pediculosis capitis). They cannot be brushed off the hair shaft like
dandruff. (Gingrich, Medical-Surgical Nursing, 2
nd
Edition)

72. To treat the condition of Mrs. Cotto, Nurse Poohkyaw should instruct her to:
a. Saturate her hair with vinegar for 30 minutes, massage vigorously, and then wash
with hot water and shampoo
b. Wash her hair with a pediculicide and then comb thoroughly with a fine-toothed
comb
c. Apply an antibacterial cream to scalp lesions
d. Shave her head because that is the only way the problem can be completely
eradicated
Answer: B
Rationale: Mrs. Cotto should be instructed to wash her hair with a pediculicide, an
agent designed to kill lice. After shampooing she should comb her hair with a fine-
toothed comb to remove the nits or eggs from the hair shafts. (Gingrich, Medical-
Surgical Nursing, 2
nd
Edition)

73. Nurse Poohkyaw has provided instructions regarding the use of permethrin 1% (Nix)
to Mrs. Cotto. Which statement if made by the client indicates a need for further
instructions?
a. The Nix can be obtained over the counter in a local pharmacy.
b. It is applied to the hair after shampooing and left on for 24 hours.
c. It is applied to the hair after shampooing, left on for 10 minutes, and then rinsed
out.
d. The hair should not be shampooed for 24 hours following treatment.
Answer: B
Rationale: Option B is correct because the client needs further instruction on the
application of Nix. (Silvestri, Saunders Comprehensive Review for the NCLEX-RN
Examination, 3
rd
Edition)

74. Nurse Poohkyaw prepares a list of home care instructions for Mrs. Cotto. Which of
the following will the nurse include in the list?
a. Use anti-lice sprays on all bedding and furniture
b. Bring all bedding and linens to the cleaners to be dry cleaned
c. Soak combs and brushes in warm water
d. Vacuum floors, play areas, and furniture to remove any hairs that might carry live
nits
Answer: D
Rationale: Thorough home cleaning is necessary to remove any remaining lice or nits.
rd
Edition)

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75. Nurse Poohkyaw, the school nurse, initiates a screening program for the condition
in #71. When searching for nits clinging to the hair shafts, the nurse might also
observe:
a. Bites, pustules, and excoriated areas on the scalp from scratching
b. Pruritic, scaling, erythematous papules, plaques, and patches with well-defined
borders
c. Beefy-red erythematous areas with a few surrounding papules and pustules
d. An inflammation of the hair follicles with pus-filled nodules
Answer: A
Rationale: The scalp itches from the crawling and saliva of the adult louse. The childs
fingernails scratch the skin, leaving red marks. (NSNA, NCLEX-RN Review, 4
th
Edition)

Situation 16. Mrs. Baby James, age 57, went to her doctor complaining of difficulty
breathing and pain in the left side of her chest. She states she has had shaking chills and
a productive cough. The doctor advises Mrs. Jamess husband to take her to the hospital
for admission.
76. The doctor has ordered a sputum specimen for culture and sensitivity. In order to
obtain a good specimen, Nurse Noypi should:
a. Teach the patient deep breathing and coughing techniques
b. Use nasotracheal suction
c. Obtain the specimen after starting antibiotics
d. Withhold food and fluid 30 minutes prior to specimen collection
Answer: A
Rationale: Deep breathing and coughing are essential for obtaining mucus from the
bronchi. (NSNA NCLEX-RN Review, 4
th
Edition)

77. Mrs. James is admitted to the medical-surgical floor with a diagnosis of bacterial
pneumonia in the left lower lobe. Percussion of the patients left lower lobe would
most likely produce which of the following findings?
a. Rales c. Hyperresonance
b. Rhonchi d. Dullness
Answer: D
Rationale: When pneumonia is localized in a single lobe, consolidation or infiltration of
exudate into the alveoli can be expected. Dullness is revealed by percussion over the
lobe where consolidation has occurred. (NSNA NCLEX-RN Review, 4
th
Edition)

78. Which is the most appropriate nursing diagnosis for Mrs. James with bacterial
pneumonia?
a. Fluid volume deficit
b. Decreased cardiac output
c. Impaired gas exchange
d. Risk for infection

Answer: C
Rationale: Impaired gas exchange is the most appropriate nursing diagnosis for a
patient with bacterial pneumonia. (Gingrich, Medical-Surgical nursing, 2
nd
Edition)

79. Aggressive chest physiotherapy is instituted but isnt successful in removing Mrs.
Jamess secretions. Which type of drug would Nurse Noypi expect the doctor to

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prescribe following physiotherapy?
a. Anticholinergic c. Antibiotic
b. Mucolytic d. Diuretic
Answer: B
Rationale: The doctor would prescribe a mucolytic to thin the secretions. (Gingrich,
Medical-Surgical nursing, 2
nd
Edition)

80. Two days after admission, Mrs. James now has an order to be up in the chair as
much as possible. Nurse Noypi plans to get her up and help her with her morning care.
The best plan to accomplish this would be to:
a. Get her up before breakfast, have her eat in the chair, then bathe while still up
b. Allow her to eat breakfast in bed, rest for 30 minutes, get up in the chair, and rest
for a few minutes then allow her to wash her hands and face nurse to complete
bath
c. Allow her to eat in bed, get her up, and provide her with a pan of water for her to
bathe
d. Get her up before breakfast, have her bathe before breakfast, eat in the chair, then
a rest in the chair
Answer: B
Rationale: This plan allows frequent rest periods for the client. The client should not
rush through morning care activities as rushing will increase hypoxemia, dyspnea, and
fatigue. (NSNA NCLEX-RN Review, 4
th
Edition)

Situation 17. WHO is actively monitoring the progress of the pandemic H1N1 infection
through frequent consultations with the WHO Regional Offices. Here in the Philippines,
the Department of Health is strengthening its efforts in the fight against pandemic (H1N1)
2009.
81. The following are true statements regarding pandemic (H1N1) 2009 infection,
except:
a. It is a swine origin Influenza A virus subtype H1N1 virus strain
b. Existing vaccines against seasonal flu provide no protection
c. The virus is contagious and is believed to spread from human to human in much the
same way as seasonal flu. However, pandemic (H1N1) 2009 infection is more
contagious than seasonal flu
d. Pandemic (H1N1) 2009 virus can be transmitted from pigs to humans
Answer: D
Rationale:
Option D is not a true statement because the pandemic (H1N1) virus is not zoonotic
swine flu, as it is not transmitted from pigs to humans, but from person to person.

82. Individuals that have been identified as at greatest risk or highly susceptible to
infection by pandemic (H1N1) influenza virus include the following, except:
a. Elderly (more than 65 years of age) and obese patients
b. Pregnant women during the third trimester of pregnancy
c. Infants and children less than 2 years of age
d. Patients with chronic health conditions, such as cardiovascular, respiratory or liver
disease, or diabetes
Answer: A

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Rationale: Individuals that have been identified as at greatest risk or highly
susceptible to infection by pandemic (H1N1) influenza virus include the following:
1. Pregnant women during the third trimester of pregnancy (option B);
2. Infants and children less than 2 years of age (option C);
3. Patients with chronic health conditions, such as cardiovascular, respiratory or
liver disease, or diabetes (option D);
4. Immunosuppressed patients related to treatment for transplant surgery, cancer,
or due to other diseases.
5. Neurological disorders can increase the risk of severe disease in children.

83. Antiviral drugs are being used to treat pandemic (H1N1) 2009 infection. Which of
the following statements is true?
a. Zanamivir (Relenza) is taken PO as a tablet
b. It is necessary to wait for a laboratory result before starting antiviral drug treatment
with either oseltamivir or zanamivir
c. For oseltamivir (Tamiflu), the standard adult treatment course is one 75 mg capsule
twice a day for five days.
d. M2 inhibitors (amantadine and rimantadine) can be effective for treating pandemic
(H1N1) 2009 infection
Answer: C
Rationale: There are two approved antiviral drugs for influenza that are available for
treatment of pandemic influenza. These are the neuraminidase inhibitors oseltamivir
and zanamivir, more commonly known by their trade names Tamiflu and Relenza. For
oseltamivir (Tamiflu), the standard adult treatment course is one 75 mg capsule twice
a day for five days. For severe or prolonged illness, physicians may decide to use a
higher dose or continue the treatment for longer.

84. Which of these complications is the most common cause of death among patients
with pandemic (H1N1) influenza?
a. Sepsis
b. Respiratory failure
c. Dehydration
d. Electrolyte imbalance
Answer: B
Rationale: The most common cause of death is respiratory failure. Other causes of
death are pneumonia (leading to sepsis), high fever (leading to neurological problems),
dehydration (from vomiting and diarrhea) and electrolyte imbalance. Fatalities are
more likely in young children and the elderly.

85. Nurses should be knowledgeable on the WHO Pandemic Influenza Phases. This six-
phased approach allows for easy incorporation of new recommendations and
approaches into existing national preparedness and response plans. The current WHO
phase of pandemic alert is 6, which means:
a. An animal influenza virus circulating among domesticated or wild animals is known
to have caused infection in humans, and is therefore considered a potential
pandemic threat
b. There is verified human-to-human transmission of an animal or human-animal
influenza reassortant virus able to cause community-level outbreaks
c. A human-animal influenza reassortant virus has caused sporadic cases or small

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clusters of disease in people, but has not resulted in human-to-human transmission
sufficient to sustain community-level outbreaks
d. There is human-to-human spread of the virus into at least two countries in one WHO
region and community level outbreaks in at least one other country in a different
WHO region
Answer: D
Rationale: The WHO Pandemic Influenza Phases is a six-phased approach that allows
for easy incorporation of new recommendations and approaches into existing national
preparedness and response plans. Phases 1-3 correlate with preparedness, including
capacity development and response planning activities, while Phases 4-6 clearly signal
the need for response and mitigation efforts.

Situation 18. A female patient goes to the clinic with chief complaint of creamy pus-like
vaginal discharges. The female patient tells the nurse in the health clinic that she had
sexual intercourse four days ago with her boyfriend who has gonorrhea. After laboratory
work-up, the patient is found to be positive for gonorrhea.
91. The nurse teaches the patient that gonorrhea is highly infectious and:
a. Is easily cured
b. Occurs very rarely
c. Can produce sterility
d. Is limited to the external genitalia
Answer: C
Rationale: Inflammation associated with gonorrhea may lead to destruction of the
epididymis in males and tubal mucosal destruction in females

92. The female patient wants to know when she can expect symptoms. The nurse
replies that the unusual time between initial infection with Neisseria gonorrhoeae and
the onset of symptoms is:
a. Two to five days
b. Five to seven days
c. One to two weeks
d. Two to three weeks
Answer: A
Rationale: The usual incubation period between infection with Neisseria gonorrhoeae
and the onset of symptoms is two to five days. (NSNA, NCLEX-RN Review, 4
th
Edition)

93. For a patient diagnosed with gonorrhea, the nurse should expect the physician to
order:
a. Acyclovir (Zovirax)
b. Colistin (Cortisporin)
c. Ceftriaxone (Rocephin)
d. Dactinomycin (Actinomycin)
Answer: C
Rationale: Ceftriaxone (Rocephin) inhibits the synthesis of bacterial cell walls. It is
effective against Neisseria gonorrhoeae, gram-negative diplococci.

94. When teaching the patient about the drug therapy for gonorrhea, the nurse should
state that it:
a. Cures the infection

CODES I 131
well - research.
b. Prevents complications
c. Controls its transmission
d. Reverses pathologic changes
Answer: A
Rationale: Ceftriaxone followed by Doxycyline is specific for and eradicates the
microorganism. Other treatment regimens are available for resistant strains.

95. The nurse knows that the major reason treatment of the majority of STDs is delayed
is because:
a. The client is embarrassed
b. Symptoms are thought to be caused by something else
c. Symptoms are ignored
d. The client never has symptoms
Answer: D
Rationale: Chlamydia is the number 1 STD. many women who harbor Chlamydia in the
cervix are asymptomatic. As many as 15%-50% of females and 5%-25% of males with
Neisseria gonorrhoeae infection are asymptomatic carriers. In women, the primary
chancre of syphilis may be on the endocervix and thus be undetected.
(NSNA, NCLEX-RN Review, 4
th
Edition)

Situation 19. Melason, age 26, is 10 weeks pregnant and tested positive for syphilis but
has no symptoms.
91. Which of the following is the incubation period of syphilis?
a. 2 to 3 weeks for males; usually no symptoms in females
b. 10 days to 3 months, with average of 21 days
c. 4 to 20 days, with average being 7 days
d. 2 to 8 weeks; it can be as long as a year or several years depending on the severity
of the wounds
Answer: B
Rationale: The incubation period of syphilis is 10 days to 3 months, with average of 21
days.

92. Melason asks Nurse Jocath why she needs to be treated since she feels fine. The
nurses best response to the patient would include which of the following?
a. Syphilis can be transmitted to the baby and may cause it to die before birth if you
are not treated.
b. If you do not receive treatment before the baby is born, your baby could become
blind.
c. If syphilis is untreated, the baby may be mentally retarded at birth.
d. Syphilis may cause your baby to have a heart problem when it is born.
Answer: A
Rationale: Syphilis is associated with stillbirth, premature birth, and neonatal death.

93. Baby Dengue, 3 months old, was born to Melason who was diagnosed with syphilis.
Which information would be most useful in determining if baby Dengue has
congenital syphilis?
a. Irritability
b. Red rash around anus
c. Rhinitis

CODES I 132
well - research.
d. Positive serology
Answer: D
Rationale: Congenital syphilis is difficult to diagnose until the infant develops his own
antibodies. A positive serology confirms the diagnosis of congenital syphilis.

94. Baby Dengue was confirmed positive in congenital syphilis. He is started on
penicillin. Which statement is true about the babys ability to transmit the disease now
that treatment is started?
a. He will not be contagious after 48 hours of penicillin therapy
b. After 10 days of antibiotic therapy he will not be contagious
c. He will always be infected and be contagious
d. Congenital syphilis is not contagious
Answer: A
Rationale: After 48 hours of penicillin therapy the infant should not be contagious. Until
that time he should be in isolation.

95. Baby Dengue develops vesicular lesions on the soles of his feet and has a rash on
his face. What is the most appropriate initial intervention for Nurse Jocath?
a. Call the physician immediately
b. Apply Neosporin ointment to the rash
c. Cover the infants hands with mittens
d. Give diphenhydramine (Benadryl) by mouth
Answer: C
Rationale: Covering the infants hands will minimize trauma to his skin from
scratching.
th
Edition)

Situation 20. AIDS cases have been all over the country and yet only few are reported
cases due to the stigma attach to it.
96. The nurse is planning care for an HIV-infected drug abuser. Which goal is
unrealistic?
a. Quitting the drug addiction
b. Cooperating with unit goals
c. Learning to clean drug equipment
d. Remaining for the full treatment course
Answer: A
Rationale: Counseling may be insufficient to obtain desired behaviors when the
negative consequences seem distant. Objectives must take into consideration the
lifestyle of the individual and where changes can be made with the clients
cooperation. Therefore, quitting the drug addiction can be unrealistic or inappropriate
for clients seeking only care for their medical problems. (NSNA, NCLEX-RN Review, 4
th

Edition)

97. During the past 6 months, a patient diagnosed with acquired immunodeficiency
syndrome (AIDS) has had chronic diarrhea and has lost 18 pounds. Additional
assessment findings include tented skin turgor, dry mucous membranes, and
listlessness. Which nursing diagnosis focuses attention on the patients most
immediate problem?
a. Deficient fluid volume related to diarrhea and abnormal fluid loss

CODES I 133
well - research.
b. Imbalanced nutrition: less than body requirements related to nausea and vomiting
c. Disturbed thought processes related to central nervous system effects of disease
d. Diarrhea related to the disease process and acute infection
Answer: A
Rationale: Based on the clients assessment findings, the most immediate problem is
dehydration because of the chronic diarrhea. The nursing diagnosis of deficient fluid
volume is the priority, and interventions are geared to improving the clients fluid
status. (Lippincotts Review Series: Medical-Surgical Nursing, 4
th
Edition)

98. A patient is admitted to the medical unit. She is in the terminal stages of AIDS.
During the admission assessment, the nurse would ask her if she had which of the
following?
a. A will
b. A do not resuscitate (DNR) order
c. An organ donation card
d. Healthcare proxy
Answer: D
Rationale: A living will, durable power of attorney for healthcare, or a healthcare proxy
is an important part of an admission assessment, especially for a terminally ill client.
th
Edition)

99. Which statement, from a participant attending a class on AIDS prevention, indicates
an understanding of how to reduce transmission of HIV?
a. Mothers who are HIV-positive should still be encouraged to breast feed their babies
because breast milk is superior to cows milk.
b. I think a needle exchange program, where clean needles are exchanged for dirty
needles, should be offered in every city.
c. Orgasms are necessary for the heterosexual transmission of the virus.
d. Its okay to use natural skin condoms since they offer the same protection as the
latex condoms.
Answer: B
Rationale: Although needle exchange programs are very controversial, it is evident the
transmission of HIV can be significantly reduced when needle exchange programs are
introduced.
Option A is incorrect because HIV-positive mothers are encouraged to refrain from
breast feeding their infants because studies have shown that the virus can be passed
from the mother to the infant via breast milk.
th
Edition)

100. What should be included in the teaching plan to young adults about the spread of
AIDS?
a. Heterosexual transmission of HIV is on the rise
b. The increase of HIV in children is primarily attributed to the rise of sexual abuse
c. The greatest increase of HIV infection is by homosexual transmission
d. Transmission of HIV by IV drug users is prominent even when sterile equipment is
used
Answer: A

CODES I 134
well - research.
Rationale: Heterosexual transmission of HIV is a concern, especially in this age group.
It is on the rise and this is often overlooked because the more known transmissions
take place among homosexuals and IV drug abusers.
th
Edition)

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