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PNLE Pre-board Preparation Exam

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

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

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

a. Assess temperature frequently.
b. Provide diversional activities.
c. Check circulation every 15-30 minutes.
d. Socialize with other patients once a shift.

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

a. Prevent stress ulcer
b. Block prostaglandin synthesis
c. Facilitate protein synthesis.
d. Enhance gas exchange

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

a. Increase the I.V. fluid infusion rate
b. Irrigate the indwelling urinary catheter
c. Notify the physician
d. Continue to monitor and record hourly urine output
5. Tony, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain
and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by Tony suggests
that ice application has been effective?

a. My ankle looks less swollen now.
b. My ankle feels warm.
c. My ankle appears redder now.
d. I need something stronger for pain relief

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

a. Hypernatremia
b. Hyperkalemia
c. Hypokalemia
d. Hypervolemia

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

a. Have condescending trust and confidence in their subordinates.
b. Gives economic and ego awards.
c. Communicates downward to staffs.
d. Allows decision making among subordinates.

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

a. Provides continuous, coordinated and comprehensive nursing services.
b. One-to-one nurse patient ratio.
c. Emphasize the use of group collaboration.
d. Concentrates on tasks and activities.

9.Which type of medication order might read "Vitamin K 10 mg I.M. daily 3 days?"
a. Single order
b. Standard written order
c. Standing order
d. Stat order

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

a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools

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

a. Pulling the lobule down and back
b. Pulling the helix up and forward
c. Pulling the helix up and back
d. Pulling the lobule down and forward

12. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware
that one of the following is unassociated with this condition?
a. Excessive fetal activity.
b. Larger than normal uterus for gestational age.
c. Vaginal bleeding
d. Elevated levels of human chorionic gonadotropin.

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

a. Urinary output 90 cc in 2 hours.
b. Absent patellar reflexes.
c. Rapid respiratory rate above 40/min.
d. Rapid rise in blood pressure.

14. During vaginal examination of Janah who is in labor, the presenting part is at station plus two. Nurse,
correctly interprets it as:
a. Presenting part is 2 cm above the plane of the ischial spines.
b. Biparietal diameter is at the level of the ischial spines.
c. Presenting part in 2 cm below the plane of the ischial spines.
d. Biparietal diameter is 2 cm above the ischial spines.

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

a. Contractions every 1 minutes lasting 70-80 seconds.
b. Maternal temperature 101.2
c. Early decelerations in the fetal heart rate.
d. Fetal heart rate baseline 140-160 bpm.

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

a. Ventilator assistance
b. CVP readings
c. EKG tracings
d. Continuous CPR

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

a. First low transverse cesarean was for active herpes type 2 infections; vaginal culture at 39 weeks
pregnancy was positive.
b. First and second caesareans were for cephalopelvic disproportion.
c. First caesarean through a classic incision as a result of severe fetal distress.
d. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex
presentation.
18.Nurse Ryan is aware that the best initial approach when trying to take a crying toddlers temperature
is:
a. Talk to the mother first and then to the toddler.
b. Bring extra help so it can be done quickly.
c. Encourage the mother to hold the child.
d. Ignore the crying and screaming.

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

a. Avoid touching the suture line, even when cleaning.
b. Place the baby in prone position.
c. Give the baby a pacifier.
d. Place the infants arms in soft elbow restraints.

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

a. Feed the infant when he cries.
b. Allow the infant to rest before feeding.
c. Bathe the infant and administer medications before feeding.
d. Weigh and bathe the infant before feeding.

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

a. Skim milk and baby food.
b. Whole milk and baby food.
c. Iron-rich formula only.
d. Iron-rich formula and baby food.
22. Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails
of the bed and unresponsive to shaking or shouting. Which is the nurse next action?

a. Call for help and note the time.
b. Clear the airway
c. Give two sharp thumps to the precordium, and check the pulse.
d. Administer two quick blows.

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

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

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

a. Stop the I.V. infusion of heparin and notify the physician.
b. Continue treatment as ordered.
c. Expect the warfarin to increase the PTT.
d. Increase the dosage, because the level is lower than normal.

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

a. 24 hours later, when edema has subsided.
b. In the operating room.
c. After the ileostomy begin to function.
d. When the client is able to begin self-care procedures.

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

a. On the side, to prevent obstruction of airway by tongue.
b. Flat on back.
c. On the back, with knees flexed 15 degrees.
d. Flat on the stomach, with the head turned to the side.

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

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

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

a. Altered mental status and dehydration
b. Fever and chills
c. Hemoptysis and Dyspnea
d. Pleuritic chest pain and cough

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

a. Chest and lower back pain
b. Chills, fever, night sweats, and hemoptysis
c. Fever of more than 104F (40C) and nausea
d. Headache and photophobia

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

a. Acute asthma
b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease (COPD)
d. Emphysema

31. Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4
breaths/minute. If action isnt taken quickly, she might have
which of the following reactions?

a. Asthma attack
b. Respiratory arrest
c. Seizure
d. Wake up on his own

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

a. Increased elastic recoil of the lungs
b. Increased number of functional capillaries in the alveoli
c. Decreased residual volume
d. Decreased vital capacity

33. Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby
should monitor the client for the systemic side effect of:

a. Ascites
b. Nystagmus
c. Leukopenia
d. Polycythemia

34. Norma, with recent colostomy expresses concern about the inability to control the passage of gas.
Nurse Oliver should suggest that the client plan to:

a. Eliminate foods high in cellulose.
b. Decrease fluid intake at meal times.
c. Avoid foods that in the past caused flatus.
d. Adhere to a bland diet prior to social events.

35. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would
evaluate that the instructions were understood when the client states, I should:

a. Lie on my left side while instilling the irrigating solution.
b. Keep the irrigating container less than 18 inches above the stoma.
c. Instill a minimum of 1200 ml of irrigating solution to stimulate
evacuation of the bowel.
d. Insert the irrigating catheter deeper into the stoma if cramping
occurs during the procedure.
36. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and electrolyte
imbalances. The client is somewhat confused and complains of nausea and muscle weakness. As part of
the prescribed therapy to correct this electrolyte imbalance, the nurse would expect to:

a. Administer Kayexalate
b. Restrict foods high in protein
c. Increase oral intake of cheese and milk.
d. Administer large amounts of normal saline via I.V.

37. Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV fluid to be
administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:

a. 18 gtt/min
b. 28 gtt/min
c. 32 gtt/min
d. 36 gtt/min

38.Terence suffered form burn injury. Using the rule of nines, which has the largest percent of burns?

a. Face and neck
b. Right upper arm and penis
c. Right thigh and penis
d. Upper trunk

39. Herbert, a 45 year old construction engineer is brought to the hospital unconscious after falling from
a 2-story building. When assessing the client, the nurse would be most concerned if the assessment
revealed:

a. Reactive pupils
b. A depressed fontanel
c. Bleeding from ears
d. An elevated temperature

40. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which
information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?

a. take the pulse rate once a day, in the morning upon awakening
b. May be allowed to use electrical appliances
c. Have regular follow up care
d. May engage in contact sports

41.The nurse is ware that the most relevant knowledge about oxygen administration to a male client
with COPD is

a. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
b. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.
c. Oxygen is administered best using a non-rebreathing mask
d. Blood gases are monitored using a pulse oximeter.

42.Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted,
and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit
Tonny is placed in Fowler's position on either his right side or on his back. The nurse is aware that this
position:

a. Reduce incisional pain.
b. Facilitate ventilation of the left lung.
c. Equalize pressure in the pleural space.
d. Increase venous return

43. What is Nurse John likely to note in a male client being admitted for alcohol withdrawal?
a. Perceptual disorders.
b. Impending coma.
c. Recent alcohol intake.
d. Depression with mutism.

44. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that it doesnt help and
refuses to take it. What should the nurse say or do?
a. Withhold the drug.
b. Record the clients response.
c. Encourage the client to tell the doctor.
d. Suggest that it takes awhile before seeing the results.

45. Dervid, an adolescent has a history of truancy from school, running away from home and
barrowing other peoples things without their permission. The adolescent denies stealing, rationalizing
instead that as long as no one was using the items, it was all right to borrow them. It is important for the
nurse to understand the psychodynamically, this behavior may be largely attributed to a developmental
defect related to the:
a. Id
b. Ego
c. Superego
d. Oedipal complex

46. In preparing a female client for electroconvulsive therapy (ECT), Nurse Michelle knows that
succinylcoline (Anectine) will be administered for which therapeutic effect?
a. Short-acting anesthesia
b. Decreased oral and respiratory secretions.
c. Skeletal muscle paralysis.
d. Analgesia.

47. Nurse Gina is aware that the dietary implications for a client in manic phase of bipolar disorder is:
a. Serve the client a bowl of soup, buttered French bread, and apple slices.
b. Increase calories, decrease fat, and decrease protein.
c. Give the client pieces of cut-up steak, carrots, and an apple.
d. Increase calories, carbohydrates, and protein.

48.What parental behavior toward a child during an admission procedure should cause Nurse Ron to
suspect child abuse?
a. Flat affect
b. Expressing guilt
c. Acting overly solicitous toward the child.
d. Ignoring the child.

49.Nurse Lynnette notices that a female client with obsessive-compulsive disorder washes her hands for
long periods each day. How should the nurse respond to this compulsive behavior?
a. By designating times during which the client can focus on the behavior.
b. By urging the client to reduce the frequency of the behavior as rapidly as possible.
c. By calling attention to or attempting to prevent the behavior.
d. By discouraging the client from verbalizing anxieties.

50.After seeking help at an outpatient mental health clinic, Ruby who was raped while walking her dog is
diagnosed with posttraumatic stress disorder (PTSD). Three months later, Ruby returns to the
clinic, complaining of fear, loss of control, and helpless feelings. Which nursing intervention is most
appropriate for Ruby?
a. Recommending a high-protein, low-fat diet.
b. Giving sleep medication, as prescribed, to restore a normal sleepwake cycle.
c. Allowing the client time to heal.
d. Exploring the meaning of the traumatic event with the client.


PNLE Pre-board Preparation Exam -Answer and Rationale
1. Answer: (B) A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
Rationale: Nausea is a symptom of impending myocardial infarction (MI) and should be assessed
immediately so that treatment can be instituted and further damage to the heart is avoided.

2. Answer: (C) Check circulation every 15-30 minutes.
Rationale: Restraints encircle the limbs, which place the client at risk for circulation being restricted to
the distal areas of the extremities. Checking the clients circulation every 15-30 minutes will allow the
nurse to adjust the restraints before injury from decreased blood flow occurs.

3. Answer: (A) Prevent stress ulcer
Rationale: Curlings ulcer occurs as a generalized stress response in burn patients. This results in a
decreased production of mucus and increased secretion of gastric acid. The best treatment for this
prophylactic use of antacids and H2 receptor blockers.

4. Answer: (D) Continue to monitor and record hourly urine output
Rationale: Normal urine output for an adult is approximately 1 ml/minute (60 ml/hour). Therefore, this
client's output is normal. Beyond continued evaluation, no nursing action is warranted.

5. Answer: (A) My ankle looks less swollen now
Rationale: Ice application decreases pain and swelling. Continued or increased pain, redness, and
increased warmth are signs of inflammation that shouldn't occur after ice application

6. Answer: (C) Hypokalemia
Rationale: A loop diuretic removes water and, along with it, sodium and potassium. This may result in
hypokalemia, hypovolemia, and hyponatremia.

7. Answer:(A) Have condescending trust and confidence in their subordinates
Rationale: Benevolent-authoritative managers pretentiously show their trust and confidence to their
followers.

8. Answer: (A) Provides continuous, coordinated and comprehensive nursing services.
Rationale: Functional nursing is focused on tasks and activities and not on the care of the patients.

9. Answer: (B) Standard written order
Rationale: This is a standard written order. Prescribers write a single order for medications given only
once. A stat order is written for
medications given immediately for an urgent client problem. A standing order, also known as a protocol,
establishes guidelines for treating a
particular disease or set of symptoms in special care areas such as the coronary care unit. Facilities also
may institute medication protocols that specifically designate drugs that a nurse may not give.

10. Answer: (D) Liquid or semi-liquid stools
Rationale: Passage of liquid or semi-liquid stools results from seepage of unformed bowel contents
around the impacted stool in the rectum. Clients
with fecal impaction don't pass hard, brown, formed stools because the feces can't move past the
impaction. These clients typically report the urge
to defecate (although they can't pass stool) and a decreased appetite.

11. Answer: (C) Pulling the helix up and back
Rationale: To perform an otoscopic examination on an adult, the nurse grasps the helix of the ear and
pulls it up and back to straighten the ear canal. For a child, the nurse grasps the helix and pulls it down
to straighten the ear canal. Pulling the lobule in any direction wouldn't straighten the ear canal for
visualization.

12. Answer: (A) Excessive fetal activity.
Rationale: The most common signs and symptoms of hydatidiform mole includes elevated levels of
human chorionic gonadotropin, vaginal bleeding, larger than normal uterus for gestational age, failure
to detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting, and early
development of pregnancy-induced hypertension. Fetal activity would not be noted.

13. Answer: (B) Absent patellar reflexes
Rationale: Absence of patellar reflexes is an indicator of hypermagnesemia, which requires
administration of calcium gluconate.

14. Answer: (C) Presenting part in 2 cm below the plane of the ischial spines.
Rationale: Fetus at station plus two indicates that the presenting part is 2 cm below the plane of the
ischial spines.

15. Answer: (A) Contractions every 1 minutes lasting 70-80 seconds.
Rationale: Contractions every 1 minutes lasting 70-80 seconds, is indicative of hyperstimulation of the
uterus, which could result in injury to the mother and the fetus if Pitocin is not discontinued.

16. Answer: (C) EKG tracings
Rationale: A potential side effect of calcium gluconate administration is cardiac arrest. Continuous
monitoring of cardiac activity (EKG) throught administration of calcium gluconate is an essential part of
care.

17. Answer: (D) First low transverse caesarean was for breech position. Fetus in this pregnancy is in a
vertex presentation.
Rationale: This type of client has no obstetrical indication for a caesarean section as she did with her
first caesarean delivery.

18. Answer: (A) Talk to the mother first and then to the toddler.
Rationale: When dealing with a crying toddler, the best approach is to talk to the mother and ignore the
toddler first. This approach helps the toddler get used to the nurse before she attempts any procedures.
It also gives the toddler an opportunity to see that the mother trusts the nurse.

19. Answer: (D) Place the infants arms in soft elbow restraints.
Rationale: Soft restraints from the upper arm to the wrist prevent the infant from touching her lip but
allow him to hold a favorite item such as a blanket. Because they could damage the operative site, such
as objects as pacifiers, suction catheters, and small spoons shouldnt be placed in a babys mouth after
cleft repair. A baby in a prone position may rub her face on the sheets and traumatize the operative site.
The suture line should be cleaned gently to prevent infection, which could interfere with healing and
damage the cosmetic appearance of the repair.

20. Answer: (B) Allow the infant to rest before feeding.
Rationale: Because feeding requires so much energy, an infant with heart failure should rest before
feeding.

21. Answer: (C) Iron-rich formula only.
Rationale: The infants at age 5 months should receive iron-rich formula and that they shouldnt receive
solid food, even baby food until age 6 months.


22. Answer: (A) Call for help and note the time.
Rationale: Having established, by stimulating the client, that the client is unconscious rather than sleep,
the nurse should immediately call for help. This may be done by dialing the operator from the clients
phone and giving the hospital code for cardiac arrest and the clients room number to the operator, of if
the phone is not available, by pulling the emergency call button. Noting the time is important baseline
information for cardiac arrest procedure.

23. Answer: (C) Make sure that the client takes food and medications at prescribed intervals.
Rationale: Food and drug therapy will prevent the accumulation of hydrochloric acid, or will neutralize
and buffer the acid that does accumulate.

24. Answer: (B) Continue treatment as ordered.
Rationale: The effects of heparin are monitored by the PTT is normally 30 to 45 seconds; the therapeutic
level is 1.5 to 2 times the normal level.

25. Answer: (B) In the operating room.
Rationale: The stoma drainage bag is applied in the operating room. Drainage from the ileostomy
contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the
skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short
time becomes reddened, painful, and excoriated.

26. Answer: (B) Flat on back.
Rationale: To avoid the complication of a painful spinal headache that can last for several days, the
client is kept in flat in a supine position for approximately 4 to 12 hours postoperatively. Headaches are
believed to be causes by the seepage of cerebral spinal fluid from the puncture site. By keeping the
client flat, cerebral spinal fluid pressures are equalized, which avoids trauma to the neurons.

27. Answer: (C) The client is oriented when aroused from sleep, and goes back to sleep immediately.
Rationale: This finding suggest that the level of consciousness is decreasing.

28. Answer: (A) Altered mental status and dehydration
Rationale: Fever, chills, hemortysis, dyspnea, cough, and pleuritic chest pain are the common symptoms
of pneumonia, but elderly clients may first appear with only an altered lentil status and dehydration due
to a blunted immune response.

29. Answer: (B) Chills, fever, night sweats, and hemoptysis
Rationale: Typical signs and symptoms are chills, fever, night sweats, and hemoptysis. Chest pain may be
present from coughing, but isnt usual. Clients with TB typically have low-grade fevers, not higher
than 102F (38.9C). Nausea, headache, and photophobia arent usual TB symptoms.

30. Answer:(A) Acute asthma
Rationale: Based on the clients history and symptoms, acute asthma is the most likely diagnosis. Hes
unlikely to have bronchial pneumonia without a productive cough and fever and hes too young to
have developed (COPD) and emphysema.

31. Answer: (B) Respiratory arrest
Rationale: Narcotics can cause respiratory arrest if given in large quantities. Its unlikely the client will
have asthma attack or a seizure or wake up on his own.

32. Answer: (D) Decreased vital capacity
Rationale: Reduction in vital capacity is a normal physiologic changes include decreased elastic recoil of
the lungs, fewer functional capillaries in the alveoli, and an increased in residual volume.

33. Answer: (C) Leukopenia
Rationale: Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as a result of
myelosuppression.

34. Answer: (C) Avoid foods that in the past caused flatus.
Rationale: Foods that bothered a person preoperatively will continue to do so after a colostomy.

35. Answer: (B) Keep the irrigating container less than 18 inches above the stoma.
Rationale: This height permits the solution to flow slowly with little force so that excessive peristalsis is
not immediately precipitated.

36. Answer: (A) Administer Kayexalate
Rationale: Kayexalate,a potassium exchange resin, permits sodium to be exchanged for potassium in the
intestine, reducing the serum potassium level.

37. Answer:(B) 28 gtt/min
Rationale: This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor
(10) and divide the result by the amount of time in minutes (12 hours x 60 minutes)

38. Answer: (D) Upper trunk
Rationale: The percentage designated for each burned part of the body using the rule of nines: Head and
neck 9%; Right upper extremity 9%; Left upper extremity 9%; Anterior trunk 18%; Posterior trunk 18%;
Right lower extremity 18%; Left lower extremity 18%; Perineum 1%.

39. Answer: (C) Bleeding from ears
Rationale: The nurse needs to perform a thorough assessment that could indicate alterations in cerebral
function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only
with basal skull fractures that can easily contribute to increased intracranial pressure and brain
herniation.

40. Answer: (D) may engage in contact sports
Rationale: The client should be advised by the nurse to avoid contact sports. This will prevent trauma to
the area of the pacemaker generator.

41. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
Rationale: COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2
stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing.
Giving the client oxygen in low concentrations will maintain the clients hypoxic drive.

42. Answer: (B) Facilitate ventilation of the left lung.
Rationale: Since only a partial pneumonectomy is done, there is a need to promote expansion of this
remaining Left lung by positioning the client on the opposite unoperated side.

43. Answer: (A) Perceptual disorders.
Rationale: Frightening visual hallucinations are especially common in clients experiencing alcohol
withdrawal.

44. Answer: (D) Suggest that it takes awhile before seeing the results.
Rationale: The client needs a specific response; that it takes 2 to 3 weeks (a delayed effect) until the
therapeutic blood level is reached.

45. Answer: (C) Superego
Rationale: This behavior shows a weak sense of moral consciousness. According to Freudian theory,
personality disorders stem from a weak superego.

46. Answer: (C) Skeletal muscle paralysis.
Rationale: Anectine is a depolarizing muscle relaxant causing paralysis. It is used to reduce the intensity
of muscle contractions during the convulsive stage, thereby reducing the risk of bone fractures
or dislocation.

47. Answer: (D) Increase calories, carbohydrates, and protein.
Rationale: This client increased protein for tissue building and increased calories to replace what is
burned up (usually via carbohydrates).

48. Answer: (C) Acting overly solicitous toward the child.
Rationale: This behavior is an example of reaction formation, a coping mechanism.

49. Answer: (A) By designating times during which the client can focus on the behavior.
Rationale: The nurse should designate times during which the client can focus on the compulsive
behavior or obsessive thoughts. The nurse should urge the client to reduce the frequency of the
compulsive behavior gradually, not rapidly. She shouldn't call attention to or try to prevent the behavior.
Trying to prevent the behavior may cause pain and terror in the client. The nurse should encourage the
client to verbalize anxieties to help distract attention from the compulsive behavior.

50. Answer: (D) Exploring the meaning of the traumatic event with the client.
Rationale: The client with PTSD needs encouragement to examine and understand the meaning of the
traumatic event and consequent losses. Otherwise, symptoms may worsen and the client may become
depressed or engage in self-destructive behavior such as substance abuse. The client must explore the
meaning of the event and won't heal without this, no matter how much time passes. Behavioral
techniques, such as relaxation therapy, may help decrease the client's anxiety and induce sleep. The
physician may prescribe antianxiety agents or antidepressants cautiously to avoid dependence; sleep
medication is rarely appropriate. A special diet isn't indicated unless the client also has an eating
disorder or a nutritional problem.

































Nursing Practice I -Foundation of Professional Nursing Practice
1. The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a client without
checking the clients pulse. The standard that would be used to determine if the nurse was negligent is:

a. The physicians orders.
b. The action of a clinical nurse specialist who is recognized expert in the field.
c. The statement in the drug literature about administration of terbutaline.
d. The actions of a reasonably prudent nurse with similar education and experience.

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

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

a. Digoxin .1250 mg P.O. once daily
b. Digoxin 0.1250 mg P.O. once daily
c. Digoxin 0.125 mg P.O. once daily
d. Digoxin .125 mg P.O. once daily

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

a. Ineffective peripheral tissue perfusion related to venous congestion.
b. Risk for injury related to edema.
c. Excess fluid volume related to peripheral vascular disease.
d. Impaired gas exchange related to increased blood flow.

5. Nurse Betty is assigned to the following clients. The client that the nurse would see first after
endorsement?
a. A 34 year-old post operative appendectomy client of five hours who is complaining of pain.
b. A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
c. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.
d. A 63 year-old post operatives abdominal hysterectomy client of three days whose incisional dressing
is saturated with serosanguinous fluid.

6. Nurse Gail places a client in a four-point restraint following orders from the physician. The client care
plan should include:
a. Assess temperature frequently.
b. Provide diversional activities.
c. Check circulation every 15-30 minutes.
d. Socialize with other patients once a shift.

7. A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse In-charge
knows the purpose of this therapy is to:
a. Prevent stress ulcer
b. Block prostaglandin synthesis
c. Facilitate protein synthesis.
d. Enhance gas exchange

8. The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish
records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on
these amounts, which action should the nurse take?
a. Increase the I.V. fluid infusion rate
b. Irrigate the indwelling urinary catheter
c. Notify the physician
d. Continue to monitor and record hourly urine output

9. Tony, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain
and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by Tony suggests
that ice application has been effective?
a. My ankle looks less swollen now.
b. My ankle feels warm.
c. My ankle appears redder now.
d. I need something stronger for pain relief

10.The physician prescribes a loop diuretic for a client. When administering this drug, the nurse
anticipates that the client may develop which electrolyte imbalance?
a. Hypernatremia
b. Hyperkalemia
c. Hypokalemia
d. Hypervolemia

11.She finds out that some managers have benevolent-authoritative style of management. Which of the
following behaviors will she exhibit most likely?
a. Have condescending trust and confidence in their subordinates.
b. Gives economic and ego awards.
c. Communicates downward to staffs.
d. Allows decision making among subordinates.

12. Nurse Amy is aware that the following is true about functional nursing
a. Provides continuous, coordinated and comprehensive nursing services.
b. One-to-one nurse patient ratio.
c. Emphasize the use of group collaboration.
d. Concentrates on tasks and activities.

13.Which type of medication order might read "Vitamin K 10 mg I.M. daily 3 days?"

a. Single order
b. Standard written order
c. Standing order
d. Stat order

14.A female client with a fecal impaction frequently exhibits which clinical manifestation?
a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools

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

a. Pulling the lobule down and back
b. Pulling the helix up and forward
c. Pulling the helix up and back
d. Pulling the lobule down and forward

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

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

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

a. Encourage the client to void following preoperative medication.
b. Explore the clients fears and anxieties about the surgery.
c. Assist the client in removing dentures and nail polish.
d. Encourage the client to drink water prior to surgery.

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

a. Blood pressure above normal range.
b. Presence of crackles in both lung fields.
c. Hyperactive bowel sounds
d. Sudden onset of continuous epigastric and back pain.

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

a. Provide high-fiber, high-fat diet
b. Provide high-protein, high-carbohydrate diet.
c. Monitor intake to prevent weight gain.
d. Provide ice chips or water intake.

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

a. Blood pressure and pulse rate.
b. Height and weight.
c. Calcium and potassium levels
d. Hgb and Hct levels.

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

a. Takes a set of vital signs.
b. Call the radiology department for X-ray.
c. Reassure the client that everything will be alright.
d. Immobilize the leg before moving the client.

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

a. Place client on reverse isolation.
b. Admit the client into a private room.
c. Encourage the client to take frequent rest periods.
d. Encourage family and friends to visit.

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

a. Constipation
b. Diarrhea
c. Risk for infection
d. Deficient knowledge

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

a. Notify the physician.
b. Place the client on the left side in the Trendelenburg position.
c. Place the client in high-Fowlers position.
d. Stop the total parenteral nutrition.

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

a. Autocratic.
b. Laissez-faire.
c. Democratic.
d. Situational

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

a. .5 cc
b. 5 cc
c. 1.5 cc
d. 2.5 cc

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

a. 50 cc/ hour
b. 55 cc/ hour
c. 24 cc/ hour
d. 66 cc/ hour

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

a. Assess the IV for type of fluid and rate of flow.
b. Assess the client for presence of pain.
c. Assess the Foley catheter for patency and urine output
d. Assess the dressing for drainage.

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

a. BP 80/60, Pulse 110 irregular
b. BP 90/50, Pulse 50 regular
c. BP 130/80, Pulse 100 regular
d. BP 180/100, Pulse 90 irregular

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

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

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

a. Assessment
b. Evaluation
c. Implementation
d. Planning and goals

32.Which of the following item is considered the single most important factor in assisting the health
professional in arriving at a diagnosis or determining the persons needs?

a. Diagnostic test results
b. Biographical date
c. History of present illness
d. Physical examination

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

a. Trochanter roll extending from the crest of the ileum to the midthigh.
b. Pillows under the lower legs.
c. Footboard
d. Hip-abductor pillow

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

a. Stage I
b. Stage II
c. Stage III
d. Stage IV

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

a. Second intention healing
b. Primary intention healing
c. Third intention healing
d. First intention healing

36.An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver
learns that the client lives alone and hasnt been eating or drinking. When assessing him for
dehydration, nurse Oliver would expect to find:

a. Hypothermia
b. Hypertension
c. Distended neck veins
d. Tachycardia

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

a. 0.75
b. 0.6
c. 0.5
d. 0.25

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

a. Its a common measurement in the metric system.
b. Its the basis for solids in the avoirdupois system.
c. Its the smallest measurement in the apothecary system.
d. Its a measure of effect, not a standard measure of weight or quantity.

39.Nurse Oliver measures a clients temperature at 102 F. What is the equivalent Centigrade
temperature?

a. 40.1 C
b. 38.9 C
c. 48 C
d. 38 C

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

a. Accepting limitations while developing assets.
b. Increasing loss of muscle tone.
c. Failing eyesight, especially close vision.
d. Having more frequent aches and pains.

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

a. Checking and taping all connections.
b. Checking patency of the chest tube.
c. Keeping the head of the bed slightly elevated.
d. Keeping the chest drainage system below the level of the chest.

42.Nurse Trish must verify the clients identity before administering medication. She is aware that the
safest way to verify identity is to:

a. Check the clients identification band.
b. Ask the client to state his name.
c. State the clients name out loud and wait a client to repeat it.
d. Check the room number and the clients name on the bed.

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

a. 30 drops/minute
b. 32 drops/minute
c. 20 drops/minute
d. 18 drops/minute

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

a. Clamp the catheter
b. Call another nurse
c. Call the physician
d. Apply a dry sterile dressing to the site.

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

a. Palpation, auscultation, and percussion.
b. Percussion, palpation, and auscultation.
c. Palpation, percussion, and auscultation.
d. Auscultation, percussion, and palpation.

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

a. Fingertips
b. Finger pads
c. Dorsal surface of the hand
d. Ulnar surface of the hand

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

a. Summative
b. Informative
c. Formative
d. Retrospective

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

a. Twice per year
b. Once per year
c. Every 2 years
d. Once, to establish baseline

49.A male client has the following arterial blood gas values: pH 7.30; Pao2 89 mmHg; Paco2 50 mmHg;
and HCO3 26mEq/L. Based on these values, Nurse Patricia should expect which condition?

a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis

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

a. To help the client find appropriate treatment options.
b. To provide support for the client and family in coping with terminal illness.
c. To ensure that the client gets counseling regarding health care costs.
d. To teach the client and family about cancer and its treatment.

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

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

52.Nurse Oliver must apply an elastic bandage to a clients ankle and calf. He should apply the bandage
beginning at the clients:

a. Knee
b. Ankle
c. Lower thigh
d. Foot

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

a. Hypernatremia
b. Hypokalemia
c. Hyperphosphatemia
d. Hypercalcemia

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

a. Throbbing headache or dizziness
b. Nervousness or paresthesia.
c. Drowsiness or blurred vision.
d. Tinnitus or diplopia.

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

a. Prepare for cardioversion
b. Prepare to defibrillate the client
c. Call a code
d. Check the clients level of consciousness

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

a. On the unaffected side of the client.
b. On the affected side of the client.
c. In front of the client.
d. Behind the client.

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

a. Urine output: 45 ml/hr
b. Capillary refill: 5 seconds
c. Serum pH: 7.32
d. Blood pressure: 90/48 mmHg

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

a. Wiping the port with an alcohol swab before inserting the syringe.
b. Aspirating a sample from the port on the drainage bag.
c. Clamping the tubing of the drainage bag.
d. Obtaining the specimen from the urinary drainage bag.

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

a. Immediately walk out of the clients room and answer the phone call.
b. Cover the client, place the call light within reach, and answer the phone call.
c. Finish the bed bath before answering the phone call.
d. Leave the clients door open so the client can be monitored and the nurse can answer the phone call.

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

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

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

a. Puts all the four points of the walker flat on the floor, puts weight on the hand pieces, and then walks
into it.
b. Puts weight on the hand pieces, moves the walker forward, and then walks into it.
c. Puts weight on the hand pieces, slides the walker forward, and then walks into it.
d. Walks into the walker, puts weight on the hand pieces, and then puts all four points of the walker flat
on the floor.

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

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

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

a. Moves the client rapidly from the table to the stretcher.
b. Uncovers the client completely before transferring to the stretcher.
c. Secures the client safety belts after transferring to the stretcher.
d. Instructs the client to move self from the table to the stretcher.

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

a. Gown and goggles
b. Gown and gloves
c. Gloves and shoe protectors
d. Gloves and goggles

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

a. Crutches
b. Single straight-legged cane
c. Quad cane
d. Walker

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

a. Prone with head turned toward the side supported by a pillow.
b. Sims position with the head of the bed flat.
c. Right side-lying with the head of the bed elevated 45 degrees.
d. Left side-lying with the head of the bed elevated 45 degrees.

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

a. Validity
b. Specificity
c. Sensitivity
d. Reliability

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

a. Keep the identities of the subject secret
b. Obtain informed consent
c. Provide equal treatment to all the subjects of the study.
d. Release findings only to the participants of the study
69.Patients refusal to divulge information is a limitation because it is beyond the control of Tifanny.
What type of research is appropriate for this study?

a. Descriptive- correlational
b. Experiment
c. Quasi-experiment
d. Historical

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

a. Interview schedule
b. Questionnaire
c. Use of laboratory data
d. Observation

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

a. Field study
b. Quasi-experiment
c. Solomon-Four group design
d. Post-test only design

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

a. Footnote
b. Bibliography
c. Primary source
d. Endnotes

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

a. Non-maleficence
b. Beneficence
c. Justice
d. Solidarity

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

a. Force majeure
b. Respondeat superior
c. Res ipsa loquitor
d. Holdover doctrine

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

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

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

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

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

a. Formulating the research hypothesis
b. Review related literature
c. Formulating and delimiting the research problem
d. Design the theoretical and conceptual framework

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

a. Cause and effect
b. Hawthorne effect
c. Halo effect
d. Horns effect

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

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

80. The nursing theorist who developed transcultural nursing theory is:

a. Florence Nightingale
b. Madeleine Leininger
c. Albert Moore
d. Sr. Callista Roy

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

a. Random
b. Accidental
c. Quota
d. Judgment

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

a. Degree of agreement and disagreement
b. Compliance to expected standards
c. Level of satisfaction
d. Degree of acceptance

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

a. Madeleine Leininger
b. Sr. Callista Roy
c. Florence Nightingale
d. Jean Watson

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

a. Span of control
b. Unity of command
c. Downward communication
d. Leader

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

a. Beneficence
b. Autonomy
c. Veracity
d. Non-maleficence

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

a. Avoid wearing cotton socks.
b. Avoid using a nail clipper to cut toenails.
c. Avoid wearing canvas shoes.
d. Avoid using cornstarch on feet.

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

a. Fresh orange slices
b. Steamed broccoli
c. Ice cream
d. Ground beef patties

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

a. Lithotomy
b. Supine
c. Prone
d. Sims left lateral

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

a. Arrange for typing and cross matching of the clients blood.
b. Compare the clients identification wristband with the tag on the unit of blood.
c. Start an I.V. infusion of normal saline solution.
d. Measure the clients vital signs.

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

a. Independent
b. Dependent
c. Interdependent
d. Intradependent

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

a. Assessment
b. Diagnosis
c. Implementation
d. Evaluation

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

a. To increase blood flow to the heart
b. To observe the lower extremities
c. To allow the leg muscles to stretch and relax
d. To permit veins in the legs to fill with blood.

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

a. Instructing the client to report any itching, swelling, or dyspnea.
b. Informing the client that the transfusion usually take 1 to 2 hours.
c. Documenting blood administration in the client care record.
d. Assessing the clients vital signs when the transfusion ends.

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

a. Give the feedings at room temperature.
b. Decrease the rate of feedings and the concentration of the formula.
c. Place the client in semi-Fowler's position while feeding.
d. Change the feeding container every 12 hours.

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

a. Do nothing.
b. Invert the vial and let it stand for 3 to 5 minutes.
c. Shake the vial vigorously.
d. Roll the vial gently between the palms.

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

a. Secure the elastic band tightly around the client's head.
b. Assist the client to the semi-Fowler position if possible.
c. Apply the face mask from the client's chin up over the nose.
d. Loosen the connectors between the oxygen equipment and humidifier.

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

a. 6 hours
b. 4 hours
c. 3 hours
d. 2 hours

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

a. 1 hour before administering the next dose.
b. Immediately before administering the next dose.
c. Immediately after administering the next dose.
d. 30 minutes after administering the next dose.

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

a. The nurse can implement medication orders quickly.
b. The nurse receives input from the pharmacist.
c. The system minimizes transcription errors.
d. The system reinforces accurate calculations.

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

a. Dullness over the liver.
b. Bowel sounds occurring every 10 seconds.
c. Shifting dullness over the abdomen.
d. Vascular sounds heard over the renal arteries





Nursing Practice I-Answers and Rationale
1. Answer: (D) The actions of a reasonably prudent nurse with similar education and experience.
Rationale: The standard of care is determined by the average degree of skill, care, and diligence by
nurses in similar circumstances.

2. Answer: (B) I.M
Rationale: With a platelet count of 22,000/l, the clients tends to bleed easily. Therefore, the nurse
should avoid using the I.M. route because the area is a highly vascular and can bleed readily when
penetrated by a needle. The bleeding can be difficult to stop.

3. Answer: (C) Digoxin 0.125 mg P.O. once daily
Rationale: The nurse should always place a zero before a decimal point so that no one misreads the
figure, which could result in a dosage error. The nurse should never insert a zero at the end of a dosage
that includes a decimal point because this could be misread, possibly leading to a tenfold increase in the
dosage.

4. Answer: (A) Ineffective peripheral tissue perfusion related to venous congestion.
Rationale: Ineffective peripheral tissue perfusion related to venous congestion takes the highest priority
because venous inflammation and clot formation impede blood flow in a client with deep vein
thrombosis.

5. Answer: (B) A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
Rationale: Nausea is a symptom of impending myocardial infarction (MI) and should be assessed
immediately so that treatment can be instituted and further damage to the heart is avoided.

6. Answer: (C) Check circulation every 15-30 minutes.
Rationale: Restraints encircle the limbs, which place the client at risk for circulation being restricted to
the distal areas of the extremities. Checking the clients circulation every 15-30 minutes will allow the
nurse to adjust the restraints before injury from decreased blood flow occurs.

7. Answer: (A) Prevent stress ulcer
Rationale: Curlings ulcer occurs as a generalized stress response in burn patients. This results in a
decreased production of mucus and increased secretion of gastric acid. The best treatment for this
prophylactic use of antacids and H2 receptor blockers.

8. Answer: (D) Continue to monitor and record hourly urine output
Rationale: Normal urine output for an adult is approximately 1 ml/minute (60 ml/hour). Therefore, this
client's output is normal. Beyond continued evaluation, no nursing action is warranted.

9. Answer: (B) My ankle feels warm.
Rationale: Ice application decreases pain and swelling. Continued or increased pain, redness, and
increased warmth are signs of inflammation that shouldn't occur after ice application

10. Answer: (B) Hyperkalemia
Rationale: A loop diuretic removes water and, along with it, sodium and potassium. This may result in
hypokalemia, hypovolemia, and hyponatremia.

11. Answer:(A) Have condescending trust and confidence in their subordinates
Rationale: Benevolent-authoritative managers pretentiously show their trust and confidence to their
followers.

12. Answer: (A) Provides continuous, coordinated and comprehensive nursing services.
Rationale: Functional nursing is focused on tasks and activities and not on the care of the patients.

13. Answer: (B) Standard written order
Rationale: This is a standard written order. Prescribers write a single order for medications given only
once. A stat order is written for
medications given immediately for an urgent client problem. A standing order, also known as a protocol,
establishes guidelines for treating a
particular disease or set of symptoms in special care areas such as the coronary care unit. Facilities also
may institute medication protocols that specifically designate drugs that a nurse may not give.

14. Answer: (D) Liquid or semi-liquid stools
Rationale: Passage of liquid or semi-liquid stools results from seepage of unformed bowel contents
around the impacted stool in the rectum. Clients
with fecal impaction don't pass hard, brown, formed stools because the feces can't move past the
impaction. These clients typically report the urge
to defecate (although they can't pass stool) and a decreased appetite.

15. Answer: (C) Pulling the helix up and back
Rationale: To perform an otoscopic examination on an adult, the nurse grasps the helix of the ear and
pulls it up and back to straighten the ear canal. For a child, the nurse grasps the helix and pulls it down
to straighten the ear canal. Pulling the lobule in any direction wouldn't straighten the ear canal for
visualization.
16. Answer: (A) Protect the irritated skin from sunlight.
Rationale: Irradiated skin is very sensitive and must be protected with clothing or sunblock. The priority
approach is the avoidance of strong sunlight.
17. Answer: (C) Assist the client in removing dentures and nail polish.
Rationale: Dentures, hairpins, and combs must be removed. Nail polish must be removed so that
cyanosis can be easily monitored by observing the nail beds.
18. Answer: (D) Sudden onset of continuous epigastric and back pain.
Rationale: The autodigestion of tissue by the pancreatic enzymes results in pain from inflammation,
edema, and possible hemorrhage. Continuous, unrelieved epigastric or back pain reflects the
inflammatory process in the pancreas.
19. Answer: (B) Provide high-protein, high-carbohydrate diet.
Rationale: A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and
resistance to infection. Caloric goals may be as high as 5000 calories per day.
20. Answer: (A) Blood pressure and pulse rate.
Rationale: The baseline must be established to recognize the signs of an anaphylactic or hemolytic
reaction to the transfusion.
21. Answer: (D) Immobilize the leg before moving the client.
Rationale: If the nurse suspects a fracture, splinting the area before moving the client is imperative. The
nurse should call for emergency help if the client is not hospitalized and call for a physician for the
hospitalized client.
22. Answer: (B) Admit the client into a private room.
Rationale: The client who has a radiation implant is placed in a private room and has a limited number of
visitors. This reduces the exposure of others to the radiation.
23. Answer: (C) Risk for infection
Rationale: Agranulocytosis is characterized by a reduced number of leukocytes (leucopenia) and
neutrophils (neutropenia) in the blood. The client is at high risk for infection because of the decreased
body defenses against microorganisms. Deficient knowledge related to the nature of the disorder may
be appropriate diagnosis but is not the priority.
24. Answer: (B) Place the client on the left side in the Trendelenburg position.
Rationale: Lying on the left side may prevent air from flowing into the pulmonary veins. The
Trendelenburg position increases intrathoracic pressure, which decreases the amount of blood pulled
into the vena cava during aspiration.
25. Answer: (A) Autocratic.
Rationale: The autocratic style of leadership is a task-oriented and directive.
26. Answer: (D) 2.5 cc
Rationale: 2.5 cc is to be added, because only a 500 cc bag of solution is being medicated instead of a 1
liter.
27. Answer: (A) 50 cc/ hour
Rationale: A rate of 50 cc/hr. The child is to receive 400 cc over a period of 8 hours = 50 cc/hr.
28. Answer: (B) Assess the client for presence of pain.
Rationale: Assessing the client for pain is a very important measure. Postoperative pain is an indication
of complication. The nurse should also assess the client for pain to provide for the clients comfort.
29. Answer: (A) BP 80/60, Pulse 110 irregular
Rationale: The classic signs of cardiogenic shock are low blood pressure, rapid and weak irregular pulse,
cold, clammy skin, decreased urinary output, and cerebral hypoxia.
30. Answer: (A) Take the proper equipment, place the client in a comfortable position, and record the
appropriate information in the clients chart.
Rationale: It is a general or comprehensive statement about the correct procedure, and it includes the
basic ideas which are found in the other options
31. Answer: (B) Evaluation
Rationale: Evaluation includes observing the person, asking questions, and comparing the patients
behavioral responses with the expected outcomes.
32. Answer: (C) History of present illness
Rationale: The history of present illness is the single most important factor in assisting the health
professional in arriving at a diagnosis or determining the persons needs.
33. Answer: (A) Trochanter roll extending from the crest of the ileum to the mid-thigh.
Rationale: A trochanter roll, properly placed, provides resistance to the external rotation of the hip.
34. Answer: (C) Stage III
Rationale: Clinically, a deep crater or without undermining of adjacent tissue is noted.
35. Answer: (A) Second intention healing
Rationale: When wounds dehisce, they will allowed to heal by secondary intention
36. Answer: (D) Tachycardia
Rationale: With an extracellular fluid or plasma volume deficit, compensatory mechanisms stimulate the
heart, causing an increase in heart rate.
37. Answer: (A) 0.75
Rationale: To determine the number of milliliters the client should receive, the nurse uses the fraction
method in the following equation.
75 mg/X ml = 100 mg/1 ml
To solve for X, cross-multiply:
75 mg x 1 ml = X ml x 100 mg
75 = 100X
75/100 = X
0.75 ml (or ml) = X

38. Answer: (D) Its a measure of effect, not a standard measure of weight or quantity.
Rationale: An insulin unit is a measure of effect, not a standard measure of weight or quantity. Different
drugs measured in units may have no relationship to one another in quality or quantity.
39. Answer: (B) 38.9 C
Rationale: To convert Fahrenheit degreed to Centigrade, use this formula
C = (F 32) 1.8
C = (102 32) 1.8
C = 70 1.8
C = 38.9
40. Answer: (C) Failing eyesight, especially close vision.
Rationale: Failing eyesight, especially close vision, is one of the first signs of aging in middle life (ages 46
to 64). More frequent aches and pains begin in the early late years (ages 65 to 79). Increase in loss of
muscle tone occurs in later years (age 80 and older).
41. Answer: (A) Checking and taping all connections
Rationale: Air leaks commonly occur if the system isnt secure. Checking all connections and taping them
will prevent air leaks. The chest drainage system is kept lower to promote drainage not to prevent
leaks.
42. Answer: (A) Check the clients identification band.
Rationale: Checking the clients identification band is the safest way to verify a clients identity because
the band is assigned on admission and isnt be removed at any time. (If it is removed, it must be
replaced). Asking the clients name or having the client repeated his name would be appropriate only for
a client whos alert, oriented, and able to understand what is being said, but isnt the safe standard of
practice. Names on bed arent always reliable
43. Answer: (B) 32 drops/minute
Rationale: Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes). Find the
number of milliliters per minute as follows:
125/60 minutes = X/1 minute
60X = 125 = 2.1 ml/minute
To find the number of drops per minute:
2.1 ml/X gtt = 1 ml/ 15 gtt
X = 32 gtt/minute, or 32 drops/minute

44. Answer: (A) Clamp the catheter
Rationale: If a central venous catheter becomes disconnected, the nurse should immediately apply a
catheter clamp, if available. If a clamp isnt available, the nurse can place a sterile syringe or catheter
plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse
must replace the I.V. extension and restart the infusion.
45. Answer: (D) Auscultation, percussion, and palpation.
Rationale: The correct order of assessment for examining the abdomen is inspection, auscultation,
percussion, and palpation. The reason for this approach is that the less intrusive techniques should be
performed before the more intrusive techniques. Percussion and palpation can alter natural findings
during auscultation.
46. Answer: (D) Ulnar surface of the hand
Rationale: The nurse uses the ulnar surface, or ball, of the hand to asses tactile fremitus, thrills, and
vocal vibrations through the chest wall. The
fingertips and finger pads best distinguish texture and shape. The dorsal surface best feels warmth.
47. Answer: (C) Formative
Rationale: Formative (or concurrent) evaluation occurs continuously throughout the teaching and
learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance
learning. Summative, or retrospective, evaluation occurs at the conclusion of the teaching and learning
session. Informative is not a type of evaluation.

48. Answer: (B) Once per year
Rationale: Yearly mammograms should begin at age 40 and continue for
as long as the woman is in good health. If health risks, such as family
history, genetic tendency, or past breast cancer, exist, more frequent
examinations may be necessary.
49. Answer: (A) Respiratory acidosis
Rationale: The client has a below-normal (acidic) blood pH value and an above-normal partial pressure
of arterial carbon dioxide (Paco2) value, indicating respiratory acidosis. In respiratory alkalosis, the pH
value is above normal and in the Paco2 value is below normal. In metabolic acidosis, the pH and
bicarbonate (Hco3) values are below normal. In metabolic alkalosis, the pH and Hco3 values are above
normal.
50. Answer: (B) To provide support for the client and family in coping with terminal illness.
Rationale: Hospices provide supportive care for terminally ill clients and their families. Hospice care
doesnt focus on counseling regarding health care costs. Most client referred to hospices have been
treated for their disease without success and will receive only palliative care in the hospice.
51. Answer: (C) Using normal saline solution to clean the ulcer and applying a protective dressing as
necessary.
Rationale: Washing the area with normal saline solution and applying a protective dressing are within
the nurses realm of interventions and will protect the area. Using a povidone-iodine wash and an
antibiotic cream require a physicians order. Massaging with an astringent can further damage the skin.
52. Answer: (D) Foot
Rationale: An elastic bandage should be applied form the distal area to the proximal area. This method
promotes venous return. In this case, the nurse should begin applying the bandage at the clients foot.
Beginning at the ankle, lower thigh, or knee does not promote venous return.
53. Answer: (B) Hypokalemia
Rationale: Insulin administration causes glucose and potassium to move into the cells, causing
hypokalemia.
54. Answer: (A) Throbbing headache or dizziness
Rationale: Headache and dizziness often occur when nitroglycerin is taken at the beginning of therapy.
However, the client usually develops tolerance

55. Answer: (D) Check the clients level of consciousness
Rationale: Determining unresponsiveness is the first step assessment action to take. When a client is in
ventricular tachycardia, there is a significant decrease in cardiac output. However, checking the
unresponsiveness ensures whether the client is affected by the decreased cardiac output.
56. Answer: (B) On the affected side of the client.
Rationale: When walking with clients, the nurse should stand on the affected side and grasp the security
belt in the midspine area of the small of the back. The nurse should position the free hand at the
shoulder area so that the client can be pulled toward the nurse in the event that there is a forward fall.
The client is instructed to look up and outward rather than at his or her feet.
57. Answer: (A) Urine output: 45 ml/hr
Rationale: Adequate perfusion must be maintained to all vital organs in order for the client to remain
visible as an organ donor. A urine output of 45 ml per hour indicates adequate renal perfusion. Low
blood pressure and delayed capillary refill time are circulatory system indicators of inadequate
perfusion. A serum pH of 7.32 is acidotic, which adversely affects all body tissues.
58. Answer: (D ) Obtaining the specimen from the urinary drainage bag.
Rationale: A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical
changes while sitting in the bag and does not necessarily reflect the current client status. In addition, it
may become contaminated with bacteria from opening the system.
59. Answer: (B) Cover the client, place the call light within reach, and answer the phone call.
Rationale: Because telephone call is an emergency, the nurse may need to answer it. The other
appropriate action is to ask another nurse to accept the call. However, is not one of the options. To
maintain privacy and safety, the nurse covers the client and places the call light within the clients reach.
Additionally, the clients door should be closed or the room curtains pulled around the bathing area.
60. Answer: (C) Use a sterile plastic container for obtaining the specimen.
Rationale: Sputum specimens for culture and sensitivity testing need to be obtained using sterile
techniques because the test is done to determine the presence of organisms. If the procedure for
obtaining the specimen is not sterile, then the specimen is not sterile, then the specimen would be
contaminated and the results of the test would be invalid.

61. Answer: (A) Puts all the four points of the walker flat on the floor, puts weight on the hand pieces,
and then walks into it.
Rationale: When the client uses a walker, the nurse stands adjacent to the affected side. The client is
instructed to put all four points of the walker 2 feet forward flat on the floor before putting weight on
hand pieces. This will ensure client safety and prevent stress cracks in the walker. The client is then
instructed to move the walker forward and walk into it.
62. Answer: (C) Draws one line to cross out the incorrect information and then initials the change.
Rationale: To correct an error documented in a medical record, the nurse draws one line through the
incorrect information and then initials the error. An error is never erased and correction fluid is never
used in the medical record.
63. Answer: (C) Secures the client safety belts after transferring to the stretcher.
Rationale: During the transfer of the client after the surgical procedure is complete, the nurse should
avoid exposure of the client because of the risk for potential heat loss. Hurried movements and rapid
changes in the position should be avoided because these predispose the client to hypotension. At the
time of the transfer from the surgery table to the stretcher, the client is still affected by the effects of
the anesthesia; therefore, the client should not move self. Safety belts can prevent the client from
falling off the stretcher.
64. Answer: (B) Gown and gloves
Rationale: Contact precautions require the use of gloves and a gown if direct client contact is
anticipated. Goggles are not necessary unless the
nurse anticipates the splashes of blood, body fluids, secretions, or excretions may occur. Shoe
protectors are not necessary.
65. Answer: (C) Quad cane
Rationale: Crutches and a walker can be difficult to maneuver for a client with weakness on one side. A
cane is better suited for client with weakness of the arm and leg on one side. However, the quad cane
would provide the most stability because of the structure of the cane and because a quad cane has four
legs.
66. Answer: (D) Left side-lying with the head of the bed elevated 45 degrees.
Rationale: To facilitate removal of fluid from the chest wall, the client is positioned sitting at the edge of
the bed leaning over the bedside table with the feet supported on a stool. If the client is unable to sit up,
the client is positioned lying in bed on the unaffected side with the head of the bed elevated 30 to 45
degrees.

67. Answer: (D) Reliability
Rationale: Reliability is consistency of the research instrument. It refers to
the repeatability of the instrument in extracting the same responses upon
its repeated administration.
68. Answer: (A) Keep the identities of the subject secret
Rationale: Keeping the identities of the research subject secret will ensure anonymity because this will
hinder providing link between the information given to whoever is its source.
69. Answer: (A) Descriptive- correlational
Rationale: Descriptive- correlational study is the most appropriate for this study because it studies the
variables that could be the antecedents of the increased incidence of nosocomial infection.
70. Answer: (C) Use of laboratory data
Rationale: Incidence of nosocomial infection is best collected through the use of biophysiologic
measures, particularly in vitro measurements, hence laboratory data is essential.
71. Answer: (B) Quasi-experiment
Rationale: Quasi-experiment is done when randomization and control of the variables are not possible.
72. Answer: (C) Primary source
Rationale: This refers to a primary source which is a direct account of the investigation done by the
investigator. In contrast to this is a secondary source, which is written by someone other than the
original researcher.
73. Answer: (A) Non-maleficence
Rationale: Non-maleficence means do not cause harm or do any action that will cause any harm to the
patient/client. To do good is referred as beneficence.
74. Answer: (C) Res ipsa loquitor
Rationale: Res ipsa loquitor literally means the thing speaks for itself. This means in operational terms
that the injury caused is the proof that there was a negligent act.
75. Answer: (B) The Board can investigate violations of the nursing law and code of ethics
Rationale: Quasi-judicial power means that the Board of Nursing has the authority to investigate
violations of the nursing law and can issue summons, subpoena or subpoena duces tecum as needed.

76. Answer: (C) May apply for re-issuance of his/her license based on certain conditions stipulated in RA
9173
Rationale: RA 9173 sec. 24 states that for equity and justice, a revoked license maybe re-issued provided
that the following conditions are met: a)
the cause for revocation of license has already been corrected or removed; and, b) at least four years
has elapsed since the license has been revoked.
77. Answer: (B) Review related literature
Rationale: After formulating and delimiting the research problem, the researcher conducts a review of
related literature to determine the extent of what has been done on the study by previous researchers.
78. Answer: (B) Hawthorne effect
Rationale: Hawthorne effect is based on the study of Elton Mayo and company about the effect of an
intervention done to improve the working conditions of the workers on their productivity. It resulted to
an increased productivity but not due to the intervention but due to the psychological effects of being
observed. They performed differently because they were under observation.
79. Answer: (B) Determines the different nationality of patients frequently admitted and decides to get
representations samples from each.
Rationale: Judgment sampling involves including samples according to the knowledge of the investigator
about the participants in the study.
80. Answer: (B) Madeleine Leininger
Rationale: Madeleine Leininger developed the theory on transcultural theory based on her observations
on the behavior of selected people within a culture.
81. Answer: (A) Random
Rationale: Random sampling gives equal chance for all the elements in the population to be picked as
part of the sample.
82. Answer: (A) Degree of agreement and disagreement
Rationale: Likert scale is a 5-point summated scale used to determine the degree of agreement or
disagreement of the respondents to a statement in a study
83. Answer: (B) Sr. Callista Roy
Rationale: Sr. Callista Roy developed the Adaptation Model which involves the physiologic mode, self-
concept mode, role function mode and dependence mode.
84. Answer: (A) Span of control
Rationale: Span of control refers to the number of workers who report directly to a manager.
85. Answer: (B) Autonomy
Rationale: Informed consent means that the patient fully understands about the surgery, including the
risks involved and the alternative solutions. In giving consent it is done with full knowledge and is given
freely. The action of allowing the patient to decide whether a surgery is to be done or not exemplifies
the bioethical principle of autonomy.
86. Answer: (C) Avoid wearing canvas shoes.
Rationale: The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to
perspire, which may, in turn, cause skin
irritation and breakdown. Both cotton and cornstarch absorb perspiration. The client should be
instructed to cut toenails straight across with nail
clippers.

87. Answer: (D) Ground beef patties
Rationale: Meat is an excellent source of complete protein, which this client needs to repair the tissue
breakdown caused by pressure ulcers.
Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete
protein, making it less helpful in tissue repair.

88. Answer: (D) Sims left lateral
Rationale: The Sims' left lateral position is the most common position used to administer a cleansing
enema because it allows gravity to aid the flow of fluid along the curve of the sigmoid colon. If the client
can't assume this position nor has poor sphincter control, the dorsal recumbent or right lateral position
may be used. The supine and prone positions are inappropriate and uncomfortable for the client.

89. Answer: (A) Arrange for typing and cross matching of the clients blood.
Rationale: The nurse first arranges for typing and cross matching of the client's blood to ensure
compatibility with donor blood. The other options,
although appropriate when preparing to administer a blood transfusion, come later.

90. Answer: (A) Independent
Rationale: Nursing interventions are classified as independent, interdependent, or dependent. Altering
the drug schedule to coincide with the client's daily routine represents an independent intervention,
whereas consulting with the physician and pharmacist to change a client's medication because of
adverse reactions represents an interdependent intervention. Administering an already-prescribed drug
on time is a dependent intervention. An intradependent nursing intervention doesn't exist.

91. Answer: (D) Evaluation
Rationale: The nursing actions described constitute evaluation of the expected outcomes. The findings
show that the expected outcomes have been achieved. Assessment consists of the client's history,
physical examination, and laboratory studies. Analysis consists of considering assessment information to
derive the appropriate nursing diagnosis. Implementation is the phase of the nursing process where the
nurse puts the plan of care into action.

92. Answer: (B) To observe the lower extremities
Rationale: Elastic stockings are used to promote venous return. The nurse needs to remove them once
per day to observe the condition of the skin underneath the stockings. Applying the stockings increases
blood flow to the heart. When the stockings are in place, the leg muscles can still stretch and relax, and
the veins can fill with blood.

93. Answer:(A) Instructing the client to report any itching, swelling, or dyspnea.
Rationale: Because administration of blood or blood products may cause serious adverse effects such as
allergic reactions, the nurse must monitor the client for these effects. Signs and symptoms of life-
threatening allergic reactions include itching, swelling, and dyspnea. Although the nurse should inform
the client of the duration of the transfusion and should document its administration, these actions are
less critical to the client's immediate health. The nurse should assess vital signs at least hourly during the
transfusion.

94. Answer: (B) Decrease the rate of feedings and the concentration of the formula.
Rationale: Complaints of abdominal discomfort and nausea are common in clients receiving tube
feedings. Decreasing the rate of the feeding and the concentration of the formula should decrease the
client's discomfort. Feedings are normally given at room temperature to minimize abdominal cramping.
To prevent aspiration during feeding, the head of the client's bed should be elevated at least 30 degrees.
Also, to prevent bacterial growth, feeding containers should be routinely changed every 8 to 12 hours.

95. Answer: (D) Roll the vial gently between the palms.
Rationale: Rolling the vial gently between the palms produces heat, which helps dissolve the medication.
Doing nothing or inverting the vial wouldn't help dissolve the medication. Shaking the vial vigorously
could cause the medication to break down, altering its action.

96. Answer: (B) Assist the client to the semi-Fowler position if possible.
Rationale: By assisting the client to the semi-Fowler position, the nurse promotes easier chest
expansion, breathing, and oxygen intake. The nurse should secure the elastic band so that the face mask
fits comfortably and snugly rather than tightly, which could lead to irritation. The nurse should apply the
face mask from the client's nose down to the chin not vice versa. The nurse should check the
connectors between the oxygen equipment and humidifier to ensure that they're airtight; loosened
connectors can cause loss of oxygen.

97. Answer: (B) 4 hours
Rationale: A unit of packed RBCs may be given over a period of between 1 and 4 hours. It shouldn't
infuse for longer than 4 hours because the risk of contamination and sepsis increases after that time.
Discard or return to the blood bank any blood not given within this time, according to facility policy.

98. Answer: (B) Immediately before administering the next dose.
Rationale: Measuring the blood drug concentration helps determine whether the dosing has achieved
the therapeutic goal. For measurement of the trough, or lowest, blood level of a drug, the nurse draws a
blood sample immediately before administering the next dose. Depending on the drug's duration of
action and half-life, peak blood drug levels typically are drawn after administering the next dose.

99. Answer: (A) The nurse can implement medication orders quickly.
Rationale: A floor stock system enables the nurse to implement medication orders quickly. It doesn't
allow for pharmacist input, nor does it minimize transcription errors or reinforce accurate calculations.

100. Answer: (C) Shifting dullness over the abdomen.
Rationale: Shifting dullness over the abdomen indicates ascites, an abnormal finding. The other options
are normal abdominal findings.



















Nursing Practice II- Community Health Nursing and Care of the Mother and Child

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

a. Inevitable
b. Incomplete
c. Threatened
d. Septic

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

a. Age 36 years
b. History of syphilis
c. History of genital herpes
d. History of diabetes mellitus

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

a. Monitoring weight
b. Assessing for edema
c. Monitoring apical pulse
d. Monitoring temperature

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

a. Decreased caloric intake
b. Increased caloric intake
c. Decreased Insulin
d. Increase Insulin

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

a. Excessive fetal activity.
b. Larger than normal uterus for gestational age.
c. Vaginal bleeding
d. Elevated levels of human chorionic gonadotropin.

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

a. Urinary output 90 cc in 2 hours.
b. Absent patellar reflexes.
c. Rapid respiratory rate above 40/min.
d. Rapid rise in blood pressure.

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

a. Presenting part is 2 cm above the plane of the ischial spines.
b. Biparietal diameter is at the level of the ischial spines.
c. Presenting part in 2 cm below the plane of the ischial spines.
d. Biparietal diameter is 2 cm above the ischial spines.

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

a. Contractions every 1 minutes lasting 70-80 seconds.
b. Maternal temperature 101.2
c. Early decelerations in the fetal heart rate.
d. Fetal heart rate baseline 140-160 bpm.

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

a. Ventilator assistance
b. CVP readings
c. EKG tracings
d. Continuous CPR

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

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

11.Nurse Ryan is aware that the best initial approach when trying to take a crying toddlers temperature
is:

a. Talk to the mother first and then to the toddler.
b. Bring extra help so it can be done quickly.
c. Encourage the mother to hold the child.
d. Ignore the crying and screaming.

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

a. Avoid touching the suture line, even when cleaning.
b. Place the baby in prone position.
c. Give the baby a pacifier.
d. Place the infants arms in soft elbow restraints.

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

a. Feed the infant when he cries.
b. Allow the infant to rest before feeding.
c. Bathe the infant and administer medications before feeding.
d. Weigh and bathe the infant before feeding.

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

a. Skim milk and baby food.
b. Whole milk and baby food.
c. Iron-rich formula only.
d. Iron-rich formula and baby food.

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

a. 6 months
b. 4 months
c. 8 months
d. 10 months

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

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

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

a. Effectiveness
b. Efficiency
c. Adequacy
d. Appropriateness

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

a. Department of Health
b. Provincial Health Office
c. Regional Health Office
d. Rural Health Unit

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

a. Mayor
b. Municipal Health Officer
c. Public Health Nurse
d. Any qualified physician

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

a. 1
b. 2
c. 3
d. The RHU does not need any more midwife item.

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

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

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

a. Poliomyelitis
b. Measles
c. Rabies
d. Neonatal tetanus

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

a. Integration
b. Community organization
c. Community study
d. Core group formation

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

a. To educate the people regarding community health problems
b. To mobilize the people to resolve community health problems
c. To maximize the communitys resources in dealing with health problems.
d. To maximize the communitys resources in dealing with health problems.

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

a. Pre-pathogenesis
b. Pathogenesis
c. Prodromal
d. Terminal

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

a. Intrauterine fetal death.
b. Placenta accreta.
c. Dysfunctional labor.
d. Premature rupture of the membranes.

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

a. 80 to 100 beats/minute
b. 100 to 120 beats/minute
c. 120 to 160 beats/minute
d. 160 to 180 beats/minute

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

a. Change the diaper more often.
b. Apply talc powder with diaper changes.
c. Wash the area vigorously with each diaper change.
d. Decrease the infants fluid intake to decrease saturating diapers.

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

a. Atrial septal defect
b. Pulmonic stenosis
c. Ventricular septal defect
d. Endocardial cushion defect

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

a. Anemia
b. Decreased urine output
c. Hyperreflexia
d. Increased respiratory rate

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

a. Menorrhagia
b. Metrorrhagia
c. Dyspareunia
d. Amenorrhea

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

a. Oxygen saturation
b. Iron binding capacity
c. Blood typing
d. Serum Calcium

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

a. Metabolic alkalosis
b. Respiratory acidosis
c. Mastitis
d. Physiologic anemia

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

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

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

a. Placenta previa
b. Abruptio placentae
c. Premature labor
d. Sexually transmitted disease

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

a. Just before bedtime
b. After the child has been bathe
c. Any time during the day
d. Early in the morning

37.In doing a childs admission assessment, Nurse Betty should be alert to note which signs or symptoms
of chronic lead poisoning?

a. Irritability and seizures
b. Dehydration and diarrhea
c. Bradycardia and hypotension
d. Petechiae and hematuria

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

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

39.Hypoxia is a common complication of laryngotracheobronchitis. Nurse Oliver should frequently
assess a child with laryngotracheobronchitis for:
a. Drooling
b. Muffled voice
c. Restlessness
d. Low-grade fever

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

a. Without touching the child, talk continuously as the child walks down the hall.
b. Walk one step ahead, with the childs hand on the nurses elbow.
c. Walk slightly behind, gently guiding the child forward.
d. Walk next to the child, holding the childs hand.

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

a. Loud, machinery-like murmur.
b. Bluish color to the lips.
c. Decreased BP reading in the upper extremities
d. Increased BP reading in the upper extremities.

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

a. Less oxygen, and the newborns metabolic rate increases.
b. More oxygen, and the newborns metabolic rate decreases.
c. More oxygen, and the newborns metabolic rate increases.
d. Less oxygen, and the newborns metabolic rate decreases.

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

a. Stable blood pressure
b. Patant fontanelles
c. Moros reflex
d. Voided

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

a. Baby oil
b. Baby lotion
c. Laundry detergent
d. Powder with cornstarch

45.During tube feeding, how far above an infants stomach should the nurse hold the syringe with
formula?

a. 6 inches
b. 12 inches
c. 18 inches
d. 24 inches

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

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

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

a. Advice them on the signs of German measles.
b. Avoid crowded places, such as markets and movie houses.
c. Consult at the health center where rubella vaccine may be given.
d. Consult a physician who may give them rubella immunoglobulin.

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

a. Contact tracing
b. Community survey
c. Mass screening tests
d. Interview of suspects

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

a. Hepatitis A
b. Hepatitis B
c. Tetanus
d. Leptospirosis

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

a. Giardiasis
b. Cholera
c. Amebiasis
d. Dysentery

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

a. Hemophilus influenzae
b. Morbillivirus
c. Steptococcus pneumoniae
d. Neisseria meningitidis

52.The student nurse is aware that the pathognomonic sign of measles is Kopliks spot and you may see
Kopliks spot by inspecting the:

a. Nasal mucosa
b. Buccal mucosa
c. Skin on the abdomen
d. Skin on neck

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

a. 3 seconds
b. 6 seconds
c. 9 seconds
d. 10 seconds

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

a. Mastoiditis
b. Severe dehydration
c. Severe pneumonia
d. Severe febrile disease

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

a. 45 infants
b. 50 infants
c. 55 infants
d. 65 infants

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

a. DPT
b. Oral polio vaccine
c. Measles vaccine
d. MMR

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

a. Use of molluscicides
b. Building of foot bridges
c. Proper use of sanitary toilets
d. Use of protective footwear, such as rubber boots

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

a. 3 skin lesions, negative slit skin smear
b. 3 skin lesions, positive slit skin smear
c. 5 skin lesions, negative slit skin smear
d. 5 skin lesions, positive slit skin smear

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

a. Macular lesions
b. Inability to close eyelids
c. Thickened painful nerves
d. Sinking of the nosebridge

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

a. Perform a tourniquet test.
b. Ask where the family resides.
c. Get a specimen for blood smear.
d. Ask if the fever is present everyday.

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

a. Inability to drink
b. High grade fever
c. Signs of severe dehydration
d. Cough for more than 30 days

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

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

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

a. Bring the child to the nearest hospital for further assessment.
b. Bring the child to the health center for intravenous fluid therapy.
c. Bring the child to the health center for assessment by the physician.
d. Let the child rest for 10 minutes then continue giving Oresol more slowly.

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

a. No signs of dehydration
b. Some dehydration
c. Severe dehydration
d. The data is insufficient.

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

a. Fast
b. Slow
c. Normal
d. Insignificant

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

a. 1 year
b. 3 years
c. 5 years
d. Lifetime

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

a. 2 hours
b. 4 hours
c. 8 hours
d. At the end of the day

68.The nurse explains to a breastfeeding mother that breast milk is sufficient for all of the babys
nutrient needs only up to:

a. 5 months
b. 6 months
c. 1 year
d. 2 years
69.Nurse Ron is aware that the gestational age of a conceptus that is considered viable (able to live
outside the womb) is:

a. 8 weeks
b. 12 weeks
c. 24 weeks
d. 32 weeks

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

a. Aspiration
b. Sudden infant death syndrome (SIDS)
c. Suffocation
d. Gastroesophageal reflux (GER)

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

a. Flushed cheeks
b. Increased temperature
c. Decreased temperature
d. Increased activity level

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

a. Anemia probably due to chronic fetal hyposia
b. Hyperthermia due to decreased glycogen stores
c. Hyperglycemia due to decreased glycogen stores
d. Polycythemia probably due to chronic fetal hypoxia

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

a. A sleepy, lethargic baby
b. Lanugo covering the body
c. Desquamation of the epidermis
d. Vernix caseosa covering the body

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

a. Hypoglycemia
b. Jitteriness
c. Respiratory depression
d. Tachycardia

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

a. Nasal flaring
b. Light audible grunting
c. Respiratory rate 40 to 60 breaths/minute
d. Respiratory rate 60 to 80 breaths/minute

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

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

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

a. Simian crease
b. Conjunctival hemorrhage
c. Cystic hygroma
d. Bulging fontanelle

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

a. To determine fetal well-being.
b. To assess for prolapsed cord
c. To assess fetal position
d. To prepare for an imminent delivery.

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

a. The parents willingness to touch and hold the new born.
b. The parents expression of interest about the size of the new born.
c. The parents indication that they want to see the newborn.
d. The parents interactions with each other.

80.Following a precipitous delivery, examination of the client's vagina reveals

a fourth-degree laceration. Which of the following would be contraindicated when caring for this client?
a. Applying cold to limit edema during the first 12 to 24 hours.
b. Instructing the client to use two or more peripads to cushion the area.
c. Instructing the client on the use of sitz baths if ordered.
d. Instructing the client about the importance of perineal (kegel) exercises.

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

a. Do you have any chronic illnesses?
b. Do you have any allergies?
c. What is your expected due date?
d. Who will be with you during labor?
82.A neonate begins to gag and turns a dusky color. What should the nurse do first?

a. Calm the neonate.
b. Notify the physician.
c. Provide oxygen via face mask as ordered
d. Aspirate the neonates nose and mouth with a bulb syringe.

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

a. Observing the pooling of straw-colored fluid.
b. Checking vaginal discharge with nitrazine paper.
c. Conducting a bedside ultrasound for an amniotic fluid index.
d. Observing for flakes of vernix in the vaginal discharge.

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

a. Cover his eyes while receiving oxygen.
b. Keep her body temperature low.
c. Monitor partial pressure of oxygen (Pao2) levels.
d. Humidify the oxygen.

85. Which of the following is normal newborn calorie intake?

a. 110 to 130 calories per kg.
b. 30 to 40 calories per lb of body weight.
c. At least 2 ml per feeding
d. 90 to 100 calories per kg

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

a. 16 to 18 weeks
b. 18 to 22 weeks
c. 30 to 32 weeks
d. 38 to 40 weeks

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

a. conjoined twins
b. diamniotic dichorionic twins
c. diamniotic monochorionic twin
d. monoamniotic monochorionic twins

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

a. Amniocentesis
b. Digital or speculum examination
c. External fetal monitoring
d. Ultrasound

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

a. Increased tidal volume
b. Increased expiratory volume
c. Decreased inspiratory capacity
d. Decreased oxygen consumption

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

a. Diet
b. Long-acting insulin
c. Oral hypoglycemic
d. Oral hypoglycemic drug and insulin

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

a. Hemorrhage
b. Hypertension
c. Hypomagnesemia
d. Seizure

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

a. Antihypertensive agents
b. Diuretic agents
c. I.V. fluids
d. Acetaminophen (Tylenol) for pain

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

a. Calcium gluconate (Kalcinate)
b. Hydralazine (Apresoline)
c. Naloxone (Narcan)
d. Rho (D) immune globulin (RhoGAM)

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

a. An indurated wheal under 10 mm in diameter appears in 6 to 12 hours.
b. An indurated wheal over 10 mm in diameter appears in 48 to 72 hours.
c. A flat circumcised area under 10 mm in diameter appears in 6 to 12 hours.
d. A flat circumcised area over 10 mm in diameter appears in 48 to 72 hours.

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

a. Asymptomatic bacteriuria
b. Bacterial vaginosis
c. Pyelonephritis
d. Urinary tract infection (UTI)

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

a. Rh-positive maternal blood crosses into fetal blood, stimulating fetal
antibodies.
b. Rh-positive fetal blood crosses into maternal blood, stimulating
maternal antibodies.
c. Rh-negative fetal blood crosses into maternal blood, stimulating
maternal antibodies.
d. Rh-negative maternal blood crosses into fetal blood, stimulating fetal
antibodies.

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

a. Lateral position
b. Squatting position
c. Supine position
d. Standing position

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

a. Lethargy 2 days after birth.
b. Irritability and poor sucking.
c. A flattened nose, small eyes, and thin lips.
d. Congenital defects such as limb anomalies.

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

a. 7th to 9th day postpartum.
b. 2 weeks postpartum.
c. End of 6th week postpartum.
d. When the lochia changes to alba.

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

a. Uterine inversion
b. Uterine atony
c. Uterine involution
d. Uterine discomfort

Answer and Rationale- Nursing Practice II- Community Health Nursing and Care of the Mother and
Child

1. Answer: (A) Inevitable
Rationale: An inevitable abortion is termination of pregnancy that cannot be prevented. Moderate to
severe bleeding with mild cramping and cervical dilation would be noted in this type of abortion.

2. Answer: (B) History of syphilis
Rationale: Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous
abortion.

3. Answer: (C) Monitoring apical pulse
Rationale: Nursing care for the client with a possible ectopic pregnancy is focused on preventing or
identifying hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of shock.

4. Answer: (B) Increased caloric intake
Rationale: Glucose crosses the placenta, but insulin does not. High fetal demands for glucose, combined
with the insulin resistance caused by hormonal changes in the last half of pregnancy can result in
elevation of maternal blood glucose levels. This increases the mothers demand for insulin and is
referred to as the diabetogenic effect of pregnancy.

5. Answer: (A) Excessive fetal activity.
Rationale: The most common signs and symptoms of hydatidiform mole includes elevated levels of
human chorionic gonadotropin, vaginal bleeding, larger than normal uterus for gestational age, failure
to detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting, and early
development of pregnancy-induced hypertension. Fetal activity would not be noted.

6. Answer: (B) Absent patellar reflexes
Rationale: Absence of patellar reflexes is an indicator of hypermagnesemia, which requires
administration of calcium gluconate.

7. Answer: (C) Presenting part in 2 cm below the plane of the ischial spines.
Rationale: Fetus at station plus two indicates that the presenting part is 2 cm below the plane of the
ischial spines.

8. Answer: (A) Contractions every 1 minutes lasting 70-80 seconds.
Rationale: Contractions every 1 minutes lasting 70-80 seconds, is indicative of hyperstimulation of the
uterus, which could result in injury to the mother and the fetus if Pitocin is not discontinued.

9. Answer: (C) EKG tracings
Rationale: A potential side effect of calcium gluconate administration is cardiac arrest. Continuous
monitoring of cardiac activity (EKG) throught administration of calcium gluconate is an essential part of
care.

10. Answer: (D) First low transverse caesarean was for breech position. Fetus in this pregnancy is in a
vertex presentation.
Rationale: This type of client has no obstetrical indication for a caesarean section as she did with her
first caesarean delivery.

11. Answer: (A) Talk to the mother first and then to the toddler.
Rationale: When dealing with a crying toddler, the best approach is to talk to the mother and ignore the
toddler first. This approach helps the toddler get used to the nurse before she attempts any procedures.
It also gives the toddler an opportunity to see that the mother trusts the nurse.

12. Answer: (D) Place the infants arms in soft elbow restraints.
Rationale: Soft restraints from the upper arm to the wrist prevent the infant from touching her lip but
allow him to hold a favorite item such as a blanket. Because they could damage the operative site, such
as objects as pacifiers, suction catheters, and small spoons shouldnt be placed in a babys mouth after
cleft repair. A baby in a prone position may rub her face on the sheets and traumatize the operative site.
The suture line should be cleaned gently to prevent infection, which could interfere with healing and
damage the cosmetic appearance of the repair.

13. Answer: (B) Allow the infant to rest before feeding.
Rationale: Because feeding requires so much energy, an infant with heart failure should rest before
feeding.

14. Answer: (C) Iron-rich formula only.
Rationale: The infants at age 5 months should receive iron-rich formula and that they shouldnt receive
solid food, even baby food until age 6 months.

15. Answer: (D) 10 months
Rationale: A 10 month old infant can sit alone and understands object permanence, so he would look for
the hidden toy. At age 4 to 6 months, infants cant sit securely alone. At age 8 months, infants can sit
securely alone but cannot understand the permanence of objects.

16. Answer: (D) Public health nursing focuses on preventive, not curative, services.
Rationale: The catchments area in PHN consists of a residential community, many of whom are well
individuals who have greater need for
preventive rather than curative services.

17. Answer: (B) Efficiency
Rationale: Efficiency is determining whether the goals were attained at the least possible cost.

18. Answer: (D) Rural Health Unit
Rationale: R.A. 7160 devolved basic health services to local government units (LGUs ). The public health
nurse is an employee of the LGU.

19. Answer: (A) Mayor
Rationale: The local executive serves as the chairman of the Municipal Health Board.

20. Answer: (A) 1
Rationale: Each rural health midwife is given a population assignment of about 5,000.

21. Answer: (B) Health education and community organizing are necessary in providing community
health services.
Rationale: The community health nurse develops the health capability of people through health
education and community organizing activities.

22. Answer: (B) Measles
Rationale: Presidential Proclamation No. 4 is on the Ligtas Tigdas Program.

23. Answer: (D) Core group formation
Rationale: In core group formation, the nurse is able to transfer the technology of community organizing
to the potential or informal community leaders through a training program.

24. Answer: (D) To maximize the communitys resources in dealing with health problems.
Rationale: Community organizing is a developmental service, with the goal of developing the peoples
self-reliance in dealing with community
health problems. A, B and C are objectives of contributory objectives to this goal.

25. Answer: (D) Terminal
Rationale: Tertiary prevention involves rehabilitation, prevention of permanent disability and disability
limitation appropriate for convalescents, the disabled, complicated cases and the terminally ill (those in
the terminal stage of a disease).

26. Answer: (A) Intrauterine fetal death.
Rationale: Intrauterine fetal death, abruptio placentae, septic shock, and amniotic fluid embolism may
trigger normal clotting mechanisms; if clotting factors are depleted, DIC may occur. Placenta accreta,
dysfunctional labor, and premature rupture of the membranes aren't associated with DIC.

27. Answer: (C) 120 to 160 beats/minute
Rationale: A rate of 120 to 160 beats/minute in the fetal heart appropriate for filling the heart with
blood and pumping it out to the system.

28. Answer: (A) Change the diaper more often.
Rationale: Decreasing the amount of time the skin comes contact with wet soiled diapers will help heal
the irritation.

29. Answer: (D) Endocardial cushion defect
Rationale: Endocardial cushion defects are seen most in children with Down syndrome, asplenia, or
polysplenia.

30. Answer: (B) Decreased urine output
Rationale: Decreased urine output may occur in clients receiving I.V. magnesium and should be
monitored closely to keep urine output at
greater than 30 ml/hour, because magnesium is excreted through the kidneys and can easily accumulate
to toxic levels.

31. Answer: (A) Menorrhagia
Rationale: Menorrhagia is an excessive menstrual period.

32. Answer: (C) Blood typing
Rationale: Blood type would be a critical value to have because the risk of blood loss is always a
potential complication during the labor and delivery process. Approximately 40% of a womans cardiac
output is delivered to the uterus, therefore, blood loss can occur quite rapidly in the event of
uncontrolled bleeding.

33. Answer: (D) Physiologic anemia
Rationale: Hemoglobin values and hematocrit decrease during pregnancy as the increase in plasma
volume exceeds the increase in red blood cell production.

34. Answer: (D) A 2 year old infant with stridorous breath sounds, sitting up in his mothers arms and
drooling.
Rationale: The infant with the airway emergency should be treated first, because of the risk of
epiglottitis.

35. Answer: (A) Placenta previa
Rationale: Placenta previa with painless vaginal bleeding.

36. Answer: (D) Early in the morning
Rationale: Based on the nurses knowledge of microbiology, the specimen should be collected early in
the morning. The rationale for this
timing is that, because the female worm lays eggs at night around the perineal area, the first bowel
movement of the day will yield the best
results. The specific type of stool specimen used in the diagnosis of pinworms is called the tape test.

37. Answer: (A) Irritability and seizures
Rationale: Lead poisoning primarily affects the CNS, causing increased intracranial pressure. This
condition results in irritability and changes in level of consciousness, as well as seizure disorders,
hyperactivity, and learning disabilities.

38. Answer: (D) I really need to use the diaphragm and jelly most during the middle of my menstrual
cycle.
Rationale: The woman must understand that, although the fertile period is approximately mid-cycle,
hormonal variations do occur and can result in early or late ovulation. To be effective, the diaphragm
should be inserted before every intercourse.

39. Answer: (C) Restlessness
Rationale: In a child, restlessness is the earliest sign of hypoxia. Late signs of hypoxia in a child are
associated with a change in color, such as pallor or cyanosis.

40. Answer: (B) Walk one step ahead, with the childs hand on the nurses elbow.
Rationale: This procedure is generally recommended to follow in guiding a person who is blind.

41. Answer: (A) Loud, machinery-like murmur.
Rationale: A loud, machinery-like murmur is a characteristic finding associated with patent ductus
arteriosus.

42. Answer: (C) More oxygen, and the newborns metabolic rate increases.
Rationale: When cold, the infant requires more oxygen and there is an increase in metabolic rate. Non-
shievering thermogenesis is a complex process that increases the metabolic rate and rate of oxygen
consumption, therefore, the newborn increase heat production.

43. Answer: (D) Voided
Rationale: Before administering potassium I.V. to any client, the nurse must first check that the clients
kidneys are functioning and that the client is voiding. If the client is not voiding, the nurse should
withhold the potassium and notify the physician.

44. Answer: (c) Laundry detergent
Rationale: Eczema or dermatitis is an allergic skin reaction caused by an offending allergen. The topical
allergen that is the most common causative factor is laundry detergent.

45. Answer: (A) 6 inches
Rationale: This distance allows for easy flow of the formula by gravity, but the flow will be slow enough
not to overload the stomach too rapidly.

46. Answer: (A) The older one gets, the more susceptible he becomes to the complications of chicken
pox.
Rationale: Chicken pox is usually more severe in adults than in children. Complications, such as
pneumonia, are higher in incidence in adults.

47. Answer: (D) Consult a physician who may give them rubella immunoglobulin.
Rationale: Rubella vaccine is made up of attenuated German measles viruses. This is contraindicated in
pregnancy. Immune globulin, a specific prophylactic against German measles, may be given to pregnant
women.

48. Answer: (A) Contact tracing
Rationale: Contact tracing is the most practical and reliable method of finding possible sources of
person-to-person transmitted infections, such as sexually transmitted diseases.

49. Answer: (D) Leptospirosis
Rationale: Leptospirosis is transmitted through contact with the skin or mucous membrane with water
or moist soil contaminated with urine of infected animals, like rats.

50. Answer: (B) Cholera
Rationale: Passage of profuse watery stools is the major symptom of cholera. Both amebic and bacillary
dysentery are characterized by the
presence of blood and/or mucus in the stools. Giardiasis is characterized by fat malabsorption and,
therefore, steatorrhea.

51. Answer: (A) Hemophilus influenzae
Rationale: Hemophilus meningitis is unusual over the age of 5 years. In developing countries, the peak
incidence is in children less than 6 months of age. Morbillivirus is the etiology of measles. Streptococcus
pneumoniae and Neisseria meningitidis may cause meningitis, but age distribution is not specific in
young children.

52. Answer: (B) Buccal mucosa
Rationale: Kopliks spot may be seen on the mucosa of the mouth or the throat.

53. Answer: (A) 3 seconds
Rationale: Adequate blood supply to the area allows the return of the color of the nailbed within 3
seconds.

54. Answer: (B) Severe dehydration
Rationale: The order of priority in the management of severe dehydration is as follows: intravenous fluid
therapy, referral to a facility where IV fluids can be initiated within 30 minutes, Oresol or nasogastric
tube. When the foregoing measures are not possible or effective, then urgent referral to the hospital is
done.

55. Answer: (A) 45 infants
Rationale: To estimate the number of infants, multiply total population by 3%.

56. Answer: (A) DPT
Rationale: DPT is sensitive to freezing. The appropriate storage temperature of DPT is 2 to 8 C only. OPV
and measles vaccine are highly
sensitive to heat and require freezing. MMR is not an immunization in the Expanded Program on
Immunization.

57. Answer: (C) Proper use of sanitary toilets
Rationale: The ova of the parasite get out of the human body together with feces. Cutting the cycle at
this stage is the most effective way of preventing the spread of the disease to susceptible hosts.

58. Answer: (D) 5 skin lesions, positive slit skin smear
Rationale: A multibacillary leprosy case is one who has a positive slit skin smear and at least 5 skin
lesions.

59. Answer: (C) Thickened painful nerves
Rationale: The lesion of leprosy is not macular. It is characterized by a change in skin color (either
reddish or whitish) and loss of sensation, sweating and hair growth over the lesion. Inability to close the
eyelids (lagophthalmos) and sinking of the nosebridge are late symptoms.

60. Answer: (B) Ask where the family resides.
Rationale: Because malaria is endemic, the first question to determine malaria risk is where the clients
family resides. If the area of residence is not a known endemic area, ask if the child had traveled within
the past 6 months, where she was brought and whether she stayed overnight in that area.

61. Answer: (A) Inability to drink
Rationale: A sick child aged 2 months to 5 years must be referred urgently to a hospital if he/she has one
or more of the following signs: not able to feed or drink, vomits everything, convulsions, abnormally
sleepy or difficult to awaken.

62. Answer: (A) Refer the child urgently to a hospital for confinement.
Rationale: Baggy pants is a sign of severe marasmus. The best management is urgent referral to a
hospital.

63. Answer: (D) Let the child rest for 10 minutes then continue giving Oresol more slowly.
Rationale: If the child vomits persistently, that is, he vomits everything that he takes in, he has to be
referred urgently to a hospital. Otherwise, vomiting is managed by letting the child rest for 10 minutes
and then continuing with Oresol administration. Teach the mother to give Oresol more slowly.

64. Answer: (B) Some dehydration
Rationale: Using the assessment guidelines of IMCI, a child (2 months to 5 years old) with diarrhea is
classified as having SOME DEHYDRATION if he shows 2 or more of the following signs: restless or
irritable, sunken eyes, the skin goes back slow after a skin pinch.

65. Answer: (C) Normal
Rationale: In IMCI, a respiratory rate of 50/minute or more is fast breathing for an infant aged 2 to 12
months.

66. Answer: (A) 1 year
Rationale: The baby will have passive natural immunity by placental transfer of antibodies. The mother
will have active artificial immunity
lasting for about 10 years. 5 doses will give the mother lifetime protection.

67. Answer: (B) 4 hours
Rationale: While the unused portion of other biologicals in EPI may be given until the end of the day,
only BCG is discarded 4 hours after
reconstitution. This is why BCG immunization is scheduled only in the morning.

68. Answer: (B) 6 months
Rationale: After 6 months, the babys nutrient needs, especially the babys iron requirement, can no
longer be provided by mothers milk
alone.

69. Answer: (C) 24 weeks
Rationale: At approximately 23 to 24 weeks gestation, the lungs are developed enough to sometimes
maintain extrauterine life. The lungs are the most immature system during the gestation period. Medical
care for premature labor begins much earlier (aggressively at 21 weeks gestation)

70. Answer: (B) Sudden infant death syndrome (SIDS)
Rationale: Supine positioning is recommended to reduce the risk of SIDS in infancy. The risk of aspiration
is slightly increased with the supine position. Suffocation would be less likely with an infant supine than
prone and the position for GER requires the head of the bed to be elevated.

71. Answer: (C) Decreased temperature
Rationale: Temperature instability, especially when it results in a low temperature in the neonate, may
be a sign of infection. The neonates
color often changes with an infection process but generally becomes ashen or mottled. The neonate
with an infection will usually show a
decrease in activity level or lethargy.

72. Answer: (D) Polycythemia probably due to chronic fetal hypoxia
Rationale: The small-for-gestation neonate is at risk for developing polycythemia during the transitional
period in an attempt to decrease
hypoxia. The neonates are also at increased risk for developing hypoglycemia and hypothermia due to
decreased glycogen stores.

73. Answer: (C) Desquamation of the epidermis
Rationale: Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated.
These neonates are usually very alert. Lanugo is missing in the postdate neonate.

74. Answer: (C) Respiratory depression
Rationale: Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory
depression, hypotonia, and bradycardia. The serum blood sugar isnt affected by magnesium sulfate.
The neonate would be floppy, not jittery.

75. Answer: (C) Respiratory rate 40 to 60 breaths/minute
Rationale: A respiratory rate 40 to 60 breaths/minute is normal for a neonate during the transitional
period. Nasal flaring, respiratory rate more than 60 breaths/minute, and audible grunting are signs of
respiratory distress.

76. Answer: (C) Keep the cord dry and open to air
Rationale: Keeping the cord dry and open to air helps reduce infection and hastens drying. Infants arent
given tub bath but are sponged off until the cord falls off. Petroleum jelly prevents the cord from drying
and encourages infection. Peroxide could be painful and isnt recommended.

77. Answer: (B) Conjunctival hemorrhage
Rationale: Conjunctival hemorrhages are commonly seen in neonates secondary to the cranial pressure
applied during the birth process. Bulging fontanelles are a sign of intracranial pressure. Simian creases
are present in 40% of the neonates with trisomy 21. Cystic hygroma is a neck mass that can affect the
airway.

78. Answer: (B) To assess for prolapsed cord
Rationale: After a client has an amniotomy, the nurse should assure that the cord isn't prolapsed and
that the baby tolerated the procedure well. The most effective way to do this is to check the fetal heart
rate. Fetal well-being is assessed via a nonstress test. Fetal position is determined by vaginal
examination. Artificial rupture of membranes doesn't indicate an imminent delivery.

79. Answer: (D) The parents interactions with each other.
Rationale: Parental interaction will provide the nurse with a good assessment of the stability of the
family's home life but it has no indication for parental bonding. Willingness to touch and hold the
newborn, expressing interest about the newborn's size, and indicating a desire to see the newborn are
behaviors indicating parental bonding.

80. Answer: (B) Instructing the client to use two or more peripads to cushion the area
Rationale: Using two or more peripads would do little to reduce the pain or promote perineal healing.
Cold applications, sitz baths, and Kegel
exercises are important measures when the client has a fourth-degree laceration.

81. Answer: (C) What is your expected due date?
Rationale: When obtaining the history of a client who may be in labor, the nurse's highest priority is to
determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect
the duration of labor and the potential for labor complications. Later, the nurse should ask about
chronic illnesses, allergies, and support persons.

82. Answer: (D) Aspirate the neonates nose and mouth with a bulb syringe.
Rationale: The nurse's first action should be to clear the neonate's airway with a bulb syringe. After the
airway is clear and the neonate's color improves, the nurse should comfort and calm the neonate. If the
problem recurs or the neonate's color doesn't improve readily, the nurse should notify the physician.
Administering oxygen when the airway isn't clear would be ineffective.

83. Answer: (C) Conducting a bedside ultrasound for an amniotic fluid index.
Rationale: It isn't within a nurse's scope of practice to perform and interpret a bedside ultrasound under
these conditions and without
specialized training. Observing for pooling of straw-colored fluid, checking vaginal discharge with
nitrazine paper, and observing for flakes of vernix are appropriate assessments for determining whether
a client has ruptured membranes.

84. Answer: (C) Monitor partial pressure of oxygen (Pao2) levels.
Rationale: Monitoring PaO2 levels and reducing the oxygen concentration to keep PaO2 within normal
limits reduces the risk of retinopathy of prematurity in a premature infant receiving oxygen. Covering
the infant's eyes and humidifying the oxygen don't reduce the risk of retinopathy of prematurity.
Because cooling increases the risk of acidosis, the infant should be kept warm so that his respiratory
distress
isn't aggravated.

85. Answer: (A) 110 to 130 calories per kg.
Rationale: Calories per kg is the accepted way of determined appropriate nutritional intake for a
newborn. The recommended calorie requirement is 110 to 130 calories per kg of newborn body weight.
This level will maintain a consistent blood glucose level and provide enough calories for continued
growth and development.

86. Answer: (C) 30 to 32 weeks
Rationale: Individual twins usually grow at the same rate as singletons until 30 to 32 weeks gestation,
then twins dont gain weight as rapidly as singletons of the same gestational age. The placenta can no
longer keep pace with the nutritional requirements of both fetuses after 32 weeks, so theres some
growth retardation in twins if they remain in utero at 38 to 40 weeks.

87. Answer: (A) conjoined twins
Rationale: The type of placenta that develops in monozygotic twins depends on the time at which
cleavage of the ovum occurs. Cleavage in conjoined twins occurs more than 13 days after fertilization.
Cleavage that occurs less than 3 day after fertilization results in diamniotic dicchorionic twins. Cleavage
that occurs between days 3 and 8 results in diamniotic monochorionic twins. Cleavage that occurs
between days 8 to 13 result in monoamniotic monochorionic twins.

88. Answer: (D) Ultrasound
Rationale: Once the mother and the fetus are stabilized, ultrasound evaluation of the placenta should be
done to determine the cause of the bleeding. Amniocentesis is contraindicated in placenta previa. A
digital or speculum examination shouldnt be done as this may lead to severe bleeding or hemorrhage.
External fetal monitoring wont detect a placenta previa, although it will detect fetal distress, which may
result from blood loss or placenta separation.

89. Answer: (A) Increased tidal volume
Rationale: A pregnant client breathes deeper, which increases the tidal volume of gas moved in and out
of the respiratory tract with each breath. The expiratory volume and residual volume decrease as the
pregnancy progresses. The inspiratory capacity increases during pregnancy. The increased oxygen
consumption in the pregnant client is 15% to 20% greater than in the nonpregnant state.

90. Answer: (A) Diet
Rationale: Clients with gestational diabetes are usually managed by diet alone to control their glucose
intolerance. Oral hypoglycemic drugs are contraindicated in pregnancy. Long-acting insulin usually isnt
needed for blood glucose control in the client with gestational diabetes.

91. Answer: (D) Seizure
Rationale: The anticonvulsant mechanism of magnesium is believes to depress seizure foci in the brain
and peripheral neuromuscular blockade. Hypomagnesemia isnt a complication of preeclampsia.
Antihypertensive drug other than magnesium are preferred for sustained hypertension. Magnesium
doesnt help prevent hemorrhage in preeclamptic clients.

92. Answer: (C) I.V. fluids
Rationale: A sickle cell crisis during pregnancy is usually managed by exchange transfusion oxygen, and
L.V. Fluids. The client usually needs a stronger analgesic than acetaminophen to control the pain of a
crisis. Antihypertensive drugs usually arent necessary. Diuretic wouldnt be used unless fluid overload
resulted.

93. Answer: (A) Calcium gluconate (Kalcinate)
Rationale: Calcium gluconate is the antidote for magnesium toxicity. Ten milliliters of 10% calcium
gluconate is given L.V. push over 3 to 5 minutes. Hydralazine is given for sustained elevated blood
pressure in preeclamptic clients. Rho (D) immune globulin is given to women with Rh-negative blood to
prevent antibody formation from RH-positive conceptions. Naloxone is used to correct narcotic toxicity.

94. Answer: (B) An indurated wheal over 10 mm in diameter appears in 48 to 72 hours.
Rationale: A positive PPD result would be an indurated wheal over 10 mm in diameter that appears in 48
to 72 hours. The area must be a raised wheal, not a flat circumcised area to be considered positive.

95. Answer: (C) Pyelonephritis
Rational: The symptoms indicate acute pyelonephritis, a serious condition in a pregnant client. UTI
symptoms include dysuria, urgency, frequency, and suprapubic tenderness. Asymptomatic bacteriuria
doesnt cause symptoms. Bacterial vaginosis causes milky white vaginal discharge but no systemic
symptoms.

96. Answer: (B) Rh-positive fetal blood crosses into maternal blood, stimulating maternal antibodies.
Rationale: Rh isoimmunization occurs when Rh-positive fetal blood cells cross into the maternal
circulation and stimulate maternal antibody
production. In subsequent pregnancies with Rh-positive fetuses, maternal antibodies may cross back
into the fetal circulation and destroy the fetal blood cells.

97. Answer: (C) Supine position
Rationale: The supine position causes compression of the client's aorta and inferior vena cava by the
fetus. This, in turn, inhibits maternal
circulation, leading to maternal hypotension and, ultimately, fetal hypoxia. The other positions promote
comfort and aid labor progress. For instance, the lateral, or side-lying, position improves maternal and
fetal circulation, enhances comfort, increases maternal relaxation, reduces muscle tension, and
eliminates pressure points. The squatting position promotes comfort by taking advantage of gravity. The
standing position also takes advantage of gravity and aligns the fetus with the pelvic angle.

98. Answer: (B) Irritability and poor sucking.
Rationale: Neonates of heroin-addicted mothers are physically dependent on the drug and experience
withdrawal when the drug is no
longer supplied. Signs of heroin withdrawal include irritability, poor sucking, and restlessness. Lethargy
isn't associated with neonatal heroin
addiction. A flattened nose, small eyes, and thin lips are seen in infants with fetal alcohol syndrome.
Heroin use during pregnancy hasn't been linked to specific congenital anomalies.

99. Answer: (A) 7th to 9th day postpartum
Rationale: The normal involutional process returns the uterus to the pelvic cavity in 7 to 9 days. A
significant involutional complication is the failure of the uterus to return to the pelvic cavity within the
prescribed time period. This is known as subinvolution.

100. Answer: (B) Uterine atony
Rationale: Multiple fetuses, extended labor stimulation with oxytocin, and traumatic delivery commonly
are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may
precede or follow delivery and commonly results from apparent excessive traction on the umbilical cord
and attempts to deliver the placenta manually. Uterine involution and some uterine discomfort are
normal after delivery.

















NURSING PRACTICE III- Care of Clients with Physiologic and Psychosocial Alterations Nursing

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

a. Green liquid
b. Solid formed
c. Loose, bloody
d. Semiformed

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

a. On the clients right side
b. On the clients left side
c. Directly in front of the client
d. Where the client like

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

a. Check respiration, circulation, neurological response.
b. Align the spine, check pupils, and check for hemorrhage.
c. Check respirations, stabilize spine, and check circulation.
d. Assess level of consciousness and circulation.

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

a. Increasing contractility and slowing heart rate.
b. Increasing AV conduction and heart rate.
c. Decreasing contractility and oxygen consumption.
d. Decreasing venous return through vasodilation.

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

a. Call for help and note the time.
b. Clear the airway
c. Give two sharp thumps to the precordium, and check the pulse.
d. Administer two quick blows.

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

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

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

a. Stop the I.V. infusion of heparin and notify the physician.
b. Continue treatment as ordered.
c. Expect the warfarin to increase the PTT.
d. Increase the dosage, because the level is lower than normal.

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

a. 24 hours later, when edema has subsided.
b. In the operating room.
c. After the ileostomy begin to function.
d. When the client is able to begin self-care procedures.

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

a. On the side, to prevent obstruction of airway by tongue.
b. Flat on back.
c. On the back, with knees flexed 15 degrees.
d. Flat on the stomach, with the head turned to the side.

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

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


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

a. Altered mental status and dehydration
b. Fever and chills
c. Hemoptysis and Dyspnea
d. Pleuritic chest pain and cough

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

a. Chest and lower back pain
b. Chills, fever, night sweats, and hemoptysis
c. Fever of more than 104F (40C) and nausea
d. Headache and photophobia


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

a. Acute asthma
b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease (COPD)
d. Emphysema


14. Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4
breaths/minute. If action isnt taken quickly, she might have
which of the following reactions?

a. Asthma attack
b. Respiratory arrest
c. Seizure
d. Wake up on his own


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

a. Increased elastic recoil of the lungs
b. Increased number of functional capillaries in the alveoli
c. Decreased residual volume
d. Decreased vital capacity


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

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


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

a. Report incidents of diarrhea.
b. Avoid foods high in vitamin K
c. Use a straight razor when shaving.
d. Take aspirin to pain relief.


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

a. Leaving the hair intact
b. Shaving the area
c. Clipping the hair in the area
d. Removing the hair with a depilatory.


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

a. Bone fracture
b. Loss of estrogen
c. Negative calcium balance
d. Dowagers hump


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

a. Cancerous lumps
b. Areas of thickness or fullness
c. Changes from previous examinations.
d. Fibrocystic masses


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

a. Provide extra blankets and clothing to keep the client warm.
b. Monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid
replacement therapy.
c. Balance the clients periods of activity and rest.
d. Encourage the client to be active to prevent constipation.


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

a. Avoid focusing on his weight.
b. Increase his activity level.
c. Follow a regular diet.
d. Continue leading a high-stress lifestyle.


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

a. Laminectomy
b. Thoracotomy
c. Hemorrhoidectomy
d. Cystectomy.


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

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


25. George should be taught about testicular examinations during:

a. when sexual activity starts
b. After age 69
c. After age 40
d. Before age 20.


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

a. Call the physician
b. Place a saline-soaked sterile dressing on the wound.
c. Take a blood pressure and pulse.
d. Pull the dehiscence closed.


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

a. A progressively deeper breaths followed by shallower breaths with apneic periods.
b. Rapid, deep breathing with abrupt pauses between each breath.
c. Rapid, deep breathing and irregular breathing without pauses.
d. Shallow breathing with an increased respiratory rate.


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

a. Tracheal
b. Fine crackles
c. Coarse crackles
d. Friction rubs


29. The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing and
breath sounds arent audible. The reason for this
change is that:

a. The attack is over.
b. The airways are so swollen that no air cannot get through.
c. The swelling has decreased.
d. Crackles have replaced wheezes.


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

a. Place the client on his back remove dangerous objects, and insert a bite block.
b. Place the client on his side, remove dangerous objects, and insert a bite block.
c. Place the client o his back, remove dangerous objects, and hold down his arms.
d. Place the client on his side, remove dangerous objects, and protect his head.


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

a. Infection of the lung.
b. Kinked or obstructed chest tube
c. Excessive water in the water-seal chamber
d. Excessive chest tube drainage


32. Nurse Maureen is talking to a male client, the client begins choking on his lunch. Hes coughing
forcefully. The nurse should:

a. Stand him up and perform the abdominal thrust maneuver from behind.
b. Lay him down, straddle him, and perform the abdominal thrust maneuver.
c. Leave him to get assistance
d. Stay with him but not intervene at this time.


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

a. General health for the last 10 years.
b. Current health promotion activities.
c. Family history of diseases.
d. Marital status.


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

a. Apply lemon glycerin to the clients lips at least every 2 hours.
b. Brush the teeth with client lying supine.
c. Place the client in a side lying position, with the head of the bed lowered.
d. Clean the clients mouth with hydrogen peroxide.


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

a. Adult respiratory distress syndrome (ARDS)
b. Myocardial infarction (MI)
c. Pneumonia
d. Tuberculosis


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

a. A 16-year-old female high school student
b. A 33-year-old day-care worker
c. A 43-yesr-old homeless man with a history of alcoholism
d. A 54-year-old businessman


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

a. To confirm the diagnosis
b. To determine if a repeat skin test is needed
c. To determine the extent of lesions
d. To determine if this is a primary or secondary infection


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

a. Beta-adrenergic blockers
b. Bronchodilators
c. Inhaled steroids
d. Oral steroids


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

a. Adult respiratory distress syndrome (ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema


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

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

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


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

a. Call the physician
b. Document the patients status in his charts.
c. Prepare oxygen treatment
d. Raise the side rails


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

a. Crowd red blood cells
b. Are not responsible for the anemia.
c. Uses nutrients from other cells
d. Have an abnormally short life span of cells.


43. Diagnostic assessment of Francis would probably not reveal:

a. Predominance of lymhoblasts
b. Leukocytosis
c. Abnormal blast cells in the bone marrow
d. Elevated thrombocyte counts


44. Robert, a 57-year-old client with acute arterial occlusion of the left leg undergoes an emergency
embolectomy. Six hours later, the nurse isnt able to obtain pulses in his left foot using Doppler
ultrasound. The nurse immediately notifies the physician, and asks her to prepare the client for surgery.
As the nurse enters the clients room to prepare him, he states that he wont have any more surgery.
Which of the following is the best initial response by the nurse?

a. Explain the risks of not having the surgery
b. Notifying the physician immediately
c. Notifying the nursing supervisor
d. Recording the clients refusal in the nurses notes


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

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


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

a. Barbiturates
b. Opioids
c. Cocaine
d. Benzodiazepines


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

a. Eversion of the right nipple and mobile mass
b. Nonmobile mass with irregular edges
c. Mobile mass that is soft and easily delineated
d. Nonpalpable right axillary lymph nodes


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

a. Surgery
b. Chemotherapy
c. Radiation
d. Immunotherapy


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

a. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant
metastasis
b. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
c. Can't assess tumor or regional lymph nodes and no evidence of metastasis
d. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of
distant metastasis


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

a. "Keep the stoma uncovered."
b. "Keep the stoma dry."
c. "Have a family member perform stoma care initially until you get used to the procedure."
d. "Keep the stoma moist."


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

a. Breast cancer
b. Lung cancer
c. Brain cancer
d. Colon and rectal cancer


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

a. miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
b. chest pain, dyspnea, cough, weight loss, and fever.
c. arm and shoulder pain and atrophy of arm and hand muscles, both on the affected side.
d. hoarseness and dysphagia.


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

a. prostate-specific antigen, which is used to screen for prostate cancer.
b. protein serum antigen, which is used to determine protein levels.
c. pneumococcal strep antigen, which is a bacteria that causes pneumonia.
d. Papanicolaou-specific antigen, which is used to screen for cervical cancer.


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

a. "Avoid drinking liquids until the gag reflex returns."
b. "Avoid eating milk products for 24 hours."
c. "Notify a nurse if you experience blood in your urine."
d. "Remain supine for the time specified by the physician."


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

a. Stool Hematest
b. Carcinoembryonic antigen (CEA)
c. Sigmoidoscopy
d. Abdominal computed tomography (CT) scan


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

a. Slight asymmetry of the breasts.
b. A fixed nodular mass with dimpling of the overlying skin
c. Bloody discharge from the nipple
d. Multiple firm, round, freely movable masses that change with the menstrual cycle


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

a. Liver
b. Colon
c. Reproductive tract
d. White blood cells (WBCs)


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

a. The client lies still.
b. The client asks questions.
c. The client hears thumping sounds.
d. The client wears a watch and wedding band.


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

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


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

a. Joint pain
b. Joint deformity
c. Joint flexion of less than 50%
d. Joint stiffness


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

a. Septic arthritis
b. Traumatic arthritis
c. Intermittent arthritis
d. Gouty arthritis


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

a. 15 ml/hour
b. 30 ml/hour
c. 45 ml/hour
d. 50 ml/hour


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

a. Elbow contracture secondary to spasticity
b. Loss of muscle contraction decreasing venous return
c. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side
d. Hypoalbuminemia due to protein escaping from an inflamed glomerulus


64. Heberdens nodes are a common sign of osteoarthritis. Which of the following statement is correct
about this deformity?

a. It appears only in men
b. It appears on the distal interphalangeal joint
c. It appears on the proximal interphalangeal joint
d. It appears on the dorsolateral aspect of the interphalangeal joint.


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

a. Osteoarthritis is gender-specific, rheumatoid arthritis isnt
b. Osteoarthritis is a localized disease rheumatoid arthritis is systemic
c. Osteoarthritis is a systemic disease, rheumatoid arthritis is localized
d. Osteoarthritis has dislocations and subluxations, rheumatoid arthritis doesnt


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

a. A walker is a better choice than a cane.
b. The cane should be used on the affected side
c. The cane should be used on the unaffected side
d. A client with osteoarthritis should be encouraged to ambulate without the cane


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

a. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).
b. 21 U regular insulin and 9 U NPH.
c. 10 U regular insulin and 20 U NPH.
d. 20 U regular insulin and 10 U NPH.


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

a. aspirin
b. furosemide (Lasix)
c. colchicines
d. calcium gluconate (Kalcinate)


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

a. Adrenal cortex
b. Pancreas
c. Adrenal medulla
d. Parathyroid


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

a. They contain exudate and provide a moist wound environment.
b. They protect the wound from mechanical trauma and promote healing.
c. They debride the wound and promote healing by secondary intention.
d. They prevent the entrance of microorganisms and minimize wound discomfort.


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

a. Hyperkalemia
b. Reduced blood urea nitrogen (BUN)
c. Hypernatremia
d. Hyperglycemia


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

a. Infusing I.V. fluids rapidly as ordered
b. Encouraging increased oral intake
c. Restricting fluids
d. Administering glucose-containing I.V. fluids as ordered


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

a. urine glucose level.
b. fasting blood glucose level.
c. serum fructosamine level.
d. glycosylated hemoglobin level.


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

a. 10:00 am
b. Noon
c. 4:00 pm
d. 10:00 pm


75. The adrenal cortex is responsible for producing which substances?

a. Glucocorticoids and androgens
b. Catecholamines and epinephrine
c. Mineralocorticoids and catecholamines
d. Norepinephrine and epinephrine


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

a. Hypocalcemia
b. Hyponatremia
c. Hyperkalemia
d. Hypermagnesemia


77. Which laboratory test value is elevated in clients who smoke and can't be used as a general indicator
of cancer?

a. Acid phosphatase level
b. Serum calcitonin level
c. Alkaline phosphatase level
d. Carcinoembryonic antigen level


78. Francis with anemia has been admitted to the medical-surgical unit. Which assessment findings are
characteristic of iron-deficiency anemia?

a. Nights sweats, weight loss, and diarrhea
b. Dyspnea, tachycardia, and pallor
c. Nausea, vomiting, and anorexia
d. Itching, rash, and jaundice


79. In teaching a female client who is HIV-positive about pregnancy, the nurse would know more
teaching is necessary when the client says:

a. The baby can get the virus from my placenta."
b. "I'm planning on starting on birth control pills."
c. "Not everyone who has the virus gives birth to a baby who has the virus."
d. "I'll need to have a C-section if I become pregnant and have a baby."


80. When preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the home,
the nurse should be sure to include which instruction?

a. "Put on disposable gloves before bathing."
b. "Sterilize all plates and utensils in boiling water."
c. "Avoid sharing such articles as toothbrushes and razors."
d. "Avoid eating foods from serving dishes shared by other family members."


81. Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings
should the nurse expect when assessing the
client?

a. Pallor, bradycardia, and reduced pulse pressure
b. Pallor, tachycardia, and a sore tongue
c. Sore tongue, dyspnea, and weight gain
d. Angina, double vision, and anorexia


82. After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina
suspects the client is experiencing anaphylactic shock. What should the nurse do first?

a. Page an anesthesiologist immediately and prepare to intubate the client.
b. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.
c. Administer the antidote for penicillin, as prescribed, and continue to monitor the client's vital signs.
d. Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered.


83. Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation.
When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin
therapy. These include:

a. weight gain.
b. fine motor tremors.
c. respiratory acidosis.
d. bilateral hearing loss.


84. A 23-year-old client is diagnosed with human immunodeficiency virus (HIV). After recovering from
the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV
and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system,
the nurse states that adaptive immunity is provided by which type of white blood cell?

a. Neutrophil
b. Basophil
c. Monocyte
d. Lymphocyte


85. In an individual with Sjgren's syndrome, nursing care should focus on:

a. moisture replacement.
b. electrolyte balance.
c. nutritional supplementation.
d. arrhythmia management.


86. During chemotherapy for lymphocytic leukemia, Mathew develops abdominal pain, fever, and
"horse barn" smelling diarrhea. It would be most important for the nurse to advise the physician to
order:

a. enzyme-linked immunosuppressant assay (ELISA) test.
b. electrolyte panel and hemogram.
c. stool for Clostridium difficile test.
d. flat plate X-ray of the abdomen.


87. A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks.
To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse
expects the physician to order:

a. E-rosette immunofluorescence.
b. quantification of T-lymphocytes.
c. enzyme-linked immunosorbent assay (ELISA).
d. Western blot test with ELISA.


88. A complete blood count is commonly performed before a Joe goes into surgery. What does this test
seek to identify?

a. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels
b. Low levels of urine constituents normally excreted in the urine
c. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
d. Electrolyte imbalance that could affect the blood's ability to coagulate properly


89. While monitoring a client for the development of disseminated intravascular coagulation (DIC), the
nurse should take note of what assessment parameters?

a. Platelet count, prothrombin time, and partial thromboplastin time
b. Platelet count, blood glucose levels, and white blood cell (WBC) count
c. Thrombin time, calcium levels, and potassium levels
d. Fibrinogen level, WBC, and platelet count


90. When taking a dietary history from a newly admitted female client, Nurse Len should remember that
which of the following foods is a common allergen?

a. Bread
b. Carrots
c. Orange
d. Strawberries


91. Nurse John 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 cast on the right leg who states, I have a funny feeling in my right leg.
c. A client with osteomyelitis of the spine who states, I am so nauseous that I cant eat.
d. A client with rheumatoid arthritis who states, I am having trouble sleeping.


92. Nurse Sarah is caring for clients on the surgical floor and has just received report from the previous
shift. Which of the following clients should the nurse see first?

a. A 35-year-old admitted three hours ago with a gunshot wound; 1.5 cm area of dark drainage noted on
the dressing.
b. A 43-year-old who had a mastectomy two days ago; 23 ml of serosanguinous fluid noted in the
Jackson-Pratt drain.
c. A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous eight hours.
d. A 62-year-old who had an abdominal-perineal resection three days ago; client complaints of chills.


93. Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for treatment of Graves
disease. The nurse would be most concerned if which of the following was observed?

a. Blood pressure 138/82, respirations 16, oral temperature 99 degrees Fahrenheit.
b. The client supports his head and neck when turning his head to the right.
c. The client spontaneously flexes his wrist when the blood pressure is obtained.
d. The client is drowsy and complains of sore throat.


94. Julius is admitted with complaints of severe pain in the lower right quadrant of the abdomen. To
assist with pain relief, the nurse should take which of the following actions?

a. Encourage the client to change positions frequently in bed.
b. Administer Demerol 50 mg IM q 4 hours and PRN.
c. Apply warmth to the abdomen with a heating pad.
d. Use comfort measures and pillows to position the client.


95. Nurse Tina prepares a client for peritoneal dialysis. Which of the following actions should the nurse
take first?

a. Assess for a bruit and a thrill.
b. Warm the dialysate solution.
c. Position the client on the left side.
d. Insert a Foley catheter


96. Nurse Jannah teaches an elderly client with right-sided weakness how to use cane. Which of the
following behaviors, if demonstrated by the client to the nurse, indicates that the teaching was
effective?

a. The client holds the cane with his right hand, moves the can forward followed by the right leg, and
then moves the left leg.
b. The client holds the cane with his right hand, moves the cane forward followed by his left leg, and
then moves the right leg.
c. The client holds the cane with his left hand, moves the cane forward followed by the right leg, and
then moves the left leg.
d. The client holds the cane with his left hand, moves the cane forward followed by his left leg, and then
moves the right leg.


97. An elderly client is admitted to the nursing home setting. The client is occasionally confused and her
gait is often unsteady. Which of the following actions, if taken by the nurse, is most appropriate?

a. Ask the womans family to provide personal items such as photos or mementos.
b. Select a room with a bed by the door so the woman can look down the hall.
c. Suggest the woman eat her meals in the room with her roommate.
d. Encourage the woman to ambulate in the halls twice a day.


98. Nurse Evangeline teaches an elderly client how to use a standard aluminum walker. Which of the
following behaviors, if demonstrated by the client, indicates that the nurses teaching was effective?

a. The client slowly pushes the walker forward 12 inches, then takes small steps forward while leaning
on the walker.
b. The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward.
c. The client supports his weight on the walker while advancing it forward, then takes small steps while
balancing on the walker.
d. The client slides the walker 18 inches forward, then takes small steps while holding onto the walker
for balance.


99. Nurse Deric is supervising a group of elderly clients in a residential home setting. The nurse knows
that the elderly are at greater risk of developing sensory deprivation for what reason?

a. Increased sensitivity to the side effects of medications.
b. Decreased visual, auditory, and gustatory abilities.
c. Isolation from their families and familiar surroundings.
d. Decrease musculoskeletal function and mobility.


100. A male client with emphysema becomes restless and confused. What step should nurse Jasmine
take next?

a. Encourage the client to perform pursed lip breathing.
b. Check the clients temperature.
c. Assess the clients potassium level.
d. Increase the clients oxygen flow rate.


Answers and Rationale- NURSING PRACTICE III- Care of Clients with Physiologic and Psychosocial
Alterations Nursing

1. Answer: (C) Loose, bloody
Rationale: Normal bowel function and soft-formed stool usually do not occur until around the seventh
day following surgery. The stool consistency is related to how much water is being absorbed.

2. Answer: (A) On the clients right side
Rationale: The client has left visual field blindness. The client will see only from the right side.

3. Answer: (C) Check respirations, stabilize spine, and check circulation
Rationale: Checking the airway would be priority, and a neck injury should be suspected.

4. Answer: (D) Decreasing venous return through vasodilation.
Rationale: The significant effect of nitroglycerin is vasodilation and decreased venous return, so the
heart does not have to work hard.

5. Answer: (A) Call for help and note the time.
Rationale: Having established, by stimulating the client, that the client is unconscious rather than sleep,
the nurse should immediately call for help. This may be done by dialing the operator from the clients
phone and giving the hospital code for cardiac arrest and the clients room number to the operator, of if
the phone is not available, by pulling the emergency call button. Noting the time is important baseline
information for cardiac arrest procedure.

6. Answer: (C) Make sure that the client takes food and medications at prescribed intervals.
Rationale: Food and drug therapy will prevent the accumulation of hydrochloric acid, or will neutralize
and buffer the acid that does accumulate.

7. Answer: (B) Continue treatment as ordered.
Rationale: The effects of heparin are monitored by the PTT is normally 30 to 45 seconds; the therapeutic
level is 1.5 to 2 times the normal level.

8. Answer: (B) In the operating room.
Rationale: The stoma drainage bag is applied in the operating room. Drainage from the ileostomy
contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the
skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short
time becomes reddened, painful, and excoriated.

9. Answer: (B) Flat on back.
Rationale: To avoid the complication of a painful spinal headache that can last for several days, the
client is kept in flat in a supine position for approximately 4 to 12 hours postoperatively. Headaches are
believed to be causes by the seepage of cerebral spinal fluid from the puncture site. By keeping the
client flat, cerebral spinal fluid pressures are equalized, which avoids trauma to the neurons.

10. Answer: (C) The client is oriented when aroused from sleep, and goes back to sleep immediately.
Rationale: This finding suggest that the level of consciousness is decreasing.

11. Answer: (A) Altered mental status and dehydration
Rationale: Fever, chills, hemortysis, dyspnea, cough, and pleuritic chest pain are the common symptoms
of pneumonia, but elderly clients may first appear with only an altered lentil status and dehydration due
to a blunted immune response.

12. Answer: (B) Chills, fever, night sweats, and hemoptysis
Rationale: Typical signs and symptoms are chills, fever, night sweats, and hemoptysis. Chest pain may be
present from coughing, but isnt usual. Clients with TB typically have low-grade fevers, not higher
than 102F (38.9C). Nausea, headache, and photophobia arent usual TB symptoms.

13. Answer:(A) Acute asthma
Rationale: Based on the clients history and symptoms, acute asthma is the most likely diagnosis. Hes
unlikely to have bronchial pneumonia without a productive cough and fever and hes too young to
have developed (COPD) and emphysema.

14. Answer: (B) Respiratory arrest
Rationale: Narcotics can cause respiratory arrest if given in large quantities. Its unlikely the client will
have asthma attack or a seizure or wake up on his own.

15. Answer: (D) Decreased vital capacity
Rationale: Reduction in vital capacity is a normal physiologic changes include decreased elastic recoil of
the lungs, fewer functional capillaries in the alveoli, and an increased in residual volume.

16. Answer: (C) Presence of premature ventricular contractions (PVCs) on a cardiac monitor.
Rationale: Lidocaine drips are commonly used to treat clients whose arrhythmias havent been
controlled with oral medication and who are having PVCs that are visible on the cardiac monitor. SaO2,
blood pressure, and ICP are important factors but arent as significant as PVCs in the situation.

17. Answer: (B) Avoid foods high in vitamin K
Rationale: The client should avoid consuming large amounts of vitamin K because vitamin K can interfere
with anticoagulation. The client may need to report diarrhea, but isnt effect of taking an anticoagulant.
An electric razor-not a straight razor-should be used to prevent cuts that cause bleeding. Aspirin may
increase the risk of bleeding; acetaminophen should be used to pain relief.

18. Answer: (C) Clipping the hair in the area
Rationale: Hair can be a source of infection and should be removed by clipping. Shaving the area can
cause skin abrasions and depilatories can irritate the skin.

19. Answer: (A) Bone fracture
Rationale: Bone fracture is a major complication of osteoporosis that results when loss of calcium and
phosphate increased the fragility of bones. Estrogen deficiencies result from menopause-not
osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, But
a negative calcium balance isnt a complication of osteoporosis. Dowagers hump results from bone
fractures. It develops when repeated vertebral fractures increase spinal curvature.

20. Answer: (C) Changes from previous examinations.
Rationale: Women are instructed to examine themselves to discover changes that have occurred in the
breast. Only a physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal
the presence of a malignancy, or masses that are fibrocystic as opposed to malignant.

21. Answer: (C) Balance the clients periods of activity and rest.
Rationale: A client with hyperthyroidism needs to be encouraged to balance periods of activity and rest.
Many clients with hyperthyroidism are hyperactive and complain of feeling very warm.

22. Answer: (B) Increase his activity level.
Rationale: The client should be encouraged to increase his activity level. Maintaining an ideal weight;
following a low-cholesterol, low sodium diet; and avoiding stress are all important factors in decreasing
the risk of atherosclerosis.

23. Answer: (A) Laminectomy
Rationale: The client who has had spinal surgery, such as laminectomy, must be log rolled to keep the
spinal column straight when turning. Thoracotomy and cystectomy may turn themselves or may be
assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient
procedure, and the client may resume normal activities immediately after surgery.

24. Answer: (D) Avoiding straining during bowel movement or bending at the waist.
Rationale: The client should avoid straining, lifting heavy objects, and coughing harshly because these
activities increase intraocular pressure. Typically, the client is instructed to avoid lifting objects weighing
more than 15 lb (7kg) not 5lb. instruct the client when lying in bed to lie on either the side or back. The
client should avoid bright light by wearing sunglasses.

25. Answer: (D) Before age 20.
Rationale: Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be
taught how to perform testicular selfexamination before age 20, preferably when he enters his teens.

26. Answer: (B) Place a saline-soaked sterile dressing on the wound.
Rationale: The nurse should first place saline-soaked sterile dressings on the open wound to prevent
tissue drying and possible infection. Then the nurse should call the physician and take the clients vital
signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.

27. Answer: (A) A progressively deeper breaths followed by shallower breaths with apneic periods.
Rationale: Cheyne-Strokes respirations are breaths that become progressively deeper fallowed by
shallower respirations with apneas periods. Biots respirations are rapid, deep breathing with abrupt
pauses between each breath, and equal depth between each breath. Kussmauls respirations are rapid,
deep breathing without pauses. Tachypnea is shallow breathing with increased respiratory rate.

28. Answer: (B) Fine crackles
Rationale: Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart
failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are caused by
secretion accumulation in the airways. Friction rubs occur with pleural inflammation.

29. Answer: (B) The airways are so swollen that no air cannot get through
Rationale: During an acute attack, wheezing may stop and breath sounds become inaudible because the
airways are so swollen that air cant get through. If the attack is over and swelling has decreased, there
would be no more wheezing and less emergent concern. Crackles do not replace wheezes during an
acute asthma attack.

30. Answer: (D) Place the client on his side, remove dangerous objects, and protect his head.
Rationale: During the active seizure phase, initiate precautions by placing the client on his side,
removing dangerous objects, and protecting his head from injury. A bite block should never be inserted
during the active seizure phase. Insertion can break the teeth and lead to aspiration.

31. Answer: (B) Kinked or obstructed chest tube
Rationales: Kinking and blockage of the chest tube is a common cause of a tension pneumothorax.
Infection and excessive drainage wont cause a tension pneumothorax. Excessive water wont affect the
chest tube drainage.

32. Answer: (D) Stay with him but not intervene at this time.
Rationale: If the client is coughing, he should be able to dislodge the object or cause a complete
obstruction. If complete obstruction occurs, the nurse should perform the abdominal thrust maneuver
with the client standing. If the client is unconscious, she should lay him down. A nurse should never
leave a choking client alone.

33. Answer: (B) Current health promotion activities
Rationale: Recognizing an individuals positive health measures is very useful. General health in the
previous 10 years is important, however, the current activities of an 84 year old client are most
significant in planning care. Family history of disease for a client in later years is of minor significance.
Marital status information may be important for discharge planning but is not as significant for
addressing the immediate medical problem.

34. Answer: (C) Place the client in a side lying position, with the head of the bed lowered.
Rationale: The client should be positioned in a side-lying position with the head of the bed lowered to
prevent aspiration. A small amount of toothpaste should be used and the mouth swabbed or suctioned
to remove pooled secretions. Lemon glycerin can be drying if used for extended periods. Brushing the
teeth with the client lying supine may lead to aspiration. Hydrogen peroxide is caustic to tissues and
should not be used.

35. Answer: (C) Pneumonia
Rationale: Fever productive cough and pleuritic chest pain are common signs and symptoms of
pneumonia. The client with ARDS has dyspnea and hypoxia with worsening hypoxia over time, if not
treated aggressively. Pleuritic chest pain varies with respiration, unlike the constant chest pain during an
MI; so this client most likely isnt having an MI. the client with TB typically has a cough producing blood-
tinged sputum. A sputum culture should be obtained to confirm the nurses suspicions.

36. Answer: (C) A 43-yesr-old homeless man with a history of alcoholism
Rationale: Clients who are economically disadvantaged, malnourished, and have reduced immunity,
such as a client with a history of alcoholism, are at extremely high risk for developing TB. A high school
student, daycare worker, and businessman probably have a much low risk of contracting TB.

37. Answer: (C ) To determine the extent of lesions
Rationale: If the lesions are large enough, the chest X-ray will show their presence in the lungs. Sputum
culture confirms the diagnosis. There can be false-positive and false-negative skin test results. A chest X-
ray cant determine if this is a primary or secondary infection.

38. Answer: (B) Bronchodilators
Rationale: Bronchodilators are the first line of treatment for asthma because broncho-constriction is the
cause of reduced airflow. Beta adrenergic blockers arent used to treat asthma and can cause
bronchoconstriction. Inhaled oral steroids may be given to reduce the inflammation but arent used for
emergency relief.

39. Answer: (C) Chronic obstructive bronchitis
Rationale: Because of this extensive smoking history and symptoms the client most likely has chronic
obstructive bronchitis. Client with ARDS have acute symptoms of hypoxia and typically need large
amounts of oxygen. Clients with asthma and emphysema tend not to have chronic cough or peripheral
edema.

40. Answer: (A) The patient is under local anesthesia during the procedure
Rationale: Before the procedure, the patient is administered with drugs that would help to prevent
infection and rejection of the transplanted cells such as antibiotics, cytotoxic, and corticosteroids.
During the transplant, the patient is placed under general anesthesia.

41. Answer: (D) Raise the side rails
Rationale: A patient who is disoriented is at risk of falling out of bed. The initial action of the nurse
should be raising the side rails to ensure patients safety.

42. Answer: (A) Crowd red blood cells
Rationale: The excessive production of white blood cells crowd out red blood cells production which
causes anemia to occur.

43. Answer: (B) Leukocytosis
Rationale: Chronic Lymphocytic leukemia (CLL) is characterized by increased production of leukocytes
and lymphocytes resulting in leukocytosis, and proliferation of these cells within the bone
marrow, spleen and liver.

44. Answer: (A) Explain the risks of not having the surgery
Rationale: The best initial response is to explain the risks of not having the surgery. If the client
understands the risks but still refuses the nurse should notify the physician and the nurse supervisor and
then record the clients refusal in the nurses notes.

45. Answer: (D) The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation
and is receiving L.V. dilitiazem (Cardizem)
Rationale: The client with atrial fibrillation has the greatest potential to become unstable and is on L.V.
medication that requires close monitoring. After assessing this client, the nurse should assess the client
with thrombophlebitis who is receiving a heparin infusion, and then the 58- year-old client admitted 2
days ago with heart failure (his signs and symptoms are resolving and dont require immediate
attention). The lowest priority is the 89-year-old with end stage right-sided heart failure, who requires
time-consuming supportive measures.

46. Answer: (C) Cocaine
Rationale: Because of the clients age and negative medical history, the nurse should question her about
cocaine use. Cocaine increases myocardial oxygen consumption and can cause coronary artery
spasm, leading to tachycardia, ventricular fibrillation, myocardial ischemia, and myocardial infarction.
Barbiturate overdose may trigger respiratory depression and slow pulse. Opioids can cause marked
respiratory depression, while benzodiazepines can cause drowsiness and confusion.

47. Answer: (B) Nonmobile mass with irregular edges
Rationale: Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. A mobile
mass that is soft and easily delineated is most often a fluid-filled benign cyst. Axillary lymph nodes may
or may not be palpable on initial detection of a cancerous mass. Nipple retraction not eversion
may be a sign of cancer.

48. Answer: (C) Radiation
Rationale: The usual treatment for vaginal cancer is external or intravaginal radiation therapy. Less
often, surgery is performed. Chemotherapy typically is prescribed only if vaginal cancer is diagnosed
in an early stage, which is rare. Immunotherapy isn't used to treat vaginal cancer.

49. Answer: (B) Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant
metastasis
Rationale: TIS, N0, M0 denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of
distant metastasis. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence
of distant metastasis is classified as T0, N0, M0. If the tumor and regional lymph nodes can't be assessed
and no evidence of metastasis exists, the lesion is classified as TX, NX, M0. A progressive increase in
tumor size, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant
metastasis is classified as T1, T2, T3, or T4; N0; and M1, M2, or M3.

50. Answer: (D) "Keep the stoma moist."
Rationale: The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer
of petroleum jelly around the edges, because a dry stoma may become irritated. The nurse should
recommend placing a stoma bib over the stoma to filter and warm air before it enters the stoma. The
client should begin performing stoma care without assistance as soon as possible to gain independence
in self-care activities.

51. Answer: (B) Lung cancer
Rationale: Lung cancer is the most deadly type of cancer in both women and men. Breast cancer ranks
second in women, followed (in descending order) by colon and rectal cancer, pancreatic cancer, ovarian
cancer, uterine cancer, lymphoma, leukemia, liver cancer, brain cancer, stomach cancer, and multiple
myeloma.

52. Answer: (A) miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
Rationale: Horner's syndrome, which occurs when a lung tumor invades the ribs and affects the
sympathetic nerve ganglia, is characterized by miosis, partial eyelid ptosis, and anhidrosis on the
affected side of the face. Chest pain, dyspnea, cough, weight loss, and fever are associated with pleural
tumors. Arm and shoulder pain and atrophy of the arm and hand muscles on the affected side suggest
Pancoast's tumor, a lung tumor involving the first thoracic and eighth cervical nerves within the brachial
plexus. Hoarseness in a client with lung cancer suggests that the tumor has extended to the recurrent
laryngeal nerve; dysphagia suggests that the lung tumor is compressing the esophagus.

53. Answer: (A) prostate-specific antigen, which is used to screen for prostate cancer.
Rationale: PSA stands for prostate-specific antigen, which is used to screen for prostate cancer. The
other answers are incorrect.

54. Answer: (D) "Remain supine for the time specified by the physician."
Rationale: The nurse should instruct the client to remain supine for the time specified by the physician.
Local anesthetics used in a subarachnoid block don't alter the gag reflex. No interactions between local
anesthetics and food occur. Local anesthetics don't cause hematuria.

55. Answer: (C) Sigmoidoscopy
Rationale: Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection of
two-thirds of all colorectal cancers. Stool Hematest detects blood, which is a sign of colorectal
cancer; however, the test doesn't confirm the diagnosis. CEA may be elevated in colorectal cancer but
isn't considered a confirming test. An abdominal CT scan is used to stage the presence of colorectal
cancer.

56. Answer: (B) A fixed nodular mass with dimpling of the overlying skin
Rationale: A fixed nodular mass with dimpling of the overlying skin is common during late stages of
breast cancer. Many women have slightly asymmetrical breasts. Bloody nipple discharge is a sign of
intraductal papilloma, a benign condition. Multiple firm, round, freely movable masses that change with
the menstrual cycle indicate fibrocystic breasts, a benign condition.

57. Answer: (A) Liver
Rationale: The liver is one of the five most common cancer metastasis sites. The others are the lymph
nodes, lung, bone, and brain. The colon, reproductive tract, and WBCs are occasional metastasis sites.

58. Answer: (D) The client wears a watch and wedding band.
Rationale: During an MRI, the client should wear no metal objects, such as jewelry, because the strong
magnetic field can pull on them, causing injury to the client and (if they fly off) to others. The client must
lie still during the MRI but can talk to those performing the test by way of the microphone inside the
scanner tunnel. The client should hear thumping sounds, which are caused by the sound waves
thumping on the magnetic field.

59. Answer: (C) The recommended daily allowance of calcium may be found in a wide variety of foods.
Rationale: Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women
require 1,500 mg per day. It's often, though not always, possible to get the recommended daily
requirement in the foods we eat. Supplements are available but not always necessary. Osteoporosis
doesn't show up on ordinary X-rays until 30% of the bone loss has occurred. Bone densitometry can
detect bone loss of 3% or less. This test is sometimes recommended routinely for women over 35
who are at risk. Strenuous exercise won't cause fractures.

60. Answer: (C) Joint flexion of less than 50%
Rationale: Arthroscopy is contraindicated in clients with joint flexion of less than 50% because of
technical problems in inserting the instrument into the joint to see it clearly. Other contraindications for
this procedure include skin and wound infections. Joint pain may be an indication, not
a contraindication, for arthroscopy. Joint deformity and joint stiffness aren't contraindications for this
procedure.

61. Answer: (D) Gouty arthritis
Rationale: Gouty arthritis, a metabolic disease, is characterized by urate deposits and pain in the joints,
especially those in the feet and legs. Urate
deposits don't occur in septic or traumatic arthritis. Septic arthritis results from bacterial invasion of a
joint and leads to inflammation of the synovial
lining. Traumatic arthritis results from blunt trauma to a joint or ligament. Intermittent arthritis is a rare,
benign condition marked by regular, recurrent joint effusions, especially in the knees.

62. Answer: (B) 30 ml/hou
Rationale: An infusion prepared with 25,000 units of heparin in 500 ml of saline solution yields 50 units
of heparin per milliliter of solution. The equation is set up as 50 units times X (the unknown quantity)
equals 1,500 units/hour, X equals 30 ml/hour.

63. Answer: (B) Loss of muscle contraction decreasing venous return
Rationale: In clients with hemiplegia or hemiparesis loss of muscle contraction decreases venous return
and may cause swelling of the affected extremity. Contractures, or bony calcifications may occur with
a stroke, but dont appear with swelling. DVT may develop in clients with a stroke but is more likely to
occur in the lower extremities. A stroke isnt linked to protein loss.

64. Answer: (B) It appears on the distal interphalangeal joint
Rationale: Heberdens nodes appear on the distal interphalageal joint on both men and women.
Bouchards node appears on the dorsolateral aspect of the proximal interphalangeal joint.

65. Answer: (B) Osteoarthritis is a localized disease rheumatoid arthritis is systemic
Rationale: Osteoarthritis is a localized disease, rheumatoid arthritis is systemic. Osteoarthritis isnt
gender-specific, but rheumatoid arthritis is. Clients have dislocations and subluxations in both disorders.

66. Answer: (C) The cane should be used on the unaffected side
Rationale: A cane should be used on the unaffected side. A client with osteoarthritis should be
encouraged to ambulate with a cane, walker, or other assistive device as needed; their use takes weight
and stress off joints.

67. Answer: (A) a. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).
Rationale: A 70/30 insulin preparation is 70% NPH and 30% regular insulin. Therefore, a correct
substitution requires mixing 21 U of NPH and 9 U of regular insulin. The other choices are incorrect
dosages for the prescribed insulin.

68. Answer: (C) colchicines
Rationale: A disease characterized by joint inflammation (especially in the great toe), gout is caused by
urate crystal deposits in the joints. The physician prescribes colchicine to reduce these deposits and thus
ease joint inflammation. Although aspirin is used to reduce joint inflammation and pain in clients with
osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no effect on urate
crystal formation. Furosemide, a diuretic, doesn't relieve gout. Calcium gluconate is used to reverse a
negative calcium balance and relieve muscle cramps, not to treat gout.

69. Answer: (A) Adrenal cortex
Rationale: Excessive secretion of aldosterone in the adrenal cortex is responsible for the client's
hypertension. This hormone acts on the renal tubule, where it promotes reabsorption of sodium and
excretion of potassium and hydrogen ions. The pancreas mainly secretes hormones involved in fuel
metabolism. The adrenal medulla secretes the catecholamines epinephrine and norepinephrine. The
parathyroids secrete parathyroid hormone.

70. Answer: (C) They debride the wound and promote healing by secondary intention
Rationale: For this client, wet-to-dry dressings are most appropriate because they clean the foot ulcer by
debriding exudate and necrotic tissue, thus promoting healing by secondary intention. Moist,
transparent dressings contain exudate and provide a moist wound environment. Hydrocolloid dressings
prevent the entrance of microorganisms and minimize wound discomfort. Dry sterile dressings protect
the wound from mechanical trauma and promote healing.

71. Answer: (A) Hyperkalemia
Rationale: In adrenal insufficiency, the client has hyperkalemia due to reduced aldosterone secretion.
BUN increases as the glomerular filtration rate is reduced. Hyponatremia is caused by reduced
aldosterone secretion. Reduced cortisol secretion leads to impaired glyconeogenesis and a reduction of
glycogen in the liver and muscle, causing hypoglycemia.

72. Answer: (C) Restricting fluids
Rationale: To reduce water retention in a client with the SIADH, the nurse should restrict fluids.
Administering fluids by any route would further increase the client's already heightened fluid load.

73. Answer: (D) glycosylated hemoglobin level.
Rationale: Because some of the glucose in the bloodstream attaches to some of the hemoglobin and
stays attached during the 120-day life span of red blood cells, glycosylated hemoglobin levels provide
information about blood glucose levels during the previous 3 months. Fasting blood glucose and urine
glucose levels only give information about glucose levels at the point in time when they were obtained.
Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks.

74. Answer: (C) 4:00 pm
Rationale: NPH is an intermediate-acting insulin that peaks 8 to 12 hours after administration. Because
the nurse administered NPH insulin at 7 a.m., the client is at greatest risk for hypoglycemia from 3 p.m.
to 7 p.m.

75. Answer: (A) Glucocorticoids and androgens
Rationale: The adrenal glands have two divisions, the cortex and medulla. The cortex produces three
types of hormones: glucocorticoids, mineralocorticoids, and androgens. The medulla produces
catecholamines epinephrine and norepinephrine.

76. Answer: (A) Hypocalcemia
Rationale: Hypocalcemia may follow thyroid surgery if the parathyroid glands were removed
accidentally. Signs and symptoms of hypocalcemia may be delayed for up to 7 days after surgery.
Thyroid surgery doesn't directly cause serum sodium, potassium, or magnesium
abnormalities. Hyponatremia may occur if the client inadvertently received too much fluid; however,
this can happen to any surgical client receiving I.V. fluid therapy, not just one recovering from thyroid
surgery. Hyperkalemia and hypermagnesemia usually are associated with reduced renal excretion
of potassium and magnesium, not thyroid surgery.

77. Answer: (D) Carcinoembryonic antigen level
Rationale: In clients who smoke, the level of carcinoembryonic antigen is elevated. Therefore, it can't be
used as a general indicator of cancer. However, it is helpful in monitoring cancer treatment because the
level usually falls to normal within 1 month if treatment is successful. An elevated acid phosphatase
level may indicate prostate cancer. An elevated alkaline phosphatase level may reflect bone metastasis.
An elevated serum calcitonin level usually signals thyroid cancer.

78. Answer: (B) Dyspnea, tachycardia, and pallor
Rationale: Signs of iron-deficiency anemia include dyspnea, tachycardia, and pallor as well as fatigue,
listlessness, irritability, and headache. Night sweats, weight loss, and diarrhea may signal acquired
immunodeficiency syndrome (AIDS). Nausea, vomiting, and anorexia may be signs of hepatitis B. Itching,
rash, and jaundice may result from an allergic or hemolytic reaction.

79. Answer: (D) "I'll need to have a C-section if I become pregnant and have a baby."
Rationale: The human immunodeficiency virus (HIV) is transmitted from mother to child via the
transplacental route, but a Cesarean section delivery isn't necessary when the mother is HIV-positive.
The use of birth control will prevent the conception of a child who might have HIV. It's true that a
mother who's HIV positive can give birth to a baby who's HIV negative.

80. Answer: (C) "Avoid sharing such articles as toothbrushes and razors."
Rationale: The human immunodeficiency virus (HIV), which causes AIDS, is most concentrated in the
blood. For this reason, the client shouldn't share personal articles that may be blood-contaminated,
such as toothbrushes and razors, with other family members. HIV isn't transmitted by bathing or by
eating from plates, utensils, or serving dishes used by a person with AIDS.

81. Answer: (B) Pallor, tachycardia, and a sore tongue
Rationale: Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia.
Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse
pressure; palpitations; angina; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia,
reduced pulse pressure, weight gain, and double vision aren't characteristic findings in pernicious
anemia.

82. Answer: (B) Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.
Rationale: To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent
bronchodilator as prescribed. The physician is likely to order additional medications, such as
antihistamines and corticosteroids; if these medications don't relieve the respiratory compromise
associated with anaphylaxis, the nurse should prepare to intubate the client. No antidote for penicillin
exists; however, the nurse should continue to monitor the client's vital signs. A client who
remains hypotensive may need fluid resuscitation and fluid intake and output monitoring; however,
administering epinephrine is the first priority.

83. Answer: (D) bilateral hearing loss.
Rationale: Prolonged use of aspirin and other salicylates sometimes causes bilateral hearing loss of 30 to
40 decibels. Usually, this adverse effect resolves within 2 weeks after the therapy is discontinued.
Aspirin doesn't lead to weight gain or fine motor tremors. Large or toxic salicylate doses may cause
respiratory alkalosis, not respiratory acidosis.

84. Answer: (D) Lymphocyte
Rationale: The lymphocyte provides adaptive immunity recognition of a foreign antigen and
formation of memory cells against the antigen.
Adaptive immunity is mediated by B and T lymphocytes and can be acquired actively or passively. The
neutrophil is crucial to phagocytosis. The basophil plays an important role in the release of
inflammatory mediators. The monocyte functions in phagocytosis and monokine production.

85. Answer: (A) moisture replacement.
Rationale: Sjogren's syndrome is an autoimmune disorder leading to progressive loss of lubrication of
the skin, GI tract, ears, nose, and vagina. Moisture replacement is the mainstay of therapy. Though
malnutrition and electrolyte imbalance may occur as a result of Sjogren's syndrome's effect on the GI
tract, it isn't the predominant problem. Arrhythmias aren't a problem associated with Sjogren's
syndrome.

86. Answer: (C) stool for Clostridium difficile test.
Rationale: Immunosuppressed clients for example, clients receiving chemotherapy, are at risk for
infection with C. difficile, which causes "horse barn" smelling diarrhea. Successful treatment begins with
an accurate diagnosis, which includes a stool test. The ELISA test is diagnostic for human
immunodeficiency virus (HIV) and isn't indicated in this case. An electrolyte panel and hemogram may
be useful in the overall evaluation of a client but aren't diagnostic for specific causes of diarrhea. A flat
plate of the abdomen may provide useful information about bowel function but isn't indicated in the
case of "horse barn" smelling diarrhea.

87. Answer: (D) Western blot test with ELISA.
Rationale: HIV infection is detected by analyzing blood for antibodies to HIV, which form approximately
2 to 12 weeks after exposure to HIV and denote infection. The Western blot test electrophoresis of
antibody proteins is more than 98% accurate in detecting HIV antibodies when used in conjunction
with the ELISA. It isn't specific when used alone. Erosette immunofluorescence is used to detect viruses
in general; it doesn't confirm HIV infection. Quantification of T-lymphocytes is a useful monitoring test
but isn't diagnostic for HIV. The ELISA test detects HIV antibody particles but may yield inaccurate
results; a positive ELISA result must be confirmed by the Western blot test.

88. Answer: (C) Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
Rationale: Low preoperative HCT and Hb levels indicate the client may require a blood transfusion
before surgery. If the HCT and Hb levels decrease during surgery because of blood loss, the potential
need for a transfusion increases. Possible renal failure is indicated by elevated BUN or creatinine levels.
Urine constituents aren't found in the blood. Coagulation is determined by the presence of appropriate
clotting factors, not electrolytes.

89. Answer: (A) Platelet count, prothrombin time, and partial thromboplastin time
Rationale: The diagnosis of DIC is based on the results of laboratory studies of prothrombin time,
platelet count, thrombin time, partial thromboplastin time, and fibrinogen level as well as client history
and other assessment factors. Blood glucose levels, WBC count, calcium levels, and potassium levels
aren't used to confirm a diagnosis of DIC.

90. Answer: (D) Strawberries
Rationale: Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs.
Bread, carrots, and oranges rarely cause allergic reactions.

91. Answer: (B) A client with cast on the right leg who states, I have a funny feeling in my right leg.
Rationale: It may indicate neurovascular compromise, requires immediate assessment.

92. Answer: (D) A 62-year-old who had an abdominal-perineal resection three days ago; client
complaints of chills.
Rationale: The client is at risk for peritonitis; should be assessed for further symptoms and infection.

93. Answer: (C) The client spontaneously flexes his wrist when the blood pressure is obtained.
Rationale: Carpal spasms indicate hypocalcemia.

94. Answer: (D) Use comfort measures and pillows to position the client.
Rationale: Using comfort measures and pillows to position the client is a non-pharmacological methods
of pain relief.

95. Answer: (B) Warm the dialysate solution.
Rationale: Cold dialysate increases discomfort. The solution should be warmed to body temperature in
warmer or heating pad; dont use microwave oven.

96. Answer: (C) The client holds the cane with his left hand, moves the cane forward followed by the
right leg, and then moves the left leg.
Rationale: The cane acts as a support and aids in weight bearing for the weaker right leg.

97. Answer: (A) Ask the womans family to provide personal items such as photos or mementos.
Rationale: Photos and mementos provide visual stimulation to reduce sensory deprivation.

98. Answer: (B) The client lifts the walker, moves it forward 10 inches, and then takes several small steps
forward.
Rationale: A walker needs to be picked up, placed down on all legs.

99. Answer: (C) Isolation from their families and familiar surroundings.
Rationale: Gradual loss of sight, hearing, and taste interferes with normal functioning.

100. Answer: (A) Encourage the client to perform pursed lip breathing.
Rationale: Purse lip breathing prevents the collapse of lung unit and helps client control rate and depth
of breathing.




Practice Test IV- Psychiatric Nursing
1. Marco approached Nurse Trish asking for advice on how to deal with his alcohol addiction. Nurse
Trish should tell the client that the only effective treatment for alcoholism is:

a. Psychotherapy
b. Alcoholics anonymous (A.A.)
c. Total abstinence
d. Aversion Therapy


2. Nurse Hazel is caring for a male client who experience false sensory perceptions with no basis in
reality. This perception is known as:

a. Hallucinations
b. Delusions
c. Loose associations
d. Neologisms


3. Nurse Monet is caring for a female client who has suicidal tendency. When accompanying the client to
the restroom, Nurse Monet should

a. Give her privacy
b. Allow her to urinate
c. Open the window and allow her to get some fresh air
d. Observe her


4. Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. Which action
should the nurse include in the plan?

a. Provide privacy during meals
b. Set-up a strict eating plan for the client
c. Encourage client to exercise to reduce anxiety
d. Restrict visits with the family


5. A client is experiencing anxiety attack. The most appropriate nursing intervention should include?

a. Turning on the television
b. Leaving the client alone
c. Staying with the client and speaking in short sentences
d. Ask the client to play with other clients


6. A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects a belief
that one is:

a. Being Killed
b. Highly famous and important
c. Responsible for evil world
d. Connected to client unrelated to oneself


7. A 20 year old client was diagnosed with dependent personality disorder. Which behavior is not likely
to be evidence of ineffective individual coping?

a. Recurrent self-destructive behavior
b. Avoiding relationship
c. Showing interest in solitary activities
d. Inability to make choices and decision without advise


8. A male client is diagnosed with schizotypal personality disorder. Which signs would this client exhibit
during social situation?

a. Paranoid thoughts
b. Emotional affect
c. Independence need
d. Aggressive behavior


9. Nurse Claire is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client
diagnosed with bulimia is?

a. Encourage to avoid foods
b. Identify anxiety causing situations
c. Eat only three meals a day
d. Avoid shopping plenty of groceries


10. Nurse Tony was caring for a 41 year old female client. Which behavior by the client indicates adult
cognitive development?

a. Generates new levels of awareness
b. Assumes responsibility for her actions
c. Has maximum ability to solve problems and learn new skills
d. Her perception are based on reality


11.A neuromuscular blocking agent is administered to a client before ECT therapy. The Nurse should
carefully observe the client for?

a. Respiratory difficulties
b. Nausea and vomiting
c. Dizziness
d. Seizures


12.A 75 year old client is admitted to the hospital with the diagnosis of dementia of the Alzheimers type
and depression. The symptom that is unrelated to depression would be?

a. Apathetic response to the environment
b. I dont know answer to questions
c. Shallow of labile effect
d. Neglect of personal hygiene


13.Nurse Trish is working in a mental health facility; the nurse priority nursing intervention for a newly
admitted client with bulimia nervosa would be to?

a. Teach client to measure I & O
b. Involve client in planning daily meal
c. Observe client during meals
d. Monitor client continuously


14.Nurse Patricia is aware that the major health complication associated with intractable anorexia
nervosa would be?

a. Cardiac dysrhythmias resulting to cardiac arrest
b. Glucose intolerance resulting in protracted hypoglycemia
c. Endocrine imbalance causing cold amenorrhea
d. Decreased metabolism causing cold intolerance


15.Nurse Anna can minimize agitation in a disturbed client by?

a. Increasing stimulation
b. limiting unnecessary interaction
c. increasing appropriate sensory perception
d. ensuring constant client and staff contact


16.A 39 year old mother with obsessive-compulsive disorder has become immobilized by her elaborate
hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C. disorder is often:

a. Problems with being too conscientious
b. Problems with anger and remorse
c. Feelings of guilt and inadequacy
d. Feeling of unworthiness and hopelessness


17.Mario is complaining to other clients about not being allowed by staff to keep food in his room.
Which of the following interventions would be most appropriate?

a. Allowing a snack to be kept in his room
b. Reprimanding the client
c. Ignoring the clients behavior
d. Setting limits on the behavior


18.Conney with borderline personality disorder who is to be discharge soon threatens to do
something to herself if discharged. Which of the following actions by the nurse would be most
important?

a. Ask a family member to stay with the client at home temporarily
b. Discuss the meaning of the clients statement with her
c. Request an immediate extension for the client
d. Ignore the clients statement because its a sign of manipulation


19.Joey a client with antisocial personality disorder belches loudly. A staff member asks Joey, Do you
know why people find you repulsive? this statement most likely would elicit which of the following
client reaction?

a. Depensiveness
b. Embarrassment
c. Shame
d. Remorsefulness


20.Which of the following approaches would be most appropriate to use with a client suffering from
narcissistic personality disorder when discrepancies exist between what the client states and what
actually exist?

a. Rationalization
b. Supportive confrontation
c. Limit setting
d. Consistency


21.Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis and hyperactivity. Blood
pressure is 190/87 mmhg and pulse is 92 bpm. Which of the medications would the nurse expect to
administer?

a. Naloxone (Narcan)
b. Benzlropine (Cogentin)
c. Lorazepam (Ativan)
d. Haloperidol (Haldol)


22.Which of the following foods would the nurse Trish eliminate from the diet of a client in alcohol
withdrawal?

a. Milk
b. Orange Juice
c. Soda
d. Regular Coffee


23.Which of the following would Nurse Hazel expect to assess for a client who is exhibiting late signs of
heroin withdrawal?

a. Yawning & diaphoresis
b. Restlessness & Irritability
c. Constipation & steatorrhea
d. Vomiting and Diarrhea


24.To establish open and trusting relationship with a female client who has been hospitalized with
severe anxiety, the nurse in charge should?

a. Encourage the staff to have frequent interaction with the client
b. Share an activity with the client
c. Give client feedback about behavior
d. Respect clients need for personal space


25. Nurse Monette recognizes that the focus of environmental (MILIEU) therapy is to:

a. Manipulate the environment to bring about positive changes in behavior
b. Allow the clients freedom to determine whether or not they will be involved in activities
c. Role play life events to meet individual needs
d. Use natural remedies rather than drugs to control behavior


26.Nurse Trish would expect a child with a diagnosis of reactive attachment disorder to:

a. Have more positive relation with the father than the mother
b. Cling to mother & cry on separation
c. Be able to develop only superficial relation with the others
d. Have been physically abuse


27.When teaching parents about childhood depression Nurse Trina should say?

a. It may appear acting out behavior
b. Does not respond to conventional treatment
c. Is short in duration & resolves easily
d. Looks almost identical to adult depression


28.Nurse Perry is aware that language development in autistic child resembles:

a. Scanning speech
b. Speech lag
c. Shuttering
d. Echolalia


29.A 60 year old female client who lives alone tells the nurse at the community health center I really
dont need anyone to talk to. The TV is
my best friend. The nurse recognizes that the client is using the defense mechanism known as?

a. Displacement
b. Projection
c. Sublimation
d. Denial


30.When working with a male client suffering phobia about black cats, Nurse Trish should anticipate that
a problem for this client would be?

a. Anxiety when discussing phobia
b. Anger toward the feared object
c. Denying that the phobia exist
d. Distortion of reality when completing daily routines


31.Linda is pacing the floor and appears extremely anxious. The duty nurse approaches in an attempt to
alleviate Lindas anxiety. The most therapeutic question by the nurse would be?

a. Would you like to watch TV?
b. Would you like me to talk with you?
c. Are you feeling upset now?
d. Ignore the client


32.Nurse Penny is aware that the symptoms that distinguish post traumatic stress disorder from other
anxiety disorder would be:


a. Avoidance of situation & certain activities that resemble the stress
b. Depression and a blunted affect when discussing the traumatic
situation
c. Lack of interest in family & others
d. Re-experiencing the trauma in dreams or flashback


33.Nurse Benjie is communicating with a male client with substance-induced persisting dementia; the
client cannot remember facts and fills in the gaps with imaginary information. Nurse Benjie is aware that
this is typical of?
a. Flight of ideas
b. Associative looseness
c. Confabulation
d. Concretism


34.Nurse Joey is aware that the signs & symptoms that would be most specific for diagnosis anorexia
are?
a. Excessive weight loss, amenorrhea & abdominal distension
b. Slow pulse, 10% weight loss & alopecia
c. Compulsive behavior, excessive fears & nausea
d. Excessive activity, memory lapses & an increased pulse


35.A characteristic that would suggest to Nurse Anne that an adolescent may have bulimia would be:
a. Frequent regurgitation & re-swallowing of food
b. Previous history of gastritis
c. Badly stained teeth
d. Positive body image


36.Nurse Monette is aware that extremely depressed clients seem to do best in settings where they
have:
a. Multiple stimuli
b. Routine Activities
c. Minimal decision making
d. Varied Activities


37.To further assess a clients suicidal potential. Nurse Katrina should be especially alert to the client
expression of:
a. Frustration & fear of death
b. Anger & resentment
c. Anxiety & loneliness
d. Helplessness & hopelessness


38.A nursing care plan for a male client with bipolar I disorder should include:
a. Providing a structured environment
b. Designing activities that will require the client to maintain contact with reality
c. Engaging the client in conversing about current affairs
d. Touching the client provide assurance


39.When planning care for a female client using ritualistic behavior, Nurse Gina must recognize that the
ritual:

a. Helps the client focus on the inability to deal with reality
b. Helps the client control the anxiety
c. Is under the clients conscious control
d. Is used by the client primarily for secondary gains


40.A 32 year old male graduate student, who has become increasingly withdrawn and neglectful of his
work and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed
assessment, a diagnosis of schizophrenia is made. It is unlikely that the client will demonstrate:
a. Low self esteem
b. Concrete thinking
c. Effective self boundaries
d. Weak ego


41.A 23 year old client has been admitted with a diagnosis of schizophrenia says to the nurse Yes, its
march, March is little woman. Thats literal you know. These statement illustrate:
a. Neologisms
b. Echolalia
c. Flight of ideas
d. Loosening of association


42.A long term goal for a paranoid male client who has unjustifiably accused his wife of having many
extramarital affairs would be to help the client develop:
a. Insight into his behavior
b. Better self control
c. Feeling of self worth
d. Faith in his wife


43.A male client who is experiencing disordered thinking about food being poisoned is admitted to the
mental health unit. The nurse uses which communication technique to encourage the client to eat
dinner?
a. Focusing on self-disclosure of own food preference
b. Using open ended question and silence
c. Offering opinion about the need to eat
d. Verbalizing reasons that the client may not choose to eat


44.Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina enters
the clients room, the client is found lying on the bed with a body pulled into a fetal position. Nurse Nina
should?
a. Ask the client direct questions to encourage talking
b. Rake the client into the dayroom to be with other clients
c. Sit beside the client in silence and occasionally ask open-ended question
d. Leave the client alone and continue with providing care to the other clients


45.Nurse Tina is caring for a client with delirium and states that look at the spiders on the wall. What
should the nurse respond to the client?
a. Youre having hallucination, there are no spiders in this room at all
b. I can see the spiders on the wall, but they are not going to hurt you
c. Would you like me to kill the spiders
d. I know you are frightened, but I do not see spiders on the wall


46.Nurse Jonel is providing information to a community group about violence in the family. Which
statement by a group member would indicate a need to provide additional information?
a. Abuse occurs more in low-income families
b. Abuser Are often jealous or self-centered
c. Abuser use fear and intimidation
d. Abuser usually have poor self-esteem


47.During electroconvulsive therapy (ECT) the client receives oxygen by mask via positive pressure
ventilation. The nurse assisting with this procedure knows that positive pressure ventilation is necessary
because?
a. Anesthesia is administered during the procedure
b. Decrease oxygen to the brain increases confusion and disorientation
c. Grand mal seizure activity depresses respirations
d. Muscle relaxations given to prevent injury during seizure activity depress respirations.


48.When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of
the discharge maintenance goals. Which goal would be most appropriately having been included in the
plan of care requiring evaluation?
a. The client eliminates all anxiety from daily situations
b. The client ignores feelings of anxiety
c. The client identifies anxiety producing situations
d. The client maintains contact with a crisis counselor


49.Nurse Tina is caring for a client with depression who has not responded to antidepressant
medication. The nurse anticipates that what treatment procedure may be prescribed.
a. Neuroleptic medication
b. Short term seclusion
c. Psychosurgery
d. Electroconvulsive therapy


50.Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of
prescribed antipsychotic medication. The most important piece of information the nurse in charge
should obtain initially is the:
a. Length of time on the med.
b. Name of the ingested medication & the amount ingested
c. Reason for the suicide attempt
d. Name of the nearest relative & their phone number















Answer and Rationale- Practice Test IV- Psychiatric Nursing

1. C . Total abstinence is the only effective treatment for alcoholism

2. A . Hallucinations are visual, auditory, gustatory, tactile or olfactory perceptions that have no
basis in reality.

3. D . The Nurse has a responsibility to observe continuously the acutely suicidal client. The Nurse
should watch for clues, such as communicating suicidal thoughts, and messages; hoarding
medications and talking about death.

4. B . Establishing a consistent eating plan and monitoring clients weight are important to this
disorder.

5. C . Appropriate nursing interventions for an anxiety attack include using short sentences,
staying with the client, decreasing stimuli, remaining calm and medicating as needed.

6. B . Delusion of grandeur is a false belief that one is highly famous and important.

7. D . Individual with dependent personality disorder typically shows indecisiveness
submissiveness and clinging behavior so that others will make decisions with them.

8. A . Clients with schizotypal personality disorder experience excessive social anxiety that can
lead to paranoid thoughts

9. B . Bulimia disorder generally is a maladaptive coping response to stress and underlying issues.
The client should identify anxiety causing situation that
stimulate the bulimic behavior and then learn new ways of coping with the anxiety.

10. A . An adult age 31 to 45 generates new level of awareness.

11. A . Neuromuscular Blocker, such as SUCCINYLCHOLINE (Anectine) produces respiratory
depression because it inhibits contractions of respiratory muscles.

12. C . With depression, there is little or no emotional involvement therefore little alteration in
affect.

13. D . These clients often hide food or force vomiting; therefore they must be carefully
monitored.

14. A . These clients have severely depleted levels of sodium and potassium because of their
starvation diet and energy expenditure, these electrolytes are
necessary for cardiac functioning.

15. B . Limiting unnecessary interaction will decrease stimulation and agitation.

16. C . Ritualistic behavior seen in this disorder is aimed at controlling guilt and inadequacy by
maintaining an absolute set pattern of behavior.

17. D . The nurse needs to set limits in the clients manipulative behavior to help the client
control dysfunctional behavior. A consistent approach by the staff is necessary to decrease
manipulation.

18. B . Any suicidal statement must be assessed by the nurse. The nurse should discuss the
clients statement with her to determine its meaning in terms of
suicide.

19. A . When the staff member ask the client if he wonders why others find him repulsive, the
client is likely to feel defensive because the question is belittling. The natural tendency is to
counterattack the threat to self image.

20. B . The nurse would specifically use supportive confrontation with the client to point out
discrepancies between what the client states and what actually exists to increase responsibility
for self.

21. C . The nurse would most likely administer benzodiazepine, such as lorazepan (ativan) to the
client who is experiencing symptom: The clients experiences symptoms of withdrawal because
of the rebound phenomenon when the sedation of the CNS from alcohol begins to decrease.

22. D . Regular coffee contains caffeine which acts as psychomotor stimulants and leads to
feelings of anxiety and agitation. Serving coffee top the client may add to tremors or
wakefulness.

23. D . Vomiting and diarrhea are usually the late signs of heroin withdrawal, along with muscle
spasm, fever, nausea, repetitive, abdominal cramps and backache.

24. D . Moving to a clients personal space increases the feeling of threat, which increases
anxiety.

25. A . Environmental (MILIEU) therapy aims at having everything in the clients surrounding area
toward helping the client.

26. C . Children who have experienced attachment difficulties with primary caregiver are not able
to trust others and therefore relate superficially

27. A . Children have difficulty verbally expressing their feelings, acting out behavior, such as
temper tantrums, may indicate underlying depression.

28. D . The autistic child repeat sounds or words spoken by others.

29. D . The client statement is an example of the use of denial, a defense that blocks problem by
unconscious refusing to admit they exist

30. A . Discussion of the feared object triggers an emotional response to the object.

31. B . The nurse presence may provide the client with support & feeling of control.

32. D . Experiencing the actual trauma in dreams or flashback is the major symptom that
distinguishes post traumatic stress disorder from other anxiety disorder.

33. C . Confabulation or the filling in of memory gaps with imaginary facts is a defense
mechanism used by people experiencing memory deficits.

34. A . These are the major signs of anorexia nervosa. Weight loss is excessive (15% of expected
weight)

35. C . Dental enamel erosion occurs from repeated self-induced vomiting.

36. B . Depression usually is both emotional & physical. A simple daily routine is the best, least
stressful and least anxiety producing.

37. D . The expression of these feeling may indicate that this client is unable to continue the
struggle of life.

38. A . Structure tends to decrease agitation and anxiety and to increase the clients feeling of
security.

39. B . The rituals used by a client with obsessive compulsive disorder help control the anxiety
level by maintaining a set pattern of action.

40. C . A person with this disorder would not have adequate self-boundaries

41. D . Loose associations are thoughts that are presented without the logical connections usually
necessary for the listening to interpret the message.

42. C . Helping the client to develop feeling of self worth would reduce the clients need to use
pathologic defenses.

43. B . Open ended questions and silence are strategies used to encourage clients to discuss their
problem in descriptive manner.

44. C . Clients who are withdrawn may be immobile and mute, and require consistent, repeated
interventions. Communication with withdrawn clients
requires much patience from the nurse. The nurse facilitates communication with the client by
sitting in silence, asking open-ended question and pausing
to provide opportunities for the client to respond.

45. D . When hallucination is present, the nurse should reinforce reality with the client.

46. A . Personal characteristics of abuser include low self-esteem, immaturity, dependence,
insecurity and jealousy.

47. D . A short acting skeletal muscle relaxant such as succinylcholine (Anectine) is administered
during this procedure to prevent injuries during seizure.

48. C . Recognizing situations that produce anxiety allows the client to prepare to cope with
anxiety or avoid specific stimulus.

49. D . Electroconvulsive therapy is an effective treatment for depression that has not responded
to medication

50. B . In an emergency, lives saving facts are obtained first. The name and the amount of
medication ingested are of outmost important in treating this
potentially life threatening situation.




Board Exam Nursing Test IV NLE
The scope of this Nursing Test IV is parallel to the NP4 NLE Coverage:

Medical Surgical Nursing

1. Following spinal injury, the nurse should encourage the client to drink fluids to avoid:

A) Urinary tract infection.
B) Fluid and electrolyte imbalance.
C) Dehydration.
D) Skin breakdown.


2. The client is transferred from the operating room to recovery room after an open-heart surgery. The
nurse assigned is taking the vital signs of the client. The nurse notified the physician when the
temperature of the client rises to 38.8 C or 102 F because elevated temperatures:

A) May be a forerunner of hemorrhage.
B) Are related to diaphoresis and possible chilling.
C) May indicate cerebral edema.
D) Increase the cardiac output.


3. After radiation therapy for cancer of the prostate, the client experienced irritation in the bladder.
Which of the following sign of bladder irritability is correct?

A) Hematuria
B) Dysuria
C) Polyuria
D) Dribbling


4. A client is diagnosed with a brain tumor in the occipital lobe. Which of the following will the client
most likely experience?

A) Visual hallucinations.
B) Receptive aphasia.
C) Hemiparesis.
D) Personality changes.


5. A client with Addisons disease has a blood pressure of 65/60. The nurse understands that decreased
blood pressure of the client with Addisons disease involves a disturbance in the production of:

A) Androgens
B) Glucocorticoids
C) Mineralocorticoids
D) Estrogen


6. The nurse is planning to teach the client about a spontaneous pneumothorax. The nurse would base
the teaching on the understanding that:

A) Inspired air will move from the lung into the pleural space.
B) There is greater negative pressure within the chest cavity.
C) The heart and great vessels shift to the affected side.
D) The other lung will collapse if not treated immediately.


7. During an assessment, the nurse recognizes that the client has an increased risk for developing cancer
of the tongue. Which of the following health history will be a concern?

A) Heavy consumption of alcohol.
B) Frequent gum chewing.
C) Nail biting.
D) Poor dental habits.


8. The client in the orthopedic unit asks the nurse the reason behind why compact bone is stronger than
cancellous bone. Which of the following is the correct response of the nurse?

A) Compact bone is stronger than cancellous bone because of its greater size.
B) Compact bone is stronger than cancellous bone because of its greater weight.
C) Compact bone is stronger than cancellous bone because of its greater volume.
D) Compact bone is stronger than cancellous bone because of its greater density.


9. The nurse is reviewing the laboratory results of the client. In reviewing the results of the RBC count,
the nurse understands that the higher the red blood cell count, the :

A) Greater the blood viscosity.
B) Higher the blood pH.
C) Less it contributes to immunity.
D) Lower the hematocrit.


10. The physician advised the client with Hemiparesis to use a cane. The client asks the nurse why cane
will be needed. The nurse explains to the client that cane is advised specifically to:

A) Aid in controlling involuntary muscle movements.
B) Relieve pressure on weight-bearing joints.
C) Maintain balance and improve stability.
D) Prevent further injury to weakened muscles.


11. The nurse is conducting a discharge teaching regarding the prevention of further problems to a client
who undergone surgery for carpal tunnel syndrome of the right hand. Which of the following instruction
will the nurse includes?

A) Learn to type using your left hand only.
B) Avoid typing in a long period of time.
C) Avoid carrying heavy things using the right hand.
D) Do manual stretching exercise during breaks.


12. A female client is admitted because of recurrent urinary tract infections. The client asks the nurse
why she is prone to this disease. The nurse states that the client is most susceptible because of:

A) Continuity of the mucous membrane.
B) Inadequate fluid intake.
C) The length of the urethra.
D) Poor hygienic practices.


13. A 55-year-old client is admitted with chest pain that radiates to the neck, jaw and shoulders that
occurs at rest, with high body temperature, weak with generalized sweating and with decreased blood
pressure. A myocardial infarction is diagnosed. The nurse knows that the most accurate explanation for
one of these presenting adaptations is:

A) Catecholamines released at the site of the infarction causes intermittent localized pain.
B) Parasympathetic reflexes from the infarcted myocardium causes diaphoresis.
C) Constriction of central and peripheral blood vessels causes a decrease in blood pressure.
D) Inflammation in the myocardium causes a rise in the systemic body temperature.


14. Following an amputation of a lower limb to a male client, the nurse provides an instruction on how
to prevent a hip flexion contracture. The nurse should instruct the client to:.

A) Perform quadriceps muscle setting exercises twice a day.
B) Sit in a chair for 30 minutes three times a day.
C) Lie on the abdomen 30 minutes every four hours.
D) Turn from side to side every 2 hours.


15. The physician scheduled the client with rheumatoid arthritis for the injection of hydrocortisone into
the knee joint. The client asks the nurse why there is a need for this injection. The nurse explains that
the most important reason for doing this is to:

A) Lubricate the joint.
B) Prevent ankylosis of the joint.
C) Reduce inflammation.
D) Provide physiotherapy.


16. The nurse is assigned to care for a 57-year-old female client who had a cataract surgery an hour ago.
The nurse should:

A) Advise the client to refrain from vigorous brushing of teeth and hair.
B) Instruct the client to avoid driving for 2 weeks.
C) Encourage eye exercises to strengthen the ocular musculature.
D) Teach the client coughing and deep-breathing techniques.


17. A client with AIDS develops bacterial pneumonia is admitted in the emergency department. The
clients arterial blood gases is drawn and the result is PaO2 80mmHg. then arterial blood gases are
drawn again and the level is reduced from 80 mmHg to 65 mmHg. The nurse should;

A) Have arterial blood gases performed again to check for accuracy.
B) Increase the oxygen flow rate.
C) Notify the physician.
D) Decrease the tension of oxygen in the plasma.


18. An 18-year-old college student is brought to the emergency department due to serious motor
vehicle accident. Right above-knee-amputation is done. Upon awakening from surgery the client tells
the nurse, What happened to me? I cannot remember anything? Which of the following would be the
appropriate initial nursing response?

A) You sound concerned; Youll probably remember more as you wake up.
B) Tell me what you think happened.
C) You were in a car accident this morning.
D) An amputation of your right leg was necessary because of an accident.


19. A 38-year-old client with severe hypertension is hospitalized. The physician prescribed a Captopril
(Capoten) and Alprazolam (Xanax) for treatment. The client tells the nurse that there is something
wrong with the medication and nursing care. The nurse recognizes this behavior is probably a
manifestation of the clients:

A) Reaction to hypertensive medications.
B) Denial of illness.
C) Response to cerebral anoxia.
D) Fear of the health problem.


20. Before discharge, the nurse scheduled the client who had a colostomy for colorectal cancer for
discharge instruction about resuming activities. The nurse should plan to help the client understands
that:

A) After surgery, changes in activities must be made to accommodate for the physiologic changes
caused by the operation.
B) Most sports activities, except for swimming, can be resumed based on the clients overall physical
condition.
C) With counseling and medical guidance, a near normal lifestyle, including complete sexual function is
possible.
D) Activities of daily living should be resumed as quickly as possible to avoid depression and further
dependency.


21. A client is scheduled for bariatric surgery. Preoperative teaching is done. Which of the following
statement would alert the nurse that further teaching to the client is necessary?

A) I will be limiting my intake to 600 to 800 calories a day once I start eating again.
B) Im going to have a figure like a model in about a year.
C) I need to eat more high-protein foods.
D) I will be going to be out of bed and sitting in a chair the first day after surgery..


22. The client who had transverse colostomy asks the nurse about the possible effect of the surgery on
future sexual relationship. What would be the best nursing response?

A) The surgery will temporarily decrease the clients sexual impulses.
B) Sexual relationships must be curtailed for several weeks.
C) The partner should be told about the surgery before any sexual activity.
D) The client will be able to resume normal sexual relationships.


23. A 75-year-old male client tells the nurse that his wife has osteoporosis and asks what chances he had
of getting also osteoporosis like his wife. Which of the following is the correct response of the nurse?

A) This is only a problem for women.
B) You are not at risk because of your small frame.
C) You might think about having a bone density test,
D) Exercise is a good way to prevent this problem.


24. An older adult client with acute pain is admitted in the hospital. The nurse understands that in
managing acute pain of the client during the first 24 hours, the nurse should ensure that:

A) Ordered PRN analgesics are administered on a scheduled basis.
B) Patient controlled analgesia is avoided in this population.
C) Pain medication is ordered via the intramuscular route.
D) An order for meperidine (Demerol) is secured for pain relief.


25. A nurse is caring to an older adult with presbycusis. In formulating nursing care plan for this client,
the nurse should expect that hearing loss of the client that is caused by aging to have:

A) Overgrowth of the epithelial auditory lining.
B) Copious, moist cerumen.
C) Difficulty hearing womens voices.
D) Tears in the tympanic membrane.


26. The nurse is reviewing the clients chart about the ordered medication. The nurse must observe for
signs of hyperkalemia when administering:

A) Furosemide (Lasix)
B) Hydrochlorothiazide (HydroDIURIL)
C) Metolazone (Zaroxolyn)
D) Spironolactone (Aldactone)


27. The physician prescribed Albuterol (Proventil) to the client with severe asthma. After the
administration of the medication the nurse should monitor the client for:

A) Palpitation
B) Visual disturbance
C) Decreased pulse rate
D) Lethargy


28. A client is receiving diltiazem (Cardizem). What should the nurse include in a teaching plan aimed at
reducing the side effects of this medication?

A) Take the drug with an antacid.
B) Lie down after meals.
C) Avoid dairy products in diet.
D) Change positions slowly.


29. A client is receiving simvastatin (Zocor). The nurse is aware that this medication is effective when
there is decrease in:

A) The triglycerides
B) The INR
C) Chest pain
D) Blood pressure


30. A client is taking nitroglycerine tablets, the nurse should teach the client the importance of:

A) Increasing the number of tablets if dizziness or hypertension occurs.
B) Limiting the number of tablets to 4 per day.
C) Making certain the medication is stored in a dark container.
D) Discontinuing the medication if a headache develops.


31. The physician prescribes Ibuprofen (Motrin) and hydroxychloroquine sulfate (Plaquenil) for a 58-
year-old male client with arthritis. The nurse provides information about toxicity of the
hydroxychloroquine. The nurse can determine if the information is clearly understood if the client
states:

A) I will contact the physician immediately if I develop blurred vision.
B) I will contact the physician immediately if I develop urinary retention.
C) I will contact the physician immediately if I develop swallowing difficulty.
D) I will contact the physician immediately if I develop feelings of irritability.


32. The client with an acute myocardial infarction is hospitalized for almost one week. The client
experiences nausea and loss of appetite. The nurse caring for the client recognizes that these symptoms
may indicate the:

A) Adverse effects of spironolactone (Aldactone)
B) Adverse effects of digoxin (Lanoxin)
C) Therapeutic effects of propranolol (Indiral)
D) Therapeutic effects of furosemide (Lasix)


33. A client with a partial occlusion of the left common carotid artery is scheduled for discharge. The
client is still receiving Coumadin. The nurse provided a discharge instruction to the client regarding
adverse effects of Coumadin. The nurse should tell the client to consult with the physician if:

A) Swelling of the ankles increases.
B) Blood appears in the urine.
C) Increased transient Ischemic attacks occur.
D) The ability to concentrate diminishes.


34. Levodopa is ordered for a client with Parkinsons disease. Before starting the medication, the nurse
should know that:

A) Levodopa is inadequately absorbed if given with meals.
B) Levodopa may cause the side effects of orthostatic hypotension.
C) Levodopa must be monitored by weekly laboratory tests.
D) Levodopa causes an initial euphoria followed by depression.


35. In making a diagnosis of myasthenia gravis Edrophonium HCI (Tensilon) is used. The nurse knows
that this drug will cause a temporary increase in:

A) Muscle strength
B) Symptoms
C) Blood pressure
D) Consciousness


36. The nurse can determine the effectiveness of carbamazepine (Tegretol) in the management of
trigeminal neuralgia by monitoring the clients:

A) Seizure activity
B) Liver function
C) Cardiac output
D) Pain relief


37. Administration of potassium iodide solution is ordered to the client who will undergo a subtotal
thyroidectomy. The nurse understands that this medication is given to:

A) Ablate the cells of the thyroid gland that produce T4.
B) Decrease the total basal metabolic rate.
C) Decrease the size and vascularity of the thyroid.
D) Maintain function of the parathyroid gland.


38. A client with Addisons disease is scheduled for discharge. Before the discharge, the physician
prescribes hydrocortisone and fludrocortisone. The nurse expects the hydrocortisone to:

A) Increase amounts of angiotensin II to raise the clients blood pressure.
B) Control excessive loss of potassium salts.
C) Prevent hypoglycemia and permit the client to respond to stress.
D) Decrease cardiac dysrhythmias and dyspnea.


39. A client with diabetes insipidus is taking Desmopressin acetate (DDAVP). To determine if the drug is
effective, the nurse should monitor the clients:

A) Arterial blood pH
B) Pulse rate
C) Serum glucose
D) Intake and output


40. A client with recurrent urinary tract infections is to be discharged. The client will be taking
nitrofurantoin (Macrobid) 50 mg po every evening at home. The nurse provides discharge instructions to
the client. Which of the following instructions will be correct?

A) Strain urine for crystals and stones
B) Increase fluid intake.
C) Stop the drug if the urinary output increases
D) Maintain the exact time schedule for drug taking.


41. A client with cancer of the lung is receiving chemotherapy. The physician orders antibiotic therapy
for the client. The nurse understands that chemotherapy destroys rapidly growing leukocytes in the:

A) Bone marrow
B) Liver
C) Lymph nodes
D) Blood


42. The physician reduced the clients Dexamethasone (Decadron) dosage gradually and to continue a
lower maintenance dosage. The client asks the nurse about the change of dosage. The nurse explains to
the client that the purpose of gradual dosage reduction is to allow:

A) Return of cortisone production by the adrenal glands.
B) Production of antibodies by the immune system
C) Building of glycogen and protein stores in liver and muscle
D) Time to observe for return of increases intracranial pressure


43. The nurse is assigned to care for a client with diarrhea. Excessive fluid loss is expected. The nurse is
aware that fluid deficit can most accurately be assessed by:

A) The presence of dry skin
B) A change in body weight
C) An altered general appearance
D) A decrease in blood pressure


44. Which of the following is the most important electrolyte of intracellular fluid?

A) Potassium
B) Sodium
C) Chloride
D) Calcium


45. Which of the following client has a high risk for developing hyperkalemia?

A) Crohns disease
B) End-Stage renal disease
C) Cushings syndrome
D) Chronic heart failure


46. The nurse is reviewing the laboratory result of the client. The clients serum potassium level is 5.8
mEq/L. Which of the following is the initial nursing action?

A) Call the cardiac arrest team to alert them
B) Call the laboratory and repeat the test
C) Take the clients vital signs and notify the physician
D) Obtain an ECG strip and have lidocaine available


47. Potassium chloride, 20 mEq, is ordered and to be added in the IV solution of a client in a diabetic
ketoacidosis. The primary reason for administering this drug is:

A) Replacement of excessive losses
B) Treatment of hyperpnea
C) Prevention of flaccid paralysis
D) Treatment of cardiac dysrhythmias


48. A female client is brought to the emergency unit. The client is complaining of abdominal cramps. On
assessment, client is experiencing anorexia and weight is reduced. The physicians diagnosis is colitis.
Which of the following symptoms of fluid and electrolyte imbalance should the nurse report
immediately?

A) Skin rash, diarrhea, and diplopia
B) Development of tetaniy with muscles spasms
C) Extreme muscle weakness and tachycardia
D) Nausea, vomiting, and leg and stomach cramps.


49. The client is to receive an IV piggyback medication. When preparing the medication the nurse should
be aware that it is very important to:

A) Use strict sterile technique
B) Use exactly 100mL of fluid to mix the medication
C) Change the needle just before adding the medication
D) Rotate the bag after adding the medication


50. The nurse is reviewing the laboratory result of the client. An arterial blood gas report indicates the
clients pH is 7.20, PCO2 35 mmHg and HCO3 is 19 mEq/L. The results are consistent with:

A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis

Answer and Rationale: Board Exam Nursing Test IV NLE
<< Back to Questions

1. A. Clients in the early stage of spinal cord damage experience an atonic bladder, which is
characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort with
distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid
intake limits urinary stasis and infection by diluting the urine and increasing urinary output.

2. D. The temperature of 102 F (38.8C) or greater lead to an increased metabolism and cardiac
workload.

3. B. Dysuria, nocturia, and urgency are all signs an irritable bladder after radiation therapy.

4. A. The occipital lobe is involve with visual interpretation.

5. C. Mineralocorticoids such as aldosterone cause the kidneys to retain sodium ions. With
sodium, water is also retained, elevating blood pressure. Absence of this hormone thus causes
hypotension.

6. B. As a person with a tear in the lung inhales, air moves through that opening into the
intrapleural and causes partial or complete collapse of the lungs.

7. A. Heavy alcohol ingestion predisposes an individual to the development of oral cancer.

8. D. The greater the density of compact bone makes it stronger than the cancellous bone.
Compact bone forms from cancellous bone by the addition of concentric rings of bones
substances to the marrow spaces of cancellous bone. The large marrow spaces are reduced to
haversian canals.

9. A. Viscosity, a measure of a fluids internal resistance to flow, is increased as the number of
red cells suspended in plasma.

10. C. Hemiparesis creates instability. Using a cane provides a wider base of support and,
therefore greater stability.

11. D. Manual stretching exercises will assist in keeping the muscles and tendons supple and
pliable, reducing the traumatic consequences of repetitive activity.

12. C. The length of the urethra is shorter in females than in males; therefore microorganisms
have a shorter distance to travel to reach the bladder. The proximity of the meatus to the anus in
females also increases this incidence.

13. D. Temperature may increase within the first 24 hours and persist as long as a week.

14. C. The hips are in extension when the client is prone; this keeps the hips from flexing.

15. C. Steroids have an anti-inflammatory effect that can reduce arthritic pannus formation.

16. A. Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure
and may lead to hemorrhage in the anterior chamber.

17. C. This decrease in PaO2 indicates respiratory failure; it warrants immediate medical
evaluation.

18. C. This is truthful and provides basic information that may prompt recollection of what
happened; it is a starting point.

19. D. Clients adapting to illness frequently feel afraid and helpless and strike out at health team
members as a way of maintaining control or denying their fear.

20. C. There are few physical restraints on activity postoperatively, but the client may have
emotional problems resulting from the body image changes.

21. B. Clients need to be prepared emotionally for the body image changes that occur after
bariatric surgery. Clients generally experience excessive abdominal skin folds after weight
stabilizes, which may require a panniculectomy. Body image disturbance often occurs in
response to incorrectly estimating ones size; it is not uncommon for the client to still feel fat no
matter how much weight is lost.

22. D. Surgery on the bowel has no direct anatomic or physiologic effect on sexual performance.
However, the nurse should encourage verbalization.

23. C. Osteoporosis is not restricted to women; it is a potential major health problem of all older
adults; estimates indicate that half of all women have at least one osteoporitic fracture and the
risk in men is estimated between 13% and 25%; a bone mineral density measurement assesses
the mass of bone per unit volume or how tightly the bone is packed.

24. A. Around-the-clock administration of analgesics is recommended for acute pain in the older
adult population; this help to maintain a therapeutic blood level of pain medication.

25. C. Generally, female voices have a higher pitch than male voices; older adults with
presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher-
pitched sounds.

26. D. Aldactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect.

27. A. Albuterols sympathomimetic effect causes cardiac stimulation that may cause tachycardia
and palpitation.

28. D. Changing positions slowly will help prevent the side effect of orthostatic hypotension.

29. A. Therapeutic effects of simvastatin include decreased serum triglyceries, LDL and
cholesterol.

30. C. Nitroglycerine is sensitive to light and moisture ad must be stored in a dark, airtight
container.

31. A. Visual disturbance are a sign of toxicity because retinopathy can occur with this drug.

32. B. Toxic levels of Lanoxin stimulate the medullary chemoreceptor trigger zone, resulting in
nausea and subsequent anorexia.

33. B. Warfarin derivatives cause an increase in the prothrombin time and INR, leading to an
increased risk for bleeding. Any abnormal or excessive bleeding must be reported, because it
may indicate toxic levels of the drug.

34. B. Levodopa is the metabolic precursor of dopamine. It reduces sympathetic outflow by
limiting vasoconstriction, which may result in orthostatic hypotension.

35. A. Tensilon, an anticholinesterase drug, causes temporary relief of symptoms of myasthenia
gravis in client who have the disease and is therefore an effective diagnostic aid.

36. D. Carbamazepine ( Tegretol) is administered to control pain by reducing the transmission of
nerve impulses in clients with trigeminal neuralgia.

37. C. Potassium iodide, which aids in decreasing the vascularity of the thyroid gland, decreases
the risk for hemorrhage.

38. C. Hydrocortisone is a glucocorticoid that has anti-inflammatory action and aids in
metabolism of carbohydrate, fat, and protein, causing elevation of blood glucose. Thus it enables
the body to adapt to stress.

39. D. DDAVP replaces the ADH, facilitating reabsorption of water and consequent return of
normal urine output and thirst.

40. B. To prevent crystal formation, the client should have sufficient intake to produce 1000 to
1500 mL of urine daily while taking this drug.

41. A. Prolonged chemotherapy may slow the production of leukocytes in bone marrow, thus
suppressing the activity of the immune system. Antibiotics may be required to help counter
infections that the body can no longer handle easily.

42. A. Any hormone normally produced by the body must be withdrawn slowly to allow the
appropriate organ to adjust and resume production.

43. B. Dehydration is most readily and accurately measured by serial assessment of body weight;
1 L of fluid weighs 2.2 pounds.

44. A. The concentration of potassium is greater inside the cell and is important in establishing a
membrane potential, a critical factor in the cells ability to function.

45. B. The kidneys normally eliminate potassium from the body; hyperkalemia may necessitate
dialysis.

46. C. Vital signs monitor cardiorespiratory status; hyperkalemia causes serious cardiac
dysrhythmias.

47. A. Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the
cell, causing hypokalemia; therefore potassium, along with the replacement fluid, is generally
supplied.

48. C. Potassium, the major intracellular cation, functions with sodium and calcium to regulate
neuromuscular activity and contraction of muscle fibers, particularly the heart muscle. In
hypokalemia these symptoms develop.

49. A. Because IV solutions enter the bodys internal environment, all solutions and medications
utilizing this route must be sterile to prevent the introduction of microbes.

50. A. A low pH and bicarbonate level are consistent with metabolic acidosis.










CANCER NURSING
1. You are caring for a patient with esophageal cancer. Which task could be delegated to the
nursing assistant?

a. Assist the patient with oral hygiene.
b. Observe the patients response to feedings.
c. Facilitate expression of grief or anxiety.
d. Initiate daily weights.


2. A 56-year-old patient comes to the walk-in clinic for scant rectal bleeding and
intermittent diarrhea and constipation for the past several months. There is a history of
polyps and a family history for colorectal cancer. While you are trying to teach about
colonoscopy, the patient becomes angry and threatens to leave. What is the priority
diagnosis?

a. Diarrhea/Constipation related to altered bowel patterns
b. Knowledge Deficit related to disease process and diagnostic procedure
c. Risk for Fluid Volume Deficit related to rectal bleeding and diarrhea
d. Anxiety related to unknown outcomes and perceive threat to body integrity


3. Which patient is at greatest risk for pancreatic cancer?

a. An elderly black male with a history of smoking and alcohol use
b. A young, white obese female with no known health issues
c. A young black male with juvenile onset diabetes
d. An elderly white female with a history of pancreatitis


4. The disease progress of cancers, such as cervical or Hodgkins, can be classified
according to a clinical staging system. Place the description of stages 0-IV in the correct
order.

a. Metastasis
b. Limited local spread
c. Cancer in situ
d. Tumor limited to tissue of origin
e. Extensive local and regional spread
_____, _____, _____, _____, _____

5. In assigning patients with alterations related to gastrointestinal (GI) cancer, which would
be the most appropriate nursing care tasks to assign to the LPN/LVN, under supervision of
the team leader RN?

a. A patient with severe anemia secondary to GI bleeding
b. A patient who needs enemas and antibiotics to control GI bacteria
c. A patient who needs pre-op teaching for bowel resection surgery
d. A patient who needs central line insertion for chemotherapy


6. A community health center is preparing a presentation on the prevention and detection of
cancer. Which health care professional (RN, LPN/LVN, nurse practitioner, nutritionist) should
be assigned to address the following topics?

a. Explain screening exams and diagnostic testing for common cancers
____________________________
b. How to plan a balanced diet and reduce fats and preservatives
_______________________
c. Prepare a poster on the seven warning signs of cancer
____________________________
d. How to practice breast or testicular self-examination _______________________
e. Strategies for reducing risk factors such as smoking and obesity
___________________________


7. The physician tells the patient that there will be an initial course of treatment with
continued maintenance treatments and ongoing observation for signs and symptoms over a
prolonged period of time. You can help the patient by reinforcing that the primary goal for
this type of treatment is:

a. Cure
b. Control
c. Palliation
d. Permanent remission


8. For a patient who is experiencing side effects of radiation therapy, which task would be
the most appropriate to delegate to the nursing assistant?

a. Assist the patient to identify patterns of fatigue.
b. Recommend participation in a walking program.
c. Report the amount and type of food consumed from the tray.
d. Check the skin for redness and irritation after the treatment.


9. For a patient on the chemotherapeutic drug vincristine (Oncovin), which of the following
side effects should be reported to the physician?

a. Fatigue
b. Nausea and vomiting
c. Paresthesia
d. Anorexia


10.For a patient who is receiving chemotherapy, which laboratory result is of particular
importance?

a. WBC
b. PT and PTT
c. Electrolytes
d. BUN


11.For care of a patient who has oral cancer, which task would be appropriate to delegate to
the LPN/LVN?

a. Assist the patient to brush and floss.
b. Explain when brushing and flossing are contraindicated.
c. Give antacids and sucralfate suspension as ordered.
d. Recommend saliva substitutes.


12.When assigning staff to patients who are receiving chemotherapy, what is the major
consideration about chemotherapeutic drugs?

a. During preparation, drugs may be absorbed through the skin or inhaled.
b. Many chemotherapeutics are vesicants.
c. Chemotherapeutics are frequently given through central nervous access devices.
d. Oral and venous routes are the most common.


13.You have just received the morning report from the night shift nurses. List the order of
priority for assessing and caring for these patients.

a. A patient who developed tumor lysis syndrome around 5:00 AM
b. A patient with frequent reports of break-through pain over the past 24 hours
c. A patient scheduled for exploratory laparotomy this morning
d. A patient with anticipatory nausea and vomiting for the past 24 hours
_____, _____, _____, _____

14.In monitoring patients who are at risk for spinal cord compression related to tumor
growth, what is the most likely early manifestation?

a. Sudden-onset back pain
b. Motor loss
c. Constipation
d. Urinary hesitancy


15.Chemotherapeutic treatment of acute leukemia is done in four phases. Place these
phases in the correct order.

a. Maintenance
b. Induction
c. Intensification
d. Consolidation
_____, _____, _____, _____


16.Which set of classification values indicates the most extensive and progressed cancer?

a. T1 N0 M0
b. Tis N0 M0
c. T1 N1 M0
d. T4 N3 M1


17.For a patient with osteogenic sarcoma, you would be particularly vigilant for elevations in
which laboratory value?

a. Sodium
b. Calcium
c. Potassium
d. Hematocrit

18.Which of the following cancer patients could potentially be placed together as
roommates?

a. A patient with a neutrophil count of 1000/mm3
b. A patient who underwent debulking of a tumor to relieve pressure
c. A patient receiving high-dose chemotherapy after a bone marrow harvest
d. A patient who is post-op laminectomy for spinal cord compression


19.What do you tell patients is the most important risk factor for lung cancer when you are
teaching about lung cancer prevention?

a. Cigarette smoking
b. Exposure to environmental/occupational carcinogens
c. Exposure to environmental tobacco smoke (ETS)
d. Pipe or cigar smoking

20.Following chemotherapy, a patient is being closely monitored for tumor lysis syndrome.
Which laboratory value requires particular attention?

a. Platelet count
b. Electrolytes
c. Hemoglobin
d. Hematocrit


21.Persons at risk are the greater target population for cancer screening programs. Which
asymptomatic patient(s) needs extra encouragement to participate in cancer screening?
(Choose all that apply).

a. A 19-year-old white-American female who is sexually inactive for a Pap smear
b. A 35-year-old white-American female for an annual mammogram
c. A 45-year-old African-American male for an annual prostate-specific antigen
d. A 49year-old African-American male for an annual fecal occult blood test


22.A patient with lung cancer develops syndrome of inappropriate antidiuretic hormone
secretion (SIADH). After reporting symptoms of weight gain, weakness, and nausea and
vomiting to the physician, you would anticipate which initial order for the treatment of this
patient?

a. A fluid bolus as ordered
b. Fluid restrictions as ordered
c. Urinalysis as ordered
d. Sodium-restricted diet as ordered


23.In caring for a patient with neutropenia, what tasks can be delegated to the nursing
assistant? (Choose all that apply).

a. Take vital signs every 4 hours
b. Report temperature elevation >100.4o F
c. Assess for sore throat, cough, or burning with urination.
d. Gather the supplies to prepare the room for protective isolation.
e. Report superinfections, such as candidiasis
f. Practice good handwashing technique.

24.A primary nursing responsibility is the prevention of lung cancer by assisting patients in
smoking/tobacco cessation. Which tasks would be appropriate to delegate to the LPN/LVN?

a. Develop a quit plan
b. Explain the application of a nicotine patch
c. Discuss strategies to avoid relapse
d. Suggest ways to deal with urges for a tobacco


Answer and Rationale - Cancer

RATIONALE
CANCER

1. ANSWER A Oral hygiene is within the scope of responsibilities of the nursing assistant. It is
the responsibility of the nurse to observe response to treatments and to help the patient deal
with loss or anxiety. The nursing assistant can be directed to weigh the patient, but should not be
expected to know when to initiate that measurement.

2. ANSWER D The patients physical condition is currently stable, but emotional needs are
affecting his or her ability to receive the information required to make an informed decision. The
other diagnoses are relevant, but if the patient leaves the clinic for interventions may be delayed
or ignored.

3. ANSWER A Pancreatic cancer is more common in blacks, males, and smokers. Other links
include alcohol, diabetes, obesity, history of pancreatitis, organic chemicals, a high-fat diet, and
previous abdominal radiation.

4. ANSWER C, D, B, E, A This classification system is based on the extent of the disease rather
than the histological changes, Stage 0: cancer in situ, stage I: tumor limited to tissue of origin,
stage II: limited local spread, stage III: extensive local and regional spread, stage IV: metastasis.

5. ANSWER B Administering enemas and antibiotics is within the scope of practice for
LPN/LVNs. Although some states may allow the LPN/LVN to administer blood, in general, blood
administration, pre-operative teaching, and assisting with central line insertion are the
responsibilities of the RN>

6. ANSWER A. Nurse Practitioner, B. Nutritionist, C. LPN/LVN, D. Nurse Practitioner, E. RN The
nurse practitioner is often the provider who performs the physical examinations and
recommends diagnostic testing. The nutritionist can give information about diet. The LPN/LVN
will know the standard seven warning signs and can educate through standard teaching
programs in some states. However, the RN has primary responsibility for educating people about
risk factors.

7. ANSWER B The physician has described a treatment for controlling cancer that is not curable.
When the goal is cure, the patient will be deemed free of disease after treatments. In palliation,
the treatment is given primarily for pain relief. Permanent remission is another term to describe
cure.

8. ANSWER C The nursing assistant can observe the amount that patient eats (or what is gone
from the tray) and report to the nurse. Assessing patterns of fatigue or skin reaction is the
responsibility of the RN. The initial recommendation for exercise should come from the
physician.

9. ANSWER C Paresthesia is a side effect associated with some chemotherapy drugs such as
vincristine (Oncovin). The physician can modify the dose or discontinue the drug. Fatigue,
nausea, vomiting, and anorexia are common side effects for many chemotherapy medications.
The nurse can assist the patient by planning for rest periods, giving antiemetics as ordered, and
encouraging small meals with high-protein and high-calorie foods.

10. ANSWER A WBC count is especially important because chemotherapy can cause decreases
in WBCs, particularly neutrophils, which leaves the patient vulnerable to infection. The other
tests are important in the total management, but less directly specific to
chemotherapy.

11. ANSWER C Giving medications is within the scope of practice for the LPN/LVN. Assisting the
patient to brush and floss should be delegated to the nursing assistant. Explaining
contraindications is the responsibility of the RN. Recommendations for saliva substitutes should
come from the physician or pharmacist.

12. ANSWER A Ideally, chemotherapy drugs should be given by nurses who have received
additional training in how to safely prepare and deliver the drugs and protect themselves from
exposure. The other options are a concern but the general principles of drug administration
apply.

13. ANSWER A, C, B, D Tumor lysis syndrome is an emergency of electrolyte imbalances and
potential renal failure. A patient scheduled for surgery should be assessed and prepared for
surgery. A patient with breakthrough pain needs assessment and the physician may need to be
contacted for a change of dose or medication. Anticipatory nausea and vomiting has a
psychogenic component that requires assessment, teaching, reassurance, and antiemetics.

14. ANSWER A Back pain is an early sign occurring in 95% of patients. The other symptoms are
later signs.

15. ANSWER B, C, D, A Induction is the initial aggressive treatment to destroy leukemia cells.
Intensification starts immediately after induction, lasting for several months and targeting
persistent, undetected leukemia cells. Consolidation occurs after remission to eliminate any
remaining leukemia cells. Maintenance involves lower doses to keep the body free of leukemia
cells.

16. ANSWER D T (tumor) 0-4 signifies tumors increasing size. N (regional lymph nodes) 0-3
signifies increasing involvement of lymph nodes. M (metastasis) 0 signifies no metastasis and 1
signifies distal metastasis.

17. ANSWER B Potentially life-threatening hypercalcemia can occur in cancers with destruction
of bone. Other laboratory values are pertinent for overall patient management but are less
specific to bone cancers.

18. ANSWER B, D Debulking of tumor and laminectomy are palliative procedures. These
patients can be placed in the same room. The patient with low neutrophil count and the patient
who has had a bone marrow harvest need protective isolation.

19. ANSWER A Cigarette smoking is associated with 80-90% of lung cancers. Occupational
exposure coupled with cigarette smoking increases risks. ETS increases risk by 35%. Cigar
smoking provides higher risk than pipe smoking, but both are lower risks than cigarette smoking.

20. ANSWER B Tumor lysis syndrome can result in severe electrolyte imbalances and potential
renal failure. The other laboratory values are important to monitor for general chemotherapy
side effects, but are less pertinent to tumor lysis syndrome.

21. ANSWER A, C After age 18, females should annual Pap smears, regardless of sexual activity.
African-American males should begin prostate-specific antigen testing at age 45. Annual
mammograms are recommended for women over the age of 40. Annual fecal occult blood
testing is recommended starting at age 50.

22. ANSWER B Hyponatremia is a concern; therefore, fluid restrictions would be ordered.
Urinalysis is less pertinent; however, the nurse should monitor for increased urine specific
gravity. The diet may need to include sodium supplements. Fluid bolus is unlikely to be ordered
for SIADH.

23. ANSWER A, B, D,F Vital signs and reporting on specific parameters, good hand washing, and
gathering equipment are within the scope of duties for an nursing assistant. Assessing for
symptoms of infection/superinfections is the responsibility of the RN.

24. ANSWER B The LPN/LVN is versed in medication administration and able to teach patients
standardized information. The other options require more in-depth assessment, planning, and
teaching, which should be performed by the RN.



















Medical-Surgical Emergencies

1. You are the charge nurse in an emergency department (ED) and must assign two staff
members to cover the triage area. Which team is the most appropriate for this
assignment?

a. An advanced practice nurse and an experienced LPN/LVN
b. An experienced LPN/LVN and an inexperienced RN
c. An experienced RN and an inexperienced RN
d. An experienced RN and a nursing assistant


2. You are working in the triage area of an ED, and four patients approach the triage desk
at the same time. List the order in which you will assess these patients.

a. An ambulatory, dazed 25-year-old male with a bandaged head wound
b. An irritable infant with a fever, petechiae, and nuchal rigidity
c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity
d. A 50-year-old female with moderate abdominal pain and occasional vomiting
_____, _____, _____, _____


3. In conducting a primary survey on a trauma patient, which of the following is considered
one of the priority elements of the primary survey?

a. Complete set of vital signs
b. Palpation and auscultation of the abdomen
c. Brief neurologic assessment
d. Initiation of pulse oximetry


4. A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and
dizziness. This patient should be prioritized into which category?

a. High urgent
b. Urgent
c. Non-urgent
d. Emergent

5. The physician has ordered cooling measures for a child with fever who is likely to be
discharged when the temperature comes down. Which of the following would be appropriate
to delegate to the nursing assistant?

a. Assist the child to remove outer clothing.
b. Advise the parent to use acetaminophen instead of aspirin.
c. Explain the need for cool fluids.
d. Prepare and administer a tepid bath.


6. It is the summer season, and patients with signs and symptoms of heat-related illness
present in the ED. Which patient needs attention first?

a. An elderly person complains of dizziness and syncope after standing in the sun for several
hours to view a parade
b. A marathon runner complains of severe leg cramps and nausea. Tachycardia,
diaphoresis, pallor, and weakness are observed.
c. A previously healthy homemaker reports broken air conditioner for days. Tachypnea,
hypotension, fatigue, and profuse diaphoresis are observed.
d. A homeless person, poor historian, presents with altered mental status, poor muscle
coordination, and hot, dry, ashen skin. Duration of exposure is unknown.


7. You respond to a call for help from the ED waiting room. There is an elderly patient lying
on the floor. List the order for the actions that you must perform.

a. Perform the chin lift or jaw thrust maneuver.
b. Establish unresponsiveness.
c. Initiate cardiopulmonary resuscitation (CPR).
d. Call for help and activate the code team.
e. Instruct a nursing assistant to get the crash cart.
_____, _____, _____, _____, _____


8. The emergency medical service (EMS) has transported a patient with severe chest pain.
As the patient is being transferred to the emergency stretcher, you note unresponsiveness,
cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the
nursing assistant?

a. Chest compressions
b. Bag-valve mask ventilation
c. Assisting with oral intubation
d. Placing the defibrillator pads


9. An anxious 24-year-old college student complains of tingling sensations, palpitations, and
chest tightness. Deep, rapid breathing and carpal spasms are noted. What priority nursing
action should you take?

a. Notify the physician immediately.
b. Administer supplemental oxygen.
c. Have the student breathe into a paper bag.
d. Obtain an order for an anxiolytic medication.


10.An experienced traveling nurse has been assigned to work in the ED; however, this is
the nurses first week on the job. Which area of the ED is the most
appropriate assignment for the nurse?

a. Trauma team
b. Triage
c. Ambulatory or fats track clinic
d. Pediatric medicine team


11.A tearful parent brings a child to the ED for taking an unknown amount of childrens
chewable vitamins at an unknown time. The child is currently alert and asymptomatic. What
information should be immediately reported to the physician?

a. The ingested childrens chewable vitamins contain iron.
b. The child has been treated several times for ingestion of toxic substances.
c. The child has been treated several times for accidental injuries.
d. The child was nauseated and vomited once at home.


12.In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN?

a. Assess immediate emotional state and physical injuries
b. Collect hair samples, saliva swabs, and scrapings beneath fingernails.
c. Provide emotional support and supportive communication.
d. Ensure that the chain of custody is maintained.


13.You are caring for a victim of frostbite to the feet. Place the following interventions in the
correct order.

a. Apply a loose, sterile, bulky dressing.
b. Give pain medication.
c. Remove the victim from the cold environment.
d. Immerse the feet in warm water 100o F to 105o F (40.6o C to 46.1o C)
_____, _____, _____, _____


14.A patient sustains an amputation of the first and second digits in a chainsaw accident.
Which task should be delegated to the LPN/LVN?

a. Gently cleanse the amputated digits with Betadine solution.
b. Place the amputated digits directly into ice slurry.
c. Wrap the amputated digits in sterile gauze moistened with saline.
d. Store the amputated digits in a solution of sterile normal saline.


15.A 36-year-old patient with a history of seizures and medication compliance of phenytoin
(Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for
repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the
physician will order which drug for status epilepticus?

a. PO phenytoin and carbamazepine
b. IV lorazepam (Ativan)
c. IV carbamazepam
d. IV magnesium sulfate


16.You are preparing a child for IV conscious sedation prior to repair of a facial laceration.
What information should you immediately report to the physician?

a. The parent is unsure about the childs tetanus immunization status.
b. The child is upset and pulls out the IV.
c. The parent declines the IV conscious sedation.
d. The parent wants information about the IV conscious sedation.


17.An intoxicated patient presents with slurred speech, mild confusion, and uncooperative
behavior. The patient is a poor historian but admits to drinking a
few on the weekend. What is the priority nursing action for this patient?

a. Obtain an order for a blood alcohol level.
b. Contact the family to obtain additional history and baseline information.
c. Administer naloxone (Narcan) 2 - 4 mg as ordered.
d. Administer IV fluid support with supplemental thiamine as ordered.


18.When an unexpected death occurs in the ED, which of the following tasks is most
appropriate to delegate to the nursing assistant?

a. Escort the family to a place of privacy.
b. Go with the organ donor specialist to talk to the family.
c. Assist with postmortem care.
d. Assist the family to collect belongings.


19.Following emergency endotracheal intubation, you must verify tube placement and
secure the tube. List in order the steps that are required to perform this function?

a. Obtain an order for a chest x-ray to document tube placement.
b. Secure the tube in place.
c. Auscultate the chest during assisted ventilation.
d. Confirm that the breath sounds are equal and bilateral.
_____, _____, _____, _____


20.A teenager arrives by private car. He is alert and ambulatory, but this shirt and pants
are covered with blood. He and his hysterical friends are yelling and trying to explain that
that they were goofing around and he got poked in the abdomen with a stick. Which of the
following comments should be given first consideration?

a. There was a lot of blood and we used three bandages.
b. He pulled the stick out, just now, because it was hurting him.
c. The stick was really dirty and covered with mud.
d. Hes a diabetic, so he needs attention right away.


21.A prisoner, with a known history of alcohol abuse, has been in police custody for 48
hours. Initially, anxiety, sweating, and tremors were noted. Now,
disorientation, hallucination, and hyper-reactivity are observed. The medical diagnosis is
delirium tremens. What is the priority nursing diagnosis?

a. Risk for Injury related to seizures
b. Risk for Other-Directed Violence related to hallucinations
c. Risk for Situational Low Self-esteem related to police custody
d. Risk for Nutritional Deficit related to chronic alcohol abuse


22.You are assigned to telephone triage. A patient who was stung by a common honey bee
calls for advice, reports pain and localized swelling, but denies any respiratory distress or
other systemic signs of anaphylaxis. What is the action that you should direct the caller to
perform?

a. Call 911.
b. Remove the stinger by scraping.
c. Apply a cool compress.
d. Take an oral antihistamine.


23.In relation to submersion injuries, which task is most appropriate to delegate to an
LPN/LVN?

a. Talk to a community group about water safety issues.
b. Stabilize the cervical spine for an unconscious drowning victim.
c. Remove wet clothing and cover the victim with a warm blanket.
d. Monitor an asymptomatic near-drowning victim.


24.You are assessing a patient who has sustained a cat bite to the left hand. The cat is up-
to-date immunizations. The date of the patients last tetanus shot is unknown. Which of the
following is the priority nursing diagnosis?

a. Risk for Infection related to organisms specific to cat bites
b. Impaired Skin Integrity related to puncture wounds
c. Ineffective Health Maintenance related to immunization status
d. Risk for Impaired Mobility related to potential tendon damage


25.These patients present to the ED complaining of acute abdominal pain. Prioritize them in
order of severity.

a. A 35-year-old male complaining of severe, intermittent cramps with three episodes of
watery diarrhea, 2 hours after eating
b. A 11-year-old boy with a low-grade fever, left lower quadrant tenderness, nausea, and
anorexia for the past 2 days
c. A 40-year-old female with moderate left upper quadrant pain, vomiting small amounts of
yellow bile, and worsening symptoms over the past week
d. A 56-year-old male with a pulsating abdominal mass and sudden onset of pressure-like
pain in the abdomen and flank within the past hour
_____, _____, _____, _____


26.The nursing manager decides to form a committee to address the issue of violence
against ED personnel. Which combination of employees is best suited to fulfill this
assignment?

a. ED physicians and charge nurses
b. Experienced RNs and experienced paramedics
c. RNs, LPN/LVNs, and nursing assistants
d. At least one representative from each group of ED personnel


27.In a multiple-trauma victim, which assessment finding signals the most serious and life-
threatening condition?

a. A deviated trachea
b. Gross deformity in a lower extremity
c. Decreased bowel sounds
d. Hematuria


28.A patient in a one-car rollover presents with multiple injuries. Prioritize the interventions
that must be initiated for this patient.

a. Secure/start two large-bore IVs with normal saline
b. Use the chin lift or jaw thrust method to open the airway.
c. Assess for spontaneous respirations
d. Give supplemental oxygen per mask.
e. Obtain a full set of vital signs.
f. Remove patients clothing.
g. Insert a Foley catheter if not contraindicated.
_____, _____, _____, _____, ____, ____, ____


29.In the work setting, what is your primary responsibility in preparing for disaster
management that includes natural disasters or bioterrorism incidents?

a. Knowledge of the agencys emergency response plan
b. Awareness of the signs and symptoms for potential agnets of bioterrorism
c. Knowledge of how and what to report to the CDC
d. Ethical decision-making about exposing self to potentially lethal substances


30.You are giving discharge instructions to a woman who has been treated for contusions
and bruises sustained during an episode of domestic violence. What is your priority
intervention for this patient?

a. Transportation arrangements to a safe house
b. Referral to a counselor
c. Advise about contacting the police
d. Follow-up appointment for injuries

Answer and Rationale - Medical-Surgical
Emergencies
<< Back to Questions


RATIONALE
MEDICAL SURGICAL EMERGENCIES

1. ANSWER C Triage requires at least one experienced RN. Pairing an experienced RN with
inexperienced RN provides opportunities for mentoring. Advanced practice nurses are qualified
to perform triage; however, their services are usually required in other areas of the ED. An
LPN/LVN is not qualified to perform the initial patient assessment or decision making. Pairing an
experienced RN with a nursing assistant is the second best option, because the assistant can
obtain vital signs and assist in transporting.

2. ANSWER B, A, D, C An irritable infant with fever and petechiae should be further assessed for
other meningeal signs. The patient with the head wound needs additional history and
assessment for intracranial pressure. The patient with moderate abdominal pain is
uncomfortable, but not unstable at this point. For the ankle injury, medical evaluation can be
delayed 24 48 hours if necessary.

3. ANSWER C A brief neurologic assessment to determine level of consciousness and pupil
reaction is part of the primary survey. Vital signs, assessment of the abdomen, and initiation of
pulse oximetry are considered part of the secondary survey.

4. ANSWER D Chest pain is considered an emergent priority, which is defined as potentially life-
threatening. Patients with urgent priority need treatment within 2 hours of triage (e.g. kidney
stones). Non-urgent conditions can wait for hours or even days. (High urgent is not commonly
used; however, in 5-tier triage systems, High urgent patients fall between emergent and urgent
in terms of the time lapsing prior to treatment).

5. ANSWER A The nursing assistant can assist with the removal of the outer clothing, which
allows the heat to dissipate from the childs skin. Advising and
explaining are teaching functions that are the responsibility of the RN. Tepid baths are not
usually performed because of potential for rebound and shivering.

6. ANSWER D The homeless person has symptoms of heat stroke, a medical emergency, which
increases risk for brain damage. Elderly patients are at risk for
heat syncope and should be educated to rest in cool area and avoid future similar situations. The
runner is having heat crams, which can be managed with rest and fluids. The housewife is
experiencing heat exhaustion, and management includes fluids (IV or parenteral) and cooling
measures. The prognosis for recovery is good.

7. ANSWER B, D, A, C, E Establish unresponsiveness first. (The patient may have fallen and
sustained a minor injury.) If the patient is unresponsive, get help and have someone initiate the
code. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then
responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is
determined that heroic efforts have been exhausted. A crash cart should be at the site when the
code team arrives; however, basic CPR can be effectively performed until the team arrives.

8. ANSWER A Nursing assistants are trained in basic cardiac life support and can perform chest
compressions. The use of the bag-valve mask requires practice and usually a respiratory therapist
will perform this function. The nurse or the respiratory therapist should provide PRN assistance
during intubation. The defibrillator pads are clearly marked; however, placement should be done
by the RN or physician because of the potential for skin damage and electrical arcing.

9. ANSWER C The patient is hyperventilating secondary to anxiety, and breathing into a paper
bag will allow rebreathing of carbon dioxide. Also, encouraging slow breathing will help. Other
treatments such as oxygen and medication may be needed if other causes are identified.

10. ANSWER C The fast track clinic will deal with relatively stable patients. Triage, trauma, and
pediatric medicine should be staffed with experienced nurses who know the hospital routines
and policies and can rapidly locate equipment.

11. ANSWER A Iron is a toxic substance that can lead to massive hemorrhage, coma, shock, and
hepatic failure. Deferoxame is an antidote that can be used for severe cases of iron poisoning.
Other information needs additional investigation, but will not change the immediate diagnostic
testing or treatment plan.

12. ANSWER C The LPN/LVN is able to listen and provide emotional support for her patients.
The other tasks are the responsibility of an RN or, if available, a SANE (sexual assault nurse
examiner) who has received training to assess, collect and safeguard evidence, and care for these
victims.

13. ANSWER C, B, D, A The victim should be removed from the cold environment first, and then
the rewarming process can be initiated. It will be painful, so give pain medication prior to
immersing the feet in warmed water.

14. ANSWER C The only correct intervention is C. the digits should be gently cleansed with
normal saline, wrapped in sterile gauze moistened with saline, and placed in a plastic bag or
container. The container is then placed on ice.

15. ANSWER B IV Lorazepam (Ativan) is the drug of choice for status epilepticus. Tegretol is
used in the management of generalized tonic-clonic, absence or mixed type seizures, but it does
not come in an IV form. PO (per os) medications are inappropriate for this emergency situation.
Magnesium sulfate is given to control seizures in toxemia of pregnancy.

16. ANSWER C Parent refusal is an absolute contraindication; therefore, the physician must be
notified. Tetanus status can be addressed later. The RN can
restart the IV and provide information about conscious sedation; if the parent still notsatisfied,
the physician can give more information.

17. ANSWER D The patient presents with symptoms of alcohol abuse and there is a risk for
Wernickes syndrome, which is caused by a thiamine deficiency. Multiples drug abuse is not
uncommon; however, there is nothing in the question that suggests an opiate overdose that
requires naloxone. Additional information or the results of the blood alcohol level are part of the
total treatment plan but should not delay the immediate treatment.

18. ANSWER C Postmortem care requires some turning, cleaning, lifting, etc., and the nursing
assistant is able to assist with these duties. The RN should take responsibility for the other tasks
to help the family begin the grieving process. In cases of questionable death, belongings may be
retained for evidence, so the chain of custody would have to be maintained.

19. ANSWER C, D, B, A Auscultating and confirming equal bilateral breath sounds should be
performed in rapid succession. If the sounds are not equal or if the sounds are heard over the
mid-epigastric area, tube placement must be corrected immediately. Securing the tube is
appropriate while waiting for the x-ray study.

20. ANSWER B An impaled object may be providing a tamponade effect, and removal can
precipitate sudden hemodynamic decompensation. Additional history including a more definitive
description of the blood loss, depth of penetration, and medical history should be obtained.
Other information, such as the dirt on the stick or history of diabetes, is important in the overall
treatment plan, but can be addressed later.

21. ANSWER A The patient demonstrates neurologic hyperactivity and is on the verge of a
seizure. Patient safety is the priority. The patient needs chlordiazepoxide (Librium) to decrease
neurologic irritability and phenytoin (Dilantin) for seizures. Thiamine and haloperidol (Haldol) will
also be ordered to address the other problems. The other diagnoses are pertinent but not as
immediate.

22. ANSWER B The stinger will continue to release venom into the skin, so prompt removal of
the stinger is advised. Cool compresses and antihistamines can follow. The caller should be
further advised about symptoms that require 911 assistance.

23. ANSWER D The asymptomatic patient is currently stable but should be observed for
delayed pulmonary edema, cerebral edema, or pneumonia. Teaching and care of critical patients
is an RN responsibility. Removing clothing can be delegated to a nursing assistant.

24. ANSWER A Cats mouths contain a virulent organism, Pasteurella multocida, that can lead
to septic arthritis or bacteremia. There is also a risk for tendon damage due to deep puncture
wounds. These wounds are usually not sutured. A tetanus shot can be given before discharge.

25. ANSWER D, B, C, A The patient with a pulsating mass has an abdominal aneurysm that may
rupture and he may decompensate suddenly. The 11-year-old boy needs evaluation to rule out
appendicitis. The woman needs evaluation for gallbladder problems that appear to be
worsening. The 35-year-old man has food poisoning, which is usually self-limiting.

26. ANSWER D At least one representative from each group should be included because all
employees are potential targets fro violence in the ED.

27. ANSWER A A deviated trachea is a symptoms of tension pneumothorax. All of the other
symptoms need to be addressed, but are of lesser priority.

28. ANSWER C, B, D, A, E, F, G For a multiple trauma victim, many interventions will occur
simultaneously as team members assist in the resuscitation. Methods to open the airway such as
the chin lift or jaw thrust can be used simultaneously while assessing for spontaneous
respirations. However, airway and oxygenation are priority. Starting IVs for fluid resuscitation is
part of supporting circulation. (EMS will usually establish at least one IV in the field.) Nursing
assistants can be directed to take vitals and remove clothing. Foley catheter is necessary to
closely monitor output.

29. ANSWER A In preparing for disasters, the RN should be aware of the emergency response
plan. The plan gives guidance that includes roles of team members, responsibilities, and
mechanisms of reporting. Signs and symptoms of many agents will mimic common complaints,
such as flu-like symptoms. Discussions with colleagues and supervisors may help the individual
nurse to sort through ethical dilemmas related to potential danger to self.

30. ANSWER A Safety is a priority for this patient, and she should not return to a place where
violence could reoccur. The other options are important for the long term management of this
care.

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