A.
Vaginal instillation of conjugated estrogen
PNLE I for Foundation of Nursing
1. Which element in the circular chain of infection can be
eliminated by preserving skin integrity?
A. Host
B. Reservoir
C. Mode of transmission
D. Portal of entry
Answer: D. In the circular chain of infection, pathogens must
be able to leave their reservoir and be transmitted to a
susceptible host through a portal of entry, such as broken skin.
2. Which of the following will probably result in a break in
sterile technique for respiratory isolation?
A. Opening the patient’s window to the outside
environment
B. Turning on the patient’s room ventilator
C. Opening the door of the patient’s room leading into
the hospital corridor
D. Failing to wear gloves when administering a bed bath
Answer: C. Respiratory isolation, like strict isolation,
requires that the door to the door patient’s room remain
closed. However, the patient’s room should be well
ventilated, so opening the window or turning on the
ventricular is desirable. The nurse does not need to wear
gloves for respiratory isolation, but good hand washing is
important for all types of isolation
3. Which of the following patients is at greater risk for
contracting an infection?
A. A patient with leukopenia
B. A patient receiving broad-spectrum antibiotics
C. A postoperative patient who has undergone orthopedic
surgery
D. A newly diagnosed diabetic patient
Answer: A. Leukopenia is a decreased number of leukocytes
(white blood cells), which are important in resisting infection.
None of the other situations would put the patient at risk for
contracting an infection; taking broadspectrum antibiotics
might actually reduce the infection risk.
4. Effective hand washing requires the use of:
A. Soap or detergent to promote emulsification
B. Hot water to destroy bacteria
C. A disinfectant to increase surface tension
D. All of the above
Answer: A. Soaps and detergents are used to help remove
bacteria because of their ability to lower the surface tension
of water and act as emulsifying agents. Hot water may lead to
skin irritation or burns
5. After routine patient contact, hand washing should last at
least:
A. 30 seconds
B. 1 minute
C. 2 minute
D. 3 minutes
Answer: A. Depending on the degree of exposure to
pathogens, hand washing may last from 10 seconds to 4
minutes. After routine patient contact, hand washing for 30
seconds effectively minimizes the risk of
pathogen transmission.
6. Which of the following procedures always requires surgical
asepsis?
B. Urinary catheterization
C.
D.
Nasogastric tube insertion
Colostomy irrigation
Answer: B. The urinary system is normally free of
microorganisms except at the urinary meatus. Any procedure
that involves entering this system must use surgically aseptic
measures to maintain a bacteria-free state
7. Sterile technique is used whenever:
A. Strict isolation is required
B. Terminal disinfection is performed
C. Invasive procedures are performed
D. Protective isolation is necessary
Answer: C. All invasive procedures, including surgery,
catheter insertion, and administration of parenteral therapy,
require sterile technique to maintain a sterile environment.
All equipment must be sterile, and the nurse and
the physician must wear sterile gloves and maintain surgical
asepsis. In the operating room, the nurse and physician are
required to wear sterile gowns, gloves, masks, hair covers,
and shoe covers for all invasive procedures. Strict isolation
requires the use of clean gloves, masks, gowns and
equipment to prevent the transmission of highly
communicable diseases by contact or by airborne routes.
Terminal disinfection is the disinfection of all contaminated
supplies and equipment after a patient has been discharged to
prepare them for reuse by another patient. The purpose of
protective (reverse) isolation is to prevent a person
with seriously impaired resistance from coming into contact
who potentially pathogenic organisms.
8. Which of the following constitutes a break in sterile
technique while preparing a sterile field for a dressing change?
A. Using sterile forceps, rather than sterile gloves, to handle
a sterile item
B. Touching the outside wrapper of sterilized material
without sterile gloves
C. Placing a sterile object on the edge of the sterile field
D. Pouring out a small amount of solution (15 to 30 ml)
before pouring the solution into a sterile container
Answer: C. The edges of a sterile field are considered
contaminated. When sterile items are allowed to come in
contact with the edges of the field, the sterile items also
become contaminated
9. A natural body defense that plays an active role in
preventing infection is:
A. Yawning
B. Body hair
C. Hiccupping
D. Rapid eye movements
Answer: B. Hair on or within body areas, such as the nose,
traps and holds particles that contain microorganisms.
Yawning and hiccupping do not prevent microorganisms
from entering or leaving the body. Rapid eye movement
marks the stage of sleep during which dreaming occurs.
10. All of the following statement are true about donning
sterile gloves except:
A. The first glove should be picked up by grasping the
inside of the cuff.
B. The second glove should be picked up by inserting the
gloved fingers under the cuff outside the glove.
C. The gloves should be adjusted by sliding the gloved
fingers under the sterile cuff and pulling the glove over
the wrist
 D. The inside of the glove is considered sterile
Answer: D. The inside of the glove is always considered to
be clean, but not sterile.
11.When removing a contaminated gown, the nurse should be
careful that the first thing she touches is the:
A. Waist tie and neck tie at the back of the gown
B. Waist tie in front of the gown
C. Cuffs of the gown
D. Inside of the gown
Answer: A. The back of the gown is considered clean, the
front is contaminated. So, after removing gloves and washing
hands, the nurse should untie the back of the gown; slowly
move backward away from the gown, holding the inside of
the gown and keeping the edges off the floor; turn and fold
the gown inside out; discard it in a contaminated linen
container; then wash her hands again.
12.Which of the following nursing interventions is considered
the most effective form or universal precautions?
A. Cap all used needles before removing them from their
syringes
B. Discard all used uncapped needles and syringes in
an impenetrable protective container
C. Wear gloves when administering IM injections
D. Follow enteric precautions
Answer: B. According to the Centers for Disease Control
(CDC), blood-to-blood contact occurs most commonly when
a health care worker attempts to cap a used needle. Therefore,
used needles should never be recapped; instead they should
be inserted in a specially designed puncture resistant, labeled
container. Wearing gloves is not always necessary
when administering an I.M. injection. Enteric precautions
prevent the transfer of pathogens via feces.
13.All of the following measures are recommended to prevent
pressure ulcers except:
A. Massaging the reddened are with lotion
B. Using a water or air mattress
C. Adhering to a schedule for positioning and turning
D. Providing meticulous skin care
Answer: A. Nurses and other health care professionals
previously believed that massaging a reddened area with
lotion would promote venous return and reduce edema to the
area. However, research has shown that massage only
increases the likelihood of cellular ischemia and necrosis to
the area
14.Which of the following blood tests should be performed
before a blood transfusion?
A. Prothrombin and coagulation time
B. Blood typing and cross-matching
C. Bleeding and clotting time
D. Complete blood count (CBC) and electrolyte levels.
Answer: B. Before a blood transfusion is performed, the
blood of the donor and recipient must be checked for
compatibility. This is done by blood typing (a test that
determines a person’s blood type) and cross-matching
(a procedure that determines the compatibility of the donor’s
and recipient’s blood after the blood types has been matched).
If the blood specimens are incompatible, hemolysis and
antigen-antibody reactions will occur
15.The primary purpose of a platelet count is to evaluate the:
A. Potential for clot formation
B. Potential for bleeding
C. Presence of an antigen-antibody response
D. Presence of cardiac enzymes
Answer: A. Platelets are disk-shaped cells that are essential for
blood coagulation. A platelet count determines the number of
thrombocytes in blood available for promoting hemostasis and
assisting with blood coagulation after injury. It also is used to
evaluate the patient’s potential for bleeding; however, this is
not its primary purpose. The normal count ranges from
150,000 to 350,000/mm3. A count of 100,000/mm3 or less
indicates a potential for bleeding; count of less than
20,000/mm3 is associated with spontaneous bleeding.
16.Which of the following white blood cell (WBC) counts
clearly indicates leukocytosis?
A. 4,500/mm³
B. 7,000/mm³
C. 10,000/mm³
D. 25,000/mm³
Answer: D. Leukocytosis is any transient increase in the
number of white blood cells (leukocytes) in the blood. Normal
WBC counts range from 5,000 to 100,000/mm3. Thus, a count
of 25,000/mm3 indicates leukocytosis
17. After 5 days of diuretic therapy with 20mg of furosemide
(Lasix) daily, a patient begins to exhibit fatigue, muscle
cramping and muscle weakness. These symptoms probably
indicate that the patient is experiencing:
A. Hypokalemia
B. Hyperkalemia
C. Anorexia
D. Dysphagia
Answer: A. Fatigue, muscle cramping, and muscle weaknesses
are symptoms of hypokalemia (an inadequate potassium level),
which is a potential side effect of diuretic therapy. The
physician usually orders supplemental potassium to prevent
hypokalemia in patients receiving diuretics. Anorexia is
another symptom of hypokalemia. Dysphagia means
difficulty swallowing.
18.Which of the following statements about chest X-ray is
false?
A. No contradictions exist for this test
B. Before the procedure, the patient should remove all
jewelry, metallic objects, and buttons above the waist
C. A signed consent is not required
D. Eating, drinking, and medications are allowed before this
test
Answer: A. Pregnancy or suspected pregnancy is the only
contraindication for a chest X-ray. However, if a chest X-ray
is necessary, the patient can wear a lead apron to protect the
pelvic region from radiation. Jewelry, metallic objects, and
buttons would interfere with the X-ray and thus should not
be worn above the waist. A signed consent is not required
because a chest X-ray is not an invasive examination. Eating,
drinking and medications are allowed because the X-ray is of
the chest, not the abdominal region.
19.The most appropriate time for the nurse to obtain a sputum
specimen for culture is:
A. Early in the morning
B. After the patient eats a light breakfast
C. After aerosol therapy
D. After chest physiotherapy
Answer: A. Obtaining a sputum specimen early in this
morning ensures an adequate supply of bacteria for culturing
and decreases the risk of contamination from food or
medication.
20.A patient with no known allergies is to receive penicillin A. 18G, 1 ½” long
every 6 hours. When administering the medication, the nurse B. 22G, 1” long
observes a fine rash on the C. 22G, 1 ½” long
D. 25G, 5/8” long
patient’s skin. The most appropriate nursing action would be
to: Answer: D. A 25G, 5/8” needle is the recommended size for
insulin injection because insulin is administered by the
A. Withhold the moderation and notify the physician subcutaneous route. An 18G, 1 ½” needle is usually used for
B. Administer the medication and notify the physician I.M. injections in children, typically in the vastus lateralis. A
C. Administer the medication with an antihistamine 22G, 1 ½” needle is usually used for adult I.M. injections,
D. Apply corn starch soaks to the rash which are typically administered in the vastus lateralis or
ventrogluteal site.
Answer: A. Initial sensitivity to penicillin is commonly
manifested by a skin rash, even in individuals who have not 25.The appropriate needle gauge for intradermal injection is:
been allergic to it previously. Because of the danger of
anaphylactic shock, he nurse should withhold the drug A. 20G
and notify the physician, who may choose to substitute B. 22G
another drug. Administering an antihistamine is a dependent C. 25G
nursing intervention that requires a written physician’s order. D. 26G
Although applying corn starch to the rash may relieve
discomfort, it is not the nurse’s top priority in such Answer: D. Because an intradermal injection does not
a potentially life-threatening situation. penetrate deeply into the skin, a small-bore 25G needle is
recommended. This type of injection is used primarily to
21.All of the following nursing interventions are correct when administer antigens to evaluate reactions for allergy
using the Ztrack method of drug injection except: or sensitivity studies. A 20G needle is usually used for I.M.
injections of oilbased medications; a 22G needle for I.M.
A. Prepare the injection site with alcohol injections; and a 25G needle, for I.M. injections; and a 25G
B. Use a needle that’s a least 1” long needle, for subcutaneous insulin injections.
C. Aspirate for blood before injection
D. Rub the site vigorously after the injection to promote 26.Parenteral penicillin can be administered as an:
absorption
A. IM injection or an IV solution
Answer: D. The Z-track method is an I.M. injection B. IV or an intradermal injection
technique in which the patient’s skin is pulled in such a way C. Intradermal or subcutaneous injection
that the needle track is sealed off after the injection. This D. IM or a subcutaneous injection
procedure seals medication deep into the muscle,
thereby minimizing skin staining and irritation. Rubbing the Answer: A. Parenteral penicillin can be administered I.M. or
injection site is contraindicated because it may cause the added to a solution and given I.V. It cannot be administered
medication to extravasate into the skin subcutaneously or intradermally.

22.The correct method for determining the vastus lateralis site 27.The physician orders gr 10 of aspirin for a patient. The
for I.M. injection is to: equivalent dose in milligrams is:

A. Locate the upper aspect of the upper outer quadrant of A. 0.6 mg

the buttock about 5 to 8 cm below the iliac crest B. 10 mg
B. Palpate the lower edge of the acromion process and the C. 60 mg
midpoint lateral aspect of the arm D. 600 mg
C. Palpate a 1” circular area anterior to the umbilicus
D. Divide the area between the greater femoral trochanter Answer: D. gr 10 x 60mg/gr 1 = 600 mg
and the lateral femoral condyle into thirds, and select the
middle third on the anterior of the thigh 28.The physician orders an IV solution of dextrose 5% in
water at 100ml/hour. What would the flow rate be if the drop
Answer: D. The vastus lateralis, a long, thick muscle that factor is 15 gtt = 1 ml?
extends the full length of the thigh, is viewed by many
clinicians as the site of choice for I.M. injections because it A. 5 gtt/minute
has relatively few major nerves and blood vessels. The middle B. 13 gtt/minute
third of the muscle is recommended as the injection site. C. 25 gtt/minute
The patient can be in a supine or sitting position for an D. 50 gtt/minute
injection into this site.
Answer: C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute

23.The mid-deltoid injection site is seldom used for I.M. 29.Which of the following is a sign or symptom of a
injections because it: hemolytic reaction to blood transfusion?

A. Can accommodate only 1 ml or less of medication A. Hemoglobinuria

B. Bruises too easily B. Chest pain
C. Can be used only when the patient is lying down C. Urticaria
D. Does not readily parenteral medication D. Distended neck veins

Answer: A. The mid-deltoid injection site can accommodate
only 1 ml or less of medication because of its size and
location (on the deltoid muscle of the arm, close to the
brachial artery and radial nerve
24.The appropriate needle size for insulin injection is:
Answer: A. Hemoglobinuria, the abnormal presence of
hemoglobin in the urine, indicates a hemolytic reaction
(incompatibility of the donor’s and recipient’s blood). In this
reaction, antibodies in the recipient’s plasma combine rapidly
with donor RBC’s; the cells are hemolyzed in
either circulatory or reticuloendothelial system. Hemolysis
occurs more rapidly in ABO incompatibilities than in Rh
incompatibilities. Chest pain and urticaria may be symptoms
of impending anaphylaxis. Distended neck veins are
an indication of hypervolemia.
30.Which of the following conditions may require fluid
restriction?
A. Fever
B. Chronic Obstructive Pulmonary Disease
C. Renal Failure
D. Dehydration
Answer: C. In real failure, the kidney loses their ability to
effectively eliminate wastes and fluids. Because of this,
limiting the patient’s intake of oral and I.V. fluids may be
necessary. Fever, chronic obstructive pulmonary disease, and
dehydration are conditions for which fluids should
be encouraged.
31.All of the following are common signs and symptoms of
phlebitis except:
A. Pain or discomfort at the IV insertion site
B. Edema and warmth at the IV insertion site
C. A red streak exiting the IV insertion site
D. Frank bleeding at the insertion site
Answer: D. Phlebitis, the inflammation of a vein, can be
caused by chemical irritants (I.V. solutions or medications),
mechanical irritants (the needle or catheter used during
venipuncture or cannulation), or a localized allergic reaction to
the needle or catheter. Signs and symptoms of
phlebitis include pain or discomfort, edema and heat at the I.V.
insertion site, and a red streak going up the arm or leg from
the I.V. insertion site.
32.The best way of determining whether a patient has learned
to instill ear medication properly is for the nurse to:
A. Ask the patient if he/she has used ear drops before
B. Have the patient repeat the nurse’s instructions using her
own words
C. Demonstrate the procedure to the patient and encourage
to ask questions
D. Ask the patient to demonstrate the procedure
Answer: D. Return demonstration provides the most certain
evidence for evaluating the effectiveness of patient teaching.
33.Which of the following types of medications can be
administered via gastrostomy tube?
A. Any oral medications
B. Capsules whole contents are dissolve in water
C. Enteric-coated tablets that are thoroughly dissolved in
water
D. Most tablets designed for oral use, except for
extended-duration compounds
Answer: D. Capsules, enteric-coated tablets, and most
extended duration or sustained release products should not be
dissolved for use in a gastrostomy tube. They are
pharmaceutically manufactured in these forms for valid
reasons, and altering them destroys their purpose. The
nurse should seek an alternate physician’s order when an
ordered medication is inappropriate for delivery by tube.
34.A patient who develops hives after receiving an antibiotic
is exhibiting drug:
A. Tolerance
B. Idiosyncrasy
C. Synergism
D. Allergy
Answer: D. A drug-allergy is an adverse reaction resulting
from an immunologic response following a previous
sensitizing exposure to the drug. The reaction can range from
a rash or hives to anaphylactic shock. Tolerance to a drug
means that the patient experiences a decreasing
physiologic response to repeated administration of the drug in
the same dosage. Idiosyncrasy is an individual’s unique
hypersensitivity to a drug, food, or other substance; it appears
to be genetically determined. Synergism, is a drug interaction
in which the sum of the drug’s combined effects is
greater than that of their separate effects.
35.A patient has returned to his room after femoral
arteriography. All of the following are appropriate nursing
interventions except:
A. Assess femoral, popliteal, and pedal pulses every 15
minutes for 2 hours
B. Check the pressure dressing for sanguineous drainage
C. Assess a vital signs every 15 minutes for 2 hours
D. Order a hemoglobin and hematocrit count 1 hour
after the arteriography
Answer: D. A hemoglobin and hematocrit count would be
ordered by the physician if bleeding were suspected. The other
answers are appropriate nursing interventions for a patient
who has undergone femoral arteriography.
36.The nurse explains to a patient that a cough:
A. Is a protective response to clear the respiratory tract
of irritants
B. Is primarily a voluntary action
C. Is induced by the administration of an antitussive drug
D. Can be inhibited by “splinting” the abdomen
Answer: A. Coughing, a protective response that clears the
respiratory tract of irritants, usually is involuntary; however
it can be voluntary, as when a patient is taught to perform
coughing exercises. An antitussive drug inhibits coughing.
Splinting the abdomen supports the abdominal muscles when
a patient coughs
37.An infected patient has chills and begins shivering. The
best nursing intervention is to:
A. Apply iced alcohol sponges
B. Provide increased cool liquids
C. Provide additional bedclothes
D. Provide increased ventilation
Answer: C. In an infected patient, shivering results from the
body’s attempt to increase heat production and the production
of neutrophils and phagocytotic action through increased
skeletal muscle tension and contractions. Initial
vasoconstriction may cause skin to feel cold to the touch.
Applying additional bed clothes helps to equalize the
body temperature and stop the chills. Attempts to cool the
body result in further shivering, increased metabloism, and
thus increased heat production.
38.A clinical nurse specialist is a nurse who has:
A. Been certified by the National League for Nursing
B. Received credentials from the Philippine Nurses’
Association
C. Graduated from an associate degree program and is a
registered professional nurse
D. Completed a master’s degree in the prescribed
clinical area and is a registered professional nurse.
Answer: D. A clinical nurse specialist must have completed a
master’s degree in a clinical specialty and be a registered
professional nurse. The National League of Nursing accredits
educational programs in nursing and provides a testing service
to evaluate student nursing competence but it does not certify
nurses. The American Nurses Association identifies
requirements for certification and offers examinations for
certification in many areas of nursing., such as medical
surgical nursing. These certification (credentialing)
demonstrates that the nurse has the knowledge and the ability
to provide high quality nursing care in the area of her
certification. A graduate of an associate degree program is not
a clinical nurse specialist: however, she is prepared to provide
bed side nursing with a high degree of knowledge and skill.
She must successfully complete the licensing examination to
become a registered professional nurse.
39.The purpose of increasing urine acidity through dietary
means is to:
A. Decrease burning sensations
B. Change the urine’s color
C. Change the urine’s concentration
D. Inhibit the growth of microorganisms
Answer: D. Microorganisms usually do not grow in an acidic
environment.
40.Clay colored stools indicate:
A. Upper GI bleeding
B. Impending constipation
C. An effect of medication
D. Bile obstruction
Answer: D. Bile colors the stool brown. Any inflammation or
obstruction that impairs bile flow will affect the stool pigment,
yielding light, clay-colored stool. Upper GI bleeding results in
black or tarry stool. Constipation is characterized by small,
hard masses. Many medications and foods will discolor stool –
for example, drugs containing iron turn stool black.; beets turn
stool red.
41.In which step of the nursing process would the nurse ask a
patient if the medication she administered relieved his pain?
A. Assessment
B. Analysis
C. Planning
D. Evaluation
Answer: D. In the evaluation step of the nursing process, the
nurse must decide whether the patient has achieved the
expected outcome that was identified in the planning phase.
42.All of the following are good sources of vitamin A except:
A. White potatoes
B. Carrots
C. Apricots
D. Egg yolks
Answer: A. The main sources of vitamin A are yellow and
green vegetables (such as carrots, sweet potatoes, squash,
spinach, collard greens, broccoli, and cabbage) and yellow
fruits (such as apricots, and cantaloupe). Animal sources
include liver, kidneys, cream, butter, and egg yolks.
43.Which of the following is a primary nursing intervention
necessary for all patients with a Foley Catheter in place?
A. Maintain the drainage tubing and collection bag level
with the patient’s bladder
B. Irrigate the patient with 1% Neosporin solution three
times a daily
C. Clamp the catheter for 1 hour every 4 hours to maintain
the bladder’s elasticity
D. Maintain the drainage tubing and collection bag
below bladder level to facilitate drainage by gravity
Answer: D. Maintaing the drainage tubing and collection bag
level with the patient’s bladder could result in reflux of urine
into the kidney. Irrigating the bladder with Neosporin and
clamping the catheter for 1 hour every 4 hours must be
prescribed by a physician
44.The ELISA test is used to:
A. Screen blood donors for antibodies to human
immunodeficiency virus (HIV)
B. Test blood to be used for transfusion for HIV antibodies
C. Aid in diagnosing a patient with AIDS
D. All of the above
Answer: D. The ELISA test of venous blood is used to assess
blood and potential blood donors to human immunodeficiency
virus (HIV). A positive ELISA test combined with various
signs and symptoms helps to diagnose acquired
immunodeficiency syndrome (AIDS)
45.The two blood vessels most commonly used for TPN
infusion are the:
A. Subclavian and jugular veins
B. Brachial and subclavian veins
C. Femoral and subclavian veins
D. Brachial and femoral veins
Answer: D. Tachypnea (an abnormally rapid rate of breathing)
would indicate that the patient was still hypoxic (deficient in
oxygen).The partial pressures of arterial oxygen and carbon
dioxide listed are within the normal range. Eupnea refers to
normal respiration.
46.Effective skin disinfection before a surgical procedure
includes which of the following methods?
A. Shaving the site on the day before surgery
B. Applying a topical antiseptic to the skin on the evening
before surgery
C. Having the patient take a tub bath on the morning of
surgery
D. Having the patient shower with an antiseptic soap on
the evening v=before and the morning of surgery
Answer: D. Studies have shown that showering with an
antiseptic soap before surgery is the most effective method of
removing microorganisms from the skin. Shaving the site of
the intended surgery might cause breaks in the skin, thereby
increasing the risk of infection; however, if indicated, shaving,
should be done immediately before surgery, not the day
before. A topical antiseptic would not remove microorganisms
and would be beneficial only after proper cleaning and rinsing.
Tub bathing might transfer organisms to another body site
rather than rinse them away.
47.When transferring a patient from a bed to a chair, the nurse
should use which muscles to avoid back injury?
A. Abdominal muscles
B. Back muscles
C. Leg muscles
D. Upper arm muscles
Answer: C. The leg muscles are the strongest muscles in the
body and should bear the greatest stress when lifting. Muscles
of the abdomen, back, and upper arms may be easily injured.
48.Thrombophlebitis typically develops in patients with which
of the following conditions?
 A. Increases partial thromboplastin time
B. Acute pulsus paradoxus
C. An impaired or traumatized blood vessel wall
D. Chronic Obstructive Pulmonary Disease (COPD)
Answer: C. The factors, known as Virchow’s triad,
collectively predispose a patient to thromboplebitis; impaired
venous return to the heart, blood hypercoagulability, and
injury to a blood vessel wall. Increased partial thromboplastin
time indicates a prolonged bleeding time during fibrin
clot formation, commonly the result of anticoagulant (heparin)
therapy. Arterial blood disorders (such as pulsus paradoxus)
and lung diseases (such as COPD) do not necessarily impede
venous return of injure vessel walls.
49.In a recumbent, immobilized patient, lung ventilation can
become altered, leading to such respiratory complications as:
A. Respiratory acidosis, ateclectasis, and hypostatic
pneumonia
B. Appneustic breathing, atypical pneumonia and
respiratory alkalosis
C. Cheyne-Strokes respirations and spontaneous
pneumothorax
D. Kussmail’s respirations and hypoventilation
Answer: A. Because of restricted respiratory movement, a
recumbent, immobilize patient is at particular risk for
respiratory acidosis from poor gas exchange; atelectasis from
reduced surfactant and accumulated mucus in the bronchioles,
and hypostatic pneumonia from bacterial growth caused by
stasis of mucus secretions
50.Immobility impairs bladder elimination, resulting in such
disorders as
A. Increased urine acidity and relaxation of the perineal
muscles, causing incontinence
B. Urine retention, bladder distention, and infection
C. Diuresis, natriuresis, and decreased urine specific gravity
D. Decreased calcium and phosphate levels in the urine
Answer: B. The immobilized patient commonly suffers from
urine retention caused by decreased muscle tone in the
perineum. This leads to bladder distention and urine
stagnation, which provide an excellent medium for bacterial
growth leading to infection. Immobility also results in
more alkaline urine with excessive amounts of calcium,
sodium and phosphate, a gradual decrease in urine
production, and an increased specific gravity.
PNLE II for 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
Answer: Answer: (A) Inevitable. 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. Nurse Reese is reviewing the record of a pregnant client for
her first prenatal visit. Which of the following data, if noted
on the client’s record, would alert the nurse that the client is
at risk for a spontaneous abortion?
A. Age 36 years
B. History of syphilis
C. History of genital herpes
D. History of diabetes mellitus
Answer: Answer: (B) History of syphilis. Maternal infections
such as syphilis, toxoplasmosis, and rubella are causes of
spontaneous abortion.
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
Answer: Answer: (C) Monitoring apical pulse. 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. 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
Answer: (B) Increased caloric intake. 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 mother’s
demand for insulin and is referred to as the diabetogenic
effect of pregnancy.
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.
Answer: Answer: (A) Excessive fetal activity. 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. 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.
Answer: Answer: (B) Absent patellar reflexes. Absence of
patellar reflexes is an indicator of hypermagnesemia, which
requires administration of calcium gluconate
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.
Answer: Answer: (C) Presenting part in 2 cm below the plane
of the ischial spines. Fetus at station plus two indicates that
the presenting part is 2 cm below the plane of 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 ½ 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.
Answer: Answer: (A) Contractions every 1 ½ minutes lasting
70-80 seconds. Contractions every 1 ½ 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. 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
Answer: Answer: (C) EKG tracings. 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. 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.
Answer: Answer: (D) First low transverse caesarean was for
breech position. Fetus in this pregnancy is in a vertex
presentation. This type of client has no obstetrical indication
for a caesarean section as she did with her first caesarean
delivery.
11.Nurse Ryan is aware that the best initial approach when
trying to take a crying toddler’s 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.
Answer: Answer: (A) Talk to the mother first and then to the
toddler. 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.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 infant’s arms in soft elbow restraints.
Answer: Answer: (D) Place the infant’s arms in soft elbow
restraints. 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 shouldn’t be placed in a baby’s
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. 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.
Answer: Answer: (B) Allow the infant to rest before
feeding. Because feeding requires so much energy, an infant
with heart failure should rest 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 infant’s 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.
Answer: Answer: (C) Iron-rich formula only. The infants at
age 5 months should receive iron-rich formula and that they
shouldn’t receive solid food, even baby food until age 6
months.
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
Answer: Answer: (D) 10 months. 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 can’t sit
securely alone. At age 8 months, infants can sit securely alone
but cannot understand the permanence of objects.
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.
Answer: Answer: (D) Public health nursing focuses on
preventive, not curative, services. 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.When the nurse determines whether resources were
maximized in implementing Ligtas Tigdas, she is evaluating
A. Effectiveness
B. Efficiency
C. Adequacy
D. Appropriateness
Answer: Answer: (B) Efficiency. Efficiency is determining
whether the goals were attained at the least possible cost.
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
Answer: Answer: (D) Rural Health Unit. R.A. 7160 devolved
basic health services to local government units (LGU’s ). The
public health nurse is an employee of the LGU.
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
Answer: Answer: (A) Mayor. The local executive serves as the
chairman of the Municipal Health Board
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.
Answer: Answer: (A) 1. Each rural health midwife is given a
population assignment of about 5,000.
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.
Answer: Answer: (B) Health education and community
organizing are necessary in providing community health
services. The community health nurse develops the health
capability of people through health education and
community organizing activities
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
Answer: Answer: (B) Measles. Presidential Proclamation No.
4 is on the Ligtas Tigdas Program.
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
Answer: Answer: (D) Core group formation. 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.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 community’s resources in dealing
with health problems.
D. To maximize the community’s resources in dealing
with health problems.
Answer: (D) To maximize the community’s resources in
dealing with health problems. Community organizing is a
developmental service, with the goal of developing the
people’s self-reliance in dealing with community health
problems. A, B and C are objectives of contributory
objectives to this goal.
25.Tertiary prevention is needed in which stage of the natural
history of disease?
A. Pre-pathogenesis
B. Pathogenesis
C. Prodromal
D. Terminal
Answeer: Answer: Answer: (D) Terminal. 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.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.
Answer: Answer: (A) Intrauterine fetal death. 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.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
Answer: Answer: (C) 120 to 160 beats/minute. 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.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 infant’s fluid intake to decrease saturating
diapers.
Answer: Answer: (A) Change the diaper more
often. Decreasing the amount of time the skin comes contact
with wet soiled diapers will help heal the irritation.
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
Answer: (D) Endocardial cushion defect. Endocardial cushion
defects are seen most in children with Down syndrome,
asplenia, or polysplenia
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
Answer: Answer: (B) Decreased urine output. 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.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
Answer: Answer: (A) Menorrhagia. Menorrhagia is an
excessive menstrual period.
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
Answer: Answer: (C) Blood typing. 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 woman’s cardiac output is
delivered to the uterus, therefore, blood loss can occur
quite rapidly in the event of uncontrolled bleeding
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
Answer: Answer: (D) Physiologic anemia. Hemoglobin values
and hematocrit decrease during pregnancy as the increase in
plasma volume exceeds the increase in red blood cell
production.
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 mother’s arms.
D. A 2 year old infant with stridorous breath sounds,
sitting up in his mother’s arms and drooling.
Answer: Answer: (D) A 2 year old infant with stridorous
breath sounds, sitting up in his mother’s arms and
drooling. The infant with the airway emergency should be
treated first, because of the risk of epiglottitis.
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
Answer: Answer: (A) Placenta previa. Placenta previa with
painless vaginal bleeding.
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
Answer: Answer: (D) Early in the morning. Based on the
nurse’s 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.In doing a child’s 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
:Answer: (A) Irritability and seizures. 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.To evaluate a woman’s understanding about the use of
diaphragm for family planning, Nurse Trish asks her to explain
how she will use the appliance. Which response indicates a
need for further health teaching?
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”.
Answer: (D) “I really need to use the diaphragm and jelly
most during the middle of my menstrual cycle”. 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.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
Answer: (C) Restlessness. 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.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 child’s hand on the
nurse’s elbow.
C. Walk slightly behind, gently guiding the child forward.
D. Walk next to the child, holding the child’s hand.
Answer: (B) Walk one step ahead, with the child’s hand on
the nurse’s elbow. This procedure is generally recommended
to follow in guiding a person who is blind.
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.
Answer: (A) Loud, machinery-like murmur. A loud,
machinery-like murmur is a characteristic finding associated
with patent ductus arteriosus
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 newborn’s metabolic rate
increases.
B. More oxygen, and the newborn’s metabolic rate
decreases.
C. More oxygen, and the newborn’s metabolic rate
increases.
D. Less oxygen, and the newborn’s metabolic rate
decreases.
Answer: (C) More oxygen, and the newborn’s metabolic
rate increases. 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.Before adding potassium to an infant’s I.V. line, Nurse Ron
must be sure to assess whether this infant has:
A. Stable blood pressure
B. Patant fontanelles
C. Moro’s reflex
D. Voided
Answer: (D) Voided. Before administering potassium I.V. to
any client, the nurse must first check that the client’s 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.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
Answer: Answer: (C) Laundry detergent. 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.During tube feeding, how far above an infant’s stomach
should the nurse hold the syringe with formula?
A. 6 inches
B. 12 inches
C. 18 inches
D. 24 inches
Answer: (A) 6 inches. 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. 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.
Answer: (A) The older one gets, the more susceptible he
becomes to the complications of chicken pox. Chicken pox is
usually more severe in adults than in children. Complications,
such as pneumonia, are higher in incidence in adults.
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.
Answer: (D) Consult a physician who may give them rubella
immunoglobulin. 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.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
Answer: (A) Contact tracing. 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.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
Answer: (D) Leptospirosis. 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.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
Answer: (B) Cholera. 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.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 meningitides
Answer: (A) Hemophilus influenzae. 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.The student nurse is aware that the pathognomonic sign
of measles is Koplik’s spot and you may see Koplik’s spot by
inspecting the:
A. Nasal mucosa
B. Buccal mucosa
C. Skin on the abdomen
D. Skin on neck
Answer: (B) Buccal mucosa. Koplik’s spot may be seen on the
mucosa of the mouth or the throat.
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
 Answer: (A) 3 seconds. Adequate blood supply to the area
allows the return of the color of the nailbed within 3
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
Answer: (B) Severe dehydration. 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.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
Answer: (A) 45 infants. To estimate the number of infants,
multiply total population by 3%.
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
Answer: (A) DPT. 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.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
Answer: (C) Proper use of sanitary toilets. 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.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
Answer: (D) 5 skin lesions, positive slit skin smear. A
multibacillary leprosy case is one who has a positive slit skin
smear and at least 5 skin lesions.
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
Answer: Answer: (C) Thickened painful nerves. 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.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.
Answer: (B) Ask where the family resides. Because malaria is
endemic, the first question to determine malaria risk is where
the client’s 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.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
Answer: (A) Inability to drink. 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.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.
Answer: (A) Refer the child urgently to a hospital for
confinement. “Baggy pants” is a sign of severe marasmus. The
best management is urgent referral to a hospital.
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.
Answer: (D) Let the child rest for 10 minutes then continue
giving Oresol more slowly. 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.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.
Answer: (B) Some dehydration. 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.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
Answer: (C) Normal. In IMCI, a respiratory rate of 50/minute
or more is fast breathing for an infant aged 2 to 12 months.
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
Answer: (A) 1 year. 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.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
Answer: (B) 4 hours. 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.The nurse explains to a breastfeeding mother that breast
milk is sufficient for all of the baby’s nutrient needs only up to:
A. 5 months
B. 6 months
C. 1 year
D. 2 years
Answer: (B) 6 months. After 6 months, the baby’s nutrient
needs, especially the baby’s iron requirement, can no longer
be provided by mother’s milk alone
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
Answer: (C) 24 weeks. 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.When teaching parents of a neonate the proper position
for the neonate’s sleep, the nurse Patricia stresses the
importance of placing the neonate on his back to reduce the
risk of which of the following?
A. Aspiration
B. Sudden infant death syndrome (SIDS)
C. Suffocation
D. Gastroesophageal reflux (GER)
Answer: (B) Sudden infant death syndrome (SIDS). 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.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
Answer: (C) Decreased temperature. Temperature instability,
especially when it results in a low temperature in the neonate,
may be a sign of infection. The neonate’s 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.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
Answer: (D) Polycythemia probably due to chronic fetal
hypoxia. The small-for-gestation neonate is at risk for
developing polycythemia during the transitional period in an
attempt to decreasehypoxia. The neonates are also at
increased risk for developing hypoglycemia and hypothermia
due to decreased glycogen stores.
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
Answer: (C) Desquamation of the epidermis. 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.After reviewing the Myrna’s maternal history of
magnesium sulfate during labor, which condition would nurse
Richard anticipate as a potential problem in the neonate?
A. Hypoglycemia
B. Jitteriness
C. Respiratory depression
D. Tachycardia
Answer: (C) Respiratory depression. Magnesium sulfate
crosses the placenta and adverse neonatal effects are
respiratory depression, hypotonia, and bradycardia. The
serum blood sugar isn’t affected by magnesium sulfate. The
neonate would be floppy, not jittery.
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
Answer: (C) Respiratory rate 40 to 60 breaths/minute. 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. 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.
Answer: (C) Keep the cord dry and open to air. Keeping the
cord dry and open to air helps reduce infection and hastens
drying. Infants aren’t 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 isn’t recommended.
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
Answer: (B) Conjunctival hemorrhage. 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.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.
Answer: (B) To assess for prolapsed cord. 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.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 parent’s 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.
Answer: (D) The parents’ interactions with each
other. 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.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.
Answer: (B) Instructing the client to use two or more peripads
to cushion the area. 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. 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?”
Answer: (C) “What is your expected due date?” 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.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 neonate’s nose and mouth with a bulb
syringe.
Answer: (D) Aspirate the neonate’s nose and mouth with a
bulb syringe. 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. 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.
Answer: (C) Conducting a bedside ultrasound for an amniotic
fluid index. 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. 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.
Answer: (C) Monitor partial pressure of oxygen (Pao2)
levels. 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. 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
Answer: (A) 110 to 130 calories per kg. 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. 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
Answer: (C) 30 to 32 weeks. Individual twins usually grow at
the same rate as singletons until 30 to 32 weeks’ gestation,
then twins don’t’ 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 there’s some growth retardation in twins if they
remain in utero at 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
Answer: (A) conjoined twins. 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. 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
Answer: (D) Ultrasound. 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 shouldn’t be done as this may lead to severe
bleeding or hemorrhage. External fetal monitoring won’t
detect a placenta previa, although it will detect fetal distress,
which may result from blood loss or placenta separation.
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
Answer: (A) Increased tidal volume. 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. 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
 Answer: (A) Diet. 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 isn’t needed for blood
glucose control in the client with gestational diabetes
91. Magnesium sulfate is given to Jemma with preeclampsia
to prevent which of the following condition?
A. Hemorrhage
B. Hypertension
C. Hypomagnesemia
D. Seizure
1. Answer: (D) Seizure. The anticonvulsant mechanism of
magnesium is believes to depress seizure foci in the
brain and peripheral neuromuscular blockade.
Hypomagnesemia isn’t a complication of preeclampsia.
Antihypertensive drug other than magnesium are
preferred for sustained hypertension. Magnesium
doesn’t help prevent hemorrhage in preeclamptic
clients.
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
Answer: (C) I.V. fluids. 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 aren’t necessary. Diuretic
wouldn’t be used unless fluid overload resulted.
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)
Answer: (A) Calcium gluconate (Kalcinate). 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. 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.
Answer: (B) An indurated wheal over 10 mm in diameter
appears in 48 to 72 hours. 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. Dianne, 24 year-old is 27 weeks’ pregnant arrives at her
physician’s office with complaints of fever, nausea, vomiting,
malaise, unilateral flank pain, and costovertebral angle
tenderness. Which of the following diagnoses is most likely?
A. Asymptomatic bacteriuria
B. Bacterial vaginosis
C. Pyelonephritis
D. Urinary tract infection (UTI)
Answer: (C) Pyelonephritis. The symptoms indicate acute
pyelonephritis, a serious condition in a pregnant client. UTI
symptoms include dysuria, urgency, frequency, and
suprapubic tenderness. Asymptomatic bacteriuria doesn’t
cause symptoms. Bacterial vaginosis causes milky white
vaginal discharge but no systemic symptoms
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.
Answer: (B) Rh-positive fetal blood crosses into maternal
blood, stimulating maternal antibodies. 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. 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
Answer: (C) Supine position. 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. 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.
Answer: (B) Irritability and poor sucking. 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. 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.
Answer: (A) 7th to 9th day postpartum. 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. 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: (B) Uterine atony. 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.
PNLE III for Care of Clients with
Physiologic and Psychosocial
Alterations (Part 1)
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
Answer: (C) Loose, bloody. 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. 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 client’s right side
B. On the client’s left side
C. Directly in front of the client
D. Where the client like
Answer: (A) On the client’s right side. The client has left
visual field blindness. The client will see only from the right
side
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.
Answer: (C) Check respirations, stabilize spine, and check
circulation. Checking the airway would be priority, and a
neck injury should be suspected
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.
Answer: (D) Decreasing venous return through
vasodilation. The significant effect of nitroglycerin is
vasodilation and decreased venous return, so the heart does
not have to work hard.
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.
Answer: (A) Call for help and note the time. 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 client’s phone and giving the hospital
code for cardiac arrest and the client’s 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. 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.
Answer: (C) Make sure that the client takes food and
medications at prescribed intervals. Food and drug therapy
will prevent the accumulation of hydrochloric acid, or will
neutralize and buffer the acid that does accumulate.
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.
Answer: (B) Continue treatment as ordered. 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. 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.
Answer: (B) In the operating room. 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. 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.
Answer: (B) Flat on back. 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.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.
Answer: (C) The client is oriented when aroused from sleep,
and goes back to sleep immediately. This finding suggest that
the level of consciousness is decreasing.
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
Answer: (A) Altered mental status and dehydration. 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. 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 104°F (40°C) and nausea
D. Headache and photophobia
Answer: (B) Chills, fever, night sweats, and
hemoptysis. Typical signs and symptoms are chills, fever,
night sweats, and hemoptysis. Chest pain may be present
from coughing, but isn’t usual. Clients with TB typically have
low-grade fevers, not higher than 102°F (38.9°C). Nausea,
headache, and photophobia aren’t usual TB symptoms.
13. Mark, a 7-year-old client is brought to the emergency
department. He’s tachypneic and afebrile and has a
respiratory rate of 36 breaths/minute and has a
nonproductive cough. He recently had a cold. Form this
history; the client may have which of the following conditions?
A. Acute asthma
B. Bronchial pneumonia
C. Chronic obstructive pulmonary disease (COPD)
D. Emphysema
Answer:(A) Acute asthma. Based on the client’s history and
symptoms, acute asthma is the most likely diagnosis. He’s
unlikely to have bronchial pneumonia without a productive
cough and fever and he’s too young to have developed
(COPD) and emphysema.
14. Marichu was given morphine sulfate for pain. She is
sleeping and her respiratory rate is 4 breaths/minute. If
action isn’t taken quickly, she might have which of the
following reactions?
A. Asthma attack
B. Respiratory arrest
C. Seizure
D. Wake up on his own
Answer: (B) Respiratory arrest. Narcotics can cause
respiratory arrest if given in large quantities. It’s unlikely the
client will have asthma attack or a seizure or 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
Answer: (D) Decreased vital capacity. 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. 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).
Answer: (C) Presence of premature ventricular contractions
(PVCs) on a cardiac monitor. Lidocaine drips are commonly
used to treat clients whose arrhythmias haven’t 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 aren’t as significant as PVCs in
the situation.
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.
Answer: (B) Avoid foods high in vitamin K. 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 isn’t 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. 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.
Answer: (C) Clipping the hair in the area. 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. 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. Dowager’s hump
Answer: (A) Bone fracture. 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 isn’t a complication of osteoporosis.
Dowager’s hump results from bone fractures. It
develops when repeated vertebral fractures increase spinal
curvature.
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
Answer: (C) Changes from previous examinations. 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. 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 client’s periods of activity and rest.
D. Encourage the client to be active to prevent
constipation
Answer: (C) Balance the client’s periods of activity and
rest. 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. 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.
Answer: (B) Increase his activity level. 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. Nurse Greta is working on a surgical floor. Nurse Greta
must logroll a client following a:
A. Laminectomy
B. Thoracotomy
C. Hemorrhoidectomy
D. Cystectomy.
Answer: (A) Laminectomy. 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. 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.
Answer: (D) Avoiding straining during bowel movement or
bending at the waist. 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. 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.
Answer: (D) Before age 20. 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. 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.
Answer: (B) Place a saline-soaked sterile dressing on the
wound. 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 client’s vital signs. The dehiscence needs to be
surgically closed, so the nurse should never try to close it.
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.
Answer: (A) A progressively deeper breaths followed by
shallower breaths with apneic periods. Cheyne-Strokes
respirations are breaths that become progressively deeper
fallowed by shallower respirations with apneas periods. Biot’s
respirations are rapid, deep breathing with abrupt
pauses between each breath, and equal depth between each
breath. Kussmaul’s respirations are rapid, deep breathing
without pauses. Tachypnea is shallow breathing with
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
Answer: (B) Fine crackles. 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. The nurse is caring for Kenneth experiencing an acute
asthma attack. The client stops wheezing and breath sounds
aren’t audible. The reason for this change is that:
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.
Answer: (B) The airways are so swollen that no air cannot get
through. During an acute attack, wheezing may stop and
breath sounds become inaudible because the airways are so
swollen that air can’t 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. 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.
Answer: (D) Place the client on his side, remove dangerous
objects, and protect his head. 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. 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
Answer: (B) Kinked or obstructed chest tube. Kinking and
blockage of the chest tube is a common cause of a tension
pneumothorax. Infection and excessive drainage won’t cause
a tension pneumothorax. Excessive water won’t affect the
chest tube drainage.
32. Nurse Maureen is talking to a male client, the client
begins choking on his lunch. He’s 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.
Answer: (D) Stay with him but not intervene at this time. 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. 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.
Answer: (B) Current health promotion activities. Recognizing
an individual’s 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. When performing oral care on a comatose client, Nurse
Krina should:
A. Apply lemon glycerin to the client’s 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 client’s mouth with hydrogen peroxide.
Answer: (C) Place the client in a side lying position, with the
head of the bed lowered. 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. A 77-year-old male client is admitted with a diagnosis of
dehydration and change in mental status. He’s being
hydrated with L.V. fluids. When the nurse takes his vital signs,
she notes he has a fever of 103°F (39.4°C) a cough producing
yellow sputum and pleuritic chest pain. The nurse suspects
this client may have which of the following conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Myocardial infarction (MI)
C. Pneumonia
D. Tuberculosis
Answer: (C) Pneumonia. 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 isn’t having an MI. the client with TB typically has
a cough producing blood-tinged sputum. A sputum
culture should be obtained to confirm the nurse’s suspicions.
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
Answer: (C) A 43-yesr-old homeless man with a history of
alcoholism. 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. 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
Answer: (C ) To determine the extent of lesions. 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 can’t 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
Answer: (B) Bronchodilators. Bronchodilators are the first line
of treatment for asthma because broncho-constriction is the
cause of reduced airflow. Beta adrenergic blockers aren’t
used to treat asthma and can cause
bronchoconstriction. Inhaled oral steroids may be given to
reduce the inflammation but aren’t used for emergency relief.
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
Answer: (C) Chronic obstructive bronchitis. 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
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.
Answer: (A) The patient is under local anesthesia during the
procedure. 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. 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 patient’s status in his charts.
C. Prepare oxygen treatment
D. Raise the side rails
Answer: (D) Raise the side rails. 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. 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.
Answer: (A) Crowd red blood cells. The excessive production
of white blood cells crowd out red blood cells production
which causes anemia to occur.
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
Answer: (B) Leukocytosis. 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. Robert, a 57-year-old client with acute arterial occlusion
of the left leg undergoes an emergency embolectomy. Six
hours later, the nurse isn’t able to obtain pulses in his left
foot using Doppler ultrasound. The nurse
immediately notifies the physician, and asks her to prepare
the client for surgery. As the nurse enters the client’s room to
prepare him, he states that he won’t have any more surgery.
Which of the following is the best initial response by the
nurse?
A. Explain the risks of not having the surgery
B. Notifying the physician immediately
C. Notifying the nursing supervisor
D. Recording the client’s refusal in the nurses’ notes
Answer: (A) Explain the risks of not having the surgery. 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 client’s 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)
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). 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 don’t
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. Honey, a 23-year old client complains of substernal chest
pain and states that her heart feels like “it’s racing out of the
chest”. She reports no history of cardiac disorders. The nurse
attaches her to a cardiac monitor and notes sinus tachycardia
with a rate of 136beats/minutes. Breath sounds are clear and
the respiratory rate is 26 breaths/minutes. Which of the
following drugs should the nurse question the client about
using?
A. Barbiturates
B. Opioids
C. Cocaine
D. Benzodiazepines
Answer: (C) Cocaine. Because of the client’s 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. 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
Answer: (B) Nonmobile mass with irregular edges. 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. 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
Answer: (C) Radiation. 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. 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
Answer: (B) Carcinoma in situ, no abnormal regional lymph
nodes, and no evidence of distant metastasis. 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. 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.”
Answer: (D) “Keep the stoma moist.” 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. 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
Answer: (B) Lung cancer. 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. 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.
Answer: (A) miosis, partial eyelid ptosis, and anhidrosis on the
affected side of the face. 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. 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.
Answer: (A) prostate-specific antigen, which is used to
screen for prostate cancer. PSA stands for prostate-specific
antigen, which is used to screen for prostate cancer. The
other answers are incorrect
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.”
Answer: (D) “Remain supine for the time specified by the
physician.” 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. 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
Answer: (C) Sigmoidoscopy. 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. 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
Answer: (B) A fixed nodular mass with dimpling of the
overlying skin. 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. 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)
Answer: (A) Liver. 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. 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.
Answer: (D) The client wears a watch and wedding
band. 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. 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
Answer: (C) The recommended daily allowance of calcium
may be found in a wide variety of foods. 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. 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
Answer: (C) Joint flexion of less than 50%. 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. 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
Answer: (D) Gouty arthritis. 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. 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
Answer: (B) 30 ml/hour. 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. 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
Answer: (B) Loss of muscle contraction decreasing venous
return. 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 don’t appear with
swelling. DVT may develop in clients with a stroke but is
more likely to occur in the lower extremities. A stroke
isn’t linked to protein loss
64. Heberden’s 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.
Answer: (B) It appears on the distal interphalangeal
joint. Heberden’s nodes appear on the distal interphalageal
joint on both men and women. Bouchard’s node appears on
the dorsolateral aspect of the proximal interphalangeal joint.
65. Which of the following statements explains the main
difference between rheumatoid arthritis and osteoarthritis?
A. Osteoarthritis is gender-specific, rheumatoid arthritis
isn’t
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 doesn’t
Answer: (B) Osteoarthritis is a localized disease rheumatoid
arthritis is systemic. Osteoarthritis is a localized disease,
rheumatoid arthritis is systemic. Osteoarthritis isn’t gender-
specific, but rheumatoid arthritis is. Clients have dislocations
and subluxations in both disorders.
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
Answer: (C) The cane should be used on the unaffected
side. 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. 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.
Answer: (A) 9 U regular insulin and 21 U neutral protamine
Hagedorn (NPH). 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. Nurse Len should expect to administer which medication
to a client with gout?
A. aspirin
B. furosemide (Lasix)
C. colchicines
D. calcium gluconate (Kalcinate)
Answer: (C) colchicines. 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. 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
Answer: (A) Adrenal cortex. 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. 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.
Answer: (C) They debride the wound and promote healing
by secondary intention. 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. 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
Answer: (A) Hyperkalemia. 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. 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
Answer: (C) Restricting fluids. 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. 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.
Answer: (D) glycosylated hemoglobin level. 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. 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
Answer: (C) 4:00 pm. 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. 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
Answer: (A) Glucocorticoids and androgens. 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. 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
Answer: (A) Hypocalcemia. 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. 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
Answer: (D) Carcinoembryonic antigen level. 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. 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
Answer: (B) Dyspnea, tachycardia, and pallor. 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. 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.”
Ans wer: (D) “I’ll need to have a C-section if I become
pregnant and have a baby.” 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. 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.”
Answer: (C) “Avoid sharing such articles as toothbrushes and
razors.” 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. 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
Answer: (B) Pallor, tachycardia, and a sore tongue. 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. 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.
Answer: (B) Administer epinephrine, as prescribed, and
prepare to intubate the client if necessary. 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. 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.
Answer: (D) bilateral hearing loss. 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. 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
Answer: (D) Lymphocyte. 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. In an individual with Sjögren’s syndrome, nursing care
should focus on:
A. moisture replacement.
B. electrolyte balance.
C. nutritional supplementation.
D. arrhythmia management.
Answer: (A) moisture replacement. 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. 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.
Answer: (C) stool for Clostridium difficile
test. 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. 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.
Answer: (D) Western blot test with ELISA. 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. 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
Answer: (C) Abnormally low hematocrit (HCT) and
hemoglobin (Hb) levels. 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. 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
Answer: (A) Platelet count, prothrombin time, and partial
thromboplastin time. 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. 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
Answer: (D) Strawberries. Common food allergens include
berries, peanuts, Brazil nuts, cashews, shellfish, and eggs.
Bread, carrots, and oranges rarely cause allergic reactions.
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 can’t eat.”
D. A client with rheumatoid arthritis who states, “I am
having trouble sleeping.”
Answer: (B) A client with cast on the right leg who states, “I
have a funny feeling in my right leg.” It may indicate
neurovascular compromise, requires immediate assessment
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.
Answer: (D) A 62-year-old who had an abdominal-perineal
resection three days ago; client complaints of chills. The client
is at risk for peritonitis; should be assessed for further
symptoms and infection.
93. Nurse Eve is caring for a client who had a thyroidectomy
12 hours ago for treatment of Grave’s disease. The nurse
would be most concerned if which of the following was
observed?
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.
Answer: (C) The client spontaneously flexes his wrist when
the blood pressure is obtained. Carpal spasms indicate
hypocalcemia.
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.
Answer: (D) Use comfort measures and pillows to position
the client.Using comfort measures and pillows to position
the client is a non-pharmacological methods of pain relief
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
Answer: (B) Warm the dialysate solution. Cold dialysate
increases discomfort. The solution should be warmed to body
temperature in warmer or heating pad; don’t use microwave
oven.
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.
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. The cane acts as a support and aids in
weight bearing for the weaker 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 woman’s 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.
Answer: (A) Ask the woman’s family to provide personal
items such as photos or mementos.Photos and mementos
provide visual stimulation to reduce sensory deprivation.
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 nurse’s
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.
Answer: (B) The client lifts the walker, moves it forward 10
inches, and then takes several small steps forward. A walker
needs to be picked up, placed down on all legs.
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.
Answer: (C) Isolation from their families and familiar
surroundings. Gradual loss of sight, hearing, and taste
interferes with normal functioning.
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 client’s temperature.
C. Assess the client’s potassium level.
D. Increase the client’s oxygen flow rate.
Answer: (A) Encourage the client to perform pursed lip
breathing. Purse lip breathing prevents the collapse of lung
unit and helps client control rate and depth of breathing.
PNLE IV for Care of
Clients with Physiologic
and Psychosocial
Alterations (Part 2)
1. Randy has undergone kidney transplant, what assessment
would prompt Nurse Katrina to suspect organ rejection?
A. Sudden weight loss
B. Polyuria
C. Hypertension
D. Shock
Answer: (C) Hypertension. Hypertension, along with fever,
and tenderness over the grafted kidney, reflects acute
rejection.
2. The immediate objective of nursing care for an overweight,
mildly hypertensive male client with ureteral colic and
hematuria is to decrease:
A. Pain
B. Weight
C. Hematuria
D. Hypertension
Answer: (A) Pain. Sharp, severe pain (renal colic) radiating
toward the genitalia and thigh is caused by uretheral
distention and smooth muscle spasm; relief form pain is the
priority.
3. Matilda, with hyperthyroidism is to receive Lugol’s iodine
solution before a subtotal thyroidectomy is performed. The
nurse is aware that this medication is given to:
A. Decrease the total basal metabolic rate.
B. Maintain the function of the parathyroid glands.
C. Block the formation of thyroxine by the thyroid gland.
D. Decrease the size and vascularity of the thyroid gland.
Answer: (D) Decrease the size and vascularity of the thyroid
gland. Lugol’s solution provides iodine, which aids in
decreasing the vascularity of the thyroid gland, which limits
the risk of hemorrhage when surgery is performed.
4. Ricardo, was diagnosed with type I diabetes. The nurse is
aware that acute hypoglycemia also can develop in the client
who is diagnosed with:
A. Liver disease
B. HypertensionX
C. Type 2 diabetes
D. Hyperthyroidism
Answer: (A) Liver Disease. The client with liver disease has a
decreased ability to metabolize carbohydrates because of a
decreased ability to form glycogen (glycogenesis) and to form
glucose from glycogen.
5. 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.
E.
F. Polycythemia
Answer: (C) Leukopenia. Leukopenia, a reduction in WBCs, is
a systemic effect of chemotherapy as a result of
myelosuppression
6. 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.
Answer: (C) Avoid foods that in the past caused flatus. Foods
that bothered a person preoperatively will continue to do so
after a colostomy.
7. 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.”
Answer: (B) Keep the irrigating container less than 18 inches
above the stoma.” This height permits the solution to flow
slowly with little force so that excessive peristalsis is not
immediately precipitated
8. 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.
Answer: (A) Administer Kayexalate. Kayexalate,a potassium
exchange resin, permits sodium to be exchanged for
potassium in the intestine, reducing the serum
potassium level.
9. 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. X18 gtt/min
B. 28 gtt/min
C. 32 gtt/min
D. 36 gtt/min
Answer:(B) 28 gtt/min. 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
10.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
Answer: (D) Upper trunk. 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%.
11. 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
Answer: (C) Bleeding from ears. 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
12. 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
Answer: (D) may engage in contact sports. The client should
be advised by the nurse to avoid contact sports. This will
prevent trauma to the area of the pacemaker generator.
13.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.
Answer: (A) Oxygen at 1-2L/min is given to maintain the
hypoxic stimulus for breathing. 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 client’s hypoxic drive.
14.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
Answer: (B) Facilitate ventilation of the left lung. 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.
15.Kristine is scheduled for a bronchoscopy. When teaching
Kristine what to expect afterward, the nurse’s highest priority
of information would be:
A. Food and fluids will be withheld for at least 2 hours.
B. Warm saline gargles will be done q 2h.
C. Coughing and deep-breathing exercises will be done
q2h.
D. Only ice chips and cold liquids will be allowed initially.
Answer: (A) Food and fluids will be withheld for at least 2
hours. Prior to bronchoscopy, the doctors sprays the back
of the throat with anesthetic to minimize the gag reflex and
thus facilitate the insertion of the bronchoscope. Giving the
client food and drink after the procedure without checking
on the return of the gag reflex can cause the client to
aspirate. The gag reflex usually returns after two hours
16.Nurse Tristan is caring for a male client in acute renal
failure. The nurse should expect hypertonic glucose, insulin
infusions, and sodium bicarbonate to be used to treat:
A. hypernatremia.
B. hypokalemia.
C. hyperkalemia.
D. hypercalcemia.
Answer: (C) hyperkalemia. Hyperkalemia is a common
complication of acute renal failure. It’s life-threatening if
immediate action isn’t taken to reverse it.
The administration of glucose and regular insulin, with
sodium bicarbonate if necessary, can temporarily prevent
cardiac arrest by moving potassium into the cells and
temporarily reducing serum potassium
levels. Hypernatremia, hypokalemia, and hypercalcemia
don’t usually occur with acute renal failure and aren’t
treated with glucose, insulin, or sodium bicarbonate
17.Ms. X has just been diagnosed with condylomata
acuminata (genital warts). What information is appropriate to
tell this client?
 A. This condition puts her at a higher risk for cervical
cancer; therefore, she should have a Papanicolaou
(Pap) smear annually.
B. The most common treatment is metronidazole (Flagyl),
which should eradicate the problem within 7 to 10 days.
C. The potential for transmission to her sexual partner will
be eliminated if condoms are used every time they have
sexual intercourse.
D. The human papillomavirus (HPV), which causes
condylomata acuminata, can’t be transmitted during
oral sex.
Answer: (A) This condition puts her at a higher risk for
cervical cancer; therefore, she should have a Papanicolaou
(Pap) smear annually. Women with condylomata acuminata
are at risk for cancer of the cervix and vulva. Yearly Pap
smears are very important for early detection. Because
condylomata acuminata is a virus, there is no permanent
cure. Because condylomata acuminata can occur on the
vulva, a condom won’t protect sexual partners. HPV can be
transmitted to other parts of the body, such as the mouth,
oropharynx, and larynx.
18.Maritess was recently diagnosed with a genitourinary
problem and is being examined in the emergency department.
When palpating the her kidneys, the nurse should keep which
anatomical fact in mind?
A. The left kidney usually is slightly higher than the right
one.
B. The kidneys are situated just above the adrenal glands.
C. The average kidney is approximately 5 cm (2″) long and
2 to 3 cm (¾” to 1-1/8″) wide.
D. The kidneys lie between the 10th and 12th thoracic
vertebrae.
Answer: (A) The left kidney usually is slightly higher than the
right one. The left kidney usually is slightly higher than the
right one. An adrenal gland lies atop each kidney. The
average kidney measures approximately 11 cm (4-3/8″) long,
5 to 5.8 cm (2″ to 2¼”) wide, and 2.5 cm (1″) thick. The
kidneys are located retroperitoneally, in the posterior aspect
of the abdomen, on either side of the vertebral column. They
lie between the 12th thoracic and 3rd lumbar vertebrae.
19.Jestoni with chronic renal failure (CRF) is admitted to the
urology unit. The nurse is aware that the diagnostic test are
consistent with CRF if the result is:
A. Increased pH with decreased hydrogen ions.
B. Increased serum levels of potassium, magnesium, and
calcium.
C. Blood urea nitrogen (BUN) 100 mg/dl and serum
creatinine 6.5 mg/ dl.
D. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein
(PSP) excretion 75%.
Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and serum
creatinine 6.5 mg/dl. The normal BUN level ranges 8 to 23
mg/dl; the normal serum creatinine level ranges from 0.7 to
1.5 mg/dl. The test results in option C are abnormally
elevated, reflecting CRF and the kidneys’ decreased ability to
remove nonprotein nitrogen waste from the blood. CRF
causes decreased pH and increased hydrogen ions — not vice
versa. CRF also increases serum levels of potassium,
magnesium, and phosphorous, and decreases serum levels of
calcium. A uric acid analysis of 3.5 mg/dl falls within the
normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75%
also falls with the normal range of 60% to 75%.
20. Katrina has an abnormal result on a Papanicolaou test.
After admitting that she read her chart while the nurse was
out of the room, Katrina asks what dysplasia means. Which
definition should the nurse provide?
A. Presence of completely undifferentiated tumor cells
that don’t resemble cells of the tissues of their origin.
B. Increase in the number of normal cells in a normal
arrangement in a tissue or an organ.
C. Replacement of one type of fully differentiated cell by
another in tissues where the second type normally isn’t
found.
D. Alteration in the size, shape, and organization of
differentiated cells.
Answer: (D) Alteration in the size, shape, and organization
of differentiated cells. Dysplasia refers to an alteration in the
size, shape, and organization of differentiated cells. The
presence of completely undifferentiated tumor cells that
don’t resemble cells of the tissues of their origin is called
anaplasia. An increase in the number of normal cells in
a normal arrangement in a tissue or an organ is called
hyperplasia. Replacement of one type of fully differentiated
cell by another in tissues where the second type normally
isn’t found is called metaplasia.
21. During a routine checkup, Nurse Mariane assesses a male
client with acquired immunodeficiency syndrome (AIDS) for
signs and symptoms of cancer. What is the most common
AIDS-related cancer?
A. Squamous cell carcinoma
B. Multiple myeloma
C. Leukemia
D. Kaposi’s sarcoma
Answer: (D) Kaposi’s sarcoma. Kaposi’s sarcoma is the most
common cancer associated with AIDS. Squamous cell
carcinoma, multiple myeloma, and leukemia may occur in
anyone and aren’t associated specifically with AIDS.
22.Ricardo is scheduled for a prostatectomy, and the
anesthesiologist plans to use a spinal (subarachnoid) block
during surgery. In the operating room, the nurse positions the
client according to the anesthesiologist’s instructions. Why
does the client require special positioning for this type of
anesthesia?
A. To prevent confusion
B. To prevent seizures
C. To prevent cerebrospinal fluid (CSF) leakage
D. To prevent cardiac arrhythmias
Answer: (C) To prevent cerebrospinal fluid (CSF) leakage. The
client receiving a subarachnoid block requires
special positioning to prevent CSF leakage and headache and
to ensure proper anesthetic distribution. Proper positioning
doesn’t help prevent confusion, seizures, or cardiac
arrhythmias.
23.A male client had a nephrectomy 2 days ago and is now
complaining of abdominal pressure and nausea. The first
nursing action should be to:
A. Auscultate bowel sounds.
B. Palpate the abdomen.
C. Change the client’s position.
D. Insert a rectal tube.
Answer: (A) Auscultate bowel sounds. If abdominal distention
is accompanied by nausea, the nurse must first auscultate
bowel sounds. If bowel sounds are absent, the nurse should
suspect gastric or small intestine dilation and these findings
must be reported to the physician. Palpation should be
avoided postoperatively with abdominal distention. If
peristalsis is absent, changing positions and inserting a rectal
tube won’t relieve the client’s discomfort.
24.Wilfredo with a recent history of rectal bleeding is being
prepared for a colonoscopy. How should the nurse Patricia
position the client for this test initially?
A. Lying on the right side with legs straight
B. Lying on the left side with knees bent
C. Prone with the torso elevated
D. Bent over with hands touching the floor
Answer: (B) Lying on the left side with knees bent. For a
colonoscopy, the nurse initially should position the client on
the left side with knees bent. Placing the client on the right
side with legs straight, prone with the torso elevated, or bent
over with hands touching the floor wouldn’t allow proper
visualization of the large intestine.
25.A male client with inflammatory bowel disease undergoes
an ileostomy. On the first day after surgery, Nurse Oliver
notes that the client’s stoma appears dusky. How should the
nurse interpret this finding?
A. Blood supply to the stoma has been interrupted.
B. This is a normal finding 1 day after surgery.
C. The ostomy bag should be adjusted.
D. An intestinal obstruction has occurred.
Answer: (A) Blood supply to the stoma has been
interrupted. An ileostomy stoma forms as the ileum is
brought through the abdominal wall to the surface skin,
creating an artificial opening for waste elimination. The
stoma should appear cherry red, indicating adequate arterial
perfusion. A dusky stoma suggests decreased perfusion,
which may result from interruption of the stoma’s blood
supply and may lead to tissue damage or necrosis. A dusky
stoma isn’t a normal finding. Adjusting the ostomy bag
wouldn’t affect stoma color, which depends on blood supply
to the area. An intestinal obstruction also wouldn’t change
stoma color.
26.Anthony suffers burns on the legs, which nursing
intervention helps prevent contractures?
A. Applying knee splints
B. Elevating the foot of the bed
C. Hyperextending the client’s palms
D. Performing shoulder range-of-motion exercises
Answer: (A) Applying knee splints. Applying knee splints
prevents leg contractures by holding the joints in a position of
function. Elevating the foot of the bed can’t
prevent contractures because this action doesn’t hold the
joints in a position of function. Hyperextending a body part
for an extended time is inappropriate because it can cause
contractures. Performing shoulder range-of-motion exercises
can prevent contractures in the shoulders, but not in the legs.
27.Nurse Ron is assessing a client admitted with second- and
third-degree burns on the face, arms, and chest. Which
finding indicates a potential problem?
A. Partial pressure of arterial oxygen (PaO2) value of 80
mm Hg.
B. Urine output of 20 ml/hour.
C. White pulmonary secretions.
D. Rectal temperature of 100.6° F (38° C).
Answer: (B) Urine output of 20 ml/hour. A urine output of
less than 40 ml/hour in a client with burns indicates a fluid
volume deficit. This client’s PaO2 value falls within the normal
range (80 to 100 mm Hg). White pulmonary secretions also
are normal. The client’s rectal temperature isn’t significantly
elevated and probably results from the fluid volume deficit.
28. Mr. Mendoza who has suffered a cerebrovascular
accident (CVA) is too weak to move on his own. To help the
client avoid pressure ulcers, Nurse Celia should:
A. Turn him frequently.
B. Perform passive range-of-motion (ROM) exercises.
C. Reduce the client’s fluid intake.
D. Encourage the client to use a footboard.
Answer: (A) Turn him frequently. The most important
intervention to prevent pressure ulcers is frequent position
changes, which relieve pressure on the skin and underlying
tissues. If pressure isn’t relieved, capillaries become
occluded, reducing circulation and oxygenation of the tissues
and resulting in cell death and ulcer formation. During passive
ROM exercises, the nurse moves each joint through its range
of movement, which improves joint mobility and circulation
to the affected area but doesn’t prevent pressure ulcers.
Adequate hydration is necessary to maintain healthy skin
and ensure tissue repair. A footboard prevents plantar flexion
and footdrop by maintaining the foot in a dorsiflexed position.
29.Nurse Maria plans to administer dexamethasone cream to
a female client who has dermatitis over the anterior chest.
How should the nurse apply this topical agent?
A. With a circular motion, to enhance absorption.
B. With an upward motion, to increase blood supply to the
affected area
C. In long, even, outward, and downward strokes in the
direction of hair growth
D. In long, even, outward, and upward strokes in the
direction opposite hair growth
Answer: (C) In long, even, outward, and downward strokes in
the direction of hair growth. When applying a topical agent,
the nurse should begin at the midline and use long, even,
outward, and downward strokes in the direction of hair
growth. This application pattern reduces the risk of
follicle irritation and skin inflammation.
30.Nurse Kate is aware that one of the following classes of
medication protect the ischemic myocardium by blocking
catecholamines and sympathetic nerve stimulation is:
A. Beta -adrenergic blockers
B. Calcium channel blocker
C. Narcotics
D. Nitrates
Answer: (A) Beta -adrenergic blockers. Beta-adrenergic
blockers work by blocking beta receptors in the myocardium,
reducing the response to catecholamines and sympathetic
nerve stimulation. They protect the myocardium, helping
to reduce the risk of another infraction by decreasing
myocardial oxygen demand. Calcium channel blockers reduce
the workload of the heart by decreasing the heart rate.
Narcotics reduce myocardial oxygen demand, promote
vasodilation, and decrease anxiety. Nitrates reduce
myocardial oxygen consumption bt decreasing left ventricular
end diastolic pressure (preload) and systemic vascular
resistance (afterload).
31.A male client has jugular distention. On what position
should the nurse place the head of the bed to obtain the
most accurate reading of jugular vein distention?
A. High Fowler’s
B. Raised 10 degrees
C. Raised 30 degrees
D. Supine position

Answer: (C) Raised 30 degrees. Jugular venous pressure is
measured with a centimeter ruler to obtain the vertical
distance between the sternal angle and the point of highest
pulsation with the head of the bed inclined between 15 to
30 degrees. Increased pressure can’t be seen when the client
is supine or when the head of the bed is raised 10 degrees
because the point that marks the pressure level is above the
jaw (therefore, not visible). In high Fowler’s position, the
veins would be barely discernible above the clavicle.
32.The nurse is aware that one of the following classes of
medications maximizes cardiac performance in clients with
heart failure by increasing ventricular contractility?
A. Beta-adrenergic blockers
B. Calcium channel blocker
C. Diuretics
D. Inotropic agents
Answer: (D) Inotropic agents. Inotropic agents are
administered to increase the force of the heart’s contractions,
thereby increasing ventricular contractility and ultimately
increasing cardiac output. Beta-adrenergic blockers and
calcium channel blockers decrease the heart rate and
ultimately decreased the workload of the heart. Diuretics are
administered to decrease the overall vascular volume, also
decreasing the workload of the heart.
33.A male client has a reduced serum high-density lipoprotein
(HDL) level and an elevated low-density lipoprotein (LDL)
level. Which of the following dietary modifications is not
appropriate for this client?
A. Fiber intake of 25 to 30 g daily
B. Less than 30% of calories form fat
C. Cholesterol intake of less than 300 mg daily
D. Less than 10% of calories from saturated fat
Answer: (B) Less than 30% of calories form fat. A client with
low serum HDL and high serum LDL levels should get less than
30% of daily calories from fat. The other modifications
are appropriate for this client.
34. A 37-year-old male client was admitted to the coronary
care unit (CCU) 2 days ago with an acute myocardial
infarction. Which of the following actions would breach the
client confidentiality?
A. The CCU nurse gives a verbal report to the nurse on the
telemetry unit before transferring the client to that unit
B. The CCU nurse notifies the on-call physician about a
change in the client’s condition
C. The emergency department nurse calls up the latest
electrocardiogram results to check the client’s progress.
D. At the client’s request, the CCU nurse updates the
client’s wife on his condition
Answer: (C) The emergency department nurse calls up the
latest electrocardiogram results to check the client’s
progress. The emergency department nurse is no longer
directly involved with the client’s care and thus has no legal
right to information about his present condition. Anyone
directly involved in his care (such as the telemetry nurse and
the on-call physician) has the right to information about his
condition. Because the client requested that the nurse
update his wife on his condition, doing so doesn’t breach
confidentiality
35. A male client arriving in the emergency department is
receiving cardiopulmonary resuscitation from paramedics
who are giving ventilations through an endotracheal (ET) tube
that they placed in the client’s home. During a pause in
compressions, the cardiac monitor shows narrow QRS
complexes and a heart rate of beats/minute with a palpable
pulse. Which of the following actions
should the nurse take first?
A. Start an L.V. line and administer amiodarone
(Cardarone), 300 mg L.V. over 10 minutes.
B. Check endotracheal tube placement.
C. Obtain an arterial blood gas (ABG) sample.
D. Administer atropine, 1 mg L.V.
Answer: (B) Check endotracheal tube placement. ET tube
placement should be confirmed as soon as the client arrives
in the emergency department. Once the airways is
secured, oxygenation and ventilation should be confirmed
using an end-tidal carbon dioxide monitor and pulse oximetry.
Next, the nurse should make sure L.V. access is established. If
the client experiences symptomatic bradycardia, atropine is
administered as ordered 0.5 to 1 mg every 3 to 5 minutes to a
total of 3 mg. Then the nurse should try to find the cause
of the client’s arrest by obtaining an ABG sample.
Amiodarone is indicated for ventricular tachycardia,
ventricular fibrillation and atrial flutter – not symptomatic
bradycardia.
36. After cardiac surgery, a client’s blood pressure measures
126/80 mm Hg. Nurse Katrina determines that mean arterial
pressure (MAP) is which of the following?
A. 46 mm Hg
B. 80 mm Hg
C. 95 mm Hg
D. 90 mm Hg
Answer: (C) 95 mm Hg. Use the following formula to calculate
MAP
 MAP = systolic + 2 (diastolic) /3
 MAP=[126 mm Hg + 2 (80 mm Hg) ]/3
 MAP=286 mm HG/ 3
 MAP=95 mm Hg
37. A female client arrives at the emergency department with
chest and stomach pain and a report of black tarry stool for
several months. Which of the following order should the
nurse Oliver anticipate?
A. Cardiac monitor, oxygen, creatine kinase and lactate
dehydrogenase levels
B. Prothrombin time, partial thromboplastin time,
fibrinogen and fibrin split product values.
C. Electrocardiogram, complete blood count, testing for
occult blood, comprehensive serum metabolic panel.
D. Electroencephalogram, alkaline phosphatase and
aspartate aminotransferase levels, basic serum
metabolic panel
Answer: (C) Electrocardiogram, complete blood count, testing
for occult blood, comprehensive serum metabolic panel. An
electrocardiogram evaluates the complaints of chest
pain, laboratory tests determines anemia, and the stool test
for occult blood determines blood in the stool. Cardiac
monitoring, oxygen, and creatine kinase and lactate
dehydrogenase levels are appropriate for a cardiac primary
problem. A basic metabolic panel and alkaline phosphatase
and aspartate aminotransferase levels assess liver function.
Prothrombin time, partial thromboplastin time, fibrinogen
and fibrin split products are measured to verify bleeding
dyscrasias, An electroencephalogram evaluates brain
electrical activity.
38. Macario had coronary artery bypass graft (CABG) surgery
3 days ago. Which of the following conditions is suspected by
the nurse when a decrease in platelet count from 230,000 ul
to 5,000 ul is noted?
A. Pancytopenia
B. Idiopathic thrombocytopemic purpura (ITP)
C. Disseminated intravascular coagulation (DIC)
D. Heparin-associated thrombosis and thrombocytopenia
(HATT)
Answer: (D) Heparin-associated thrombosis and
thrombocytopenia (HATT). HATT may occur after CABG
surgery due to heparin use during surgery. Although DIC and
ITP cause platelet aggregation and bleeding, neither is
common in a client after revascularization
surgery. Pancytopenia is a reduction in all blood cells.
39. Which of the following drugs would be ordered by the
physician to improve the platelet count in a male client with
idiopathic thrombocytopenic purpura (ITP)?
A. Acetylsalicylic acid (ASA)
B. Corticosteroids
C. Methotrezate
D. Vitamin K
Answer: (B) Corticosteroids. Corticosteroid therapy can
decrease antibody production and phagocytosis of the
antibody-coated platelets, retaining more
functioning platelets. Methotrexate can cause
thrombocytopenia. Vitamin K is used to treat an excessive
anticoagulate state from warfarin overload, and
ASA decreases platelet aggregation.
40. A female client is scheduled to receive a heart valve
replacement with a porcine valve. Which of the following
types of transplant is this?
A. Allogeneic
B. Autologous
C. Syngeneic
D. Xenogeneic
Answer: (D) Xenogeneic. An xenogeneic transplant is
between is between human and another species. A syngeneic
transplant is between identical twins, allogeneic transplant is
between two humans, and autologous is a transplant from
the same individual.
41. Marco falls off his bicycle and injuries his ankle. Which of
the following actions shows the initial response to the injury
in the extrinsic pathway?
A. Release of Calcium
B. Release of tissue thromboplastin
C. Conversion of factors XII to factor XIIa
D. Conversion of factor VIII to factor VIIIa
Answer: (B). Tissue thromboplastin is released when
damaged tissue comes in contact with clotting factors.
Calcium is released to assist the conversion of factors X to Xa.
Conversion of factors XII to XIIa and VIII to VIII a are part of
the intrinsic pathway
42. Instructions for a client with systemic lupus
erythematosus (SLE) would include information about which
of the following blood dyscrasias?
A. Dressler’s syndrome
B. Polycythemia
C. Essential thrombocytopenia
D. Von Willebrand’s disease
Answer: (C) Essential thrombocytopenia. Essential
thrombocytopenia is linked to immunologic disorders, such as
SLE and human immunodeficiency vitus. The disorder known
as von Willebrand’s disease is a type of hemophilia and isn’t
linked to SLE. Moderate to severe anemia is associated with
SLE, not polycythermia. Dressler’s syndrome is pericarditis
that occurs after a myocardial infarction and isn’t linked to
SLE.
43. The nurse is aware that the following symptoms is most
commonly an early indication of stage 1 Hodgkin’s disease?
A. Pericarditis
B. Night sweat
C. Splenomegaly
D. Persistent hypothermia
Answer: (B) Night sweat. In stage 1, symptoms include a
single enlarged lymph node (usually), unexplained fever,
night sweats, malaise, and generalized pruritis. Although
splenomegaly may be present in some clients, night sweats
are generally more prevalent. Pericarditis isn’t associated
with Hodgkin’s disease, nor is hypothermia. Moreover,
splenomegaly and pericarditis aren’t symptoms. Persistent
hypothermia is associated with Hodgkin’s but isn’t an early
sign of the disease.
44. Francis with leukemia has neutropenia. Which of the
following functions must frequently assessed?
A. Blood pressure
B. Bowel sounds
C. Heart sounds
D. Breath sounds
Answer: (D) Breath sounds. Pneumonia, both viral and
fungal, is a common cause of death in clients with
neutropenia, so frequent assessment of respiratory rate
and breath sounds is required. Although assessing blood
pressure, bowel sounds, and heart sounds is important, it
won’t help detect pneumonia
45. The nurse knows that neurologic complications of
multiple myeloma (MM) usually involve which of the
following body system?
A. Brain
B. Muscle spasm
C. Renal dysfunction
D. Myocardial irritability
Answer: (B) Muscle spasm. Back pain or paresthesia in the
lower extremities may indicate impending spinal cord
compression from a spinal tumor. This should be recognized
and treated promptly as progression of the tumor may result
in paraplegia. The other options, which reflect parts of the
nervous system, aren’t usually affected by MM.
46. Nurse Patricia is aware that the average length of time
from human immunodeficiency virus (HIV) infection to the
development of acquired immunodeficiency syndrome (AIDS)?
A. Less than 5 years
B. 5 to 7 years
C. 10 years
D. More than 10 years
Answer: (C)10 years. Epidermiologic studies show the
average time from initial contact with HIV to the
development of AIDS is 10 years
47. An 18-year-old male client admitted with heat stroke
begins to show signs of disseminated intravascular
coagulation (DIC). Which of the following laboratory findings
is most consistent with DIC?
A. Low platelet count
B. Elevated fibrinogen levels
 C. Low levels of fibrin degradation products
D. Reduced prothrombin time
Answer: (A) Low platelet count. In DIC, platelets and clotting
factors are consumed, resulting in microthrombi and
excessive bleeding. As clots form, fibrinogen levels decrease
and the prothrombin time increases. Fibrin
degeneration products increase as fibrinolysis takes places.
48. Mario comes to the clinic complaining of fever, drenching
night sweats, and unexplained weight loss over the past 3
months. Physical examination reveals a single enlarged
supraclavicular lymph node. Which of the following is the
most probable diagnosis?
A. Influenza
B. Sickle cell anemia
C. Leukemia
D. Hodgkin’s disease
Answer: (D) Hodgkin’s disease. Hodgkin’s disease typically
causes fever night sweats, weight loss, and lymph mode
enlargement. Influenza doesn’t last for months. Clients with
sickle cell anemia manifest signs and symptoms of
chronic anemia with pallor of the mucous membrane,
fatigue, and decreased tolerance for exercise; they don’t
show fever, night sweats, weight loss or lymph node
enlargement. Leukemia doesn’t cause lymph
node enlargement
49. A male client with a gunshot wound requires an
emergency blood transfusion. His blood type is AB negative.
Which blood type would be the safest for him to receive?
A. AB Rh-Xpositive
B. A Rh-positive
C. A Rh-negative
D. O Rh-positive
Answer: (C) A Rh-negative. Human blood can sometimes
contain an inherited D antigen. Persons with the D antigen
have Rh-positive blood type; those lacking the antigen have
Rh-negative blood. It’s important that a person with
Rhnegative blood receives Rh-negative blood. If Rh-positive
blood is administered to an Rh-negative person, the
recipient develops anti-Rh agglutinins, and sub sequent
transfusions with Rh-positive blood may cause serious
reactions with clumping and hemolysis of red blood cells
Situation: Stacy is diagnosed with acute lymphoid leukemia
(ALL) and beginning chemotherapy.
50. Stacy is discharged from the hospital following her
chemotherapy treatments. Which statement of Stacy’s
mother indicated that she understands when she will contact
the physician?
A. “I should contact the physician if Stacy has difficulty in
sleeping”.
B. “I will call my doctor if Stacy has persistent vomiting
and diarrhea”.
C. “My physician should be called if Stacy is irritable and
unhappy”.
D. “Should Stacy have continued hair loss, I need to call
the doctor”.
Answer: (B) “I will call my doctor if Stacy has persistent
vomiting and diarrhea”. Persistent (more than 24 hours)
vomiting, anorexia, and diarrhea are signs of toxicity and the
patient should stop the medication and notify the health
care provider. The other manifestations are expected side
effects of chemotherapy
51. Stacy’s mother states to the nurse that it is hard to see
Stacy with no hair. The best response for the nurse is:
A. “Stacy looks very nice wearing a hat”.
B. “You should not worry about her hair, just be glad that
she is alive”.
C. “Yes it is upsetting. But try to cover up your feelings
when you are with her or else she may be upset”.
D. “This is only temporary; Stacy will re-grow new hair in
3-6 months, but may be different in texture”.
Answer: (D) “This is only temporary; Stacy will re-grow new
hair in 3-6 months, but may be different in texture”. This is
the appropriate response. The nurse should help the mother
how to cope with her own feelings regarding the child’s
disease so as not to affect the child negatively. When the hair
grows back, it is still of the same color and texture.
52. Stacy has beginning stomatitis. To promote oral hygiene
and comfort, the nurse in-charge should:
A. Provide frequent mouthwash with normal saline.
B. Apply viscous Lidocaine to oral ulcers as needed.
C. Use lemon glycerine swabs every 2 hours.
D. Rinse mouth with Hydrogen Peroxide.
Answer: (B) Apply viscous Lidocaine to oral ulcers as
needed. Stomatitis can cause pain and this can be relieved by
applying topical anesthetics such as lidocaine before mouth
care. When the patient is already comfortable, the nurse can
proceed with providing the patient with oral rinses of saline
solution mixed with equal part of water or hydrogen peroxide
mixed water in 1:3 concentrations to promote oral hygiene.
Every 2-4 hours.
53. During the administration of chemotherapy agents, Nurse
Oliver observed that the IV site is red and swollen, when the
IV is touched Stacy shouts in pain. The first nursing action to
take is:
A. Notify the physician
B. Flush the IV line with saline solution
C. Immediately discontinue the infusion
D. Apply an ice pack to the site, followed by warm
compress.
Answer: (C) Immediately discontinue the infusion. Edema or
swelling at the IV site is a sign that the needle has been
dislodged and the IV solution is leaking into the tissues
causing the edema. The patient feels pain as the nerves are
irritated by pressure and the IV solution. The first action of
the nurse would be to discontinue the infusion right away to
prevent further edema and other complication
54. The term “blue bloater” refers to a male client which of
the following conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Asthma
C. Chronic obstructive bronchitis
D. Emphysema
Answer: (C) Chronic obstructive bronchitis. Clients with
chronic obstructive bronchitis appear bloated; they have
large barrel chest and peripheral edema, cyanotic nail beds,
and at times, circumoral cyanosis. Clients with ARDS are
acutely short of breath and frequently need intubation for
mechanical ventilation and large amount of oxygen. Clients
with asthma don’t exhibit characteristics of chronic disease,
and clients with emphysema appear pink and cachectic.
55. The term “pink puffer” refers to the female client with
which of the following conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Asthma
 C. Chronic obstructive bronchitis
D. Emphysema
Answer: (D) Emphysema. Because of the large amount of
energy it takes to breathe, clients with emphysema are
usually cachectic. They’re pink and usually breathe through
pursed lips, hence the term “puffer.” Clients with ARDS are
usually acutely short of breath. Clients with asthma don’t
have any particular characteristics, and clients with chronic
obstructive bronchitis are bloated and cyanotic in appearance.
56. Jose is in danger of respiratory arrest following the
administration of a narcotic analgesic. An arterial blood gas
value is obtained. Nurse Oliver would expect the paco2 to be
which of the following values?
A. 15 mm Hg
B. 30 mm Hg
C. 40 mm Hg
D. 80 mm Hg
Answer: D 80 mm Hg. A client about to go into respiratory
arrest will have inefficient ventilation and will be retaining
carbon dioxide. The value expected would be around 80 mm
Hg. All other values are lower than expected.
57. Timothy’s arterial blood gas (ABG) results are as follows;
pH 7.16; Paco2 80 mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L;
Sao2 81%. This ABG result represents which of the following
conditions?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respirator y alkalosis
Answer: (C) Respiratory acidosis. Because Paco2 is high at 80
mm Hg and the metabolic measure, HCO3- is normal, the
client has respiratory acidosis. The pH is less than 7.35,
academic, which eliminates metabolic and
respiratory alkalosis as possibilities. If the HCO3- was below
22 mEq/L the client would have metabolic acidosis.
58. Norma has started a new drug for hypertension. Thirty
minutes after she takes the drug, she develops chest
tightness and becomes short of breath and tachypneic. She
has a decreased level of consciousness. These signs indicate
which of the following conditions?
A. Asthma attack
B. Pulmonary embolism
C. Respiratory failure
D. Rheumatoid arthritis
Answer: (C) Respiratory failure. The client was reacting to the
drug with respiratory signs of impending anaphylaxis, which
could lead to eventually respiratory failure. Although the
signs are also related to an asthma attack or a
pulmonary embolism, consider the new drug first.
Rheumatoid arthritis doesn’t manifest these signs.
Situation: Mr. Gonzales was admitted to the hospital with
ascites and jaundice. To rule out cirrhosis of the liver:
59. Which laboratory test indicates liver cirrhosis?
A. Decreased red blood cell count
B. Decreased serum acid phosphate level
C. Elevated white blood cell count
D. Elevated serum aminotransferase
Answer: (D) Elevated serum aminotransferase. Hepatic cell
death causes release of liver enzymes
alanine aminotransferase (ALT), aspartate aminotransferase
(AST) and lactate dehydrogenase (LDH) into the circulation.
Liver cirrhosis is a chronic and irreversible disease of the liver
characterized by generalized inflammation and fibrosis of the
liver tissues.
60.The biopsy of Mr. Gonzales confirms the diagnosis of
cirrhosis. Mr. Gonzales is at increased risk for excessive
bleeding primarily because of:
A. Impaired clotting mechanism
B. Varix formation
C. Inadequate nutrition
D. Trauma of invasive procedure
Answer: (A) Impaired clotting mechanism. Cirrhosis of the
liver results in decreased Vitamin K absorption and formation
of clotting factors resulting in impaired clotting mechanism.
61. Mr. Gonzales develops hepatic encephalopathy. Which
clinical manifestation is most common with this condition?
A. Increased urine output
B. Altered level of consciousness
C. Decreased tendon reflex
D. Hypotension
Answer: (B) Altered level of consciousness. Changes in
behavior and level of consciousness are the first sins of
hepatic encephalopathy. Hepatic encephalopathy is caused
by liver failure and develops when the liver is unable to
convert protein metabolic product ammonia to urea. This
results in accumulation of ammonia and other toxic in the
blood that damages the cells.
62. When Mr. Gonzales regained consciousness, the physician
orders 50 ml of Lactose p.o. every 2 hours. Mr. Gozales
develops diarrhea. The nurse best action would be:
A. “I’ll see if your physician is in the hospital”.
B. “Maybe your reacting to the drug; I will withhold the
next dose”.
C. “I’ll lower the dosage as ordered so the drug causes
only 2 to 4 stools a day”.
D. “Frequently, bowel movements are needed to reduce
sodium level”.
Answer: (C) “I’ll lower the dosage as ordered so the drug
causes only 2 to 4 stools a day”. Lactulose is given to a
patients with hepatic encephalopathy to reduce absorption of
ammonia in the intestines by binding with ammonia and
promoting more frequent bowel movements. If the patient
experience diarrhea, it indicates over dosage and the nurse
must reduce the amount of medication given to the patient.
The stool will be mashy or soft. Lactulose is also very sweet
and may cause cramping and bloating.
63. Which of the following groups of symptoms indicates a
ruptured abdominal aortic aneurysm?
A. Lower back pain, increased blood pressure, decreased
re blood cell (RBC) count, increased white blood (WBC)
count.
B. Severe lower back pain, decreased blood pressure,
decreased RBC count, increased WBC count.
C. Severe lower back pain, decreased blood pressure,
decreased RBC count, decreased RBC count, decreased
WBC count.
D. Intermitted lower back pain, decreased blood pressure,
decreased RBC count, increased WBC count.
Answer: (B) Severe lower back pain, decreased blood
pressure, decreased RBC count, increased WBC count.Severe
lower back pain indicates an aneurysm rupture, secondary to
pressure being applied within the abdominal cavity.
When ruptured occurs, the pain is constant because it can’t
be alleviated until the aneurysm is repaired. Blood pressure
decreases due to the loss of blood. After the aneurysm
ruptures, the vasculature is interrupted and blood volume is
lost, so blood pressure wouldn’t increase. For the
same reason, the RBC count is decreased – not increased. The
WBC count increases as cell migrate to the site of injury.
64. After undergoing a cardiac catheterization, Tracy has a
large puddle of blood under his buttocks. Which of the
following steps should the nurse take first?
A. Call for help.
B. Obtain vital signs
C. Ask the client to “lift up”
D. Apply gloves and assess the groin site
Answer: (D) Apply gloves and assess the groin site. Observing
standard precautions is the first priority when dealing with
any blood fluid. Assessment of the groin site is the
second priority. This establishes where the blood is coming
from and determineshow much blood has been lost. The goal
in this situation is to stop the bleeding. The nurse would call
for help if it were warranted after the assessment of the
situation. After determining the extent of the bleeding, vital
signs assessment is important. The nurse should never move
the client, in case a clot has formed. Moving can disturb the
clot and cause rebleeding.
65. Which of the following treatment is a suitable surgical
intervention for a client with unstable angina?
A. Cardiac catheterization
B. Echocardiogram
C. Nitroglycerin
D. Percutaneous transluminal coronary angioplasty (PTCA)
Answer: (D) Percutaneous transluminal coronary angioplasty
(PTCA). PTCA can alleviate the blockage and restore blood
flow and oxygenation. An echocardiogram is a noninvasive
diagnosis test. Nitroglycerin is an oral sublingual medication.
Cardiac catheterization is a diagnostic tool – not a treatment
66. The nurse is aware that the following terms used to
describe reduced cardiac output and perfusion impairment
due to ineffective pumping of the heart is:
A. Anaphylactic shock
B. Cardiogenic shock
C. Distributive shock
D. Myocardial infarction (MI)
Answer: (B) Cardiogenic shock. Cardiogenic shock is shock
related to ineffective pumping of the heart. Anaphylactic
shock results from an allergic reaction. Distributive shock
results from changes in the intravascular volume distribution
and is usually associated with increased cardiac output. MI
isn’t a shock state, though a severe MI can lead to shock.
67. A client with hypertension ask the nurse which factors can
cause blood pressure to drop to normal levels?
A. Kidneys’ excretion to sodium only.
B. Kidneys’ retention of sodium and water
C. Kidneys’ excretion of sodium and water
D. Kidneys’ retention of sodium and excretion of water
Answer: (C) Kidneys’ excretion of sodium and water. The
kidneys respond to rise in blood pressure by excreting sodium
and excess water. This response ultimately affects sysmolic
blood pressure by regulating blood volume. Sodium or water
retention would only further increase blood pressure. Sodium
and water travel together across the membrane in the
kidneys; one can’t travel without the other.
68. Nurse Rose is aware that the statement that best explains
why furosemide (Lasix) is administered to treat hypertension
is:
A. It dilates peripheral blood vessels.
B. It decreases sympathetic cardioacceleration.
C. It inhibits the angiotensin-coverting enzymes
D. It inhibits reabsorption of sodium and water in the
loop of Henle
Answer: (D) It inhibits reabsorption of sodium and water in
the loop of Henle. Furosemide is a loop diuretic that inhibits
sodium and water reabsorption in the loop Henle, thereby
causing a decrease in blood pressure. Vasodilators cause
dilation of peripheral blood vessels, directly relaxing vascular
smooth muscle and decreasing blood pressure. Adrenergic
blockers decrease sympathetic cardioacceleration
and decrease blood pressure. Angiotensin-converting enzyme
inhibitors decrease blood pressure due to their action on
angiotensin.
.
69. Nurse Nikki knows that laboratory results supports the
diagnosis of systemic lupus erythematosus (SLE) is:
A. Elavated serum complement level
B. Thrombocytosis, elevated sedimentation rate
C. Pancytopenia, elevated antinuclear antibody (ANA)
titer
D. Leukocysis, elevated blood urea nitrogen (BUN) and
creatinine levels
Answer: (C) Pancytopenia, elevated antinuclear antibody
(ANA) titer. Laboratory findings for clients with SLE usually
show pancytopenia, elevated ANA titer, and decreased
serum complement levels. Clients may have elevated BUN
and creatinine levels from nephritis, but the increase does
not indicate SLE
70. Arnold, a 19-year-old client with a mild concussion is
discharged from the emergency department. Before
discharge, he complains of a headache. When offered
acetaminophen, his mother tells the nurse the headache is
severe and she would like her son to have something stronger.
Which of the following responses by the nurse is appropriate?
A. “Your son had a mild concussion, acetaminophen is
strong enough.”
B. “Aspirin is avoided because of the danger of Reye’s
syndrome in children or young adults.”
C. “Narcotics are avoided after a head injury because
they may hide a worsening condition.”
D. Stronger medications may lead to vomiting, which
increases the intracarnial pressure (ICP).”
Answer: (C) Narcotics are avoided after a head injury because
they may hide a worsening condition. Narcotics may mask
changes in the level of consciousness that indicate increased
ICP and shouldn’t acetaminophen is strong enough ignores
the mother’s question and therefore isn’t appropriate.
Aspirin is contraindicated in conditions that may have
bleeding, such as trauma, and for children or young adults
with viral illnesses due to the danger of Reye’s syndrome.
Stronger medications may not necessarily lead to vomiting
but will sedate the client, thereby masking changes in his
level of consciousness.
71. When evaluating an arterial blood gas from a male client
with a subdural hematoma, the nurse notes the Paco2 is 30
mm Hg. Which of the following responses best describes the
result?
A. Appropriate; lowering carbon dioxide (CO2) reduces
intracranial pressure (ICP)
B. Emergent; the client is poorly oxygenated
C. Normal
 D. Significant; the client has alveolar hypoventilation
Answer: (A) Appropriate; lowering carbon dioxide (CO2)
reduces intracranial pressure (ICP). A normal Paco2 value is
35 to 45 mm Hg CO2 has vasodilating properties; therefore,
lowering Paco2 through hyperventilation will lower ICP
caused by dilated cerebral vessels. Oxygenation is evaluated
through Pao2 and oxygen saturation. Alveolar
hypoventilation would be reflected in an increased Paco2.
72. When prioritizing care, which of the following clients
should the nurse Olivia assess first?
A. A 17-year-old clients 24-hours postappendectomy
B. A 33-year-old client with a recent diagnosis of Guillain-
Barre syndrome
C. A 50-year-old client 3 days postmyocardial infarction
D. A 50-year-old client with diverticulitis
Answer: (B) A 33-year-old client with a recent diagnosis of
Guillain-Barre syndrome . Guillain-Barre syndrome is
characterized by ascending paralysis and potential respiratory
failure. The order of client assessment should follow client
priorities, with disorder of airways, breathing, and
then circulation. There’s no information to suggest the
postmyocardial infarction client has an arrhythmia or other
complication. There’s no evidence to suggest hemorrhage or
perforation for the remaining clients as a priority of care.
73. JP has been diagnosed with gout and wants to know why
colchicine is used in the treatment of gout. Which of the
following actions of colchicines explains why it’s effective for
gout?
A. Replaces estrogen
B. Decreases infection
C. Decreases inflammation
D. Decreases bone demineralization
Answer: (C) Decreases inflammation. Then action of
colchicines is to decrease inflammation by reducing the
migration of leukocytes to synovial fluid. Colchicine
doesn’t replace estrogen, decrease infection, or decrease
bone demineralization.
74. Norma asks for information about osteoarthritis. Which of
the following statements about osteoarthritis is correct?
A. Osteoarthritis is rarely debilitating
B. Osteoarthritis is a rare form of arthritis
C. Osteoarthritis is the most common form of arthritis
D. Osteoarthritis afflicts people over 60
Answer: (C) Osteoarthritis is the most common form of
arthritis. Osteoarthritis is the most common form of arthritis
and can be extremely debilitating. It can afflict people of any
age, although most are elderly
75. Ruby is receiving thyroid replacement therapy develops
the flu and forgets to take her thyroid replacement medicine.
The nurse understands that skipping this medication will put
the client at risk for developing which of the following
lifethreatening complications?
A. Exophthalmos
B. Thyroid storm
C. Myxedema coma
D. Tibial myxedema
Answer: (C) Myxedema coma. Myxedema coma, severe
hypothyroidism, is a life-threatening condition that may
develop if thyroid replacement medication isn’t
taken. Exophthalmos, protrusion of the eyeballs, is seen
with hyperthyroidism. Thyroid storm is life-threatening but
is caused by severe hyperthyroidism. Tibial myxedema,
peripheral mucinous edema involving the lower leg,
is associated with hypothyroidism but isn’t life-threatening
76. Nurse Sugar is assessing a client with Cushing’s syndrome.
Which observation should the nurse report to the physician
immediately?
A. Pitting edema of the legs
B. An irregular apical pulse
C. Dry mucous membranes
D. Frequent urination
Answer: (B) An irregular apical pulse. Because Cushing’s
syndrome causes aldosterone overproduction, which
increases urinary potassium loss, the disorder may lead to
hypokalemia. Therefore, the nurse should immediately report
signs and symptoms of hypokalemia, such as an irregular
apical pulse, to the physician. Edema is an expected finding
because aldosterone overproduction causes sodium and fluid
retention. Dry mucous membranes and frequent urination
signal dehydration, which isn’t associated with Cushing’s
syndrome.
77. Cyrill with severe head trauma sustained in a car accident
is admitted to the intensive care unit. Thirty-six hours later,
the client’s urine output suddenly rises above 200 ml/hour,
leading the nurse to suspect diabetes insipidus. Which
laboratory findings support the nurse’s suspicion of diabetes
insipidus?
A. Above-normal urine and serum osmolality levels
B. Below-normal urine and serum osmolality levels
C. Above-normal urine osmolality level, below-normal
serum osmolality level
D. Below-normal urine osmolality level, above-normal
serum osmolality level
Answer: (D) Below-normal urine osmolality level, above-
normal serum osmolality level. In diabetes insipidus,
excessive polyuria causes dilute urine, resulting in a below-
normal urine osmolality level. At the same time, polyuria
depletes the body of water, causing dehydration that leads to
an above-normal serum osmolality level. For the same
reasons, diabetes insipidus doesn’t cause above-normal urine
osmolality or below-normal serum osmolality levels.
78. Jomari is diagnosed with hyperosmolar hyperglycemic
nonketotic syndrome (HHNS) is stabilized and prepared for
discharge. When preparing the client for discharge and home
management, which of the following statements indicates
that the client understands her condition and how to control
it?
A. “I can avoid getting sick by not becoming dehydrated
and by paying attention to my need to urinate, drink,
or eat more than usual.”
B. “If I experience trembling, weakness, and headache, I
should drink a glass of soda that contains sugar.”
C. “I will have to monitor my blood glucose level closely
and notify the physician if it’s constantly elevated.”
D. “If I begin to feel especially hungry and thirsty, I’ll eat a
snack high in carbohydrates.”
Answer: (A) “I can avoid getting sick by not becoming
dehydrated and by paying attention to my need to urinate,
drink, or eat more than usual.” Inadequate fluid intake during
hyperglycemic episodes often leads to HHNS. By recognizing
the signs of hyperglycemia (polyuria, polydipsia, and
polyphagia) and increasing fluid intake, the client
may prevent HHNS. Drinking a glass of nondiet soda would be
appropriate for hypoglycemia. A client whose diabetes is
controlled with oral antidiabetic agents usually doesn’t need
to monitor blood glucose levels. A highcarbohydrate diet
would exacerbate the client’s condition, particularly if fluid
intake is low.
79. A 66-year-old client has been complaining of sleeping
more, increased urination, anorexia, weakness, irritability,
depression, and bone pain that interferes with her going
outdoors. Based on these assessment findings, the nurse
would suspect which of the following disorders?
A. Diabetes mellitus
B. Diabetes insipidus
C. Hypoparathyroidism
D. Hyperparathyroidism
Answer: (D) Hyperparathyroidism. Hyperparathyroidism is
most common in older women and is characterized by bone
pain and weakness from excess parathyroid hormone (PTH).
Clients also exhibit hypercaliuria-causing polyuria.
While clients with diabetes mellitus and diabetes insipidus
also have polyuria, they don’t have bone pain and increased
sleeping. Hypoparathyroidism is characterized by urinary
frequency rather than polyuria.
80. Nurse Lourdes is teaching a client recovering from
addisonian crisis about the need to take fludrocortisone
acetate and hydrocortisone at home. Which statement by the
client indicates an understanding of the instructions?
A. “I’ll take my hydrocortisone in the late afternoon,
before dinner.”
B. “I’ll take all of my hydrocortisone in the morning, right
after I wake up.”
C. “I’ll take two-thirds of the dose when I wake up and
one-third in the late afternoon.”
D. “I’ll take the entire dose at bedtime.”
Answer: (C) “I’ll take two-thirds of the dose when I wake up
and one-third in the late afternoon.” Hydrocortisone, a
glucocorticoid, should be administered according to a
schedule that closely reflects the body’s own secretion of this
hormone; therefore, two-thirds of the dose of hydrocortisone
should be taken in the morning and one-third in the late
afternoon. This dosage schedule reduces adverse effects.
81. Which of the following laboratory test results would
suggest to the nurse Len that a client has a corticotropin-
secreting pituitary adenoma?
A. High corticotropin and low cortisol levels
B. Low corticotropin and high cortisol levels
C. High corticotropin and high cortisol levels
D. Low corticotropin and low cortisol levels
Answer: (C) High corticotropin and high cortisol levels. A
corticotropin-secreting pituitary tumor would cause
high corticotropin and high cortisol levels. A high
corticotropin level with a low cortisol level and a low
corticotropin level with a low cortisol level would
be associated with hypocortisolism. Low corticotropin and
high cortisol levels would be seen if there was a primary
defect in the adrenal glands
82. A male client is scheduled for a transsphenoidal
hypophysectomy to remove a pituitary tumor. Preoperatively,
the nurse should assess for potential complications by doing
which of the following?
A. Testing for ketones in the urine
B. Testing urine specific gravity
C. Checking temperature every 4 hours
D. Performing capillary glucose testing every 4 hours
Answer: (D) Performing capillary glucose testing every 4
hours. The nurse should perform capillary glucose testing
every 4 hours because excess cortisol may cause insulin
resistance, placing the client at risk for hyperglycemia. Urine
ketone testing isn’t indicated because the client does secrete
insulin and, therefore, isn’t at risk for ketosis. Urine specific
gravity isn’t indicated because although fluid balance can be
compromised, it usually isn’t dangerously
imbalanced. Temperature regulation may be affected by
excess cortisol and isn’t an accurate indicator of infection.
83. Capillary glucose monitoring is being performed every 4
hours for a client diagnosed with diabetic ketoacidosis. Insulin
is administered using a scale of regular insulin according to
glucose results. At 2 p.m., the client has a capillary glucose
level of 250 mg/dl for which he receives 8 U of regular insulin.
Nurse Mariner should expect the dose’s:
A. onset to be at 2 p.m. and its peak to be at 3 p.m.
B. onset to be at 2:15 p.m. and its peak to be at 3 p.m.
C. onset to be at 2:30 p.m. and its peak to be at 4 p.m.
D. onset to be at 4 p.m. and its peak to be at 6 p.m.
Answer: (C) onset to be at 2:30 p.m. and its peak to be at 4
p.m.. Regular insulin, which is a short-acting insulin, has an
onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because
the nurse gave the insulin at 2 p.m., the expected onset
would be from 2:15 p.m. to 2:30 p.m. and the peak from 4
p.m. to 6 p.m.
84. The physician orders laboratory tests to confirm
hyperthyroidism in a female client with classic signs and
symptoms of this disorder. Which test result would confirm
the diagnosis?
A. No increase in the thyroid-stimulating hormone (TSH)
level after 30 minutes during the TSH stimulation test
B. A decreased TSH level
C. An increase in the TSH level after 30 minutes during the
TSH stimulation test
D. Below-normal levels of serum triiodothyronine (T3) and
serum thyroxine (T4) as detected by radioimmunoassay
Answer: (A) No increase in the thyroid-stimulating hormone
(TSH) level after 30 minutes during the TSH stimulation
test. In the TSH test, failure of the TSH level to rise after
30 minutes confirms hyperthyroidism. A decreased TSH level
indicates a pituitary deficiency of this hormone. Below-
normal levels of T3 and T4, as detected by radioimmunoassay,
signal hypothyroidism. A below-normal T4 level also occurs in
malnutrition and liver disease and may result
from administration of phenytoin and certain other drugs.
85. Rico with diabetes mellitus must learn how to self-
administer insulin. The physician has prescribed 10 U of U-
100 regular insulin and 35 U of U-100 isophane insulin
suspension (NPH) to be taken before breakfast. When
teaching the client how to select and rotate insulin injection
sites, the nurse should provide which instruction?
A. “Inject insulin into healthy tissue with large blood
vessels and nerves.”
B. “Rotate injection sites within the same anatomic
region, not among different regions.”
C. “Administer insulin into areas of scar tissue or
hypotrophy whenever possible.”
D. “Administer insulin into sites above muscles that you
plan to exercise heavily later that day.”
Answer: (B) “Rotate injection sites within the same anatomic
region, not among different regions.” The nurse should
instruct the client to rotate injection sites within the same
anatomic region. Rotating sites among different regions may
cause excessive day-to-day variations in the blood glucose
level; also, insulin absorption differs from one region to the
next. Insulin should be injected only into healthy tissue
lacking large blood vessels, nerves, or scar tissue or other
deviations. Injecting insulin into areas of hypertrophy may
delay absorption. The client shouldn’t inject insulin into areas
of lipodystrophy (such as hypertrophy or atrophy); to prevent
lipodystrophy, the client should rotate injection sites
systematically. Exercise speeds drug absorption, so the client
shouldn’t inject insulin into sites above muscles that will be
exercised heavily.
86. Nurse Sarah expects to note an elevated serum glucose
level in a client with hyperosmolar hyperglycemic nonketotic
syndrome (HHNS). Which other laboratory finding should the
nurse anticipate?
A. Elevated serum acetone level
B. Serum ketone bodies
C. Serum alkalosis
D. Below-normal serum potassium level
Answer: (D) Below-normal serum potassium level. A client
with HHNS has an overall body deficit of potassium resulting
from diuresis, which occurs secondary to the
hyperosmolar, hyperglycemic state caused by the relative
insulin deficiency. An elevated serum acetone level and
serum ketone bodies are characteristic of diabetic
ketoacidosis. Metabolic acidosis, not serum alkalosis, may
occur in HHNS.
87. For a client with Graves’ disease, which nursing
intervention promotes comfort?
A. Restricting intake of oral fluids
B. Placing extra blankets on the client’s bed
C. Limiting intake of high-carbohydrate foods
D. Maintaining room temperature in the low-normal range
Answer: (D) Maintaining room temperature in the low-
normal range. Graves’ disease causes signs and symptoms
of hypermetabolism, such as heat intolerance, diaphoresis,
excessive thirst and appetite, and weight loss. To reduce heat
intolerance and diaphoresis, the nurse should keep the
client’s room temperature in the low-normal range. To
replace fluids lost via diaphoresis, the nurse
should encourage, not restrict, intake of oral fluids. Placing
extra blankets on the bed of a client with heat intolerance
would cause discomfort. To provide needed energy and
calories, the nurse should encourage the client to eat high-
carbohydrate foods.
88. Patrick is treated in the emergency department for a
Colles’ fracture sustained during a fall. What is a Colles’
fracture?
A. Fracture of the distal radius
B. Fracture of the olecranon
C. Fracture of the humerus
D. Fracture of the carpal scaphoid
Answer: (A) Fracture of the distal radius. Colles’ fracture is a
fracture of the distal radius, such as from a fall on an
outstretched hand. It’s most common in women.
Colles’ fracture doesn’t refer to a fracture of the olecranon,
humerus, or carpal scaphoid
89. Cleo is diagnosed with osteoporosis. Which electrolytes
are involved in the development of this disorder?
A. Calcium and sodium
B. Calcium and phosphorous
C. Phosphorous and potassium
D. Potassium and sodium
Answer: (B) Calcium and phosphorous. In osteoporosis, bones
lose calcium and phosphate salts, becoming porous, brittle,
and abnormally vulnerable to fracture. Sodium and potassium
aren’t involved in the development of osteoporosis.
90. Johnny a firefighter was involved in extinguishing a house
fire and is being treated to smoke inhalation. He develops
severe hypoxia 48 hours after the incident, requiring
intubation and mechanical ventilation. He most likely has
developed which of the following conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Atelectasis
C. Bronchitis
D. Pneumonia
Answer: (A) Adult respiratory distress syndrome
(ARDS). Severe hypoxia after smoke inhalation is typically
related to ARDS. The other conditions listed aren’t typically
associated with smoke inhalation and severe hypoxia.
91. A 67-year-old client develops acute shortness of breath
and progressive hypoxia requiring right femur. The hypoxia
was probably caused by which of the following conditions?
A. Asthma attack
B. Atelectasis
C. Bronchitis
D. Fat embolism
Answer: (D) Fat embolism. Long bone fractures are correlated
with fat emboli, whichcause shortness of breath and hypoxia.
It’s unlikely the client has developed asthma or bronchitis
without a previous history. He could develop atelectasis but it
typically doesn’t produce progressive hypoxia.
92. A client with shortness of breath has decreased to absent
breath sounds on the right side, from the apex to the base.
Which of the following conditions would best explain this?
A. Acute asthma
B. Chronic bronchitis
C. Pneumonia
D. Spontaneous pneumothorax
Answer: (D) Spontaneous pneumothorax. A spontaneous
pneumothorax occurs when the client’s lung collapses,
causing an acute decreased in the amount of functional
lung used in oxygenation. The sudden collapse was the
cause of his chest pain and shortness of breath. An asthma
attack would show wheezing breath sounds, and bronchitis
would have rhonchi. Pneumonia would have bronchial
breath sounds over the area of consolidation
93. A 62-year-old male client was in a motor vehicle accident
as an unrestrained driver. He’s now in the emergency
department complaining of difficulty of breathing and chest
pain. On auscultation of his lung field, no breath sounds are
present in the upper lobe. This client may have which of the
following conditions?
A. Bronchitis
B. Pneumonia
C. Pneumothorax
D. Tuberculosis (TB)
Answer: (C) Pneumothorax. From the trauma the client
experienced, it’s unlikely he has bronchitis, pneumonia, or
TB; rhonchi with bronchitis, bronchial breath sounds with TB
would be heard.
94. If a client requires a pneumonectomy, what fills the area
of the thoracic cavity?
 A. The space remains filled with air only
B. The surgeon fills the space with a gel
C. Serous fluids fills the space and consolidates the region
D. The tissue from the other lung grows over to the other
side
Answer: (C) Serous fluids fills the space and consolidates the
region. Serous fluid fills the space and eventually
consolidates, preventing extensive mediastinal shift of the
heart and remaining lung. Air can’t be left in the space.
There’s no gel that can be placed in the pleural space. The
tissue from the other lung can’t cross the
mediastinum, although a temporary mediastinal shift exits
until the space is filled.
95. Hemoptysis may be present in the client with a
pulmonary embolism because of which of the following
reasons?
A. Alveolar damage in the infracted area
B. Involvement of major blood vessels in the occluded area
C. Loss of lung parenchyma
D. Loss of lung tissue
Answer: (A) Alveolar damage in the infracted area. The
infracted area produces alveolar damage that can lead
to the production of bloody sputum, sometimes in massive
amounts. Clot formation usually occurs in the legs. There’s a
loss of lung parenchyma and subsequent scar tissue
formation
96. Aldo with a massive pulmonary embolism will have an
arterial blood gas analysis performed to determine the extent
of hypoxia. The acid-base disorder that may be present is?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Answer: (D) Respiratory alkalosis. A client with massive
pulmonary embolism will have a large region and blow off
large amount of carbon dioxide, which crosses the unaffected
alveolar-capillary membrane more readily than does
oxygen and results in respiratory alkalosis.
97. After a motor vehicle accident, Armand an 22-year-old
client is admitted with a pneumothorax. The surgeon inserts a
chest tube and attaches it to a chest drainage system.
Bubbling soon appears in the water seal chamber. Which of
the following is the most likely cause of the bubbling?
A. Air leak
B. Adequate suction
C. Inadequate suction
D. Kinked chest tube
Answer: (A) Air leak. Bubbling in the water seal chamber of a
chest drainage system stems from an air leak. In
pneumothorax an air leak can occur as air is pulled from the
pleural space. Bubbling doesn’t normally occur with
either adequate or inadequate suction or any preexisting
bubbling in the water seal chamber.
98. Nurse Michelle calculates the IV flow rate for a
postoperative client. The client receives 3,000 ml of Ringer’s
lactate solution IV to run over 24 hours. The IV infusion set
has a drop factor of 10 drops per milliliter. The nurse should
regulate the client’s IV to deliver how many drops per minute?
A. 18
B. 21
C. 35
D. 40
Answer: (B) 21. 3000 x 10 divided by 24 x 60
99. Mickey, a 6-year-old child with a congenital heart disorder
is admitted with congestive heart failure. Digoxin (lanoxin)
0.12 mg is ordered for the child. The bottle of Lanoxin
contains .05 mg of Lanoxin in 1 ml of solution. What amount
should the nurse administer to the child?
A. 1.2 ml
B. 2.4 ml
C. 3.5 ml
D. 4.2 ml
Answer: (B) 2.4 ml. .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x =
2.4 ml.
100. Nurse Alexandra teaches a client about elastic stockings.
Which of the following statements, if made by the client,
indicates to the nurse that the teaching was successful?
A. “I will wear the stockings until the physician tells me to
remove them.”
B. “I should wear the stockings even when I am sleep.”
C. “Every four hours I should remove the stockings for a
half hour.”
D. “I should put on the stockings before getting out of
bed in the morning.”
Answer: (D) “I should put on the stockings before getting out
of bed in the morning. Promote venous return by applying
external pressure on veins.
PNLE V for Care of Clients with
Physiologic and Psychosocial
Alterations (Part 3)
1. Mr. Marquez reports of losing his job, not being able to
sleep at night, and feeling upset with his wife. Nurse John
responds to the client, “You may want to talk about your
employment situation in group today.” The Nurse is using
which therapeutic technique?
A. Observations
B. Restating
C. Exploring
D. Focusing\
Answer: (D) Focusing. The nurse is using focusing by
suggesting that the client discuss a specific issue. The nurse
didn’t restate the question, make observation, or ask further
question (exploring).
2. Tony refuses his evening dose of Haloperidol (Haldol), then
becomes extremely agitated in the dayroom while other
clients are watching television. He begins cursing and
throwing furniture. Nurse Oliver first action is to:
A. Check the client’s medical record for an order for an as-
needed I.M. dose of medication for agitation.
B. Place the client in full leather restraints.
C. Call the attending physician and report the behavior.
D. Remove all other clients from the dayroom.
Answer: (D) Remove all other clients from the dayroom. The
nurse’s first priority is to consider the safety of the clients in
the therapeutic setting. The other actions are appropriate
responses after ensuring the safety of other clients.
3. Tina who is manic, but not yet on medication, comes to the
drug treatment center. The nurse would not let this client join
the group session because:
A. The client is disruptive.
B. The client is harmful to self.
C. The client is harmful to others.
D. The client needs to be on medication first.
Answer: (A) The client is disruptive. Group activity provides
too much stimulation, which the client will not be able to
handle (harmful to self) and as a result will be disruptive to
others.
4. Dervid, an adolescent boy was admitted for substance
abuse and hallucinations. The client’s mother asks Nurse
Armando to talk with his husband when he arrives at the
hospital. The mother says that she is afraid of what the father
might say to the boy. The most appropriate nursing
intervention would be to:
A. Inform the mother that she and the father can work
through this problem themselves.
B. Refer the mother to the hospital social worker.
C. Agree to talk with the mother and the father together.
D. Suggest that the father and son work things out.
Answer: (C) Agree to talk with the mother and the father
together. By agreeing to talk with both parents, the nurse can
provide emotional support and further assess and validate
the family’s needs.
5. 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.
Answer: (A) Perceptual disorders. Frightening visual
hallucinations are especially common in clients experiencing
alcohol withdrawal.
6. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now
complains that it “doesn’t help” and refuses to take it. What
should the nurse say or do?
A. Withhold the drug.
B. Record the client’s response.
C. Encourage the client to tell the doctor.
D. Suggest that it takes awhile before seeing the results.
Answer: (D) Suggest that it takes awhile before seeing the
results. The client needs a specific response; that it takes 2
to 3 weeks (a delayed effect) until the therapeutic blood
level is reached
7. Dervid, an adolescent has a history of truancy from school,
running away from home and “barrowing” other people’s
things without their permission. The adolescent denies
stealing, rationalizing instead that as long as no one was using
the items, it was all right to borrow them. It is important for
the nurse to understand the psychodynamically, this behavior
may be largely attributed to a developmental defect related
to the:
A. Id
B. Ego
C. Superego
D. Oedipal complex
Answer: (C) Superego. This behavior shows a weak sense of
moral consciousness. According to Freudian theory,
personality disorders stem from a weak superego.
8. 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.
Answer: (C) Skeletal muscle paralysis. 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
9. 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.
Answer: (D) Increase calories, carbohydrates, and
protein.This client increased protein for tissue building and
increased calories to replace what is burned up (usually via
carbohydrates).
10.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.
Answer: (C) Acting overly solicitous toward the child. This
behavior is an example of reaction formation, a
coping mechanism.
11.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.
Answer: (A) By designating times during which the client can
focus on the behavior. 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.
12.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.
Answer: (D) Exploring the meaning of the traumatic event
with the client. 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.
13.Meryl, age 19, is highly dependent on her parents and
fears leaving home to go away to college. Shortly before the
semester starts, she complains that her legs are paralyzed
and is rushed to the emergency department. When physical
examination rules out a physical cause for her paralysis, the
physician admits her to the psychiatric unit where she is
diagnosed with conversion disorder. Meryl asks the nurse,
“Why has this happened to me?” What is the nurse’s best
response?
A. “You’ve developed this paralysis so you can stay with
your parents. You must deal with this conflict if you
want to walk again.”
B. “It must be awful not to be able to move your legs. You
may feel better if you realize the problem is
psychological, not physical.”
C. “Your problem is real but there is no physical basis for
it. We’ll work on what is going on in your life to find
out why it’s happened.”
D. “It isn’t uncommon for someone with your personality
to develop a conversion disorder during times of stress.”
Answer: (C) “Your problem is real but there is no physical
basis for it. We’ll work on what is going on in your life to find
out why it’s happened.” The nurse must be honest with the
client by telling her that the paralysis has no physiologic
cause while also conveying empathy and acknowledging that
her symptoms are real. The client will benefit from psychiatric
treatment, which will help her understand the underlying
cause of her symptoms. After the psychological conflict is
resolved, her symptoms will disappear. Saying that it must be
awful not to be able to move her legs wouldn’t answer the
client’s question; knowing that the cause is psychological
wouldn’t necessarily make her feel better. Telling her that she
has developed paralysis to avoid leaving her parents or
that her personality caused her disorder wouldn’t help her
understand and resolve the underlying conflict.
14.Nurse Krina knows that the following drugs have been
known to be effective in treating obsessive-compulsive
disorder (OCD):
A. benztropine (Cogentin) and diphenhydramine
(Benadryl).
B. chlordiazepoxide (Librium) and diazepam (Valium)
C. fluvoxamine (Luvox) and clomipramine (Anafranil)
D. divalproex (Depakote) and lithium (Lithobid)
Answer: (C) fluvoxamine (Luvox) and clomipramine
(Anafranil). The antidepressants fluvoxamine and
clomipramine have been effective in the treatment of OCD.
Librium and Valium may be helpful in treating anxiety related
to OCD but aren’t drugs of choice to treat the illness. The
other medications mentioned aren’t effective in the
treatment of OCD.
15.Alfred was newly diagnosed with anxiety disorder. The
physician prescribed buspirone (BuSpar). The nurse is aware
that the teaching instructions for newly prescribed buspirone
should include which of the following?
A. A warning about the drugs delayed therapeutic effect,
which is from 14 to 30 days.
B. A warning about the incidence of neuroleptic malignant
syndrome (NMS).
C. A reminder of the need to schedule blood work in 1
week to check blood levels of the drug.
D. A warning that immediate sedation can occur with a
resultant drop in pulse.
Answer: (A) A warning about the drugs delayed therapeutic
effect, which is from 14 to 30 days. The client should be
informed that the drug’s therapeutic effect might not be
reached for 14 to 30 days. The client must be instructed
to continue taking the drug as directed. Blood level checks
aren’t necessary. NMS hasn’t been reported with this drug,
but tachycardia is frequently reported
16.Richard with agoraphobia has been symptom-free for 4
months. Classic signs and symptoms of phobias include:
A. Insomnia and an inability to concentrate.
B. Severe anxiety and fear.
C. Depression and weight loss.
D. Withdrawal and failure to distinguish reality from
fantasy.
Answer: (B) Severe anxiety and fear. Phobias cause severe
anxiety (such as a panic attack) that is out of proportion to
the threat of the feared object or situation. Physical signs and
symptoms of phobias include profuse sweating, poor
motor control, tachycardia, and elevated blood pressure.
Insomnia, an inability to concentrate, and weight loss are
common in depression. Withdrawal and failure to distinguish
reality from fantasy occur in schizophrenia.
17.Which medications have been found to help reduce or
eliminate panic attacks?
A. Antidepressants
B. Anticholinergics
C. Antipsychotics
D. Mood stabilizers
Answer: (A) Antidepressants. Tricyclic and monoamine
oxidase (MAO) inhibitor antidepressants have been found to
be effective in treating clients with panic attacks. Why these
drugs help control panic attacks isn’t clearly understood.
Anticholinergic agents, which are smooth-muscle
relaxants, relieve physical symptoms of anxiety but don’t
relieve the anxiety itself. Antipsychotic drugs are
inappropriate because clients who experience panic attacks
aren’t psychotic. Mood stabilizers aren’t indicated
because panic attacks are rarely associated with mood
changes.
18.A client seeks care because she feels depressed and has
gained weight. To treat her atypical depression, the physician
prescribes tranylcypromine sulfate (Parnate), 10 mg by
mouth twice per day. When this drug is used to treat atypical
depression, what is its onset of action?
A. 1 to 2 days
B. 3 to 5 days
C. 6 to 8 days
D. 10 to 14 days
Answer: (B) 3 to 5 days. Monoamine oxidase inhibitors,
such as tranylcypromine, have an onset of action of
approximately 3 to 5 days. A full clinical response may be
delayed for 3 to 4 weeks. The therapeutic effects may
continue for 1 to 2 weeks after discontinuation
19. A 65 years old client is in the first stage of Alzheimer’s
disease. Nurse Patricia should plan to focus this client’s care
on:
A. Offering nourishing finger foods to help maintain the
client’s nutritional status.
B. Providing emotional support and individual counseling.
C. Monitoring the client to prevent minor illnesses from
turning into major problems.
D. Suggesting new activities for the client and family to do
together.
Answer: (B) Providing emotional support and individual
counseling. Clients in the first stage of Alzheimer’s disease are
aware that something is happening to them and may become
overwhelmed and frightened. Therefore, nursing care
typically focuses on providing emotional support and
individual counseling. The other options are appropriate
during the second stage of Alzheimer’s disease, when
the client needs continuous monitoring to prevent minor
illnesses from progressing into major problems and when
maintaining adequate nutrition may become a challenge.
During this stage, offering nourishing finger foods helps
clients to feed themselves and maintain adequate nutrition.
20.The nurse is assessing a client who has just been admitted
to the emergency department. Which signs would suggest an
overdose of an antianxiety agent?
A. Combativeness, sweating, and confusion
B. Agitation, hyperactivity, and grandiose ideation
C. Emotional lability, euphoria, and impaired memory
D. Suspiciousness, dilated pupils, and increased blood
pressure
Answer: (C) Emotional lability, euphoria, and impaired
memory. Signs of antianxiety agent overdose include
emotional lability, euphoria, and impaired memory.
Phencyclidine overdose can cause combativeness, sweating,
and confusion. Amphetamine overdose can result in agitation,
hyperactivity, and grandiose ideation. Hallucinogen overdose
can produce suspiciousness, dilated pupils, and increased
blood pressure.
21.The nurse is caring for a client diagnosed with antisocial
personality disorder. The client has a history of fighting,
cruelty to animals, and stealing. Which of the following traits
would the nurse be most likely to uncover during assessment?
A. History of gainful employment
B. Frequent expression of guilt regarding antisocial
behavior
C. Demonstrated ability to maintain close, stable
relationships
D. d. A low tolerance for frustration
Answer: (D) A low tolerance for frustration. Clients with an
antisocial personality disorder exhibit a low tolerance for
frustration, emotional immaturity, and a lack of
impulse control. They commonly have a history of
unemployment, miss work repeatedly, and quit work without
other plans for employment. They don’t feel guilt about their
behavior and commonly perceive themselves as victims. They
also display a lack of responsibility for the outcome of
their actions. Because of a lack of trust in others, clients with
antisocial personality disorder commonly have difficulty
developing stable, close relationships.
22.Nurse Amy is providing care for a male client undergoing
opiate withdrawal. Opiate withdrawal causes severe physical
discomfort and can be life-threatening. To minimize these
effects, opiate users are commonly detoxified with:
A. Barbiturates
B. Amphetamines
C. Methadone
D. Benzodiazepines
Answer: (C) Methadone. Methadone is used to detoxify
opiate users because it binds with opioid receptors at many
sites in the central nervous system but doesn’t have the same
deterious effects as other opiates, such as cocaine, heroin,
and morphine. Barbiturates, amphetamines,
and benzodiazepines are highly addictive and would require
detoxification treatment.
23.Nurse Cristina is caring for a client who experiences false
sensory perceptions with no basis in reality. These
perceptions are known as:
A. Delusions
B. Hallucinations
C. Loose associations
D. Neologisms
Answer: (B) Hallucinations. Hallucinations are visual, auditory,
gustatory, tactile, or olfactory perceptions that have no basis
in reality. Delusions are false beliefs, rather than perceptions,
that the client accepts as real. Loose associations are rapid
shifts among unrelated ideas. Neologisms are bizarre words
that have meaning only to the client.
24. Nurse Marco is developing a plan of care for a client with
anorexia nervosa. Which action should the nurse include in
the plan?
A. Restricts visits with the family and friends until the
client begins to eat.
B. Provide privacy during meals.
C. Set up a strict eating plan for the client.
 D. Encourage the client to exercise, which will reduce her
anxiety.
Answer: (C) Set up a strict eating plan for the
client. Establishing a consistent eating plan and monitoring
the client’s weight are very important in this disorder. The
family and friends should be included in the client’s care. The
client should be monitored during meals-not given privacy.
Exercise must be limited and supervised.
25.Tim is admitted with a diagnosis of delusions of grandeur.
The nurse is aware that this diagnosis reflects a belief that
one is:
A. Highly important or famous.
B. Being persecuted
C. Connected to events unrelated to oneself
D. Responsible for the evil in the world.
Answer: (A) Highly important or famous. A delusion of
grandeur is a false belief that one is highly important or
famous. A delusion of persecution is a false belief that one
is being persecuted. A delusion of reference is a false belief
that one is connected to events unrelated to oneself or a
belief that one is responsible for the evil in the world
26.Nurse Jen is caring for a male client with manic depression.
The plan of care for a client in a manic state would include:
A. Offering a high-calorie meals and strongly encouraging
the client to finish all food.
B. Insisting that the client remain active through the day
so that he’ll sleep at night.
C. Allowing the client to exhibit hyperactive, demanding,
manipulative behavior without setting limits.
D. Listening attentively with a neutral attitude and
avoiding power struggles.
Answer: (D) Listening attentively with a neutral attitude and
avoiding power struggles. The nurse should listen to the
client’s requests, express willingness to seriously consider the
request, and respond later. The nurse should encourage the
client to take short daytime naps because he expends so
much energy. The nurse shouldn’t try to restrain the
client when he feels the need to move around as long as his
activity isn’t harmful. High calorie finger foods should be
offered to supplement the client’s diet, if he can’t remain
seated long enough to eat a complete meal. The nurse
shouldn’t be forced to stay seated at the table to finish
a meal. The nurse should set limits in a calm, clear, and self-
confident tone of voice.
27.Ramon is admitted for detoxification after a cocaine
overdose. The client tells the nurse that he frequently uses
cocaine but that he can control his use if he chooses. Which
coping mechanism is he using?
A. Withdrawal
B. Logical thinking
C. Repression
D. Denial
Answer: (D) Denial. Denial is unconscious defense mechanism
in which emotional conflict and anxiety is avoided by refusing
to acknowledge feelings, desires, impulses, or external facts
that are consciously intolerable. Withdrawal is a common
response to stress, characterized by apathy. Logical thinking
is the ability to think rationally and make
responsible decisions, which would lead the client admitting
the problem and seeking help. Repression is suppressing past
events from the consciousness because of guilty association.
28.Richard is admitted with a diagnosis of schizotypal
personality disorder. Which signs would this client exhibit
during social situations?
A. Aggressive behavior
B. Paranoid thoughts
C. Emotional affect
D. Independence needs
Answer: (B) Paranoid thoughts. Clients with schizotypal
personality disorder experience excessive social anxiety that
can lead to paranoid thoughts. Aggressive behavior is
uncommon, although these clients may experience
agitation with anxiety. Their behavior is emotionally cold with
a flattened affect, regardless of the situation. These clients
demonstrate a reduced capacity for close or dependent
relationships.
29. Nurse Mickey is caring for a client diagnosed with bulimia.
The most appropriate initial goal for a client diagnosed with
bulimia is to:
A. Avoid shopping for large amounts of food.
B. Control eating impulses.
C. Identify anxiety-causing situations
D. Eat only three meals per day.
Answer: (C) Identify anxiety-causing situations. Bulimic
behavior is generally a maladaptive coping response to stress
and underlying issues. The client must identify anxiety-
causing situations that stimulate the bulimic behavior and
then learn new ways of coping with the anxiety.
30.Rudolf is admitted for an overdose of amphetamines.
When assessing the client, the nurse should expect to see:
A. Tension and irritability
B. Slow pulse
C. Hypotension
D. Constipation
Answer: (A) Tension and irritability. An amphetamine is a
nervous system stimulant that is subject to abuse because of
its ability to produce wakefulness and euphoria.
An overdose increases tension and irritability. Options B and
C are incorrect because amphetamines stimulate
norepinephrine, which increase the heart rate and blood
flow. Diarrhea is a common adverse effect so option D in is
incorrect
31.Nicolas is experiencing hallucinations tells the nurse, “The
voices are telling me I’m no good.” The client asks if the nurse
hears the voices. The most appropriate response by the nurse
would be:
A. “It is the voice of your conscience, which only you can
control.”
B. “No, I do not hear your voices, but I believe you can
hear them”.
C. “The voices are coming from within you and only you
can hear them.”
D. “Oh, the voices are a symptom of your illness; don’t pay
any attention to them.”
Answer: (B) “No, I do not hear your voices, but I believe you
can hear them”. The nurse, demonstrating knowledge and
 understanding, accepts the client’s perceptions even though
they are hallucinatory 37.When assessing a premorbid personality characteristics of
a client with a major depression, it would be unusual for the
32.The nurse is aware that the side effect of nurse to find that this client demonstrated:
electroconvulsive therapy that a client may experience:
A. Rigidity
A. Loss of appetite B. Stubbornness
B. Postural hypotension C. Diverse interest
C. Confusion for a time after treatment D. Over meticulousness
D. Complete loss of memory for a time
Answer: (C) Diverse interest. Before onset of depression,
Answer: (C) Confusion for a time after treatment. The these clients usually have very narrow, limited interest.
electrical energy passing through the cerebral cortex during
ECT results in a temporary state of confusion after treatment. 38.Nurse Krina recognizes that the suicidal risk for depressed
client is greatest:
33.A dying male client gradually moves toward resolution of
feelings regarding impending death. Basing care on the A. As their depression begins to improve
theory of Kubler-Ross, Nurse Trish plans to use nonverbal B. When their depression is most severe
interventions when assessment reveals that the client is in C. Before nay type of treatment is started
the: D. As they lose interest in the environment

A. Anger stage Answer: (A) As their depression begins to improve. At this

B. Denial stage point the client may have enough energy to plan
C. Bargaining stage and execute an attempt
D. Acceptance stage
39.Nurse Kate would expect that a client with vascular
Answer: (D) Acceptance stage. Communication and dementis would experience:
intervention during this stage are mainly nonverbal, as when
the client gestures to hold the nurse’s hand A. Loss of remote memory related to anoxia
34.The outcome that is unrelated to a crisis state is: B. Loss of abstract thinking related to emotional state
C. Inability to concentrate related to decreased stimuli
A. Learning more constructive coping skills D. Disturbance in recalling recent events related to
B. Decompensation to a lower level of functioning. cerebral hypoxia.
C. Adaptation and a return to a prior level of functioning.
D. A higher level of anxiety continuing for more than 3 Answer: (D) Disturbance in recalling recent events related to
months. cerebral hypoxia. Cell damage seems to interfere with
registering input stimuli, which affects the ability to register
Answer: (D) A higher level of anxiety continuing for more and recall recent events; vascular dementia is related to
than 3 months. This is not an expected outcome of a crisis multiple vascular lesions of the cerebral cortex
because by definition a crisis would be resolved in 6 weeks. and subcortical structure.

35.Miranda a psychiatric client is to be discharged with orders 40.Josefina is to be discharged on a regimen of lithium
for haloperidol (haldol) therapy. When developing a teaching carbonate. In the teaching plan for discharge the nurse
plan for discharge, the nurse should include cautioning the should include:
client against:
A. Advising the client to watch the diet carefully
A. Driving at night B. Suggesting that the client take the pills with milk
B. Staying in the sun C. Reminding the client that a CBC must be done once a
C. Ingesting wines and cheeses month.
D. Taking medications containing aspirin D. Encouraging the client to have blood levels checked as
ordered.
Answer: (B) Staying in the sun. Haldol causes
photosensitivity. Severe sunburn can occur on exposure to Answer: (D) Encouraging the client to have blood levels
the sun checked as ordered. Blood levels must be checked monthly
or bimonthly when the client is on maintenance therapy
36.Jen a nursing student is anxious about the upcoming board because there is only a small range between therapeutic and
examination but is able to study intently and does not toxic levels.
become distracted by a roommate’s talking and loud music.
The student’s ability to ignore distractions and to focus on 41.The psychiatrist orders lithium carbonate 600 mg p.o t.i.d
studying demonstrates: for a female client. Nurse Katrina would be aware that the
teaching about the side effects of this drug were understood
A. Mild-level anxiety when the client state, “I will call my doctor immediately if I
B. Panic-level anxiety notice any:
C. Severe-level anxiety
D. Moderate-level anxiety A. Sensitivity to bright light or sun
B. Fine hand tremors or slurred speech
Answer: (D) Moderate-level anxiety. A moderately anxious C. Sexual dysfunction or breast enlargement
person can ignore peripheral events and focuses on central D. d. Inability to urinate or difficulty when urinating
concerns
Answer: (B) Fine hand tremors or slurred speech. These are
common side effects of lithium carbonate.
42.Nurse Mylene recognizes that the most important factor
necessary for the establishment of trust in a critical care area
is:
A. Privacy
B. Respect
C. Empathy
D. Presence
Answer: (D) Presence. The constant presence of a nurse
provides emotional support because the client knows that
someone is attentive and available in case of an emergency
43.When establishing an initial nurse-client relationship,
Nurse Hazel should explore with the client the:
A. Client’s perception of the presenting problem.
B. Occurrence of fantasies the client may experience.
C. Details of any ritualistic acts carried out by the client
D. Client’s feelings when external; controls are instituted.
Answer: (A) Client’s perception of the presenting
problem. The nurse can be most therapeutic by starting
where the client is, because it is the client’s concept of the
problem that serves as the starting point of the relationship.
44.Tranylcypromine sulfate (Parnate) is prescribed for a
depressed client who has not responded to the tricyclic
antidepressants. After teaching the client about the
medication, Nurse Marian evaluates that learning has
occurred when the client states, “I will avoid:
A. Citrus fruit, tuna, and yellow vegetables.”
B. Chocolate milk, aged cheese, and yogurt’”
C. Green leafy vegetables, chicken, and milk.”
D. Whole grains, red meats, and carbonated soda.”
Answer: (B) Chocolate milk, aged cheese, and yogurt’. These
high-tyramine foods, when ingested in the presence of an
MAO inhibitor, cause a severe hypertensive response.
45.Nurse John is a aware that most crisis situations should
resolve in about:
A. 1 to 2 weeks
B. 4 to 6 weeks
C. 4 to 6 months
D. 6 to 12 months
Answer: (B) 4 to 6 weeks. Crisis is self-limiting and lasts from
4 to 6 weeks.
46. Nurse Judy knows that statistics show that in adolescent
suicide behavior:
A. Females use more dramatic methods than males
B. Males account for more attempts than do females
C. Females talk more about suicide before attempting it
D. Males are more likely to use lethal methods than are
females
Answer: (D) Males are more likely to use lethal methods than
are females. This finding is supported by research; females
account for 90% of suicide attempts but males are three
times more successful because of methods used.
47. Dervid with paranoid schizophrenia repeatedly uses
profanity during an activity therapy session. Which response
by the nurse would be most appropriate?
A. “Your behavior won’t be tolerated. Go to your room
immediately.”
B. “You’re just doing this to get back at me for making you
come to therapy.”
C. “Your cursing is interrupting the activity. Take time out
in your room for 10 minutes.”
D. “I’m disappointed in you. You can’t control yourself
even for a few minutes.”
Answer: (C) “Your cursing is interrupting the activity. Take
time out in your room for 10 minutes.” The nurse should set
limits on client behavior to ensure a comfortable
environment for all clients. The nurse should accept hostile
or quarrelsome client outbursts within limits without
becoming personally offended, as in option A. Option B is
incorrect because it implies that the client’s actions reflect
feelings toward the staff instead of the client’s own misery.
Judgmental remarks, such as option D, may decrease the
client’s self-esteem
48.Nurse Maureen knows that the nonantipsychotic
medication used to treat some clients with schizoaffective
disorder is:
A. phenelzine (Nardil)
B. chlordiazepoxide (Librium)
C. lithium carbonate (Lithane)
D. imipramine (Tofranil)
Answer: (C) lithium carbonate (Lithane). Lithium carbonate,
an antimania drug, is used to treat clients with cyclical
schizoaffective disorder, a psychotic disorder once
classified under schizophrenia that causes affective
symptoms, including maniclike activity. Lithium helps control
the affective component of this disorder. Phenelzine is a
monoamine oxidase inhibitor prescribed for clients
who don’t respond to other antidepressant drugs such as
imipramine. Chlordiazepoxide, an antianxiety agent,
generally is contraindicated in psychotic clients. Imipramine,
primarily considered an antidepressant agent, is also used to
treat clients with agoraphobia and that undergoing cocaine
detoxification
49.Which information is most important for the nurse Trinity
to include in a teaching plan for a male schizophrenic client
taking clozapine (Clozaril)?
A. Monthly blood tests will be necessary.
B. Report a sore throat or fever to the physician
immediately.
C. Blood pressure must be monitored for hypertension.
D. Stop the medication when symptoms subside.
Answer: (B) Report a sore throat or fever to the physician
immediately. A sore throat and fever are indications of an
infection caused by agranulocytosis, a potentially life-
threatening complication of clozapine. Because of the risk of
agranulocytosis, white blood cell (WBC) counts are necessary
weekly, not monthly. If the WBC count drops below
3,000/μl, the medication must be stopped. Hypotension may
occur in clients taking this medication. Warn the client to
stand up slowly to avoid dizziness from orthostatic
hypotension. The medication should be continued, even
when symptoms have been controlled. If the medication
must be stopped, it should be slowly tapered over 1 to 2
weeks and only under the supervision of a physician.

50.Ricky with chronic schizophrenia takes neuroleptic
medication is admitted to the psychiatric unit. Nursing
assessment reveals rigidity, fever, hypertension, and
diaphoresis. These findings suggest which
lifethreatening reaction:
A. Tardive dyskinesia.
B. Dystonia.
C. Neuroleptic malignant syndrome.
D. Akathisia.
Answer: (C) Neuroleptic malignant syndrome. The client’s
signs and symptoms suggest neuroleptic malignant syndrome,
a life-threatening reaction to neuroleptic medication that
requires immediate treatment. Tardive dyskinesia causes
involuntary movements of the tongue, mouth, facial muscles,
and arm and leg muscles. Dystonia is characterized by cramps
and rigidity of the tongue, face, neck, and back muscles.
Akathisia causes restlessness, anxiety, and jitteriness.
51.Which nursing intervention would be most appropriate if a
male client develop orthostatic hypotension while taking
amitriptyline (Elavil)?
A. Consulting with the physician about substituting a
different type of antidepressant.
B. Advising the client to sit up for 1 minute before getting
out of bed.
C. Instructing the client to double the dosage until the
problem resolves.
D. Informing the client that this adverse reaction should
disappear within 1 week.
Answer: (B) Advising the client to sit up for 1 minute before
getting out of bed. To minimize the effects of amitriptyline-
induced orthostatic hypotension, the nurse should advise the
client to sit up for 1 minute before getting out of bed.
Orthostatic hypotension commonly occurs with tricyclic
antidepressant therapy. In these cases, the dosage may
be reduced or the physician may prescribe nortriptyline,
another tricyclic antidepressant. Orthostatic hypotension
disappears only when the drug is discontinued.
52.Mr. Cruz visits the physician’s office to seek treatment for
depression, feelings of hopelessness, poor appetite, insomnia,
fatigue, low selfesteem, poor concentration, and difficulty
making decisions. The client states that these symptoms
began at least 2 years ago. Based on this report, the nurse
Tyfany suspects:
A. Cyclothymic disorder.
B. Atypical affective disorder.
C. Major depression.
D. Dysthymic disorder.
Answer: (D) Dysthymic disorder. Dysthymic disorder is
marked by feelings of depression lasting at least 2 years,
accompanied by at least two of the following
symptoms: sleep disturbance, appetite disturbance, low
energy or fatigue, low selfesteem, poor concentration,
difficulty making decisions, and hopelessness. These
symptoms may be relatively continuous or separated by
intervening periods of normal mood that last a few days to
a few weeks. Cyclothymic disorder is a chronic mood
disturbance of at least 2 years’ duration marked by numerous
periods of depression and hypomania. Atypical affective
disorder is characterized by manic signs and symptoms.
Major depression is a recurring, persistent sadness or loss
of interest or pleasure in almost all activities, with signs and
symptoms recurring for at least 2 weeks.
53. After taking an overdose of phenobarbital (Barbita),
Mario is admitted to the emergency department. Dr. Trinidad
prescribes activated charcoal (Charcocaps) to be
administered by mouth immediately. Before administering
the dose, the nurse verifies the dosage ordered. What is
the usual minimum dose of activated charcoal?
A. 5 g mixed in 250 ml of water
B. 15 g mixed in 500 ml of water
C. 30 g mixed in 250 ml of water
D. 60 g mixed in 500 ml of water
Answer: (C) 30 g mixed in 250 ml of water. The usual adult
dosage of activated charcoal is 5 to 10 times the estimated
weight of the drug or chemical ingested, or a minimum
dose of 30 g, mixed in 250 ml of water. Doses less than this
will be ineffective; doses greater than this can increase the
risk of adverse reactions, although toxicity doesn’t occur with
activated charcoal, even at the maximum dose.
54.What herbal medication for depression, widely used in
Europe, is now being prescribed in the United States?
A. Ginkgo biloba
B. Echinacea
C. St. John’s wort
D. Ephedra
Answer: (C) St. John’s wort. St. John’s wort has been found to
have serotonin-elevating properties, similar to prescription
antidepressants. Ginkgo biloba is prescribed to enhance
mental acuity. Echinacea has immune-stimulating properties.
Ephedra is a naturally occurring stimulant that is similar
to ephedrine.
55.Cely with manic episodes is taking lithium. Which
electrolyte level should the nurse check before administering
this medication?
A. Calcium
B. Sodium
C. Chloride
D. Potassium
Answer: (B) Sodium. Lithium is chemically similar to sodium. If
sodium levels are reduced, such as from sweating or diuresis,
lithium will be reabsorbed by the kidneys, increasing the risk
of toxicity. Clients taking lithium shouldn’t restrict their intake
of sodium and should drink adequate amounts of fluid each
day. The other electrolytes are important for normal body
functions but sodium is most important to the absorption of
lithium.
56.Nurse Josefina is caring for a client who has been
diagnosed with delirium. Which statement about delirium is
true?
A. It’s characterized by an acute onset and lasts about 1
month.
B. It’s characterized by a slowly evolving onset and lasts
about 1 week.
C. It’s characterized by a slowly evolving onset and lasts
about 1 month.
D. It’s characterized by an acute onset and lasts hours to
a number of days.
 Answer: (D) It’s characterized by an acute onset and lasts
hours to a number of days. Delirium has an acute onset and
typically can last from several hours to several days.
57.Edward, a 66 year old client with slight memory
impairment and poor concentration is diagnosed with
primary degenerative dementia of the Alzheimer’s type. Early
signs of this dementia include subtle personality changes and
withdrawal from social interactions. To assess for progression
to the middle stage of Alzheimer’s disease, the nurse
should observe the client for:
A. Occasional irritable outbursts.
B. Impaired communication.
C. Lack of spontaneity.
D. Inability to perform self-care activities.
Answer: (B) Impaired communication. Initially, memory
impairment may be the only cognitive deficit in a client with
Alzheimer’s disease. During the early stage of this
disease, subtle personality changes may also be present.
However, other than occasional irritable outbursts and lack
of spontaneity, the client is usually cooperative and exhibits
socially appropriate behavior. Signs of advancement to the
middle stage of Alzheimer’s disease include exacerbated
cognitive impairment with obvious personality changes
and impaired communication, such as inappropriate
conversation, actions, and responses. During the late stage,
the client can’t perform self-care activities and may become
mute
58.Isabel with a diagnosis of depression is started on
imipramine (Tofranil), 75 mg by mouth at bedtime. The nurse
should tell the client that:
A. This medication may be habit forming and will be
discontinued as soon as the client feels better.
B. This medication has no serious adverse effects.
C. The client should avoid eating such foods as aged
cheeses, yogurt, and chicken livers while taking the
medication.
D. This medication may initially cause tiredness, which
should become less bothersome over time.
Answer: (D) This medication may initially cause tiredness,
which should become less bothersome over time. Sedation is
a common early adverse effect of imipramine, a tricyclic
antidepressant, and usually decreases as tolerance
develops. Antidepressants aren’t habit forming and don’t
cause physical or psychological dependence. However, after a
long course of high-dose therapy, the dosage should be
decreased gradually to avoid mild withdrawal symptoms.
Serious adverse effects, although rare, include myocardial
infarction, heart failure, and tachycardia. Dietary
restrictions, such as avoiding aged cheeses, yogurt, and
chicken livers, are necessary for a client taking a monoamine
oxidase inhibitor, not a tricyclic antidepressant.
59.Kathleen is admitted to the psychiatric clinic for treatment
of anorexia nervosa. To promote the client’s physical health,
the nurse should plan to:
A. Severely restrict the client’s physical activities.
B. Weigh the client daily, after the evening meal.
C. Monitor vital signs, serum electrolyte levels, and acid-
base balance.
D. Instruct the client to keep an accurate record of food
and fluid intake.
Answer: (C) Monitor vital signs, serum electrolyte levels, and
acid-base balance. An anorexic client who requires
hospitalization is in poor physical condition from starvation
and may die as a result of arrhythmias, hypothermia,
malnutrition, infection, or cardiac abnormalities secondary
to electrolyte imbalances. Therefore, monitoring the client’s
vital signs, serum electrolyte level, and acid base balance is
crucial. Option A may worsen anxiety. Option B is incorrect
because a weight obtained after breakfast is more accurate
than one obtained after the evening meal. Option D
would reward the client with attention for not eating and
reinforce the control issues that are central to the underlying
psychological problem; also, the client may record food and
fluid intake inaccurately.
60.Celia with a history of polysubstance abuse is admitted to
the facility. She complains of nausea and vomiting 24 hours
after admission. The nurse assesses the client and notes
piloerection, pupillary dilation, and lacrimation. The nurse
suspects that the client is going through which of the
following withdrawals?
A. Alcohol withdrawal
B. Cannibis withdrawal
C. Cocaine withdrawal
D. Opioid withdrawal
Answer: (D) Opioid withdrawal. The symptoms listed are
specific to opioid withdrawal. Alcohol withdrawal would show
elevated vital signs. There is no real withdrawal from cannibis.
Symptoms of cocaine withdrawal include depression, anxiety,
and agitation.
61.Mr. Garcia, an attorney who throws books and furniture
around the office after losing a case is referred to the
psychiatric nurse in the law firm’s employee assistance
program. Nurse Beatriz knows that the client’s behavior most
likely represents the use of which defense mechanism?
A. Regression
B. Projection
C. Reaction-formation
D. Intellectualization
Answer: (A) Regression. An adult who throws temper
tantrums, such as this one, is displaying regressive behavior,
or behavior that is appropriate at a younger age. In projection,
the client blames someone or something other than the
source. In reaction formation, the client acts in opposition to
his feelings. In intellectualization, the client overuses rational
explanations orabstract thinking to decrease the significance
of a feeling or event.
62.Nurse Anne is caring for a client who has been treated
long term with antipsychotic medication. During the
assessment, Nurse Anne checks the client for tardive
dyskinesia. If tardive dyskinesia is present, Nurse Anne would
most likely observe:
A. Abnormal movements and involuntary movements of
the mouth, tongue, and face.
B. Abnormal breathing through the nostrils accompanied
by a “thrill.”
C. Severe headache, flushing, tremors, and ataxia.
D. Severe hypertension, migraine headache,
Answer: (A) Abnormal movements and involuntary
movements of the mouth, tongue, and face. Tardive
dyskinesia is a severe reaction associated with long term use
of antipsychotic medication. The clinical manifestations
include abnormal movements (dyskinesia) and involuntary
movements of the mouth, tongue (fly catcher tongue), and
face.
63.Dennis has a lithium level of 2.4 mEq/L. The nurse
immediately would assess the client for which of the
following signs or symptoms?
A. Weakness
B. Diarrhea
C. Blurred vision
D. Fecal incontinence
Answer: (C) Blurred vision. At lithium levels of 2 to 2.5 mEq/L
the client will experienced blurred vision, muscle twitching,
severe hypotension, and persistent nausea and vomiting.
With levels between 1.5 and 2 mEq/L the client experiencing
vomiting, diarrhea, muscle weakness, ataxia,
dizziness, slurred speech, and confusion. At lithium levels of
2.5 to 3 mEq/L or higher, urinary and fecal incontinence
occurs, as well as seizures, cardiac dysrythmias, peripheral
vascular collapse, and death.
64.Nurse Jannah is monitoring a male client who has been
placed inrestraints because of violent behavior. Nurse
determines that it will be safe to remove the restraints when:
A. The client verbalizes the reasons for the violent
behavior.
B. The client apologizes and tells the nurse that it will
never happen again.
C. No acts of aggression have been observed within 1
hour after the release of two of the extremity
restraints.
D. The administered medication has taken effect.
Answer: (C) No acts of aggression have been observed
within 1 hour after the release of two of the extremity
restraints. The best indicator that the behavior is controlled,
if the client exhibits no signs of aggression after partial
release of restraints. Options A, B, and D do not ensure that
the client has controlled the behavior.
65.Nurse Irish is aware that Ritalin is the drug of choice for a
child with ADHD. The side effects of the following may be
noted by the nurse:
A. Increased attention span and concentration
B. Increase in appetite
C. Sleepiness and lethargy
D. Bradycardia and diarrhea
Answer: (A) increased attention span and concentration. The
medication has a paradoxic effect that decrease hyperactivity
and impulsivity among children with ADHD. B, C, D.
Side effects of Ritalin include anorexia, insomnia, diarrhea
and irritability.
66.Kitty, a 9 year old child has very limited vocabulary and
interaction skills. She has an I.Q. of 45. She is diagnosed to
have Mental retardation of this classification:
A. Profound
B. Mild
C. Moderate
D. Severe
Answer: (C) Moderate. The child with moderate mental
retardation has an I.Q. of 35- 50 Profound Mental retardation
has an I.Q. of below 20; Mild mental retardation 50-70 and
Severe mental retardation has an I.Q. of 20-35.
67.The therapeutic approach in the care of Armand an
autistic child include the following EXCEPT:
A. Engage in diversionary activities when acting -out
B. Provide an atmosphere of acceptance
C. Provide safety measures
D. Rearrange the environment to activate the child
Answer: (D) Rearrange the environment to activate the
child. The child with autistic disorder does not want
change. Maintaining a consistent environment is therapeutic.
A. Angry outburst can be re-channeling through safe
activities. B. Acceptance enhances a trusting relationship. C.
Ensure safety from self-destructive behaviors like head
banging and hair pulling
68.Jeremy is brought to the emergency room by friends who
state that he took something an hour ago. He is actively
hallucinating, agitated, with irritated nasal septum.
A. Heroin
B. Cocaine
C. LSD
D. Marijuana
Answer: (B) cocaine. The manifestations indicate intoxication
with cocaine, a CNS stimulant. A. Intoxication with heroine is
manifested by euphoria then impairment in judgment,
attention and the presence of papillary constriction. C.
Intoxication with hallucinogen like LSD is manifested
by grandiosity, hallucinations, synesthesia and increase in
vital signs D. Intoxication with Marijuana, a cannabinoid is
manifested by sensation of slowed time, conjunctival redness,
social withdrawal, impaired judgment and hallucinations.
69.Nurse Pauline is aware that Dementia unlike delirium is
characterized by:
A. Slurred speech
B. Insidious onset
C. Clouding of consciousness
D. Sensory perceptual change
Answer: (B) insidious onset. Dementia has a gradual onset
and progressive deterioration. It causes pronounced memory
and cognitive disturbances. A,C and D are all characteristics of
delirium.
70.A 35 year old female has intense fear of riding an elevator.
She claims “ As if I will die inside.” The client is suffering from:
A. Agoraphobia
B. Social phobia
C. Claustrophobia
D. Xenophobia
Answer: (C) Claustrophobia. Claustrophobia is fear of closed
space. A. Agoraphobia is fear of open space or being a
situation where escape is difficult. B. Social phobia is fear of
performing in the presence of others in a way that will
be humiliating or embarrassing. D. Xenophobia is fear of
strangers.
71.Nurse Myrna develops a counter-transference reaction.
This is evidenced by:
 A. Revealing personal information to the client
B. Focusing on the feelings of the client.
C. Confronting the client about discrepancies in verbal or
non-verbal behavior
D. The client feels angry towards the nurse who resembles
his mother.
Answer: (A) Revealing personal information to the
client. Counter-transference is an emotional reaction of the
nurse on the client based on her unconscious needs and
conflicts. B and C. These are therapeutic approaches. D. This
is transference reaction where a client has an emotional
reaction towards the nurse based on her past.
72.Tristan is on Lithium has suffered from diarrhea and
vomiting. What should the nurse in-charge do first:
A. Recognize this as a drug interaction
B. Give the client Cogentin
C. Reassure the client that these are common side effects
of lithium therapy
D. Hold the next dose and obtain an order for a stat
serum lithium level
Answer: (D) Hold the next dose and obtain an order for a stat
serum lithium level. Diarrhea and vomiting are manifestations
of Lithium toxicity. The next dose of lithium should be
withheld and test is done to validate the observation. A. The
manifestations are not due to drug interaction. B. Cogentin is
used to manage the extra pyramidal symptom side effects
of antipsychotics. C. The common side effects of Lithium are
fine hand tremors, nausea, polyuria and polydipsia.
73.Nurse Sarah ensures a therapeutic environment for all the
client. Which of the following best describes a therapeutic
milieu?
A. A therapy that rewards adaptive behavior
B. A cognitive approach to change behavior
C. A living, learning or working environment.
D. A permissive and congenial environment
Answer: (C) A living, learning or working environment. A
therapeutic milieu refers to a broad conceptual approach
in which all aspects of the environment are channeled to
provide a therapeutic environment for the client. The six
environmental elements include structure, safety, norms;
limit setting, balance and unit modification. A. Behavioral
approach in psychiatric care is based on the premise that
behavior can be learned or unlearned through the use
of reward and punishment. B. Cognitive approach to change
behavior is done by correcting distorted perceptions and
irrational beliefs to correct maladaptive behaviors. D. This is
not congruent with therapeutic milieu.
74.Anthony is very hostile toward one of the staff for no
apparent reason. He is manifesting:
A. Splitting
B. Transference
C. Countertransference
D. Resistance
Answer: (B) Transference. Transference is a positive or
negative feeling associated with a significant person in the
client’s past that are unconsciously assigned to another A.
Splitting is a defense mechanism commonly seen in a
client with personality disorder in which the world is
perceived as all good or all bad C. Countert-transference is a
phenomenon where the nurse shifts feelings assigned to
someone in her past to the patient D. Resistance is the
client’s refusal to submit himself to the care of the nurse
75.Marielle, 17 years old was sexually attacked while on her
way home from school. She is brought to the hospital by her
mother. Rape is an example of which type of crisis:
A. Situational
B. Adventitious
C. Developmental
D. Internal
Answer: (B) Adventitious. Adventitious crisis is a crisis
involving a traumatic event. It is not part of everyday life. A.
Situational crisis is from an external source that upset ones
psychological equilibrium C and D. Are the same. They are
transitional or developmental periods in life
76. Nurse Greta is aware that the following is classified as an
Axis I disorder by the Diagnosis and Statistical Manual of
Mental Disorders, Text Revision (DSM-IV-TR) is:
A. Obesity
B. Borderline personality disorder
C. Major depression
D. Hypertension
Answer: (C) Major depression. The DSM-IV-TR classifies major
depression as an Axis I disorder. Borderline personality
disorder as an Axis II; obesity and hypertension, Axis III.
77.Katrina, a newly admitted is extremely hostile toward a
staff member she has just met, without apparent reason.
According to Freudian theory, the nurse should suspect that
the client is experiencing which of the following phenomena?
A. Intellectualization
B. Transference
C. Triangulation
D. Splitting
Answer: (B) Transference. Transference is the unconscious
assignment of negative or positive feelings evoked by a
significant person in the client’s past to another person.
Intellectualization is a defense mechanism in which the client
avoids dealing with emotions by focusing on facts.
Triangulation refers to conflicts involving three family
members. Splitting is a defense mechanism commonly seen
in clients with personality disorder in which the world is
perceived as all good or all bad.
78.An 83year-old male client is in extended care facility is
anxious most of the time and frequently complains of a
number of vague symptoms that interfere with his ability to
eat. These symptoms indicate which of the following
disorders?
A. Conversion disorder
B. Hypochondriasis
C. Severe anxiety
D. Sublimation
Answer: (B) Hypochondriasis. Complains of vague physical
symptoms that have no apparent medical causes are
characteristic of clients with hypochondriasis. In many cases,
the GI system is affected. Conversion disorders are
characterized by one or more neurologic symptoms. The
client’s symptoms don’t suggest severe anxiety. A client
experiencing sublimation channels maladaptive feelings or
impulses into socially acceptable behavior
79. Charina, a college student who frequently visited the
health center during the past year with multiple vague
complaints of GI symptoms before course examinations.
Although physical causes have been eliminated, the
student continues to express her belief that she has a serious
illness. These symptoms are typically of which of the
following disorders?
A. Conversion disorder
B. Depersonalization
C. Hypochondriasis
D. Somatization disorder
Answer: (C) Hypochondriasis. Hypochodriasis in this case is
shown by the client’s belief that she has a serious illness,
although pathologic causes have been eliminated. The
disturbance usually lasts at lease 6 with identifiable
life stressor such as, in this case, course examinations.
Conversion disorders are characterized by one or more
neurologic symptoms. Depersonalization refers to persistent
recurrent episodes of feeling detached from one’s self or
body. Somatoform disorders generally have a chronic course
with few remissions
80. Nurse Daisy is aware that the following pharmacologic
agents are sedative hypnotic medication is used to induce
sleep for a client experiencing a sleep disorder is:
A. Triazolam (Halcion)
B. Paroxetine (Paxil)\
C. Fluoxetine (Prozac)
D. Risperidone (Risperdal)
Answer: (A) Triazolam (Halcion). Triazolam is one of a group
of sedative hypnotic medication that can be used for a limited
time because of the risk of dependence. Paroxetine is a
scrotonin-specific reutake inhibitor used for treatment
of depression panic disorder, and obsessive-compulsive
disorder. Fluoxetine is a scrotonin-specific reuptake inhibitor
used for depressive disorders and obsessive-compulsive
disorders. Risperidome is indicated for psychotic disorders.
81. Aldo, with a somatoform pain disorder may obtain
secondary gain. Which of the following statement refers to a
secondary gain?
A. It brings some stability to the family
B. It decreases the preoccupation with the physical illness
C. It enables the client to avoid some unpleasant activity
D. It promotes emotional support or attention for the
client
Answer: (D) It promotes emotional support or attention for
the client. Secondary gain refers to the benefits of the illness
that allow the client to receive emotional support or
attention. Primary gain enables the client to avoid some
unpleasant activity. A dysfunctional family may disregard the
real issue, although some conflict is relieved.
Somatoform pain disorder is a preoccupation with pain in the
absence of physical disease.
82. Dervid is diagnosed with panic disorder with agoraphobia
is talking with the nurse in-charge about the progress made in
treatment. Which of the following statements indicates a
positive client response?
A. “I went to the mall with my friends last Saturday”
B. “I’m hyperventilating only when I have a panic attack”
C. “Today I decided that I can stop taking my medication”
D. “Last night I decided to eat more than a bowl of cereal”
Answer: (A) “I went to the mall with my friends last
Saturday”. Clients with panic disorder tent to be socially
withdrawn. Going to the mall is a sign of working on
avoidance behaviors. Hyperventilating is a key symptom of
panic disorder. Teaching breathing control is a
major intervention for clients with panic disorder. The client
taking medications for panic disorder; such as tricylic
antidepressants and benzodiazepines, must be weaned off
these drugs. Most clients with panic disorder
with agoraphobia don’t have nutritional problems.
83. The effectiveness of monoamine oxidase (MAO) inhibitor
drug therapy in client with posttraumatic stress disorder can
be demonstrated by which of the following client self –
reports?
A. “I’m sleeping better and don’t have nightmares”
B. “I’m not losing my temper as much”
C. “I’ve lost my craving for alcohol”
D. “I’ve lost my phobia for water”
Answer: (A) “I’m sleeping better and don’t have
nightmares” MAO inhibitors are used to treat sleep problems,
nightmares, and intrusive daytime thoughts in individual with
posttraumatic stress disorder. MAO inhibitors aren’t used to
help control flashbacks or phobias or to decrease the craving
for alcohol.
84. Mark, with a diagnosis of generalized anxiety disorder
wants to stop taking his lorazepam (Ativan). Which of the
following important facts should nurse Betty discuss with the
client about discontinuing the medication?
A. Stopping the drug may cause depression
B. Stopping the drug increases cognitive abilities
C. Stopping the drug decreases sleeping difficulties
D. Stopping the drug can cause withdrawal symptoms
Answer: (D) Stopping the drug can cause withdrawal
symptoms. Stopping antianxiety drugs such as
benzodiazepines can cause the client to have withdrawal
symptoms. Stopping a benzodiazepine doesn’t tend to cause
depression, increase cognitive abilities, or decrease sleeping
difficulties.
85. Jennifer, an adolescent who is depressed and reported by
his parents as having difficulty in school is brought to the
community mental health center to be evaluated. Which of
the following other health problems would the nurse suspect?
A. Anxiety disorder
B. Behavioral difficulties
C. Cognitive impairment
D. Labile moods
Answer: (B) Behavioral difficulties. Adolescents tend to
demonstrate severe irritability and behavioral problems
rather than simply a depressed mood. Anxiety disorder is
more commonly associated with small children rather than
with adolescents. Cognitive impairment is typically
associated with delirium or dementia. Labile mood is more
characteristic of a client with cognitive impairment or
bipolar disorder
86. Ricardo, an outpatient in psychiatric facility is diagnosed
with dysthymic disorder. Which of the following statement
about dysthymic disorder is true?
A. It involves a mood range from moderate depression to
hypomania
B. It involves a single manic depression
C. It’s a form of depression that occurs in the fall and
winter
D. It’s a mood disorder similar to major depression but of
mild to moderate severity
Answer: (D) It’s a mood disorder similar to major depression
but of mild to moderate severity. Dysthymic disorder is a
mood disorder similar to major depression but it remains
mild to moderate in severity. Cyclothymic disorder is a mood
disorder characterized by a mood range from
moderate depression to hypomania. Bipolar I disorder is
characterized by a single manic episode with no past major
depressive episodes. Seasonalaffective disorder is a form of
depression occurring in the fall and winter.
87. The nurse is aware that the following ways in vascular
dementia different from Alzheimer’s disease is:
A. Vascular dementia has more abrupt onset
B. The duration of vascular dementia is usually brief
C. Personality change is common in vascular dementia
D. The inability to perform motor activities occurs in
vascular dementia
Answer: (A) Vascular dementia has more abrupt
onset. Vascular dementia differs from Alzheimer’s disease
in that it has a more abrupt onset and runs a highly variable
course. Personally change is common in Alzheimer’s disease.
The duration of delirium is usually brief. The inability to
carry out motor activities is common in Alzheimer’s disease
88. Loretta, a newly admitted client was diagnosed with
delirium and has history of hypertension and anxiety. She had
been taking digoxin, furosemide (Lasix), and diazepam
(Valium) for anxiety. This client’s impairment may be related
to which of the following conditions?
A. Infection
B. Metabolic acidosis
C. Drug intoxication
D. Hepatic encephalopathy
Answer: (C) Drug intoxication. This client was taking several
medications that have a propensity for producing delirium;
digoxin (a digitalis glycoxide), furosemide (a thiazide diuretic),
and diazepam (a benzodiazepine). Sufficient supporting data
don’t exist to suspect the other options as causes.
89. Nurse Ron enters a client’s room, the client says, “They’re
crawling on my sheets! Get them off my bed!” Which of the
following assessment is the most accurate?
A. The client is experiencing aphasia
B. The client is experiencing dysarthria
C. The client is experiencing a flight of ideas
D. The client is experiencing visual hallucination
Answer: (D) The client is experiencing visual
hallucination. The presence of a sensory stimulus correlates
with the definition of a hallucination, which is a false sensory
perception. Aphasia refers to a communication problem.
Dysarthria is difficulty in speech production. Flight of ideas is
rapid shifting from one topic to another
90. Which of the following descriptions of a client’s
experience and behavior can be assessed as an illusion?
A. The client tries to hit the nurse when vital signs must be
taken
B. The client says, “I keep hearing a voice telling me to run
away”
C. The client becomes anxious whenever the nurse leaves
the bedside
D. The client looks at the shadow on a wall and tells the
nurse she sees frightening faces on the wall.
Answer: (D) The client looks at the shadow on a wall and tells
the nurse she sees frightening faces on the wall. Minor
memory problems are distinguished from dementia by their
minor severity and their lack of significant interference with
the client’s social or occupational lifestyle. Other options
would be included in the history data but don’t directly
correlate with the client’s lifestyle.
91. During conversation of Nurse John with a client, he
observes that the client shift from one topic to the next on a
regular basis. Which of the following terms describes this
disorder?
A. Flight of ideas
B. Concrete thinking
C. Ideas of reference
D. Loose association
Answer: (D) Loose association. Loose associations are
conversations that constantly shift in topic. Concrete
thinking implies highly definitive thought processes. Flight of
ideas is characterized by conversation that’s disorganized
from the onset. Loose associations don’t necessarily start in
a cogently, then becomes loose
92. Francis tells the nurse that her coworkers are sabotaging
the computer. When the nurse asks questions, the client
becomes argumentative. This behavior shows personality
traits associated with which of the following personality
disorder?
A. Antisocial
B. Histrionic
C. Paranoid
D. Schizotypal
Answer: (C) Paranoid. Because of their suspiciousness,
paranoid personalities ascribe malevolent activities to others
and tent to be defensive, becoming quarrelsome and
argumentative. Clients with antisocial personality disorder
can also be antagonistic and argumentative but are
less suspicious than paranoid personalities. Clients with
histrionic personality disorder are dramatic, not suspicious
and argumentative. Clients with schizoid personality disorder
are usually detached from other and tend to have eccentric
behavior.
93. Which of the following interventions is important for a
Cely experiencing with paranoid personality disorder taking
olanzapine (Zyprexa)?
A. Explain effects of serotonin syndrome
B. Teach the client to watch for extrapyramidal adverse
reaction
 C. Explain that the drug is less affective if the client
smokes
D. Discuss the need to report paradoxical effects such as
euphoria
Answer: (C) Explain that the drug is less affective if the client
smokes. Olanzapine (Zyprexa) is less effective for clients who
smoke cigarettes. Serotonin syndrome occurs with clients
who take a combination of antidepressant medications.
Olanzapine doesn’t cause euphoria, and extrapyramidal
adverse reactions aren’t a problem. However, the client
should be aware of adverse effects such as tardive dyskinesia.
94. Nurse Alexandra notices other clients on the unit avoiding
a client diagnosed with antisocial personality disorder. When
discussing appropriate behavior in group therapy, which of
the following comments is expected about this client by his
peers?
A. Lack of honesty
B. Belief in superstition
C. Show of temper tantrums
D. Constant need for attention
Answer: (A) Lack of honesty. Clients with antisocial
personality disorder tent to engage in acts of dishonesty,
shown by lying. Clients with schizotypal personality disorder
tend to be superstitious. Clients with histrionic
personality disorders tend to overreact to frustrations and
disappointments, have temper tantrums, and seek attention.
95. Tommy, with dependent personality disorder is working
to increase his selfesteem. Which of the following statements
by the Tommy shows teaching was successful?
A. “I’m not going to look just at the negative things about
myself”
B. “I’m most concerned about my level of competence and
progress”
C. “I’m not as envious of the things other people have as I
used to be”
D. “I find I can’t stop myself from taking over things other
should be doing”
Answer: (A) “I’m not going to look just at the negative things
about myself”. As the clients makes progress on improving
self-esteem, selfblame and negative self evaluation will
decrease. Clients with dependent personality disorder tend to
feel fragile and inadequate and would be extremely unlikely
to discuss their level of competence and progress. These
clients focus on self and aren’t envious or jealous. Individuals
with dependent personality disorders don’t take over
situations because they see themselves as inept and
inadequate.
96. Norma, a 42-year-old client with a diagnosis of chronic
undifferentiated schizophrenia lives in a rooming house that
has a weekly nursing clinic. She scratches while she tells the
nurse she feels creatures eating away at her skin. Which of
the following interventions should be done first?
A. Talk about his hallucinations and fears
B. Refer him for anticholinergic adverse reactions
C. Assess for possible physical problems such as rash
D. Call his physician to get his medication increased to
control his psychosis
Answer: (C) Assess for possible physical problems such as
rash. Clients with schizophrenia generally have poor
visceral recognition because they live so fully in their fantasy
world. They need to have as in-depth assessment of physical
complaints that may spill over into their delusional symptoms.
Talking with the client won’t provide as assessment of his
itching, and itching isn’t as adverse reaction of antipsychotic
drugs, calling the physician to get the client’s
medication increased doesn’t address his physical complaints.
97. Ivy, who is on the psychiatric unit is copying and imitating
the movements of her primary nurse. During recovery, she
says, “I thought the nurse was my mirror. I felt connected
only when I saw my nurse.” This behavior is known by which
of the following terms?
A. Modeling
B. Echopraxia
C. Ego-syntonicity
D. Ritualism
Answer: (B) Echopraxia. Echopraxia is the copying of
another’s behaviors and is the result of the loss of ego
boundaries. Modeling is the conscious copying of someone’s
behaviors. Ego-syntonicity refers to behaviors that
correspond with the individual’s sense of self. Ritualism
behaviors are repetitive and compulsive
98. Jun approaches the nurse and tells that he hears a voice
telling him that he’s evil and deserves to die. Which of the
following terms describes the client’s perception?
A. Delusion
B. Disorganized speech
C. Hallucination
D. Idea of reference
Answer: (C) Hallucination. Hallucinations are sensory
experiences that are misrepresentations of reality or have no
basis in reality. Delusions are beliefs not based in reality.
Disorganized speech is characterized by jumping from one
topic to the next or using unrelated words. An idea
of reference is a belief that an unrelated situation holds
special meaning for the client.
99. Mike is admitted to a psychiatric unit with a diagnosis of
undifferentiated schizophrenia. Which of the following
defense mechanisms is probably used by mike?
A. Projection
B. Rationalization
C. Regression
D. Repression
Answer: (C) Regression. Regression, a return to earlier
behavior to reduce anxiety, is the basic defense mechanism
in schizophrenia. Projection is a defense mechanism in
which one blames others and attempts to justify actions;
it’s used primarily by people with paranoid schizophrenia
and delusional disorder. Rationalization is a defense
mechanism used to justify one’s action. Repression is the
basic defense mechanism in the neuroses; it’s an involuntary
exclusion of painful thoughts, feelings, or experiences
from awareness
100. Rocky has started taking haloperidol (Haldol). Which of
the following instructions is most appropriate for Ricky before
taking haloperidol?
A. Should report feelings of restlessness or agitation at
once
B. Use a sunscreen outdoors on a year-round basis
 C. Be aware you’ll feel increased energy taking this drug
D. This drug will indirectly control essential hypertension
Answer: (A) Should report feelings of restlessness or agitation
at once. Agitation and restlessness are adverse effect of
haloperidol and can be treated with antocholinergic drugs.
Haloperidol isn’t likely to cause photosensitivity or control
essential hypertension. Although the client may experience
increased concentration and activity, these effects are due to
a decreased in symptoms, not the drug itself.
SET 2
PNLE I Nursing Practice
Scope of this Nursing Test I is parallel to the NP1 NLE
Coverage:
 Foundation of Nursing
 Nursing Research
 Professional Adjustment
 Leadership and Management
1. The registered nurse is planning to delegate tasks to
unlicensed assistive personnel (UAP). Which of the following
task could the registered nurse safely assigned to a UAP?
A. Monitor the I&O of a comatose toddler client with
salicylate poisoning
B. Perform a complete bed bath on a 2-year-old with
multiple injuries from a serious fall
C. Check the IV of a preschooler with Kawasaki disease
D. Give an outmeal bath to an infant with eczema
Answer: D. Bathing an infant with eczema can be safely
delegated to an aide; this task is basic and can competently
performed by an aid.
2. A nurse manager assigned a registered nurse from telemetry
unit to the pediatrics unit. There were three patients assigned
to the RN. Which of the following patients should not be
assigned to the floated nurse?
A. A 9-year-old child diagnosed with rheumatic fever
B. A young infant after pyloromyotomy
C. A 4-year-old with VSD following cardiac catheterization
D. A 5-month-old with Kawasaki disease
Answer: B. The RN floated from the telemetry unit would be
least prepared to care for a young infant who has just had GI
surgery and requires a specific feeding regimen.
3. A nurse in charge in the pediatric unit is absent. The nurse
manager decided to assign the nurse in the obstetrics unit to
the pediatrics unit. Which of the following patients could the
nurse manager safely assign to the float nurse?
A. A child who had multiple injuries from a serious vehicle
accident
B. A child diagnosed with Kawasaki disease and with
cardiac complications
C. A child who has had a nephrectomy for Wilm’s
tumor
D. A child receiving an IV chelating therapy for lead
poisoning
Answer: C. RN floated from the obstetrics unit should be
able to care for a client with major abdominal surgery,
because this nurse has experienced caring for clients with
cesarean births.
4. The registered nurse is planning to delegate task to a
certified nursing assistant. Which of the following clients
should not be assigned to a CAN?
A. A client diagnosed with diabetes and who has an
infected toe
B. A client who had a CVA in the past two months
C. A client with Chronic renal failure
D. A client with chronic venous insufficiency
Answer: A. The patient is experiencing a potentially serious
complication related to diabetes and needs ongoing
assessment by an RN
5. The nurse in the medication unit passes the medications for
all the clients on the nursing unit. The head nurse is making
rounds with the physician and coordinates clients’ activities
with other departments. The nurse assistant changes the bed
lines and answers call lights. A second nurse is assigned for
changing wound dressings; a licensed practitioner nurse takes
vital signs and bathes theclients. This illustrates of what
method of nursing care?
A. Case management method
B. Primary nursing method
C. Team method
D. Functional method
Answer: D. It describes functional nursing. Staff is assigned
to specific task rather than specific clients.
6. A registered nurse has been assigned to six clients on the
12-hour shift. The RN is responsible for every aspect of care
such as formulating the care of plan, intervention and
evaluating the care during her shift. At the end of her shift, the
RN will pass this same task to the next RN in charge. This
nursing care illustrates of what kind of method?
A. primary nursing method
B. case method
C. team method
D. functional method
Answer: B. Case management. The nurse assumes total
responsibility for meeting the needs of the client during her
entire duty.
7. A newly hired nurse on an adult medicine unit with 3
months experience was asked to float to pediatrics. The nurse
hesitates to perform pediatric skills and receive an interesting
assignment that feels overwhelming. The nurse should:
A. resign on the spot from the nursing position and apply
for a position that does not require floating
B. Inform the nursing supervisor and the charge nurse
on the pediatric floor about the nurse’s lack of skill
and feelings of hesitations and request assistance
C. Ask several other nurses how they feel about pediatrics
and find someone else who is willing to accept the
assignment
D. Refuse the assignment and leave the unit requesting a
vacation a day
Answer: B. The nurse is ethically obligated to inform the
person responsible for the assignment and the person
responsible for the unit about the nurse’s skill level. The
nurse therefore avoids a situation of abandoningclients and
exposing them to greater risks
8. An experienced nurse who voluntarily trained a less
experienced nurse with the intention of enhancing the skills
and knowledge and promoting professional advancement to
the nurse is called a:
 A. mentor
B. team leader
C. case manager
D. change agent
Answer: A. This describes a mentor
9. The pediatrics unit is understaffed and the nurse manager
informs the nurses in the obstetrics unit that she is going to
assign one nurse to float in the pediatric units. Which
statement by the designated float nurse may put her job at risk?
A. “I do not get along with one of the nurses on the
pediatrics unit”
B. “I have a vacation day coming and would like to take
that now”
C. “I do not feel competent to go and work on that area”
D. “ I am afraid I will get the most serious clients in the unit”
Answer:B. This action demonstrates a lack of responsibility
and the nurse should attempt negotiation with the nurse
manager
10. The newly hired staff nurse has been working on a medical
unit for 3 weeks. The nurse manager has posted the team
leader assignments for the following week. The new staff
knows that a major responsibility of the team leader is to:
A. Provide care to the most acutely ill client on the team
B. Know the condition and needs of all the patients on
the team
C. Document the assessments completed by the team
members
D. Supervise direct care by nursing assistants
Answer: B. The team leader is responsible for the overall
management of all clients and staff on the team, and this
information is essential in order to accomplish this
11. A 15-year-old girl just gave birth to a baby boy who needs
emergency surgery. The nurse prepared the consent form and
it should be signed by:
A. The Physician
B. The Registered Nurse caring for the client
C. The 15-year-old mother of the baby boy
D. The mother of the girl
Answer: C. Even though the mother is a minor, she is legally
able to sign consent for her own child.
12. A nurse caring to a client with Alzheimer’s disease
overheard a family member say to the client, “if you pee one
more time, I won’t give you any more food and drinks”. What
initial action is best for the nurse to take?
A. Take no action because it is the family member saying
that to the client
B. Talk to the family member and explain that what
she/he has said is not appropriate for the client
C. Give the family member the number for an Elder Abuse
Hot line
D. Document what the family member has said
Answer: B. This response is the most direct and immediate.
This is a case of potential need for advocacy and patient’s
rights.
13. Which is true about informed consent?
A. A nurse may accept responsibility signing a consent
form if the client is unable
B. Obtaining consent is not the responsibility of the
physician
C. A physician will not subject himself to liability if he
withholds any facts that are necessary to form the basis
of an intelligent consent
D. If the nurse witnesses a consent for surgery, the nurse
is, in effect, indicating that the signature is that of the
purported person and that the person’s condition is
as indicated at the time of signing
Answer: D. The nurse who witness a consent for treatment
or surgery is witnessing only that the client signed the form
and that the client’s condition is as indicated at the time of
signing. The nurse is not witnessing that the client is
“informed”.
14. A mother in labor told the nurse that she was expecting
that her baby has no chance to survive and expects that the
baby will be born dead. The mother accepts the fate of the
baby and informs the nurse that when the baby is born and
requires resuscitation, the mother refuses any treatment to her
baby and expresses hostility toward the nurse while the
pediatric team is taking care of the baby. The nurse is legally
obligated to:
A. Notify the pediatric team that the mother has refused
resuscitation and any treatment for the baby and take the
baby to the mother
B. Get a court order making the baby a ward of the court
C. Record the statement of the mother, notify the
pediatric team, and observe carefully for signs of
impaired bonding and neglect as a reasonable
suspicion of child abuse
D. Do nothing except record the mother’s statement in the
medical record
Answer: C. Although the statements by the mother may not
create a suspicion of neglect, when they are coupled with
observations about impaired bonding and maternal
attachment, they may impose the obligation to report child
neglect. The nurse is further obligated to notify caregivers of
refusal to consent to treatment
15. The hospitalized client with a chronic cough is scheduled
for bronchoscopy. The nurse is tasks to bring the informed
consent document into the client’s room for a signature. The
client asks the nurse for details of the procedure and demands
an explanation why the process of informed consent is
necessary. The nurse responds that informed consent means:
A. The patient releases the physician from all responsibility
for the procedure.
B. The immediate family may make decision against the
patient’s will.
C. The physician must give the client or surrogates
enough information to make health care judgments
consistent with their values and goals.
D. The patient agrees to a procedure ordered by the
physician even if the client does not understand what the
outcome will be.
1. Answer: C. It best explains what informed consent is and
provides for legal rights of the patient
16. A hospitalized client with severe necrotizing ulcer of the
lower leg is schedule for an amputation. The client tells the
nurse that he will not sign the consent form and he does not
want any surgery or treatment because of religious beliefs
about reincarnation. What is the role of the RN?
A. call a family meeting
B. discuss the religious beliefs with the physician
C. encourage the client to have the surgery
D. inform the client of other options
 Answer: A. Phenytoin (Dilantin) can cause venous irritation
Answer: B. The physician may not be aware of the role that due to its alkalinity, therefore it should be mixed with normal
religious beliefs play in making a decision about surgery. saline.

17. While in the hospital lobby, the RN overhears the three 22. The nurse is caring to a client who is hypotensive.
staff discussing the health condition of her client. What would Following a large hematemesis, how should the nurse position
be the appropriate nursing action for the RN to take? the client?

A. Tell them it is not appropriate to discuss the
condition of the client
B. Ignore them, because it is their right to discuss anything
they want to
C. Join in the conversation, giving them supportive input
about the case of the client
D. Report this incident to the nursing supervisor
Answer: A. The behavior should be stopped. The first step is
to remind the staff that confidentiality may be violated
A. Feet and legs elevated 20 degrees, trunk horizontal,
head on small pillow
B. Low Fowler’s with knees gatched at 30 degrees
C. Supine with the head turned to the left
D. Bed sloped at a 45 degree angle with the head lowest and
the legs highest
Answer: A. This position increases venous return, improves
cardiac volume, and promotes adequate ventilation and
cerebral perfusion

18. A staff nurse has had a serious issue with her colleague. In 23. The client is brought to the emergency department after a
this situation, it is best to: serious accident. What would be the initial nursing action of
the nurse to the client?
A. Discuss this with the supervisor
B. Not discuss the issue with anyone. It will probably A. assess the level of consciousness and circulation
resolve itself B. check respirations, circulation, neurological response
C. Try to discuss with the colleague about the issue and C. align the spine, check pupils, check for hemorrhage
resolve it when both are calmer D. check respiration, stabilize spine, check circulation
D. Tell other members of the network what the team
member did Answer: D. Checking the airway would be a priority, and a
neck injury should be suspected
Answer: C. Waiting for emotions to dissipate and sitting
down with the colleague is the first rule of conflict resolution. 24. A nurse is assigned to care to a client with Parkinson’s
disease. What interventions are important if the nurse wants to
19. The nurse is caring to a client who just gave birth to a improve nutrition and promote effective swallowing of the
healthy baby boy. The nurse may not disclose confidential client?
information when:
A. Eat solid food
A. The nurse discusses the condition of the client in a B. Give liquids with meals
clinical conference with other nurses C. Feed the client
B. The client asks the nurse to discuss the her condition D. Sit in an upright position to eat
with the family
C. The father of a woman who just delivered a baby is Answer: D. Client with Parkinson’s disease are at a high risk
on the phone to find out the sex of the baby for aspiration and undernutrition. Sitting upright promotes
D. A researcher from an institutionally approved research more effective swallowing.
study reviews the medical record of a patient
25. During tracheal suctioning, the nurse should implement
Answer: C. The nurse has no idea who the person is on the safety measures. Which of the following should the nurse
phone and therefore may not share the information even if implements?
the patient gives permission
A. limit suction pressure to 150-180 mmHg
20. A 17-year-old married client is scheduled for surgery. The B. suction for 15-20 seconds
nurse taking care of the client realizes that consent has not C. wear eye goggles
been signed after preoperative medications were given. What D. remove the inner cannula
should the nurse do?
Answer: C. It is important to protect the RN’s eyes from the
A. Call the surgeon possible contamination of coughed-up secretions
B. Ask the spouse to sign the consent
C. Obtain a consent from the client as soon as possible 26. The nurse is conducting a discharge instructions to a client
D. Get a verbal consent from the parents of the client diagnosed with diabetes. What sign of hypoglycemia should
be taught to a client?
Answer: A. The priority is to let the surgeon know, who in
turn may ask the husband to sign the consent A. warm, flushed skin
B. hunger and thirst
21. A 12-year-old client is admitted to the hospital. The C. increase urinary output
physician ordered Dilantin to the client. In administering IV D. palpitation and weakness
phenytoin (Dilantin) to a child, the nurse would be most
correct in mixing it with: Answer: D. There has been too little food or too much insulin.
Glucose levels can be markedly decreased (less than 50
A. Normal Saline mg/dl). Severe hypoglycemia may be fatal if not detected
B. Heparinized normal saline
C. 5% dextrose in water 27. A client admitted to the hospital and diagnosed with
D. Lactated Ringer’s solution Addison’s disease. What would be the appropriate nursing
action to the client?
 A. administering insulin-replacement therapy
B. providing a low-sodium diet
C. restricting fluids to 1500 ml/day
D. reducing physical and emotional stress
Answer: D. Because the client’s ability to react to stress is
decreased, maintaining a quiet environment becomes a
nursing priority. Dehydration is a common problem in
Addison’s disease, so close observation of the client’s
hydration level is crucial.
28. The nurse is to perform tracheal suctioning. During
tracheal suctioning, which nursing action is essential to
prevent hypoxemia?
A. aucultating the lungs to determine the baseline data to
assess the effectiveness of suctioning
B. removing oral and nasal secretions
C. encouraging the patient to deep breathe and cough to
facilitate removal of upper-airway secretions
D. administering 100% oxygen to reduce the effects of
airway obstruction during suctioning.
Answer: D. Presuctioning and postsuctioning ventilation
with 100% oxygen is important in reducing hypoxemia
which occurs when the flow of gases in the airway is
obstructed by the suctioning catheter.
29. An infant is admitted and diagnosed with pneumonia and
suspicious-looking red marks on the swollen face resembling a
handprint. The nurse does further assessment to the client.
How would the nurse document the finding?
A. Facial edema with ecchymosis and handprint mark:
crackles and wheezes
B. Facial edema, with red marks; crackles in the lung
C. Facial edema with ecchymosis that looks like a
handprint
D. Red bruise mark and ecchymosis on face
Answer: B. This is an example of objective data of both
pulmonary status and direct observation on the skin by the
nurse.
30. On the evening shift, the triage nurse evaluates several
clients who were brought to the emergency department. Which
in the following clients should receive highest priority?
A. an elderly woman complaining of a loss of appetite and
fatigue for the past week
B. A football player limping and complaining of pain and
swelling in the right ankle
C. A 50-year-old man, diaphoretic and complaining of
severe chest pain radiating to his jaw
D. A mother with a 5-year-old boy who says her son has
been complaining of nausea and vomited once since
noon
Answer: C. These are likely signs of an acute myocardial
infarction (MI). An acute MI is a cardiovascular emergency
requiring immediate attention. Acute MI is potentially fatal if
not treated immediately.
31. A 80-year-old female client is brought to the emergency
department by her caregiver, on the nurse’s assessment; the
following are the manifestations of the client: anorexia,
cachexia and multiple bruises. What would be the best nursing
intervention?
A. check the laboratory data for serum albumin, hematocrit,
and hemoglobin
B. talk to the client about the caregiver and support system
C. complete a police report on elder abuse
D. complete a gastrointestinal and neurological
assessment
Answer: D. Assessment and more data collection are needed.
The client may have gastrointestinal or neurological
problems that account for the symptoms. The anorexia could
result from medications, poor dentition, or indigestion, and
the bruises may be attributed to ataxia, frequent falls, vertigo
or medication.
32. The night shift nurse is making rounds. When the nurse
enters a client’s room, the client is on the floor next to the bed.
What would be the initial action of the nurse?
A. chart that the patient fell
B. call the physician
C. chart that the client was found on the floor next to the
bed
D. fill out an incident report
Answer: B. This is closest to suggesting action-assessment,
rather than paperwork- and is therefore the best of the four.
33. The nurse on the night shift is about to administer
medication to a preschooler client and notes that the child has
no ID bracelet. The best way for the nurse to identify the client
is to ask:
A. The adult visiting, “The child’s name is
____________________?”
B. The child, “Is your name____________?”
C. Another staff nurse to identify this child
D. The other children in the room what the child’s name is
Answer: C. The only acceptable way to identify a
preschooler client is to have a parent or another staff member
identify the client.
34. The nurse caring to a client has completed the assessment.
Which of the following will be considered to be the most
accurate charting of a lump felt in the right breast?
A. “abnormally felt area in the right breast, drainage noted”
B. “hard nodular mass in right breast nipple”
C. “firm mass at five ‘ clock, outer quadrant, 1cm from
right nipple’
D. “mass in the right breast 4cmx1cm
Answer: C. It describes the mass in the greatest detail.
35. The physician instructed the nurse that intravenous
pyelogram will be done to the client. The client asks the nurse
what is the purpose of the procedure. The appropriate nursing
response is to:
A. outline the kidney vasculature
B. determine the size, shape, and placement of the kidneys
C. test renal tubular function and the patency of the
urinary tract
D. measure renal blood flow
Answer: C. Intravenous pyelogram tests both the function
and patency of the kidneys. After the intravenous injection of
a radiopaque contrast medium, the size, location, and patency
of the kidneys can be observed by roentgenogram, as well as
the patency of the urethra and bladder as the kidneys function
to excrete the contrast medium.
36. A client visits the clinic for screening of scoliosis. The
nurse should ask the client to:
A. bend all the way over and touch the toes
 B. stand up as straight and tall as possible
C. bend over at a 90-degree angle from the waist
D. bend over at a 45-degree angle from the waist
Answer: C. This is the recommended position for screening
for scoliosis. It allows the nurse to inspect the alignment of
the spine, as well as to compare both shoulders and both hips.
37. A client with tuberculosis is admitted in the hospital for 2
weeks. When a client’s family members come to visit, they
would be adhering to respiratory isolation precautions when
they:
A. wash their hands when leaving
B. put on gowns, gloves and masks
C. avoid contact with the client’s roommate
D. keep the client’s room door open
Answer: A. Handwashing is the best method for reducing
cross-contamination. Gowns and gloves are not always
required when entering a client’s room.
38. An infant is brought to the emergency department and
diagnosed with pyloric stenosis. The parents of the client ask
the nurse, “Why does my baby continue to vomit?” Which of
the following would be the best nursing response of the nurse?
A. “Your baby eats too rapidly and overfills the stomach,
which causes vomiting
B. “Your baby can’t empty the formula that is in the
stomach into the bowel”
C. “The vomiting is due to the nausea that accompanies
pyloric stenosis”
D. “Your baby needs to be burped more thoroughly after
feeding”
Answer: B. Pyloric stenosis is an anomaly of the upper
gastrointestinal tract. The condition involves a thickening, or
hypertrophy, of the pyloric sphincter located at the distal end
of the stomach. This causes a mechanical intestinal
obstruction, which leads to vomiting after feeding the infant.
The vomiting associated with pyloric stenosis is described as
being projectile in nature. This is due to the increasing
amounts of formula the infant begins to consume coupled
with the increasing thickening of the pyloric sphincter.
39. A 70-year-old client with suspected tuberculosis is brought
to the geriatric care facilities. An intradermal tuberculosis test
is schedule to be done. The client asks the nurse what is the
purpose of the test. Which of the following would be the best
rationale for this?
A. reactivation of an old tuberculosis infection
B. increased incidence of new cases of tuberculosis in
persons over 65 years old
C. greater exposure to diverse health care workers
D. respiratory problems are characteristic in this population
Answer: B. Increased incidence of TB has been seen in the
general population with a high incidence reported in
hospitalized elderly clients. Immunosuppression and lack of
classic manifestations because of the aging process are just
two of the contributing factors of tuberculosis in the elderly.
40. The nurse is making a health teaching to the parents of the
client. In teaching parents how to measure the area of
induration in response to a PPD test, the nurse would be most
accurate in advising the parents to measure:
A. both the areas that look red and feel raised
B. The entire area that feels itchy to the child
C. Only the area that looks reddened
D. Only the area that feels raised
Answer: D. Parents should be taught to feel the area that is
raised and measure only that
41. A community health nurse is schedule to do home visit.
She visits to an elderly person living alone. Which of the
following observation would be a concern?
A. Picture windows
B. Unwashed dishes in the sink
C. Clear and shiny floors
D. Brightly lit rooms
Answer: C. It is a safety hazard to have shiny floors because
they can cause falls.
42. After a birth, the physician cut the cord of the baby, and
before the baby is given to the mother, what would be the
initial nursing action of the nurse?
A. examine the infant for any observable abnormalities
B. confirm identification of the infant and apply bracelet to
mother and infant
C. instill prophylactic medication in the infant’s eyes
D. wrap the infant in a prewarmed blanket and cover
the head
Answer:D. The first priority, beside maintaining a newborn’s
patent airway, is body temperature.
43. A 2-year-old client is admitted to the hospital with severe
eczema lesions on the scalp, face, neck and arms. The client is
scratching the affected areas. What would be the best nursing
intervention to prevent the client from scratching the affected
areas?
A. elbow restraints to the arms
B. Mittens to the hands
C. Clove-hitch restraints to the hands
D. A posey jacket to the torso
Answer: B. The purpose of restraints for this child is to keep
the child from scratching the affected areas. Mittens restraint
would prevent scratching, while allowing the most movement
permissible.
44. The parents of the hospitalized client ask the nurse how
their baby might have gotten pyloric stenosis. The appropriate
nursing response would be:
A. There is no way to determine this preoperatively
B. Their baby was born with this condition
C. Their baby developed this condition during the first
few weeks of life
D. Their baby acquired it due to a formula allergy
Answer: C. Pyloric stenosis is not a congenital anatomical
defect, but the precise etiology is unknown. It develops
during the first few weeks of life.
45. A male client comes to the clinic for check-up. In doing a
physical assessment, the nurse should report to the physician
the most common symptom of gonorrhea, which is:
A. pruritus
B. pus in the urine
C. WBC in the urine
D. Dysuria
Answer: B. Pus is usually the first symptom, because the
bacteria reproduce in the bladder.
46. Which of the following would be the most important goal Answer: D. The tumor infiltrates nearby tissue, it can cause
in the nursing care of an infant client with eczema? retraction of the overlying skin and create a dimpling
appearance.
A. preventing infection
B.
C.
maintaining the comfort level
providing for adequate nutrition
PNLE II Nursing Practice
D. decreasing the itching

Answer:A. Preventing infection in the infant with eczema is
the nurse’s most important goal. The infant with eczema is at
high risk for infection due to numerous breaks in the skin’s
integrity. Intact skin is always the infant’s first line of
defense against infection.
47. The nurse is making a discharge instruction to a client
receiving chemotherapy. The client is at risk for bone marrow
depression. The nurse gives instructions to the client about
how to prevent infection at home. Which of the following
health teaching would be included?
A. “Get a weekly WBC count”
B. “Do not share a bathroom with children or pregnant
woman”
C. “Avoid contact with others while receiving
chemotherapy”
D. “Do frequent hand washing and maintain good
hygiene”
Answer: D. Frequent hand washing and good hygiene are the
best means of preventing infection.
48. The nurse is assigned to care the client with infectious
disease. The best antimicrobial agent for the nurse to use in
handwashing is:
A. Isopropyl alcohol
B. Hexachlorophene (Phisohex)
C. Soap and water
D. Chlorhexidine gluconate (CHG) (Hibiclens)
Answer: D. CHG is a highly effective antimicrobial
ingredient, especially when it is used consistently over time.
49. The mother of the client tells the nurse, “ I’m not going to
have my baby get any immunization”. What would be the best
nursing response to the mother?
A. “You and I need to review your rationale for this
decision”
B. “Your baby will not be able to attend day care without
immunizations”
C. “Your decision can be viewed as a form of child abuse
and neglect”
D. “You are needlessly placing other people at risk for
communicable diseases”
Answer: A. The mother may have many reasons for such a
decision. It is the nurse’s responsibility to review this
decision with the mother and clarify any misconceptions
regarding immunizations that may exist.
50. The nurse is teaching the client about breast self-
examination. Which observation should the client be taught to
recognize when doing the examination for detection of breast
cancer?
A. tender, movable lump
B. pain on breast self-examination
C. round, well-defined lump
D. dimpling of the breast tissue
The scope of this Nursing Test II is parallel to the NP2 NLE
Coverage:
 Maternal and Child Health
 Community Health Nursing
 Communicable Diseases
 Integrated Management of Childhood Illness
1. The student nurse is assigned to take the vital signs of the
clients in the pediatric ward. The student nurse reports to the
staff nurse that the parent of a toddler who is 2 days
postoperative after a cleft palate repair has given the toddler
a pacifier. What would be the best immediate action of the
nurse?
A. Notify the pediatrician of this finding
B. Reassure the student that this is an acceptable action
on the parent’s part
C. Discuss this action with the parents
D. Ask the student nurse to remove the pacifier from the
toddler’s mouth
Answer: C. Nothing must be placed in the mouth of a
toddler who just undergone a cleft palate repair until the
suture line has completely healed. It is the nurse’s
responsibility to inform the parent of the client. Spoon, forks,
straws, and tongue blades are other unacceptable items to
place in the mouth of a toddler who just undergone cleft
palate repair. The general principle of care is that nothing
should enter the mouth until the suture line has completely
healed.
2. The nurse is providing a health teaching to the mother of
an 8-year-old child with cystic fibrosis. Which of the following
statement if made by the mother would indicate to the nurse
the need for further teaching about the medication regimen
of the child?
A. “My child might need an extra capsule if the meal is
high in fat”
B. “I’ll give the enzyme capsule before every snack”
C. “I’ll give the enzyme capsule before every meal”
D. “My child hates to take pills, so I’ll mix the capsule into
a cup of hot chocolate
Answer: D. The pancreatic capsules contain pancreatic
enzyme that should be administered in a cold, not a hot,
medium (example: chilled applesauce versus hot chocolate)
to maintain the medication’s integrity.
3. The mother brought her child to the clinic for follow-up
check up. The mother tells the nurse that 14 days after
starting an oral iron supplement, her child’s stools are black.
Which of the following is the best nursing response to the
mother?
A. “I will notify the physician, who will probably decrease
the dosage slightly”
B. “This is a normal side effect and means the medication
is working”
C. “You sound quite concerned. Would you like to talk
about this further?”
D. “I will need a specimen to check the stool for possible
bleeding”

Answer: B. When oral iron preparations are given correctly,
the stools normally turn dark green or black. Parents of
children receiving this medication should be advised that
this side effect indicates the medication is being absorbed
and is working well.
4. An 8-year-old boy with asthma is brought to the clinic for
check up. The mother asks the nurse if the treatment given to
her son is effective. What would be the appropriate response
of the nurse?
A. I will review first the child’s height on a growth chart to
know if the treatment is working
B. I will review first the child’s weight on a growth chart to
know if the treatment is working
C. I will review first the number of prescriptions refills the
child has required over the last 6 months to give you
an accurate answer
D. I will review first the number of times the child has seen
the pediatrician during the last 6 months to give you an
accurate answer
Answer: C. Reviewing the number of prescription refills the
child has required over the last 6 months would be the best
indicator of how well controlled and thus how effective the
child’s asthma treatment is. Breakthrough wheezing,
shortness of breath, and upper respiratory infections would
require that the child take additional medication. This would
be reflected in the number of prescription refills.
5. The nurse is caring to a child client who is receiving
tetracycline. The nurse is aware that in taking this medication,
it is very important to:
A. Administer the drug between meals
B. Monitor the child’s hearing
C. Give the drug through a straw
D. Keep the child out of the sunlight
Answer: D. Tetracycline may cause a phototoxic reaction.
6. A 14 day-old infant with a cyanotic heart defects and mild
congestive heart failure is brought to the emergency
department. During assessment, the nurse checks the apical
pulse rate of the infant. The apical pulse rate is 130 beats per
minute. Which of the following is the appropriate nursing
action?
A. Retake the apical pulse in 15 minutes
B. Retake the apical pulse in 30 minutes
C. Notify the pediatrician immediately
D. Administer the medication as scheduled
Answer: D. The normal heart rate of an infant is 120-160
beats per minute
7. The physician prescribed gentamicin (Garamycin) to a child
who is also receiving chemotherapy. Before administering the
drug, the nurse should check the results of the child’s:
A. CBC and platelet count
B. Auditory tests
C. Renal Function tests
D. Abdominal and chest x-rays
Answer: C. Both gentamicin and chemotherapeutic agents
can cause renal impairment and acute renal failure; thus
baseline renal function must be evaluated before initiating
either medication.
8. Which of the following is the suited size of the needle
would the nurse select to administer the IM injection to a
preschool child?
A. 18 G, 1-1/2 inch
B. 25 G, 5/8 inch
C. 21 G, 1 inch
D. 18 G, 1inch
Answer: C. In selecting the correct needle to administer an
IM injection to a preschooler, the nurse should always look
at the child and use judgment in evaluating muscle mass and
amount of subcutaneous fat. In this case, in the absence of
further data, the nurse would be most correct in selecting a
needle gauge and length appropriate for the “average’
preschool child. A medium-gauge needle (21G) that is 1 inch
long would be most appropriate.
9. A 9-year-old boy is admitted to the hospital. The boy is
being treated with salicylates for the migratory polyarthritis
accompanying the diagnosis of rheumatic fever. Which of the
following activities performed by the child would give a best
sign that the medication is effective?
A. Listening to story of his mother
B. Listening to the music in the radio
C. Playing mini piano
D. Watching movie in the dvd mini player
Answer: C. The purpose of the salicylate therapy is to relieve
the pain associated with the migratory polyarthritis
accompanying the rheumatic fever. Playing mini piano
would require movement of the child’s joints and would
provide the nurse with a means of evaluating the child’s
level of pain.
10. The physician decided to schedule the 4-year-old client
for repair of left undescended testicle. The Injection of a
hormone, HCG finds it less successful for treatment. To
administer a pentobarbital sodium (Nembutal) suppository
preoperatively to this client, in which position should the
nurse place him?
A. Supine with foot of bed elevated
B. Prone with legs abducted
C. Sitting with foot of bed elevated
D. Side-lying with upper leg flexed
Answer: D. The recommended position to administer rectal
medications to children is side-lying with the upper leg
flexed. This position allows the nurse to safely and
effectively administer the medication while promoting
comfort for the child.
11. The nurse is caring to a 24-month-old child diagnosed
with congenital heart defect. The physician prescribed digoxin
(Lanoxin) to the client. Before the administration of the drug,
the nurse checks the apical pulse rate to be 110 beats per
minute and regular. What would be the next nursing action?
A. Check the other vital signs and level of consciousness
B. Withhold the digoxin and notify the physician
C. Give the digoxin as prescribed
D. Check the apical and radial simultaneously, and if they
are the same, give the digoxin.
 Answer:C. For a 12month-old child, 110 apical pulse rate is
normal and therefore it is safe to give the digoxin. A
toddler’s normal pulse rate is slightly lower than an infant’s
(120).
12. An 8-year-old client with cystic fibrosis is admitted to the
hospital and will undergo a chest physiotherapy treatment.
The therapy should be properly coordinated by the nurse
with the respiratory therapy department so that treatments
occur during:
A. After meals
B. Between meals
C. After medication
D. Around the child’s play schedule
Answer: B. Chest physiotherapy treatments are scheduled
between meals to prevent aspiration of stomach contents,
because the child is placed in a variety of positions during
the treatment process.
13. The nurse is providing health teaching about the
breastfeeding and family planning to the client who gave
birth to a healthy baby girl. Which of the following statement
would alert the nurse that the client needs further teaching?
A. “I understand that the hormones for breastfeeding may
affect when my periods come”
B. “Breastfeeding causes my womb to tighten and bleed
less after birth”
C. “I may not have periods while I am breastfeeding, so I
don’t need family planning”
D. “I can get pregnant as early as one month after my baby
was born”
Answer: C. It is common misconception that breastfeeding
may prevent pregnancy.
14. A toddler is brought to the hospital because of severe
diarrhea and vomiting. The nurse assigned to the client enters
the client’s room and finds out that the client is using a soiled
blanket brought in from home. The nurse attempts to remove
the blanket and replace it with a new and clean blanket. The
toddler refuses to give the soiled blanket. The nurse realizes
that the best explanation for the toddler’s behavior is:
A. The toddler did not bond well with the maternal figure
B. The blanket is an important transitional object
C. The toddler is anxious about the hospital experience
D. The toddler is resistive to nursing interventions
Answer: B. The “security blanket” is an important transitional
object for the toddler. It provides a feeling of comfort and
safety when the maternal figure is not present or when in a
new situation for which the toddler was not prepared.
Virtually any object (stuffed animal, doll, book etc) can
become a security blanket for the toddler
15. The nurse has knowledge about the developmental task
of the child. In caring a 3-year-old-client, the nurse knows
that the suited developmental task of this child is to:
A. Learn to play with other children
B. Able to trust others
C. Express all needs through speaking
D. Explore and manipulate the environment
Answer: D. Toddlers need to meet the developmental
milestone of autonomy versus shame and doubt. In order to
accomplish this, the toddler must be able to explore and
manipulate the environment.
16. A mother who gave birth to her second daughter is so
concerned about her 2-year old daughter. She tells the nurse,
“I am afraid that my 2-year-old daughter may not accept her
newly born sister”. It is appropriate to the nurse to response
that:
A. The older daughter be given more responsibility and
assure her “that she is a big girl now, and doesn’t need
Mommy as much”
B. The older daughter not have interaction with the baby
at the hospital, because she may harm her new sibling
C. The older daughter stay with her grandmother for a few
days until the parents and new baby are settled at
home
D. The mother spend time alone with her older daughter
when the baby is sleeping
Answer: D. The introduction of a baby into a family with one
or more children challenges parent to promote acceptance
of the baby by siblings. The parent’s attitudes toward the
arrival of the baby can set the stage for the other children’s
reaction. Spending time with the older siblings alone will
also reassure them of their place in the family, even though
the older children will have to eventually assume new
positions within the family hierarchy.
17. A 2-year-old client with cystic fibrosis is confined to bed
and is not allowed to go to the playroom. Which of the
following is an appropriate toy would the nurse select for the
child:
A. Puzzle
B. Musical automobile
C. Arranging stickers in the album
D. Pounding board and hammer
Answer: D. The autonomous toddler would be frustrated by
being confined to be. The pounding board and hammer is
developmentally appropriate and an excellent way for the
toddler to release frustration.
18. Which of the following clients is at high risk for
developmental problem?
A. A toddler with acute Glomerulonephritis on
antihypertensive and antibiotics
B. A 5-year-old with asthma on cromolyn sodium
C. A preschooler with tonsillitis
D. A 2 1/2 –year old boy with cystic fibrosis
Answer: D. It is the developmental task of an 18-month-old
toddler to explore and learn about the environment. The
respiratory complications associated with cystic fibrosis
(which are present in almost all children with cystic fibrosis)
could prevent this development task from occurring.
19. Which of the following would be the best divesionary
activity for the nurse to select for a 2 weeks hospitalized 3-
year-old girl?
A. Crayons and coloring books
B. doll
C. xylophone toy
D. Puzzles
 Answer: C. The best diversion for a hospitalized child aged 2-
3 years old would be anything that makes noise or makes a
mess; xylophone which certainly makes noise or music
would be the best choice.
20. A nurse is providing safety instructions to the parents of
the 11-month-old child. Which of the following will the nurse
includes in the instructions?
A. Plugging all electrical outlets in the house
B. Installing a gate at the top and bottom of any stairs in
the home
C. Purchasing an infant car seat as soon as possible
D. Begin to teach the child not to place small objects in the
mouth
Answer: B. An 11-month-old child stands alone and can walk
holding onto people or objects. Therefore the installation of a
gate at the top and bottom of any stairs in the house is crucial
for the child’s safety
21. An 8-year-old girl is in second grade and the parents
decided to enroll her to a new school. While the child is
focusing on adjusting to new environment and peers, her
grades suffer. The child’s father severely punishes the child
and forces her daughter to study after school. The father
does not allow also her daughter to play with other children.
These data indicate to the nurse that this child is deprived of
forming which normal phase of development?
A. Heterosexual relationships
B. A love relationship with the father
C. A dependency relationship with the father
D. Close relationship with peers
Answer: D. In second grade a child needs to form a close
relationships with peers.
22. A 5-year-old boy client is scheduled for hernia surgery.
The nurse is preparing to do preoperative teaching with the
child. The nurse should knows that the 5-year-old would:
A. Expect a simple yet logical explanation regarding the
surgery
B. Asks many questions regarding the condition and the
procedure
C. Worry over the impending surgery
D. Be uninterested in the upcoming surgery
Answer: B. A 5-year-old is highly concerned with body
integrity. The preschool-age child normally asks many
questions and in a situation such as this, could be expected to
ask even more
23. The nine-year-old client is admitted in the hospital for
almost 1 week and is on bed rest. The child complains of
being bored and it seems tiresome to stay on bed and doing
nothing. What activity selected by the nurse would the child
most likely find stimulating?
A. Watching a video
B. Putting together a puzzle
C. Assembling handouts with the nurse for an upcoming
staff development meeting
D. Listening to a compact disc
Answer: C. A 9-year-old enjoys working and feeling a sense
of accomplishment. The school-age child also enjoys
“showing off,” and doing something with the nurse on the
pediatric unit would allow this. This activity also provides
the school-age child a needed opportunity to interact with
others in the absence of school and personal friends.
24. The parent of a 16-year-old boy tells the nurse that his
son is driving a motorbike very fast and with one hand. “It is
making me crazy!” What would be the best explanation of
the nurse to the behavior of the boy?
A. The adolescent might have an unconscious death wish
B. The adolescent feels indestructible
C. The adolescent lacks life experience to realize how
dangerous the behavior is
D. The adolescent has found a way to act out hostility
toward the parent
Answer: B. Adolescents do feel indestructible, and this is
reflected in many risk-taking behaviors.
25. An 8-month-old infant is admitted to the hospital due to
diarrhea. The nurse caring for the client tells the mother to
stay beside the infant while making assessment. Which of the
following developmental milestones the infant has reached?
A. Has a three-word vocabulary
B. Interacts with other infants
C. Stands alone
D. Recognizes but is fearful of strangers
Answer: D. An 8-month-old infant both recognizes and is
fearful of strangers. This developmental milestone is known
as “stranger anxiety”.
26. The community nurse is conducting a health teaching in
the group of married women. When teaching a woman about
fertility awareness, the nurse should emphasize that the basal
body temperature:
A. Should be recorded each morning before any activity
B. Is the average temperature taken each morning
C. Can be done with a mercury thermometer but not a
digital one
D. Has a lower degree of accuracy in predicting ovulation
than the cervical mucus test
Answer: A. The basal body temperature (BBT) is the lowest
body temperature of a healthy person that is taken
immediately after waking and before getting out of bed. The
BBT usually varies from 36.2 – 36.3 degree Celsius during
menses and for about 5-7 days afterward. About the time of
ovulation, a slight drop approximately 0.05 degree Celsius in
temperature may be seen; after ovulation, in concert with
the increasing progesterone levels of the early luteal phase,
the BBT rises 0.2-0.4 degree Celsius. This elevation remains
until 2-3 days before menstruation, or if pregnancy has
occurred.
27. The community nurse is providing an instruction to the
clients in the health center about the use of diaphragm for
family planning. To evaluate the understanding of the woman,
the nurse asks her to demonstrate the use of the diaphragm.
Which of following statement indicates a need for further
health teaching?
A. “I should check the diaphragm carefully for holes every
time I use it.”
B. “The diaphragm must be left in place for at least 6 hours
after intercourse.”
 C. “I really need to use the diaphragm and jelly most
during the middle of my menstrual cycle
D. “I may need a different size diaphragm if I gain or lose
more than 20 pounds”
Answer: C. The woman must understand that, although the
“fertile” period is approximately midcycle, hormonal
variations do occur and can result in early or late ovulations.
To be effective, the diaphragm should be inserted before
every intercourse.
28. The client visits the clinic for prenatal check-up. While
waiting for the physician, the nurse decided to conduct health
teaching to the client. The nurse informed the client that
primigravida mother should go to the hospital when which
patter is evident?
A. Contractions are 2-3 minutes apart, lasting 90 seconds,
and membranes have ruptured
B. Contractions are 5-10 minutes apart, lasting 30 seconds,
and are felt as strong menstrual cramps
C. Contractions are 3-5 minutes apart, accompanied by
rectal pressure and bloody show
D. Contractions are 5 minutes apart, lasting 60 seconds,
and increasing in intensity
Answer: D. Although instructions vary among birth centers,
primigravidas should seek care when regular contractions
are felt about 5 minutes apart, becoming longer and
stronger.
29. A nurse is planning a home visit program to a new mother
who is 2 weeks postpartum and breastfeeding, the nurse
includes in her health teaching about the resumption of
fertility, contraception and sexual activity. Which of the
following statement indicates that the mother has
understood the teaching?
A. “Because breastfeeding speeds the healing process
after birth, I can have sex right away and not worry
about infection”
B. “Because I am breastfeeding and my hormones are
decreased, I may need to use a vaginal lubricant when
I have sex”
C. “After birth, you have to have a period before you can
get pregnant again’
D. “Breastfeeding protects me from pregnancy because it
keeps my hormones down, so I don’t need any
contraception until I stop breastfeeding”
Answer: B. Prolactin suppresses estrogen, which is needed
to stimulate vaginal lubrication during arousal.
30. A community nurse enters the home of the client for
follow-up visit. Which of the following is the most
appropriate area to place the nursing bag of the nurse when
conducting a home visit?
A. cushioned footstool
B. bedside wood table
C. kitchen countertop
D. living room sofa
Answer: B. A wood surface provides the least chance for
organisms to be present.
31. The nurse in the health center is making an assessment to
the infant client. The nurse notes some rashes and small
fluid-filled bumps in the skin. The nurse suspects that the
infant has eczema. Which of the following is the most
important nursing goal:
A. Preventing infection
B. Providing for adequate nutrition
C. Decreasing the itching
D. Maintaining the comfort level
Answer: A. Preventing infection in the infant with eczema is
the nurse’s most important goal. The infant with eczema is
at high risk for infection due to numerous breaks in the
skin’s integrity. Intact skin is always the infant’s first line of
defense against infection.
32. The nurse in the health center is providing immunization
to the children. The nurse is carefully assessing the condition
of the children before giving the vaccines. Which of the
following would the nurse note to withhold the infant’s
scheduled immunizations?
A. a dry cough
B. a skin rash
C. a low-grade fever
D. a runny nose
Answer: B. A skin rash could indicate a concurrent
infectious disease process in the infant. The scheduled
immunizations should be withheld until the status of the
infant’s health can be determined. Fevers above 38.5
degrees Celsius, alteration in skin integrity, and infectious-
appearing secretions are indications to withhold
immunizations.
33. A mother brought her child in the health center for
hepatitis B vaccination in a series. The mother informs the
nurse that the child missed an appointment last month to
have the third hepatitis B vaccination. Which of the following
statements is the appropriate nursing response to the mother?
A. “I will examine the child for symptoms of hepatitis B”
B. “Your child will start the series again”
C. “Your child will get the next dose as soon as possible”
D. “Your child will have a hepatitis titer done to determine
if immunization has taken place.”
Answer: C. Continuity is essential to promote active
immunity and give hepatitis B lifelong prophylaxis. Optimally,
the third vaccination is given 6 months after the first.
34. The community health nurse implemented a new
program about effective breast cancer screening technique
for the female personnel of the health department of
Valenzuela. Which of the following technique should the
nurse consider to be of the lowest priority?
A. Yearly breast exam by a trained professional
B. Detailed health history to identify women at risk
C. Screening mammogram every year for women over age
50
D. Screening mammogram every 1-2 years for women over
age of 40.
Answer: B. Because of the high incidence of breast cancer,
all women are considered to be at risk regardless of health
history.
35. Which of the following technique is considered an aseptic
practice during the home visit of the community health nurse?
 A. Wrapping used dressing in a plastic bag before placing
them in the nursing bag
B. Washing hands before removing equipment from the
nursing bag
C. Using the client’s soap and cloth towel for hand washing
D. Placing the contaminated needles and syringes in a
labeled container inside the nursing bag
Answer: B. Handwashing is the best way to prevent the
spread of infection.
36. The nurse is planning to conduct a home visit in a small
community. Which of the following is the most important
factor when planning the best time for a home care visit?
A. Purpose of the home visit
B. Preference of the patient’s family
C. Location of the patient’s home
D. Length of time of the visit will take
Answer: A. The purpose of the visit takes priority.
37. The nurse assigned in the health center is counseling a 30-
year-old client requesting oral contraceptives. The client tells
the nurse that she has an active yeast infection that has
recurred several times in the past year. Which statement by
the nurse is inaccurate concerning health promotion actions
to prevent recurring yeast infection?
A. “During treatment for yeast, avoid vaginal intercourse
for one week”
B. “Wear loose-fitting cotton underwear”
C. “Avoid eating large amounts of sugar or sugar-bingeing”
D. “Douche once a day with a mild vinegar and water
solution”
Answer: D. Frequent douching interferes with the natural
protective barriers in the vagina that resist yeast infection
and should be avoided.
38. During immunization week in the health center, the
parent of a 6-month-old infant asks the health nurse, “Why is
our baby going to receive so many immunizations over a long
time period?” The best nursing response would be:
A. “The number of immunizations your baby will receive
shows how many pediatric communicable and
infectious diseases can now be prevented.”
B. “You need to ask the physician”
C. “The number of immunizations your baby will receive is
determined by your baby’s health history and age”
D. “It is easier on your baby to receive several
immunizations rather than one at a time”
Answer: A. Completion for the recommended schedule of
infant immunizations does not require a large number of
immunizations, but it also provides protection against
multiple pediatric communicable and infectious diseases.
39. The community health nurse is conducting a health
teaching about nutrition to a group of pregnant women who
are anemic and are lactose intolerant. Which of the following
foods should the nurse especially encourage during the third
trimester?
A. Cheese, yogurt, and fish for protein and calcium needs
plus prenatal vitamins and iron supplements
B. Prenatal iron and calcium supplements plus a regular
adult diet
C. Red beans, green leafy vegetables, and fish for iron
and calcium needs plus prenatal vitamins and iron
supplements
D. Red meat, milk and eggs for iron and calcium needs plus
prenatal vitamins and iron supplements
Answer: C. This is appropriate foods that are high in iron and
calcium but would not affect lactose intolerance.
40. A woman with active tuberculosis (TB) and has visited the
health center for regular therapy for five months wants to
become pregnant. The nurse knows that further information
is necessary when the woman states:
A. “Spontaneous abortion may occur in one out of five
women who are infected”
B. “Pulmonary TB may jeopardize my pregnancy”
C. “I know that I may not be able to have close contact
with my baby until contagious is no longer a problem
D. “I can get pregnant after I have been free of TB for 6
months”
Answer: D. Intervention is needed when the woman thinks
that she needs to wait only 6 months after being free of TB
before she can get pregnant. She needs to wait 1.5-2years
after she is declared to be free of TB before she should
attempt pregnancy.
41. The Department of Health is alarmed that almost 33
million people suffer from food poisoning every year.
Salmonella enteritis is responsible for almost 4 million cases
of food poisoning. One of the major goals is to promote
proper food preparation. The community health nurse is
tasks to conduct health teaching about the prevention of
food poisoning to a group of mother everyday. The nurse can
help identify signs and symptoms of specific organisms to
help patients get appropriate treatment. Typical symptoms of
salmonella include:
A. Nausea, vomiting and paralysis
B. Bloody diarrhea
C. Diarrhea and abdominal cramps
D. Nausea, vomiting and headache
Answer: C. Salmonella organisms cause lower GI symptoms
42. A community health nurse makes a home visit to an
elderly person living alone in a small house. Which of the
following observation would be a great concern?
A. Big mirror in a wall
B. Scattered and unwashed dishes in the sink
C. Shiny floors with scattered rugs
D. Brightly lit rooms
Answer: C. It is a safety hazard to have shiny floors and
scattered rugs because they can cause falls and rugs should
be removed.
43. The health nurse is conducting health teaching about
“safe” sex to a group of high school students. Which of the
following statement about the use of condoms should the
nurse avoid making?
A. “Condoms should be used because they can prevent
infection and because they may prevent pregnancy”
B. “Condoms should be used even if you have recently
tested negative for HIV”
 C. “Condoms should be used every time you have sex
because condoms prevent all forms of sexually
transmitted diseases”
D. “Condoms should be used every time you have sex even
if you are taking the pill because condoms can prevent
the spread of HIV and gonorrhea”
Answer: C. Condoms do not prevent ALL forms of sexually
transmitted diseases
44. The department of health is promoting the breastfeeding
program to all newly mothers. The nurse is formulating a plan
of care to a woman who gave birth to a baby girl. The nursing
care plan for a breast-feeding mother takes into account that
breast-feeding is contraindicated when the woman:
A. Is pregnant
B. Has genital herpes infection
C. Develops mastitis
D. Has inverted nipples
Answer: A. Pregnancy is one contraindication to breast-
feeding. Milk secretion is inhibited and the baby’s sucking
may stimulate uterine contractions.
45. The City health department conducted a medical mission
in Barangay Marulas. Majority of the children in the Barangay
Marulas were diagnosed with pinworms. The community
health nurse should anticipate that the children’s chief
complaint would be:
A. Lack of appetite
B. Severe itching of the scalp
C. Perianal itching
D. Severe abdominal pain
Answer: C. Perianal itching is the child’s chief complaint
associated with the diagnosis of pinworms. The itching, in this
instance, is often described as being “intense” in nature.
Pinworms infestation usually occurs because the child is in
the anus-to-mouth stage of development (child uses the
toilet, does not wash hands, places hands and pinworm eggs
in mouth). Teaching the child hand washing before eating and
after using the toilet can assist in breaking the cycle
46. The mother brought her daughter to the health center.
The child has head lice. The nurse anticipates that the nursing
diagnosis most closely correlated with this is:
A. Fluid volume deficit related to vomiting
B. Altered body image related to alopecia
C. Altered comfort related to itching
D. Diversional activity deficit related to hospitalization
Answer: C. Severe itching of the scalp is the classic sign and
symptom of head lice in a child. In turn, this would lead to
the nursing diagnosis of “altered comfort”.
47. The mother brings a child to the health care clinic because
of severe headache and vomiting. During the assessment of
the health care nurse, the temperature of the child is 40
degree Celsius, and the nurse notes the presence of nuchal
rigidity. The nurse is suspecting that the child might be
suffering from bacterial meningitis. The nurse continues to
assess the child for the presence of Kernig’s sign. Which
finding would indicate the presence of this sign?
A. Flexion of the hips when the neck is flexed from a lying
position
B. Calf pain when the foot is dorsiflexed
C. Inability of the child to extend the legs fully when lying
supine
D. Pain when the chin is pulled down to the chest
Answer: C. Kernig’s sign is the inability of the child to extend
the legs fully when lying supine. This sign is frequently
present in bacterial meningitis. Nuchal rigidity is also
present in bacterial meningitis and occurs when pain
prevents the child from touching the chin to the chest.
48. A community health nurse makes a home visit to a child
with an infectious and communicable disease. In planning
care for the child, the nurse must determine that the primary
goal is that the:
A. Child will experience mild discomfort
B. Child will experience only minor complications
C. Child will not spread the infection to others
D. Public health department will be notified
Answer: C. The primary goal is to prevent the spread of the
disease to others. The child should experience no
complication. Although the health department may need to
be notified at some point, it is no the primary goal. It is also
important to prevent discomfort as much as possible
49. The mother brings her daughter to the health care clinic.
The child was diagnosed with conjunctivitis. The nurse
provides health teaching to the mother about the proper care
of her daughter while at home. Which statement by the
mother indicates a need for additional information?
A. “I do not need to be concerned about the spreading of
this infection to others in my family”
B. “I should apply warm compresses before instilling
antibiotic drops if purulent discharge is present in my
daughter’s eye”
C. “I can use an ophthalmic analgesic ointment at
nighttime if I have eye discomfort”
D. “I should perform a saline eye irrigation before instilling,
the antibiotic drops into my daughter’s eye if purulent
discharge is present”
Answer: A. Conjunctivitis is highly contagious. Antibiotic
drops are usually administered four times a day. When
purulent discharge is present, saline eye irrigations or eye
applications of warm compresses may be necessary before
instilling the medication. Ophthalmic analgesic ointment or
drops may be instilled, especially at bedtime, because
discomfort becomes more noticeable when the eyelids are
closed.
50. A community health nurse is caring for a group of flood
victims in Marikina area. In planning for the potential needs
of this group, which is the most immediate concern?
A. Finding affordable housing for the group
B. Peer support through structured groups
C. Setting up a 24-hour crisis center and hotline
D. Meeting the basic needs to ensure that adequate food,
shelter and clothing are available
Answer: D. The question asks about the immediate concern.
The ABCs of community health care are always attending to
people’s basic needs of food, shelter, and clothing
 5. The physician has given instruction to the nurse that the
PNLE III Nursing Practice client can be ambulated on crutches, with no weight bearing
on the affected limb. The nurse is aware that the appropriate
The scope of this Nursing Test III is parallel to the NP3 NLE
crutch gait for the nurse to teach the client would be:
Coverage:
 Medical Surgical Nursing
1. The nurse is going to replace the Pleur-O-Vac attached to A. Tripod gait
the client with a small, persistent left upper lobe B. Two-point gait
pneumothorax with a Heimlich Flutter Valve. Which of the C. Four-point gait
following is the best rationale for this? D. Three-point gait

Answer: D. The three-point gait is appropriate when weight

A. Promote air and pleural drainage
bearing is not allowed on the affected limb. The swing-to
B. Prevent kinking of the tube
and swing-through crutch gaits may also be used when only
C. Eliminate the need for a dressing
one leg can be used for weight bearing
D. Eliminate the need for a water-seal drainage
6. The client is transferred to the nursing care unit from the
Answer: D. The Heimlich flutter valve has a one-way valve
operating room after a transurethral resection of the prostate.
that allows air and fluid to drain. Underwater seal drainage
The client is complaining of pain in the abdomen area. The
is not necessary. This can be connected to a drainage bag for
nurse suspects of bladder spasms, which of the following is
the patient’s mobility. The absence of a long drainage tubing
the best nursing action to minimize the pain felt by the client?
and the presence of a one-way valve promote effective
therapy
A. Advising the client not to urinate around catheter
2. The client with acute pancreatitis and fluid volume deficit is B. Intermittent catheter irrigation with saline
transferred from the ward to the ICU. Which of the following C. Giving prescribed narcotics every 4 hour
will alert the nurse? D. Repositioning catheter to relieve pressure

Answer: A. The client needs to be told before surgery that

A. Decreased pain in the fetal position
the catheter causes the urge to void. Attempts to void
B. Urine output of 35mL/hr
around the catheter cause the bladder muscles to contract
C. CVP of 12 mmHg
and result in painful spasms.
D. Cardiac output of 5L/min
7. A client is diagnosed with peptic ulcer. The nurse caring for
Answer: C. C = the normal CVP is 0-8 mmHg. This value
the client expects the physician to order which diet?
reflects hypervolemia. The right ventricular function of this
client reflects fluid volume overload, and the physician
should be notified. A. NPO
B. Small feedings of bland food
3. The nurse in the morning shift is making rounds in the ward. C. A regular diet given frequently in small amounts
The nurse enters the client’s room and found the client in D. Frequent feedings of clear liquids
discomfort condition. The client complains of stiffness in the
joints. To reduce the early morning stiffness of the joints of Answer; B. Bland feedings should be given in small amounts
the client,the nurse can encourage the client to: on a frequent basis to neutralize the hydrochloric acid and
to prevent overload
A. Sleep with a hot pad
8. The nurse is going to insert a Miller-Abbott tube to the
B. Take to aspirins before arising, and wait 15 minutes
client. Before insertion of the tube, the balloon is tested for
before attempting locomotion
patency and capacity and then deflated. Which of the
C. Take a hot tub bath or shower in the morning
following nursing measure will ease the insertion to the tube?
D. Put joints through passive ROM before trying to move
them actively
A. Positioning the client in Semi-Fowler’s position
Answer: C. A hot tub bath or shower in the morning helps B. Administering a sedative to reduce anxiety
many patients limber up and reduces the symptoms of early C. Chilling the tube before insertion
morning stiffness. Cold and ice packs are used to a lesser D. Warming the tube before insertion
degree, though some clients state that cold decreases
localized pain, particularly during acute attacks. Answer: C. Chilling the tube before insertion assists in
relieving some of the nasal discomfort. Water-soluble
4. The nurse is planning of care to a client with peptic ulcer lubricants along with viscous lidocaine (Xylocaine) may also
disease. To avoid the worsening condition of the client, the be used. It is usually only lightly lubricated before insertion
nurse should carefully plan the diet of the client. Which of the
following will be included in the diet regime of the client? 9. The physician ordered a low-sodium diet to the client.
Which of the following food will the nurse avoid to give to the
client?
A. Eating mainly bland food and milk or dairy products
B. Reducing intake of high-fiber foods
C. Eating small, frequent meals and a bedtime snack A. Orange juice.
D. Eliminating intake of alcohol and coffee B. Whole milk.
C. Ginger ale.
Answer: D. These substances stimulate the production of D. Black coffee.
hydrochloric acid, which is detrimental in peptic ulcer
disease.
Answer: B. Whole milk should be avoided to include in the
client’s diet because it has 120 mg of sodium in 8 0z of milk
10. Mr. Bean, a 70-year-old client is admitted in the hospital
for almost one month. The nurse understands that prolonged
immobilization could lead to decubitus ulcers. Which of the
following would be the least appropriate nursing intervention
in the prevention of decubitus?
A. Giving backrubs with alcohol
B. Use of a bed cradle
C. Frequent assessment of the skin
D. Encouraging a high-protein diet
Answer: A. Alcohol is extremely drying and contributes to
skin break down. An emollient lotion should be used.
11. The physician prescribed digoxin 0.125 mg PO qd to a
client and instructed the nurse that the client is on high-
potassium diet. High potassium foods are recommended in
the diet of a client taking digitalis preparations because a low
serum potassium has which of the following effects?
A. Potentiates the action of digoxin
B. Promotes calcium retention
C. Promotes sodium excretion
D. Puts the client at risk for digitalis toxicity
Answer: D. Potassium influences the excitability of nerves
and muscles. When potassium is low and the client is on
digoxin, the risk of digoxin toxicity is increased.
12. The nurse is caring for a client who is transferred from the
operating room for pneumonectomy. The nurse knows that
immediately following pneumonectomy; the client should be
in what position?
A. Supine on the unaffected side
B. Low-Fowler’s on the back
C. Semi-Fowler’s on the affected side
D. Semi-Fowler’s on the unaffected side
Answer: C. This position allows maximum expansion,
ventilation, and perfusion of the remaining lung.
13. A client is placed on digoxin, high potassium foods are
recommended in the diet of the client. Which of the following
foods willthe nurse give to the client?
A. Whole grain cereal, orange juice, and apricots
B. Turkey, green bean, and Italian bread
C. Cottage cheese, cooked broccoli, and roast beef
D. Fish, green beans and cherry pie
Answer: C. This position allows maximum expansion,
ventilation, and perfusion of the remaining lung.
14. The nurse is assigned to care to a client who undergone
thyroidectomy. What nursing intervention is important
during the immediate postoperative period following a
thyroidectomy?
A. Assess extremities for weakness and flaccidity
B. Support the head and neck during position changes
C. Position the client in high Fowler’s
D. Medicate for restlessness and anxiety
Answer: B. Stress on the suture line should be avoided.
Prevent flexion or hyperextension of the neck, and provide a
small pillow under thehead and neck. Neck muscles have
been affected during a thyroidectomy, support essential for
comfort and incisional support.
15. What would be the recommended diet the nurse will
implement to a client with burns of the head, face, neck and
anterior chest?
A. Serve a high-protein, high-carbohydrate diet
B. Encourage full liquid diet
C. Serve a high-fat diet, high-fiber diet
D. Monitor intake to prevent weight gain
Answer: A. 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.
16. A client with multiple fractures of both lower extremities
is admitted for 3 days ago and is on skeletal traction. The
client is complaining of having difficulty in bowel movement.
Which of the following would be the most appropriate
nursing intervention?
A. Administer an enema
B. Perform range-of-motion exercise to all extremities
C. Ensure maximum fluid intake (3000ml/day)
D. Put the client on the bedpan every 2 hours
Answer: C. The best early intervention would be to increase
fluid intake, because constipation is common when activity
is decreased or usual routines have been interrupted.
17. John is diagnosed with Addison’s disease and admitted in
the hospital. What would be the appropriate nursing care for
John?
A. Reducing physical and emotional stress
B. Providing a low-sodium diet
C. Restricting fluids to 1500ml/day
D. Administering insulin-replacement therapy
Answer: A. Because the client’s ability is to react to stress is
decreased, maintaining a quiet environment becomes A
nursing priority. Dehydration is a common problem in
Addison’s disease, so close observation of the client’s
hydration level is crucial. To promote optimal hydration and
sodium intake, fluid intake is increased, particularly fluid
containing electrolytes, such as broths, carbonated
beverages, and juices.
18. Mr. Smith is scheduled for an above-the-knee amputation.
After the surgery he was transferred to the nursing care unit.
The nurse assigned to him knows that 72 hours after the
procedure the client should be positioned properly to prevent
contractures. Which of the following is the best position to
the client?
A. Side-lying, alternating left and right sides
B. Sitting in a reclining chair twice a day
C. Lying on abdomen several times daily
D. Supine with stump elevated at least 30 degrees
Answer: C. At about 48-72 hours, the client must be turned
onto the abdomen to prevent flexion contractures.
19. A client is scheduled to have an inguinal herniorraphy in
the outpatient surgical department. The nurse is providing
health teaching about post surgical care to the client. Which
of the following statement if made by the client would reflect 23. Following a needle biopsy of the kidney, which
the need for more teaching? assessment is an indication that the client is bleeding?

A. “I should call the physician if I have a cough or cold A. Slow, irregular pulse
before surgery” B. Dull, abdominal discomfort
B. “I will be able to drive soon after surgery” C. Urinary frequency
C. “I will not be able to do any heavy lifting for 3-6 weeks D. Throbbing headache
after surgery”
D. “I should support my incision if I have to cough or turn” Answer: B. An accumulation of blood from the kidney into
the abdomen would manifest itself with these symptoms
Answer:B. The client should not drive for 2 weeks after
surgery to avoid stress on the incision. This reflects a need 24. A client with acute bronchitis is admitted in the hospital.
for additional teaching. The nurse assigned to the client is making a plan of care
regarding expectoration of thick sputum. Which nursing
20. Ms Jones is brought to the emergency room and is action is most effective?
complaining of muscle spasms, numbness, tremors and
weakness in the arms and legs. The client was diagnosed with A. Place the client in a lateral position every 2 hour
multiple sclerosis. The nurse assigned to Ms. Jones is aware B. Splint the patient’s chest with pillows when coughing
that she has to prevent fatigue to the client to alleviate the C. Use humified oxygen
discomfort. Which of the following teaching is necessary to D. Offer fluids at regular intervals
prevent fatigue?
Answer: D. Fluids liquefy secretions and therefore make it
A. Avoid extremes in temperature easier to expectorate
B. Install safety devices in the home
C. Attend support group meetings 25. The nurse is going to assess the bowel sound of the client.
D. Avoid physical exercise For accurate assessment of the bowel sound, the nurse
should listen for at least:
Answer: A. Extremes in heat and cold will exacerbate
symptoms. Heat delays transmission of impulses and A. 5 minutes
increases fatigue. B. 60 seconds
C. 30 seconds
D. 2 minutes
21. Mr. Stewart is in sickle cell crisis and complaining pain in
the joints and difficulty of breathing. On the assessment of Answer: D. Physical assessment guidelines recommend
the nurse, his temperature is 38.1 ºC. The physician ordered listening for atleast 2 minutes in each quadrant (and up to 5
Morphine sulfate via patient-controlled analgesia (PCA), and minutes, not at least 5 minutes).
oxygen at 4L/min. A priority nursing diagnosis to Mr. Stewart
is risk for infection. A nursing intervention to assist in 26. The nurse encourages the client to wear compression
preventing infection is: stockings. What is the rationale behind in using compression
stockings?
A. Using standard precautions and medical asepsis
B. Enforcing a “no visitors” rule A. Compression stockings promote venous return
C. Using moist heat on painful joints B. Compression stockings divert blood to major vessels
D. Monitoring a vital signs every 2 hour C. Compression stockings decreases workload on the heart
D. Compression stockings improve arterial circulation
Answer: A. Vigilant implementation of standard precautions
and medical asepsis is an effective means of preventing Answer: A. Compression stockings promote venous return
infection and prevent peripheral pooling.

22. Mrs. Maupin is a professor in a prestigious university for 27. Mr. Whitman is a stroke client and is having difficulty in
30 years. After lecture, she experience blurring of vision and swallowing. Which is the best nursing intervention is most
tiredness. Mrs. Maupin is brought to the emergency likely to assist the client?
department. On assessment, the nurse notes that the blood
pressure of the client is 139/90. Mrs. Maupin has been
A. Placing food in the unaffected side of the mouth
diagnosed with essential hypertension and placed on
B. Increasing fiber in the diet
medication to control her BP. Which potential nursing
C. Asking the patient to speak slowly
diagnosis will be a priority for discharge teaching?
D. Increasing fluid intake

A. Sleep Pattern disturbance Answer: A. Placing food in the unaffected side of the mouth
B. Impaired physical mobility assists in the swallowing process because the client has
C. Noncompliance sensation on that side and will have more control over the
D. Fluid volume excess swallowing process.

Answer: C. Noncompliance is a major problem in the
management of chronic disease. In hypertension, the client
often does not feel ill and thus does not see a need to follow
a treatment regimen.
28. Following nephrectomy, the nurse closely monitors the
urinary output of the client. Which assessment finding is an
early indicator of fluid retention in the postoperative period?
A. Periorbital edema
B. Increased specific gravity of urine
 C. A urinary output of 50mL/hr
D. Daily weight gain of 2 lb or more
Answer: D. Daily weights are taken following nephrectomy.
Daily increases of 2 lb or more are indicative of fluid
retention and should be reported to the physician. Intake
and output records may also reflect this imbalance.
29. A nurse is completing an assessment to a client with
cirrhosis. Which of the following nursing assessment is
important to notify the physician?
A. Expanding ecchymosis
B. Ascites and serum albumin of 3.2 g/dl
C. Slurred speech
D. Hematocrit of 37% and hemoglobin of 12g/dl
Answer: A. Clients with cirrhosis have already coagulation
due to thrombocytopenia and vitamin K deficiency. This
could be a sign of bleeding
30. Mr. Park is 32-year-old, a badminton player and has a
type 1 diabetes mellitus. After the game, the client complains
of becoming diaphoretic and light-headedness. The client
asks the nurse how to avoid this reaction. The nurse will
recommend to:
A. Allow plenty of time after the insulin injection and
before beginning the match
B. Eat a carbohydrate snack before and during the
badminton match
C. Drink plenty of fluids before, during, and after bed time
D. Take insulin just before starting the badminton match
Answer: B. Exercise enhances glucose uptake, and the client
is at risk for an insulin reaction. Snacks with carbohydrates
will help.
31. A client is rushed to the emergency room due to serious
vehicle accident. The nurse is suspecting of head injury.
Which of the following assessment findings would the nurse
report to the physician?
A. CVP of 5mmHa
B. Glasgow Coma Scale score of 13
C. Polyuria and dilute urinary output
D. Insomnia
Answer: C. These are symptoms of diabetes insipidus. The
patient can become hypovolemic and vasopressin may
reverse the Polyuria.
32. Mrs. Moore, 62-year-old, with diabetes is in the
emergency department. She stepped on a sharp sea shells
while walking barefoot along the beach. Mrs. Moore did not
notice that the object pierced the skin until later that evening.
What problem does the client most probably have?
A. Nephropathy
B. Macroangiopathy
C. Carpal tunnel syndrome
D. Peripheral neuropathy
Answer: D. Peripheral neuropathy refers to nerve damage of
the hands and feet. The client did not notice that the object
pierced the skin.
33. A client with gangrenous foot has undergone a below-
knee amputation. The nurse in the nursing care unit knows
that the priority nursing intervention in the immediate post
operative care of this client is:
A. Elevate the stump on a pillow for the first 24 hours
B. Encourage use of trapeze
C. Position the client prone periodically
D. Apply a cone-shaped dressing
Answer: A. The elevation of the stump on a pillow for the
first 24 hours decreases edema and increases venous return.
34. A client with a diagnosis of gastric ulcer is complaining of
syncope and vertigo. What would be the initial nursing
intervention by the nurse?
A. Monitor the client’s vital signs
B. Keep the client on bed rest
C. Keep the patient on bed rest
D. Give a stat dose of Sucralfate (Carafate)
Answer: B. The priority is to maintain client’s safety. With
syncope and vertigo, the client is at high risk for falling.
35. After a right lower lobectomy on a 55-year-old client,
which action should the nurse initiate when the client is
transferred from the post anesthesia care unit?
A. Notify the family to report the client’s condition
B. Immediately administer the narcotic as ordered
C. Keep client on right side supported by pillows
D. Encourage coughing and deep breathing every 2 hours
Answer: D. Coughing and deep breathing are essential for
re-expansion of the lung
36. The nurse is providing a discharge instruction about the
prevention of urinary stasis to a client with frequent bladder
infection. Which of the following will the nurse include in the
instruction?
A. Drink 3-4 quarts of fluid every day
B. Empty the bladder every 2-4 hours while awake
C. Encourage the use of coffee, tea, and colas for their
diuretic effect
D. Teach Kegel exercises to control bladder flow
Answer:B. Avoiding stasis of urine by emptying the bladder
every 2-4 hours will prevent overdistention of the bladder
and future urinary tract infections.
37. A male client visits the clinic for check-up. The client tells
the nurse that there is a yellow discharge from his penis. He
also experiences a burning sensation when urinating. The
nurse is suspecting of gonorrhea. What teaching is necessary
for this client?
A. Sex partner of 3 months ago must be treated
B. Women with gonorrhea are symptomatic
C. Use a condom for sexual activity
D. Sex partner needs to be evaluated
Answer: D. If infected, the sex partner must be evaluated
and treated
38. A client with AIDS is admitted in the hospital. He is
receiving intravenous therapy. While the nurse is assessing
the IV site, the client becomes confused and restless and the
intravenous catheter becomes disconnected and minimal
amount of the client’s blood spills onto the floor. Which
action will the nurse take to remove the blood spill?
A. Promptly clean with a 1:10 solution of household
bleach and water
B. Promptly clean up the blood spill with full-strength
antimicrobial cleaning solution
C. Immediately mop the floor with boiling water
D. Allow the blood to dry before cleaning to decrease the
possibility of cross-contamination
Answer: A. A 1:10 solution of household bleach and water is
recommended by the Centers for Disease Control and
Prevention to kill the human immunodeficiency virus (HIV).
39. Before surgery, the physician ordered pentobarbital
sodium (Nembutal) for the client to sleep. The night before
the scheduled surgery, the nurse gave the pre-medication.
One hour later the client is still unable to sleep. The nurse
review the client’s chart and note the physician’s prescription
with an order to repeat. What should the nurse do next?
A. Rub the client’s back until relaxed
B. Prepare a glass of warm milk
C. Give the second dose of pentobarbital sodium
D. Explore the client’s feelings about surgery
Answer: D. Given the data, presurgical anxiety is suspected.
The client needs an opportunity to talk about concerns
related to surgery before further actions (which may mask
the anxiety).
40. The nurse on the night shift is making rounds in the
nursing care unit. The nurse is about to enter to the client’s
room when a ventilator alarm sounds, what is the first action
the nurse should do?
A. Assess the lung sounds
B. Suction the client right away
C. Look at the client
D. Turn and position the client
Answer: C. A quick look at the client can help identify the
type and cause of the ventilator alarm. Disconnection of the
tube from the ventilator, bronchospasm, and anxiety are
some of the obvious reasons that could trigger an alarm.
41. What effective precautions should the nurse use to
control the transmission of methicillin-resistant
Staphylococcus aureus (MRSA)?
A. Use gloves and handwashing before and after client
contact
B. Do nasal cultures on healthcare providers
C. Place the client on total isolation
D. Use mask and gown during care of the MRSA client
Answer: A. Contact isolation has been advised by the
Centers for Disease Control and Prevention (CDC) to control
transmission of MRSA, which includes gloves and
handwashing.
42. The postoperative gastrectomy client is scheduled for
discharge. The client asks the nurse, “When I will be allowed
to eat three meals a day like the rest of my family?”. The
appropriate nursing response is:
A. “You will probably have to eat six meals a day for the
rest of your life.”
B. “Eating six meals a day can be a bother, can’t it?”
C. “Some clients can tolerate three meals a day by the
time they leave the hospital. Maybe it will be a little
longer for you.”
D. “ It varies from client to client, but generally in 6-12
months most clients can return to their previous meal
patterns”
Answer:D. In response to the question of the client, the nurse
needs to provide brief, accurate information. Some clients
who have had gastrectomies are able to tolerate three meals
a day before discharge from the hospital. However, for the
majority of clients, it takes 6-12 months before their
surgically reduced stomach has stretched enough to
accommodate a larger meal
43. A male client with cirrhosis is complaining of belly pain,
itchiness and his breasts are getting larger and also the
abdomen. The client is so upset because of the discomfort
and asks the nurse why his breast and abdomen are getting
larger. Which of the following is the appropriate nursing
response?
A. “How much of a difference have you noticed”
B. “It’s part of the swelling your body is experiencing”
C. “It’s probably because you have been less physically
active”
D. “Your liver is not destroying estrogen hormones that all
men produce”
Answer: A. This allows the client to elaborate his concern
and provides the nurse a baseline of assessment
44. A client is diagnosed with detached retina and scheduled
for surgery. Preoperative teaching of the nurse to the client
includes:
A. No eye pain is expected postoperatively
B. Semi-fowler’s position will be used to reduce pressure
in the eye.
C. Eye patches may be used postoperatively
D. Return of normal vision is expected following surgery
Answer: C. Use of eye patches may be continued
postoperatively, depending on surgeon preference. This is
done to achieve >90% success rate of the surgery.
45. A 70-year-old client is brought to the emergency
department with a caregiver. The client has manifestations of
anorexia, wasting of muscles and multiple bruises. What
nursing interventions would the nurse implement?
A. Talk to the client about the caregiver and support
system
B. Complete a gastrointestinal and neurological
assessment
C. Check the lab data for serum albumin, hematocrit and
hemoglobin
D. Complete a police report on elder abuse
Answer: B. Assessment and more data collection are needed.
The client may have gastrointestinal or neurological
problems that account for the symptoms. The anorexia
could result from medications, poor dentition, or indigestion,
the bruises may be attributed to ataxia, frequent falls,
vertigo, or medication.
46. A nurse is providing a discharge instruction to the client
about the self-catheterization at home. Which of the
following instructions would the nurse include?
 A. Wash the catheter with soap and water after each use Answer: B. Toxoplasmosis is an opportunistic infection and a
B. Lubricate the catheter with Vaseline parasite of birds and mammals. The oocysts remain infectious
C. Perform the Valsalva maneuver to promote insertion in moist soil for about 1 year
D. Replace the catheter with a new one every 24 hour

Answer: A. The catheter should be washed with soap and

PNLE IV Nursing Practice
water after withdrawal and placed in a clean container. It
The scope of this Nursing Test IV is parallel to the NP4 NLE
can be reused until it is too hard or too soft for insertion.
Coverage:
Self-care, prevention of complications, and cost-
 Medical Surgical Nursing
effectiveness are important in home management.
1. Following spinal injury, the nurse should encourage the
client to drink fluids to avoid:
47. The nurse in the nursing care unit is assigned to care to a
client who is Immunocompromised. The client tells the nurse
that his chest is painful and the blisters are itchy. What would A. Urinary tract infection.
be the nursing intervention to this client? B. Fluid and electrolyte imbalance.
C. Dehydration.
D. Skin breakdown.
A. Call the physician
B. Give a prn pain medication
Answer: A. Clients in the early stage of spinal cord damage
C. Clarify if the client is on a new medication
experience an atonic bladder, which is characterized by the
D. Use gown and gloves while assessing the lesions
absence of muscle tone, an enlarged capacity, no feeling of
discomfort with distention, and overflow with a large
Answer: D. The client may have herpes zoster (shingles), a
residual. This leads to urinary stasis and infection. High fluid
viral infection. The nurse should use standard precautions in
intake limits urinary stasis and infection by diluting the urine
assessing the lesions. Immunocompromised clients are at
and increasing urinary output.
risk for infection.
2. The client is transferred from the operating room to
48. A client is admitted and has been diagnosed with bacterial
recovery room after an open-heart surgery. The nurse
(meningococcal) meningitis. The infection control registered
assigned is taking the vital signs of the client. The nurse
nurse visits the staff nurse caring to the client. What
notified the physician when the temperature of the client
statement made by the nurse reflects an understanding of
rises to 38.8 ºC or 102 ºF because elevated temperatures:
the management of this client?

A. May be a forerunner of hemorrhage.

A. speech pattern may be altered
B. Are related to diaphoresis and possible chilling.
B. Respiratory isolation is necessary for 24 hours after
C. May indicate cerebral edema.
antibiotics are started
D. Increase the cardiac output.
C. Perform skin culture on the macular popular rash
D. Expect abnormal general muscle contractions
Answer: D. The temperature of 102 ºF (38.8ºC) or greater
lead to an increased metabolism and cardiac workload.
Answer: B. After a minimum of 24 hours of IV antibiotics, the
client is no longer considered communicable. Evaluation of
3. After radiation therapy for cancer of the prostate, the
the nurse’s knowledge is needed for safe care and continuity
client experienced irritation in the bladder. Which of the
of care
following sign of bladder irritability is correct?
49. A 18-year-old male client had sustained a head injury
from a motorbike accident. It is uncertain whether the client A. Hematuria
may have minimal but permanent disability. The family is B. Dysuria
concerned regarding the client’s difficulty accepting the C. Polyuria
possibility of long term effects. Which nursing diagnosis is D. Dribbling
best for this situation?
ANSWER: B. Dysuria, nocturia, and urgency are all signs an
irritable bladder after radiation therapy.
A. Nutrition, less than body requirements
B. Injury, potential for sensory-perceptual alterations
4. A client is diagnosed with a brain tumor in the occipital
C. Impaired mobility, related to muscle weakness
lobe. Which of the following will the client most likely
D. Anticipatory grieving, due to the loss of independence
experience?
Answer: D. Stem of the question supports this choice by
stating that the client has difficulty accepting the potential A. Visual hallucinations.
disability. B. Receptive aphasia.
C. Hemiparesis.
50. A client with AIDS is scheduled for discharge. The client D. Personality changes.
tells the nurse that one of his hobbies at home is gardening.
What will be the discharge instruction of the nurse to the ANSWER: A. The occipital lobe is involve with visual
client knowing that the client is prone to toxoplasmosis? interpretation.

5. A client with Addison’s disease has a blood pressure of

A. Wash all vegetables before cooking
65/60. The nurse understands that decreased blood pressure
B. Wear gloves when gardening
of the client with Addison’s disease involves a disturbance in
C. Wear a mask when travelling to foreign countries
the production of:
D. Avoid contact with cats and birds

A. Androgens
 B. Glucocorticoids
C. Mineralocorticoids
D. Estrogen
ANSWER: 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. 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.
ANSWER: 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. 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.
ANSWER: A. Heavy alcohol ingestion predisposes an
individual to the development of oral cancer.
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.
ANSWER: 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. 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.
ANSWER: A. Viscosity, a measure of a fluid’s internal
resistance to flow, is increased as the number of red cells
suspended in plasma.
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.
ANSWER: C. Hemiparesis creates instability. Using a cane
provides a wider base of support and, therefore greater
stability.
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.
ANSWER: D. Manual stretching exercises will assist in
keeping the muscles and tendons supple and pliable,
reducing the traumatic consequences of repetitive activity.
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.
ANSWER: 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. 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.
ANSWER: D. Temperature may increase within the first 24
hours and persist as long as a week.
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.
ANSWER: C. The hips are in extension when the client is
prone; this keeps the hips from flexing.
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.
ANSWER: C. Steroids have an anti-inflammatory effect that
can reduce arthritic pannus formation.
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.
ANSWER: A. Activities such as rigorous brushing of hair and
teeth cause increased intraocular pressure and may lead to
hemorrhage in the anterior chamber.
17. A client with AIDS develops bacterial pneumonia is
admitted in the emergency department. The client’s arterial
blood gases is drawn and the result is PaO2 80mmHg. then
arterial blood gases are drawn again and the level is reduced
from 80 mmHg to 65 mmHg. The nurse should;
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.
ANSWER: C. This decrease in PaO2 indicates respiratory
failure; it warrants immediate medical evaluation.
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; You’ll 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.”
ANSWER: C. This is truthful and provides basic information
that may prompt recollection of what happened; it is a
starting point.
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 client’s:
A. Reaction to hypertensive medications.
B. Denial of illness.
C. Response to cerebral anoxia.
D. Fear of the health problem.
ANSWER: 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. 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 client’s 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.
ANSWER: C. There are few physical restraints on activity
postoperatively, but the client may have emotional
problems resulting from the body image changes.
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. “I’m 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.”.
ANSWER: 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 one’s size; it is not uncommon for the
client to still feel fat no matter how much weight is lost.
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 client’s 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.
 ANSWER: D. Surgery on the bowel has no direct anatomic or 27. The physician prescribed Albuterol (Proventil) to the
physiologic effect on sexual performance. However, the client with severe asthma. After the administration of the
nurse should encourage verbalization. medication the nurse should monitor the client for:

23. A 75-year-old male client tells the nurse that his wife has A. Palpitation
osteoporosis and asks what chances he had of getting also B. Visual disturbance
osteoporosis like his wife. Which of the following is the C. Decreased pulse rate
correct response of the nurse? D. Lethargy

A. “This is only a problem for women.” ANSWER: A. Albuterol’s sympathomimetic effect causes
B. “You are not at risk because of your small frame.” cardiac stimulation that may cause tachycardia and
C. “You might think about having a bone density test,” palpitation.
D. “Exercise is a good way to prevent this problem.”
28. A client is receiving diltiazem (Cardizem). What should the
ANSWER: C. Osteoporosis is not restricted to women; it is a nurse include in a teaching plan aimed at reducing the side
potential major health problem of all older adults; estimates effects of this medication?
indicate that half of all women have at least one osteoporitic
fracture and the risk in men is estimated between 13% and A. Take the drug with an antacid.
25%; a bone mineral density measurement assesses the B. Lie down after meals.
mass of bone per unit volume or how tightly the bone is C. Avoid dairy products in diet.
packed. D. Change positions slowly.

24. An older adult client with acute pain is admitted in the ANSWER: D. Changing positions slowly will help prevent the
hospital. The nurse understands that in managing acute pain side effect of orthostatic hypotension.
of the client during the first 24 hours, the nurse should
ensure that: 29. A client is receiving simvastatin (Zocor). The nurse is
aware that this medication is effective when there is decrease
A. Ordered PRN analgesics are administered on a in:
scheduled basis.
B. Patient controlled analgesia is avoided in this A. The triglycerides
population. B. The INR
C. Pain medication is ordered via the intramuscular route. C. Chest pain
D. An order for meperidine (Demerol) is secured for pain D. Blood pressure
relief.
ANSWER: A. Therapeutic effects of simvastatin include
ANSWER: A. Around-the-clock administration of analgesics is decreased serum triglyceries, LDL and cholesterol.
recommended for acute pain in the older adult population;
this help to maintain a therapeutic blood level of pain 30. A client is taking nitroglycerine tablets, the nurse should
medication. teach the client the importance of:

25. A nurse is caring to an older adult with presbycusis. In

A. Increasing the number of tablets if dizziness or
formulating nursing care plan for this client, the nurse should
hypertension occurs.
expect that hearing loss of the client that is caused by aging
B. Limiting the number of tablets to 4 per day.
to have:
C. Making certain the medication is stored in a dark
container.
A. Overgrowth of the epithelial auditory lining. D. Discontinuing the medication if a headache develops.
B. Copious, moist cerumen.
C. Difficulty hearing women’s voices. ANSWER: C. Nitroglycerine is sensitive to light and moisture
D. Tears in the tympanic membrane. ad must be stored in a dark, airtight container.

ANSWER: C. Generally, female voices have a higher pitch 31. The physician prescribes Ibuprofen (Motrin) and
than male voices; older adults with presbycusis (hearing loss hydroxychloroquine sulfate (Plaquenil) for a 58-year-old male
caused by the aging process) have more difficulty hearing client with arthritis. The nurse provides information about
higher-pitched sounds. toxicity of the hydroxychloroquine. The nurse can determine
if the information is clearly understood if the client states:
26. The nurse is reviewing the client’s chart about the
ordered medication. The nurse must observe for signs of
A. “I will contact the physician immediately if I develop
hyperkalemia when administering:
blurred vision.”
B. “I will contact the physician immediately if I develop
A. Furosemide (Lasix) urinary retention.”
B. Hydrochlorothiazide (HydroDIURIL) C. “I will contact the physician immediately if I develop
C. Metolazone (Zaroxolyn) swallowing difficulty.”
D. Spironolactone (Aldactone) D. “I will contact the physician immediately if I develop
feelings of irritability.”
ANSWER: D. Aldactone is a potassium-sparing diuretic;
hyperkalemia is an adverse effect. ANSWER: A. Visual disturbance are a sign of toxicity because
retinopathy can occur with this drug.
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)
ANSWER: B. Toxic levels of Lanoxin stimulate the medullary
chemoreceptor trigger zone, resulting in nausea and
subsequent anorexia.
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.
Answer: 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. Levodopa is ordered for a client with Parkinson’s 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.
Answer: B. Levodopa is the metabolic precursor of
dopamine. It reduces sympathetic outflow by limiting
vasoconstriction, which may result in orthostatic
hypotension.
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
Answer: 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. The nurse can determine the effectiveness of
carbamazepine (Tegretol) in the management of trigeminal
neuralgia by monitoring the client’s:
A. Seizure activity
B. Liver function
C. Cardiac output
D. Pain relief
Answer: D. Carbamazepine ( Tegretol) is administered to
control pain by reducing the transmission of nerve impulses
in clients with trigeminal neuralgia.
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.
Answer: C. Potassium iodide, which aids in decreasing the
vascularity of the thyroid gland, decreases the risk for
hemorrhage.
38. A client with Addison’s 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 client’s
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.
Answer: 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. A client with diabetes insipidus is taking Desmopressin
acetate (DDAVP). To determine if the drug is effective, the
nurse should monitor the client’s:
A. Arterial blood pH
B. Pulse rate
C. Serum glucose
D. Intake and output
Answer: D. DDAVP replaces the ADH, facilitating
reabsorption of water and consequent return of normal
urine output and thirst.
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.
Answer: 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 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
Answer: 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. The physician reduced the client’s Dexamethasone
(Decadron) dosage gradually and to continue a lower
maintenance dosage. The client asks the nurse about the
change of dosage. The nurse explains to the client that the
purpose of gradual dosage reduction is to allow:
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
Answer: A. Any hormone normally produced by the body
must be withdrawn slowly to allow the appropriate organ to
adjust and resume production.
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
Answer: B. Dehydration is most readily and accurately
measured by serial assessment of body weight; 1 L of fluid
weighs 2.2 pounds.
44. Which of the following is the most important electrolyte
of intracellular fluid?
A. Potassium
B. Sodium
C. Chloride
D. Calcium
Answer: A. The concentration of potassium is greater inside
the cell and is important in establishing a membrane
potential, a critical factor in the cell’s ability to function.
45. Which of the following client has a high risk for
developing hyperkalemia?
A. Crohn’s disease
B. End-Stage renal disease
C. Cushing’s syndrome
D. Chronic heart failure
Answer: B. The kidneys normally eliminate potassium from
the body; hyperkalemia may necessitate dialysis.
46. The nurse is reviewing the laboratory result of the client.
The client’s serum potassium level is 5.8 mEq/L. Which of the
following is the initial nursing action?
A. Call the cardiac arrest team to alert them
B. Call the laboratory and repeat the test
C. Take the client’s vital signs and notify the physician
D. Obtain an ECG strip and have lidocaine available
Answer: C. Vital signs monitor cardiorespiratory status;
hyperkalemia causes serious cardiac dysrhythmias.
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
Answer: 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. A female client is brought to the emergency unit. The
client is complaining of abdominal cramps. On assessment,
client is experiencing anorexia and weight is reduced. The
physician’s diagnosis is colitis. Which of the following
symptoms of fluid and electrolyte imbalance should the nurse
report immediately?
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.
Answer: 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. 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
Answer: A. Because IV solutions enter the body’s internal
environment, all solutions and medications utilizing this
route must be sterile to prevent the introduction of
microbes.
50. The nurse is reviewing the laboratory result of the client.
An arterial blood gas report indicates the client’s pH is 7.20,
PCO2 35 mmHg and HCO3 is 19 mEq/L. The results are
consistent with:
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Answer: A. A low pH and bicarbonate level are consistent
with metabolic acidosis.
PNLE V Nursing Practice
The scope of this Nursing Test V is parallel to the NP5
NLE Coverage:
 Psychiatric Nursing
1. A 17-year-old client has a record of being absent in the
class without permission, and “borrowing” other people’s
things without asking permission. The client denies stealing;
rationalizing instead that as long as no one was using the items,
there is no problem to use it by other people. It is important
for the nurse to understand that psychodynamically, the
behavior of the client may be largely attributed to a
development defect related to the:
A. Oedipal complex
B. Superego
C. Id
D. Ego
Answer: B. This shows a weak sense of moral consciousness.
According to Freudian theory, personality disorders stem
from a weak superego.
2. A client tells the nurse, “Yesterday, I was planning to kill
myself.” What is the best nursing response to this cient?
A. “What are you going to do this time?”
B. Say nothing. Wait for the client’s next comment
C. “You seem upset. I am going to be here with you;
perhaps you will want to talk about it”
D. “Have you felt this way before?”
Answer: C. The client needs to have his or her feelings
acknowledged, with encouragement to discuss feelings, and
be reassured about the nurse’s presence.
3. In crisis intervention therapy, which of the following
principle that the nurse will use to plan her/his goals?
A. Crises are related to deep, underlying problems
B. Crises seldom occur in normal people’s lives
C. Crises may go on indefinitely.
D. Crises usually resolved in 4-6 weeks.
Answer: D. Part of the definition of a crisis is a time span of
4-6 weeks.
4. The nurse enters the room of the male client and found out
that the client urinates on the floor. The client hides when the
nurse is about to talk to him. Which of the following is the
best nursing intervention?
A. Place restriction on the client’s activities when his
behavior occurs.
B. Ask the client to clean the soiled floor.
C. Take the client to the bathroom at regular intervals.
D. Limit fluid intake.
Answer; C. The client is most likely confused, rather than
exhibiting acting-out, hostile behavior. Frequent toileting will
allow urination in an appropriate place.
5. A young lady with a diagnosis of schizophrenic reaction is
admitted to the psychiatric unit. In the past two months, the
client has poor appetite, experienced difficulty in sleeping,
was mute for long periods of time, just stayed in her room,
grinning and pointing at things. What would be the initial
nursing action on admitting the client to the unit?
A. Assure the client that “ You will be well cared for.”
B. Introduce the client to some of the other clients.
C. Ask “Do you know where you are?”
D. Take the client to the assigned room.
Answer: D. The client needs basic, simple orientation that
directly relates to the here-and-now, and does not require
verbal interaction.
6. A 16-year-old girl was diagnosed with anorexia. What
would be the first assessment of the nurse?
A. What food she likes.
B. Her desired weight.
C. Her body image.
D. What causes her behavior.
Answer: A. Although all options may appear correct. A is the
best because it focuses on a range of possible positive
reinforcers, a basis for an effective behavior modification
program. It can lead to concrete, specific nursing
interventions right away and provides a therapeutic use of
“control” for the 16-year-old.
7. On an adolescent unit, a nurse caring to a client was
informed that her client’s closest roommate dies at night.
What would be the most appropriate nursing action?
A. Do not bring it up unless the client asks.
B. Tell the client that her roommate went home.
C. Tell the client, if asked, “You should ask the doctor.”
D. Tell the client that her closest roommate died.
Answer: A. The nurse needs to wait and see: do not “jump
the gun”; do not assume that the client wants to know now.
8. A woman gave birth to an unhealthy infant, and with some
body defects. The nurse should expect the woman’s initial
reactions to include:
A. Depression
B. Withdrawal
C. Apathy
D. Anger
Answer: D. The woman is experiencing an actual loss and
will probably exhibit many of the same symptoms as a
person who has lost someone to death.
9. A client in the psychiatric unit is shouting out loud and tells
the nurse, “Please, help me. They are coming to get me.” What
would be the appropriate nursing response?
A. “ I won’t let anyone get you.”
B. “Who are they?”
C. “I don’t see anyone coming.”
D. “You look frightened.”
Answer: C. This option is an example of pointing out reality-
the nurse’s perception.
10. A client who is severely obese tells the nurse, “My
therapist told me that I eat a lot because I didn’t get any
attention and love from my mother. What does the therapist
mean?” What is the best nursing response?
A. “What do you think is the connection between your not
getting enough love and overeating?”
B. “Tell me what you think the therapist means.”
C. “You need to ask your therapist.”
D. “ We are here to deal with your diet, not with your
psychological problems.”
Answer: B. This response asks information that the nurse can
use. If the client understands the statement, the nurse can
support the therapist when focusing on connection between
food, love, and mother. If the client does not understand
thestatement, the nurse can help get clarification from the
therapist.
11. After the discussion about the procedure the physician
scheduled the client for mastectomy. The client tells the nurse,
“If my breasts will be removed, I’m afraid my husband will
not love me anymore and maybe he will never touch me.”
What should the nurse’s response?
A. “I doubt that he feels that way.”
B. “What makes you feel that way?”
C. “Have you discussed your feelings with your
husband?”
D. Ask the husband, in front of the wife, how he feels about
this.
Answer: C. This option redirects the client to talk to her
husband.
12. The child is brought to the hospital by the parents. During
assessment of the nurse, what parental behavior toward a child
should alert the nurse to suspect child abuse?
A. Ignoring the child.
B. Flat affect.
C. Expressions of guilt.
D. Acting overly solicitous toward the child
Answer: D. This is an example of reaction formation, a
coping mechanism.
13. A nurse is caring to a client with manic disorder in the
psychiatric ward. On the morning shift, the nurse is talking
with the client who is now exhibiting a manic episode with
flight of ideas. The nurse primarily needs to:
A. Focus on the feelings conveyed rather than the
thoughts expressed.
B. Speak loudly and rapidly to keep the client’s attention,
because the client is easily distracted.
C. Allow the client to talk freely.
D. Encourage the client to complete one thought at a time.
Answer: A. Often the verbalized ideas are jumbled, but the
underlying feelings are discernible and must be
acknowledged.
14. The nurse is caring to an autistic child. Which of the
following play behavior would the nurse expect to see in a
child?
A. competitive play
B. nonverbal play
C. cooperative play
D. solitary play
Answer: D. Autistic children do best with solitary play
because they typically do not interact with others in a socially
comprehensible and acceptable way.
15. The client is telling the nurse in the psychiatric ward, “I
hate them.” Which of the following is the most appropriate
nursing response to the client?
A. “Tell me about your hate.”
B. “I will stay with you as long as you feel this way.”
C. “For whom do you have these feelings?”
D. “I understand how you can feel this way.”
Answer: A. The nurse is asking the client to clarify and
further discuss feelings.
16. The mother visits her son with major depression in the
psychiatric unit. After the conversation of the client and the
mother, the nurse asks the mother how it is talking to her son.
The mother tells the nurse that it was a stressful time. During
an interview with the client, the client says, “we had a
marvelous visit.” Which of the following coping mechanism
can be described to thestatement of the client?
A. Identification.
B. Rationalization.
C. Denial.
D. Compensation.
Answer: C. Denial is the act of avoiding disagreeable
realities by ignoring them.
17. A male client is quiet when the physician told him that he
has stage IV cancer and has 4 months to live. The nurse
determines that this reaction may be an example of:
A. Indifference
B. Denial
C. Resignation
D. Anger
Answer: B. Reactions when told of a life-threatening illness
stem from Kübler-Ross’ ideas on death and dying. Denial is a
typical grief response, and usually is a first reaction.
18. A nurse is caring to a female client with five young
children. The family member told the client that her ex-
husband has died 2 days ago. The reaction of the client is
stunned silence, followed by anger that the ex-husband left no
insurance money for their young children. The nurse should
understand that:
A. The children and the injustice done to them by their
father’s death are the woman’s main concern.
B. To explain the woman’s reaction, the nurse needs more
information about the relationship and breakup.
C. The woman is not reacting normally to the news.
D. The woman is experiencing a normal bereavement
reaction.
Answer: D. Shock and anger are commonly the primary
initial reactions.
19. A client who is manic comes to the outpatient department.
The nurse is assigning an activity for the client. What activity
is best for the nurse to encourage for a client in a manic phase?
A. Solitary activity, such as walking with the nurse, to
decrease stimulation.
B. Competitive activity, such as bingo, to increase the
client’s self-esteem.
C. Group activity, such as basketball, to decrease isolation.
D. Intellectual activity, such as scrabble, to increase
concentration.
Answer: A. This option avoids external stimuli, yet channels
the excess motor activity that is often part of the manic phase.
20. The nurse is about to administer Imipramine HCI (Tofranil)
to the client, the client says, “Why should I take this?” The
doctor started me on this 10days ago; it didn’t help me at all.”
Which of the following is the best nursing response:
A. “What were you expecting to happen?”
B. “It usually takes 2-3 weeks to be effective.”
C. “Do you want to refuse this medication? You have the
right.”
D. “That’s a long time wait when you feel so depressed.”
Answer: B. The patient needs a brief, factual answer.
21. Which of the following drugs the nurse should choose to
administer to a client to prevent pseudoparkinsonism?
 A. Isocarboxazid (Marplan)
B. Chlorpromazine HCI (Thorazine) Answer: A. It is important to acknowledge a statement, even
C. Trihexyphenidyl HCI (Artane) if it is not understood.
D. Trifluoperazine HCI (Stelazine)
27. A male client diagnosed with depression tells the nurse, “I
Answer: C. Trihexyphenidyl HCI (Artane) is often used to don’t want to look weak and I don’t even cry because my wife
counteract side effect of pseudoparkinsonism, which often and my kids can’t bear it.” The nurse understands that this is
accompanies the use of phenothiazine, such as an example of:
chlorpromazine HCI (Thorazine or Trifluoperazine HCI
(Stelazine). A. Repression.
B. Suppression.
22. The nurse is caring to an 80-year-old client with dementia? C. Undoing.
What is the most important psychosocial need for this client? D. Rationalization.

A. Focus on the there-and-then rather the here-and-now. Answer: D. Rationalization is the process of constructing
B. Limit in the number of visitors, to minimize confusion. plausible reasons for one’s responses
C. Variety in their daily life, to decrease depression.
D. A structured environment, to minimize regressive 28. A female client tells the nurse that she is afraid to go out
behaviors. from her room because she thinks that the other client might
kill her. The nurse is aware that this behavior is related to:
Answer: D. Persons with dementia needs sameness,
consistency, structure, routine, and predictability. A. Hallucination.
B. Ideas of reference.
23. A client tells the nurse, “I don’t want to eat any meals C. Delusion of persecution.
offered in this hospital because the food is poisoned.” The D. Illusion.
nurse is aware that the client is expressing an example of:
Answer: C. The client has ideas that someone is out to kill
A. Delusion. her.
B. Hallucination.
C. Negativism. 29. A female client is taking Imipramine HCI (Tofranil) for
D. Illusion. almost 1 week and shows less awareness of the physical body.
What problem would the nurse be most concerned?
Answer: A. This is a false belief developed in response to an
emotional need. A. Nausea.
B. Gait disturbances.
24. A client is admitted in the hospital. On assessment, the C. Bowel movements.
nurse found out that the client had several suicidal attempts. D. Voiding.
Which of the following is the most important nursing action?
Answer: D. A serious side effect of Imipramine HCI
A. Ignore the client as long as he or she is talking about (Tofranil) is urinary retention (voiding problems)
suicide, because suicide attempt is unlikely.
B. Administer medication. 30. A 6-year-old client dies in the nursing unit. The parents
C. Relax vigilance when the client seems to be recovering want to see the child. What is the most appropriate nursing
from depression. action?
D. Maintain constant awareness of the client’s
whereabouts. A. Give the parents time alone with the body.
B. Ask the physician for permission.
Answer:D. The client must be constantly observed. C. Complete the postmortem care and quietly accompany
the family to the child’s room.
25. The nurse suspects that the client is suffering from D. Suggest the parents to wait until the funeral service to
depression. During assessment, what are the most say “good-bye.”
characteristic signs and symptoms of depression the nurse
would note? Answer: A. This allows the parents/family to grieve over the
loss of the child, by going through the steps of leave taking.
A. Constipation, increased appetite.
B. Anorexia, insomnia. 31. A 20-year-old female client is diagnosed with anxiety
C. Diarrhea, anger. disorder. The physician prescribed Flouxetine (Prozac). What
D. Verbosity, increased social interaction is the most important side effects should a nurse be concerned?

Answer: B. The appetite is diminished and sleeping is A. Tremor, drowsiness.

affected to a client with depression. B. Seizures, suicidal tendencies.
. C. Visual disturbance, headache.
26. The client in the psychiatric unit states that, “The goodas D. Excessive diaphoresis, diarrhea.
are coming! I must be ready.” In response to this neologism,
the nurse’s initial response is to: Answer: B. Assess for suicidal tendencies, especially during
early therapy. There is an increased risk of seizures in
A. Acknowledge that the word has some special meaning debilitated client and those with a history of seizures.
for the client.
B. Try to interpret what the client means. 32. A nurse is assigned to activate a client who is withdrawn,
C. Divert the client’s attention to an aspect of reality. hears voices and negativistic. What would be the best nursing
D. State that what the client is saying has not been approach?
understood and then divert attention to something that is
really bound.
 A. Mention that the “voices” would want the client to
participate.
B. Demand that the client must join a group activity.
C. Give the client a long explanation of the benefits of
activity.
D. Tell the client that the nurse needs a partner for an
activity.
Answer: D. The nurse helps to activate by doing something
with the client.
33. A nurse is going to give a rectal suppository as a
preoperative medication to a 4-year-old boy. The boy is very
anxious and frightened. Which of the following statement by
the nurse would be most appropriate to gain the child’s
cooperation?
A. “Be a big kid! Everyone’s waiting for you.”
B. “Lie still now and I’ll let you have one of your presents
before you even have your operation.”
C. “Take a nice, big, deep breath and then let me hear
you count to five.”
D. “You look so scared. Want to know a secret? This won’t
hurt a bit!”
Answer: C. Preschool children commonly experience fears
and fantasies regarding invasive procedures. The nurse
should attempts to momentarily distract the child with a
simple task that can be easily accomplished while the child
remains in the side-lying position. The suppository can be
slipped into place while the child is counting, and then the
nurse can praise the child for cooperating, while holding the
buttocks together to prevent expulsion of the suppository.
34. A depressed client is on an MAO inhibitor? What should
the nurse watch out for?
A. Hypertensive crisis.
B. Diet restrictions.
C. Taking medication with meals.
D. Exposure to sunlight.
Answer: A. This is the more inclusive answer, although diet
restrictions (answer1) are important, their purpose is to
prevent hypertensive crisis (answer 2).
35. A 16-year-old girl is admitted for treatment of a fracture.
The client shares to the nurse caring to her that her step-father
has made sexual advances to her. She got the chance to tell it
to her mother but refuses to believe. What is the most
therapeutic action of the nurse would be:
A. Tell the client to work it out with her father.
B. Tell the client to discuss it with her mother.
C. Ask the father about it.
D. Ask the mother what she thinks.
Answer: D. This comes closest to beginning to focus on
family-centered approach to intervene in the “conspiracy of
silence”. This is therefore the best among the options.
36. A client with a diagnosis of paranoid disorder is admitted
in the psychiatric hospital. The client tells the nurse, “the FBI
is following me. These people are plotting against me.” With
this statement the nurse will need to:
A. Acknowledge that this is the client’s belief but not the
nurse’s belief.
B. Ask how that makes the client feel.
C. Show the client that no one is behind.
D. Use logic to help the client doubt this belief.
Answer: A. The nurse should neither challenge nor use logic
to dispel an irrational belief.
37. A nurse is completing the routine physical examination to
a healthy 16-year-old male client. The client shares to the
nurse that he feels like killing his girlfriend because he found
out that her girlfriend had another boyfriend. He then laughs,
and asks the nurse to keep this a secret just between the two of
them. The nurse reviews his chart and notes that there is no
previously history of violence or psychiatric illness. Which of
the following would be the best action of the nurse to take at
this time?
A. Suggest the teen meet with a counselor to discuss his
feelings about his girlfriend.
B. Tell the teen that his feelings are normal, and
recommend that he find another girlfriend to take his
mind off the problem.
C. Recall the teenage boys often say things they really do
not mean and ignore the comment.
D. Regard the comment seriously and notify the teen’s
primary health care provider and parents
Answer: D. Any threat to the safety of oneself or other
should always be taken seriously and never disregarded by
the nurse.
38. Which of the following person will be at highest risk for
suicide?
A. A student at exam time
B. A married woman, age 40, with 6 children.
C. A person who is an alcoholic.
D. A person who made a previous suicide attempt.
Answer: C. The likelihood of multiple contributing factors
may make this person at higher risk for suicide. Some factors
that may exist are physical illness related to alcoholism,
emotional factors ( anxiety, guilt, remorse), social isolation
due to impaired relationships and economic problems related
to employment.
39. A male client is repetitively doing the handwashing every
time he touches things. It is important for a nurse to
understand that the client’s behavior is probably an attempt to:
A. Seek attention from the staff.
B. Control unacceptable impulses or feelings.
C. Do what the voices the patient hears tell him or her to do.
D. Punish himself or herself for guilt feeling.
Answer: B. A ritual, such as compulsive handwashing, is an
attempt to allay anxiety caused by unconscious impulses that
are frightening.
40. In a mental health settings, the basic goal of nursing is to:
A. Advance the science of psychiatry by initiating research
and gathering data for current statistics on emotional
illness.
B. Plan activity programs for clients.
C. Understand various types of family therapy and
psychological tests and how to interpret them.
D. Maintain a therapeutic environment.
Answer: D. This is the most neutral answer by process of
elimination.
41. A 3-year-old boy is brought to the emergency department.
After an hour, the boy dies of respiratory failure. The mother
of the boy becomes upset, shouting and abusive, saying to the
nurse, “If it had been your son, they would have done more to
save it. “What should the nurse say or do?
 A. Touch her and tell her exactly what was done for her
baby.
B. Allow the mother to continue her present behavior
while sitting quietly with her.
C. “No, all clients are given the same good care.”
D. “Yes, you’re probably right. Your son did not get better
care.”
Answer: B. This option allows a normal grief response
(anger).
42. The nurse is interacting to a client with an antisocial
personality disorder. What would be the most therapeutic
approach of the nurse to an antisocial behavior?
A. Gratify the client’s inner needs.
B. Give the client opportunities to test reality.
C. Provide external controls.
D. Reinforce the client’s self-concept.
Answer: C. Personality disorders stem from a weak superego,
implying a lack of adequate controls.
43. A 55-year-old male client tells the nurse that he needs his
glasses and hearing aid with him in the recovery room after
the surgery, or he will be upset for not granting his request.
What is the appropriate nursing response?
A. “Do you get upset and confused often?”
B. “You won’t need your glasses or hearing aid. The nurses
will take care of you.”
C. “I understand. You will be able to cooperate best if
you know what is going on, so I will find out how I
can arrange to have your glasses and hearing aid
available to you in the recovery room.”
D. I understand you might be more cooperative if you have
your aid and glasses, but that is just not possible. Rules,
you know.”
Answer: C. The client will be easier to care for if he has his
hearing aid and glasses.
44. The male client had fight with his roommates in the
psychiatric unit. The client agitated client is placed in isolation
for seclusion. The nurse knows it is essential that:
A. A staff member has frequent contacts with the client.
B. Restraints are applied.
C. The client is allowed to come out after 4 hours.
D. All the furniture is removed form the isolation room.
Answer: A. Frequent contacts at times of stress are important,
especially when a client is isolated.
45. A medical representative comes to the hospital unit for the
promotion of a new product. A female client, admitted for
hysterical behavior, is found embracing him. What should the
nurse say?
A. “Have you considered birth control?”
B. “This isn’t the purpose of either of you being here.”
C. “I see you’ve made a new friend.”
D. “Think about what you are doing.”
Answer: B. This response is aimed at redirecting the
inappropriate behavior.
46. A client with dementia is for discharge. The nurse is
providing a discharge instruction to the family member
regarding safety measures at home. What suggestion can the
nurse make to the family members?
A. Avoid stairs without banisters.
B. Use restraints while the client is in bed to keep him or
her from wandering off during the night.
C. Use restraints while the client is sitting in a chair to keep
him or her from wandering off during the day.
D. Provide a night-light and a big clock.
Answer: D. This option is best to decrease confusion and
disorientation to place and time
47. A 30-year-old married woman comes to the hospital for
treatment of fractures. The woman tells the nurse that she was
physically abused by her husband. The woman receives a call
from her husband telling her to get home and things will be
different. He felt sorry of what he did. What can the nurse
advise her?
A. “Do you think so?”
B. “It’s not likely.”
C. “What will be different?”
D. “I hope so, for your sake.”
Answer: C. This option helps the woman to think through
and elaborate on her own thoughts and prognosis.
48. A female client was diagnosed with breast cancer. It is
found to be stage IV, and a modified mastectomy is performed.
After the procedure, what behaviors could the nurse expects
the client to display?
A. Denial of the possibility of carcinoma.
B. Signs of grief reaction.
C. Relief that the operation is over.
D. Signs of deep depression.
Answer:B. It is mostly likely that grief would be expressed
because of object loss.
49. A client is withdrawn and does not want to interact to
anybody even to the nurse. What is the best initial nursing
approach to encourage communication with this client?
A. Use simple questions that call for a response.
B. Encourage discussion of feelings.
C. Look through a photo album together.
D. Bring up neutral topics.
Answer: D. Neutral, nonthreatening topics are best in
attempting to encourage a response.
50. Which of the following nursing approach is most
important in a client with depression?
A. Deemphasizing preoccupation with elimination,
nourishment, and sleep.
B. Protecting against harm to others.
C. Providing motor outlets for aggressive, hostile
feelings.
D. Reducing interpersonal contacts.
Answer: C. It is important to externalize the anger away from
self.
SET 3
PNLE I for Foundation of Nursing
1. Which element in the circular chain of infection can be
eliminated by preserving skin integrity?
A. Host
B. Reservoir
 C. Mode of transmission
D. Portal of entry
Answer: D. In the circular chain of infection, pathogens must
be able to leave their reservoir and be transmitted to a
susceptible host through a portal of entry, such as broken
skin.
2. Which of the following will probably result in a break in
sterile technique for respiratory isolation?
A. Opening the patient’s window to the outside
environment
B. Turning on the patient’s room ventilator
C. Opening the door of the patient’s room leading into
the hospital corridor
D. Failing to wear gloves when administering a bed bath
Answer: C. Respiratory isolation, like strict isolation,
requires that the door to the door patient’s room remain
closed. However, the patient’s room should be well
ventilated, so opening the window or turning on the
ventricular is desirable. The nurse does not need to wear
gloves for respiratory isolation, but good hand washing is
important for all types of isolation.
3. Which of the following patients is at greater risk for
contracting an infection?
A. A patient with leukopenia
B. A patient receiving broad-spectrum antibiotics
C. A postoperative patient who has undergone orthopedic
surgery
D. A newly diagnosed diabetic patient
Answer: A. Leukopenia is a decreased number of leukocytes
(white blood cells), which are important in resisting infection.
None of the other situations would put the patient at risk for
contracting an infection; taking broadspectrum antibiotics
might actually reduce the infection risk.
4. Effective hand washing requires the use of:
A. Soap or detergent to promote emulsification
B. Hot water to destroy bacteria
C. A disinfectant to increase surface tension
D. All of the above
Answer: A. Soaps and detergents are used to help remove
bacteria because of their ability to lower the surface tension
of water and act as emulsifying agents. Hot water may lead to
skin irritation or burns.
5. After routine patient contact, hand washing should last at
least:
A. 30 seconds
B. 1 minute
C. 2 minute
D. 3 minutes
Answer: A. Depending on the degree of exposure to
pathogens, hand washing may last from 10 seconds to 4
minutes. After routine patient contact, hand washing for 30
seconds effectively minimizes the risk of
pathogen transmission.
6. Which of the following procedures always requires surgical
asepsis?
A. Vaginal instillation of conjugated estrogen
B. Urinary catheterization
C. Nasogastric tube insertion
D. Colostomy irrigation
Answer: B. The urinary system is normally free of
microorganisms except at the urinary meatus. Any procedure
that involves entering this system must use surgically aseptic
measures to maintain a bacteria-free state.
7. Sterile technique is used whenever:
A. Strict isolation is required
B. Terminal disinfection is performed
C. Invasive procedures are performed
D. Protective isolation is necessary
Answer: C. All invasive procedures, including surgery,
catheter insertion, and administration of parenteral therapy,
require sterile technique to maintain a sterile environment.
All equipment must be sterile, and the nurse and
the physician must wear sterile gloves and maintain surgical
asepsis. In the operating room, the nurse and physician are
required to wear sterile gowns, gloves, masks, hair covers,
and shoe covers for all invasive procedures. Strict isolation
requires the use of clean gloves, masks, gowns and
equipment to prevent the transmission of highly
communicable diseases by contact or by airborne routes.
Terminal disinfection is the disinfection of all contaminated
supplies and equipment after a patient has been discharged to
prepare them for reuse by another patient. The purpose of
protective (reverse) isolation is to prevent a person
with seriously impaired resistance from coming into contact
who potentially pathogenic organisms.
8. Which of the following constitutes a break in sterile
technique while preparing a sterile field for a dressing change?
A. Using sterile forceps, rather than sterile gloves, to handle
a sterile item
B. Touching the outside wrapper of sterilized material
without sterile gloves
C. Placing a sterile object on the edge of the sterile field
D. Pouring out a small amount of solution (15 to 30 ml)
before pouring the solution into a sterile container
Answer: C. The edges of a sterile field are considered
contaminated. When sterile items are allowed to come in
contact with the edges of the field, the sterile items also
become contaminated.
9. A natural body defense that plays an active role in
preventing infection is:
A. Yawning
B. Body hair
C. Hiccupping
D. Rapid eye movements
Answer: B. Hair on or within body areas, such as the nose,
traps and holds particles that contain microorganisms.
Yawning and hiccupping do not prevent microorganisms
from entering or leaving the body. Rapid eye movement
marks the stage of sleep during which dreaming occurs.
10. All of the following statement are true about donning
sterile gloves except:
A. The first glove should be picked up by grasping the
inside of the cuff.
B. The second glove should be picked up by inserting the
gloved fingers under the cuff outside the glove.
C. The gloves should be adjusted by sliding the gloved
fingers under the sterile cuff and pulling the glove over
the wrist
D. The inside of the glove is considered sterile
Answer: D. The inside of the glove is always considered to
be clean, but not sterile.
11.When removing a contaminated gown, the nurse should be
careful that the first thing she touches is the:
A. Waist tie and neck tie at the back of the gown
B. Waist tie in front of the gown
C. Cuffs of the gown
D. Inside of the gown
Answer: A. The back of the gown is considered clean, the
front is contaminated. So, after removing gloves and washing
hands, the nurse should untie the back of the gown; slowly
move backward away from the gown, holding the inside of
the gown and keeping the edges off the floor; turn and fold
the gown inside out; discard it in a contaminated linen
container; then wash her hands again.
12.Which of the following nursing interventions is considered
the most effective form or universal precautions?
A. Cap all used needles before removing them from their
syringes
B. Discard all used uncapped needles and syringes in
an impenetrable protective container
C. Wear gloves when administering IM injections
D. Follow enteric precautions
Answer: B. According to the Centers for Disease Control
(CDC), blood-to-blood contact occurs most commonly when
a health care worker attempts to cap a used needle. Therefore,
used needles should never be recapped; instead they should
be inserted in a specially designed puncture resistant, labeled
container. Wearing gloves is not always necessary
when administering an I.M. injection. Enteric precautions
prevent the transfer of pathogens via feces.
13.All of the following measures are recommended to prevent
pressure ulcers except:
A. Massaging the reddened are with lotion
B. Using a water or air mattress
C. Adhering to a schedule for positioning and turning
D. Providing meticulous skin care
Answer: A. Nurses and other health care professionals
previously believed that massaging a reddened area with
lotion would promote venous return and reduce edema to the
area. However, research has shown that massage only
increases the likelihood of cellular ischemia and necrosis to
the area.
14.Which of the following blood tests should be performed
before a blood transfusion?
A. Prothrombin and coagulation time
B. Blood typing and cross-matching
C. Bleeding and clotting time
D. Complete blood count (CBC) and electrolyte levels.
Answer: B. Before a blood transfusion is performed, the
blood of the donor and recipient must be checked for
compatibility. This is done by blood typing (a test that
determines a person’s blood type) and cross-matching
(a procedure that determines the compatibility of the donor’s
and recipient’s blood after the blood types has been matched).
If the blood specimens are incompatible, hemolysis and
antigen-antibody reactions will occur.
15.The primary purpose of a platelet count is to evaluate the:
A. Potential for clot formation
B. Potential for bleeding
C. Presence of an antigen-antibody response
D. Presence of cardiac enzymes
Answer: A. Platelets are disk-shaped cells that are essential
for blood coagulation. A platelet count determines the
number of thrombocytes in blood available for promoting
hemostasis and assisting with blood coagulation after
injury. It also is used to evaluate the patient’s potential for
bleeding; however, this is not its primary purpose. The
normal count ranges from 150,000 to 350,000/mm3. A count
of 100,000/mm3 or less indicates a potential for bleeding;
count of less than 20,000/mm3 is associated with
spontaneous bleeding.
16.Which of the following white blood cell (WBC) counts
clearly indicates leukocytosis?
A. 4,500/mm³
B. 7,000/mm³
C. 10,000/mm³
D. 25,000/mm³
Answer: D. Leukocytosis is any transient increase in the
number of white blood cells (leukocytes) in the blood.
Normal WBC counts range from 5,000 to 100,000/mm3.
Thus, a count of 25,000/mm3 indicates leukocytosis.
17. After 5 days of diuretic therapy with 20mg of furosemide
(Lasix) daily, a patient begins to exhibit fatigue, muscle
cramping and muscle weakness. These symptoms probably
indicate that the patient is experiencing:
A. Hypokalemia
B. Hyperkalemia
C. Anorexia
D. Dysphagia
Answer: A. Fatigue, muscle cramping, and muscle
weaknesses are symptoms of hypokalemia (an inadequate
potassium level), which is a potential side effect of diuretic
therapy. The physician usually orders
supplemental potassium to prevent hypokalemia in patients
receiving diuretics. Anorexia is another symptom of
hypokalemia. Dysphagia means difficulty swallowing.
18.Which of the following statements about chest X-ray is
false?
A. No contradictions exist for this test
B. Before the procedure, the patient should remove all
jewelry, metallic objects, and buttons above the waist
C. A signed consent is not required
D. Eating, drinking, and medications are allowed before this
test
Answer: A. Pregnancy or suspected pregnancy is the only
contraindication for a chest X-ray. However, if a chest X-ray
is necessary, the patient can wear a lead apron to protect the
pelvic region from radiation. Jewelry, metallic objects, and
buttons would interfere with the X-ray and thus should not
be worn above the waist. A signed consent is not required
because a chest X-ray is not an invasive examination. Eating,
drinking and medications are allowed because the X-ray is of
the chest, not the abdominal region.
19.The most appropriate time for the nurse to obtain a sputum
specimen for culture is:
A. Early in the morning
B. After the patient eats a light breakfast
C. After aerosol therapy
D. After chest physiotherapy
Answer: A. Obtaining a sputum specimen early in this
morning ensures an adequate supply of bacteria for culturing
and decreases the risk of contamination from food or
medication.
20.A patient with no known allergies is to receive penicillin A. 18G, 1 ½” long
every 6 hours. When administering the medication, the nurse B. 22G, 1” long
observes a fine rash on the C. 22G, 1 ½” long
D. 25G, 5/8” long
patient’s skin. The most appropriate nursing action would be
to: Answer: D. A 25G, 5/8” needle is the recommended size for
insulin injection because insulin is administered by the
A. Withhold the moderation and notify the physician subcutaneous route. An 18G, 1 ½” needle is usually used for
B. Administer the medication and notify the physician I.M. injections in children, typically in the vastus lateralis. A
C. Administer the medication with an antihistamine 22G, 1 ½” needle is usually used for adult I.M. injections,
D. Apply corn starch soaks to the rash which are typically administered in the vastus lateralis or
ventrogluteal site.
Answer: A. Initial sensitivity to penicillin is commonly
manifested by a skin rash, even in individuals who have not 25.The appropriate needle gauge for intradermal injection is:
been allergic to it previously. Because of the danger of
anaphylactic shock, he nurse should withhold the drug A. 20G
and notify the physician, who may choose to substitute B. 22G
another drug. Administering an antihistamine is a dependent C. 25G
nursing intervention that requires a written physician’s order. D. 26G
Although applying corn starch to the rash may relieve
discomfort, it is not the nurse’s top priority in such Answer:D. Because an intradermal injection does not
a potentially life-threatening situation. penetrate deeply into the skin, a small-bore 25G needle is
recommended. This type of injection is used primarily to
21.All of the following nursing interventions are correct when administer antigens to evaluate reactions for allergy
using the Ztrack method of drug injection except: or sensitivity studies. A 20G needle is usually used for I.M.
injections of oilbased medications; a 22G needle for I.M.
A. Prepare the injection site with alcohol injections; and a 25G needle, for I.M. injections; and a 25G
B. Use a needle that’s a least 1” long needle, for subcutaneous insulin injections.
C. Aspirate for blood before injection
D. Rub the site vigorously after the injection to promote 26.Parenteral penicillin can be administered as an:
absorption
A. IM injection or an IV solution
Answer: D. The Z-track method is an I.M. injection B. IV or an intradermal injection
technique in which the patient’s skin is pulled in such a way C. Intradermal or subcutaneous injection
that the needle track is sealed off after the injection. This D. IM or a subcutaneous injection
procedure seals medication deep into the muscle,
thereby minimizing skin staining and irritation. Rubbing the Answer: A. Parenteral penicillin can be administered I.M. or
injection site is contraindicated because it may cause the added to a solution and given I.V. It cannot be administered
medication to extravasate into the skin. subcutaneously or intradermally.

22.The correct method for determining the vastus lateralis site 27.The physician orders gr 10 of aspirin for a patient. The
for I.M. injection is to: equivalent dose in milligrams is:

A. Locate the upper aspect of the upper outer quadrant of A. 0.6 mg

the buttock about 5 to 8 cm below the iliac crest B. 10 mg
B. Palpate the lower edge of the acromion process and the C. 60 mg
midpoint lateral aspect of the arm D. 600 mg
C. Palpate a 1” circular area anterior to the umbilicus
D. Divide the area between the greater femoral Answer:D. gr 10 x 60mg/gr 1 = 600 mg
trochanter and the lateral femoral condyle into thirds,
and select the middle third on the anterior of the 28.The physician orders an IV solution of dextrose 5% in
thigh water at 100ml/hour. What would the flow rate be if the drop
factor is 15 gtt = 1 ml?
Answer: D. The vastus lateralis, a long, thick muscle that
extends the full length of the thigh, is viewed by many A. 5 gtt/minute
clinicians as the site of choice for I.M. injections because it B. 13 gtt/minute
has relatively few major nerves and blood vessels. The C. 25 gtt/minute
middle third of the muscle is recommended as the injection D. 50 gtt/minute
site. The patient can be in a supine or sitting position for an
injection into this site. Answer: C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute

23.The mid-deltoid injection site is seldom used for I.M. 29.Which of the following is a sign or symptom of a
injections because it: hemolytic reaction to blood transfusion?

A. Can accommodate only 1 ml or less of medication A. Hemoglobinuria

B. Bruises too easily B. Chest pain
C. Can be used only when the patient is lying down C. Urticaria
D. Does not readily parenteral medication D. Distended neck veins

Answer: A. The mid-deltoid injection site can accommodate
only 1 ml or less of medication because of its size and
location (on the deltoid muscle of the arm, close to the
brachial artery and radial nerve).
24.The appropriate needle size for insulin injection is:
Answer: A. Hemoglobinuria, the abnormal presence of
hemoglobin in the urine, indicates a hemolytic reaction
(incompatibility of the donor’s and recipient’s blood). In this
reaction, antibodies in the recipient’s plasma combine rapidly
with donor RBC’s; the cells are hemolyzed in
either circulatory or reticuloendothelial system. Hemolysis
 occurs more rapidly in ABO incompatibilities than in Rh
incompatibilities. Chest pain and urticaria may be symptoms
of impending anaphylaxis. Distended neck veins are
an indication of hypervolemia.
30.Which of the following conditions may require fluid
restriction?
A. Fever
B. Chronic Obstructive Pulmonary Disease
C. Renal Failure
D. Dehydration
Answer: C. In real failure, the kidney loses their ability to
effectively eliminate wastes and fluids. Because of this,
limiting the patient’s intake of oral and I.V. fluids may be
necessary. Fever, chronic obstructive pulmonary disease, and
dehydration are conditions for which fluids should
be encouraged.
31.All of the following are common signs and symptoms of
phlebitis except:
A. Pain or discomfort at the IV insertion site
B. Edema and warmth at the IV insertion site
C. A red streak exiting the IV insertion site
D. Frank bleeding at the insertion site
Answer: D. Phlebitis, the inflammation of a vein, can be
caused by chemical irritants (I.V. solutions or medications),
mechanical irritants (the needle or catheter used during
venipuncture or cannulation), or a localized allergic reaction
to the needle or catheter. Signs and symptoms of
phlebitis include pain or discomfort, edema and heat at the
I.V. insertion site, and a red streak going up the arm or leg
from the I.V. insertion site.
32.The best way of determining whether a patient has learned
to instill ear medication properly is for the nurse to:
A. Ask the patient if he/she has used ear drops before
B. Have the patient repeat the nurse’s instructions using her
own words
C. Demonstrate the procedure to the patient and encourage
to ask questions
D. Ask the patient to demonstrate the procedure
Answer: D. Return demonstration provides the most certain
evidence for evaluating the effectiveness of patient teaching.
33.Which of the following types of medications can be
administered via gastrostomy tube?
A. Any oral medications
B. Capsules whole contents are dissolve in water
C. Enteric-coated tablets that are thoroughly dissolved in
water
D. Most tablets designed for oral use, except for
extended-duration compounds
Answer: D. Capsules, enteric-coated tablets, and most
extended duration or sustained release products should not be
dissolved for use in a gastrostomy tube. They are
pharmaceutically manufactured in these forms for valid
reasons, and altering them destroys their purpose. The
nurse should seek an alternate physician’s order when an
ordered medication is inappropriate for delivery by tube.
34.A patient who develops hives after receiving an antibiotic
is exhibiting drug:
A. Tolerance
B. Idiosyncrasy
C. Synergism
D. Allergy
Answer: D. A drug-allergy is an adverse reaction resulting
from an immunologic response following a previous
sensitizing exposure to the drug. The reaction can range from
a rash or hives to anaphylactic shock. Tolerance to a drug
means that the patient experiences a decreasing
physiologic response to repeated administration of the drug
in the same dosage. Idiosyncrasy is an individual’s unique
hypersensitivity to a drug, food, or other substance; it appears
to be genetically determined. Synergism, is a drug interaction
in which the sum of the drug’s combined effects is
greater than that of their separate effects.
35.A patient has returned to his room after femoral
arteriography. All of the following are appropriate nursing
interventions except:
A. Assess femoral, popliteal, and pedal pulses every 15
minutes for 2 hours
B. Check the pressure dressing for sanguineous drainage
C. Assess a vital signs every 15 minutes for 2 hours
D. Order a hemoglobin and hematocrit count 1 hour
after the arteriography
Answer: D. A hemoglobin and hematocrit count would be
ordered by the physician if bleeding were suspected. The
other answers are appropriate nursing interventions for a
patient who has undergone femoral arteriography.
36.The nurse explains to a patient that a cough:
A. Is a protective response to clear the respiratory tract
of irritants
B. Is primarily a voluntary action
C. Is induced by the administration of an antitussive drug
D. Can be inhibited by “splinting” the abdomen
Answer: A. Coughing, a protective response that clears the
respiratory tract of irritants, usually is involuntary; however
it can be voluntary, as when a patient is taught to perform
coughing exercises. An antitussive drug inhibits coughing.
Splinting the abdomen supports the abdominal muscles when
a patient coughs.
37.An infected patient has chills and begins shivering. The
best nursing intervention is to:
A. Apply iced alcohol sponges
B. Provide increased cool liquids
C. Provide additional bedclothes
D. Provide increased ventilation
Answer: C. In an infected patient, shivering results from the
body’s attempt to increase heat production and the
production of neutrophils and phagocytotic action through
increased skeletal muscle tension and contractions. Initial
vasoconstriction may cause skin to feel cold to the touch.
Applying additional bed clothes helps to equalize the
body temperature and stop the chills. Attempts to cool the
body result in further shivering, increased metabloism, and
thus increased heat production.
38.A clinical nurse specialist is a nurse who has:
A. Been certified by the National League for Nursing
B. Received credentials from the Philippine Nurses’
Association
C. Graduated from an associate degree program and is a
registered professional nurse
D. Completed a master’s degree in the prescribed
clinical area and is a registered professional nurse
Answer: .D. A clinical nurse specialist must have completed
a master’s degree in a clinical specialty and be a registered
professional nurse. The National League of Nursing accredits
 educational programs in nursing and provides a testing
service to evaluate student nursing competence but it does
not certify nurses. The American Nurses Association
identifies requirements for certification and offers
examinations for certification in many areas of nursing., such
as medical surgical nursing. These certification (credentialing)
demonstrates that the nurse has the knowledge and the ability
to provide high quality nursing care in the area of her
certification. A graduate of an associate degree program is
not a clinical nurse specialist: however, she is prepared to
provide bed side nursing with a high degree of knowledge
and skill. She must successfully complete the
licensing examination to become a registered professional
nurse.
39.The purpose of increasing urine acidity through dietary
means is to:
A. Decrease burning sensations
B. Change the urine’s color
C. Change the urine’s concentration
D. Inhibit the growth of microorganisms
Answer: D. Microorganisms usually do not grow in an acidic
environment.
40.Clay colored stools indicate:
A. Upper GI bleeding
B. Impending constipation
C. An effect of medication
D. Bile obstruction
Answer: D. Bile colors the stool brown. Any inflammation or
obstruction that impairs bile flow will affect the stool
pigment, yielding light, clay-colored stool. Upper GI
bleeding results in black or tarry stool. Constipation
is characterized by small, hard masses. Many medications
and foods will discolor stool – for example, drugs containing
iron turn stool black.; beets turn stool red.
41.In which step of the nursing process would the nurse ask a
patient if the medication she administered relieved his pain?
A. Assessment
B. Analysis
C. Planning
D. Evaluation
Answer: D. In the evaluation step of the nursing process, the
nurse must decide whether the patient has achieved the
expected outcome that was identified in the planning phase.
42.All of the following are good sources of vitamin A except:
A. White potatoes
B. Carrots
C. Apricots
D. Egg yolks
Answer: A. The main sources of vitamin A are yellow and
green vegetables (such as carrots, sweet potatoes, squash,
spinach, collard greens, broccoli, and cabbage) and yellow
fruits (such as apricots, and cantaloupe). Animal sources
include liver, kidneys, cream, butter, and egg yolks.
43.Which of the following is a primary nursing intervention
necessary for all patients with a Foley Catheter in place?
A. Maintain the drainage tubing and collection bag level
with the patient’s bladder
B. Irrigate the patient with 1% Neosporin solution three
times a daily
C. Clamp the catheter for 1 hour every 4 hours to maintain
the bladder’s elasticity
D. Maintain the drainage tubing and collection bag
below bladder level to facilitate drainage by gravity
Answer: D. Maintaing the drainage tubing and collection bag
level with the patient’s bladder could result in reflux of urine
into the kidney. Irrigating the bladder with Neosporin and
clamping the catheter for 1 hour every 4 hours must be
prescribed by a physician.
44.The ELISA test is used to:
A. Screen blood donors for antibodies to human
immunodeficiency virus (HIV)
B. Test blood to be used for transfusion for HIV antibodies
C. Aid in diagnosing a patient with AIDS
D. All of the above
Answer: D. The ELISA test of venous blood is used to assess
blood and potential blood donors to human
immunodeficiency virus (HIV). A positive ELISA test
combined with various signs and symptoms helps to
diagnose acquired immunodeficiency syndrome (AIDS)
45.The two blood vessels most commonly used for TPN
infusion are the:
A. Subclavian and jugular veins
B. Brachial and subclavian veins
C. Femoral and subclavian veins
D. Brachial and femoral veins
: D. Tachypnea (an abnormally rapid rate of breathing) would
indicate that the patient was still hypoxic (deficient in
oxygen).The partial pressures of arterial oxygen and carbon
dioxide listed are within the normal range. Eupnea refers to
normal respiration.
46.Effective skin disinfection before a surgical procedure
includes which of the following methods?
A. Shaving the site on the day before surgery
B. Applying a topical antiseptic to the skin on the evening
before surgery
C. Having the patient take a tub bath on the morning of
surgery
D. Having the patient shower with an antiseptic soap on
the evening v=before and the morning of surgery
Answer: D. Studies have shown that showering with an
antiseptic soap before surgery is the most effective method of
removing microorganisms from the skin. Shaving the site of
the intended surgery might cause breaks in the skin, thereby
increasing the risk of infection; however, if
indicated, shaving, should be done immediately before
surgery, not the day before. A topical antiseptic would not
remove microorganisms and would be beneficial only after
proper cleaning and rinsing. Tub bathing might transfer
organisms to another body site rather than rinse them away.
47.When transferring a patient from a bed to a chair, the nurse
should use which muscles to avoid back injury?
A. Abdominal muscles
B. Back muscles
C. Leg muscles
D. Upper arm muscles
Answer: C. The leg muscles are the strongest muscles in the
body and should bear the greatest stress when lifting. Muscles
of the abdomen, back, and upper arms may be easily injured
48.Thrombophlebitis typically develops in patients with which
of the following conditions?
A. Increases partial thromboplastin time
 B. Acute pulsus paradoxus
C. An impaired or traumatized blood vessel wall
D. Chronic Obstructive Pulmonary Disease (COPD)
Answer: C. The factors, known as Virchow’s triad,
collectively predispose a patient to thromboplebitis; impaired
venous return to the heart, blood hypercoagulability, and
injury to a blood vessel wall. Increased
partial thromboplastin time indicates a prolonged bleeding
time during fibrin clot formation, commonly the result of
anticoagulant (heparin) therapy. Arterial blood disorders
(such as pulsus paradoxus) and lung diseases (such as COPD)
do not necessarily impede venous return of injure vessel
walls.
49.In a recumbent, immobilized patient, lung ventilation can
become altered, leading to such respiratory complications as:
A. Respiratory acidosis, ateclectasis, and hypostatic
pneumonia
B. Appneustic breathing, atypical pneumonia and
respiratory alkalosis
C. Cheyne-Strokes respirations and spontaneous
pneumothorax
D. Kussmail’s respirations and hypoventilation
Answer: A. Because of restricted respiratory movement, a
recumbent, immobilize patient is at particular risk for
respiratory acidosis from poor gas exchange; atelectasis from
reduced surfactant and accumulated mucus in the bronchioles,
and hypostatic pneumonia from bacterial growth caused by
stasis of mucus secretions.
50.Immobility impairs bladder elimination, resulting in such
disorders as
A. Increased urine acidity and relaxation of the perineal
muscles, causing incontinence
B. Urine retention, bladder distention, and infection
C. Diuresis, natriuresis, and decreased urine specific gravity
D. Decreased calcium and phosphate levels in the urine
Answer: B. The immobilized patient commonly suffers from
urine retention caused by decreased muscle tone in the
perineum. This leads to bladder distention and urine stagnation,
which provide an excellent medium for bacterial growth
leading to infection. Immobility also results in more alkaline
urine with excessive amounts of calcium, sodium and
phosphate, a gradual decrease in urine production, and an
increased specific gravity.
PNLE II for Maternal
and Child Health
1. For the client who is using oral
contraceptives, the nurse informs the
client about the need to take the pill at the
same time each day to accomplish which of
the following?
A. Decrease the incidence of nausea
B. Maintain hormonal levels
C. Reduce side effects
D. Prevent drug interactions
Answer: B . Regular timely ingestion of oral
contraceptives is necessary to
maintain hormonal levels of the drugs to
suppress the action of the hypothalamus and
anterior pituitary leading to inappropriate
secretion of FSH and LH. Therefore, follicles
do not mature, ovulation is inhibited, and
pregnancy is prevented. The estrogen content
of the oral site contraceptive may cause the
nausea, regardless of when the pill is taken.
Side effects and drug interactions may occur
with oral contraceptives regardless of the
time the pill is taken.
2. When teaching a client about contraception.
Which of the following would the nurse
include as the most effective method for
preventing sexually transmitted infections?
A. Spermicides
B. Diaphragm
C. Condoms
D. Vasectomy
1. Answer:C . Condoms, when used
correctly and consistently, are the most
effective contraceptive method or barrier
against bacterial and viral
sexually transmitted infections. Although
spermicides kill sperm, they do
not provide reliable protection against the
spread of sexually transmitted infections,
especially intracellular organisms such as
HIV. Insertion and removal of the
diaphragm along with the use of the
spermicides may cause vaginal irritations,
which could place the client at risk for
infection transmission. Male sterilization
eliminates spermatozoa from the
ejaculate, but it does not eliminate
bacterial and/or viral microorganisms that
can cause sexually transmitted infections.
3. When preparing a woman who is 2 days
postpartum for discharge, recommendations
for which of the following contraceptive
methods would be avoided?
A. Diaphragm
B. Female condom
C. Oral contraceptives
D. Rhythm method
Answer: A . The diaphragm must be fitted
individually to ensure effectiveness. Because
of the changes to the reproductive structures
during pregnancy and following delivery, the
diaphragm must be refitted, usually at the
6 weeks’ examination following childbirth or
after a weight loss of 15 lbs or more. In
addition, for maximum effectiveness,
spermicidal jelly should be placed in the dome
and around the rim. However, spermicidal
jelly should not be inserted into the vagina
until involution is completed at approximately
6 weeks. Use of a female condom protects the
reproductive system from the introduction of
semen or spermicides into the vagina and may
be used after childbirth. Oral contraceptives
may be started within the first postpartum
week to ensure suppression of ovulation. For
the couple who has determined the female’s
fertile period, using the rhythm
method, avoidance of intercourse during this
period, is safe and effective
4. For which of the following clients would
the nurse expect that an intrauterine device
would not be recommended?
A. Woman over age 35
B. Nulliparous woman
C. Promiscuous young adult
D. Postpartum client
Answer: C . An IUD may increase the risk of
pelvic inflammatory disease, especially in
women with more than one sexual partner,
because of the increased risk of sexually
transmitted infections. An UID should not be
used if the woman has an active or chronic
pelvic infection, postpartum
infection, endometrial hyperplasia or
carcinoma, or uterine abnormalities. Age is
not a factor in determining the risks
associated with IUD use. Most IUD users are
over the age of 30. Although there is a
slightly higher risk for infertility in women
who have never been pregnant, the IUD is an
acceptable option as long as the risk-benefit
ratio is discussed. IUDs may be
inserted immediately after delivery, but this
is not recommended because of the increased
risk and rate of expulsion at this time.
5. A client in her third trimester tells the nurse,
“I’m constipated all the time!” Which of the
following should the nurse recommend?
A. Daily enemas
B. Laxatives
C. Increased fiber intake
D. Decreased fluid intake
Answer: C . During the third trimester, the
enlarging uterus places pressure on
the intestines. This coupled with the effect of
hormones on smooth muscle relaxation
causes decreased intestinal motility
(peristalsis). Increasing fiber in the diet will
help fecal matter pass more quickly through
the intestinal tract, thus decreasing the
amount of water that is absorbed. As a result,
stool is softer and easier to pass. Enemas
could precipitate preterm labor and/or
electrolyte loss and should be avoided.
Laxatives may cause preterm labor by
stimulating peristalsis and may interfere with
the absorption of nutrients. Use for more than
1 week can also lead to laxative dependency.
Liquid in the diet helps provide a semisolid,
soft consistency to the stool. Eight to ten
glasses of fluid per day are essential to
maintain hydration and promote stool
evacuation.
6. Which of the following would the nurse use
as the basis for the teaching plan when caring
for a pregnant teenager concerned about
gaining too much weight during pregnancy?
A. 10 pounds per trimester
B. 1 pound per week for 40 weeks
C. ½ pound per week for 40 weeks
D. A total gain of 25 to 30 pounds
Answer: D . To ensure adequate fetal growth
and development during the 40 weeks of a
pregnancy, a total weight gain 25 to 30
pounds is recommended: 1.5 pounds in the
first 10 weeks; 9 pounds by 30 weeks; and
27.5 pounds by 40 weeks. The pregnant
woman should gain less weight in the first
and second trimester than in the third. During
the first trimester, the client should only gain
1.5 pounds in the first 10 weeks, not 1 pound
per week. A weight gain of ½ pound per
week would be 20 pounds for the
total pregnancy, less than the recommended
amount.
7. The client tells the nurse that her last
menstrual period started on January 14 and
ended on January 20. Using Nagele’s rule, the
nurse determines her EDD to be which of the
following?
A. September 27
B. October 21
C. November 7
D. December 27
Answer: B . To calculate the EDD by
Nagele’s rule, add 7 days to the first day of
the last menstrual period and count back 3
months, changing the year appropriately. To
obtain a date of September 27, 7 days have
been added to the last day of the LMP (rather
than the first day of the LMP), plus 4 months
(instead of 3 months) were counted back. To
obtain the date of November 7, 7 days have
been subtracted (instead of added) from
the first day of LMP plus November
indicates counting back 2 months (instead of
3 months) from January. To obtain the date
of December 27, 7 days were added to the
last day of the LMP (rather than the first day
of the LMP) and December indicates
counting back only 1 month (instead of
3 months) from January.
8. When taking an obstetrical history on a
pregnant client who states, “I had a son born
at 38 weeks gestation, a daughter born at 30
weeks gestation and I lost a baby at about 8
weeks,” the nurse should record
her obstetrical history as which of the
following?
A. G2 T2 P0 A0 L2
B. G3 T1 P1 A0 L2
C. G3 T2 P0 A0 L2
D. G4 T1 P1 A1 L2
Answer: D. The client has been pregnant four
times, including current pregnancy (G). Birth
at 38 weeks’ gestation is considered full term
(T), while birth form 20 weeks to 38 weeks is
considered preterm (P). A
spontaneous abortion occurred at 8 weeks
(A). She has two living children (L).
9. When preparing to listen to the fetal heart
rate at 12 weeks’ gestation, the nurse would
use which of the following?
A. Stethoscope placed midline at the
umbilicus
B. Doppler placed midline at the
suprapubic region
C. Fetoscope placed midway between the
umbilicus and the xiphoid process
D. External electronic fetal monitor placed at
the umbilicus
Answer: B. At 12 weeks gestation, the uterus
rises out of the pelvis and is palpable above
the symphysis pubis. The Doppler intensifies
the sound of the fetal pulse rate so it is
audible. The uterus has merely risen out of
the pelvis into the abdominal cavity and is
not at the level of the umbilicus. The
fetal heart rate at this age is not audible with
a stethoscope. The uterus at 12 weeks is just
above the symphysis pubis in the abdominal
cavity, not midway between the umbilicus
and the xiphoid process. At 12 weeks
the FHR would be difficult to auscultate with
a fetoscope. Although the external electronic
fetal monitor would project the FHR, the
uterus has not risen to the umbilicus at 12
weeks.
10.When developing a plan of care for a client
newly diagnosed with gestational diabetes,
which of the following instructions would be
the priority?
A. Dietary intake
B. Medication
C. Exercise
D. Glucose monitoring
Answer: A . Although all of the choices are
important in the management of diabetes,
diet therapy is the mainstay of the treatment
plan and should always be the priority.
Women diagnosed with gestational
diabetes generally need only diet therapy
without medication to control their
blood sugar levels. Exercise, is important for
all pregnant women and especially for
diabetic women, because it burns up glucose,
thus decreasing blood sugar. However,
dietary intake, not exercise, is the priority.
All pregnant women with diabetes should
have periodic monitoring of serum
glucose. However, those with gestational
diabetes generally do not need daily glucose
monitoring. The standard of care
recommends a fasting and 2- hour
postprandial blood sugar level every 2 weeks.
11.A client at 24 weeks gestation has gained 6
pounds in 4 weeks. Which of the following
would be the priority when assessing the
client?
A. Glucosuria
B. Depression
C. Hand/face edema
D. Dietary intake
Answer: C. After 20 weeks’ gestation, when
there is a rapid weight gain, preeclampsia
should be suspected, which may be caused
by fluid retention manifested by edema,
especially of the hands and face. The three
classic signs of preeclampsia are
hypertension, edema, and proteinuria.
Although urine is checked for glucose at each
clinic visit, this is not the priority. Depression
may cause either anorexia or excessive food
intake, leading to excessive weight gain or
loss. This is not, however, the priority
consideration at this time. Weight gain
thought to be caused by excessive food
intake would require a 24-hour diet recall.
However, excessive intake would not be the
primary consideration for this client at this
time.
12. A client 12 weeks’ pregnant come to the
emergency department with abdominal
cramping and moderate vaginal bleeding.
Speculum examination reveals 2 to 3 cms
cervical dilation. The nurse would document
these findings as which of the following?
A. Threatened abortion
B. Imminent abortion
C. Complete abortion
D. Missed abortion
Answer:B. Cramping and vaginal bleeding
coupled with cervical dilation signifies that
termination of the pregnancy is inevitable and
cannot be prevented. Thus, the nurse would
document an imminent abortion. In a
threatened abortion, cramping and vaginal
bleeding are present, but there is no cervical
dilation. The symptoms may subside or
progress to abortion. In a complete abortion
all the products of conception are expelled. A
missed abortion is early fetal intrauterine
death without expulsion of the products of
conception.
13.Which of the following would be the
priority nursing diagnosis for a client with an
ectopic pregnancy?
A. Risk for infection
B. Pain
C. Knowledge Deficit
D. Anticipatory Grieving
Answer:B . For the client with an ectopic
pregnancy, lower abdominal pain,
usually unilateral, is the primary symptom.
Thus, pain is the priority. Although
the potential for infection is always present,
the risk is low in ectopic pregnancy because
pathogenic microorganisms have not been
introduced from external sources. The client
may have a limited knowledge of
the pathology and treatment of the condition
and will most likely experience grieving, but
this is not the priority at this time.
14.Before assessing the postpartum client’s
uterus for firmness and position in relation to
the umbilicus and midline, which of the
following should the nurse do first?
A. Assess the vital signs
B. Administer analgesia
C. Ambulate her in the hall
D. Assist her to urinate
Answer: D. Before uterine assessment is
performed, it is essential that the
woman empty her bladder. A full bladder
will interfere with the accuracy of
the assessment by elevating the uterus and
displacing to the side of the midline. Vital
sign assessment is not necessary unless an
abnormality in uterine assessment is
identified. Uterine assessment should not
cause acute pain that requires administration
of analgesia. Ambulating the client is an
essential component of postpartum care, but
is not necessary prior to assessment of the
uterus.
15.Which of the following should the nurse do
when a primipara who is lactating tells the
nurse that she has sore nipples?
A. Tell her to breast feed more frequently
B. Administer a narcotic before breast
feeding
C. Encourage her to wear a nursing brassiere
D. Use soap and water to clean the nipples
Answer:A. Feeding more frequently, about
every 2 hours, will decrease the
infant’s frantic, vigorous sucking from
hunger and will decrease breast engorgement,
soften the breast, and promote ease of correct
latching-on for feeding. Narcotics
administered prior to breast feeding are
passed through the breast milk to the infant,
causing excessive sleepiness. Nipple soreness
is not severe enough to warrant narcotic
analgesia. All postpartum clients, especially
lactating mothers, should wear a
supportive brassiere with wide cotton straps.
This does not, however, prevent or reduce
nipple soreness. Soaps are drying to the skin
of the nipples and should not be used on the
breasts of lactating mothers. Dry nipple
skin predisposes to cracks and fissures,
which can become sore and painful.
16.The nurse assesses the vital signs of a
client, 4 hours’ postpartum that are as follows:
BP 90/60; temperature 100.4ºF; pulse 100
weak, thready; R 20 per minute. Which of the
following should the nurse do first?
A. Report the temperature to the physician
B. Recheck the blood pressure with another
cuff
C. Assess the uterus for firmness and
position
D. Determine the amount of lochia
Answer: D. A weak, thready pulse elevated
to 100 BPM may indicate
impending hemorrhagic shock. An increased
pulse is a compensatory mechanism of the
body in response to decreased fluid volume.
Thus, the nurse should check the amount of
lochia present. Temperatures up to 100.48F
in the first 24 hours after birth are related to
the dehydrating effects of labor and are
considered normal. Although rechecking the
blood pressure may be a correct choice of
action, it is not the first action that should
be implemented in light of the other data.
The data indicate a potential impending
hemorrhage. Assessing the uterus for
firmness and position in relation to the
umbilicus and midline is important, but the
nurse should check the extent of vaginal
bleeding first. Then it would be appropriate
to check the uterus, which may be a possible
cause of the hemorrhage.
17.The nurse assesses the postpartum vaginal
discharge (lochia) on four clients. Which of
the following assessments would warrant
notification of the physician?
A. A dark red discharge on a 2-day
postpartum client
B. A pink to brownish discharge on a client
who is 5 days postpartum
C. Almost colorless to creamy discharge on
a client 2 weeks after delivery
D. A bright red discharge 5 days after
delivery
Answer: D. Any bright red vaginal discharge
would be considered abnormal,
but especially 5 days after delivery, when the
lochia is typically pink to brownish. Lochia
rubra, a dark red discharge, is present for 2 to
3 days after delivery. Bright red vaginal
bleeding at this time suggests late postpartum
hemorrhage, which occurs after the first 24
hours following delivery and is generally
caused by retained placental fragments
or bleeding disorders. Lochia rubra is the
normal dark red discharge occurring in the
first 2 to 3 days after delivery, containing
epithelial cells, erythrocyes, leukocytes and
decidua. Lochia serosa is a pink to
brownish serosanguineous discharge
occurring from 3 to 10 days after delivery
that contains decidua, erythrocytes,
leukocytes, cervical mucus,
and microorganisms. Lochia alba is an
almost colorless to yellowish
discharge occurring from 10 days to 3 weeks
after delivery and containing leukocytes,
decidua, epithelial cells, fat, cervical mucus,
cholesterol crystals, and bacteria.
18.A postpartum client has a temperature of
101.4ºF, with a uterus that is tender when
palpated, remains unusually large, and not
descending as normally expected. Which of
the following should the nurse assess next?
A. Lochia
B. Breasts
C. Incision
D. Urine
Answer: A. The data suggests an infection of
the endometrial lining of the uterus. The
lochia may be decreased or copious, dark
brown in appearance, and foul smelling,
providing further evidence of a possible
infection. All the client’s data indicate a
uterine problem, not a breast problem.
Typically, transient fever, usually 101ºF, may
be present with breast
engorgement. Symptoms of mastitis include
influenza-like manifestations.
Localized infection of an episiotomy or C-
section incision rarely causes
systemic symptoms, and uterine involution
would not be affected. The client data do not
include dysuria, frequency, or urgency,
symptoms of urinary tract infections, which
would necessitate assessing the client’s urine.
19.Which of the following is the priority focus
of nursing practice with the current early
postpartum discharge?
A. Promoting comfort and restoration of
health
B. Exploring the emotional status of the
family
C. Facilitating safe and effective self-and
newborn care
D. Teaching about the importance of family
planning
Answer: C. Because of early postpartum
discharge and limited time for teaching, the
nurse’s priority is to facilitate the safe and
effective care of the client and newborn.
Although promoting comfort and restoration
of health, exploring the family’s emotional
status, and teaching about family
planning are important in
postpartum/newborn nursing care, they are
not the priority focus in the limited time
presented by early post-partum discharge.
20. Which of the following actions would be
least effective in maintaining a neutral thermal
environment for the newborn?
A. Placing infant under radiant warmer after
bathing
B. Covering the scale with a warmed blanket
prior to weighing
C. Placing crib close to nursery window
for family viewing
D. Covering the infant’s head with a knit
stockinette
Answer: C. Heat loss by radiation occurs
when the infant’s crib is placed too near cold
walls or windows. Thus placing the
newborn’s crib close to the viewing window
would be least effective. Body heat is lost
through evaporation during bathing. Placing
the infant under the radiant warmer after
bathing will assist the infant to be rewarmed.
Covering the scale with a warmed blanket
prior to weighing prevents heat loss through
conduction. A knit cap prevents heat loss
from the head a large head, a large
body surface area of the newborn’s body.
21.A newborn who has an asymmetrical Moro
reflex response should be further assessed for
which of the following?
A. Talipes equinovarus
B. Fractured clavicle
C. Congenital hypothyroidism
D. Increased intracranial pressure
Answer: B. A fractured clavicle would
prevent the normal Moro response
of symmetrical sequential extension and
abduction of the arms followed by flexion
and adduction. In talipes equinovarus
(clubfoot) the foot is turned medially, and in
plantar flexion, with the heel elevated. The
feet are not involved with the Moro reflex.
Hypothyroiddism has no effect on
the primitive reflexes. Absence of the Moror
reflex is the most significant single indicator
of central nervous system status, but it is not
a sign of increased intracranial pressure.
22.During the first 4 hours after a male
circumcision, assessing for which of the
following is the priority?
A. Infection
B. Hemorrhage
C. Discomfort
D. Dehydration
Answer:B. Hemorrhage is a potential risk
following any surgical procedure. Although
the infant has been given vitamin K to
facilitate clotting, the prophylactic dose is
often not sufficient to prevent bleeding.
Although infection is a possibility, signs will
not appear within 4 hours after the surgical
procedure. The primary discomfort of
circumcision occurs during the surgical
procedure, not afterward. Although feedings
are withheld prior to the circumcision, the
chances of dehydration are minimal.
23.The mother asks the nurse. “What’s wrong
with my son’s breasts? Why are they so
enlarged?” Whish of the following would be
the best response by the nurse?
A. “The breast tissue is inflamed from the
trauma experienced with birth”
B. “A decrease in material hormones
present before birth causes enlargement,”
C. “You should discuss this with your doctor.
It could be a malignancy”
D. “The tissue has hypertrophied while the
baby was in the uterus”
Answer: B . The presence of excessive
estrogen and progesterone in the maternal
fetal blood followed by prompt withdrawal at
birth precipitates breast engorgement, which
will spontaneously resolve in 4 to 5 days
after birth. The trauma of the birth process
does not cause inflammation of
the newborn’s breast tissue. Newborns do not
have breast malignancy. This reply by the
nurse would cause the mother to have undue
anxiety. Breast tissue does not hypertrophy in
the fetus or newborns.
24. Immediately after birth the nurse notes the
following on a male newborn: respirations 78;
apical hearth rate 160 BPM, nostril flaring;
mild intercostal
retractions; and grunting at the end of
expiration. Which of the following should the
nurse do?
A. Call the assessment data to the
physician’s attention
B. Start oxygen per nasal cannula at 2 L/min.
C. Suction the infant’s mouth and nares
D. Recognize this as normal first period of
reactivity
Answer: D . The first 15 minutes to 1 hour
after birth is the first period of
reactivity involving respiratory and
circulatory adaptation to extrauterine life.
The data given reflect the normal changes
during this time period. The
infant’s assessment data reflect normal
adaptation. Thus, the physician does not need
to be notified and oxygen is not needed. The
data do not indicate the presence of choking,
gagging or coughing, which are signs of
excessive secretions. Suctioning is not
necessary.
25.The nurse hears a mother telling a friend
on the telephone about umbilical cord care.
Which of the following statements by the
mother indicates effective teaching?
A. “Daily soap and water cleansing is best”
B. ‘Alcohol helps it dry and kills germs”
C. “An antibiotic ointment applied daily
prevents infection”
D. “He can have a tub bath each day”
Answer: B. Application of 70% isopropyl
alcohol to the cord
minimizes microorganisms (germicidal) and
promotes drying. The cord should be kept
dry until it falls off and the stump has healed.
Antibiotic ointment should only be used to
treat an infection, not as a prophylaxis.
Infants should not be submerged in a tub of
water until the cord falls off and the stump
has completely healed.
26.A newborn weighing 3000 grams and
feeding every 4 hours needs 120 calories/kg
of body weight every 24 hours for proper
growth and development. How many ounces
of 20 cal/oz formula should this
newborn receive at each feeding to meet
nutritional needs?
A. 2 ounces
B. 3 ounces
C. 4 ounces
D. 6 ounces
Answer:B. To determine the amount of
formula needed, do the
following mathematical calculation. 3 kg x
120 cal/kg per day = 360 calories/day feeding
q 4 hours = 6 feedings per day = 60 calories
per feeding: 60 calories per feeding; 60
calories per feeding with formula 20 cal/oz =
3 ounces per feeding. Based on the
calculation. 2, 4 or 6 ounces are incorrect.
27.The postterm neonate with meconium-
stained amniotic fluid needs care designed to
especially monitor for which of the following?
A. Respiratory problems
B. Gastrointestinal problems
C. Integumentary problems
D. Elimination problems
Answer: A. Intrauterine anoxia may cause
relaxation of the anal sphincter and emptying
of meconium into the amniotic fluid. At birth
some of the meconium fluid may be aspirated,
causing mechanical obstruction or chemical
pneumonitis. The infant is not at increased
risk for gastrointestinal problems. Even
though the skin is stained with meconium, it
is noninfectious (sterile) and nonirritating.
The postterm meconiumstained infant is not
at additional risk for bowel or urinary
problems.
28.When measuring a client’s fundal height,
which of the following techniques denotes the
correct method of measurement used by the
nurse?
A. From the xiphoid process to the umbilicus
B. From the symphysis pubis to the xiphoid
process
C. From the symphysis pubis to the
fundus
D. From the fundus to the umbilicus
Answer: C . The nurse should use a
nonelastic, flexible, paper measuring
tape, placing the zero point on the superior
border of the symphysis pubis and stretching
the tape across the abdomen at the midline to
the top of the fundus. The xiphoid and
umbilicus are not appropriate landmarks to
use when measuring the height of the fundus
(McDonald’s measurement).
29.A client with severe preeclampsia is
admitted with of BP 160/110, proteinuria, and
severe pitting edema. Which of the following
would be most important to include in the
client’s plan of care?
A. Daily weights
B. Seizure precautions
C. Right lateral positioning
D. Stress reduction
Answer: B . Women hospitalized with severe
preeclampsia need decreased
CNS stimulation to prevent a seizure. Seizure
precautions provide environmental safety
should a seizure occur. Because of edema,
daily weight is important but not the priority.
Preclampsia causes vasospasm and therefore
can reduce utero-placental perfusion. The
client should be placed on her left side to
maximize blood flow, reduce blood pressure,
and promote diuresis. Interventions to reduce
stress and anxiety are very important to
facilitate coping and a sense of control, but
seizure precautions are the priority.
30. A postpartum primipara asks the nurse,
“When can we have sexual intercourse again?”
Which of the following would be the nurse’s
best response?
A. “Anytime you both want to.”
B. “As soon as choose a contraceptive
method.”
C. “When the discharge has stopped and
the incision is healed.”
D. “After your 6 weeks examination.”
Answer: C. Cessation of the lochial
discharge signifies healing of the
endometrium. Risk of hemorrhage and
infection are minimal 3 weeks after a
normal vaginal delivery. Telling the client
anytime is inappropriate because
this response does not provide the client with
the specific information she is requesting.
Choice of a contraceptive method is
important, but not the specific criteria for
safe resumption of sexual activity. Culturally,
the 6- weeks’ examination has been used as
the time frame for resuming sexual activity,
but it may be resumed earlier.
31.When preparing to administer the vitamin
K injection to a neonate, the nurse would
select which of the following sites as
appropriate for the injection?
A. Deltoid muscle
B. Anterior femoris muscle
C. Vastus lateralis muscle
D. Gluteus maximus muscle
Answer: C . The middle third of the vastus
lateralis is the preferred injection site
for vitamin K administration because it is
free of blood vessels and nerves and is large
enough to absorb the medication. The deltoid
muscle of a newborn is not large enough for
a newborn IM injection. Injections into
this muscle in a small child might cause
damage to the radial nerve. The anterior
femoris muscle is the next safest muscle to
use in a newborn but is not the safest.
Because of the proximity of the sciatic nerve,
the gluteus maximus muscle should not be
until the child has been walking 2 years.
32.When performing a pelvic examination,
the nurse observes a red swollen area on the
right side of the vaginal orifice. The nurse
would document this as enlargement of which
of the following?
A. Clitoris
B. Parotid gland
C. Skene’s gland
D. Bartholin’s gland
Answer: D . Bartholin’s glands are the glands
on either side of the vaginal orifice. The
clitoris is female erectile tissue found in the
perineal area above the urethra. The parotid
glands are open into the mouth. Skene’s
glands open into the posterior wall of the
female urinary meatus.
33.To differentiate as a female, the hormonal
stimulation of the embryo that must occur
involves which of the following?
A. Increase in maternal estrogen secretion
B. Decrease in maternal androgen secretion
C. Secretion of androgen by the fetal gonad
D. Secretion of estrogen by the fetal gonad
Answer: D . The fetal gonad must secrete
estrogen for the embryo to differentiate as a
female. An increase in maternal estrogen
secretion does not effect differentiation of the
embryo, and maternal estrogen secretion
occurs in every pregnancy. Maternal
androgen secretion remains the same
as before pregnancy and does not effect
differentiation. Secretion of androgen by the
fetal gonad would produce a male fetus.
34.A client at 8 weeks’ gestation calls
complaining of slight nausea in the morning
hours. Which of the following client
interventions should the nurse question?
A. Taking 1 teaspoon of bicarbonate of
soda in an 8-ounce glass of water
B. Eating a few low-sodium crackers before
getting out of bed
C. Avoiding the intake of liquids in the
morning hours
D. Eating six small meals a day instead of
thee large meals
Answer: A . Using bicarbonate would
increase the amount of sodium
ingested, which can cause complications.
Eating low-sodium crackers would
be appropriate. Since liquids can increase
nausea avoiding them in the morning hours
when nausea is usually the strongest is
appropriate. Eating six small meals a day
would keep the stomach full, which often
decrease nausea.
35.The nurse documents positive ballottement
in the client’s prenatal record. The nurse
understands that this indicates which of the
following?
A. Palpable contractions on the abdomen
B. Passive movement of the unengaged
fetus
C. Fetal kicking felt by the client
D. Enlargement and softening of the uterus
Answer: B . Ballottement indicates passive
movement of the unengaged
fetus. Ballottement is not a contraction. Fetal
kicking felt by the client
represents quickening. Enlargement and
softening of the uterus is known
as Piskacek’s sign.
36.During a pelvic exam the nurse notes a
purple-blue tinge of the cervix. The nurse
documents this as which of the following?
A. Braxton-Hicks sign
B. Chadwick’s sign
C. Goodell’s sign
D. McDonald’s sign
Answer: B . Chadwick’s sign refers to the
purple-blue tinge of the cervix.
Braxton Hicks contractions are painless
contractions beginning around the 4th month.
Goodell’s sign indicates softening of the
cervix. Flexibility of the uterus against the
cervix is known as McDonald’s sign.
37.During a prenatal class, the nurse explains
the rationale for breathing techniques during
preparation for labor based on the
understanding that breathing techniques are
most important in achieving which of
the following?
A. Eliminate pain and give the expectant
parents something to do
B. Reduce the risk of fetal distress by
increasing uteroplacental perfusion
C. Facilitate relaxation, possibly reducing
the perception of pain
D. Eliminate pain so that less analgesia and
anesthesia are needed
Answer: C . Breathing techniques can raise
the pain threshold and reduce the perception
of pain. They also promote relaxation.
Breathing techniques do not eliminate pain,
but they can reduce it. Positioning, not
breathing, increases uteroplacental perfusion.
38.After 4 hours of active labor, the nurse
notes that the contractions of a primigravida
client are not strong enough to dilate the
cervix. Which of the
following would the nurse anticipate doing?
A. Obtaining an order to begin IV
oxytocin infusion
B. Administering a light sedative to allow
the patient to rest for several hour
C. Preparing for a cesarean section for
failure to progress
D. Increasing the encouragement to the
patient when pushing begins
Answer:A . The client’s labor is hypotonic.
The nurse should call the physical and obtain
an order for an infusion of oxytocin, which
will assist the uterus to contact more
forcefully in an attempt to dilate the cervix.
Administering light sedative would be done
for hypertonic uterine contractions.
Preparing for cesarean section is unnecessary
at this time. Oxytocin would increase the
uterine contractions and hopefully progress
labor before a cesarean would be necessary.
It is too early to anticipate client pushing
with contractions.
39.A multigravida at 38 weeks’ gestation is
admitted with painless, bright red bleeding
and mild contractions every 7 to 10 minutes.
Which of the following assessments should be
avoided?
A. Maternal vital sign
B. Fetal heart rate
C. Contraction monitoring
D. Cervical dilation
Answer: D . The signs indicate placenta
previa and vaginal exam to
determine cervical dilation would not be
done because it could cause
hemorrhage. Assessing maternal vital signs
can help determine maternal
physiologic status. Fetal heart rate is
important to assess fetal well-being and
should be done. Monitoring the contractions
will help evaluate the progress of labor.
40.Which of the following would be the
nurse’s most appropriate response to a client
who asks why she must have a cesarean
delivery if she has a complete placenta previa?
A. “You will have to ask your physician
when he returns.”
B. “You need a cesarean to prevent
hemorrhage.”
C. “The placenta is covering most of your
cervix.”
D. “The placenta is covering the opening
of the uterus and blocking your baby.”
Answer: D . A complete placenta previa
occurs when the placenta covers the opening
of the uterus, thus blocking the passageway
for the baby. This response explains what a
complete previa is and the reason the
baby cannot come out except by cesarean
delivery. Telling the client to ask
the physician is a poor response and would
increase the patient’s anxiety. Although a
cesarean would help to prevent hemorrhage,
the statement does not explain why the
hemorrhage could occur. With a
complete previa, the placenta is covering all
the cervix, not just most of it.
41.The nurse understands that the fetal head is
in which of the following positions with a face
presentation?
A. Completely flexed
B. Completely extended
C. Partially extended
D. Partially flexed
Answer: B . With a face presentation, the
head is completely extended. With a vertex
presentation, the head is completely or
partially flexed. With a brow (forehead)
presentation, the head would be partially
extended.
42.With a fetus in the left-anterior breech
presentation, the nurse would expect the fetal
heart rate would be most audible in which of
the following areas?
A. Above the maternal umbilicus and to the
right of midline
B. In the lower-left maternal abdominal
quadrant
C. In the lower-right maternal abdominal
quadrant
D. Above the maternal umbilicus and to
the left of midline
Answer: D . With this presentation, the fetal
upper torso and back face the left
upper maternal abdominal wall. The fetal
heart rate would be most audible above the
maternal umbilicus and to the left of the
middle.A The other positions would be
incorrect.
43.The amniotic fluid of a client has a
greenish tint. The nurse interprets this to be
the result of which of the following?
A. Lanugo
B. Hydramnio
C. Meconium
D. Vernix
Answer: C. The greenish tint is due to the
presence of meconium. Lanugo is the soft,
downy hair on the shoulders and back of the
fetus. Hydramnios represents excessive
amniotic fluid. Vernix is the white, cheesy
substance covering the fetus.
44.A patient is in labor and has just been told
she has a breech presentation. The nurse
should be particularly alert for which of the
following?
A. Quickening
B. Ophthalmia neonatorum
C. Pica
D. Prolapsed umbilical cord
Answer: D . In a breech position, because of
the space between the presenting part and the
cervix, prolapse of the umbilical cord is
common. Quickening is the woman’s first
perception of fetal movement. Ophthalmia
neonatorum usually results from maternal
gonorrhea and is conjunctivitis. Pica refers
to the oral intake of nonfood substances.
45.When describing dizygotic twins to a
couple, on which of the following would the
nurse base the explanation?
A. Two ova fertilized by separate sperm
B. Sharing of a common placenta
C. Each ova with the same genotype
D. Sharing of a common chorion
Answer: A . Dizygotic (fraternal) twins
involve two ova fertilized by separate
sperm. Monozygotic (identical) twins involve
a common placenta, same genotype, and
common chorion.
46.Which of the following refers to the single
cell that reproduces itself after conception?
A. Chromosome
B. Blastocyst
C. Zygote
D. Trophoblast
Answer: C . The zygote is the single cell that
reproduces itself after conception.
The chromosome is the material that makes
up the cell and is gained from each parent.
Blastocyst and trophoblast are later terms for
the embryo after zygote.
47.In the late 1950s, consumers and health
care professionals began challenging the
routine use of analgesics and anesthetics
during childbirth. Which of the following was
an outgrowth of this concept?
A. Labor, delivery, recovery, postpartum
(LDRP)
B. Nurse-midwifery
C. Clinical nurse specialist
D. Prepared childbirth
Answer: D . Prepared childbirth was the
direct result of the 1950’s challenging of
the routine use of analgesic and anesthetics
during childbirth. The LDRP was a much
later concept and was not a direct result of
the challenging of routine use of analgesics
and anesthetics during childbirth. Roles
for nurse midwives and clinical nurse
specialists did not develop from
this challenge.
48.A client has a midpelvic contracture from a
previous pelvic injury due to a motor vehicle
accident as a teenager. The nurse is aware that
this could PNLE III for
prevent a fetus from passing through or
around which structure during childbirth?
Medical Surgical
A. Symphysis pubis Nursing
B. Sacral promontory
C. Ischial spines 1. Marco who was diagnosed with
D. Pubic arch brain tumor was scheduled for craniotomy. In
preventing the development of cerebral edema
Answer: C . The ischial spines are located in after surgery, the nurse should expect the use
the mid-pelvic region and could be narrowed of:
due to the previous pelvic injury. The
symphysis pubis, sacral promontory, and A. Diuretics
pubic arch are not part of the mid-pelvis. B. Antihypertensive
C. Steroids
49.When teaching a group of adolescents D. Anticonvulsants
about variations in the length of the menstrual
cycle, the nurse understands that the Answer: C . Glucocorticoids (steroids) are
underlying mechanism is used for their anti-inflammatory action,
due to variations in which of the following which decreases the development of edema.
phases?
2. Halfway through the administration of
A. Menstrual phase blood, the female client complains of lumbar
B. Proliferative phase pain. After stopping the infusion Nurse Hazel
C. Secretory phase should:
D. Ischemic phase
A. Increase the flow of normal saline
Answer: B . Variations in the length of the B. Assess the pain further
menstrual cycle are due to variations in the C. Notify the blood bank
proliferative phase. The menstrual, secretory D. Obtain vital signs.
and ischemic phases do not contribute to this
variation. Answer: A . The blood must be stopped at
once, and then normal saline should
50.When teaching a group of adolescents be infused to keep the line patent and
about male hormone production, which of the maintain blood volume.
following would the nurse include as being
produced by the Leydig cells? 3. Nurse Maureen knows that the positive
diagnosis for HIV infection is made based on
A. Follicle-stimulating hormone which of the following:
B. Testosterone
C. Leuteinizing hormone A. A history of high risk sexual behaviors.
D. Gonadotropin releasing hormone B. Positive ELISA and western blot tests
C. Identification of an associated
Answer: B . Testosterone is produced by the opportunistic infection
Leyding cells in the seminiferous tubules. D. Evidence of extreme weight loss and high
Follicle-stimulating hormone and leuteinzing fever
hormone are released by the anterior pituitary
gland. The hypothalamus is responsible for Answer:B . These tests confirm the presence
releasing gonadotropin-releasing hormone. of HIV antibodies that occur in response to
the presence of the human immunodeficiency
virus (HIV).
4. Nurse Maureen is aware that a client who
has been diagnosed with chronic renal failure
recognizes an adequate amount of high-
biologic-value protein when the food the
client selected from the menu was:
A. Raw carrots
B. Apple juice
C. Whole wheat bread
D. Cottage cheese
Answer: D . One cup of cottage cheese
contains approximately 225 calories, 27 g
of protein, 9 g of fat, 30 mg cholesterol, and
6 g of carbohydrate. Proteins of high biologic
value (HBV) contain optimal levels of amino
acids essential for life.
5. Kenneth who has diagnosed with uremic
syndrome has the potential to develop
complications. Which among the following
complications should the nurse anticipates:
A. Flapping hand tremors
B. An elevated hematocrit level
C. Hypotension
D. Hypokalemia
Answer: A . Elevation of uremic waste
products causes irritation of the nerves,
resulting in flapping hand tremors.
6. A client is admitted to the hospital with
benign prostatic hyperplasia, the nurse most
relevant assessment would be:
A. Flank pain radiating in the groin
B. Distention of the lower abdomen
C. Perineal edema
D. Urethral discharge
Answer: B . This indicates that the bladder is
distended with urine, therefore palpable.
7. A client has undergone with penile implant.
After 24 hrs of surgery, the client’s scrotum
was edematous and painful. The nurse should:
A. Assist the client with sitz bath
B. Apply war soaks in the scrotum
C. Elevate the scrotum using a soft
support
D. Prepare for a possible incision and
drainage.
Answer: C . Elevation increases lymphatic
drainage, reducing edema and pain.
8. Nurse hazel receives emergency laboratory
results for a client with chest pain and
immediately informs the physician. An
increased myoglobin level suggests which of
the following?
A. Liver disease
B. Myocardial damage
C. Hypertension
D. Cancer
Answer: B . Detection of myoglobin is a
diagnostic tool to determine
whether myocardial damage has occurred.
9. Nurse Maureen would expect the a client
with mitral stenosis would demonstrate
symptoms associated with congestion in the:
A. Right atrium
B. Superior vena cava
C. Aorta
D. Pulmonary
Answer: D . When mitral stenosis is present,
the left atrium has difficulty emptying
its contents into the left ventricle because
there is no valve to prevent back ward flow
into the pulmonary vein, the pulmonary
circulation is under pressure.
10. A client has been diagnosed with
hypertension. The nurse priority nursing
diagnosis would be:
A. Ineffective health maintenance
B. Impaired skin integrity
C. Deficient fluid volume
D. Pain
Answer: A . Managing hypertension is the
priority for the client with
hypertension. Clients with hypertension
frequently do not experience pain, deficient
volume, or impaired skin integrity. It is the
asymptomatic nature of hypertension
that makes it so difficult to treat.
11. Nurse Hazel teaches the client with angina
about common expected side effects of
nitroglycerin including:
A. high blood pressure Answer: A . Good source of vitamin B12 are
B. stomach cramps dairy products and meats.
C. headache
D. shortness of breath 15. Karen has been diagnosed with aplastic
anemia. The nurse monitors for changes in
Answer: C . Because of its widespread which of the following physiologic functions?
vasodilating effects, nitroglycerin
often produces side effects such as headache, A. Bowel function
hypotension and dizziness. B. Peripheral sensation
C. Bleeding tendencies
12. The following are lipid abnormalities. D. Intake and out put
Which of the following is a risk factor for the
development of atherosclerosis and PVD? Answer: C . Aplastic anemia decreases the
bone marrow production of RBC’s,
A. High levels of low density lipid (LDL) white blood cells, and platelets. The client is
cholesterol at risk for bruising and bleeding tendencies.
B. High levels of high density lipid (HDL)
cholesterol 16. Lydia is scheduled for elective
C. Low concentration triglycerides splenectomy. Before the clients goes to
D. Low levels of LDL cholesterol. surgery, the nurse in charge final assessment
would be:
Answer: A. An increased in LDL cholesterol
concentration has been documented at risk A. signed consent
factor for the development of atherosclerosis. B. vital signs
LDL cholesterol is not broken down into the C. name band
liver but is deposited into the wall of the D. empty bladder
blood vessels.
Answer: B . An elective procedure is
13. Which of the following represents a scheduled in advance so that all preparations
significant risk immediately after surgery for can be completed ahead of time. The vital
repair of aortic aneurysm? signs are the final check that must
be completed before the client leaves the
A. Potential wound infection room so that continuity of care
B. Potential ineffective coping and assessment is provided for.
C. Potential electrolyte balance
D. Potential alteration in renal perfusion 17. What is the peak age range in acquiring
acute lymphocytic leukemia (ALL)?
Answer: D . There is a potential alteration in
renal perfusion manifested by A. 4 to 12 years.
decreased urine output. The altered renal B. 20 to 30 years
perfusion may be related to renal C. 40 to 50 years
artery embolism, prolonged hypotension, or D. 60 60 70 years
prolonged aortic cross-clamping during the
surgery. Answer: A . The peak incidence of Acute
Lymphocytic Leukemia (ALL) is 4 years
14. Nurse Josie should instruct the client to of age. It is uncommon after 15 years of age.
eat which of the following foods to obtain the
best supply of Vitamin B12? 18. Marie with acute lymphocytic leukemia
suffers from nausea and headache. These
A. dairy products clinical manifestations may indicate all of the
B. vegetables following except
C. Grains
D. Broccoli A. effects of radiation
B. chemotherapy side effects
C. meningeal irritation
D. gastric distension
Answer: D . Acute Lymphocytic Leukemia
(ALL) does not cause gastric distention.
It does invade the central nervous system,
and clients experience headaches and
vomiting from meningeal irritation.
19. A client has been diagnosed with
Disseminated Intravascular Coagulation
(DIC). Which of the following is
contraindicated with the client?
A. Administering Heparin
B. Administering Coumadin
C. Treating the underlying cause
D. Replacing depleted blood products
Answer: B . Disseminated Intravascular
Coagulation (DIC) has not been found
to respond to oral anticoagulants such as
Coumadin.
20. Which of the following findings is the best
indication that fluid replacement for the client
with hypovolemic shock is adequate?
A. Urine output greater than 30ml/hr
B. Respiratory rate of 21 breaths/minute
C. Diastolic blood pressure greater than 90
mmhg
D. Systolic blood pressure greater than 110
mmhg
Answer: A . Urine output provides the most
sensitive indication of the client’s response to
therapy for hypovolemic shock. Urine output
should be consistently greater than 30 to 35
mL/hr.
21. Which of the following signs and
symptoms would Nurse Maureen include in
teaching plan as an early manifestation of
laryngeal cancer?
A. Stomatitis
B. Airway obstruction
C. Hoarseness
D. Dysphagia
Answer: C . Early warning signs of laryngeal
cancer can vary depending on tumor location.
Hoarseness lasting 2 weeks should be
evaluated because it is one of the most
common warning signs.
22. Karina a client with myasthenia gravis is
to receive immunosuppressive therapy. The
nurse understands that this therapy is effective
because it:
A. Promotes the removal of antibodies that
impair the transmission of impulses
B. Stimulates the production of acetylcholine
at the neuromuscular junction.
C. Decreases the production of
autoantibodies that attack the
acetylcholine receptors.
D. Inhibits the breakdown of acetylcholine at
the neuromuscular junction.
Answer: C . Steroids decrease the body’s
immune response thus decreasing
the production of antibodies that attack the
acetylcholine receptors at the neuromuscular
junction
23. A female client is receiving IV Mannitol.
An assessment specific to safe administration
of the said drug is:
A. Vital signs q4h
B. Weighing daily
C. Urine output hourly
D. Level of consciousness q4h
Answer: C . The osmotic diuretic mannitol is
contraindicated in the presence of inadequate
renal function or heart failure because it
increases the intravascular volume that must
be filtered and excreted by the kidney.
24. Patricia a 20 year old college student with
diabetes mellitus requests additional
information about the advantages of using a
pen like insulin
delivery devices. The nurse explains that the
advantages of these devices over syringes
includes:
A. Accurate dose delivery
B. Shorter injection time
C. Lower cost with reusable insulin
cartridges
D. Use of smaller gauge needle.
Answer: A . These devices are more accurate
because they are easily to used and have
improved adherence in insulin regimens by
young people because the medication can be
administered discreetly.
25. A male client’s left tibia is fractures in an
automobile accident, and a cast is applied. To
assess for damage to major blood vessels from
the fracture tibia, the nurse in charge should
monitor the client for:
A. Swelling of the left thigh
B. Increased skin temperature of the foot
C. Prolonged reperfusion of the toes after
blanching
D. Increased blood pressure
Answer: C . Damage to blood vessels may
decrease the circulatory perfusion of the toes,
this would indicate the lack of blood supply
to the extremity.
26. After a long leg cast is removed, the male
client should:
A. Cleanse the leg by scrubbing with a brisk
motion
B. Put leg through full range of motion twice
daily
C. Report any discomfort or stiffness to the
physician
D. Elevate the leg when sitting for long
periods of time.
Answer: D . Elevation will help control the
edema that usually occurs.
27. While performing a physical assessment
of a male client with gout of the great toe,
NurseVivian should assess for additional
tophi (urate deposits) on the:
A. Buttocks
B. Ears
C. Face
D. Abdomen
Answer: B . Uric acid has a low solubility, it
tends to precipitate and form deposits
at various sites where blood flow is least
active, including cartilaginous tissue such as
the ears.
28. Nurse Katrina would recognize that the
demonstration of crutch walking with tripod
gait was understood when the client places
weight on the:
A. Palms of the hands and axillary regions
B. Palms of the hand
C. Axillary regions
D. Feet, which are set apart
Answer: B . The palms should bear the
client’s weight to avoid damage to the nerves
in the axilla.
29. Mang Jose with rheumatoid arthritis states,
“the only time I am without pain is when I lie
in bed perfectly still”. During the
convalescent stage, the nurse in charge with
Mang Jose should encourage:
A. Active joint flexion and extension
B. Continued immobility until pain subsides
C. Range of motion exercises twice daily
D. Flexion exercises three times daily
Answer: A . Active exercises, alternating
extension, flexion, abduction, and
adduction, mobilize exudates in the joints
relieves stiffness and pain.
30. A male client has undergone spinal
surgery, the nurse should:
A. Observe the client’s bowel movement and
voiding patterns
B. Log-roll the client to prone position
C. Assess the client’s feet for sensation
and circulation
D. Encourage client to drink plenty of fluids
Answer: C . Alteration in sensation and
circulation indicates damage to the spinal
cord, if these occurs notify physician
immediately.
31. Marina with acute renal failure moves into
the diuretic phase after one week of therapy.
During this phase the client must be assessed
for signs of developing:
A. Hypovolemia
B. renal failure
C. metabolic acidosis
D. Hyperkalemia
Answer: A . In the diuretic phase fluid
retained during the oliguric phase is
excreted and may reach 3 to 5 liters daily,
hypovolemia may occur and fluids should
be replaced.

32. Nurse Judith obtains a specimen of clear
nasal drainage from a client with a head injury.
Which of the following tests differentiates
mucus from cerebrospinal fluid (CSF)?
A. Protein
B. Specific gravity
C. Glucose
D. Microorganism
Answer: C . The constituents of CSF are
similar to those of blood plasma.
An examination for glucose content is done
to determine whether a body fluid is a mucus
or a CSF. A CSF normally contains glucose.
33. A 22 year old client suffered from his first
tonic-clonic seizure. Upon awakening the
client asks the nurse, “What caused me to
have a seizure? Which of the following would
the nurse include in the primary cause of tonic
clonic seizures in adults more the 20 years?
A. Electrolyte imbalance
B. Head trauma
C. Epilepsy
D. Congenital defect
Answer: B . Trauma is one of the primary
cause of brain damage and seizure activity
in adults. Other common causes of seizure
activity in adults include
neoplasms, withdrawal from drugs and
alcohol, and vascular disease.
34. What is the priority nursing assessment in
the first 24 hours after admission of the client
with thrombotic CVA?
A. Pupil size and papillary response
B. cholesterol level
C. Echocardiogram
D. Bowel sounds
Answer: A . It is crucial to monitor the pupil
size and papillary response to
indicate changes around the cranial nerves.
35. Nurse Linda is preparing a client with
multiple sclerosis for discharge from the
hospital to home. Which of the following
instruction is most appropriate?
A. “Practice using the mechanical aids that
you will need when future disabilities
arise”.
B. “Follow good health habits to change the
course of the disease”.
C. “Keep active, use stress reduction
strategies, and avoid fatigue.
D. “You will need to accept the necessity for
a quiet and inactive lifestyle”.
Answer: C . The nurse most positive
approach is to encourage the client with
multiple sclerosis to stay active, use stress
reduction techniques and avoid
fatigue because it is important to support the
immune system while remaining active.
36. The nurse is aware the early indicator of
hypoxia in the unconscious client is:
A. Cyanosis
B. Increased respirations
C. Hypertension
D. Restlessness
Answer: D . Restlessness is an early indicator
of hypoxia. The nurse should
suspect hypoxia in unconscious client who
suddenly becomes restless.
37. A client is experiencing spinal shock.
Nurse Myrna should expect the function of
the bladder to be which of the following?
A. Normal
B. Atonic
C. Spastic
D. Uncontrolled
Answer: B . In spinal shock, the bladder
becomes completely atonic and will
continue to fill unless the client is
catheterized.
38. Which of the following stage the
carcinogen is irreversible?
A. Progression stage
B. Initiation stage
C. Regression stage
D. Promotion stage
Answer: A . Progression stage is the change
of tumor from the preneoplastic state or low
degree of malignancy to a fast growing tumor
that cannot be reversed. 43. Nurse Jon assesses vital signs on a client
undergone epidural anesthesia.
39. Among the following components Which of the following would the nurse
thorough pain assessment, which is the most assess next?
significant?
A. Headache
A. Effect B. Bladder distension
B. Cause C. Dizziness
C. Causing factors D. Ability to move legs
D. Intensity
Answer: B . The last area to return sensation
Answer: D . Intensity is the major indicative is in the perineal area, and the nurse
of severity of pain and it is important for in charge should monitor the client for
the evaluation of the treatment. distended bladder.

40. A 65 year old female is experiencing flare 44. Nurse Katrina should anticipate that all of
up of pruritus. Which of the client’s action the following drugs may be used in the
could aggravate the cause of flare ups? attempt to control the symptoms of Meniere’s
disease except:
A. Sleeping in cool and humidified
environment A. Antiemetics
B. Daily baths with fragrant soap B. Diuretics
C. Using clothes made from 100% cotton C. Antihistamines
D. Increasing fluid intake D. Glucocorticoids

Answer: B . The use of fragrant soap is very Answer: D . Glucocorticoids play no

drying to skin hence causing the pruritus. significant role in disease treatment.

41. Atropine sulfate (Atropine) is 45. Which of the following complications

contraindicated in all but one of the following associated with tracheostomy tube?
client?
A. Increased cardiac output
A. A client with high blood B. Acute respiratory distress syndrome
B. A client with bowel obstruction (ARDS)
C. A client with glaucoma C. Increased blood pressure
D. A client with U.T.I D. Damage to laryngeal nerves

Answer: C . Atropine sulfate is Answer: D . Tracheostomy tube has several

contraindicated with glaucoma patients potential complications including
because it increases intraocular pressure. bleeding, infection and laryngeal nerve
damage.
42. Among the following clients, which
among them is high risk for potential hazards 46. Nurse Faith should recognize that fluid
from the surgical experience? shift in an client with burn injury results from
increase in the:
A. 67-year-old client
B. 49-year-old client A. Total volume of circulating whole blood
C. 33-year-old client B. Total volume of intravascular plasma
D. 15-year-old client C. Permeability of capillary walls
D. Permeability of kidney tubules
Answer: A . A 67 year old client is greater
risk because the older adult client is Answer: C . In burn, the capillaries and small
more likely to have a less-effective immune vessels dilate, and cell damage cause
system. the release of a histamine-like substance. The
substance causes the capillary walls to
become more permeable and significant
quantities of fluid are lost.
47. An 83-year-old woman has several
ecchymotic areas on her right arm. The
bruises are probably caused by:
A. increased capillary fragility and
permeability
B. increased blood supply to the skin
C. self inflicted injury
D. elder abuse
Answer: A . Aging process involves
increased capillary fragility and permeability.
Older adults have a decreased amount of
subcutaneous fat and cause an
increased incidence of bruise like lesions
caused by collection of extravascular blood
inloosely structured dermis.
48. Nurse Anna is aware that early adaptation
of client with renal carcinoma is:
A. Nausea and vomiting
B. flank pain
C. weight gain
D. intermittent hematuria
Answer: D . Intermittent pain is the classic
sign of renal carcinoma. It is primarily due
to capillary erosion by the cancerous growth.
49. A male client with tuberculosis asks Nurse
Brian how long the chemotherapy must be
continued. Nurse Brian’s accurate reply would
be:
A. 1 to 3 weeks
B. 6 to 12 months
C. 3 to 5 months
D. 3 years and more
Answer: B . Tubercle bacillus is a drug
resistant organism and takes a long time to
be eradicated. Usually a combination of three
drugs is used for minimum of 6 months and
at least six months beyond culture conversion.
50. A client has undergone laryngectomy. The
immediate nursing priority would be:
A. Keep trachea free of secretions
B. Monitor for signs of infection
C. Provide emotional support
D. Promote means of communication
Answer: A . Patent airway is the most
priority; therefore removal of secretions
is necessary.
PNLE IV for
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
Answer: C . Total abstinence is the only effective
treatment for alcoholism
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
Answer: A . Hallucinations are visual, auditory,
gustatory, tactile or olfactory perceptions that have
no basis in reality.
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
Answer: 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. 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
Answer: B . Establishing a consistent eating plan
and monitoring client’s weight are important to
this disorder.
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
Answer: 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. 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
Answer: B . Delusion of grandeur is a false belief
that one is highly famous and important.
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
Answer: D . Individual with dependent personality
disorder typically shows indecisiveness
submissiveness and clinging behavior so that
others will make decisions with them.
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
Answer: A . Clients with schizotypal personality
disorder experience excessive social anxiety that
can lead to paranoid thoughts
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
Answer: 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. 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
Answer: A . An adult age 31 to 45 generates new
level of awareness.
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
Answer: A . Neuromuscular Blocker, such as
SUCCINYLCHOLINE (Anectine) produces
respiratory depression because it inhibits
contractions of respiratory muscles.
12.A 75 year old client is admitted to the hospital
with the diagnosis of dementia of the Alzheimer’s
type and depression. The symptom that is unrelated
to depression would be?
A. Apathetic response to the environment
B. “I don’t know” answer to questions
C. Shallow of labile effect
D. Neglect of personal hygiene
Answer: C . With depression, there is little or no
emotional involvement therefore little alteration in
affect.
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
Answer: D . These clients often hide food or force
vomiting; therefore they must be carefully
monitored.
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
Answer: 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.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
Anaswer: B . Limiting unnecessary interaction will
decrease stimulation and agitation.
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
Answer: C . Ritualistic behavior seen in this
disorder is aimed at controlling guilt
and inadequacy by maintaining an absolute set
pattern of behavior.
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
Answer: D . The nurse needs to set limits in the
client’s manipulative behavior to help the client
control dysfunctional behavior. A consistent
approach by the staff is necessary to decrease
manipulation.
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 client’s statement
with her
C. Request an immediate extension for the client
D. Ignore the clients statement because it’s a sign
of manipulation
Answer: B . Any suicidal statement must be
assessed by the nurse. The nurse should discuss the
client’s statement with her to determine its meaning
in terms of suicide
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
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.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
Answer: 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.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 A. Manipulate the environment to bring about
administer? positive changes in behavior
B. Allow the client’s freedom to determine
A. Naloxone (Narcan) whether or not they will be involved in
B. Benzlropine (Cogentin) activities
C. Lorazepam (Ativan) C. Role play life events to meet individual needs
D. Haloperidol (Haldol) D. Use natural remedies rather than drugs to
control behavior
Answer: C . The nurse would most likely
administer benzodiazepine, such as Answer: A . Environmental (MILIEU) therapy
lorazepan (ativan) to the client who is experiencing aims at having everything in the
symptom: The client’s experiences symptoms of client’s surrounding area toward helping the client.
withdrawal because of the rebound phenomenon
when the sedation of the CNS from alcohol begins 26.Nurse Trish would expect a child with a
to decrease. diagnosis of reactive attachment disorder to:

22.Which of the following foods would the nurse A. Have more positive relation with the father
Trish eliminate from the diet of a client in alcohol than the mother
withdrawal? B. Cling to mother & cry on separation
C. Be able to develop only superficial relation
A. Milk with the others
B. Orange Juice D. Have been physically abuse
C. Soda
D. Regular Coffee Answer: C . Children who have experienced
attachment difficulties with primary caregiver are
Answer: D . Regular coffee contains caffeine not able to trust others and therefore relate
which acts as psychomotor stimulants and leads to superficially
feelings of anxiety and agitation. Serving coffee
top the client may add to tremors or wakefulness. 27.When teaching parents about childhood
depression Nurse Trina should say?
23.Which of the following would Nurse Hazel
expect to assess for a client who is exhibiting late A. It may appear acting out behavior
signs of heroin withdrawal? B. Does not respond to conventional treatment
C. Is short in duration & resolves easily
A. Yawning & diaphoresis D. Looks almost identical to adult depression
B. Restlessness & Irritability
C. Constipation & steatorrhea Answer: A . Children have difficulty verbally
D. Vomiting and Diarrhea expressing their feelings, acting out behavior, such
as temper tantrums, may indicate underlying
Answer: D . Vomiting and diarrhea are usually the depression.
late signs of heroin withdrawal, along with muscle
spasm, fever, nausea, repetitive, abdominal cramps 28.Nurse Perry is aware that language development
and backache. in autistic child resembles:

24.To establish open and trusting relationship with a A. Scanning speech

female client who has been hospitalized with severe B. Speech lag
anxiety, the nurse in charge should? C. Shuttering
D. Echolalia
A. Encourage the staff to have frequent interaction Answer: D . The autistic child repeat sounds or
with the client words spoken by others.
B. Share an activity with the client
C. Give client feedback about behavior 29.A 60 year old female client who lives alone tells
D. Respect client’s need for personal space the nurse at the community health center “I really
don’t need anyone to talk to”. The TV is my best
Answer: D . Moving to a client’s personal space friend. The nurse recognizes that the client is using
increases the feeling of threat, which increases the defense mechanism known as?
anxiety.
A. Displacement
25. Nurse Monette recognizes that the focus of B. Projection
environmental (MILIEU) therapy is to: C. Sublimation
D. Denial
 Answer: 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.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
Answer: A . Discussion of the feared object
triggers an emotional response to the object.
31.Linda is pacing the floor and appears extremely
anxious. The duty nurse approaches in an attempt to
alleviate Linda’s anxiety. The most therapeutic
question by the nurse would be?
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
Answer: B . The nurse presence may provide the
client with support & feeling of control.
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
Answer: D . Experiencing the actual trauma in
dreams or flashback is the major symptom that
distinguishes post traumatic stress disorder from
other anxiety disorder.
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
Answer: C . Confabulation or the filling in of
memory gaps with imaginary facts is a defense
mechanism used by people experiencing memory
deficits.
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
Answer: A . These are the major signs of anorexia
nervosa. Weight loss is excessive (15% of
expected weight)
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
Answer: C . Dental enamel erosion occurs from
repeated self-induced vomiting.
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
Answer: B . Depression usually is both emotional
& physical. A simple daily routine is the best, least
stressful and least anxiety producing.
37.To further assess a client’s 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
Answer: D . The expression of these feeling may
indicate that this client is unable to continue the
struggle of life.
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
Answer: A . Structure tends to decrease agitation
and anxiety and to increase the client’s feeling of
security.
39.When planning care for a female client using
ritualistic behavior, Nurse Gina must recognize that
the ritual:
Answer: C . Helping the client to develop feeling
of self worth would reduce the client’s need to use
pathologic defenses.
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. Helps the client focus on the inability to deal
with reality
B. Helps the client control the anxiety
C. Is under the client’s conscious control
D. Is used by the client primarily for secondary
gains
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

Answer: B . The rituals used by a client with Answer: B . Open ended questions and silence are
obsessive compulsive disorder help control the strategies used to encourage clients to discuss their
anxiety level by maintaining a set pattern of action. problem in descriptive manner.

40.A 32 year old male graduate student, who has 44.Nurse Nina is assigned to care for a client
become increasingly withdrawn and neglectful of diagnosed with Catatonic Stupor. When Nurse Nina
his work and personal hygiene, is brought to the enters the client’s room, the client is found lying on
psychiatric hospital by his parents. After detailed the bed with a body pulled into a fetal position.
assessment, a diagnosis of schizophrenia is made. It Nurse Nina should?
is unlikely that the client will demonstrate:
A. Ask the client direct questions to encourage
A. Low self esteem talking
B. Concrete thinking B. Rake the client into the dayroom to be with
C. Effective self boundaries other clients
D. Weak ego C. Sit beside the client in silence and
occasionally ask open-ended question
Answer:C . A person with this disorder would not D. Leave the client alone and continue with
have adequate self-boundaries providing care to the other clients

41.A 23 year old client has been admitted with a Answer: C . Clients who are withdrawn may be
diagnosis of schizophrenia says to the nurse “Yes, immobile and mute, and require consistent,
its march, March is little woman”. That’s literal repeated interventions. Communication with
you know”. These statement illustrate: withdrawn clients requires much patience from the
nurse. The nurse facilitates communication with
A. Neologisms the client by sitting in silence, asking open-ended
B. Echolalia question and pausing to provide opportunities for
C. Flight of ideas the client to respond.
D. Loosening of association
45.Nurse Tina is caring for a client with delirium
Answer: D . Loose associations are thoughts that and states that “look at the spiders on the wall”.
are presented without the logical connections What should the nurse respond to the client?
usually necessary for the listening to interpret the
message. A. “You’re having hallucination, there are no
spiders in this room at all”
42.A long term goal for a paranoid male client who B. “I can see the spiders on the wall, but they are
has unjustifiably accused his wife of having many not going to hurt you”
extramarital affairs would be to help the C. “Would you like me to kill the spiders”
client develop: D. “I know you are frightened, but I do not see
spiders on the wall”
A. Insight into his behavior
B. Better self control Answer: D . When hallucination is present, the
C. Feeling of self worth nurse should reinforce reality with the client.
D. Faith in his wife
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”
Answer: A . Personal characteristics of abuser
include low self-esteem, immaturity, dependence,
insecurity and jealousy
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.
Answer: D . A short acting skeletal muscle
relaxant such as succinylcholine (Anectine) is
administered during this procedure to prevent
injuries during seizure.
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
Answer: C . Recognizing situations that produce
anxiety allows the client to prepare to cope with
anxiety or avoid specific stimulus.
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
Answer: D . Electroconvulsive therapy is an
effective treatment for depression that has not
responded to medication
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: 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.
FOUNDATION OF NURSING
PNLE: FON Practice
Exam for History ,
Concepts and
Theories
1. The four major concepts in nursing theory
are the
A. Person, Environment, Nurse, Health
B. Nurse, Person, Environment, Cure
C. Promotive, Preventive, Curative,
Rehabilitative
D. Person, Environment, Nursing, Health
Answer: D. Person, Environment, Nursing,
Health. This is an actual board exam question
and is a common board question. Theorist
always describes The nursing profession by
first defining what is NURSING, followed by
the PERSON, ENVIRONMENT and
HEALTH CONCEPT. The most popular
theory was perhaps Nightingale’s. She
defined nursing as the utilization of the
persons environment to assist him towards
recovery. She defined the person as
somebody who has a reparative capabilities
mediated and enhanced by factors in his
environment. She describes the environment
as something that would facilitate the
person’s reparative process and identified
different factors like sanitation, noise, etc.
that affects a person’s reparative state.
2. The act of utilizing the environment of the
patient to assist him in his recovery is
theorized by
A. Nightingale
B. Benner
C. Swanson
D. King
Answer: A. Nightingale. Florence
nightingale do not believe in the germ theory,
and perhaps this was her biggest mistake. Yet,
her theory was the first in nursing. She
believed that manipulation of environment
that includes appropriate noise, nutrition,
hygiene, light, comfort, sanitation etc. could
provide the client’s body the nurturance it
needs for repair and recovery.
3. For her, Nursing is a theoretical system of
knowledge that prescribes a process of
analysis and action related to care of the ill
person
A. King
B. Henderson
C. Roy
D. Leininger
Answer: C. Roy. Remember the word
“ THEOROYTICAL “ For Callista Roy,
Nursing is a theoretical body of knowledge
that prescribes analysis and action to care for
an ill person. She introduced the
ADAPTATION MODEL and viewed person
as a BIOSPSYCHOSOCIAL BEING. She
believed that by adaptation, Man can
maintain homeostasis.
4. According to her, Nursing is a helping or
assistive profession to persons who are wholly
or partly dependent or when those who are
supposedly caring for them are no longer able
to give care.
A. Henderson
B. Orem
C. Swanson
D. Neuman
Answer: B. Orem. In self care deficit theory,
Nursing is defined as A helping or assistive
profession to person who are wholly or partly
dependent or when people who are to give
care to them are no longer available. Self
care, are the activities that a person do for
himself to maintain health, life and well
being.
5. Nursing is a unique profession, Concerned
with all the variables affecting an individual’s
response to stressors, which are intra, inter
and extra personal in nature.
A. Neuman
B. Johnson
C. Watson
D. Parse
Answer: A. Neuman. Neuman divided
stressors as either intra, inter and extra
personal in nature. She said that NURSING
is concerned with eliminating these stressors
to obtain a maximum level of wellness. The
nurse helps the client through PRIMARY,
SECONDARY AND TERTIARY prevention
modes. Please do not confuse this with
LEAVELL and CLARK’S level of
prevention.
6. The unique function of the nurse is to assist
the individual, sick or well, in the
performance of those activities contributing to
health that he would perform unaided if he has
the necessary strength, will and knowledge,
and do this in such a way as to help him gain
independence as rapidly as possible.
A. Henderson
B. Abdellah
C. Levin
D. Peplau
Answer: A. Henderson. This was an actual
board question. Remember this definition
and associate it with Virginia Henderson.
Henderson also describes the NATURE OF
NURSING theory. She identified 14 basic
needs of the client. She describes nursing
roles as SUBSTITUTIVE : Doing everything
for the client, SUPPLEMENTARY : Helping
the client and COMPLEMENTARY :
Working with the client. Breathing normally,
Eliminating waste, Eating and drinking
adquately, Worship and Play are some of the
basic needs according to her.
7. Caring is the essence and central unifying, a
dominant domain that distinguishes nursing
from other health disciplines. Care is an
essential human need.
A. Benner
B. Watson
C. Leininger
D. Swanson
Answer:C. Leininger. There are many
theorist that describes nursing as CARE. The
most popular was JEAN WATSON’S
Human Caring Model. But this question
pertains to Leininger’s definition of caring.
CUD I LIE IN GER? [ Could I Lie In There ]
Is the Mnemonics I am using not to get
confused. C stands for CENTRAL , U stands
for UNIFYING, D stands for DOMINANT
DOMAIN. I emphasize on this matter due to
feedback on the last June 2006 batch about a
question about CARING.
8. Caring involves 5 processes, KNOWING,
BEING WITH, DOING FOR, ENABLING
and MAINTAINING BELIEF.
A. Benner
B. Watson
C. Leininger
D. Swanson
Answer:D. Swanson . Caring according to
Swanson involves 5 processes. Knowing
means understanding the client. Being with
emphasizes the Physical presence of the
nurse for the patient. Doing for means doing
things for the patient when he is incapable of
doing it for himself. Enabling means helping
client transcend maturational and
developmental stressors in life while
Maintaining belief is the ability of the Nurse
to inculcate meaning to these events.
9. Caring is healing, it is communicated
through the consciousness of the nurse to the
individual being cared for. It allows access to
higher human spirit.
A. Benner
B. Watson
C. Leininger
D. Swanson
Answer: B. Watson. The deepest and
spiritual definition of Caring came from Jean
watson. For her, Caring expands the limits of
openess and allows access to higher human
spirit.
10. Caring means that person, events, projects
and things matter to people. It reveals stress
and coping options. Caring creates
responsibility. It is an inherent feature of
nursing practice. It helps the nurse assist
clients to recover in the face of the illness.
A. Benner
B. Watson
C. Leininger
D. Swanson
Answer: A. Benner. I think of CARE BEAR
to facilitate retainment of BENNER. As in,
Care Benner. For her, Caring means being
CONNECTED or making things matter to
people. Caring according to Benner give
meaning to illness and re establish
connection.
11. Which of the following is NOT TRUE
about profession according to Marie Jahoda?
A. A profession is an organization of an
occupational group based on the
application of special knowledge
B. It serves specific interest of a group
C. It is altruistic
D. Quality of work is of greater importance
than the rewards
Answer: B. It serves specific interest of a
group.Believe it or not, you should know the
definition of profession according to Jahoda
because it is asked in the Local boards. A
profession should serve the WHOLE
COMMUNITY and not just a specific intrest
of a group. Everything else, are correct.
12. Which of the following is NOT an
attribute of a professional?
A. Concerned with quantity
B. Self directed
C. Committed to spirit of inquiry
D. Independent
Answer: A. Concerned with quantity. A
professional is concerned with QUALITY
and not QUANTITY. In nursing, We have
methods of quality assurance and control to
evaluate the effectiveness of nursing care.
Nurses, are never concerned with
QUANTITY of care provided.
13. The most unique characteristic of nursing
as a profession is
A. Education
B. Theory
C. Caring
D. Autonomy
Answer: C. Caring. Caring and caring alone,
is the most unique quality of the Nursing
Profession. It is the one the delineate Nursing
from other professions.
14. This is the distinctive individual qualities
that differentiate a person to another
A. Philosophy
B. Personality
C. Charm
D. Character
Answer: B. Personality. Personality are
qualities that make us different from each
other. These are impressions that we made,
or the footprints that we leave behind. This is
the result of the integration of one’s talents,
behavior, appearance, mood, character,
morals and impulses into one harmonious
whole. Philosophy is the basic truth that fuel
our soul and give our life a purpose, it shapes
the facets of a person’s character. Charm is to
attract other people to be a change agent.
Character is our moral values and belief that
guides our actions in life.
15. Refers to the moral values and beliefs that
are used as guides to personal behavior and
actions
A. Philosophy
B. Personality
C. Charm
D. Character
Answer:D. Character.Rationale: Refer to
number 14
16. As a nurse manager, which of the
following best describes this function?
A. Initiate modification on client’s lifestyle
B. Protect client’s right
C. Coordinates the activities of other
members of the health team in managing
patient care
D. Provide in service education programs,
Use accurate nursing audit, formulate
philosophy and vision of the institution
Answer:Provide in service education
programs, Use accurate nursing audit,
formulate philosophy and vision of the
institution
17. What best describes nurses as a care
provider?
A. Determine client’s need
B. Provide direct nursing care
C. Help client recognize and cope with
stressful psychological situation
D. Works in combined effort with all those
involved in patient’s care
Answer: A. Determine client’s need.You can
never provide nursing care if you don’t know
what are the needs of the client. How can you
provide an effective postural drainage if you
do not know where is the bulk of the client’s
secretion. Therefore, the best description of a
care provider is the accurate and prompt
determination of the client’s need to be able
to render an appropriate nursing care.
18. The nurse questions a doctors order of
Morphine sulfate 50 mg, IM for a client with
pancreatitis. Which role best fit that statement?
A. Change agent
B. Client advocate
C. Case manager
D. Collaborator
Answer: B. Client advocate. As a client’s
advocate, Nurses are to protect the client’s
right and promotes what is best for the client.
Knowing that Morphine causes spasm of the
sphincter of Oddi and will lead to further
increase in the client’s pain, The nurse knew
that the best treatment option for the client
was not provided and intervene to provide
the best possible care.
19. These are nursing intervention that 22. This patient care model works best when
requires knowledge, skills and expertise of there are plenty of patient but few nurses
multiple health professionals.
A. Functional nursing
A. Dependent B. Team nursing
B. Independent C. Primary nursing
C. Interdependent D. Total patient care
D. Intradependent
ANSWER:A. Functional nursing. Functional
Answer: C. Interdependent. Interdependent nursing is task oriented, One nurse is
functions are those that needs expertise and assigned on a particular task leading to task
skills of multiple health professionals. expertise and efficiency. The nurse will work
Example is when A child was diagnosed with fast because the procedures are repetitive
nephrotic syndrome and the doctor ordered a leading to task mastery. This care is not
high protein diet, Budek then work together recommended as this leads fragmented
with the dietician about the age appropriate nursing care.
high protein foods that can be given to the
child, Including the preparation to entice the 23. RN assumes 24 hour responsibility for the
child into eating the food. NOTE : It is still client to maintain continuity of care across
debated if the diet in NS is low, moderate or shifts, days or visits.
high protein, In the U.S, Protein is never
restricted and can be taken in moderate A. Functional nursing
amount. As far as the local examination is B. Team nursing
concerned, answer LOW PROTEIN HIGH C. Primary nursing
CALORIC DIET. D. Total patient care

20. What type of patient care model is the Answer: C. Primary nursing. Your keyword
most common for student nurses and private in Primary nursing is the 24 hours. This does
duty nurses? not necessarily means the nurse is awake for
24 hours, She can have a SECONDARY
A. Total patient care NURSES that will take care of the patient in
B. Team nursing shifts where she is not arround.
C. Primary Nursing
D. Case management
24. Who developed the first theory of nursing?
Answer: A. Total patient care. This is also
known as case nursing. It is a method of A. Hammurabi
nursing care wherein, one nurse is assigned B. Alexander
to one patient for the delivery of total care. C. Fabiola
These are the method use by Nursing D. Nightingale
students, Private duty nurses and those in
critical or isolation units. Answer: D. Nightingale . Refer to question #
2. Hammurabi is the king of babylon that
21. This is the best patient care model when introduces the LEX TALIONES law, If you
there are many nurses but few patients. kill me, you should be killed… If you rob me,
You should be robbed, An eye for an eye and
A. Functional nursing a tooth for a tooth. Alexander the great was
B. Team nursing the son of King Philip II and is from
C. Primary nursing macedonia but he ruled Greece including
D. Total patient care Persia and Egypt. He is known to use a
hammer to pierce a dying soldier’s medulla
Answer: D. Total patient care .Total patient towards speedy death when he thinks that the
care works best if there are many nurses but soldier will die anyway, just to relieve their
few patients. suffering. Fabiola was a beautiful roman
matron who converted her house into a The nurse can help the client maintain
hospital. stability against these stressors.

25. She introduces the NATURE OF 28. Conceptualized the BEHAVIORAL

NURSING MODEL. SYSTEM MODEL

A. Henderson A. Orem
B. Nightingale B. Johnson
C. Parse C. Henderson
D. Orlando D. Parse

Answer: A. Henderson. Refer to question # 6. Answer: B. Johnson. According to Dorothy

Johnson, Each person is a behavioral system
26. She described the four conservation that is composed of 7 subsystems. Man adjust
principle. or adapt to stressors by a using a LEARNED
PATTERN OF RESPONSE. Man uses his
A. Levin behavior to meet the demands of the
B. Leininger environment, and is able to modified his
C. Orlando behavior to support these demands
D. Parse
29. Developed the CLINICAL NURSING – A
Answer: A. Levin. Myra Levin described the HELPING ART MODEL
4 Conservation principles which are
concerned with the Unity and Integrity of an A. Swanson
individual. These are ENERGY : Our output B. Hall
to facilitate meeting of our needs. C. Weidenbach
STRUCTURAL INTEGRITY : We mus D. Zderad
maintain the integrity of our organs, tissues
and systems to be able to function and prevent Asnwer: C. Weidenbach.Just remember
harmful agents entering our body. ERNESTINE WEIDENBACHLINICAL.
PERSONAL INTEGRITY : These refers to
our self esteem, self worth, self concept, 30. Developed the ROLE MODELING and
identify and personality. SOCIAL MODELING theory
INTEGRITY : Reflects our societal roles to
our society, community, family, friends and A. Erickson,Tomlin,Swain
fellow individuals B. Neuman
C. Newman
27. Proposed the HEALTH CARE SYSTEM D. Benner and Wrubel
MODEL.
Answer: A. Erickson,Tomlin,Swain
A. Henderson
B. Orem 31. Proposed the GRAND THEORY OF
C. Parse NURSING AS CARING
D. Neuman
A. Erickson, Tomlin, Swain
Answer: D. Neuman . Betty Neuman asserted B. Peterson,Zderad
that nursing is a unique profession and is C. Bnner,Wrubel
concerned with all the variables affecting the D. Boykin,Schoenhofer
individual’s response to stressors. These are
INTRA or within ourselves, EXTRA or Answer: D. Boykin,Schoenhofer . This
outside the individual, INTER means theory was called GRAND THEORY
between two or more people. She proposed because boykin and schoenofer thinks that
the HEALTH CARE SYSTEM MODEL ALL MAN ARE CARING, And that nursing
which states that by PRIMARY, is a response to this unique call. According to
SECONDARY and TERTIARY prevention, them, CARING IS A MORAL
IMPERATIVE, meaning, ALL PEOPLE will
tend to help a man who fell down the stairs
even if he is not trained to do so.
32. Postulated the INTERPERSONAL
ASPECT OF NURSING
A. Travelbee
B. Swanson
C. Zderad
D. Peplau
Answer: A. Travelbee. Travelbee’s theory
was referred to as INTERPERSONAL theory
because she postulated that NURSING is to
assist the individual and all people that
affects this individual to cope with illness,
recover and FIND MEANING to this
experience. For her, Nursing is a HUMAN
TO HUMAN relationship that is formed
during illness. To her, an individual is a
UNIQUE and irreplaceable being in
continuous process of becoming, evolving
and changing. PLEASE do remember, that it
is PARSE who postulated the theory of
HUMAN BECOMING and not
TRAVELBEE, for I read books that say it
was TRAVELBEE and not PARSE.
33. He proposed the theory of morality that is
based on MUTUAL TRUST
A. Freud
B. Erikson
C. Kohlberg
D. Peters
Answer: C. Kohlberg. Kohlber states that
relationships are based on mutual trust. He
postulated the levels of morality development.
At the first stage called the PREMORAL or
preconventional, A child do things and label
them as BAD or GOOD depending on the
PUNISHMENT or REWARD they get. They
have no concept of justice, fairness and equity,
for them, If I punch this kid and mom gets
mad, thats WRONG. But if I dance and sing,
mama smiles and give me a new toy, then I
am doing something good. In the
Conventional level, The individual actuates
his act based on the response of the people
around him. He will follow the rules,
regulations, laws and morality the society
upholds. If the law states that I should not
resuscitate this man with a DNR order, then I
would not. However, in the Post conventional
level or the AUTONOMOUS level, the
individual still follows the rules but can make
a rule or bend part of these rules according to
his own MORALITY. He can change the
rules if he thinks that it is needed to be
changed. Example is that, A nurse still
continue resuscitating the client even if the
client has a DNR order because he believes
that the client can still recover and his mission
is to save lives, not watch patients die
34. He proposed the theory of morality based
on PRINCIPLES
A. Freud
B. Erikson
C. Kohlberg
D. Peters
Answer: D. Peters . Remember PETERS for
PRINCIPLES. P is to P. He believes that
morality has 3 components : EMOTION or
how one feels, JUDGEMENT or how one
reason and BEHAVIOR or how one actuates
his EMOTION and JUDGEMENT. He
believes that MORALITY evolves with the
development of PRINCPLES or the person’s
vitrue and traits. He also believes in
AUTOMATICITY of virtues or he calls
HABIT, like kindness, charity, honesty,
sincerity and thirft which are innate to a
person and therfore, will be performed
automatically.
35. Freud postulated that child adopts parental
standards and traits through
A. Imitation
B. Introjection
C. Identification
D. Regression
Answer:C. Identification. A child, according
to Freud adopts parental standards, traits,
habits and norms through identication. A
good example is the corned beef commercial ”
WALK LIKE A MAN, TALK LIKE A
MAN ” Where the child identifies with his
father by wearing the same clothes and doing
the same thing.
36. According to them, Morality is measured
of how people treat human being and that a
moral child strives to be kind and just
A. Zderad and Peterson
B. Benner and Wrubel
C. Fowler and Westerhoff
D. Schulman and Mekler
40. Anastacia Giron-Tupas was the first
Answer: D. Schulman and Filipino nurse to occupy the position of chief
Mekler . According to Schulman and Mekler, nurse in this hospital.
there are 2 components that makes an action
MORAL : The intention should be good and A. St. Paul Hospital
the Act must be just. A good example is B. Iloilo Mission Hospital
ROBIN HOOD, His intention is GOOD but C. Philippine General Hospital
the act is UNJUST, which makes his action D. St. Luke’s Hospital
IMMORAL.
Answer:C. Philippine General Hospital
37. Postulated that FAITH is the way of
behaving. He developed four theories of faith 41. She was the daughter of Hungarian kings,
and development based on his experience. who feed 300-900 people everyday in their
gate, builds hospitals, and care of the poor and
A. Giligan sick herself.
B. Westerhoff
C. Fowler A. Elizabeth
D. Freud B. Catherine
C. Nightingale
Answer: B. Westerhoff. There are only 2 D. Sairey Gamp
theorist of FAITH that might be asked in the
board examinations. Fowler and Westerhoff. Answer:A. Elizabeth.Saint Elizabeth of
What differs them is that, FAITH of fowler is Hungary was a daughter of a King and is the
defined abstractly, Fowler defines faith as a patron saint of nurses. She build hospitals
FORCE that gives a meaning to a person’s and feed hungry people everyday using the
life while Westerhoff defines faith as a kingdom’s money. She is a princess, but
behavior that continuously develops through devoted her life in feeding the hungry and
time. serving the sick.

38. He described the development of faith. He 42. She dies of yellow fever in her search for
suggested that faith is a spiritual dimension truth to prove that yellow fever is carried by a
that gives meaning to a persons life. Faith mosquitoes.
according to him, is a relational phenomenon. A. Clara louise Maas
A. Giligan B. Pearl Tucker
B. Westerhoff C. Isabel Hampton Robb
C. Fowler D. Caroline Hampton Robb
D. Freud
Answer:A. Clara louise Maas. Clara Louise
Answer:C. Fowler. Rationale: Refer to # 37 Maas sacrificed her life in research of
YELLOW FEVER. People during her time
39. Established in 1906 by the Baptist foreign do not believe that yellow fever was brought
mission society of America. Miss rose nicolet, by mosquitoes. To prove that they are wrong,
was it’s first superintendent. She allowed herself to be bitten by the vector
and after days, She died.
A. St. Paul Hospital School of nursing
B. Iloilo Mission Hospital School of 43. He was called the father of sanitation.
nursing
C. Philippine General Hospital School of A. Abraham
nursing B. Hippocrates
D. St. Luke’s Hospital School of nursing C. Moses
D. Willam Halstead
Answer:B. Iloilo Mission Hospital School of
nursing Answer: C. Moses
44. The country where SHUSHURUTU wounded soldiers. But almost all of them are
originated influenced by the christian faith to serve and
nurse the sick. When Fliedner build the first
A. China formal school for nurses, It marked the end
B. Egypt of the APPRENTICESHIP period.
C. India
D. Babylonia 48. Period of nursing where religious
Christian orders emerged to take care of the
Answer: india
sick
45. They put girls clothes on male infants to A. Apprentice period
drive evil forces away B. Dark period
C. Contemporary period
A. Chinese D. Educative period
B. Egyptian
C. Indian Answer: A. Apprentice period. Apprentice
D. Babylonian period is marked by the emergence of
religious orders the are devoted to religious
Answer: A. Chinese. Chinese believes that life and the practice of nursing.
male newborns are demon magnets. To fool
those demons, they put female clothes to 49. Founded the second order of St. Francis of
their male newborn.
Assisi
46. In what period of nursing does people A. St. Catherine
believe in TREPHINING to drive evil forces B. St. Anne
away? C. St. Clare
D. St. Elizabeth
A. Dark period
B. Intuitive period Answer:C. St. Clare. The poor clares, is the
C. Contemporary period second order of St. Francis of assisi. The first
D. Educative period order was founded by St. Francis himself. St.
Catherine of Siena was the first lady with the
Answer: B. Intuitive period.Egyptians lamp. St. Anne is the mother of mama mary.
believe that a sick person is someone with an St. Elizabeth is the patron saint of Nursing.
evil force or demon that is inside their heads.
To release these evil spirits, They would tend 50. This period marked the religious upheaval
to drill holes on the patient’s skull and it is of Luther, Who questions the Christian faith.
called TREPHINING.
A. Apprentice period
47. This period ended when Pastor Fliedner, B. Dark period
build Kaiserwerth institute for the training of C. Contemporary period
Deaconesses D. Educative period

A. Apprentice period Answer:B. Dark period. Protestantism

B. Dark period
C. Contemporary period
D. Educative period
Answer: A. Apprentice period.What
dilineates apprentice period among others is
that, it ENDED when formal schools were
established. During the apprentice period,
There is no formal educational institution for
nurses. Most of them receive training inside
the convent or church. Some of them are
trained just for the purpose of nursing the
emerged with Martin Luther questions the
Pope and Christianity. This started the Dark
period of nursing when the christian faith
was smeared by controversies. These leads to
closure of some hospital and schools run by
the church. Nursing became the work of
prostitutes, slaves, mother and least desirable
of women.
51. According to the Biopsychosocial and
spiritual theory of Sister Callista Roy, Man,
As a SOCIAL being is
A. Like all other men Answer: B. Rogers. The wholistic theory by
B. Like some other men Martha Rogers states that MAN is greater
C. Like no other men than the sum of all its parts and that his
D. Like men dignity and worth will not be lessen even if
one of this part is missing. A good example
Answer:B. Like some other men.According is ANNE BOLEYN, The mother of Queen
to ROY, Man as a social being is like some Elizabeth and the wife of King Henry VIII.
other man. As a spiritual being and Biologic She was beheaded because Henry wants to
being, Man are all alike. As a psychologic mary another wife and that his divorce was
being, No man thinks alike. This basically not approved by the pope. Outraged, He
summarized her BIOPSYHOSOCIAL theory insisted on the separation of the Church and
which is included in our licensure exam State and divorce Anne himself by making
coverage. everyone believe that Anne is having an
affair to another man. Anne was beheaded
52. She conceptualized that man, as an Open while her lips is still saying a prayer. Even
system is in constant interaction and without her head, People still gave respect to
transaction with a changing environment. her diseased body and a separate head. She
was still remembered as Anne boleyn,
A. Roy Mother of Elizabeth who lead england to
B. Levin their GOLDEN AGE.
C. Neuman
D. Newman 55. She theorized that man is composed of sub
and supra systems. Subsystems are cells,
Answer:A. Roy. OPEN system theory is tissues, organs and systems while the
ROY. As an open system, man continuously
suprasystems are family, society and
allows input from the environment. Example
is when you tell me Im good looking, I will community.
be happy the entire day, Because I am an A. Roy
open system and continuously interact and B. Rogers
transact with my environment. A close C. Henderson
system is best exemplified by a CANDLE. D. Johnson
When you cover the candle with a glass, it
will die because it will eventually use all the Answer: B. Rogers. According to Martha
oxygen it needs inside the glass for Rogers, Man is composed of 2 systems :
combustion. A closed system do not allow SUB which includes cells, tissues, organs
inputs and output in its environment. and system and SUPRA which includes our
famly, community and society. She stated
53. In a CLOSED system, which of the that when any of these systems are affected,
following is true? it will affect the entire individual.
A. Affected by matter
56. Which of the following is not true about
B. A sole island in vast ocean
C. Allows input the human needs?
D. Constantly affected by matter, energy, A. Certain needs are common to all people
information B. Needs should be followed exactly in
accordance with their hierarchy
Answer: B. A sole island in vast ocean C. Needs are stimulated by internal factors
D. Needs are stimulated by external factors
54. Who postulated the WHOLISTIC concept
that the totality is greater than sum of its parts? Answer: B. Needs should be followed
exactly in accordance with their
A. Roy
hierarchy.Needs can be deferred. I can
B. Rogers
urinate later as not to miss the part of the
C. Henderson
movie’s climax. I can save my money that
D. Johnson
are supposedly for my lunch to watch my
idols in concert. The physiologic needs can
be meet later for some other needs and need Answer: B. Self actualization. The peak of
not be strictly followed according to their maslow’s hierarchy is the essence of mental
hierarchy. health

57. Which of the following is TRUE about the 61. Florence nightingale is born in
human needs?
A. Germany
A. May not be deferred B. Britain
B. Are not interrelated C. France
C. Met in exact and rigid way D. Italy
D. Priorities are alterable
Answer: D. Italy. Florence Nightingale was
Answer: D. Priorities are alterable. Refer to born in Florence, Italy, May 12, 1820.
question # 56. Studied in Germany and Practiced in
England.
58. According to Maslow, which of the
following is NOT TRUE about a self 62. Which is unlikely of Florence Nightingale?
actualized person? A. Born May 12, 1840
A. Understands poetry, music, philosophy, B. Built St. Thomas school of nursing when
science etc. she was 40 years old
B. Desires privacy, autonomous C. Notes in nursing
C. Follows the decision of the majority, D. Notes in hospital
uphold justice and truth
D. Problem centered 1. Answer: A. Born May 12, 1840

Answer: C. Follows the decision of the 63. What country did Florence Nightingale
majority, uphold justice and truth. A,B and D train in nursing?
are all qualities of a self actualized person. A A. Belgium
self actualized person do not follow the
B. US
decision of majority but is self directed and
C. Germany
can make decisions contrary to a popular
D. England
opinion.
Answer: germany
59. According to Maslow, which of the
following is TRUE about a self actualized 64. Which of the following is recognized for
person? developing the concept of HIGH LEVEL
A. Makes decision contrary to public WELLNESS?
opinion A. Erikson
B. Do not predict events
B. Madaw
C. Self centered C. Peplau
D. Maximum degree of self conflict
D. Dunn
Answer: A. Makes decision contrary to Answer:D. Dunn. According to Dunn, High
public opinion. Refer to question # 58.
level wellness is the ability of an individual
to maximize his full potential with the
60. This is the essence of mental health limitations imposed by his environment.
A. Self awareness According to him, An individual can be
B. Self actualization healthy or ill in both favorable and
C. Self esteem unfavorable environment.
D. Self worth
65. One of the expectations is for nurses to
join professional association primarily
because of
A. Promotes advancement and 69. Which of the following does not govern
professional growth among its nursing practice?
members
B. Works for raising funds for nurse’s A. RA 7164
benefit B. RA 9173
C. Facilitate and establishes acquaintances C. BON Res. Code Of Ethics
D. Assist them and securing jobs abroad D. BON Res. Scope of Nursing Practice

Answer: A. Promotes advancement and Answer: A. RA 7164. 7164 is an old law.

professional growth among its members This is the 1991 Nursing Law which was
repealed by the newer 9173.
66. Founder of the PNA
70. A nurse who is maintaining a private
A. Julita Sotejo clinic in the community renders service on
B. Anastacia Giron Tupas maternal and child health among the
C. Eufemia Octaviano neighborhood for a fee is:
D. Anesia Dionisio
A. Primary care nurse
Answer: Anastacia Giron Tupas B. Independent nurse practitioner
C. Nurse-Midwife
67. Which of the following provides that D. Nurse specialist
nurses must be a member of a national nurse
organization? Answer: B. Independent nurse practitioner

A. R.A 877 71. When was the PNA founded?

B. 1981 Code of ethics approved by the
house of delegates and the PNA A. September 22, 1922
C. Board resolution No. 1955 Promulgated B. September 02, 1920
by the BON C. October 21, 1922
D. RA 7164 D. September 02, 1922

Answer: C. Board resolution No. 1955 Answer: D. September 02, 1922. According
Promulgated by the BON. This is an old to the official PNA website, they are founded
board resolution. The new Board resolution September 02, 1922.
is No. 220 series of 2004 also known as the
Nursing Code Of ethics which states that 72. Who was the first president of the PNA ?
[ SECTION 17, A ] A nurse should be a A. Anastacia Giron-Tupas
member of an accredited professional B. Loreto Tupas
organization which is the PNA. C. Rosario Montenegro
D. Ricarda Mendoza
68. Which of the following best describes the
action of a nurse who documents her nursing Answer: C. Rosario Montenegro. Anastacia
diagnosis? Giron Tupas founded the FNA, the former
A. She documents it and charts it whenever name of the PNA but the first President was
necessary Rosario Montenegro.
B. She can be accused of malpractice
C. She does it regularly as an important 73. Defines health as the ability to maintain
responsibility internal milieu. Illness according to
D. She charts it only when the patient is him/her/them is the failure to maintain
acutely ill internal environment.
A. Cannon
Answer: C. She does it regularly as an
B. Bernard
important responsibility C. Leddy and Pepper
D. Roy
Answer: B. Bernard. According to Bernard, C. Rogers
Health is the ability to maintain and Internal D. King
Milieu and Illness is the failure to maintain
the internal environment. Answer: D. King .Emogene King states that
health is a state in the life cycle and Illness is
74. Postulated that health is a state and any interference on this cycle. I enjoyed the
process of being and becoming an integrated Movie LION KING and like what Mufasa
and whole person. said that they are all part of the CIRCLE OF
LIFE, or the Life cycle.
A. Cannon
B. Bernard 78. She defined health as the soundness and
C. Dunn wholness of developed human structure and
D. Roy bodily mental functioning.
Answer: D. Roy. According to ROY, Health A. Orem
is a state and process of becoming a WHOLE B. Henderson
AND INTEGRATED Person. C. Neuman
D. Clark
75. What regulates HOMEOSTASIS
according to the theory of Walter Cannon? Answer: A. Orem. Orem defined health as
the SOUNDNESS and WHOLENESS of
A. Positive feedback developed human structure and of bodily and
B. Negative feedback mental functioning.
C. Buffer system
D. Various mechanisms 79. According to her, Wellness is a condition
in which all parts and subparts of an
Answer: B. Negative feedback. The theory of
individual are in harmony with the whole
Health as the ability to maintain homeostasis
was postulated by Walter Cannon. According system.
to him, There are certain FEEDBACK A. Orem
Mechanism that regulates our Homeostasis. B. Henderson
A good example is that when we overuse our C. Neuman
arm, it will produce pain. PAIN is a negative D. Johnson
feedback that signals us that our arm needs a
rest. Answer: C. Neuman. Neuman believe that
man is composed of subparts and when this
76. Stated that health is WELLNESS. A subparts are in harmony with the whole
termed define by the culture or an individual. system, Wellness results. Please do not
confuse this with the SUB and SUPRA
A. Roy
systems of martha rogers.
B. Henderson
C. Rogers
80. Postulated that health is reflected by the
D. King
organization, interaction, interdependence and
Answer: C. Rogers. Martha Rogers states integration of the subsystem of the behavioral
that HEALTH is synonymous with system.
WELLNESS and that HEALTH and A. Orem
WELLNESS is subjective depending on the B. Henderson
definition of one’s culture. C. Neuman
D. Johnson
77. Defined health as a dynamic state in the
life cycle, and Illness as interference in the Answer: D. Johnson . Once you see the
life cycle. phrase BEHAVIORAL SYSTEM, answer
A. Roy Dorothy Johnson.
B. Henderson
81. According to them, Well being is a sanitation and over crowding. Heridity
subjective perception of BALANCE, includes congenital and diseases acquired
HARMONY and VITALITY through the genes. There are no social
precursors according to DUNN.
A. Leavell and Clark
B. Peterson and Zderad 85. According to DUNN, Overcrowding is
C. Benner and Wruber what type of illness precursor?
D. Leddy and Pepper
A. Heredity
Answer: D. Leddy and Pepper .According to B. Social
Leddy and Pepper, Wellness is subjective C. Behavioral
and depends on an individuals perception of D. Environmental
balance, harmony and vitality. Leavell and
Clark postulared the ecologic model of health Answer: Environmental
and illness or the AGENT-HOST-
ENVIRONMENT model. Peterson and 86. Health belief model was formulated in
Zderad developed the HUMANISTIC 1975 by who?
NURSING PRACTICE theory while Benner
and Wruber postulate the PRIMACY OF A. Becker
CARING MODEL. B. Smith
C. Dunn
82. He describes the WELLNESS-ILLNESS D. Leavell and Clark
Continuum as interaction of the environment
Answer:A. Becker. According to Becker,
with well being and illness. The belief of an individual greatly affects his
A. Cannon behavior. If a man believes that he is
B. Bernard susceptible to an illness, He will alter his
C. Dunn behavior in order to prevent its occurence.
D. Clark For example, If a man thinks that diabetes is
acquired through high intake of sugar and
Answer: Dunn simple carbohydrates, then he will limit the
intake of foods rich in these components.
83. An integrated method of functioning that
is oriented towards maximizing one’s 87. In health belief model, Individual
potential within the limitation of the perception matters. Which of the following is
environment. highly UNLIKELY to influence preventive
behavior?
A. Well being
B. Health A. Perceived susceptibility to an illness
C. Low level Wellness B. Perceived seriousness of an illness
D. High level Wellness C. Perceived threat of an illness
D. Perceived curability of an illness
Answer: High level Wellness
Answer: D. Perceived curability of an
84. What kind of illness precursor, according illness . If a man think he is susceptibe to a
to DUNN is cigarette smoking? certain disease, thinks that the disease is
serious and it is a threat to his life and
A. Heredity functions, he will use preventive behaviors to
B. Social avoid the occurence of this threat.
C. Behavioral
D. Environmental 88. Which of the following is not a
PERCEIVED BARRIER in preventive action?
Answer: C. Behavioral. Behavioral
precursors includes smoking, alcoholism, A. Difficulty adhering to the lifestyle
high fat intake and other lifestyle choices. B. Economic factors
Environmental factors involved poor C. Accessibility of health care facilities
D. Increase adherence to medical therapies 91. Knowledge about the disease and prior
contact with it is what type of VARIABLE
Answer:A. Difficulty adhering to the lifestyle according to the health belief model?
and B. Economic factors. Perceived barriers
are those factors that affects the individual’s A. Demographic
health preventive actions. Both A and B can B. Sociopsychologic
affect the individual’s ability to prevent the C. Structural
occurence of diseases. C and D are called D. Cues to action
Preventive Health Behaviors which enhances
the individual’s preventive capabilities. Answer: C. Structural. Modifying variables in
Becker’s health belief model includes
89. Conceptualizes that health is a condition DEMOGRAPHIC : Age, sex, race etc.
of actualization or realization of person’s SOCIOPSYCHOLOGIC : Social and Peer
potential. Avers that the highest aspiration of influence. STRUCTURAL : Knowledge about
the disease and prior contact with it and
people is fulfillment and complete
CUES TO ACTION : Which are the sign and
development actualization.
symptoms of the disease or advice from
A. Clinical Model friends, mass media and others that forces or
B. Role performance Model makes the individual seek help
C. Adaptive Model
D. Eudaemonistic Model 92. It includes internal and external factors
that leads the individual to seek help
Answer: D. Eudaemonistic Model . Smith
A. Demographic
formulated 5 models of health. Clinical
B. Sociopsychologic
model simply states that when people
C. Structural
experience sign and symptoms, they would
D. Cues to action
think that they are unhealthy therefore,
Health is the absence of clinical sign and
Answer: D. Cues to action . Refer to question
symptoms of a disease. Role performance
# 91.
model states that when a person does his role
and activities without deficits, he is healthy
93. Influence from peers and social pressure is
and the inability to perform usual roles
means that the person is ill. Adaptive Model included in what variable of HBM?
states that if a person adapts well with his A. Demographic
environment, he is healthy and maladaptation B. Sociopsychologic
equates illness. Eudaemonistic Model of C. Structural
health according to smith is the actualization D. Cues to action
of a person’s fullest potential. If a person
functions optimally and develop self Answer: B. Sociopsychologic. Refer to
actualization, then, no doubt that person is question # 91.
healthy.
94. Age, Sex, Race etc. is included in what
90. Views people as physiologic system and variable of HBM?
Absence of sign and symptoms equates health.
A. Demographic
A. Clinical Model B. Sociopsychologic
B. Role performance Model C. Structural
C. Adaptive Model D. Cues to action
D. Eudaemonistic Model
Answer: A. Demographic. Refer to question
Answer:A. Clinical Model. Rationale: Refer # 91.
to question # 89.
95. According to Leavell and Clark’s ecologic
model, All of this are factors that affects
health and illness except
A. Reservoir
B. Agent Answer: B. Disease. Disease are alteration in
C. Environment body functions resulting in reduction of
D. Host capabilities or shortening of life span.

Answer: A. Reservoir. According to L&C’s
Ecologic model, there are 3 factors that affect
health and illness. These are the AGENT or
the factor the leads to illness, either a bacteria
or an event in life. HOST are persons that
may or may not be affected by these agents.
ENVIRONMENT are factors external to the
host that may or may not predispose him to
the AGENT.
96. Is a multi dimensional model developed
by PENDER that describes the nature of
persons as they interact within the
environment to pursue health
A. Ecologic Model
B. Health Belief Model
C. Health Promotion Model
D. Health Prevention Model
Answer: C. Health Promotion Model. Pender
developed the concept of HEALTH
PROMOTION MODEL which postulated
that an individual engages in health
promotion activities to increase well being
and attain self actualization. These includes
exercise, immunization, healthy lifestyle,
good food, self responsibility and all other
factors that minimize if not totally eradicate
risks and threats of health.
97. Defined by Pender as all activities directed
toward increasing the level of well being and
self actualization.
A. Health prevention
B. Health promotion
C. Health teaching
D. Self actualization
Answer:B. Health promotion. Refer to
question # 96.
99. Personal state in which a person feels
unhealthy
A. Illness
B. Disease
C. Health
D. Wellness
Answer:A. Illness. Illness is something
PERSONAL. Unlike disease, Illness are
personal state in which person feels
unhealthy. An old person might think he is
ILL but in fact, he is not due, to diminishing
functions and capabilities, people might think
they are ILL. Disease however, is something
with tangible basis like lab results, X ray
films or clinical sign and symptoms.
100. According to her, Caring is defined as a
nurturant way of responding to a valued client
towards whom the nurse feels a sense of
commitment and responsibility.
A. Benner
B. Watson
C. Leininger
D. Swanson
Answer: B. Watson. This is Jean Watson’s
definition of Nursing as caring. This was
asked word per word last June 06′ NLE.
Benner defines caring as something that
matters to people. She postulated the
responsibility created by Caring in nursing.
She was also responsible for the PRIMACY
OF CARING MODEL. Leininger defind the
4 conservation principle while Swanson
introduced the 5 processes of caring.

98. Defined as an alteration in normal PNLE: FON Practice

function resulting in reduction of capacities
and shortening of life span. Exam for Infection,
A. Illness
B. Disease Asepsis, Basic
C. Health
D. Wellness

concept of Stress and
Illness
1. When the General adaptation
syndrome is activated, FLIGHT OR FIGHT
response sets in. Sympathetic nervous system
releases norepinephrine while the adrenal
medulla secretes epinephrine. Which of the
following is true with regards to that
statement?
A. Pupils will constrict
B. Client will be lethargic
C. Lungs will bronchodilate
D. Gastric motility will increase
Answer: C. Lungs will bronchodilate. To
better understand the concept : The
autonomic nervous system is composed of
SYMPATHETIC and
PARASYMPATHETIC Nervous system. It
is called AUTONOMIC Because it is
Involuntary and stimuli based. You cannot
tell your heart to kindly beat for 60 per
minute, Nor, Tell your blood vessels, Please
constrict, because you need to wear skirt
today and your varicosities are bulging.
Sympathetic Nervous system is the FIGHT
or FLIGHT mechanism. When people
FIGHT or RUN, we tend to stimulate the
ANS and dominate over SNS. Just Imagine a
person FIGHTING and RUNNING to get the
idea on the signs of SNS Domination.
Imagine a resting and digesting person to get
a picture of PNS Domination. A person
RUNNING or FIGHTING Needs to
bronchodilate, because the oxygen need is
increased due to higher demand of the body.
Pupils will DILATE to be able to see the
enemy clearly. Client will be fully alert to
dodge attacks and leap through obstacles
during running. The client’s gastric motility
will DECREASE Because you cannot afford
to urinate or defecate during fighting nor
running.
2. Which of the following response is not
expected to a person whose GAS is activated
and the FIGHT OR FLIGHT response sets in?
A. The client will not urinate due to
relaxation of the detrusor muscle
B. The client will be restless and alert
C. Clients BP will increase, there will be
vasodilation
D. There will be increase glycogenolysis,
Pancrease will decrease insulin secretion
Answer: C. Clients BP will increase, there
will be vasodilation. If vasodilation will
occur, The BP will not increase but decrease.
It is true that Blood pressure increases during
SNS Stimulation due to the fact that we need
more BLOOD to circulate during the FIGHT
or FLIGHT Response because the oxygen
demand has increased, but this is facilitated
by vasoconstriction and not vasodilation. A,B
and D are all correct. The liver will increase
glycogenolysis or glycogen store utilization
due to a heightened demand for energy.
Pancrease will decrease insulin secretion
because almost every aspect of digestion that
is controlled by Parasympathetic nervous
system is inhibited when the SNS dominates.
3. State in which a person’s physical,
emotional, intellectual and social development
or spiritual functioning is diminished or
impaired compared with a previous
experience.
A. Illness
B. Disease
C. Health
D. Wellness
Answer: A. Illness. Disease is a PROVEN
FACT based on a medical theory, standards,
diagnosis and clinical feature while ILLNESS
Is a subjective state of not feeling well based
on subjective appraisal, previous experience,
peer advice etc
4. This is the first stage of illness wherein, the
person starts to believe that something is
wrong. Also known as the transition phase
from wellness to illness.
A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role
Answer: A. Symptom Experience. A favorite
board question are Stages of Illness. When a
person starts to believe something is wrong,
that person is experiencing signs and
symptoms of an illness. The patient will then
ASSUME that he is sick. This is called
assumption of the sick role where the patient
accepts he is Ill and try to give up some
activities. Since the client only ASSUMES
his illness, he will try to ask someone to
validate if what he is experiencing is a
disease, This is now called as MEDICAL
CARE CONTACT. The client seeks
professional advice for validation,
reassurance, clarification and explanation of
the symptoms he is experiencing. client will
then start his dependent patient role of
receiving care from the health care providers.
The last stage of Illness is the RECOVERY
stage where the patient gives up the sick role
and assumes the previous normal gunctions.
5. In this stage of illness, the person accepts or
rejects a professionals suggestion. The person
also becomes passive and may regress to an
earlier stage.
A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role
Answer: D. Dependent patient role. In the
dependent patient role stage, Client needs
professionals for help. They have a choice
either to accept or reject the professional’s
decisions but patients are usually passive and
accepting. Regression tends to occur more in
this period.
6. In this stage of illness, The person learns to
accept the illness.
A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role
Answer:B. Assumption of sick
role. Acceptance of illness occurs in the
Assumption of sick role phase of illness.
7. In this stage, the person tries to find
answers for his illness. He wants his illness to
be validated, his symptoms explained and the
outcome reassured or predicted
A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role
Answer: C. Medical care contact. At this
stage, The patient seeks for validation of his
symptom experience. He wants to find out if
what he feels are normal or not normal. He
wants someone to explain why is he feeling
these signs and symptoms and wants to know
the probable outcome of this experience.
8. The following are true with regards to
aspect of the sick role except
A. One should be held responsible for his
condition
B. One is excused from his societal role
C. One is obliged to get well as soon as
possible
D. One is obliged to seek competent help
Answer: A. One should be held responsible
for his condition. The nurse should not judge
the patient and not view the patient as the
cause or someone responsible for his illness.
A sick client is excused from his societal roles,
Oblige to get well as soon as possible and
Obliged to seek competent help.
9. Refers to conditions that increases
vulnerability of individual or group to illness
or accident
A. Predisposing factor
B. Etiology
C. Risk factor
D. Modifiable Risks
Answer: C. Risk factor
10. Refers to the degree of resistance the
potential host has against a certain pathogen
A. Susceptibility
B. Immunity
C. Virulence
D. Etiology
Answer: A. Susceptibility. Immunity is the
ABSOLUTE Resistance to a pathogen
considering that person has an INTACT
IMMUNITY while susceptibility is the
DEGREE of resistance. Degree of resistance
means how well would the individual combat
the pathogens and repel infection or invasion
of these disease causing organisms. A
susceptible person is someone who has a 13. The classification of CANCER according
very low degree of resistance to combat to its etiology Is best described as:
pathogens. An Immune person is someone
that can easily repel specific pathogens. 1. Nosocomial
However, Remember that even if a person is 2. Idiopathic
IMMUNE [ Vaccination ] Immunity can 3. Neoplastic
always be impaired in cases of chemotherapy, 4. Traumatic
HIV, Burns, etc. 5. Congenital
6. Degenrative
11. A group of symptoms that sums up or A. 5 and 2
constitute a disease B. 2 and 3
C. 3 and 4
A. Syndrome D. 3 and 5
B. Symptoms
C. Signs Answer: B. 2 and 3. Aside from being
D. Etiology NEOPLASTIC, Cancer is considered as
IDIOPATHIC because the cause is
Answer: A. Syndrome. Symptoms are UNKNOWN.
individual manifestation of a certain disease.
For example, In Tourette syndrome, patient 14. Term to describe the reactiviation and
will manifest TICS, but this alone is not recurrence of pronounced symptoms of a
enough to diagnose the patient as other disease
diseases has the same tic manifestation.
Syndrome means COLLECTION of these A. Remission
symptoms that occurs together to B. Emission
characterize a certain disease. Tics with C. Exacerbation
coprolalia, echolalia, palilalia, choreas or D. Sub acute
other movement disorders are characteristics
of TOURETTE SYNDROME. Answer:C. Exacerbation

12. A woman undergoing radiation therapy
developed redness and burning of the skin
around the best. This is best classified as what
type of disease?
A. Neoplastic
B. Traumatic
C. Nosocomial
D. Iatrogenic
Answer: D. Iatrogenic. Iatrogenic diseases
refers to those that resulted from treatment of
a certain disease. For example, A child
frequently exposed to the X-RAY Machine
develops redness and partial thickness burns
over the chest area. Neoplastic are malignant
diseases cause by proliferation of abnormally
growing cells. Traumatic are brought about
by injuries like Motor vehicular accidents.
Nosocomial are infections that acquired
INSIDE the hospital. Example is UTI
Because of catheterization, This is commonly
caused by E.Coli.
15. A type of illness characterized by periods
of remission and exacerbation
A. Chronic
B. Acute
C. Sub acute
D. Sub chronic
Answer: A. Chronic. A good example is
Multiple sclerosis that characterized by
periods of remissions and exacerbation and it
is a CHRONIC Disease. An acute and sub
acute diseases occurs too short to manifest
remissions. Chronic diseases persists longer
than 6 months that is why remissions and
exacerbation are observable.
16. Diseases that results from changes in the
normal structure, from recognizable
anatomical changes in an organ or body tissue
is termed as
A. Functional
B. Occupational
C. Inorganic
D. Organic
Answer:D. Organic. As the word implies,
ORGANIC Diseases are those that causes a
CHANGE in the structure of the organs and
systems. Inorganic diseases is synonymous
with FUNCTIONAL diseases wherein, There
is no evident structural, anatomical or
physical change in the structure of the organ
or system but function is altered due to other
causes, which is usually due to abnormal
response of the organ to stressors. Therefore,
ORGANIC BRAIN SYNDROME are
anatomic and physiologic change in the
BRAIN that is NON PROGRESSIVE BUT
IRREVERSIBLE caused by alteration in
structure of the brain and it’s supporting
structure which manifests different sign and
symptoms of neurological, physiologic and
psychologic alterations. Mental disorders
manifesting symptoms of psychoses without
any evident organic or structural damage are
termed as INORGANIC PSYCHOSES while
alteration in the organ structures that causes
symptoms of bizaare pyschotic behavior is
termed as ORGANIC PSYCHOSES.
17. It is the science of organism as affected by
factors in their environment. It deals with the
relationship between disease and geographical
environment.
A. Epidemiology
B. Ecology
C. Statistics
D. Geography
Answer: B. Ecology. Ecology is the science
that deals with the ECOSYSTEM and its
effects on living things in the biosphere. It
deals with diseases in relationship with the
environment. Epidimiology is simply the
Study of diseases and its occurence and
distribution in man for the purpose of
controlling and preventing diseases. This was
asked during the previous boards.
18. This is the study of the patterns of health
and disease. Its occurrence and distribution in
man, for the purpose of control and prevention
of disease.
A. Epidemiology
B. Ecology
C. Statistics
D. Geography
Answer: A. Epidemiology. Refer to number
17.
19. Refers to diseases that produced no
anatomic changes but as a result from
abnormal response to a stimuli.
A. Functional
B. Occupational
C. Inorganic
D. Organic
Answer: C. Inorganic. Refer to number 16.
20. In what level of prevention according to
Leavell and Clark does the nurse support the
client in obtaining OPTIMAL HEALTH
STATUS after a disease or injury?
A. Primary
B. Secondary
C. Tertiary
D. None of the above
Answer: C. Tertiary. Perhaps one of the
easiest concept but asked frequently in the
NLE. Primary refers to preventions that aims
in preventing the disease. Examples are
healthy lifestyle, good nutrition, knowledge
seeking behaviors etc. Secondary prevention
are those that deals with early diagnostics,
case finding and treatments. Examples are
monthly breast self exam, Chest X-RAY,
Antibiotic treatment to cure infection, Iron
therapy to treat anemia etc. Tertiary
prevention aims on maintaining optimum
level of functioning during or after the
impact of a disease that threatens to alter the
normal body functioning. Examples are
prosthetis fitting for an amputated leg after
an accident, Self monitoring of glucose
among diabetics, TPA Therapy after stroke
etc. The confusing part is between the
treatment in secondary and treatment in
tertiary. To best differentiate the two, A
client with ANEMIA that is being treated
with ferrous sulfate is considered being in the
SECONDARY PREVENTION because
ANEMIA once treated, will move the client
on PRE ILLNESS STATE again. However,
In cases of ASPIRING Therapy in cases of
stroke, ASPIRING no longer cure the patient
or PUT HIM IN THE PRE ILLNESS
STATE. ASA therapy is done in order to
prevent coagulation of the blood that can lead 24. BCG in community health nursing is what
to thrombus formation and a another possible type of prevention?
stroke. You might wonder why I spelled
ASPIRIN as ASPIRING, Its side effect is A. Primary
OTOTOXICITY [ CN VIII ] that leads to B. Secondary
TINNITUS or ringing of the ears. C. Tertiary
D. None of the above
21. In what level of prevention does the nurse
encourage optimal health and increases Answer: primary
person’s susceptibility to illness?
25. A regular pap smear for woman every 3
A. Primary years after establishing normal pap smear for
B. Secondary 3 consecutive years Is advocated. What level
C. Tertiary of prevention does this belongs?
D. None of the above
A. Primary
Answer: D. None of the above. The nurse B. Secondary
never increases the person’s susceptibility to C. Tertiary
illness but rather, LESSEN the person’s D. None of the above
susceptibility to illness.
Answer: secondary
22. Also known as HEALTH
MAINTENANCE prevention. 26. Self monitoring of blood glucose for
diabetic clients is on what level of prevention?
A. Primary
B. Secondary A. Primary
C. Tertiary B. Secondary
D. None of the above C. Tertiary
D. None of the above
Answer: B. Secondary. Secondary prevention
is also known as HEALTH Answer: tertiary
MAINTENANCE Prevention. Here, The
person feels signs and symptoms and seeks 27. Which is the best way to disseminate
Diagnosis and treatment in order to prevent information to the public?
deblitating complications. Even if the person
feels healthy, We are required to A. Newspaper
MAINTAIN our health by monthly check B. School bulletins
ups, Physical examinations, Diagnostics etc. C. Community bill boards
D. Radio and Television
23. PPD In occupational health nursing is
what type of prevention? Answer: D. Radio and Television. An actual
board question, The best way to disseminate
A. Primary information to the public is by TELEVISION
B. Secondary followed by RADIO. This is how the DOH
C. Tertiary establish its IEC Programs other than
D. None of the above publising posters, leaflets and brochures. An
emerging new way to disseminate is through
Answer: A. Primary. PPD or PERSONAL the internet.
PROTECTIVE DEVICES are worn by the
workes in a hazardous environment to protect 28. Who conceptualized health as integration
them from injuries and hazards. This is of parts and subparts of an individual?
considered as a PRIMARY prevention
because the nurse prevents occurence of A. Newman
diseases and injuries. B. Neuman
C. Watson 31. Excessive alcohol intake is what type of
D. Rogers risk factor?

Answer: B. Neuman. The supra and A. Genetics

subsystems are theories of Martha Rogers but B. Age
the parts and subparts are Betty Neuman’s. C. Environment
She stated that HEALTH is a state where in D. Lifestyle
all parts and subparts of an individual are in
harmony with the whole system. Margarex Answer: lifestyle
Newman defined health as an EXPANDING
CONSCIOUSNESS. Her name is Margaret 32. Osteoporosis and degenerative diseases
not Margarex, I just used that to help you like Osteoarthritis belongs to what type of risk
remember her theory of health. factor?

29. The following are concept of health: A. Genetics

B. Age
1. Health is a state of complete physical, C. Environment
mental and social wellbeing and not D. Lifestyle
merely an absence of disease or infirmity.
2. Health is the ability to maintain balance Answer: age
3. Health is the ability to maintain internal
milieu 33. Also known as STERILE TECHNIQUE
4. Health is integration of all parts and
subparts of an individual A. Surgical Asepsis
A. 1,2,3 B. Medical Asepsis
B. 1,3,4 C. Sepsis
C. 2,3,4 D. Asepsis
D. 1,2,3,4
Answer: A. Surgical Asepsis. Surgical
Answer: D. 1,2,3,4. All of the following are Asepsis is also known as STERILE
correct statement about health. The first one TECHNIQUE while Medical Asepsis is
is the definition by WHO, The second one is synonymous with CLEAN TECHNIQUE.
from Walter Cannon’s homeostasis theory.
Third one is from Claude Bernard’s concept 34. This is a person or animal, who is without
of Health as Internal Milieu and the last one signs of illness but harbors pathogen within
is Neuman’s Theory. his body and can be transferred to another

30. The theorist the advocated that health is A. Host

the ability to maintain dynamic equilibrium is B. Agent
C. Environment
A. Bernard D. Carrier
B. Selye
C. Cannon Answer: carrier
D. Rogers
35. Refers to a person or animal, known or
Answer: C. Cannon. Walter Cannon believed to have been exposed to a disease.
advocated health as HOMEOSTASIS or the
ability to maintain dynamic equilibrium. A. Carrier
Hans Selye postulated Concepts about Stress B. Contact
and Adaptation. Bernard defined health as C. Agent
the ability to maintain internal milieu and D. Host
Rogers defined Health as Wellness that is
influenced by individual’s culture. Answer: contact
36. A substance usually intended for use on
inanimate objects, that destroys pathogens but
not the spores.
A. Sterilization
B. Disinfectant
C. Antiseptic
D. Autoclave
Answer: B. Disinfectant. Disinfectants are
used on inanimate objects while Antiseptics
are intended for use on persons and other
living things. Both can kill and inhibit
growth of microorganism but cannot kill
their spores. That is when autoclaving or
steam under pressure gets in, Autoclaving
can kill almost ALL type of microoganism
including their spores.
37. This is a process of removing pathogens
but not their spores
A. Sterilization
B. Auto claving
C. Disinfection
D. Medical asepsis
Answer: C. Disinfection. Both A and B are
capable on killing spores. Autoclaving is a
form of Sterilization. Medical Asepsis is a
PRACTICE designed to minimize or reduce
the transfer of pathogens, also known as your
CLEAN TECHNIQUE. Disinfection is the
PROCESS of removing pathogens but not
their spores.
38. The third period of infectious processes
characterized by development of specific
signs and symptoms
A. Incubation period
B. Prodromal period
C. Illness period
D. Convalescent period
Answer: C. Illness period. In incubation
period, The disease has been introduced to
the body but no sign and symptom appear
because the pathogen is not yet strong
enough to cause it and may still need to
multiply. The second period is called
prodromal period. This is when the
appearance of non specific signs and
symptoms sets in, This is when the sign and
symptoms starts to appear. Illness period is
characterized by the appearance of specific
signs and symptoms or refer tp as time with
the greatest symptom experience. Acme is
the PEAK of illness intensity while the
convalescent period is characterized by the
abatement of the disease process or it’s
gradual disappearance.
39. A child with measles developed fever and
general weakness after being exposed to
another child with rubella. In what stage of
infectious process does this child belongs?
A. Incubation period
B. Prodromal period
C. Illness period
D. Convalescent period
Answer: B. Prodromal period. To be able to
categorize MEASLES in the Illness period,
the specific signs of Fever, Koplik’s Spot and
Rashes must appear. In the situation above,
Only general signs and symptoms appeared
and the Specific signs and symptoms is yet to
appear, therefore, the illness is still in the
Prodromal period. Signs and symptoms of
measles during the prodromal phase are
Fever, fatigue, runny nose, cough and
conjunctivitis. Koplik’s spot heralds the
Illness period and cough is the last symptom
to disappear. All of this processes take place
in 10 days that is why, Measles is also known
as 10 day measles.
40. A 50 year old mailman carried a mail with
anthrax powder in it. A minute after exposure,
he still hasn’t developed any signs and
symptoms of anthrax. In what stage of
infectious process does this man belongs?
A. Incubation period
B. Prodromal period
C. Illness period
D. Convalescent period
Answer: A. Incubation period. Anthrax can
have an incubation period of hours to 7 days
with an average of 48 hours. Since the
question stated exposure, we can now assume
that the mailman is in the incubation period.
41. Considered as the WEAKEST LINK in
the chain of infection that nurses can
manipulate to prevent spread of infection and
diseases
A. Etiologic/Infectious agent
B. Portal of Entry
C. Susceptible host
D. Mode of transmission
Answer: D. Mode of transmission. Mode of
transmission is the weakest link in the chain
of infection. It is easily manipulated by the
Nurses using the tiers of prevention, either by
instituting transmission based precautions,
Universal precaution or Isolation techniques.
42. Which of the following is the exact order
of the infection chain?
1. Susceptible host
2. Portal of entry
3. Portal of exit
4. Etiologic agent
5. Reservoir
6. Mode of transmission
A. 1,2,3,4,5,6
B. 5,4,2,3,6,1
C. 4,5,3,6,2,1
D. 6,5,4,3,2,1
Answer: C. 4,5,3,6,2,1. Chain of infection
starts with the SOURCE : The etiologic agent
itself. It will first proliferate on a
RESERVOIR and will need a PORTAL OF
EXIT to be able to TRANSMIT irslef using a
PORTAL OF ENTRY to a SUSCEPTIBLE
HOST. A simple way to understand the
process is by looking at the lives of a young
queen ant that is starting to build her colony.
Imagine the QUEEN ANT as a SOURCE or
the ETIOLOGIC AGENT. She first need to
build a COLONY, OR the RESERVOIR
where she will start to lay the first eggs to be
able to produce her worker ants and soldier
ants to be able to defend and sustain the new
colony. They need to EXIT [PORTAL OF
EXIT] their colony and crawl [MODE OF
TRANSMISSION] in search of foods by
ENTERING / INVADING [PORTAL OF
ENTRY] our HOUSE [SUSCEPTIBLE
HOST]. By imagining the Ant’s life cycle,
we can easily arrange the chain of infection.
43. Markee, A 15 year old high school student
asked you. What is the mode of transmission
of Lyme disease. You correctly answered him
that Lyme disease is transmitted via
A. Direct contact transmission
B. Vehicle borne transmission
C. Air borne transmission
D. Vector borne transmission
Answer: D. Vector borne transmission. Lyme
disease is caused by Borrelia Burdorferi and
is transmitted by a TICK BITE.
44. The ability of the infectious agent to cause
a disease primarily depends on all of the
following except
A. Pathogenicity
B. Virulence
C. Invasiveness
D. Non Specificity
Answer: D. Non Specificity. To be able to
cause a disease, A pathogen should have a
TARGET ORGAN/S. The pathogen should
be specific to these organs to cause an
infection. Mycobacterium Avium is NON
SPECIFIC to human organs and therefore,
not infective to humans but deadly to birds.
An immunocompromised individual,
specially AIDS Patient, could be infected
with these NON SPECIFIC diseases due to
impaired immune system.
45. Contact transmission of infectious
organism in the hospital is usually cause by
A. Urinary catheterization
B. Spread from patient to patient
C. Spread by cross contamination via
hands of caregiver
D. Cause by unclean instruments used by
doctors and nurses
Answer: C. Spread by cross contamination
via hands of caregiver. The hands of the
caregiver like nurses, is the main cause of
cross contamination in hospital setting. That
is why HANDWASHING is the single most
important procedure to prevent the occurence
of cross contamination and nosocomial
infection. D refers to Nosocomial infection
and UTI is the most common noscomial
infection in the hospital caused by urinary
catheterization. E.Coli seems to be the major
cause of this incident. B best fits Cross
Contamination, It is the spread of
microogranisms from patient o patient.
46. Transmission occurs when an infected Answer: C. Artificial active immunity. TT1 ti
person sneezes, coughs or laugh that is usually TT2 are considered the primary dose, while
projected at a distance of 3 feet. TT3 to TT5 are the booster dose. A woman
with completed immunization of DPT need
A. Droplet transmission not receive TT1 and TT2. Tetanus toxoid is
B. Airborne transmission the actual toxin produce by clostridium tetani
C. Vehicle transmission but on its WEAK and INACTIVATED form.
D. Vector borne transmission It is Artificial because it did not occur in the
course of actual illness or infection, it is
Answer: Droplet transmission Active because what has been passed is an
actual toxin and not a ready made
47. Considered as the first line of defense of immunoglobulin.
the body against infection
50. Agatha, was hacked and slashed by a
A. Skin psychotic man while she was crossing the
B. WBC railway. She suffered multiple injuries and
C. Leukocytes was injected Tetanus toxoid Immunoglobulin.
D. Immunization Agatha asked you, What immunity does TTIg
provides? You best answered her by saying
Answer: A. Skin. Remember that intact skin TTIg provides
and mucus membrane is our first line of
defense against infection. A. Natural active immunity
B. Natural passive immunity
48. All of the following contributes to host C. Artificial active immunity
susceptibility except D. Artificial passive immunity

A. Creed Answer: D. Artificial passive immunity. In

B. Immunization
C. Current medication being taken
D. Color of the skin
Answer: A. Creed. Creed, Faith or religious
belief do not affect person’s susceptibility to
illness. Medication like corticosteroids could
supress a person’s immune system that will
lead to increase susceptibility. Color of the
skin could affect person’s susceptibility to
certain skin diseases. A dark skinned person
has lower risk of skin cancer than a fair
skinned person. Fair skinned person also has
a higher risk for cholecystitis and
cholelithiasis.
49. Graciel has been injected TT5, her last
dosed for tetanus toxoid immunization.
Graciel asked you, what type of immunity is
TT Injections? You correctly answer her by
saying Tetanus toxoid immunization is a/an
this scenario, Agatha was already wounded
and has injuries. Giving the toxin [TT
Vaccine] itself would not help Agatha
because it will take time before the immune
system produce antitoxin. What agatha needs
now is a ready made anti toxin in the form of
ATS or TTIg. This is artificial, because the
body of agatha did not produce it. It is
passive because her immune system is not
stimulated but rather, a ready made Immune
globulin is given to immediately supress the
invasion.
51. This is the single most important
procedure that prevents cross contamination
and infection
A. Cleaning
B. Disinfecting
C. Sterilizing
D. Handwashing

A. Natural active immunity Answer: D. Handwashing. When you see the

B. Natural passive immunity word HANDWASHING as one of the
C. Artificial active immunity options, 90% Chance it is the correct answer
D. Artificial passive immunity in the local board. Or should I say, 100%
because I have yet to see question from 1988
to 2005 board questions that has option
HANDWASHING on it but is not the correct
answer.
52. This is considered as the most important
aspect of handwashing
A. Time
B. Friction
C. Water
D. Soap
Answer: B. Friction. The most important
aspect of handwashing is FRICTION. The rest,
will just enhance friction. The use of soap
lowers the surface tension thereby increasing
the effectiveness of friction. Water helps
remove transient bacteria by working with
soap to create the lather that reduces surface
tension. Time is of essence but friction is the
most essential aspect of handwashing
53. In handwashing by medical asepsis, Hands
are held ….
A. Above the elbow, The hands must always
be above the waist
B. Above the elbow, The hands are cleaner
than the elbow
C. Below the elbow, Medical asepsis do not
require hands to be above the waist
D. Below the elbow, Hands are dirtier
than the lower arms
Answer: D. Below the elbow, Hands are
dirtier than the lower arms. Hands are held
BELOW the elbow in medical asepsis in
contrast with surgical asepsis, wherein,
nurses are required to keep the hands above
the waist. The rationale is because in medical
asepsis, Hands are considered dirtier than the
elbow and therefore, to limit contamination
of the lower arm, The hands should always
be below the elbow.
54. The suggested time per hand on
handwashing using the time method is
A. 5 to 10 seconds each hand
B. 10 to 15 seconds each hand
C. 15 to 30 seconds each hand
D. 30 to 60 seconds each hand
Answer: C. 15 to 30 seconds each hand. Each
hands requires atleast 15 to 30 seconds of
handwashing to effectively remove transient
microorganisms.
55. The minimum time in washing each hand
should never be below
A. 5 seconds
B. 10 seconds
C. 15 seconds
D. 30 seconds
Answer:B. 10 seconds. According to Kozier,
The minimum time required for watching
each hands is 10 seconds and should not be
lower than that. The recommended time,
again, is 15 to 30 seconds.
56. How many ml of liquid soap is
recommended for handwashing procedure?
A. 1-2 ml
B. 2-3 ml
C. 2-4 ml
D. 5-10 ml
Answer: C. 2-4 ml. If a liquid soap is to be
used, 1 tsp [ 5ml ] of liquid soap is
recommended for handwashing procedure.
57. Which of the following is not true about
sterilization, cleaning and disinfection?
A. Equipment with small lumen are easier
to clean
B. Sterilization is the complete destruction of
all viable microorganism including spores
C. Some organism are easily destroyed,
while other, with coagulated protein
requires longer time
D. The number of organism is directly
proportional to the length of time required
for sterilization
Answer: A. Equipment with small lumen are
easier to clean. Equipments with LARGE
LUMEN are easier to clean than those with
small lumen. B C and D are all correct.
58. Karlita asked you, How long should she
boil her glass baby bottle in water? You
correctly answered her by saying
A. The minimum time for boiling articles is
5 minutes
B. Boil the glass baby bottler and other
articles for atleast 10 minutes
C. For boiling to be effective, a minimum
of 15 minutes is required
D. It doesn’t matter how long you boil the
articles, as long as the water reached 100
degree Celsius
Answer: C. For boiling to be effective, a
minimum of 15 minutes is required. Boiling
is the most common and least expensive
method of sterilization used in home. For it
to be effective, you should boil articles for
atleast 15 minutes.
59. This type of disinfection is best done in
sterilizing drugs, foods and other things that
are required to be sterilized before taken in by
the human body
A. Boiling Water
B. Gas sterilization
C. Steam under pressure
D. Radiation
Answer: D. Radiation. Imagine foods and
drugs that are being sterilized by a boiling
water, ethylene oxide gas and autoclave or
steam under pressure, They will be
inactivated by these methods. Ethylene oxide
gas used in gas sterlization is TOXIC to
humans. Boiling the food will alter its
consistency and nutrients. Autoclaving the
food is never performed. Radiation using
microwave oven or Ionizing radiation
penetrates to foods and drugs thus, sterilizing
them.
60. A TB patient was discharged in the
hospital. A UV Lamp was placed in the room
where he stayed for a week. What type of
disinfection is this?
A. Concurrent disinfection
B. Terminal disinfection
C. Regular disinfection
D. Routine disinfection
Answer: B. Terminal disinfection. Terminal
disinfection refers to practices to remove
pathogens that stayed in the belongings or
immediate environemnt of an infected client
who has been discharged. An example would
be Killing airborne TB Bacilli using UV
Light. Concurrent disinfection refers to
ongoing efforts implented during the client’s
stay to remove or limit pathogens in his
supplies, belongings, immediate environment
in order to control the spread of the disease.
An example is cleaning the bedside
commode of a client with radium implant on
her cervix with a bleach disinfectant after
each voiding.
61. Which of the following is not true in
implementing medical asepsis
A. Wash hand before and after patient
contact
B. Keep soiled linens from touching the
clothings
C. Shake the linens to remove dust
D. Practice good hygiene
Answer: C. Shake the linens to remove
dust. NEVER shake the linens. Once soiled,
fold it inwards clean surface out. Shaking the
linen will further spread pathogens that has
been harbored by the fabric.
62. Which of the following is true about
autoclaving or steam under pressure?
A. All kinds of microorganism and their
spores are destroyed by autoclave
machine
B. The autoclaved instruments can be used
for 1 month considering the bags are still
intact
C. The instruments are put into unlocked
position, on their hinge, during the
autoclave
D. Autoclaving different kinds of metals at
one time is advisable
Answer: C. The instruments are put into
unlocked position, on their hinge, during the
autoclave. Only C is correct. Metals with
locks, like clamps and scissors should be
UNLOCKED in order to minimize stiffening
caused by autoclave to the hinges of these
metals. NOT ALL microorganism are
destroyed by autoclaving. There are recently
discovered microorganism that is
invulnarable to extreme heat. Autoclaved
instruments are to be used within 2 weeks.
Only the same type of metals should be
autoclaved as this will alteration in plating of
these metals.
63. Which of the following is true about
masks?
A. Mask should only cover the nose
B. Mask functions better if they are wet with
alcohol
C. Masks can provide durable protection
even when worn for a long time and after
each and every patient care
D. N95 Mask or particulate masks can
filter organism as mall as 1
micromillimeter
Answer: D. N95 Mask or particulate masks
can filter organism as mall as 1
micromillimeter. Mask should cover both
nose and mouth. Masks will not function
optimally when wet. Masks should be worn
not greater than 4 hours, as it will lose
effectiveness after 4 hours. N95 mask or
particulate mask can filter organism as small
as 1 micromillimeter.
64. Where should you put a wet adult diaper?
A. Green trashcan
B. Black trashcan
C. Orange trashcan
D. Yellow trashcan
Answer: D. Yellow trashcan. Infectious
waste like blood and blood products, wet
diapers and dressings are thrown in yellow
trashcans.
65. Needles, scalpels, broken glass and lancets
are considered as injurious wastes. As a nurse,
it is correct to put them at disposal via a/an
A. Puncture proof container
B. Reused PET Bottles
C. Black trashcan
D. Yellow trashcan with a tag “INJURIOUS
WASTES”
Answer: A. Puncture proof
container. Needles, scalpels and other sharps
are to be disposed in a puncture proof
container.
66. Miranda Priestly, An executive of RAMP
magazine, was diagnosed with cancer of the
cervix. You noticed that the radioactive
internal implant protrudes to her vagina where
supposedly, it should be in her cervix. What
should be your initial action?
A. Using a long forceps, Push it back
towards the cervix then call the physician
B. Wear gloves, remove it gently and place it
on a lead container
C. Using a long forceps, Remove it and
place it on a lead container
D. Call the physician, You are not allowed to
touch, re insert or remove it
Answer: C. Using a long forceps, Remove it
and place it on a lead container. A dislodged
radioactive cervical implant in brachytherapy
are to be picked by a LONG FORCEP and
stored in a LEAD CONTAINER in order to
prevent damage on the client’s normal tissue.
Calling the physician is the second most
appropriate action among the choices. A
nurse should never attempt to put it back nor,
touch it with her bare hands.
67. After leech therapy, Where should you put
the leeches?
A. In specially marked BIO HAZARD
Containers
B. Yellow trashcan
C. Black trashcan
D. Leeches are brought back to the culture
room, they are not thrown away for they
are reusable
Answer: A. In specially marked BIO
HAZARD Containers. Leeches, in leech
therapy or LEECH PHLEBOTOMY are to
be disposed on a BIO HAZARD container.
They are never re used as this could cause
transfer of infection. These leeches are
hospital grown and not the usual leeches
found in swamps.
68. Which of the following should the nurse
AVOID doing in preventing spread of
infection?
A. Recapping the needle before disposal to
prevent injuries
B. Never pointing a needle towards a body
part
C. Using only Standard precaution to AIDS
Patients
D. Do not give fresh and uncooked fruits and
vegetables to Mr. Gatchie, with
Neutropenia
Answer: A. Recapping the needle before
disposal to prevent injuries. Never recap
needles. They are directly disposed in a
puncture proof container after used.
Recapping the needles could cause injury to
the nurse and spread of infection. B C and D
are all appropriate. Standard precaution is
sufficient for an HIV patient. A client with
neutropenia are not given fresh and uncooked
fruits and vegetables for even the non
infective organisms found in these foods
could cause severe infection on an
immunocompromised patients.
69. Where should you put Mr. Alejar, with
Category II TB?
A. In a room with positive air pressure and
atleast 3 air exchanges an hour
B. In a room with positive air pressure and
atleast 6 air exchanges an hour
C. In a room with negative air pressure and
atleast 3 air exchanges an hour
D. In a room with negative air pressure
and atleast 6 air exchanges an hour
Answer: D. In a room with negative air
pressure and atleast 6 air exchanges an
hour. TB patients should have a private room
with negative air pressure and atleast 6 to 12
air exhanges per hour. Negative pressure
room will prevent air inside the room from
escaping. Air exchanges are necessary since
the client’s room do not allow air to get out
of the room.
70. A client has been diagnosed with
RUBELLA. What precaution is used for this
patient?
A. Standard precaution
B. Airborne precaution
C. Droplet precaution
D. Contact precaution
Answer: C. Droplet precaution. Droplet
precaution is sufficient on client’s with
RUBELLA or german measles.
71. A client has been diagnosed with
MEASLES. What precaution is used for this
patient?
A. Standard precaution
B. Airborne precaution
C. Droplet precaution
D. Contact precaution
Answer: B. Airborne precaution. Measles is
highly communicable and more contagious
than Rubella, It requires airborne precaution
as it is spread by small particle droplets that
remains suspended in air and disperesed by
air movements.
72. A client has been diagnosed with
IMPETIGO. What precaution is used for this
patient?
A. Standard precaution
B. Airborne precaution
C. Droplet precaution
D. Contact precaution
Answer:D. Contact precaution. Impetigo
causes blisters or sores in the skin. It is
generally caused by GABS or Staph Aureaus.
It is spread by skin to skin contact or by
scratching the lesions and touching another
person’s skin.
73. The nurse is to insert an NG Tube when
suddenly, she accidentally dip the end of the
tube in the client’s glass containing distilled
drinking water which is definitely not sterile.
As a nurse, what should you do?
A. Don’t mind the incident, continue to
insert the NG Tube
B. Obtain a new NG Tube for the client
C. Disinfect the NG Tube before reinserting
it again
D. Ask your senior nurse what to do
Answer: A. Don’t mind the incident,
continue to insert the NG Tube. The
digestive tract is not sterile, and therefore,
simple errors like this would not cause harm
to the patient. NGT tube need not be sterile,
and so is colostomy and rectal tubes. Clean
technique is sufficient during NGT and
colostomy care.
74. All of the following are principle of
SURGICAL ASEPSIS except
A. Microorganism travels to moist surfaces
faster than with dry surfaces
B. When in doubt about the sterility of an
object, consider it not sterile
C. Once the skin has been sterilized,
considered it sterile
D. If you can reach the object by
overreaching, just move around the sterile
field to pick it rather than reaching for it
Answer: C. Once the skin has been sterilized,
considered it sterile. Human skin is
impossible to be sterilized. It contains normal
flora of microorganism. A B and D are all
correct.
75. Which of the following is true in
SURGICAL ASEPSIS?
A. Autoclaved linens and gowns are
considered sterile for about 4 months as
long as the bagging is intact
B. Surgical technique is a sole effort of each
nurse
C. Sterile conscience, is the best method to
enhance sterile technique
D. If a scrubbed person leaves the area of the
sterile field, He/she must do handwashing
and gloving again, but the gown need not
be changed
Answer:C. Sterile conscience, is the best
method to enhance sterile technique. Sterile
conscience, or the moral imperative of a nurse
to be honest in practicing sterile technique, is
the best method to enhance sterile technique.
Autoclaved linens are considered sterile only
within 2 weeks even if the bagging is intact.
Surgical technique is a team effort of each
nurse. If a scrubbed person leave the sterile
field and area, he must do the process all over
again.
76. In putting sterile gloves, Which should be
gloved first?
A. The dominant hand
B. The non dominant hand
C. The left hand
D. No specific order, Its up to the nurse for
her own convenience
Answer: B. The non dominant hand. Gloves
are put on the non dominant hands first and
then, the dominant hand. The rationale is
simply because humans tend to use the
dominant hand first before the non dominant
hand. Out of 10 humans that will put on their
sterile gloves, 8 of them will put the gloves
on their non dominant hands first.
77. As the scrubbed nurse, when should you
apply the goggles, shoe cap and mask prior to
the operation?
A. Immediately after entering the sterile field
B. After surgical hand scrub
C. Before surgical hand scrub
D. Before entering the sterile field
Answer: C. Before surgical hand scrub. The
nurse should put his goggles, cap and mask
prior to washing the hands. If he wash his
hands prior to putting all these equipments,
he must wash his hands again as these
equipments are said to be UNSTERILE.
78. Which of the following should the nurse
do when applying gloves prior to a surgical
procedure?
A. Slipping gloved hand with all fingers
when picking up the second glove
B. Grasping the first glove by inserting four
fingers, with thumbs up underneath the
cuff
C. Putting the gloves into the dominant hand
first
D. Adjust only the fitting of the gloves
after both gloves are on
Answer: D. Adjust only the fitting of the
gloves after both gloves are on. The nurse
should only adjust fitting of the gloves when
they are both on the hands. Not doing so will
break the sterile technique. Only 4 gingers
are slipped when picking up the second
gloves. You cannot slip all of your fingers as
the cuff is limited and the thumb would not
be able to enter the cuff. The first glove is
grasp by simply picking it up with the first 2
fingers and a thumb in a pinching motion.
Gloves are put on the non dominant hands
first.
79. Which gloves should you remove first?
A. The glove of the non dominant hand Answer: A. 4,3,5,1,2. When the nurse is
B. The glove of the dominant hand about to remove his protective devices, The
C. The glove of the left hand nurse will remove the GLOVES first
D. Order in removing the gloves Is followed by the MASK and GOWN then,
unnecessary other devices like cap, shoe cover, etc. This
is to prevent contamination of hair, neck and
Answer: A. The glove of the non dominant face area.
hand. Gloves are worn in the non dominant
hand first, and is removed also from the non 82. In pouring a plain NSS into a receptacle
dominant hand first. Rationale is simply located in a sterile field, how high should the
because in 10 people removing gloves, 8 of nurse hold the bottle above the receptacle?
them will use the dominant hand first and
remove the gloves of the non dominant hand. A. 1 inch
B. 3 inches
80. Before a surgical procedure, Give the C. 6 inches
sequence on applying the protective items D. 10 inches
listed below
Answer: C. 6 inches. Even if you do not
1. Eye wear or goggles know the answer to this question, you can
2. Cap answer it correctly by imagining. If you pour
3. Mask the NSS into a receptacle 1 to 3 inch above it,
4. Gloves Chances are, The mouth of the NSS bottle
5. Gown would dip into the receptacle as you fill it,
A. 3,2,1,5,4 making it contaminated. If you pour the NSS
B. 3,2,1,4,5 bottle into a receptacle 10 inches above it,
C. 2,3,1,5,4 that is too high, chances are, as you pour the
D. 2,3,1,4,5 NSS, most will spill out because the force
will be too much for the buoyant force to
Answer: D. 2,3,1,4,5. The nurse should handle. It will also be difficult to pour
use CaMEy Hand and Body Lotion in something precisely into a receptacle as the
moisturizing his hand before surgical height increases between the receptacle and
procedure and after handwashing. Ca stands the bottle. 6 inches is the correct answer. It is
for CAP, Mstands for MASK, Ey stands for not to low nor too high.
eye goggles. The nurse will do handwashing
and then [HAND], Don the gloves first and 83. The tip of the sterile forceps is considered
wear the Gown [BODY]. I created this sterile. It is used to manipulate the objects in
mnemonic and I advise you use it because the sterile field using the non sterile hands.
you can never forget Camey hand and body How should the nurse hold a sterile forceps?
lotion. [ Yes, I know it is spelled as
CAMAY ]] A. The tip should always be lower than the
handle
81. In removing protective devices, which B. The tip should always be above the
should be the exact sequence? handle
C. The handle and the tip should be at the
1. Eye wear or goggles same level
2. Cap D. The handle should point downward and
3. Mask the tip, always upward
4. Gloves
5. Gown Answer: A. The tip should always be lower
A. 4,3,5,1,2 than the handle. A sterile forcep is usually
B. 2,3,1,5,4 dipped into a disinfectant or germicidal
C. 5,4,3,2,1 solution. Imagine, if the tip is HIGHER than
D. 1,2,3,4,5’ the handle, the solution will go into the
handle and into your hands and as you use
the forcep, you will eventually lower its tip
making the solution in your hand go BACK
into the tip thus contaminating the sterile area
of the forcep. To prevent this, the tip should
always be lower than the handle. In situation
questions like this, IMAGINATION is very
important.
84. The nurse enters the room of the client on
airborne precaution due to tuberculosis.
Which of the following are appropriate
actions by the nurse?
1. She wears mask, covering the nose and
mouth
2. She washes her hands before and after
removing gloves, after suctioning the
client’s secretion
3. She removes gloves and hands before
leaving the client’s room
4. She discards contaminated suction
catheter tip in trashcan found in the
clients room
A. 1,2
B. 1,2,3
C. 1,2,3,4
D. 1,3
Answer: C. 1,2,3,4. All soiled equipments
use in an infectious client are disposed
INSIDE the client’s room to prevent
contamination outside the client’s room. The
nurse is correct in using Mask the covers
both nose and mouth. Hands are washed
before and after removing the gloves and
before and after you enter the client’s room.
Gloves and contaminated suction tip are
thrown in trashcan found in the clients room.
85. When performing surgical hand scrub,
which of the following nursing action is
required to prevent contamination?
1. Keep fingernail short, clean and with nail
polish
2. Open faucet with knee or foot control
3. Keep hands above the elbow when
washing and rinsing
4. Wear cap, mask, shoe cover after you
scrubbed
A. 1,2
B. 2,3
C. 1,2,3
D. 2,3,4
Answer: C. 1,2,3. Cap, mask and shoe cover
are worn BEFORE scrubbing.
86. When removing gloves, which of the
following is an inappropriate nursing action?
A. Wash gloved hand first
B. Peel off gloves inside out
C. Use glove to glove skin to skin technique
D. Remove mask and gown before
removing gloves
Answer: D. Remove mask and gown before
removing gloves. Gloves are the dirtiest
protective item nurses are wearing and
therefore, the first to be removed to prevent
spread of microorganism as you remove the
mask and gown.
87. Which of the following is TRUE in the
concept of stress?
A. Stress is not always present in diseases
and illnesses
B. Stress are only psychological and
manifests psychological symptoms
C. All stressors evoke common adaptive
response
D. Hemostasis refers to the dynamic state of
equilibrium
Answer: C. All stressors evoke common
adaptive response. All stressors evoke
common adaptive response. A psychologic
fear like nightmare and a real fear or real
perceive threat evokes common
manifestation like tachycardia, tachypnea,
sweating, increase muscle tension etc. ALL
diseases and illness causes stress. Stress can
be both REAL or IMAGINARY. Hemostasis
refers to the ARREST of blood flowing
abnormally through a damage vessel.
Homeostasis is the one that refers to dynamic
state of equilibrium according to Walter
Cannon.
88. According to this theorist, in his modern
stress theory, Stress is the non specific
response of the body to any demand made
upon it.
A. Hans Selye
B. Walter Cannon
C. Claude Bernard
D. Martha Rogers

answer: A. Hans Selye. Hans Selye is the
only theorist who proposed an intriguing
theory about stress that has been widely used
and accepted by professionals today. He
conceptualized two types of human response
to stress, The GAS or general adaptation
syndrome which is characterized by stages of
ALARM, RESISTANCE and
EXHAUSTION. The Local adaptation
syndrome controls stress through a particular
body part. Example is when you have been
wounded in your finger, it will produce
PAIN to let you know that you should protect
that particular damaged area, it will also
produce inflammation to limit and control the
spread of injury and facilitate healing process.
Another example is when you are frequently
lifting heavy objects, eventually, you arm,
back and leg muscles hypertorphies to adapt
to the stress of heavy lifting.
89. Which of the following is NOT TRUE
with regards to the concept of Modern Stress
Theory?
A. Stress is not a nervous energy
B. Man, whenever he encounters stresses,
always adapts to it
C. Stress is not always something to be
avoided
D. Stress does not always lead to distress
Answer: B. Man, whenever he encounters
stresses, always adapts to it. Man, do not
always adapt to stress. Sometimes, stress can
lead to exhaustion and eventually, death. A,C
and D are all correct.
90. Which of the following is TRUE with
regards to the concept of Modern Stress
Theory?
A. Stress is essential
B. Man does not encounter stress if he is
asleep
C. A single stress can cause a disease
D. Stress always leads to distress
Answer:A. Stress is essential. Stress is
ESSENTIAL. No man can live normally
without stress. It is essential because it is
evoked by the body’s normal pattern of
response and leads to a favorable adaptive
mechanism that are utilized in the future
when more stressors are encountered by the
body. Man can encounter stress even while
asleep, example is nightmare. Disease are
multifactorial, No diseases are caused by a
single stressors. Stress are sometimes
favorable and are not always a cause for
distress. An example of favorable stress is
when a carpenter meets the demand and
stress of everyday work. He then develops
calluses on the hand to lessen the pressure of
the hammer against the tissues of his hand.
He also develop larger muscle and more
dense bones in the arm, thus, a stress will
lead to adaptations to decrease that particular
stress.
91. Which of the following is TRUE in the
stage of alarm of general adaptation syndrome?
A. Results from the prolonged exposure to
stress
B. Levels or resistance is increased
C. Characterized by adaptation
D. Death can ensue
Answer: D. Death can ensue. Death can
ensue as early as the stage of alarm.
Exhaustion results to a prolonged exposure to
stress. Resistance is when the levels of
resistance increases and characterized by
being able to adapt.
92. The stage of GAS where the adaptation
mechanism begins
A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion
Answer: A. Stage of Alarm. Adaptation
mechanisms begin in the stage of alarm. This
is when the adaptive mechanism are
mobilized. When someone shouts SUNOG!!!
your heart will begin to beat faster, you
vessels constricted and bp increased.
93. Stage of GAS Characterized by adaptation
A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion
Answer: Stage of Resistance
 the hospital. Which of the following mode of
94. Stage of GAS wherein, the Level of adaptation is Andy experiencing?
resistance are decreased
A. Biologic/Physiologic adaptive mode
A. Stage of Alarm B. Psychologic adaptive mode
B. Stage of Resistance C. Sociocultural adaptive mode
C. Stage of Homeostasis D. Technological adaptive mode
D. Stage of Exhaustion
Answer: Technological adaptive mode
Answer: A. Stage of Alarm. Resistance are
decreased in the stage of alarm. Resistance is 99. Andy is not yet fluent in French, but he
absent in the stage of exhaustion. Resistance works in Quebec where majority speaks
is increased in the stage of resistance. French. He is starting to learn the language of
the people. What type of adaptation is Andy
95. Where in stages of GAS does a person experiencing?
moves back into HOMEOSTASIS?
A. Biologic/Physiologic adaptive mode
A. Stage of Alarm B. Psychologic adaptive mode
B. Stage of Resistance C. Sociocultural adaptive mode
C. Stage of Homeostasis D. Technological adaptive mode
D. Stage of Exhaustion
Answer: C. Sociocultural adaptive
Answer: Stage of Resistance mode. Sociocultural adaptive modes include
language, communication, dressing, acting
96. Stage of GAS that results from prolonged and socializing in line with the social and
exposure to stress. Here, death will ensue cultural standard of the people around the
unless extra adaptive mechanisms are utilized adapting individual.

A. Stage of Alarm 100. Andy made an error and his senior nurse
B. Stage of Resistance issued a written warning. Andy arrived in his
C. Stage of Homeostasis house mad and kicked the door hard to shut it
D. Stage of Exhaustion off. What adaptation mode is this?

Answer:Stage of Exhaustion A. Biologic/Physiologic adaptive mode

B. Psychologic adaptive mode
97. All but one is a characteristic of adaptive C. Sociocultural adaptive mode
response D. Technological adaptive mode

A. This is an attempt to maintain Answer: Psychologic adaptive mode

homeostasis
B. There is a totality of response PNLE: FON Practice Exam for Stress,
C. Adaptive response is immediately Crisis, Crisis Intervention,
mobilized, doesn’t require time
D. Response varies from person to person
Communication, Recording, Learning
and Documentation
Answer: C. Adaptive response is 1. The coronary vessels, unlike any other
immediately mobilized, doesn’t require blood vessels in the body, respond to
time. Aside from having limits that leads to sympathetic stimulation by
exhaustion. Adaptive response requires time
for it to act. It requires energy, physical and A. Vasoconstriction
psychological taxes that needs time for our B. Vasodilatation
body to mobilize and utilize. C. Decreases force of contractility
D. Decreases cardiac output
98. Andy, a newly hired nurse, starts to learn
the new technology and electronic devices at Answer: Vasodilatation
 C. Purulent
2. What stress response can you expect from a D. Sanguinous
patient with blood sugar of 50 mg / dl?
Answer: Purulent
A. Body will try to decrease the glucose
level 7. The first manifestation of inflammation is
B. There will be a halt in release of sex
hormones A. Redness on the affected area
C. Client will appear restless B. Swelling of the affected area
D. Blood pressure will increase C. Pain, which causes guarding of the area
D. Increase heat due to transient vasodilation
Answer: Blood pressure will increase
Answer: Redness on the affected area
3. All of the following are purpose of
inflammation except
8. The client has a chronic tissue injury. Upon
A. Increase heat, thereby produce examining the client’s antibody for a
abatement of phagocytosis particular cellular response, Which of the
B. Localized tissue injury by increasing following WBC component is responsible for
capillary permeability phagocytosis in chronic tissue injury?
C. Protect the issue from injury by producing
pain A. Neutrophils
D. Prepare for tissue repair B. Basophils
C. Eosinophils
Answer: A. Increase heat, thereby produce D. Monocytes
abatement of phagocytosis
Answer: Monocytes
4. The initial response of tissue after injury is
9. Which of the following WBC component
A. Immediate Vasodilation proliferates in cases of Anaphylaxis?
B. Transient Vasoconstriction
C. Immediate Vasoconstriction A. Neutrophils
D. Transient Vasodilation B. Basophils
C. Eosinophil
Answer: C. Immediate Vasoconstriction D. Monocytes

5. The last expected process in the stages of Answer: Eosinophil

inflammation is characterized by
A. There will be sudden redness of the
affected part
B. Heat will increase on the affected part
C. The affected part will loss its normal
function
D. Exudates will flow from the injured site
10. Icheanne, ask you, her Nurse, about WBC
Components. She got an injury yesterday after
she twisted her ankle accidentally at her
gymnastic class. She asked you, which WBC
Component is responsible for proliferation at
the injured site immediately following an
injury. You answer:

Answer: . The affected part will loss its A. Neutrophils

normal function B. Basophils
C. Eosinophils
6. What kind of exudates is expected when D. Monocytes
there is an antibody-antigen reaction as a
result of microorganism infection? Answer: Neutrophils

A. Serous
B. Serosanguinous
11. Icheanne then asked you, what is the first B. Second intention
process that occurs in the inflammatory C. Third intention
response after injury, You tell her: D. Fourth intention

A. Phagocytosis Answer: Second intention

B. Emigration
C. Pavementation 16. Imelda is in the recovery stage after the
D. Chemotaxis incident. As a nurse, you know that the diet
that will be prescribed to Miss Imelda is
Answer: Pavementation
A. Low calorie, High protein with Vitamin A
12. Icheanne asked you again, What is that and C rich foods
term that describes the magnetic attraction of B. High protein, High calorie with
injured tissue to bring phagocytes to the site Vitamin A and C rich foods
of injury? C. High calorie, Low protein with Vitamin A
and C rich foods
A. Icheanne, you better sleep now, you asked D. Low calorie, Low protein with Vitamin A
a lot of questions and C rich foods
B. It is Diapedesis
C. We call that Emigration B. High protein, High calorie with Vitamin A
D. I don’t know the answer, perhaps I can and C rich foods
tell you after I find it out later
17. Miss Imelda asked you, What is WET TO
Answer: D. I don’t know the answer, perhaps DRY Dressing method? Your best response is
I can tell you after I find it out later
A. It is a type of mechanical debridement
13. This type of healing occurs when there is a using Wet dressing that is applied and
delayed surgical closure of infected wound left to dry to remove dead tissues
B. It is a type of surgical debridement with
A. First intention the use of Wet dressing to remove the
B. Second intention necrotic tissues
C. Third intention C. It is a type of dressing where in, The
D. Fourth intention wound is covered with Wet or Dry
dressing to prevent contamination
Answer: Third intention D. It is a type of dressing where in, A
cellophane or plastic is placed on the
14. Type of healing when scars are minimal wound over a wet dressing to stimulate
due to careful surgical incision and good healing of the wound in a wet medium
healing
Answer: A. It is a type of mechanical
A. First intention debridement using Wet dressing that is
B. Second intention applied and left to dry to remove dead tissues
C. Third intention
D. Fourth intention 18. The primary cause of pain in inflammation
is
Answer: First intention
A. Release of pain mediators
15. Imelda, was slashed and hacked by an B. Injury to the nerve endings
unknown suspects. She suffered massive C. Compression of the local nerve endings
tissue loss and laceration on her arms and by the edema fluids
elbow in an attempt to evade the criminal. As D. Circulation is lessen, Supply of oxygen is
a nurse, you know that the type of healing that insufficient
will most likely occur to Miss Imelda is
Answer: C. Compression of the local nerve
A. First intention endings by the edema fluids
 Answer:A. Directed towards helping an
19. The client is in stress because he was told individual both physically and emotionally
by the physician he needs to undergo surgery
for removal of tumor in his bladder. Which of 23. According to her, A nurse patient
the following are effects of sympatho-adreno- relationship is composed of 4 stages :
medullary response by the client? Orientation, Identification, Exploitation and
Resolution
1. Constipation
2. Urinary frequency A. Roy
3. Hyperglycemia B. Peplau
4. Increased blood pressure C. Rogers
A. 3,4 D. Travelbee
B. 1,3,4
C. 1,2,4 Answer: Peplau
D. 1,4
24. In what phase of Nurse patient
Answer: B. 1,3,4 relationship does a nurse review the client’s
medical records thereby learning as much as
20. The client is on NPO post midnight. possible about the client?
Which of the following, if done by the client,
is sufficient to cancel the operation in the A. Pre Orientation
morning? B. Orientation
C. Working
A. Eat a full meal at 10:00 P.M D. Termination
B. Drink fluids at 11:50 P.M
C. Brush his teeth the morning before Answer: Pre Orientation
operation
D. Smoke cigarette around 3:00 A.M 25. Nurse Aida has seen her patient, Roger for
the first time. She establish a contract about
Answer: D. Smoke cigarette around 3:00 the frequency of meeting and introduce to
A.M Roger the expected termination. She started
taking baseline assessment and set
21. The client place on NPO for preparation interventions and outcomes. On what phase of
of the blood test. Adreno-cortical response is NPR Does Nurse Aida and Roger belong?
activated and which of the following below is
an expected response? A. Pre Orientation
B. Orientation
A. Low BP C. Working
B. Decrease Urine output D. Termination
C. Warm, flushed, dry skin
D. Low serum sodium levels Answer: orientation

Answer: Decrease Urine output 26. Roger has been seen agitated, shouting
and running. As Nurse Aida approaches, he
22. Which of the following is true about shouts and swear, calling Aida names. Nurse
therapeutic relationship? Aida told Roger “That is an unacceptable
behavior Roger, Stop and go to your room
A. Directed towards helping an individual now.” The situation is most likely in what
both physically and emotionally phase of NPR?
B. Bases on friendship and mutual trust
C. Goals are set by the solely nurse A. Pre Orientation
D. Maintained even after the client doesn’t B. Orientation
need anymore of the Nurse’s help C. Working
D. Termination
Answer: working A. It has physiologic component
B. It has psychologic component
27. Nurse Aida, in spite of the incident, still C. The source of dread or uneasiness is from
consider Roger as worthwhile simply because an unrecognized entity
he is a human being. What major ingredient of D. The source of dread or uneasiness is
a therapeutic communication is Nurse Aida from a recognized entity
using?
Answer: D. The source of dread or
A. Empathy uneasiness is from a recognized entity
B. Positive regard
C. Comfortable sense of self 32. Lorraine, a 27 year old executive was
D. Self awareness brought to the ER for an unknown reason. She
is starting to speak but her speech is
Answer: Positive regard disorganized and cannot be understood. On
what level of anxiety does this features
28. Nurse Irma saw Roger and told Nurse belongs?
Aida “ Oh look at that psychotic patient
“ Nurse Aida should intervene and correct A. Mild
Nurse Irma because her statement shows that B. Moderate
she is lacking? C. Severe
D. Panic
A. Empathy
B. Positive regard Answer: Panic
C. Comfortable sense of self
D. Self awareness 33. Elton, 21 year old nursing student is
taking the board examination. She is sweating
Answer: Positive regard profusely, has decreased awareness of his
environment and is purely focused on the
29. Which of the following statement is not exam questions characterized by his selective
true about stress? attentiveness. What anxiety level is Elton
exemplifying?
A. It is a nervous energy
B. It is an essential aspect of existence A. Mild
C. It has been always a part of human B. Moderate
experience C. Severe
D. It is something each person has to cope D. Panic

Answer: A. It is a nervous energy Answer: Moderate

30. Martina, a Tennis champ was devastated 34. You noticed the patient chart : ANXIETY
after many new competitors outpaced her in +3 What will you expect to see in this client?
the Wimbledon event. She became depressed
and always seen crying. Martina is clearly on A. An optimal time for learning, Hearing and
what kind of situation? perception is greatly increased
B. Dilated pupils
A. Martina is just stressed out C. Unable to communicate
B. Martina is Anxious D. Palliative Coping Mechanism
C. Martina is in the exhaustion stage of GAS
D. Martina is in Crisis Answer: B. Dilated pupils

Answer: D. Martina is in Crisis 35. When should the nurse starts giving
XANAX?
31. Which of the following statement is not
true with regards to anxiety? A. When anxiety is +1
B. When the client starts to have a narrow D. Exercise combined with meditation to
perceptual field and selective foster relaxation and mental alacrity
inattentiveness
C. When problem solving is not possible Answer: B. Concentrating on breathing
D. When the client is immobile and without tensing the muscle, Letting go and
disorganized repeating a word or sound after each
exhalation
Answer: B. When the client starts to have a
narrow perceptual field and selective 40. What type of relaxation technique does
inattentiveness Lyza uses if a machine is showing her pulse
rate, temperature and muscle tension which
36. Which of the following behavior is not a she can visualize and assess?
sign or a symptom of Anxiety?
A. Biofeedback
A. Frequent hand movement B. Massage
B. Somatization C. Autogenic training
C. The client asks a question D. Visualization and Imagery
D. The client is acting out
Answer: biofeedback
Answer: C. The client asks a question
41. This is also known as Self-suggestion or
37. Which of the following intervention is Self-hypnosis
inappropriate for client’s with anxiety?
A. Biofeedback
A. Offer choices B. Meditation
B. Provide a quiet and calm environment C. Autogenic training
C. Provide detailed explanation on each and D. Visualization and Imagery
every procedures and equipments
D. Bring anxiety down to a controllable level Answer:Autogenic training

Answer:Offer choices 42. Which among these drugs is NOT an

anxiolytic?
38. Which of the following statement, if made
by the nurse, is considered not therapeutic? A. Valium
B. Ativan
A. “How did you deal with your anxiety C. Milltown
before?” D. Luvox
B. “It must be awful to feel anxious.”
C. “How does it feel to be anxious?” Answer: Luvox
D. “What makes you feel anxious?”
43. Kenneth, 25 year old diagnosed with HIV
Answer: D. “What makes you feel anxious?” felt that he had not lived up with God’s
expectation. He fears that in the course of his
39. Marissa Salva, Uses Benson’s relaxation. illness, God will be punitive and not be
How is it done? supportive. What kind of spiritual crisis is
Kenneth experiencing?
A. Systematically tensing muscle groups
from top to bottom for 5 seconds, and 1. Spiritual Pain
then releasing them 2. Spiritual Anxiety
B. Concentrating on breathing without 3. Spiritual Guilt
tensing the muscle, Letting go and 4. Spiritual Despair
repeating a word or sound after each A. 1,2
exhalation B. 2,3
C. Using a strong positive, feeling-rich C. 3,4
statement about a desired change D. 1,4

Answer:
44. Grace, believes that her relationship with
God is broken. She tried to go to church to ask
forgiveness everyday to remedy her feelings.
What kind of spiritual distress is Grace
experiencing?
A. Spiritual Pan
B. Spiritual Alienation
C. Spiritual Guilt
D. Spiritual Despair
45. Remedios felt “EMPTY” She felt that she
has already lost God’s favor and love because
of her sins. This is a type of what spiritual
crisis?
A. Spiritual Anger
B. Spiritual Loss
C. Spiritual Despair
D. Spiritual Anxiety
46. Budek is working with a schizophrenic
patient. He noticed that the client is agitated,
pacing back and forth, restless and
experiencing Anxiety +3. Budek said “You
appear restless” What therapeutic technique
did Budek used?
A. Offering general leads
B. Seeking clarification
C. Making observation
D. Encouraging description of perception
47. Rommel told Budek “ I SEE DEAD
PEOPLE “ Budek responded “You see dead
people?” This Is an example of therapeutic
communication technique?
A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification
48. Rommel told Budek, “Do you think Im
crazy?” Budek responded, “Do you think your
crazy?” Budek uses what example of
therapeutic communication?
A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification
49. Myra, 21 year old nursing student has
difficulty sleeping. She told Nurse Budek “I
really think a lot about my x boyfriend
recently” Budek told Myra “And that causes
you difficulty sleeping?” Which therapeutic
technique is used in this situation?
A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification
50. Myra told Budek “I cannot sleep, I stay
away all night” Budek told her “You have
difficulty sleeping” This is what type of
therapeutic communication technique?
A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification
51. Myra said “I saw my dead grandmother
here at my bedside a while ago” Budek
responded “Really? That is hard to believe,
How do you feel about it?” What technique
did Budek used?
A. Disproving
B. Disagreeing
C. Voicing Doubt
D. Presenting Reality
52. Which of the following is a therapeutic
communication in response to “I am a GOD,
bow before me Or ill summon the dreaded
thunder to burn you and purge you to pieces!”
A. “You are not a GOD, you are Professor
Tadle and you are a PE Teacher, not a
Nurse. I am Glen, Your nurse.”
B. “Oh hail GOD Tadle, everyone bow or
face his wrath!”
C. “Hello Mr. Tadle, You are here in the
hospital, I am your nurse and you are a
patient here”
D. “How can you be a GOD Mr. Tadle? Can
you tell me more about it?”
53. Erik John Senna, Told Nurse Budek “ I
don’t want to that, I don’t want that thing..
that’s too painful!” Which of the following
response is NON THERAPEUTIC
A. “ This must be difficult for you, But I
need to inject you this for your own good”
B. “ You sound afraid”
C. “Are you telling me you don’t want this
injection?”
D. “Why are you so anxious? Please tell
me more about your feelings Erik”
54. Legrande De Salvaje Y Cobrador La
Jueteng, was caught by the bacolod police
because of his illegal activities. When he got
home after paying for the bail, He shouted at
his son. What defense mechanism did Mr. La
Jueteng used?
A. Restitution
B. Projection
C. Displacement
D. Undoing
55. Later that day, he bought his son ice
cream and food. What defense mechanism is
Legrande unconsciously doing?
A. Restitution
B. Conversion
C. Redoing
D. Reaction formation
56. Crisis is a sudden event in ones life that
disturbs a person’s homeostasis. Which of the
following is NOT TRUE in crisis?
A. The person experiences heightened
feeling of stress
B. Inability to function in the usual
organized manner
C. Lasts for 4 months
D. Indicates unpleasant emotional feelings
57. Which of the following is a characteristic
of crisis?
A. Lasts for an unlimited period of time
B. There is a triggering event
C. Situation is not dangerous to the person
D. Person totality is not involved
58. Levito Devin, The Italian prime minister,
is due to retire next week. He feels depressed
due to the enormous loss of influence, power,
fame and fortune. What type of crisis is Devin
experiencing?
A. Situational
B. Maturational
C. Social
D. Phenomenal
59. Estrada, The Philippine president, has
been unexpectedly impeached and was out of
office before the end of his term. He is in
what type of crisis?
A. Situational
B. Maturational
C. Social
D. Phenomenal
60. The tsunami in Thailand and Indonesia
took thousands of people and change million
lives. The people affected by the Tsunami are
saddened and do not know how to start all
over again. What type of crisis is this?
A. Situational
B. Maturational
C. Social
D. Phenomenal
61. Which of the following is the BEST goal
for crisis intervention?
A. Bring back the client in the pre crisis state
B. Make sure that the client becomes better
C. Achieve independence
D. Provide alternate coping mechanism
62. What is the best intervention when the
client has just experienced the crisis and still
at the first phase of the crisis?
A. Behavior therapy
B. Gestalt therapy
C. Cognitive therapy
D. Milieu Therapy
63. Therapeutic nurse client relationship is
describes as follows
1. Based on friendship and mutual interest
2. It is a professional relationship
3. It is focused on helping the patient solve
problems and achieve health-related goals
4. Maintained only as long as the patient
requires professional helpA. 1,2,3
B. 1,2,4
C. 2,3,4
D. 1,3,4
64. The client is scheduled to have surgical
removal of the tumor on her left breast. Which
of the following manifestation indicates that
she is experiencing Mild Anxiety?
A. She has increased awareness of her
environmental details
B. She focused on selected aspect of her
illness
C. She experiences incongruence of action,
thoughts and feelings
D. She experiences random motor activities
65. Which of the following nursing
intervention would least likely be effective
when dealing with a client with aggressive
behavior?
A. Approach him in a calm manner
B. Provide opportunities to express
feelings
 C. Maintain eye contact with the client A. POMR
D. Isolate the client from others B. POR
66. Whitney, a patient of nurse Budek, C. Traditional
verbalizes… “I have nothing, nothing… D. Resource oriented
nothing! Don’t make me close one more door, 72. Type of recording that integrates all data
I don’t wanna hurt anymore!” Which of the about the problem, gathered by members of
following is the most appropriate response by the health team.
Budek?
A. POMR
A. Why are you singing? B. Traditional
B. What makes you say that? C. Resource oriented
C. Ofcourse you are everything! D. Source oriented
D. What is that you said? 73. These are data that are monitored by using
67. Whitney verbalizes that she is anxious that graphic charts or graphs that indicated the
the diagnostic test might reveal laryngeal progression or fluctuation of client’s
cancer. Which of the following is the most Temperature and Blood pressure.
appropriate nursing intervention?
A. Progress notes
A. Tell the client not to worry until the B. Kardex
results are in C. Flow chart
B. Ask the client to express feelings and D. Flow sheet
concern 74. Provides a concise method of organizing
C. Reassure the client everything will be and recording data about the client. It is a
alright series of flip cards kept in portable file used in
D. Advice the client to divert his attention by change of shift reports.
watching television and reading
newspapers A. Kardex
68. Considered as the most accurate B. Progress Notes
expression of person’s thought and feelings C. SOAPIE
D. Change of shift report
A. Verbal communication 75. You are about to write an information on
B. Non verbal communication the Kardex. There are 4 available writing
C. Written communication instruments to use. Which of the following
D. Oral communication should you use?
69. Represents inner feeling that a person do
not like talking about. A. Mongol #2
B. Permanent Ink
A. Overt communication C. A felt or fountain pen
B. Covert communication D. Pilot Pentel Pen marker
C. Verbal communication 76. The client has an allergy to Iodine based
D. Non verbal communication dye. Where should you put this vital
70. Which of the following is NOT a information in the client’s chart?
characteristic of an effective Nurse-Client
relationship? A. In the first page of the client’s chart
B. At the last page of the client’s chart
A. Focused on the patient C. At the front metal plate of the chart
B. Based on mutual trust D. In the Kardex
C. Conveys acceptance 77. Which of the following is NOT TRUE
D. Discourages emotional bond about the Kardex
71. A type of record wherein , each person or
department makes notation in separate records. A. It provides readily available information
A nurse will use the nursing notes, The doctor B. It is a tool of end of shift reports
will use the Physician’s order sheet etc. Data C. The primary basis of endorsement
is arranged according to information source. D. Where Allergies information are written
78. Which of the following, if seen on the C. Marsha said “ I understand “ after you a
Nurses notes, violates characteristic of good health teaching about family planning
recording? D. John rated 100% on your given quiz about
smoking and alcoholism
A. The client has a blood pressure of
120/80, Temperature of 36.6 C Pulse Answer: A. Matuts starts exercising every
rate of 120 and Respiratory rate of 22 morning and eating a balance diet after you
B. Ate 50% of food served taught her mag HL tayo program
C. Refused administration of betaxolol
D. Visited and seen By Dr. Santiago 85. In his theory of learning as a
79. The physician ordered : Mannerix a.c , BEHAVIORISM, he stated that transfer of
what does a.c means? knowledge occurs if a new situation closely
resembles an old one.
A. As desired
B. Before meals A. Bloom
C. After meals B. Lewin
D. Before bed time C. Thorndike
80. The physician ordered, Maalox, 2 hours D. Skinner
p.c, what does p.c means? 86. Which of the following is TRUE with
regards to learning?
A. As desired
B. Before meals A. Start from complex to simple
C. After meals B. Goals should be hard to achieve so patient
D. Before bed time can strive to attain unrealistic goals
81. The physician ordered, Maxitrol, Od. C. Visual learning is the best for every
What does Od means? individual
D. Do not teach a client when he is in pain
A. Left eye 87. According to Bloom, there are 3 domains
B. Right eye in learning. Which of these domains is
C. Both eye responsible for the ability of Donya Delilah to
D. Once a day inject insulin?
82. The physician orderd, Magnesium
Hydroxide cc Aluminum Hydroxide. What A. Cognitive
does cc means? B. Affective
C. Psychomotor
A. without D. Motivative
B. with 88. Which domains of learning is responsible
C. one half for making John and Marsha understand the
D. With one half dose different kinds of family planning methods?
83. Physician ordered, Paracetamol tablet ss.
What does ss means? A. Cognitive
B. Affective
A. without C. Psychomotor
B. with D. Motivative
C. one half 89. Which of the following statement clearly
D. With one half dose defines therapeutic communication?
84. Which of the following indicates that
learning has been achieved? A. Therapeutic communication is an
interaction process which is primarily
A. Matuts starts exercising every morning directed by the nurse
and eating a balance diet after you B. It conveys feeling of warmth, acceptance
taught her mag HL tayo program and empathy from the nurse to a patient in
B. Donya Delilah has been able to repeat the relaxed atmosphere
steps of insulin administration after you C. Therapeutic communication is a
taught it to her reciprocal interaction based on trust
 and aimed at identifying patient needs
and developing mutual goals
D. Therapeutic communication is an
assessment component of the nursing
process
Answer:C. Therapeutic communication is a
reciprocal interaction based on trust and
aimed at identifying patient needs and
developing mutual goals
90. Which of the following concept is most
important in establishing a therapeutic nurse
patient relationship?
A. The nurse must fully understand the
patient’s feelings, perception and
reactions before goals can be established
B. The nurse must be a role model for health
fostering behavior
C. The nurse must recognize that the patient
may manifest maladaptive behavior after
illness
D. The nurse should understand that
patients might test her before trust is
established
91. Which of the following communication
skill is most effective in dealing with covert
communication?
A. Validation
B. Listening
C. Evaluation
D. Clarification
92. Which of the following are qualities of a
good recording?
1. Brevity
2. Completeness and chronology
3. Appropriateness
4. Accuracy
A. 1,2
B. 3,4
C. 1,2,3
D. 1,2,3,4
93. All of the following chart entries are
correct except
A. V/S 36.8 C,80,16,120/80
B. Complained of chest pain
C. Seems agitated
D. Able to ambulate without assistance
94. Which of the following teaching method is
effective in client who needs to be educated
about self injection of insulin?
A. Detailed explanation
B. Demonstration
C. Use of pamphlets
D. Film showing
95. What is the most important characteristic
of a nurse patient relationship?
A. It is growth facilitating
B. Based on mutual understanding
C. Fosters hope and confidence
D. Involves primarily emotional bond
96. Which of the following nursing
intervention is needed before teaching a client
post spleenectomy deep breathing and
coughing exercises?
A. Tell the patient that deep breathing
and coughing exercises is needed to
promote good breathing, circulation
and prevent complication
B. Tell the client that deep breathing and
coughing exercises is needed to prevent
Thrombophlebitis, hydrostatic pneumonia
and atelectasis
C. Medicate client for pain
D. Tell client that cooperation is vital to
improve recovery
97. The client has an allergy with penicillin.
What is the best way to communicate this
information?
A. Place an allergy alert in the Kardex
B. Notify the attending physician
C. Write it on the patient’s chart
D. Take note when giving medications
98. An adult client is on extreme pain. He is
moaning and grimacing. What is the best way
to assess the client’s pain?
A. Perform physical assessment
B. Have the client rate his pain on the smiley
pain rating scale
C. Active listening on what the patient
says
D. Observe the client’s behavior
99. Therapeutic communication begins with?
A. Knowing your client
B. Knowing yourself
C. Showing empathy
D. Encoding
100. The PCS gave new guidelines including
leaflets to educate cancer patients. As a nurse,
When using materials like this, what is your
responsibility?
A. Read it for the patient
B. Give it for the patient to read himself
C. Let the family member read the material
for the patient
D. Read it yourself then, Have the client
read the material
PNLE: FON Practice Exam for
Nursing Process, Physical and Health
Assessment and Routine Procedures
1. She is the first one to coin the term
“NURSING PROCESS” She introduced 3
steps of nursing process which are
Observation, Ministration and Validation.
A. Nightingale
B. Johnson
C. Rogers
D. Hall
2. The American Nurses association
formulated an innovation of the Nursing
process. Today, how many distinct steps are
there in the nursing process?
A. APIE – 4
B. ADPIE – 5
C. ADOPIE – 6
D. ADOPIER – 7
3. They are the first one to suggest a 4 step
nursing process which are : APIE , or
assessment, planning, implementation and
evaluation.
1. Yura
2. Walsh
3. Roy
4. Knowles
A. 1,2
B. 1,3
C. 3,4
D. 2,3
4. Which characteristic of nursing process is
responsible for proper utilization of human
resources, time and cost resources?
A. Organized and Systematic
B. Humanistic
C. Efficient
D. Effective
5. Which characteristic of nursing process
addresses the INDIVIDUALIZED care a
client must receive?
A. Organized and Systematic
B. Humanistic
C. Efficient
D. Effective
6. A characteristic of the nursing process that
is essential to promote client satisfaction and
progress. The care should also be relevant
with the client’s needs.
A. Organized and Systematic
B. Humanistic
C. Efficient
D. Effective
7. Rhina, who has Menieres disease, said that
her environment is moving. Which of the
following is a valid assessment?
1. Rhina is giving an objective data
2. Rhina is giving a subjective data
3. The source of the data is primary
4. The source of the data is secondary
A. 1,3
B. 2,3
C. 2.4
D. 1,4
8. Nurse Angela, observe Joel who is very
apprehensive over the impending operation.
The client is experiencing dyspnea,
diaphoresis and asks lots of questions. Angela
made a diagnosis of ANXIETY R/T
INTRUSIVE PROCEDURE. This is what
type of Nursing Diagnosis?
A. Actual
B. Probable
C. Possible
D. Risk
9. Nurse Angela diagnosed Mrs. Delgado,
who have undergone a BKA. Her diagnosis is
SELF ESTEEM DISTURBANCE R/T
CHANGE IN BODY IMAGE. Although the
client has not yet seen her lost leg, Angela
already anticipated the diagnosis. This is what
type of Diagnosis?
A. Actual
B. Probable
C. Possible
D. Risk
10. Nurse Angela is about to make a diagnosis
but very unsure because the S/S the client is
experiencing is not specific with her diagnosis
of POWERLESSNESS R/T DIFFICULTY
ACCEPTING LOSS OF LOVED ONE. She
then focus on gathering data to refute or prove
her diagnosis but her plans and interventions
are already ongoing for the diagnosis. Which D. Example is : After discharge planning,
type of Diagnosis is this? Client demonstrated the proper
psychomotor skills for insulin injection.
A. Actual 16. Which of the following is a NOT a correct
B. Probable statement of an Outcome criteria?
C. Possible
D. Risk A. Ambulates 30 feet with a cane before
11. Nurse Angela knew that Stephen Lee Mu discharge
Chin, has just undergone an operation with an B. Discusses fears and concerns regarding
incision near the diaphragm. She knew that the surgical procedure
this will contribute to some complications C. Demonstrates proper coughing and
later on. She then should develop what type of breathing technique after a teaching
Nursing diagnosis? session
D. Reestablishes a normal pattern of
A. Actual elimination
B. Probable 17. Which of the following is a OBJECTIVE
C. Possible data?
D. Risk
12. Which of the following Nursing diagnosis A. Dizziness
is INCORRECT? B. Chest pain
C. Anxiety
A. Fluid volume deficit R/T Diarrhea D. Blue nails
B. High risk for injury R/T Absence of 18. A patient’s chart is what type of data
side rails source?
C. Possible ineffective coping R/T Loss of
loved one A. Primary
D. Self esteem disturbance R/T Effects of B. Secondary
surgical removal of the leg C. Tertiary
13. Among the following statements, which D. Can be A and B
should be given the HIGHEST priority? 19. All of the following are characteristic of
the Nursing process except
A. Client is in extreme pain
B. Client’s blood pressure is 60/40 A. Dynamic
C. Client’s temperature is 40 deg. Centigrade B. Cyclical
D. Client is cyanotic C. Universal
14. Which of the following need is given a D. Intrapersonal
higher priority among others? 20. Which of the following is true about the
NURSING CARE PLAN?
A. The client has attempted suicide and
safety precaution is needed A. It is nursing centered
B. The client has disturbance in his body B. Rationales are supported by interventions
image because of the recent operation C. Verbal
C. The client is depressed because her D. Atleast 2 goals are needed for every
boyfriend left her all alone nursing diagnosis
D. The client is thirsty and dehydrated 21. A framework for health assessment that
15. Which of the following is TRUE with evaluates the effects of stressors to the mind,
regards to Client Goals? body and environment in relation with the
ability of the client to perform ADL.
A. They are specific, measurable, attainable
and time bounded A. Functional health framework
B. They are general and broadly stated B. Head to toe framework
C. They should answer for WHO, WHAT C. Body system framework
ACTIONS, WHAT CIRCUMSTANCES, D. Cephalocaudal framework
HOW WELL and WHEN.
22. Client has undergone Upper GI and Lower
GI series. Which type of health assessment
framework is used in this situation?
A. Functional health framework
B. Head to toe framework
C. Body system framework
D. Cephalocaudal framework
23. Which of the following statement is true
regarding temperature?
A. Oral temperature is more accurate than
rectal temperature
B. The bulb used in Rectal temperature
reading is pear shaped or round
C. The older the person, the higher his BMR
D. When the client is swimming, BMR
Decreases
24. A type of heat loss that occurs when the
heat is dissipated by air current
A. Convection
B. Conduction
C. Radiation
D. Evaporation
25. Which of the following is TRUE about
temperature?
A. The highest temperature usually occurs
later in a day, around 8 P.M to 12 M.N
B. The lowest temperature is usually in the
Afternoon, Around 12 P.M
C. Thyroxin decreases body temperature
D. Elderly people are risk for hyperthermia
due to the absence of fats, Decreased
thermoregulatory control and sedentary
lifestyle.
26. Hyperpyrexia is a condition in which the
temperature is greater than
A. 40 degree Celsius
B. 39 degree Celsius
C. 100 degree Fahrenheit
D. 105.8 degree Fahrenheit
27. Tympanic temperature is taken from John,
A client who was brought recently into the ER
due to frequent barking cough. The
temperature reads 37.9 Degrees Celsius. As a
nurse, you conclude that this temperature is
A. High
B. Low
C. At the low end of the normal range
D. At the high end of the normal range
28. John has a fever of 38.5 Deg. Celsius. It
surges at around 40 Degrees and go back to
38.5 degrees 6 times today in a typical pattern.
What kind of fever is John having?
A. Relapsing
B. Intermittent
C. Remittent
D. Constant
29. John has a fever of 39.5 degrees 2 days
ago, But yesterday, he has a normal
temperature of 36.5 degrees. Today, his
temperature surges to 40 degrees. What type
of fever is John having?
A. Relapsing
B. Intermittent
C. Remittent
D. Constant
30. John’s temperature 10 hours ago is a
normal 36.5 degrees. 4 hours ago, He has a
fever with a temperature of 38.9 Degrees.
Right now, his temperature is back to normal.
Which of the following best describe the fever
john is having?
A. Relapsing
B. Intermittent
C. Remittent
D. Constant
31. The characteristic fever in Dengue Virus
is characterized as:
A. Tricyclic
B. Bicyclic
C. Biphasic
D. Triphasic
32. When John has been given paracetamol,
his fever was brought down dramatically from
40 degrees Celsius to 36.7 degrees in a matter
of 10 minutes. The nurse would assess this
event as:
A. The goal of reducing john’s fever has
been met with full satisfaction of the
outcome criteria
B. The desired goal has been partially met
C. The goal is not completely met
D. The goal has been met but not with the
desired outcome criteria
33. What can you expect from Marianne, who
is currently at the ONSET stage of fever?
A. Hot, flushed skin
B. Increase thirst
 C. Convulsion 41. How long should the thermometer stay in
D. Pale,cold skin the Client’s Axilla?
34. Marianne is now at the Defervescence
stage of the fever, which of the following is A. 3 minutes
expected? B. 4 minutes
C. 7 minutes
A. Delirium D. 10 minutes
B. Goose flesh 42. Which of the following statement is
C. Cyanotic nail beds TRUE about pulse?
D. Sweating
35. Considered as the most accessible and A. Young person have higher pulse than
convenient method for temperature taking older persons
B. Males have higher pulse rate than females
A. Oral after puberty
B. Rectal C. Digitalis has a positive chronotropic
C. Tympanic effect
D. Axillary D. In lying position, Pulse rate is higher
36. Considered as Safest and most non 43. The following are correct actions when
invasive method of temperature taking taking radial pulse except:

A. Oral A. Put the palms downward

B. Rectal B. Use the thumb to palpate the artery
C. Tympanic C. Use two or three fingers to palpate the
D. Axillary pulse at the inner wrist
37. Which of the following is NOT a D. Assess the pulse rate, rhythm, volume and
contraindication in taking ORAL temperature? bilateral quality
44. The difference between the systolic and
A. Quadriplegic diastolic pressure is termed as
B. Presence of NGT
C. Dyspnea A. Apical rate
D. Nausea and Vomitting B. Cardiac rate
38. Which of the following is a C. Pulse deficit
contraindication in taking RECTAL D. Pulse pressure
temperature? 45. Which of the following completely
describes PULSUS PARADOXICUS?
A. Unconscious
B. Neutropenic A. A greater-than-normal increase in systolic
C. NPO blood pressure with inspiration
D. Very young children B. A greater-than-normal decrease in
39. How long should the Rectal Thermometer systolic blood pressure with inspiration
be inserted to the clients anus? C. Pulse is paradoxically low when client is
in standing position and high when supine.
A. 1 to 2 inches D. Pulse is paradoxically high when client is
B. 5 to 1.5 inches in standing position and low when supine.
C. 3 to 5 inches 46. Which of the following is TRUE about
D. 2 to 3 inches respiration?
40. In cleaning the thermometer after use, The
direction of the cleaning to follow Medical A. I:E 2:1
Asepsis is : B. I:E : 4:3
C. I:E 1:1
A. From bulb to stem D. I:E 1:2
B. From stem to bulb 47. Contains the pneumotaxic and the
C. From stem to stem apneutic centers
D. From bulb to bulb
A. Medulla oblongata
 B. Pons 55. Refers to the pressure when the ventricles
C. Carotid bodies are at rest
D. Aortic bodies
48. Which of the following is responsible for A. Diastole
deep and prolonged inspiration B. Systole
C. Preload
A. Medulla oblongata D. Pulse pressure
B. Pons 56. Which of the following is TRUE about the
C. Carotid bodies blood pressure determinants?
D. Aortic bodies
49. Which of the following is responsible for A. Hypervolemia lowers BP
the rhythm and quality of breathing? B. Hypervolemia increases GFR
C. HCT of 70% might decrease or increase
A. Medulla oblongata BP
B. Pons D. Epinephrine decreases BP
C. Carotid bodies 57. Which of the following do not correctly
D. Aortic bodies correlates the increase BP of Ms. Aida, a 70
50. The primary respiratory center year old diabetic?

A. Medulla oblongata A. Females, after the age 65 tends to have

B. Pons lower BP than males
C. Carotid bodies B. Disease process like Diabetes increase BP
D. Aortic bodies C. BP is highest in the morning, and lowest
51. Which of the following is TRUE about the during the night
mechanism of action of the Aortic and Carotid D. Africans, have a greater risk of
bodies? hypertension than Caucasian and Asians.
58. How many minutes are allowed to pass if
A. If the BP is elevated, the RR increases the client had engaged in strenuous activities,
B. If the BP is elevated, the RR decreases smoked or ingested caffeine before taking
C. Elevated BP leads to Metabolic alkalosis his/her BP?
D. Low BP leads to Metabolic acidosis
52. All of the following factors correctly A. 5
influence respiration except one. Which of the B. 10
following is incorrect? C. 15
D. 30
A. Hydrocodone decreases RR 59. Too narrow cuff will cause what change in
B. Stress increases RR the Client’s BP?
C. Increase temperature of the
environment, Increase RR A. True high reading
D. Increase altitude, Increase RR B. True low reading
53. When does the heart receives blood from C. False high reading
the coronary artery? D. False low reading
60. Which is a preferable arm for BP taking?
A. Systole
B. Diastole A. An arm with the most contraptions
C. When the valves opens B. The left arm of the client with a CVA
D. When the valves closes affecting the right brain
54. Which of the following is more life C. The right arm
threatening? D. The left arm
61. Which of the following is INCORRECT
A. BP = 180/100 in assessing client’s BP?
B. BP = 160/120
C. BP = 90/60 A. Read the mercury at the upper
D. BP = 80/50 meniscus, preferably at the eye level to
prevent error of parallax
 B. Inflate and deflate slowly, 2-3 mmHg at a
time
C. The sound heard during taking BP is
known as KOROTKOFF sound
D. If the BP is taken on the left leg using the
popliteal artery pressure, a BP of 160/80
is normal.
62. Which of the following is the correct
interpretation of the ERROR OF PARALLAX
A. If the eye level is higher than the level of
the meniscus, it will cause a false high
reading
B. If the eye level is higher than the level
of the meniscus, it will cause a false low
reading
C. If the eye level is lower than the level of
the meniscus, it will cause a false low
reading
D. If the eye level is equal to that of the level
of the upper meniscus, the reading is
accurate
63. How many minute/s is/are allowed to pass
before making a re-reading after the first one?
A. 1
B. 5
C. 15
D. 30
64. Which of the following is TRUE about the
auscultation of blood pressure?
A. Pulse + 4 is considered as FULL
B. The bell of the stethoscope is use in
auscultating BP
C. Sound produced by BP is considered as
HIGH frequency sound
D. Pulse +1 is considered as NORMAL
65. In assessing the abdomen, Which of the
following is the correct sequence of the
physical assessment?
A. Inspection, Auscultation, Percussion,
Palpation
B. Palpation, Auscultation, Percussion,
Inspection
C. Inspection, Palpation, Auscultation,
Percussion
D. Inspection, Auscultation, Palpation,
Percussion
66. The sequence in examining the quadrants
of the abdomen is:
A. RUQ,RLQ,LUQ,LLQ
B. RLQ,RUQ,LLQ,LUQ
C. RUQ,RLQ,LLQ,LUQ
D. RLQ,RUQ,LUQ,LLQ
67. In inspecting the abdomen, which of the
following is NOT DONE?
A. Ask the client to void first
B. Knees and legs are straighten to relax
the abdomen
C. The best position in assessing the
abdomen is Dorsal recumbent
D. The knees and legs are externally rotated
68. Dr. Fabian De Las Santas, is about to
conduct an ophthalmoscope examination.
Which of the following, if done by a nurse, is
a Correct preparation before the procedure?
A. Provide the necessary draping to ensure
privacy
B. Open the windows, curtains and light to
allow better illumination
C. Pour warm water over the
ophthalmoscope to ensure comfort
D. Darken the room to provide better
illumination
69. If the client is female, and the doctor is a
male and the patient is about to undergo a
vaginal and cervical examination, why is it
necessary to have a female nurse in
attendance?
A. To ensure that the doctor performs the
procedure safely
B. To assist the doctor
C. To assess the client’s response to
examination
D. To ensure that the procedure is done in
an ethical manner
70. In palpating the client’s breast, Which of
the following position is necessary for the
patient to assume before the start of the
procedure?
A. Supine
B. Dorsal recumbent
C. Sitting
D. Lithotomy
71. When is the best time to collect urine
specimen for routine urinalysis and C/S?
A. Early morning
B. Later afternoon
C. Midnight
D. Before breakfast
72. Which of the following is among an ideal
way of collecting a urine specimen for culture
and sensitivity?
A. Use a clean container
B. Discard the first flow of urine to ensure
that the urine is not contaminated
C. Collect around 30-50 ml of urine
D. Add preservatives, refrigerate the
specimen or add ice according to the
agency’s protocol
73. In a 24 hour urine specimen started Friday,
9:00 A.M, which of the following if done by a
Nurse indicate a NEED for further procedural
debriefing?
A. The nurse ask the client to urinate at
9:00 A.M, Friday and she included the
urine in the 24 hour urine specimen
B. The nurse discards the Friday 9:00 A M
urine of the client
C. The nurse included the Saturday 9:00
A.M urine of the client to the specimen
collection
D. The nurse added preservatives as per
protocol and refrigerates the specimen
74. This specimen is required to assess
glucose levels and for the presence of albumin
the the urine
A. Midstream clean catch urine
B. 24 hours urine collection
C. Postprandial urine collection
D. Second voided urine
75. When should the client test his blood
sugar levels for greater accuracy?
A. During meals
B. In between meals
C. Before meals
D. 2 Hours after meals
76. In collecting a urine from a catheterized
patient, Which of the following statement
indicates an accurate performance of the
procedure?
A. Clamp above the port for 30 to 60
minutes before drawing the urine from the
port
B. Clamp below the port for 30 to 60
minutes before drawing the urine from
the port
C. Clamp above the port for 5 to 10 minutes
before drawing the urine from the port
D. Clamp below the port for 5 to 10 minutes
before drawing the urine from the port
77. A community health nurse should be
resourceful and meet the needs of the client. A
villager ask him, Can you test my urine for
glucose? Which of the following technique
allows the nurse to test a client’s urine for
glucose without the need for intricate
instruments.
A. Acetic Acid test
B. Nitrazine paper test
C. Benedict’s test
D. Litmus paper test
78. A community health nurse is assessing
client’s urine using the Acetic Acid solution.
Which of the following, if done by a nurse,
indicates lack of correct knowledge with the
procedure?
A. The nurse added the Urine as the 2/3 part
of the solution
B. The nurse heats the test tube after
adding 1/3 part acetic acid
C. The nurse heats the test tube after
adding 2/3 part of Urine
D. The nurse determines abnormal result if
she noticed that the test tube becomes
cloudy
79. Which of the following is incorrect with
regards to proper urine testing using
Benedict’s Solution?
A. Heat around 5ml of Benedict’s solution
together with the urine in a test tube
B. Add 8 to 10 drops of urine
C. Heat the Benedict’s solution without the
urine to check if the solution is
contaminated
D. If the color remains BLUE, the result is
POSITIVE
80. +++ Positive result after Benedicts test is
depicted by what color?
A. Blue
B. Green
C. Yellow
D. Orange
81. Clinitest is used in testing the urine of a
client for glucose. Which of the following, If
committed by a nurse indicates error?
A. Specimen is collected after meals
B. The nurse puts 1 clinitest tablet into a test
tube
 C. She added 5 drops of urine and 10 drops
of water
D. If the color becomes orange or red, It is
considered postitive
82. Which of the following nursing
intervention is important for a client
scheduled to have a Guaiac Test?
B. NPO for 12 hours pre procedure
C. Ask the client to drink 1 glass of water 1
hour prior to the procedure
D. Tell the client that the normal serum
lipase level is 50 to 140 U/L
87. The primary factor responsible for body
heat production is the

A. Avoid turnips, radish and horseradish A. Metabolism

3 days before procedure B. Release of thyroxin
B. Continue iron preparation to prevent C. Muscle activity
further loss of Iron D. Stress
C. Do not eat read meat 12 hours before 88. The heat regulating center is found in the
procedure
D. Encourage caffeine and dark colored A. Medulla oblongata
foods to produce accurate results B. Thalamus
83. In collecting a routine specimen for C. Hypothalamus
fecalysis, Which of the following, if done by a D. Pons
nurse, indicates inadequate knowledge and 89. A process of heat loss which involves the
skills about the procedure? transfer of heat from one surface to another is

A. The nurse scoop the specimen specifically A. Radiation

at the site with blood and mucus B. Conduction
B. She took around 1 inch of specimen or a C. Convection
teaspoonful D. Evaporation
C. Ask the client to call her for the 90. Which of the following is a primary factor
specimen after the client wiped off his that affects the BP?
anus with a tissue
D. Ask the client to defecate in a bedpan, A. Obesity
Secure a sterile container B. Age
84. In a routine sputum analysis, Which of the C. Stress
following indicates proper nursing action D. Gender
before sputum collection? 91. The following are social data about the
client except
A. Secure a clean container
B. Discard the container if the outside A. Patient’s lifestyle
becomes contaminated with the sputum B. Religious practices
C. Rinse the client’s mouth with Listerine C. Family home situation
after collection D. Usual health status
D. Tell the client that 4 tablespoon of sputum 92. The best position for any procedure that
is needed for each specimen for a routine involves vaginal and cervical examination is
sputum analysis
85. Who collects Blood specimen? A. Dorsal recumbent
B. Side lying
A. The nurse C. Supine
B. Medical technologist D. Lithotomy
C. Physician 93. Measure the leg circumference of a client
D. Physical therapist with bipedal edema is best done in what
86. David, 68 year old male client is position?
scheduled for Serum Lipid analysis. Which of
the following health teaching is important to A. Dorsal recumbent
ensure accurate reading? B. Sitting
C. Standing
A. Tell the patient to eat fatty meals 3 days D. Supine
prior to the procedure
94. In palpating the client’s abdomen, Which 100. In assessing the client’s chest, which
of the following is the best position for the position best show chest expansion as well as
client to assume? its movements?

A. Dorsal recumbent A. Sitting

B. Side lying B. Prone
C. Supine C. Sidelying
D. Lithotomy D. Supine
95. Rectal examination is done with a client in
what position?

A. Dorsal recumbent PNLE: FON Practice

B. Sims position
C. Supine
D. Lithotomy
Exam for
96. Which of the following is a correct
nursing action when collecting urine specimen Oxygenation and
from a client with an Indwelling catheter?

A. Collect urine specimen from the drainage

Nutrition
bag
B. Detach catheter from the connecting tube
1. Which one of the following is NOT a
and draw the specimen from the port
function of the Upper airway?
C. Use sterile syringe to aspirate urine
specimen from the drainage port For clearance mechanism such as
D. Insert the syringe straight to the port to
coughing
allow self sealing of the port Transport gases to the lower airways
97. Which of the following is inappropriate in Warming, Filtration and Humidification of
collecting mid stream clean catch urine inspired air
specimen for urine analysis? Protect the lower airway from foreign mater
2. It is the hair the lines the vestibule which
A. Collect early in the morning, First voided
function as a filtering mechanism for foreign
specimen
objects
B. Do perineal care before specimen
collection Cilia
C. Collect 5 to 10 ml for urine Nares
D. Discard the first flow of the urine Carina
98. When palpating the client’s neck for
Vibrissae
lymphadenopathy, where should the nurse 3. This is the paranasal sinus found between
position himself? the eyes and the nose that extends backward
into the skull
A. At the client’s back
B. At the client’s right side
Ehtmoid
C. At the client’s left side Sphenoid
D. In front of a sitting client Maxillary
99. Which of the following is the best position Frontal
for the client to assume if the back is to be 4. Which paranasal sinus is found over the
examined by the nurse? eyebrow?
A. Standing Ehtmoid
B. Sitting Sphenoid
C. Side lying Maxillary
D. Prone Frontal
5. Gene De Vonne Katrouchuacheulujiki
wants to change her surname to something
shorter, The court denied her request which Residual volume
depresses her and find herself binge eating. 12. This is the amount of air remained in the
She accidentally aspirate a large piece of nut lungs after a forceful expiration
and it passes the carina. Probabilty wise,
Where will the nut go? Inspiratory reserve volume
Expiratory reserve volume
Right main stem bronchus Functional residual capacity
Left main stem bronchus Residual volume
Be dislodged in between the carina 13. Casssandra, A 22 year old grade Agnostic,
Be blocked by the closed epiglottis Asked you, how many spikes of bones are
6. Which cell secretes mucus that help protect there in my ribs? Your best response is which
the lungs by trapping debris in the respiratory of the following?
tract?
We have 13 pairs of ribs Cassandra
Type I pneumocytes We have 12 pairs of ribs Cassandra
Type II pneumocytes Humans have 16 pairs of ribs, and that was
Goblet cells noted by Vesalius in 1543
Adipose cells Humans have 8 pairs of ribs. 4 of which are
7. How many lobes are there in the RIGHT floating
LUNG? 14. Which of the following is considered as
the main muscle of respiration?
One
Two Lungs
Three Intercostal Muscles
Four Diaphragm
8. The presence of the liver causes which Pectoralis major
anatomical difference of the Kidneys and the 15. Cassandra asked you : How many air is
Lungs? there in the oxygen and how many does
human requires? Which of the following is the
Left kidney slightly lower, Left lung best response :
slightly shorter
Left kidney slightly higher, Left lung slightly God is good, Man requires 21% of oxygen
shorter and we have 21% available in our air
Right kidney lower, Right lung shorter Man requires 16% of oxygen and we have 35%
Right kidney higher, Right lung shorter available in our air
9. Surfactant is produced by what cells in the Man requires 10% of oxygen and we have 50%
alveoli? available in our air
Human requires 21% of oxygen and we
Type I pneumocytes have 21% available in our air
Type II pneumocytes 16. Which of the following is TRUE about
Goblet cells Expiration?
Adipose cells
10. The normal L:S Ratio to consider the A passive process
newborn baby viable is The length of which is half of the length of
Inspiration
1:2 Stridor is commonly heard during expiration
2:1 Requires energy to be carried out
3:1 17. Which of the following is TRUE in
1:3 postural drainage?
11. Refers to the extra air that can be inhaled
beyond the normal tidal volume Patient assumes position for 10 to 15
minutes
Inspiratory reserve volume Should last only for 60 minutes
Expiratory reserve volume Done best P.C
Functional residual capacity An independent nursing action
 10-15 mmHg
18. All but one of the following is a purpose 15-25 mmHg
of steam inhalation 24. There are four catheter sizes available for
use, which one of these should you use for Mr.
Mucolytic Hamilton?
Warm and humidify air
Administer medications Fr. 18
Promote bronchoconstriction Fr. 12
Fr. 10
19. Which of the following is NOT TRUE in Fr, 5
steam inhalation? 25. Which of the following, if done by the
nurse, indicates incompetence during
It is a dependent nursing action suctioning an unconscious client?
Spout is put 12-18 inches away from the nose
Render steam inhalation for atleast 60 Measure the length of the suction catheter
minutes to be inserted by measuring from the
Cover the client’s eye with wash cloth to tip of the nose, to the earlobe, to the
prevent irritation xiphoid process
20. When should a nurse suction a client? Use KY Jelly if suctioning nasopharyngeal
secretion
As desired The maximum time of suctioning should not
As needed exceed 15 seconds
Every 1 hour Allow 30 seconds interval between
Every 4 hours suctioning
21. Ernest Arnold Hamilton, a 60 year old
American client was mobbed by teen 26. Which of the following is the initial sign
gangsters near New york, Cubao. He was of hypoxemia in an adult client?
rushed to John John Hopio Medical Center
and was Unconscious. You are his nurse and Tachypnea
you are to suction his secretions. In which Tachycardia
position should you place Mr. Hamilton? Cyanosis
Pallor
High fowlers Irritability
Semi fowlers Flaring of NaresA. 1,2
Prone B. 2,5
Side lying C. 2,6
22. You are about to set the suction pressure D. 3,4
to be used to Mr. Hamilton. You are using a 27. Which method of oxygenation least likely
Wall unit suction machine. How much produces anxiety and apprehension?
pressure should you set the valve before
suctioning Mr. Hamilton? Nasal Cannula
Simple Face mask
50-95 mmHg Non Rebreather mask
200-350 mmHg Partial Rebreather mask
100-120 mmHg
10-15 mmHg 28. Which of the following oxygen delivery
23. The wall unit is not functioning; You then method can deliver 100% Oxygen at 15 LPM?
try to use the portable suction equipment
available. How much pressure of suction Nasal Cannula
equipment is needed to prevent trauma to Simple Face mask
mucus membrane and air ways in case of Non Rebreather mask
portable suction units? Partial Rebreather mask
29. Which of the following is not true about
2-5 mmHg OXYGEN?
5-10 mmHg
Oxygen is odorless, tasteless and colorless
gas.
Oxygen can irritate mucus membrane
Oxygen supports combustion
Excessive oxygen administration results in
respiratory acidosis
30. Roberto San Andres, A new nurse in the
hospital is about to administer oxygen on
patient with Respiratory distress. As his senior
nurse, you should intervene if Roberto will:
Uses venture mask in oxygen administration
Put a non rebreather mask in the patient
before opening the oxygen source
Use a partial rebreather mask to deliver
oxygen
Check for the doctor’s order for Oxygen
administration
31. Which of the following will alert the nurse
as an early sign of hypoxia?
Client is tired and dyspneic
The client is coughing out blood
The client’s heart rate is 50 BPM
Client is frequently turning from side to
side
32. Miguelito de balboa, An OFW presents at
the admission with an A:P Diameter ratio of
2:1, Which of the following associated finding
should the nurse expect?
Pancytopenia
Anemia
Fingers are Club-like
Hematocrit of client is decreased
33. The best method of oxygen administration
for client with COPD uses:
Cannula
Simple Face mask
Non rebreather mask
Venturi mask
34. Mang dagul, a 50 year old chronic smoker
was brought to the E.R because of difficulty
in breathing. Pleural effusion was the
diagnosis and CTT was ordered. What does
C.T.T Stands for?
Chest tube thoracotomy
Chest tube thoracostomy
Closed tube thoracotomy
Closed tube thoracostmy
35. Where will the CTT be inserted if we are
to drain fluids accumulated in Mang dagul’s
pleura?
2nd ICS
4th ICS
5th ICS
8th ICS
36. There is a continuous bubbling in the
water sealed drainage system with suction.
And oscillation is observed. As a nurse, what
should you do?
Consider this as normal findings
Notify the physician
Check for tube leak
Prepare a petrolatum gauze dressing
37. Which of the following is true about
nutrition?
It is the process in which food are broken
down, for the body to use in growth and
development
It is a process in which digested proteins, fats,
minerals, vitamins and carbohydrates are
transported into the circulation
It is a chemical process that occurs in the cell
that allows for energy production, energy
use, growth and tissue repair
It is the study of nutrients and the process
in which they are use by the body
38. The majority of the digestion processes
take place in the
Mouth
Small intestine
Large intestine
Stomach
39. All of the following is true about digestion
that occurs in the Mouth except
It is where the digestion process starts
Mechanical digestion is brought about by
mastication
The action of ptyalin or the salivary
tyrpsin breaks down starches into
maltose
Deglutition occurs after food is broken down
into small pieces and well mixed with
saliva
40. Which of the following foods lowers the
cardiac sphincter pressure?
Roast beef, Steamed cauliflower and Rice
Orange juice, Non fat milk, Dry crackers
 Decaffeinated coffee, Sky flakes crackers, Trypsin
Suman Enterokinase
Coffee with coffee mate, Bacon and Egg Enterogastrone
41. Where does the digestion of carbohydrates Amylase
start? 48. The end product of protein digestion or
the “Building blocks of Protein” is what we
Mouth call
Esophagus
Small intestine Nucleotides
Stomach Fatty acids
42. Protein and Fat digestion begins where? Glucose
Amino Acids
Mouth 49. Enzyme secreted by the small intestine
Esophagus after it detects a bolus of fatty food. This will
Small intestine contract the gallbladder to secrete bile and
Stomach relax the sphincter of Oddi to aid in the
43. All but one is true about digestion that emulsification of fats and its digestion.
occurs in the Stomach
Lipase
Carbohydrates are the fastest to be digested, Amylase
in about an hour Cholecystokinin
Fat is the slowest to be digested, in about 5 Pancreozymin
hours 50. Which of the following is not true about
HCl inhibits absorption of Calcium in the the Large Intestine?
gastric mucosa
HCl converts pepsinogen to pepsin, which It absorbs around 1 L of water making the
starts the complex process of protein feces around 75% water and 25% solid
digestion The stool formed in the transverse colon is
44. Which of the following is NOT an enzyme not yet well formed
secreted by the small intestine? It is a sterile body cavity
It is called large intestine because it is longer
Sucrase than the small intestine
Enterokinase 51. This is the amount of heat required to raise
Amylase the temperature of 1 kg water to 1 degree
Enterokinase Celsius
45. The hormone secreted by the Small
intestine that stimulates the production of Calorie
pancreatic juice which primarily aids in Joules
buffering the acidic bolus passed by the Metabolism
Stomach Basal metabolic rate
52. Assuming a cup of rice provides 50 grams
Enterogastrone of carbohydrates. How many calories are
Cholecystokinin there in that cup of rice?
Pancreozymin
Enterokinase 150 calories
46. When the duodenal enzyme sucrase acts 200 calories
on SUCROSE, which 2 monosaccharides are 250 calories
formed? 400 calories
53. An average adult filipino requires how
Galactose + Galactose many calories in a day?
Glucose + Fructose
Glucose + Galactose 1,000 calories
Fructose + Fructose 1,500 calories
47. This is the enzyme secreted by the 2,000 calories
pancrease that completes the protein digestion 2,500 calories
54. Which of the following is true about an
individual’s caloric needs?
All individual have the same caloric needs
Females in general have higher BMR and
therefore, require more calories
During cold weather, people need more
calories due to increase BMR
Dinner should be the heaviest meal of the
day
55. Among the following people, who
requires the greatest caloric intake?
An individual in a long state of
gluconeogenesis
An individual in a long state of
glycogenolysis
A pregnant individual
An adolescent with a BMI of 25
56. Which nutrient deficiency is associated
with the development of Pellagra, Dermatitis
and Diarrhea?
Vitamin B1
Vitamin B2
Vitamin B3
Vitamin B6
57. Which Vitamin is not given in conjunction
with the intake of LEVODOPA in cases of
Parkinson’s Disease due to the fact that
levodopa increases its level in the body?
Vitamin B1
Vitamin B2
Vitamin B3
Vitamin B6
58. A vitamin taken in conjunction with
ISONIAZID to prevent peripheral neuritis
Vitamin B1
Vitamin B2
Vitamin B3
Vitamin B6
59. The inflammation of the Lips, Palate and
Tongue is associated in the deficiency of this
vitamin
Vitamin B1
Vitamin B2
Vitamin B3
Vitamin B6
60. Beri beri is caused by the deficiency of
which Vitamin?
Vitamin B1
Vitamin B2
Vitamin B3
Vitamin C
61. Which of the following is the best source
of Vitamin E?
Green leafy vegetables
Vegetable oil
Fortified Milk
Fish liver oil
62. Among the following foods, which food
should you emphasize giving on an Alcoholic
client?
Pork liver and organ meats, Pork
Red meat, Eggs and Dairy products
Green leafy vegetables, Yellow vegetables,
Cantaloupe and Dairy products
Chicken, Peanuts, Bananas, Wheat germs
and yeasts
63. Which food group should you emphasize
giving on a pregnant mother in first trimester
to prevent neural tube defects?
Broccoli, Guava, Citrus fruits, Tomatoes
Butter, Sardines, Tuna, Salmon, Egg yolk
Wheat germ, Vegetable Oil, soybeans, corn,
peanuts
Organ meats, Green leafy vegetables,
Liver, Eggs
64. A client taking Coumadin is to be
educated on his diet. As a nurse, which of the
following food should you instruct the client
to avoid?
Spinach, Green leafy vegetables, Cabbage,
Liver
Salmon, Sardines, Tuna
Butter, Egg yolk, breakfast cereals
Banana, Yeast, Wheat germ, Chicken
65. Vitamin E plus this mineral works as one
of the best anti oxidant in the body according
to the latest research. They are combined with
5 Alpha reductase inhibitor to reduce the risk
of acquiring prostate cancer
Zinc
Iron
Selenium
Vanadium
66. Incident of prostate cancer is found to
have been reduced on a population exposed in
tolerable amount of sunlight. Which vitamin 73. Jose Miguel, a 50 year old business man is
is associated with this phenomenon? 6’0 Tall and weights 179 lbs. As a nurse, you
know that Jose Miguel is :
Vitamin A
Vitamin B Overweight
Vitamin C Underweight
Vitamin D Normal
67. Micronutrients are those nutrients needed Obese
by the body in a very minute amount. Which 74. Jose Miguel is a little bit nauseous.
of the following vitamin is considered as a Among the following beverages, Which could
MICRONUTRIENT help relieve JM’s nausea?

Phosphorous Coke
Iron Sprite
Calcium Mirinda
Sodium Orange Juice or Lemon Juice
68. Deficiency of this mineral results in tetany, 75. Which of the following is the first sign of
osteomalacia, osteoporosis and rickets. dehydration?

Vitamin D Tachycardia
Iron Restlessness
Calcium Thirst
Sodium Poor skin turgor
69. Among the following foods, which has the 76. What Specific gravity lab result is
highest amount of potassium per area of their compatible with a dehydrated client?
meat?
1.007
Cantaloupe 1.020
Avocado 1.039
Raisin 1.029
Banana 77. Which hematocrit value is expected in a
70. A client has HEMOSIDEROSIS. Which dehydrated male client?
of the following drug would you expect to be
given to the client? 67%
50%
Acetazolamide 36%
Deferoxamine 45%
Calcium EDTA 78. Which of the following statement by a
Activated charcoal client with prolonged vomiting indicates the
71. Which of the following provides the initial onset of hypokalemia?
richest source of Iron per area of their meat?
My arm feels so weak
Pork meat I felt my heart beat just right now
Lean read meat My face muscle is twitching
Pork liver Nurse, help! My legs are cramping
Green mongo 79. Which of the following is not an anti-
emetic?
72. Which of the following is considered the
best indicator of nutritional status of an Marinol
individual? Dramamine
Benadryl
Height Alevaire
Weight
Arm muscle circumference 80. Which is not a clear liquid diet?
BMI
 Hard candy
Gelatin
Coffee with Coffee mate
Bouillon
81. Which of the following is included in a
full liquid diet?
Popsicles
Pureed vegetable meat
Pineapple juice with pulps
Mashed potato
82. Which food is included in a BLAND
DIET?
Steamed broccoli
Creamed potato
Spinach in garlic
Sweet potato
83. Which of the following if done by the
nurse, is correct during NGT Insertion?
Use an oil based lubricant
Measure the amount of the tube to be
inserted from the Tip of the nose, to the
earlobe, to the xiphoid process
Soak the NGT in a basin of ice water to
facilitate easy insertion
Check the placement of the tube by
introducing 10 cc of sterile water and
auscultating for bubbling sound
84. Which of the following is the BEST
method in assessing for the correct placement
of the NGT?
X-Ray
Immerse tip of the tube in water to check for
bubbles produced
Aspirating gastric content to check if the
content is acidic
Instilling air in the NGT and listening for a
gurgling sound at the epigastric area
85. A terminally ill cancer patient is scheduled
for an NGT feeding today. How should you
position the patient?
Semi fowlers in bed
Bring the client into a chair
Slightly elevated right side lying position
Supine in bed
86. A client is scheduled for NGT Feeding.
Checking the residual volume, you
determined that he has 40 cc residual from the
last feeding. You reinstill the 40 cc of residual
volume and added the 250 cc of feeding
ordered by the doctor. You then instill 60 cc
of water to clear the lumen and the tube. How
much will you put in the client’s chart as input?
250 cc
290 cc
350 cc
310 cc
87. Which of the following if done by a nurse
indicates deviation from the standards of NGT
feeding?
Do not give the feeding and notify the doctor
of residual of the last feeding is greater
than or equal to 50 ml
Height of the feeding should be 12 inches
about the tube point of insertion to allow
slow introduction of feeding
Ask the client to position in supine position
immediately after feeding to prevent
dumping syndrome
Clamp the NGT before all of the water is
instilled to prevent air entry in the
stomach
88. What is the most common problem in
TUBE FEEDING?
Diarrhea
Infection
Hyperglycemia
Vomiting
89. Which of the following is TRUE in
colostomy feeding?
Hold the syringe 18 inches above the stoma
and administer the feeding slowly
Pour 30 ml of water before and after feeding
administration
Insert the ostomy feeding tube 1 inch towards
the stoma
A Pink stoma means that circulation towards
the stoma is all well
90. A client with TPN suddenly develops
tremors, dizziness, weakness and diaphoresis.
The client said “I feel weak” You saw that his
TPN is already empty and another TPN is
scheduled to replace the previous one but its
provision is already 3 hours late. Which of the
following is the probable complication being
experienced by the client?
Hyperglycemia
Hypoglycemia
Infection
Fluid overload
91. To assess the adequacy of food intake, 19
which of the following assessment parameters 15
is best used? 25
99. Which finding is consistent with
Food likes and dislikes PERNICIOUS ANEMIA?
Regularity of meal times
3 day diet recall Strawberry tongue
Eating style and habits Currant Jelly stool
Beefy red tongue
92. The vomiting center is found in the Pale [ HYPOCHROMIC ] RBC
100. The nurse is browsing the chart of the
Medulla Oblongata patient and notes a normal serum lipase level.
Pons Which of the following is a normal serum
Hypothalamus lipase value?
Cerebellum
93. The most threatening complication of 10 U/L
vomiting in client’s with stroke is 100 U/L
200 U/L
Aspiration 350 U/L
Dehydration
Fluid and electrolyte imbalance
Malnutrition
94. Which among this food is the richest
PNLE Fundamentals
source of Iron?
in Nursing Exam 1
Ampalaya 1. Jake is complaining of shortness of breath.
Broccoli The nurse assesses his respiratory rate to be
Mongo 30 breaths per minute and documents that
Malunggay leaves Jake is tachypneic. The nurse understands that
95. Which of the following is a good source of tachypnea means:
Vitamin A?
Pulse rate greater than 100 beats per minute
Egg yolk Blood pressure of 140/90
Liver Respiratory rate greater than 20 breaths
Fish
per minute
Peanuts Frequent bowel sounds
96. The most important nursing action before
gastrostomy feeding is (C) Respiratory rate greater than 20 breaths
per minute. A respiratory rate of greater than
Check V/S
20 breaths per minute is tachypnea. A blood
Assess for patency of the tube
pressure of 140/90 is considered hypertension.
Measure residual feeding
Pulse greater than 100 beats per minute is
Check the placement of the tube
tachycardia. Frequent bowel sounds refer to
97. The primary advantage of gastrostomy
hyper-active bowel sounds.
feeding is
2. The nurse listens to Mrs. Sullen’s lungs and
Ensures adequate nutrition
notes a hissing sound or musical sound. The
It prevents aspiration
nurse documents this as:
Maintains Gastro esophageal sphincter
integrity
Wheezes
Minimizes fluid-electrolyte imbalance
Rhonchi
98. What is the BMI Of Budek, weighing 120
Gurgles
lbs and has a height of 5 feet 7 inches.
Vesicular
20
(A) Wheezes. Wheezes are indicated by
continuous, lengthy, musical; heard
during inspiration or expiration. Rhonchi
are usually coarse breath sounds. Gurgles
are loud gurgling, bubbling sound.
Vesicular breath sounds are low pitch,
soft intensity on expiration
3. The nurse in charge measures a patient’s
temperature at 101 degrees F. What is the
equivalent centigrade temperature?
36.3 degrees C
37.95 degrees C
40.03 degrees C
38.01 degrees C
(B) 37.95 degrees C. To convert °F to °C use
this formula, ( °F – 32 ) (0.55). While
when converting °C to °F use this formula,
( °C x 1.8) + 32. Note that 0.55 is 5/9 and
1.8 is 9/5.
4. Which approach to problem solving tests
any number of solutions until one is found
that works for that particular problem?
Intuition
Routine
Scientific method
Trial and error
(D) Trial and error. The trial and error
method of problem solving isn’t
systematic (as in the scientific method of
problem solving) routine, or based on
inner prompting (as in the intuitive
method of problem solving).
5. What is the order of the nursing process?
Assessing, diagnosing, implementing,
evaluating, planning
Diagnosing, assessing, planning,
implementing, evaluating
Assessing, diagnosing, planning,
implementing, evaluating
Planning, evaluating, diagnosing, assessing,
implementing
(C) Assessing, diagnosing, planning,
implementing, evaluating. The correct
order of the nursing process is assessing,
diagnosing, planning, implementing,
evaluating.
6. During the planning phase of the nursing
process, which of the following is the
outcome?
Nursing history
Nursing notes
Nursing care plan
Nursing diagnosis
(C) Nursing care plan. The outcome, or the
product of the planning phase of the
nursing process is a Nursing care plan.
7. What is an example of a subjective data?
Heart rate of 68 beats per minute
Yellowish sputum
Client verbalized, “I feel pain when
urinating.”
Noisy breathing
(C) Client verbalized, “I feel pain when
urinating.”. Subjective data are those that
can be described only by the person
experiencing it. Therefore, only the
patient can describe or verify whether he
is experiencing pain or not.
8. Which expected outcome is correctly
written?
“The patient will feel less nauseated in 24
hours.”
“The patient will eat the right amount of food
daily.”
“The patient will identify all the high-salt
food from a prepared list by discharge.”
(C) “The patient will identify all the high-salt
food from a prepared list by
discharge.”. Expected outcomes are
specific, measurable, realistic statements
of goal attainment. The phrases “right
amount”, “less nauseated” and “enough
sleep” are vague and not measurable.
“The patient will have enough sleep.”
9. Which of the following behaviors by Nurse
Jane Robles demonstrates that she
understands well th elements of effecting
charting?
She writes in the chart using a no. 2 pencil.
She noted: appetite is good this afternoon.
She signs on the medication sheet after
administering the medication.
She signs her charting as follow: J.R
(C) She signs on the medication sheet after
administering the medication.A nurse
should record a nursing intervention (ex.
Giving medications) after performing the
nursing intervention (not before).
Recording should also be done using a
pen, be complete, and signed with the
nurse’s full name and title.
10. What is the disadvantage of computerized
documentation of the nursing process?
Accuracy
Legibility
Concern for privacy
Rapid communication
(C) Concern for privacy. A patient’s privacy
may be violated if security measures
aren’t used properly or if policies and
procedures aren’t in place that determines
what type of information can be retrieved,
by whom, and for what purpose.
11. The theorist who believes that adaptation
and manipulation of stressors are related to
foster change is:
Dorothea Orem
Sister Callista Roy
Imogene King
Virginia Henderson
(B) Sister Callista Roy. Sister Roy’s theory is
called the adaptation theory and she
viewed each person as a unified
biophysical system in constant interaction
with a changing environment. Orem’s
theory is called self-care deficit theory
and is based on the belief that individual
has a need for self-care actions. King’s
theory is the Goal attainment theory and
described nursing as a helping profession
that assists individuals and groups in
society to attain, maintain, and restore
health. Henderson introduced the nature
of nursing model and identified the 14
basic needs.
12. Formulating a nursing diagnosis is a joint
function of:
Patient and relatives
Nurse and patient
Doctor and family
Nurse and doctor
(B) Nurse and patient. Although diagnosing
is basically the nurse’s responsibility,
input from the patient is essential to
formulate the correct nursing diagnosis.
13. Mrs. Caperlac has been diagnosed to have
hypertension since 10 years ago. Since then,
she had maintained low sodium, low fat diet,
to control her blood pressure. This practice is
viewed as:
Cultural belief
Personal belief
Health belief
Superstitious belief
(C) Health belief. Health belief of an
individual influences his/her preventive
health behavior.
14. Becky is on NPO since midnight as
preparation for blood test. Adreno-cortical
response is activated. Which of the following
is an expected response?
Low blood pressure
Warm, dry skin
Decreased serum sodium levels
Decreased urine output
(D) Decreased urine output. Adreno-cortical
response involves release of aldosterone
that leads to retention of sodium and
water. This results to decreased urine
output.
15. What nursing action is appropriate when
obtaining a sterile urine specimen from an
indwelling catheter to prevent infection?
Use sterile gloves when obtaining urine.
Open the drainage bag and pour out the urine.
Disconnect the catheter from the tubing and
get urine.
Aspirate urine from the tubing port using
a sterile syringe.
(D) Aspirate urine from the tubing port using
a sterile syringe. The nurse should
aspirate the urine from the port using a
 sterile syringe to obtain a urine specimen.
Opening a closed drainage system
increase the risk of urinary tract infection.
16. A client is receiving 115 ml/hr of
continuous IVF. The nurse notices that the
venipuncture site is red and swollen. Which of
the following interventions would the nurse
perform first?
Stop the infusion
Call the attending physician
Slow that infusion to 20 ml/hr
Place a clod towel on the site
(A) Stop the infusion. The sign and
symptoms indicate extravasation so the
IVF should be stopped immediately and
put warm not cold towel on the affected
site.
17. The nurse enters the room to give a
prescribed medication but the patient is inside
the bathroom. What should the nurse do?
Leave the medication at the bedside and
leave the room.
After few minutes, return to that patient’s
room and do not leave until the patient
takes the medication.
Instruct the patient to take the medication and
leave it at the bedside.
Wait for the patient to return to bed and just
leave the medication at the bedside.
(B) After few minutes, return to that patient’s
room and do not leave until the patient
takes the medication. This is to verify or
to make sure that the medication was
taken by the patient as directed.
18. Which of the following is inappropriate
nursing action when administering NGT
feeding?
Place the feeding 20 inches above the pint
if insertion of NGT.
Introduce the feeding slowly.
Instill 60ml of water into the NGT after
feeding.
Assist the patient in fowler’s position.
(A) Place the feeding 20 inches above the
pint if insertion of NGT. The height of the
feeding is above 12 inches above the
point of insertion, bot 20 inches. If the
height of feeding is too high, this results
to very rapid introduction of feeding. This
may trigger nausea and vomiting.
19. A female patient is being discharged after
thyroidectomy. After providing the
medication teaching. The nurse asks the
patient to repeat the instructions. The nurse is
performing which professional role?
Manager
Caregiver
Patient advocate
Educator
(D) Educator. When teaching a patient about
medications before discharge, the nurse is
acting as an educator. A caregiver
provides direct care to the patient. The
nurse acts as s patient advocate when
making the patient’s wishes known to the
doctor.
20. Which data would be of greatest concern
to the nurse when completing the nursing
assessment of a 68-year-old woman
hospitalized due to Pneumonia?
Oriented to date, time and place
Clear breath sounds
Capillary refill greater than 3 seconds and
buccal cyanosis
Hemoglobin of 13 g/dl
(C) Capillary refill greater than 3 seconds
and buccal cyanosis. Capillary refill
greater than 3 seconds and buccal
cyanosis indicate decreased oxygen to the
tissues which requires immediate
attention/intervention. Oriented to date,
time and place, hemoglobin of 13 g/dl are
normal data.
21. During a change-of-shift report, it would
be important for the nurse relinquishing
responsibility for care of the patient to
communicate. Which of the following facts to
the nurse assuming responsibility for care of
the patient?
That the patient verbalized, “My headache is
gone.”
That the patient’s barium enema performed 3
days ago was negative
Patient’s NGT was removed 2 hours ago
Patient’s family came for a visit this morning.
(C) Patient’s NGT was removed 2 hours
ago. The change-of-shift report should
indicate significant recent changes in the
patient’s condition that the nurse
assuming responsibility for care of the
patient will need to monitor. The other
options are not critical enough to include
in the report.
22. Which statement is the most appropriate
goal for a nursing diagnosis of diarrhea?
“The patient will experience decreased
frequency of bowel elimination.”
“The patient will take anti-diarrheal
medication.”
“The patient will give a stool specimen for
laboratory examinations.”
“The patient will save urine for inspection by
the nurse.
(A) “The patient will experience decreased
frequency of bowel elimination.” The
goal is the opposite, healthy response of
the problem statement of the nursing
diagnosis. In this situation, the problem
statement is diarrhea.
23. Which of the following is the most
important purpose of planning care with this
patient?
Development of a standardized NCP.
Expansion of the current taxonomy of
nursing diagnosis
Making of individualized patient care
Incorporation of both nursing and medical
diagnoses in patient care
(C) Making of individualized patient care. To
be effective, the nursing care plan
developed in the planning phase of the
nursing process must reflect the
individualized needs of the patient.
24. Using Maslow’s hierarchy of basic human
needs, which of the following nursing
diagnoses has the highest priority?
Ineffective breathing pattern related to
pain, as evidenced by shortness of
breath.
Anxiety related to impending surgery, as
evidenced by insomnia.
Risk of injury related to autoimmune
dysfunction
Impaired verbal communication related to
tracheostomy, as evidenced by inability to
speak.
(A) Ineffective breathing pattern related to
pain, as evidenced by shortness of
breath.. Physiologic needs (ex. Oxygen,
fluids, nutrition) must be met before
lower needs (such as safety and security,
love and belongingness, self-esteem and
self-actualization) can be met. Therefore,
physiologic needs have the highest
priority.
25. When performing an abdominal
examination, the patient should be in a supine
position with the head of the bed at what
position?
30 degrees
90 degrees
45 degrees
0 degree
(D) 0 degree. The patient should be positioned
with the head of the bed completely flattened
to perform an abdominal examination. If the
head of the bed is elevated, the abdominal
muscles and organs can be bunched up,
altering the findings
PNLE Fundamentals
in Nursing Exam 2
1. A patient is wearing a soft wrist-safety
device. Which of the following nursing
assessment is considered abnormal?
Palpable radial pulse
Palpable ulnar pulse
Capillary refill within 3 seconds
Bluish fingernails, cool and pale fingers
(D) Bluish fingernails, cool and pale
fingers. A safety device on the wrist may
impair blood circulation. Therefore, the
nurse should assess the patient for signs
 of impaired circulation such as bluish
fingernails, cool and pale fingers.
Palpable radial and ulnar pulses, capillary
refill within 3 seconds are all normal
findings.
2. Pia’s serum sodium level is 150 mEq/L.
Which of the following food items does the
nurse instruct Pia to avoid?
broccoli
sardines
cabbage
Tomatoes
(B) sardines. The normal serum sodium level
is 135 to 145 mEq/L, the client is having
hypernatremia. Pia should avoid food
high in sodium like processed food.
Broccoli, cabbage and tomatoes are good
source of Vitamin C.
3. Jason, 3 years old vomited. His mom stated,
“He vomited 6 ounces of his formula this
morning.” This statement is an example of:
objective data from a secondary source
objective data from a primary source
subjective data from a primary source
subjective data from a secondary source
(A) objective data from a secondary
source. Jason is the primary source; his
mother is a secondary source. The data is
objective because it can be perceived by
the senses, verified by another person
observing the same patient, and tested
against accepted standards or norms.
4. Which of the following is a nursing
diagnosis?
Hypethermia
Diabetes Mellitus
Angina
Chronic Renal Failure
A) Hypethermia. Hyperthermia is a
NANDA-approved nursing diagnosis.
Diabetes Mellitus, Angina and Chronic
Renal Failure are medical diagnoses.
5. What is the characteristic of the nursing
process?
stagnant
inflexible
asystematic
goal-oriented
(D) goal-oriented. The nursing process is
goal-oriented. It is also systematic,
patient-centered, and dynamic.
6. A skin lesion which is fluid-filled, less than
1 cm in size is called:
papule
vesicle
bulla
Macule
(B) vesicle. Vesicle is a circumscribed
circulation containing serous fluid or
blood and less than 1 cm (ex. Blister,
chicken pox).
7. During application of medication into the
ear, which of the following is inappropriate
nursing action?
In an adult, pull the pinna upward.
Instill the medication directly into the
tympanic membrane.
Warm the medication at room or body
temperature.
Press the tragus of the ear a few times to
assist flow of medication into the ear
canal.
(B) Instill the medication directly into the
tympanic membrane. During the
application of medication it is
inappropriate to instill the medication
directly into the tympanic membrane. The
right thing to do is instill the medication
along the lateral wall of the auditory canal.
8. Which of the following is appropriate
nursing intervention for a client who is
grieving over the death of her child?
Tell her not to cry and it will be better.
Provide opportunity to the client to tell
their story.
Encourage her to accept or to replace the lost
person.
Discourage the client in expressing her
emotions.
(B) Provide opportunity to the client to tell
their story. Providing a grieving person an
opportunity to tell their story allows the
person to express feelings. This is
therapeutic in assisting the client resolve
grief.
9. It is the gradual decrease of the body’s
temperature after death.
livor mortis
rigor mortis
algor mortis
none of the above
(C) algor mortis. Algor mortis is the decrease
of the body’s temperature after death.
Livor mortis is the discoloration of the
skin after death. Rigor mortis is the
stiffening of the body that occurs about 2-
4 hours after death.
10. When performing an admission
assessment on a newly admitted patient, the
nurse percusses resonance. The nurse knows
that resonance heard on percussion is most
commonly heard over which organ?
thigh
liver
intestine
Lung
(D) lung. Resonance is loud, low-pitched and
long duration that’s heard most
commonly over an air-filled tissue such as
a normal lung.
11. The nurse is aware that Bell’s palsy
affects which cranial nerve?
2nd CN (Optic)
3rd CN (Occulomotor)
4th CN (Trochlear)
7th CN (Facial)
(D) 7th CN (Facial). Bells’ palsy is the
paralysis of the motor component of the
7th caranial nerve, resulting in facial sag,
inability to close the eyelid or the mouth,
drooling, flat nasolabial fold and loss of
taste on the affected side of the face.
12. Prolonged deficiency of Vitamin B9 leads
to:
scurvy
pellagra
megaloblastic anemia
pernicious anemia
(C) megaloblastic anemia. Prolonged
Vitamin B9 deficiency will lead to
megaloblastic anemia while pernicious
anemia results in deficiency in Vitamin
B12. Prolonged deficiency of Vitamin C
leads to scurvy and Pellagra results in
deficiency in Vitamin B3.
13. Nurse Cherry is teaching a 72 year old
patient about a newly prescribed medication.
What could cause a geriatric patient to have
difficulty retaining knowledge about the
newly prescribed medication?
Absence of family support
Decreased sensory functions
Patient has no interest on learning
Decreased plasma drug levels
(B) Decreased sensory functions. Decreased
in sensory functions could cause a
geriatric patient to have difficulty
retaining knowledge about the newly
prescribed medications. Absence of
family support and no interest on learning
may affect compliance, not knowledge
retention. Decreased plasma levels do not
alter patient’s knowledge about the drug.
14. When assessing a patient’s level of
consciousness, which type of nursing
intervention is the nurse performing?
Independent
Dependent
Collaborative
Professional
(A) Independent. Independent nursing
interventions involve actions that nurses
initiate based on their own knowledge and
skills without the direction or supervision
of another member of the health care team.
15. Claire is admitted with a diagnosis of
chronic shoulder pain. By definition, the nurse
understands that the patient has had pain for
more than:
3 months
6 months
9 months
1 year
(B) 6 months. Chronic pain s usually defined
as pain lasting longer than 6 months.
16. Which of the following statements
regarding the nursing process is true?
It is useful on outpatient settings.
It progresses in separate, unrelated steps.
It focuses on the patient, not the nurse.
It provides the solution to all patient health
problems.
(C) It focuses on the patient, not the
nurse. The nursing process is patient-
centered, not nurse-centered. It can be use
in any setting, and the steps are related.
The nursing process can’t solve all patient
health problems.
17. Which of the following is considered
significant enough to require immediate
communication to another member of the
health care team?
Weight loss of 3 lbs in a 120 lb female
patient.
Diminished breath sounds in patient with
previously normal breath sounds
Patient stated, “I feel less nauseated.”
Change of heart rate from 70 to 83 beats per
minute.
(B) Diminished breath sounds in patient with
previously normal breath
sounds. Diminished breath sound is a life
threatening problem therefore it is highly
priority because they pose the greatest
threat to the patient’s well-being.
18. To assess the adequacy of food intake,
which of the following assessment parameters
is best used?
food preferences
regularity of meal times
3-day diet recall
eating style and habits
(C) 3-day diet recall. 3-day diet recall is an
example of dietary history. This is used to
indicate the adequacy of food intake of
the client.
19. Van Fajardo is a 55 year old who was
admitted to the hospital with newly diagnosed
hepatitis. The nurse is doing a patient teaching
with Mr. Fajardo. What kind of role does the
nurse assume?
talker
teacher
thinker
Doer
(B) teacher. The nurse will assume the role of
a teacher in this therapeutic relationship.
The other roles are inappropriate in this
situation.
20. When providing a continuous enteral
feeding, which of the following action is
essential for the nurse to do?
Place the client on the left side of the bed.
Attach the feeding bag to the current tubing.
Elevate the head of the bed.
Cold the formula before administering it
(C) Elevate the head of the bed. Elevating the
head of the bed during an enteral feeding
prevents aspiration. The patient may be
placed on the right side to prevent
aspiration. Enteral feedings are given at
room temperature to lessen GI distress.
The enteral tubing should be changed
every 24 hours to limit microbial growth.
.
21. Kussmaul’s breathing is;
Shallow breaths interrupted by apnea.
Prolonged gasping inspiration followed by a
very short, usually inefficient expiration.
Marked rhythmic waxing and waning of
respirations from very deep to very
shallow breathing and temporary apnea.
Increased rate and depth of respiration.
(D) Increased rate and depth of
respiration. Kussmaul breathing is also
called as hyperventilation. Seen in
metabolic acidosis and renal failure.
Option A refers to Biot’s breathing.
Option B is apneustic breathing and
option C is the Cheyne-stokes breathing.
22. Presty has terminal cancer and she refuses
to believe that loss is happening ans she
assumes artificial cheerfulness. What stage of
grieving is she in?
depression
bargaining
denial
Acceptance
(C) denial. The client is in denial stage
because she is unready to face the reality
that loss is happening and she assumes
artificial cheerfulness.
23. Immunization for healthy babies and
preschool children is an example of what level
of preventive health care?
Primary
Secondary
Tertiary
Curative
(A) Primary. The primary level focuses on
health promotion. Secondary level
focuses on health maintenance. Tertiary
focuses on rehabilitation. There is n
Curative level of preventive health care
problems.
24. Which is an example of a subjective data?
Temperature of 38 0C
Vomiting for 3 days
Productive cough
Patient stated, “My arms still hurt.”
(D) Patient stated, “My arms still
hurt.”. Subjective data are apparent only
to the person affected and can or verified
only by that person.
25. The nurse is assessing the endocrine
system. Which organ is part of the endocrine
system?
Heart
Sinus
Thyroid
Thymus
(C) Thyroid. The thyroid is part of the
endocrine system. Heart, sinus and
thymus are not.
.
PNLE Fundamentals
in Nursing Exam 3
1. Nurse Brenda is teaching a patient about a
newly prescribed drug. What could cause a
geriatric patient to have difficulty retaining
knowledge about prescribed medications?
Decreased plasma drug levels
Sensory deficits
Lack of family support
History of Tourette syndrome
(B) Sensory deficits. Sensory deficits could
cause a geriatric patient to have difficulty
retaining knowledge about prescribed
medications. Decreased plasma drug
levels do not alter the patient’s knowledge
about the drug. A lack of family support
may affect compliance, not knowledge
retention. Toilette syndrome is unrelated
to knowledge retention.
2. When examining a patient with abdominal
pain the nurse in charge should assess:
Any quadrant first
The symptomatic quadrant first
The symptomatic quadrant last
The symptomatic quadrant either second or
third
(C) The symptomatic quadrant last. The
nurse should systematically assess all
areas of the abdomen, if time and the
patient’s condition permit, concluding
with the symptomatic area. Otherwise, the
nurse may elicit pain in the symptomatic
area, causing the muscles in other areas to
tighten. This would interfere with further
assessment.
3. The nurse is assessing a postoperative adult
patient. Which of the following should the
nurse document as subjective data?
Vital signs
Laboratory test result
Patient’s description of pain
Electrocardiographic (ECG) waveforms
(C) Patient’s description of pain. Subjective
data come directly from the patient and
usually are recorded as direct quotations
that reflect the patient’s opinions or
feelings about a situation. Vital signs,
laboratory test result, and ECG
waveforms are examples of objective data.
4. A male patient has a soft wrist-safety
device. Which assessment finding should the
nurse consider abnormal?
A palpable radial pulse
A palpable ulnar pulse
Cool, pale fingers
Pink nail beds
(C) Cool, pale fingers. A safety device on the
wrist may impair circulation and restrict
blood supply to body tissues. Therefore,
the nurse should assess the patient for
signs of impaired circulation, such as cool,
pale fingers. A palpable radial or lunar
pulse and pink nail beds are normal
findings.
5. Which of the following planes divides the
body longitudinally into anterior and posterior
regions?
Frontal plane
Sagittal plane
Midsagittal plane
Transverse plane
(A) Frontal plane. Frontal or coronal plane
runs longitudinally at a right angle to a
sagittal plane dividing the body in
anterior and posterior regions. A sagittal
plane runs longitudinally dividing the
body into right and left regions; if exactly
midline, it is called a midsagittal plane. A
transverse plane runs horizontally at a
right angle to the vertical axis, dividing
the structure into superior and inferior
regions.
6. A female patient with a terminal illness is
in denial. Indicators of denial include:
Shock dismay
Numbness
Stoicism
Preparatory grief
(A) Shock dismay. Shock and dismay are
early signs of denial-the first stage of
grief. The other options are associated
with depression—a later stage of grief.
7. The nurse in charge is transferring a patient
from the bed to a chair. Which action does the
nurse take during this patient transfer?
Position the head of the bed flat
Helps the patient dangle the legs
Stands behind the patient
Places the chair facing away from the bed
(B) Helps the patient dangle the legs. After
placing the patient in high Fowler’s
position and moving the patient to the
side of the bed, the nurse helps the patient
sit on the edge of the bed and dangle the
legs; the nurse then faces the patient and
places the chair next to and facing the
head of the bed.
8. A female patient who speaks a little English
has emergency gallbladder surgery, during
discharge preparation, which nursing action
would best help this patient understand wound
care instruction?
Asking frequently if the patient understands
the instruction
Asking an interpreter to replay the
instructions to the patient.
Writing out the instructions and having a
family member read them to the patient
Demonstrating the procedure and having
the patient return the demonstration
(D) Demonstrating the procedure and having
the patient return the
demonstration. Demonstrating by the
nurse with a return demonstration by the
patient ensures that the patient can
perform wound care correctly. Patients
may claim to understand discharge
instruction when they do not. An
interpreter of family member may
communicate verbal or written
instructions inaccurately.
9. Before administering the evening dose of a
prescribed medication, the nurse on the
evening shift finds an unlabeled, filled syringe
in the patient’s medication drawer. What
should the nurse in charge do?
Discard the syringe to avoid a medication
error
Obtain a label for the syringe from the
pharmacy
Use the syringe because it looks like it
contains the same medication the nurse
was prepared to give
Call the day nurse to verify the contents of
the syringe
(A) Discard the syringe to avoid a medication
error. As a safety precaution, the nurse
should discard an unlabeled syringe that
contains medication. The other options
are considered unsafe because they
promote error.
10. When administering drug therapy to a
male geriatric patient, the nurse must stay
especially alert for adverse effects. Which
factor makes geriatric patients to adverse drug
effects?
Faster drug clearance
Aging-related physiological changes
Increased amount of neurons
Enhanced blood flow to the GI tract
(B) Aging-related physiological
changes. Aging-related physiological
changes account for the increased
frequency of adverse drug reactions in
geriatric patients. Renal and hepatic
changes cause drugs to clear more slowly
in these patients. With increasing age,
neurons are lost and blood flow to the GI
tract decreases.
11. A female patient is being discharged after
cataract surgery. After providing medication
teaching, the nurse asks the patient to repeat
the instructions. The nurse is performing
which professional role?
Manager
Educator
Caregiver
Patient advocate
(B) Educator. When teaching a patient about
medications before discharge, the nurse is
acting as an educator. The nurse acts as a
manager when performing such activities
as scheduling and making patient care
assignments. The nurse performs the care
giving role when providing direct care,
including bathing patients and
administering medications and prescribed
treatments. The nurse acts as a patient
advocate when making the patient’s
wishes known to the doctor.
12. A female patient exhibits signs of
heightened anxiety. Which response by the
nurse is most likely to reduce the patient’s
anxiety?
“Everything will be fine. Don’t worry.”
“Read this manual and then ask me any
questions you may have.”
“Why don’t you listen to the radio?”
“Let’s talk about what’s bothering you.”
(D) “Let’s talk about what’s bothering
you.” Anxiety may result from feeling of
helplessness, isolation, or insecurity. This
response helps reduce anxiety by
encouraging the patient to express
feelings. The nurse should be supportive
and develop goals together with the
patient to give the patient some control
over an anxiety-inducing situation.
Because the other options ignore the
patient’s feeling and block
communication, they would not reduce
anxiety.
13. A scrub nurse in the operating room has
which responsibility?
Positioning the patient
Assisting with gowning and gloving
Handling surgical instruments to the
surgeon
Applying surgical drapes
(C) Handling surgical instruments to the
surgeon. The scrub nurse assist the
surgeon by providing appropriate surgical
instruments and supplies, maintaining
strict surgical asepsis and, with the
circulating nurse, accounting for all gauze,
sponges, needles, and instruments. The
circulating nurse assists the surgeon and
scrub nurse, positions the patient, applies
appropriate equipment and surgical
drapes, assists with gowning and gloving,
and provides the surgeon and scrub nurse
with supplies.
14. A patient is in the bathroom when the
nurse enters to give a prescribed medication.
What should the nurse in charge do?
Leave the medication at the patient’s bedside
Tell the patient to be sure to take the
medication. And then leave it at the
bedside
Return shortly to the patient’s room and
remain there until the patient takes the
medication
Wait for the patient to return to bed, and then
leave the medication at the bedside
(C) Return shortly to the patient’s room and
remain there until the patient takes the
medication. The nurse should return
shortly to the patient’s room and remain
there until the patient takes the
medication to verify that it was taken as
directed. The nurse should never leave
medication at the patient’s bedside unless
specifically requested to do so.
15. The physician orders heparin, 7,500 units,
to be administered subcutaneously every 6
hours. The vial reads 10,000 units per
millilitre. The nurse should anticipate giving
how much heparin for each dose?
¼ ml
½ ml
¾ ml
1 ¼ ml
(C) ¾ ml. The nurse solves the problem as
follows: 10,000 units/7,500 units = 1
ml/X 10,000 X = 7,500 X= 7,500/10,000
or ¾ ml
16. The nurse in charge measures a patient’s
temperature at 102 degrees F. what is the
equivalent Centigrade temperature?
39 degrees C
47 degrees C
38.9 degrees C
40.1 degrees C
(C) 38.9 degrees C. To convert Fahrenheit
degrees to centigrade, use this formula: C
degrees = (F degrees – 32) x 5/9 C
degrees = (102 – 32) 5/9 + 70 x 5/9 38.9
degrees C
17. To evaluate a patient for hypoxia, the
physician is most likely to order which
laboratory test?
Red blood cell count
Sputum culture
Total hemoglobin
Arterial blood gas (ABG) analysis
(D) Arterial blood gas (ABG) analysis. All of
these test help evaluate a patient with
respiratory problems. However, ABG
analysis is the only test evaluates gas
exchange in the lungs, providing
information about patient’s oxygenation
status.
18. The nurse uses a stethoscope to auscultate
a male patient’s chest. Which statement about
a stethoscope with a bell and diaphragm is
true?
The bell detects high-pitched sounds best
The diaphragm detects high-pitched
sounds best
The bell detects thrills best
The diaphragm detects low-pitched sounds
best
(B) The diaphragm detects high-pitched
sounds best. The diaphragm of a
stethoscope detects high-pitched sound
best; the bell detects low pitched sounds
best. Palpation detects thrills best.
19. A male patient is to be discharged with a
prescription for an analgesic that is a
controlled substance. During discharge
teaching, the nurse should explain that the
patient must fill this prescription how soon
after the date on which it was written?
Within 1 month
Within 3 months
Within 6 months
Within 12 months
(C) Within 6 months. In most cases, an
outpatient must fill a prescription for a
controlled substance within 6 months of
the date on which the prescription was
written.
20. Which human element considered by the
nurse in charge during assessment can affect
drug administration?
The patient’s ability to recover
The patient’s occupational hazards
The patient’s socioeconomic status
The patient’s cognitive abilities
(D) The patient’s cognitive abilities. The
nurse must consider the patient’s
cognitive abilities to understand drug
instructions. If not, the nurse must find a
family member or significant other to take
on the responsibility of administering
medications in the home setting. The
patient’s ability to recover, occupational
hazards, and socioeconomic status do not
affect drug administration.
21. When explaining the initiation of I.V.
therapy to a 2-year-old child, the nurse should:
Ask the child, “Do you want me to start the
I.V. now?”
Give simple directions shortly before the
I.V. therapy is to start
Tell the child, “This treatment is for your
own good”
Inform the child that the needle will be in
place for 10 days
(B) Give simple directions shortly before the
I.V. therapy is to start. Because a 2-year-
old child has limited understanding, the
nurse should give simple directions and
explanations of what will occur shortly
before the procedure. She should try to
avoid frightening the child with the
explanation and allow the child to make
simple choices, such as choosing the I.V.
insertion site, if possible. However, she
shouldn’t ask the child if he wants the
therapy, because the answer may be “No!”
Telling the child that the treatment is for
his own good is ineffective because a 2-
year-old perceives pain as a negative
sensation and cannot understand that a
painful procedure can have position
results. Telling the child how long the
therapy will last is ineffective because the
2-year-old doesn’t have a good
understanding of time.
22. All of the following parts of the syringe
are sterile except the:
Barrel
Inside of the plunger
Needle tip
Barrel tip
(A) Barrel. All syringes have three parts: a
tip, which connects the needle to the
syringe; a barrel, the outer part on which
the measurement scales are printed; and a
plunger, which fits inside the barrel to
expel the medication. The external part of
the barrel and the plunger and (flange)
must be handled during the preparation
and administration of the injection.
However, the inside and trip of the barrel,
the inside (shaft) of the plunger, and the
needle tip must remain sterile until after
the injection.
23. The best way to instill eye drops is to:
Instruct the patient to lock upward, and
drop the medication into the center of
the lower lid
Instruct the patient to look ahead, and drop
the medication into the center of the lower
lid
Drop the medication into the inner canthus
regardless of eye position
Drop the medication into the center of the
canthus regardless of eye position
(A) Instruct the patient to lock upward, and
drop the medication into the center of the
lower lid. Having the patient look upward
reduces blinking and protects the cornea.
Instilling drops in the center of the lower
lid promotes absorption because the drops
are less likely to run into the nasolacrimal
duct or out of the eye.
24. The difference between an 18G needle
and a 25G needle is the needle’s:
Length
Bevel angle
Thickness
Sharpness
(C) Thickness. Gauge is a measure of the
needle’s thickness: The higher the number
the thinner the shaft. Therefore, an 18G
 needle is considerably thicker than a 25G
needle.
25. A patient receiving an anticoagulant
should be assessed for signs of:
Hypotension
Hypertension
An elevated hemoglobin count
An increased number of erythrocytes
Maternal and Child Nursing
PNLE Maternal and
Child Health Nursing
Exam 1
1. A client asks the nurse what a third degree laceration
is. She was informed that she had one. The nurse
explains that this is:
a) that extended their anal sphincter
b) through the skin and into the muscles
c) that involves anterior rectal wall
d) that extends through the perineal muscle.
Answer. (A) that extended their anal sphincter. Third
degree laceration involves all in the second degree
laceration and the external sphincter of the rectum.
Options B, C and D are under the second degree
laceration.
2. Betina 30 weeks AOG discharged with a diagnosis of
placenta previa. The nurse knows that the client
understands her care at home when she says:
A. I am happy to note that we can have sex occasionally
when I have no bleeding.
B. I am afraid I might have an operation when my due
comes
C. I will have to remain in bed until my due date
comes
D/ I may go back to work since I stay only at the office.
Answer. (C) I will have to remain in bed until my due
date comes. Placenta previa means that the placenta is
the presenting part. On the first and second trimester
there is spotting. On the third trimester there is bleeding
that is sudden, profuse and painless
3. The uterus has already risen out of the pelvis and is
experiencing farther into the abdominal area at about the:
a. 8th week of pregnancy
b. 10th week of pregnancy
c. 12th week of pregnancy
d. 18th week of pregnancy
(D) 18th week of pregnancy. On the 8th week of
pregnancy, the uterus is still within the pelvic area.
On the 10th week, the uterus is still within the
pelvic area. On the 12th week, the uterus and
placenta have grown, expanding into the abdominal
cavity. On the 18th week, the uterus has already
risen out of the pelvis and is expanding into the
abdominal area.
4. Which of the following urinary symptoms does the
pregnant woman most frequently experience during the
first trimester:
a) frequency
b) dysuria
c) incontinence
d) Burning
(A) frequency. Pressure and irritation of the bladder by
the growing uterus during the first trimester is
responsible for causing urinary frequency. Dysuria,
incontinence and burning are symptoms associated
with urinary tract infection.
5. Mrs. Jimenez went to the health center for pre-natal
check-up. the student nurse took her weight and revealed
142 lbs. She asked the student nurse how much should
she gain weight in her pregnancy.
a. 20-30 lbs
b. 25-35 lbs
c. 30- 40 lbs
d. 10-15 lbs
(B) 25-35 lbs. A weight gain of 11. 2 to 15.9 kg (25 to
35 lbs) is currently recommended as an average
weight gain in pregnancy. This weight gain consists
of the following: fetus- 7.5 lb; placenta- 1.5 lb;
amniotic fluid- 2 lb; uterus- 2.5 lb; breasts- 1.5 to 3
lb; blood volume- 4 lb; body fat- 7 lb; body fluid- 7
lb.
6. The nurse is preparing Mrs. Jordan for cesarean
delivery. Which of the following key concept should the
nurse consider when implementing nursing care?
a) Explain the surgery, expected outcome and kind of
anesthetics.
b) Modify preoperative teaching to meet the needs
of either a planned or emergency cesarean birth.
c) Arrange for a staff member of the anesthesia
department to explain what to expect post-
operatively.
d) Instruct the mother’s support person to remain in
the family lounge until after the delivery.
(B) Modify preoperative teaching to meet the needs of
either a planned or emergency cesarean birth. A
key point to consider when preparing the client for
a cesarean delivery is to modify the preoperative
teaching to meet the needs of either planned or
emergency cesarean birth, the depth and breadth of
instruction will depend on circumstances and time
available.
7. Bettine Gonzales is hospitalized for the treatment of indicate increases ICP or sunken, which may
severe preecplampsia. Which of the following represents indicate hydration.
an unusual finding for this condition?

a. generalized edema 11. Mrs. Quijones gave birth by spontaneous delivery to

b. proteinuria 4+ a full term baby boy. After a minute after birth, he is
c. blood pressure of 160/110 crying and moving actively. His birth weight is 6.8 lbs.
d. Convulsions What do you expect baby Quijones to weigh at 6 months?

(D) convulsions. Options A, B and C are findings of a. 13 -14 lbs

severe preeclampsia. Convulsions is a finding of b. 16 -17 lbs
eclampsia—an obstetrical emergency. c. 22 -23 lbs
d. 27 -28 lbs

8. Nurse Geli explains to the client who is 33 weeks A) 13 -14 lbs. The birth weight of an infant is doubled at
pregnant and is experiencing vaginal bleeding that coitus: 6 months and is tripled at 12 months

a) Need to be modified in any way by either partner
b) Is permitted if penile penetration is not deep.
c) Should be restricted because it may stimulate
uterine activity.
d) Is safe as long as she is in side-lying position.
(C) Should be restricted because it may stimulate
uterine activity.. Coitus is restricted when there is
watery discharge, uterine contraction and vaginal
bleeding. Also those women with a history of
spontaneous miscarriage may be advised to avoid
coitus during the time of pregnancy when a
previous miscarriage occurred.
12. During the first hours following delivery, the post
partum client is given IVF with oxytocin added to them.
The nurse understands the primary reason for this is:
a) To facilitate elimination
b) To promote uterine contraction
c) To promote analgesia
d) To prevent infection
B To promote uterine contraction. Oxytocin is a
hormone produced by the pituitary gland that produces
intermittent uterine contractions, helping to promote
uterine involution.

9. Mrs. Precilla Abuel, a 32 year old mulripara is 13. Nurse Luis is assessing the newborn’s heart rate.
admitted to labor and delivery. Her last 3 pregnancies in Which of the following would be considered normal if
short stage one of labor. The nurses decide to observe the newborn is sleeping?
her closely. The physician determines that Mrs. Abuel’s
cervix is dilated to 6 cm. Mrs. Abuel states that she is a. 80 beats per minute
extremely uncomfortable. To lessen Mrs. Abuel’s b. 100 beats per minute
discomfort, the nurse can advise her to: c. 120 beats per minute
d. 140 beats per minute
a. lie face down
b. not drink fluids (B) 100 beats per minute. The normal heart rate for a
c. practice holding breaths between contractions newborn that is sleeping is approximately 100 beats
d. assume Sim’s position per minute. If the newborn was awake, the normal
heart rate would range from 120 to 160 beats per
(D) assume Sim’s position. When the woman is in minute.
Sim’s position, this puts the weight of the fetus on
bed, not on the woman and allows good circulation 14. The infant with Down Syndrome should go through
in the lower extremities. which of the Erikson’s developmental stages first?

10. Which is true regarding the fontanels of the newborn? a) Initiative vs. Self doubt
b) Industry vs. Inferiority
a) The anterior is large in shape when compared to c) Autonomy vs. Shame and doubt
the posterior fontanel. d) Trust vs. Mistrust
b) The anterior is triangular shaped; the posterior is
diamond shaped. D) Trust vs. Mistrust. The child with Down syndrome
c) The anterior is bulging; the posterior appears will go through the same first stage, trust vs.
sunken. mistrust, only at a slow rate. Therefore, the nurse
d) The posterior closes at 18 months; the anterior should concentrate on developing on bond between
closes at 8 to 12 months. the primary caregiver and the child.

(A) The anterior is large in shape when compared to the 15. The child with phenylketonuria (PKU) must
posterior fontanel.. The anterior fontanel is larger in maintain a low phenylalanine diet to prevent which of
size than the posterior fontanel. Additionally, the the following complications?
anterior fontanel, which is diamond shaped closes
at 18 month, whereas the posterior fontanel, which a. Irreversible brain damage
is triangular in shape closes at 8 to 12 weeks. b. Kidney failure
Neither fontanel should appear bulging, which may c. Blindness
d. Neutropenia

(A) Irreversible brain damage. The child with PKU must
maintain a strict low phenylalanine diet to prevent
central nervous system damage, seizures and eventual
dea
16. Which age group is with imaginative minds and
creates imaginary friends?
a) Toddler
b) Preschool
c) School
d) Adolescence
(B) Preschool. During preschool, this is the time when
children do imitative play, imaginative play—the
occurrence of imaginative playmates, dramatic play
where children like to act, dance and sing.
17. Which of the following situations would alert you to
a potentially developmental problem with a child?
a) Pointing to body parts at 15 months of age.
b) Using gesture to communicate at 18 months.
c) Cooing at 3 months.
d) Saying “mama” or “dada” for the first time at 18
months of age.
(D) Saying “mama” or “dada” for the first time at 18
months of age.. A child should say “mama” or
“dada” during 10 to 12 months of age. Options A,
B and C are all normal assessments of language
development of a child.
18. Isabelle, a 2 year old girl loves to move around and
oftentimes manifests negativism and temper tantrums.
What is the best way to deal with her behavior?
a. Tell her that she would not be loved by others is she
behaves that way..
b. Withholding giving her toys until she behaves
properly.
c. Ignore her behavior as long as she does not hurt
herself and others.
d. Ask her what she wants and give it to pacify her.
(B) Ignore her behavior as long as she does not hurt
herself and others.. If a child is trying to get attention or
trying to get something through tantrums—ignore
his/her behavio
19. Baby boy Villanueva, 4 months old, was seen at the
pediatric clinic for his scheduled check-up. By this
period, baby Villanueva has already increased his height
by how many inches?
a) 3 inches
b) 4 inches
c) 5 inches
d) 6 inches
(B) 4 inches. From birth to 6 months, the infant grows 1
inch (2.5 cm) per month. From 6 to 12 months, the
infant grows ½ inch (1.25 cm) per month.
20. Alice, 10 years old was brought to the ER because of
Asthma. She was immediately put under aerosol
administration of Terbutaline. After sometime, you
observe that the child does not show any relief from the
treatment given. Upon assessment, you noticed that both
the heart and respiratory rate are still elevated and the
child shows difficulty of exhaling. You suspect:
a. Bronchiectasis
b. Atelectasis
c. Epiglotitis
d. Status Asthmaticus
(D) Status Asthmaticus. Status asthmaticus leads to
respiratory distress and bronchospasm despite of
treatment and interventions. Mechanical ventilation
maybe needed due to respiratory failure.
21. Nurse Jonas assesses a 2 year old boy with a
tentative diagnosis of nephroblastoma. Symptoms the
nurse observes that suggest this problem include:
a) Lymphedema and nerve palsy
b) Hearing loss and ataxia
c) Headaches and vomiting
d) Abdominal mass and weakness
(D)Abdominal mass and weakness. Nephroblastoma or
Wilm’s tumor is caused by chromosomal abnormalities,
most common kidney cancer among children
characterized by abdominal mass, hematuria,
hypertension and fever
22. Which of the following danger sings should be
reported immediately during the antepartum period?
a. blurred vision
b. nasal stuffiness
c. breast tenderness
d. Constipation
(A) blurred vision. Danger signs that require prompt
reporting are leaking of amniotic fluid, blurred
vision, vaginal bleeding, rapid weight gain and
elevated blood pressure. Nasal stuffiness, breast
tenderness, and constipation are common
discomforts associated with pregnancy.
23. Nurse Jacob is assessing a 15 month old child with
acute otitis media. Which of the following symptoms
would the nurse anticipate finding?
a) periorbital edema, absent light reflex and
translucent tympanic membrane
b) irritability, purulent drainage in middle ear,
nasal congestion and cough
c) diarrhea, retracted tympanic membrane and
enlarged parotid gland
d) Vomiting, pulling at ears and pearly white tympanic
membrane
(B) irritability, purulent drainage in middle ear, nasal
congestion and cough. Irritability, purulent
drainage in middle ear, nasal congestion and cough,
fever, loss of appetite, vomiting and diarrhea are
clinical manifestations of otitis media. Acute otitis
media is common in children 6 months to 3 years
old and 8 years old and above. Breast fed infants
have higher resistance due to protection of
Eustachian tubes and middle ear from breast milk.
24. Which of the following is the most appropriate b. Fetal movement
intervention to reduce stress in a preterm infant at 33 c. Maternal blood pressure
weeks gestation? d. Maternal uterine contractions

a. Sensory stimulation including several senses at a (B) Fetal movement. Non-stress test measures response
time of the FHR to the fetal movement. With fetal
b. tactile stimulation until signs of over stimulation movement, FHR increase by 15 beats and remain
develop for 15 seconds then decrease to average rate. No
c. An attitude of extension when prone or side lying increase means poor oxygenation perfusion to fetus.
d. Kangaroo care
2. During a 2 hour childbirth focusing on labor and
(D) Kangaroo care. Kangaroo care is the use of skin-to- delivery process for primigravida. The nurse describes
skin contact to maintain body heat. This method of the second maneuver that the fetus goes through during
care not only supplies heat but also encourages labor progress when the head is the presenting part as
parent-child interaction. which of the following:

25. The parent of a client with albinism would need to be a. Flexion

taught which preventive healthcare measure by the nurse: b. Internal rotation
c. Descent
a) Ulcerative colitis diet d. External rotation
b) Use of a high-SPF sunblock (A) Flexion. The 6 cardinal movements of labor are
c) Hair loss monitoring descent, flexion, internal rotation, extension,
d) Monitor for growth retardation external rotation and expulsion.
(B) Use of a high-SPF sunblock. Without melanin
production, the child with albinism is at risk for 3. Mrs. Jovel Diaz went to the hospital to have her serum
severe sunburns. Maximum sun protection should blood test for alpha-fetoprotein. The nurse informed her
be taken, including use of hats, long sleeves, about the result of the elevation of serum AFP. The
minimal time in the sun and high-SPF sunblock, to patient asked her what was the test for:
prevent any problems.
a) Congenital Adrenal Hyperplasia
b) PKU
c) Down Syndrome
d) Neural tube defects

(D)Neural tube defects. Alpha-fetoprotein is a substance

produces by the fetal liver that is present in amniotic
fluid and maternal serum. The level is abnormally high
in the maternal serum if the fetus has an open spinal or
abdominal defect because the open defect allows more
AFP to appear

4. Fetal heart rate can be auscultated with a fetoscope as

early as:

a. 5 weeks of gestation
b. 10 weeks of gestation
c. 15 weeks of gestation
d. 20 weeks of gestation

(D) 20 weeks of gestation. The FHR can be auscultated

with a fetoscope at about 20 weeks of gestation.
FHR is usually auscultated at the midline
suprapubic region with Doppler ultrasound at 10 to
12 weeks of gestation. FHR cannot be heard any
earlier than 10 weeks of gestation.
PNLE Maternal and Child 5. Mrs. Bendivin states that she is experiencing aching
swollen, leg veins. The nurse would explain that this is
Health Nursing Exam 2 most probably the result of which of the following:

a) Thrombophlebitis
b) PIH
1. Nurse Bella explains to a 28 year old pregnant woman c) Pressure on blood vessels from the enlarging
undergoing a non-stress test that the test is a way of uterus
evaluating the condition of the fetus by comparing the d) The force of gravity pulling down on the uterus
fetal heart rate with:
(C) Pressure on blood vessels from the enlarging
a. Fetal lie uterus. Pressure of the growing fetus on blood
 vessels results in an increase risk for venous stasis
in the lower extremities. Subsequently, edema and
varicose vein formation may occur.
6. Mrs. Ella Santoros is a 25 year old primigravida who
has Rheumatic heart disease lesion. Her pregnancy has
just been diagnosed. Her heart disease has not caused her
to limit physical activity in the past. Her cardiac disease
and functional capacity classification is:
c. Rubella titer less than 1:8
d. One hour glucose challenge test 110 g/dL
C Rubella titer less than 1:8. A rubella titer should be 1:8
or greater. Thus, a finding of a titer less than 1:8 is
significant, indicating that the client may not possess
immunity to rubella. A hematocrit of 33.5%, WBC of
8,000/mm3, and a 1 hour glucose challenge test of 110
g/dL are within normal parameters.

a. Class I
b. Class II 11. Aling Patricia is a patient with preeclampsia. You
c. Class III advise her about her condition, which would tell you that
d. class IV she has not really understood your instructions?

(A) Class I. Clients under class I has no physical activity
limitation. There is a slight limitation of physical activity
in class II, ordinary activity causes fatigue, palpitation,
dyspnea or angina. Class III is moderate limitation of
physical activity; less than ordinary activity causes
fatigue. Unable to carry on any activity without
experiencing discomfort is under class IV
7. The client asks the nurse, “When will this soft spot at
the top of the head of my baby will close?” The nurse
should instruct the mother that the neonate’s anterior
fontanel will normally close by age:
a) 2-3 months
b) 6-8 months
c) 10-12 months
d) 12-18 months
(D) 12-18 months. Anterior fontanel closes at 12-18
months while posterior fontanel closes at birth until
2 months.
8. When a mother bleeds and the uterus is relaxed, soft
and non-tender, you can account the cause to:
a. Atony of the uterus
b. Presence of uterine scar
c. Laceration of the birth canal
d. Presence of retained placenta fragments
A) Atony of the uterus. Uterine atony, or relaxation of
the uterus is the most frequent cause of postpartal
hemorrhage. It is the inability to maintain the uterus in
contracted state.
a) “I will restrict my fat in my diet.”
b) “I will limit my activities and rest more
frequently throughout the day.”
c) “I will avoid salty foods in my diet.”
d) “I will come more regularly for check-up.”
(B) “I will limit my activities and rest more frequently
throughout the day.”Pregnant woman with
preeclampsia should be in a complete bed rest.
When body is in recumbent position, sodium tends
to be excreted at a faster rate. It is the best method
of aiding increased excretion of sodium and
encouraging diuresis. Rest should always be in a
lateral recumbent position to avoid uterine pressure
on the vena cava and prevent supine hypotension.
12. Mrs. Grace Evangelista is admitted with severe
preeclampsia. What type of room should the nurse select
this patient?
a. A room next to the elevator.
b. The room farthest from the nursing station.
c. The quietest room on the floor.
d. The labor suite.
(C) The quietest room on the floor.A loud noise such as
a crying baby, or a dropped tray of equipment may
be sufficient to trigger a seizure initiating eclampsia,
a woman with severe preeclampsia should be
admiotted to a private room so she can rest as
undisturbed as possible. Darken the room if
possible because bright light can trigger seizures.
13. During a prenatal check-up, the nurse explains to a
client who is Rh negative that RhoGAM will be given:

9. Mrs. Pichie Gonzales’s LMP began April 4, 2010. Her a) Weekly during the 8th month because this is her
EDD should be which of the following: third pregnancy.
b) During the second trimester, if amniocentesis
a) February 11, 2011 indicates a problem.
b) January 11, 20111 c) To her infant immediately after delivery if the
c) December 12, 2010 Coomb’s test is positive.
d) Nowember 14, 2010 d) Within 72 hours after delivery if infant is found
to be Rh positive.
(B) January 11, 20111. Using the Nagel’s rule, he use
this formula ( -3 calendar months + 7 days). (D) Within 72 hours after delivery if infant is found to
be Rh positive. RhoGAM is given to Rh-negative
mothers within 72 hours after birth of Rh-positive
10. Which of the following prenatal laboratory test baby to prevent development of antibodies in the
values would the nurse consider as significant? maternal blood stream, which will be fata to
succeeding Rh-positive offspring.
a. Hematocrit 33.5%
b. WBC 8,000/mm3
14. A baby boy was born at 8:50pm. At 8:55pm, the b) an excess of WBC
heart rate was 99 bpm. She has a weak cry, irregular c) a deficiency of clotting factor VIII
respiration. She was moving all extremities and only her d) a deficiency of clotting factor IX
hands and feet were still slightly blue. The nurse should
enter the APGAR score as: C) a deficiency of clotting factor VIII. Hemophillia A
(classic hemophilia) is a deficiency in factor VIII
a. 5 (an alpha globulin that stabilizes fibrin clots).
b. 6
c. 7
d. 8 19. Celine, a mother of a 2 year old tells the nurse that
her child “cries and has a fit when I have to leave him
(B) 6. Heart rate of 99 bpm-1; weak cry-1; irregular with a sitter or someone else.” Which of the following
respiration-1; moving all extremities-2; extremities statements would be the nurse’s most accurate analysis
are slightly blue-1; with a total score of 6. of the mother’s comment?

15. Billy is a 4 year old boy who has an IQ of 140 which a. The child has not experienced limit-setting or
means: structure.
b. The child is expressing a physical need, such as
a. average normal hunger.
b. very superior c. The mother has nurtured overdependence in the
c. above average child.
d. Genius d. The mother is describing her child’s separation
anxiety.
(D) genius. IQ= mental age/chronological age x 100. (D) The mother is describing her child’s separation
Mental age refers to the typical intelligence level anxiety. Before coming to any conclusion, the
found for people at a give chronological age. OQ of nurse should ask the mother focused questions;
140 and above is considered genius. however, based on initial information, the analysis
of separation anxiety would be most valid.
Separation anxiety is a normal toddler response.
16. A newborn is brought to the nursery. Upon When the child senses he is being sent away from
assessment, the nurse finds that the child has short those who most provide him with love and security.
palpebral fissures, thinned upper lip. Based on this data, Crying is one way a child expresses a physical need;
the nurse suspects that the newborn is MOST likely however, the nurse would be hasty in drawing this
showing the effects of: as first conclusion based on what the mother has
said. Nurturing overdependence or not providing
a) Chronic toxoplasmosis structure for the toddler are inaccurate conclusions
b) Lead poisoning based on the information provided.
c) Congenital anomalies
d) Fetal alcohol syndrome 20. Mylene Lopez, a 16 year old girl with scoliosis has
recently received an invitation to a pool party. She asks
(D) Fetal alcohol syndrome. The newborn with fetal the nurse how she can disguise her impairment when
alcohol syndrome has a number of possible dressed in a bathing suit. Which nursing diagnosis can
problems at birth. Characteristics that mark the be justified by Mylene’s statement?
syndrome include pre and postnatal growth
retardation; CNS involvement such as cognitive a) Anxiety
challenge, microcephally and cerebral palsy; and a b) Body image disturbance
distinctive facial feature of a short palpebral fissure c) Ineffective individual coping
and thin upper lip. d) Social isolation

17. A priority nursing intervention for the infant with (B) Body image disturbance. Mylene is experiencing
cleft lip is which of the following: uneasiness about the curvative of her spine, which
will be more evident when she wears a bathing suit.
a. Monitoring for adequate nutritional intake This data suggests a body image disturbance. There
b. Teaching high-risk newborn care is no evidence of anxiety or ineffective coping. The
c. Assessing for respiratory distress fact that Mylene is planning to attend a pool party
d. Preventing injury dispels a diagnosis of social isolation.

(A) Monitoring for adequate nutritional intake. The 21. The foul-smelling, frothy characteristic of the stool
infant with cleft lip is unable to create an adequate in cystic fibrosis results from the presence of large
seal for sucking. The child is at risk for inadequate amounts of which of the following:
nutritional intake as well as aspiration.
a. sodium and chloride
18. Nurse Jacob is assessing a 12 year old who has b. undigested fat
hemophilia A. Which of the following assessment c. semi-digested carbohydrates
findings would the nurse anticipate? d. lipase, trypsin and amylase

a) an excess of RBC
 (B) undigested fat. The client with cystic fibrosis
absorbs fat poorly because of the think secretions
blocking the pancreatic duct. The lack of natural
pancreatic enzyme leads to poor absorption of
predominantly fats in the duodenum. Foul-smelling,
frothy stool is termed steatorrhea.
22. Which of the following would be a disadvantage of
breast feeding?
a) involution occurs rapidly
b) the incidence of allergies increases due to maternal
antibodies
c) the father may resent the infant’s demands on
the mother’s body
d) there is a greater chance of error during preparation
(C) the father may resent the infant’s demands on the
mother’s body. With breast feeding, the father’s
body is not capable of providing the milk for the
newborn, which may interfere with feeding the
newborn, providing fewer chances for bonding, or
he may be jealous of the infant’s demands on his
wife time and body. Breast feeding is advantageous
because uterine involution occurs more rapidly,
thus minimizing blood loss. The presence of
maternal antibodies in breast milk helps decrease
the incidence of allergies in the newborn. A greater
chance for error is associated with bottle feeding.
No preparation required for breast feeding.
23. A client is noted to have lymphedema, webbed neck
and low posterior hairline. Which of the following
diagnoses is most appropriate?
a. Turner’s syndrome
b. Down’s syndrome
c. Marfan’s syndrome
d. Klinefelter’s syndrome
(A) Turner’s syndrome. Lymphedema, webbed neck
and low posterior hairline, these are the 3 key
assessment features in Turner’s syndrome. If the
child is diagnosed early in age, proper treatment
can be offered to the family. All newborns should
be screened for possible congenital defects.
24. A 4 year old boy most likely perceives death in
which way:
a) An insignificant event unless taught otherwise
b) Punishment for something the individual did
c) Something that just happens to older people
d) Temporary separation from the loved one.
(D) Temporary separation from the loved one. The
predominant perception of death by preschool age
children is that death is temporary separation.
Because that child is losing someone significant
and will not see that person again, it’s inaccurate to
infer death is insignificant, regardless of the child’s
response.
25. Catherine Diaz is a 14 year old patient on a
hematology unit who is being treated for sickle cell
crisis. During a crisis such as that seen in sickle cell
anemia, aldosterone release is stimulated. In what way
might this influence Catherine’s fluid and electrolyte
balance?
a. sodium loss, water loss and potassium retention
b. sodium loss, water los and potassium loss
c. sodium retention, water loss and potassium
retention
d. sodium retention, water retention and potassium
loss
(D) sodium retention, water retention and potassium
loss. Stress stimulates the adrenal cortex to increase the
release of aldosterone. Aldosterone promotes the
resorption of sodium, the retention of water and the loss
of potassium
PNLE Maternal and
Child Health Nursing
Exam 3
1. A pregnant woman who is at term is admitted to
the birthing unit in active labor. The client has only
progressed from 2cm to 3 cm in 8 hours. She is
diagnosed with hypotonic dystocia and the
physician ordered Oxytocin (Pitocin) to augment
her contractions. Which of the following is the most
important aspect of nursing intervention at this time?
a) Timing and recording length of contractions.
b) Monitoring.
c) Preparing for an emergency cesarean birth.
d) Checking the perineum for bulging.
A. The oxytocic effect of Pitocin increases the
intensity and durations of contractions;
prolonged contractions will jeopardize the
safetyof the fetus and necessitate discontinuing
the drug.
2. A client who hallucinates is not in touch with
reality. It is important for the nurse to:
a. Isolate the client from other patients.
b. Maintain a safe environment.
c. Orient the client to time, place, and person.
d. Establish a trusting relationship.
B. It is of paramount importance to prevent the
client from hurting himself or herself or others
3. The nurse is caring to a child client who has had
a tonsillectomy. The child complains of having
dryness of the throat. Which of the following would
the nurse give to the child?
a) Cola with ice
b) Yellow noncitrus Jello
c) Cool cherry Kool-Aid
d) A glass of milk
B. After tonsillectomy, clear, cool liquids should
be given. Citrus, carbonated, and hot or cold
liquids should be avoided because they may
irritate the throat. Red liquids should be
avoided because they give the appearance of
blood if the child vomits. Milk and milk
products including pudding are avoided
because they coat the throat, cause the child to
clear the throat, and increase the risk of
bleeding.
4. The physician ordered Phenylephrine (Neo-
Synephrine) nasal spray to a 13-year-old client. The
nurse caring to the client provides instructions that
the nasal spray must be used exactly as directed to
prevent the development of:
a. Increased nasal congestion.
b. Nasal polyps.
c. Bleeding tendencies.
d. Tinnitus and diplopia.
A. Phenylephrine, with frequent and continued use,
can cause rebound congestion of mucous
membranes.
5. A client with tuberculosis is to be admitted in the
hospital. The nurse who will be assigned to care for
the client must institute appropriate precautions.
The nurse should:
a) Place the client in a private room.
b) Wear an N 95 respirator when caring for the
client.
c) Put on a gown every time when entering the
room.
d) Don a surgical mask with a face shield when
entering the room.
B. The N 95 respirator is a high-particulate
filtration mask that meets the CDC
performance criteria for a tuberculosis
respirator.
6. Which of the following is the most frequent cause
of noncompliance to the medical treatment of open-
angle glaucoma?
a. The frequent nausea and vomiting
accompanying use of miotic drug.
b. Loss of mobility due to severe driving
restrictions.
c. Decreased light and near-vision
accommodation due to miotic effects of
pilocarpine.
d. The painful and insidious progression of this
type of glaucoma.
C. The most frequent cause of noncompliance to
the treatment of chronic, or open-angle
glaucoma is the miotic effects of pilocarpine.
Pupillary constriction impedes normal
accommodation, making night driving difficult
and hazardous, reducing the client’s ability to
read for extended periods and making
participation in games with fast-moving objects
impossible.
7. In the morning shift, the nurse is making rounds
in the nursing care units. The nurse enters in a
client’s room and notes that the client’s tube has
become disconnected from the Pleurovac. What
would be the initial nursing action?
a) Apply pressure directly over the incision site.
b) Clamp the chest tube near the incision site.
c) Clamp the chest tube closer to the drainage
system.
d) Reconnect the chest tube to the Pleurovac.
B. This stops the sucking of air through the tube
and prevents the entry of contaminants. In
addition, clamping near the chest wall provides
for some stability and may prevent the clamp
from pulling on the chest tube.
8. Which of the following complications during a
breech birth the nurse needs to be alarmed?
a. Abruption placenta.
b. Caput succedaneum.
c. Pathological hyperbilirubinemia.
d. Umbilical cord prolapse.
D. Because umbilical cord’s insertion site is born
before the fetal head, the cord may be
compressed by the after-coming head in a
breech birth.
9. The nurse is caring to a client diagnosed with
severe depression. Which of the following nursing
approach is important in depression?
a) Protect the client against harm to others.
b) Provide the client with motor outlets for
aggressive, hostile feelings.
c) Reduce interpersonal contacts.
d) Deemphasizing preoccupation with elimination,
nourishment, and sleep.
B. It is important to externalize the anger away
from self.

10. A 3-month-old client is in the pediatric unit.
During assessment, the nurse is suspecting that the
baby may have hypothyroidism when mother states
that her baby does not:
a. Sit up.
b. Pick up and hold a rattle.
c. Roll over.
d. Hold the head up.
D. Development normally proceeds
cephalocaudally; so the first major
developmental milestone that the infant
achieves is the ability to hold the head up
within the first 8-12 weeks of life. In
hypothyroidism, the infant’s muscle tone
would be poor and the infant would not be able
to achieve this milestone.
11. The physician calls the nursing unit to leave an
order. The senior nurse had conversation with the
other staff. The newly hired nurse answers the
phone so that the senior nurses may continue their
conversation. The new nurse does not knowthe
physician or the client to whom the order pertains.
The nurse should:
a) Ask the physician to call back after the nurse
has read the hospital policy manual.
b) Take the telephone order.
c) Refuse to take the telephone order.
d) Ask the charge nurse or one of the other
senior staff nurses to take the telephone
order.
D. Get a senior nurse who know s the policies, the
client, and the doctor. Generally speaking, a
nurse should not accept telephone orders.
However, if it is necessary to take one, follow
the hospital’s policy regarding telephone orders.
Failure to followhospital policy could be
considered negligence. In this case, the nurse
was new and did not know the hospital’s policy
concerning telephone orders. The nurse was
also unfamiliar with the doctor and the client.
Therefore the nurse should not take the order
unless a) no one else is available and b) it is an
emergency situation.
12. The staff nurse on the labor and delivery unit is
assigned to care to a primigravida in transition
complicated by hypertension. A new pregnant
woman in active labor is admitted in the same unit.
The nurse manager assigned the same nurse to the
second client. The nurse feels that the client with
hypertension requires one-to-one care. What would
be the initial actionof the nurse?
a. Accept the new assignment and complete an
incident report describing a shortage of nursing
staff.
b. Report the incident to the nursing supervisor
and request to be floated.
c. Report the nursing assessment of the client
in transitional labor to the nurse manager
and discuss misgivings about the new
assignment.
Accept the new assignment and provide the best
care.
C. The nurse is obligated to inform the nurse
manager about changes in the condition of the
client, which may change the decision made by
the nurse manager.
13. A newborn infant with Down syndrome is to be
discharged today. The nurse is preparing to give the
discharge teaching regarding the proper care at
home. The nurse would anticipate that the mother is
probably at the:
a) 40 years of age.
b) 20 years of age.
c) 35 years of age.
d) 20 years of age.
A. Perinatal risk factors for the development of
Down syndrome include advanced maternal
age, especially with the first pregnancy.
14. The emergency department has shortage of staff.
The nurse manager informs the staff nurse in the
critical care unit that she has to float to the
emergency department. What should the staff nurse
expect under these conditions?
a. The float staff nurse will be informed of the
situation before the shift begins.
b. The staff nurse will be able to negotiate the
assignments in the emergency department.
c. Cross training will be available for the staff
nurse.
d. Client assignments will be equally divided
among the nurses.
B. Assignments should be based on scope of
practice and expertise.
15. The nurse is assigned to care for a child client
admitted in the pediatrics unit. The client is
receiving digoxin. Which of the following questions
will be asked by the nurse to the parents of the child
in order to assess the client’s risk for digoxin
toxicity?
a) “Has he been exposed to any childhood
communicable diseases in the past 2-3 weeks?”
b) “Has he been taking diuretics at home?”
c) “Do any of his brothers and sisters have history
of cardiac problems?”
d) “Has he been going to school regularly?”
B. The child who is concurrently taking digoxin
and diuretics is at increased risk for digoxin
 toxicity due to the loss of potassium. The child
and parents should be taught what foods are
high in potassium, and the child should be
encouraged to eat a high-potassium diet. In
addition, the child’s serum potassium level
should be carefully monitored.
16. The nurse noticed that the signed consent form
has an error. The form states, “Amputation of the
right leg” instead of the left leg that is to be
amputated. The nurse has administered already the
preoperative medications. What should the nurse do?
a. Call the physician to reschedule the surgery.
b. Call the nearest relative to come in to sign a
new form.
c. Cross out the error and initial the form.
d. Have the client sign another form.
A. The responsible for an accurate informed consent
is the physician. An exception to this answer would
be a life-threatening emergency, but there are no
data to support another response
17. The nurse in the nursing care unit checks the
fluctuation in the water-seal compartment of a
closed chest drainage system. The fluctuation has
stopped, the nurse would:
a) Vigorously strip the tube to dislodge a clot.
b) Raise the apparatus above the chest to move
fluid.
c) Increase wall suction above 20 cm H2O
pressure.
d) Ask the client to cough and take a deep
breath.
D. Asking the client to cough and take a deep breath
will help determine if the chest tube is kinked or if
the lungs has reexpanded
18. The pediatric nurse in the neonatal unit was
informed that the baby that is brought to the mother
in the hospital room is wrong. The nurse determines
that two babies were placed in the wrong cribs. The
most appropriate nursing action would be to:
a. Determine who is responsible for the mistake
and terminate his or her employment.
b. Record the event in an incident/variance
report and notify the nursing supervisor.
c. Reassure both mothers, report to the charge
nurse, and do not record.
d. Record detailed notes of the event on the
mother’s medical record.
B. Every event that exposes a client to harm should
be recorded in an incident report, as well as
reported to the appropriate supervisors in order
to resolve the current problems and permit the
institution to prevent the problem from
happening again.
19. Before the administration of digoxin, the nurse
completes an assessment to a toddler client for signs
and symptoms of digoxin toxicity. Which of the
following is the earliest and most significant sign of
digoxin toxicity?
a) Tinnitus
b) Nausea and vomiting
c) Vision problem
d) Slowing in the heart rate
D. One of the earliest signs of digoxin toxicity is
Bradycardia. For a toddler, any heart rate that
falls below the norm of about 100-120 bpm
would indicate Bradycardia and would
necessitate holding the medication and
notifying the physician.
20. Which of the following treatment modality is
appropriate for a client with paranoid tendency?
a. Activity therapy.
b. Individual therapy.
c. Group therapy.
d. Family therapy.
B. This option is least threatening.
21. The client with rheumatoid arthritis is for
discharge. In preparing the client for discharge on
prednisone therapy, the nurse should advise the
client to:
a) Wear sunglasses if exposed to bright light for
an extended period of time.
b) Take oral preparations of prednisone before
meals.
c) Have periodic complete blood counts while on
the medication.
d) Never stop or change the amount of the
medication without medical advice.
D. In preparing the client for discharge that is
receiving prednisone, the nurse should caution the
client to (a) take oral preparations after meals; (b)
remember that routine checks of vital signs, weight,
and lab studies are critical; (c) NEVER STOP OR
CHANGE THE AMOUNT OF MEDICATION
WITHOUT MEDICAL ADVICE; (d) store the
medication in a light-resistant container.
22. A pregnant client tells the nurse that she is
worried about having urinary frequency. What will
be the most appropriate nursing response?
a. “Try using Kegel (perineal) exercises and
limiting fluids before bedtime. If you have
frequency associated with fever, pain on
voiding, or blood in the urine, call your
doctor/nurse-midwife.
b. “Placental progesterone causes irritability of
the bladder sphincter. Your symptoms will go
away after the baby comes.”
c. “Pregnant women urinate frequently to get rid
of fetal wastes. Limit fluids to 1L/daily.”
d. “Frequency is due to bladder irritation from
concentrate urine and is normal in pregnancy.
Increase your daily fluid intake to 3L.”
A. Progesterone also reduces smooth muscle
motility in the urinary tract and predisposes the
pregnant woman to urinary tract infections.
Women should contact their doctors if they
exhibit signs of infection. Kegel exercise will
help strengthen the perineal muscles; limiting
fluids at bedtime reduces the possibility of
being awakened by the necessity of voiding.
23. Which of the following will help the nurse
determine that the expression of hostility is useful?
a) Expression of anger dissipates the energy.
b) Energy from anger is used to accomplish
what needs to be done.
c) Expression intimidates others.
d) Degree of hostility is less than the provocation.
B. This is the proper use of anger.
24. The nurse is providing an orientation regarding
case management to the nursing students. Which
characteristics should the nurse include in the
discussion in understanding case management?
a. Main objective is a written plan that combines
discipline-specific processes used to measure
outcomes of care.
b. Main purpose is to identify expected client,
family and staff performance against the
timeline for clients with the same diagnosis.
c. Main focus is comprehensive coordination of
client care, avoid unnecessary duplication of
services, improve resource utilization and
decrease cost.
d. Primary goal is to understand why predicted
outcomes have not been met and the correction
of identified problems.
C. There are several models of case management,
but the commonality is comprehensive
coordination of care to better predict needs of
high-risk clients, decrease exacerbations and
continually monitor progress overtime.
25. The physician orders a dose of IV phenytoin to
a child client. In preparing in the administration of
the drug, which nursing action is not correct?
a) Infuse the phenytoin into a smaller vein to
prevent purple glove syndrome.
b) Check the phenytoin solution to be sure it is
clear or light yellow in color, never cloudy.
c) Plan to give phenytoin over 30-60 minutes,
using an in-line filter.
d) Flush the IV tubing with normal saline before
starting phenytoin.
A. Phenytoin should be infused or injected into
larger veins to avoid the discoloration know as
purple glove syndrome; infusing into a smaller
vein is not appropriate.
26. The pregnant woman visits the clinic for check
–up. Which assessment findings will help the nurse
determine that the client is in 8-week gestation?
a. Leopold maneuvers.
b. Fundal height.
c. Positive radioimmunoassay test (RIA test).
d. Auscultation of fetal heart tones.
C. Serum radioimmunoassay (RIA) is accurate
within 7days of conception. This test is specific
for HCG, and accuracy is not compromised by
confusion with LH.
27. Which of the following nursing intervention is
essential for the client who had pneumonectomy?
a) Medicate for pain only when needed.
b) Connect the chest tube to water-seal drainage.
c) Notify the physician if the chest drainage
exceeds 100mL/hr.
d) Encourage deep breathing and coughing.
D. Surgery and anesthesia can increase mucus
production. Deep breathing and coughing are
essential to prevent atelectasis and pneumonia
in the client’s only remaining lung.
28. The nurse is providing a health teaching to a
group of parents regarding Chlamydia trachomatis.
The nurse is correct in the statement, “Chlamydia
trachomatis is not only an intracellular bacterium
that causes neonatal conjunctivitis, but it also can
cause:
a. Discoloration of baby and adult teeth.
b. Pneumonia in the newborn.
c. Snuffles and rhagades in the newborn.
d. Central hearing defects in infancy.
B. Newborns can get pneumonia (tachypnea, mild
hypoxia, cough, eosinophilia) and
conjunctivitis from Chlamydia.
29. The nurse is assigned to care to a 17-year-old
male client with a history of substance abuse. The
client asks the nurse, “Have you ever tried or used
drugs?” The most correct response of the nurse
would be:
a) “Yes, once I tried grass.”
b) “No, I don’t think so.”
c) “Why do you want to know that?”
d) “How will my answer help you?”
D. The client may perceive this as avoidance, but it
is more important to redirect back to the client,
especially in light of the manipulative behavior
of drug abusers and adolescents.
30. Which of the following describes a health care
team with the principles of participative leadership?
a. Each member of the team can independently
make decisions regarding the client’s care
without necessarily consulting the other
members.
b. The physician makes most of the decisions
regarding the client’s care.
c. The team uses the expertise of its members
to influence the decisions regarding the
client’s care.
d. Nurses decide nursing care; physicians decide
medical and other treatment for the client.
C. It describes a democratic process in which all
members have input in the client’s care.
31. A nurse is giving a health teaching to a woman
who wants to breastfeed her newborn baby. Which
hormone, normally secreted during the postpartum
period, influences both the milk ejection reflex and
uterine involution?
a) Oxytocin.
b) Estrogen.
c) Progesterone.
d) Relaxin.
A. Contraction of the milk ducts and let-down
reflex occur under the stimulation of oxytocin
released by the posterior pituitary gland.
32. One staff nurse is assigned to a group of 5
patients for the 12-hour shift. The nurse is
responsible for the overall planning, giving and
evaluating care during the entire shift. After the
shift, same responsibility will be endorsed to the
next nurse in charge. This describes nursing care
delivered via the:
a) Primary nursing method.
b) Case method.
c) Functional method.
d) Team method.
B. In case management, the nurse assumes total
responsibility for meeting the needs of the client
during the entire time on duty.
33. The ambulance team calls the emergency
department that they are going to bring a client who
sustained burns in a house fire. While waiting for
the ambulance, the nurse will anticipate emergency
care to include assessment for:
a. Gas exchange impairment.
b. Hypoglycemia.
c. Hyperthermia.
d. Fluid volume excess.
A. Smoke inhalation affects gas exchange.
34. Most couples are using “natural” family
planning methods. Most accidental pregnancies in
couples preferred to use this method have been
related to unprotected intercourse before ovulation.
Which of the following factor explains why
pregnancy may be achieved by unprotected
intercourse during the preovulatory period?
a) Ovum viability.
b) Tubal motility.
c) Spermatozoal viability.
d) Secretory endometrium.
C. Sperm deposited during intercourse may remain
viable for about 3 days. If ovulation occurs
during this period, conception may result.
35. An older adult client wakes up at 2 o’clock in
the morning and comes to the nurse’s station saying,
“I am having difficulty in sleeping.” What is the
best nursing response to the client?
a. “I’ll give you a sleeping pill to help you get
more sleep now.”
b. “Perhaps you’d like to sit here at the nurse’s
station for a while.”
c. “Would you like me to show you where the
bathroom is?”
d. “What woke you up?”
B. This option shows acceptance (key concept) of
this age-typical sleep pattern (that of waking in
the early morning).
36. The nurse is taking care of a multipara who is at
42 weeks of gestation and in active labor, her
membranes ruptured spontaneously 2 hours ago.
While auscultating for the point of maximum
intensity of fetal heart tones before applying an
external fetal monitor, the nurse counts 100 beats
per minute. The immediate nursing action is to:
a) Start oxygen by mask to reduce fetal distress.
b) Examine the woman for signs of a prolapsed
cord.
c) Turn the woman on her left side to increase
placental perfusion.
d) Take the woman’s radial pulse while still
auscultating the FHR.
D. Taking the mother’s pulse while listening to the
FHR will differentiate between the maternal
and fetal heart rates and rule out fetal
Bradycardia.
37. The nurse must instruct a client with glaucoma
to avoid taking over-the-counter medications like:
a. Antihistamines.
b. NSAIDs.
c. Antacids.
d. Salicylates.
A. Antihistamines cause pupil dilation and should
be avoided with glaucoma.
38. A male client is brought to the emergency
department due to motor vehicle accident. While
monitoring the client, the nurse suspects increasing
intracranial pressure when:
a) Client is oriented when aroused from sleep,
and goes back to sleep immediately.
b) Blood pressure is decreased from 160/90 to
110/70.
c) Client refuses dinner because of anorexia.
d) Pulse is increased from 88-96 with occasional
skipped beat.
A. This suggests that the level of consciousness is
decreasing.
39. The nurse is conducting a lecture to a class of
nursing students about advance directives to
preoperative clients. Which of the following
statement by the nurse js correct?
a. “The spouse, but not the rest of the family, may
override the advance directive.”
b. “An advance directive is required for a “do not
resuscitate” order.”
c. “A durable power of attorney, a form of
advance directive, may only be held by a blood
relative.”
d. “The advance directive may be enforced
even in the face of opposition by the spouse.”
D. An advance directive is a form of informed
consent, and only a competent adult or the
holder of a durable power of attorney has the
right to consent or refuse treatment. If the
spouse does not hold the power of attorney, the
decisions of the holder, even if opposed by the
spouse, are enforced.
40. A client diagnosed with schizophrenia is
shouting and banging on the door leading to the
outside, saying, “I need to go to an appointment.”
What is the appropriate nursing intervention?
a) Tell the client that he cannot bang on the door.
b) Ignore this behavior.
c) Escort the client going back into the room.
d) Ask the client to move away from the door.
C. Gentle but firm guidance and nonverbal
direction is needed to intervene when a client
with schizophrenic symptoms is being
disruptive.
41. Which of the following action is an accurate
tracheal suctioning technique?
a. 25 seconds of continuous suction during
catheter insertion.
b. 20 seconds of continuous suction during
catheter insertion.
c. 10 seconds of intermittent suction during
catheter withdrawal.
d. 15 seconds of intermittent suction during
catheter withdrawal.
C. Suctioning is only done for 10 seconds,
intermittently, as the catheter is being
withdrawn.
42. The client’s jaw and cheekbone is sutured and
wired. The nurse anticipates that the most important
thing that must be ready at the bedside is:
a) Suture set.
b) Tracheostomy set.
c) Suction equipment.
d) Wire cutters.
D. The priority for this client is being able to
establish an airway.
43. A mother is in the third stage of labor. Which of
the following signs will help the nurse determine
the signs of placental separation?
a. The uterus becomes globular.
b. The umbilical cord is shortened.
c. The fundus appears at the introitus.
d. Mucoid discharge is increased.
A. Signs of placental separation include a change
in the shape of the uterus from ovoid to
globular.
44. After therapy with the thrombolytic alteplase (t-
PA), what observation will the nurse report to the
physician?
a) 3+ peripheral pulses.
b) Change in level of consciousness and
headache.
c) Occasional dysrhythmias.
d) Heart rate of 100/bpm.
B. This could indicate intracranial bleeding.
Alteplase is a thrombolytic enzyme that lyses
thrombi and emboli. Bleeding is an adverse
effect. Monitor clotting times and signs of any
gastrointestinal or internal bleeding.
45. A client who undergone left nephrectomy has a
large flank incision. Which of the following nursing
action will facilitate deep breathing and coughing?
a. Push fluid administration to loosen respiratory
secretions.
b. Have the client lie on the unaffected side.
c. Maintain the client in high Fowler’s position.
d. Coordinate breathing and coughing exercise
with administration of analgesics.
D. Because flank incision in nephrectomy is
directly below the diaphragm, deep breathing is
painful. Additionally, there is a greater
incisional pull each time the person moves than
there is with abdominal surgery. Incisional pain
following nephrectomy generally requires
analgesics administration every 3-4 hours for
24-48 hours after surgery. Therefore, turning,
coughing and deep-breathing exercises should
be planned to maximize the analgesic effects.
46. The community nurse is teaching the group of
mothers about the cervical mucus method of natural
family planning. Which characteristics are typical
of the cervical mucus during the “fertile” period of
the menstrual cycle?
a) Absence of ferning.
b) Thin, clear, good spinnbarkeit.
c) Thick, cloudy.
d) Yellow and sticky.
B. Under high estrogen levels, during the period
surrounding ovulation, the cervical mucus
becomes thin, clear, and elastic (spinnbarkeit),
facilitating sperm passage.
47. A client with ruptured appendix had surgery an
hour ago and is transferred to the nursing care unit.
The nurse placed the client in a semi-Fowler’s
position primarily to:
a. Facilitate movement and reduce complications
from immobility.
b. Fully aerate the lungs.
c. Splint the wound.
d. Promote drainage and prevent
subdiaphragmatic abscesses.
D. After surgery for a ruptured appendix, the client
should be placed in a semi-Fowler’s position to
promote drainage and to prevent possible
complications.
48. Which of the following will best describe a
management function?
a) Writing a letter to the editor of a nursing
journal.
b) Negotiating labor contracts.
c) Directing and evaluating nursing staff
members.
d) Explaining medication side effects to a client.
C. Directing and evaluation of staff is a major
responsibility of a nursing manager
49. The parents of an infant client ask the nurse to
teach them how to administer Cortisporin eye drops.
The nurse is correct in advising the parents to place
the drops:
a. In the middle of the lower conjunctival sac of
the infant’s eye.
b. Directly onto the infant’s sclera.
c. In the outer canthus of the infant’s eye.
d. In the inner canthus of the infant’s eye.
A. The recommended procedure for administering
eyedrops to any client calls for the drops to be
placed in the middle of the lower conjunctival
sac.
50. The nurse is assessing on the client who is
admitted due to vehicle accident. Which of the
following findings will help the nurse that there is
internal bleeding?
a) Frank blood on the clothing.
b) Thirst and restlessness.
c) Abdominal pain.
d) Confusion and altered of consciousness.
B. Thirst and restlessness indicate hypovolemia
and hypoxemia. Internal bleeding is difficult to
recognized and evaluate because it is not
apparent.
51. The nurse is completing an assessment to a
newborn baby boy. The nurse observes that the skin
of the newborn is dry and flaking and there are
several areas of an apparent macular rash. The nurse
charts this as:
a. Icterus neonatorum
b. Multiple hemangiomas
c. Erythema toxicum
d. Milia
C. Erythema toxicum is the normal,
nonpathological macular newborn rash
52. The client is brought to the emergency
department because of serious vehicle accident.
After an hour, the client has been declared brain
dead. The nurse who has been with the client must
now talk to the family about organ donation. Which
of the following consideration is necessary?
a) Include as many family members as possible.
b) Take the family to the chapel.
c) Discuss life support systems.
d) Clarify the family’s understanding of brain
death.
D. The family needs to understand what brain
death is before talking about organ donation.
They need time to accept the death of their
family member. An environment conducive to
discussing an emotional issue is needed.
53. The nurse is teaching exercises that are good for
pregnant women increasing tone and fitness and
decreasing lower backache. Which of the following
should the nurse exclude in the exercise program?
a. Stand with legs apart and touch hands to
floor three times per day.
b. Ten minutes of walking per day with an
emphasis on good posture.
c. Ten minutes of swimming or leg kicking in
pool per day.
d. Pelvic rock exercise and squats three times a
day.
A. Bending from the waist in pregnancy tends to
make backache worse.
54. A client with obsessive-compulsive behavior is
admitted in the psychiatric unit. The nurse taking
care of the client knows that the primary treatment
goal is to:
a) Provide distraction.
b) Support but limit the behavior.
c) Prohibit the behavior.
d) Point out the behavior.
B. Support and limit setting decrease anxiety and
provide external control.
55. After ileostomy, the nurse expects that the
drainage appliance will be applied to the stoma:
a. When the client is able to begin self-care
procedures.
b. 24 hours later, when the swelling subsided.
c. In the operating room after the ileostomy
procedure.
d. After the ileostomy begins to function.
C. 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.
56. A female client who has a 28-day menstrual
cycle asks the community health nurse when she get
pregnant during her cycle. What will be the best
nursing response?
a) It is impossible to determine the fertile period
reliably. So it is best to assume that a woman is
always fertile.
b) In a 28-day cycle, ovulation occurs at or
about day 14. The egg lives for about 24
hours and the sperm live for about 72 hours.
The fertile period would be approximately
between day 11 and day 15.
c) In a 28- day cycle, ovulation occurs at or about
day 14. The egg lives for about 72 hours and
the sperm live for about 24 hours. The fertile
period would be approximately between day 13
and 17.
d) In a 28-day cycle, ovulation occurs 8 days
before the next period or at about day 20. The
fertile period is between day 20 and the
beginning of the next period.
B. It is the most accurate statement of
physiological facts for a 28-day menstrual
cycle: ovulation at day 14, egg life span 24
hours, sperm life span of 72 hours. Fertilization
could occur from sperm deposited before
ovulation.
57. Which of the following statement describes the
role of a nurse as a client advocate?
a. A nurse may override clients’ wishes for their
own good.
b. A nurse has the moral obligation to prevent
harm and do well for clients.
c. A nurse helps clients gain greater
independence and self-determination.
d. A nurse measures the risk and benefits of
various health situations while factoring in cost.
C. An advocate role encourage freedom of choice,
includes speaking out for the client, and
supports the client’s best interests.
58. A community health nurse is providing a health
teaching to a woman infected with herpes simplex 2.
Which of the following health teaching must the
nurse include to reduce the chances of transmission
of herpes simplex 2?
a) “Abstain from intercourse until lesions heal.”
b) “Therapy is curative.”
c) “Penicillin is the drug of choice for treatment.”
d) “The organism is associated with later
development of hydatidiform mole.
A. Abstinence will eliminate any unnecessary pain
during intercourse and will reduce the
possibility of transmitting infection to one’s
sexual partner.
59. The nurse in the psychiatric ward informed the
male client that he will be attending the 9:00 AM
group therapy sessions. The client tells the nurse
that he must wash his hands from 9:00 to 9:30 AM
each day and therefore he cannot attend. Which
concept does the nursing staff need to keep in mind
in planning nursing intervention for this client?
a. Depression underlines ritualistic behavior.
b. Fear and tensions are often expressed in
disguised form through symbolic processes.
c. Ritualistic behavior makes others
uncomfortable.
d. Unmet needs are discharged through ritualistic
behavior.
B. Anxiety is generated by group therapy at 9:00
AM. The ritualistic behavioral defense of hand
washing decreases anxiety by avoiding group
therapy.
60. The nurse assesses the health condition of the
female client. The client tells the nurse that she
discovered a lump in the breast last year and
hesitated to seek medical advice. The nurse
understands that, women who tend to delay seeking
medical advice after discovering the disease are
displaying what common defense mechanism?
a) Intellectualization.
b) Suppression.
c) Repression.
d) Denial.
D. Denial is a very strong defense mechanism used
to allay the emotional effects of discovering a
potential threat. Although denial has been
found to be an effective mechanism for
survival in some instances, such as during
natural disasters, it may in greater pathology in
a woman with potential breast carcinoma.
61. Which of the following situations cannot be
delegated by the registered nurse to the nursing
assistant?
a. A postoperative client who is stable needs to
ambulate.
b. Client in soft restraint who is very agitated
and crying.
c. A confused elderly woman who needs
assistance with eating.
d. Routine temperature check that must be done
for a client at end of shift.
B. The registered nurse cannot delegate the
responsibility for assessment and evaluation of
clients. The status of the client in restraint
requires further assessment to determine if
there are additional causes for the behavior.
62. In the admission care unit, which of the
following client would the nurse give immediate
attention?
a) A client who is 3 days postoperative with left
calf pain.
b) A client who is postoperative hip pinning who
is complaining of pain.
c) New admitted client with chest pain.
d) A client with diabetes who has a glucoscan
reading of 180.
C. The client with chest pain may be having a
myocardial infarction, and immediate
assessment and intervention is a priority.
63. A couple seeks medical advice in the
community health care unit. A couple has been
unable to conceive; the man is being evaluated for
possible problems. The physician ordered semen
analysis. Which of the following instructions is
correct regarding collection of a sperm specimen?
a. Collect a specimen at the clinic, place in iced
container, and give to laboratory personnel
immediately.
b. Collect specimen after 48-72 hours of
abstinence and bring to clinic within 2 hours.
c. Collect specimen in the morning after 24 hours
of abstinence and bring to clinic immediately.
d. Collect specimen at night, refrigerate, and bring
to clinic the next morning.
B. Is correct because semen analysis requires that a
freshly masturbated specimen be obtained after
a rest (abstinence) period of 48-72 hours.
64. The physician ordered Betamethasone to a
pregnant woman at 34 weeks of gestation with sign
of preterm labor. The nurse expects that the drug
will:
a) Treat infection.
b) Suppress labor contraction.
c) Stimulate the production of surfactant.
d) Reduce the risk of hypertension.
C. Betamethasone, a form of cortisone, acts on the
fetal lungs to produce surfactant.

65. A tracheostomy cuff is to be deflated, which of
the following nursing intervention should be
implemented before starting the procedures?
a. Suction the trachea and mouth.
b. Have the obdurator available.
c. Encourage deep breathing and coughing.
d. Do a pulse oximetry reading.
A. Secretions may have pooled above the
tracheostomy cuff. If these are not suctioned
before deflation, the secretions may be
aspirated.
66. A client is diagnosed with Tuberculosis and
respiratory isolation is initiated. This means that:
a) Gloves are worn when handling the client’s
tissue, excretions, and linen.
b) Both client and attending nurse must wear
masks at all times.
c) Nurse and visitors must wear masks until
chemotherapy is begun. Client is instructed
in cough and tissue techniques.
d) Full isolation; that is, caps and gowns are
required during the period of contagion.
C. Proper handling of sputum is essential to allay
droplet transference of bacilli in the air. Clients
need to be taught to cover their nose and mouth
with tissues when sneezing or coughing.
Chemotherapy generally renders the client
noninfectious within days to a few weeks,
usually before cultures for tubercle bacilli are
negative. Until chemical isolation is
established, many institutions require the client
to wear a mask when visitors are in the room or
when the nurse is in attendance. Client should
be in a well-ventilated room, without air
recirculation, to prevent air contamination.
67. A client with lung cancer is admitted in the
nursing care unit. The husband wants to know the
condition of his wife. How should the nurse respond
to the husband?
a. Find out what information he already has.
b. Suggest that he discuss it with his wife.
c. Refer him to the doctor.
d. Refer him to the nurse in charge.
d) Logically point out that the client is jumping to
conclusions.
C. Listening is probably the most effective
response of the four choices
69. After a cystectomy and formation of an ileal
conduit, the nurse provides instruction regarding
prevention of leakage of the pouch and backflow of
the urine. The nurse is correct to include in the
instruction to empty the urine pouch:
a. Every 3-4 hours.
b. Every hour.
c. Twice a day.
d. Once before bedtime.
A. Urine flow is continuous. The pouch has an
outlet valve for easy drainage every 3-4 hours.
(the pouch should be changed every 3-5 days,
or sooner if the adhesive is loose).
70. Which telephone call from a student’s mother
should the school nurse take care of at once?
a) A telephone call notifying the school nurse
that the child’ pediatrician has informed the
mother that the child will need cardiac
repair surgery within the next few weeks.
b) A telephone call notifying the school nurse that
the child’s pediatrician has informed the mother
that the child has head lice.
c) A telephone call notifying the school nurse that
a child has a temperature of 102ºF and a rash
covering the trunk and upper extremities of the
body.
d) A telephone call notifying the school nurse that
a child underwent an emergency appendectomy
during the previous night.
C. A high fever accompanied by a body rash could
indicate that the child has a communicable
disease and would have exposed other students
to the infection. The school nurse would want
to investigate this telephone call immediately
so that plans could be instituted to control the
spread of such infection.
71. Which of the following signs and symptoms that
require immediate attention and may indicate most
serious complications during pregnancy?

A. It is best to establish baseline information first. a.
68. A hospitalized client cannot find his b.
handkerchief and accuses other cient in the room
and the nurse of stealing them. Which is the most c.
therapeutic approach to this client?
d.
a) Divert the client’s attention.
b) Listen without reinforcing the client’s belief.
c) Inject humor to defuse the intensity.
Severe abdominal pain or fluid discharge
from the vagina.
Excessive saliva, “bumps around the areolae,
and increased vaginal mucus.
Fatigue, nausea, and urinary frequency at any
time during pregnancy.
Ankle edema, enlarging varicosities, and
heartburn.
 A. Severe abdominal pain may indicate
complications of pregnancy such as abortion,
ectopic pregnancy, or abruption placenta; fluid
discharge from the vagina may indicate
premature rupture of the membrane.
72. The nurse is assessing the newborn boy. Apgar
scores are 7 and 9. The newborn becomes slightly
cyanotic. What is the initial nursing action?
a) Elevate his head to promote gravity drainage of
secretions.
b) Wrap him in another blanket, to reduce heat
loss.
c) Stimulate him to cry,, to increase oxygenation.
d) Aspirate his mouth and nose with bulb
syringe.
D. Gentle aspiration of mucus helps maintain a
patent airway, required for effective gas
exchange.
73. The nurse is formulating a plan of care to a
client with a somatoform disorder. The nurse needs
to have knowledge of which psychodynamic
principle?
a. The symptoms of a somatoform disorder are
an attempt to adjust to painful life situations
or to cope with conflicting sexual, aggressive,
or dependent feelings.
b. The major fundamental mechanism is
regression.
c. The client’s symptoms are imaginary and the
suffering is faked.
d. An extensive, prolonged study of the symptoms
will be reassuring to the client, who seeks
sympathy, attention and love.
A. Somatoform disorders provide a way of coping
with conflicts.
74. An infant is brought to the health care clinic for
three immunizations at the same time. The nurse
knows that hepatitis B, DPT, and Haemophilus
influenzae type B immunizations should:
a) Be drawn in the same syringe and given in one
injection.
b) Be mixed and inject in the same sites.
c) Not be mixed and the nurse must give three
injections in three sites.
d) Be mixed and the nurse must give the injection
in three sites.
C. Immunization should never be mixed together
in a syringe, thus necessitating three separate
injections in three sites. Note: some
manufacturers make a premixed combination
of immunization that is safe and effective.
75. A female client with cancer has radium implants.
The nurse wants to maintain the implants in the
correct position. The nurse should position the
client:
a. Flat in bed.
b. On the side only.
c. With the foot of the bed elevated.
d. With the head elevated 45-degrees (semi-
Fowler’s).
A. Clients with radioactive implants should be
positioned flat in bed to prevent dislodgement
of the vaginal packing. The client may roll to
the side for meals but the upper body should
not be raised more than 20 degrees.
76. The nurse wants to know if the mother of a
toddler understands the instructions regarding the
administration of syrup of ipecac. Which of the
following statement will help the nurse to know that
the mother needs additional teaching?
a) “I’ll give the medicine if my child gets into
some toilet bowl cleaner.”
b) “I’ll give the medicine if my child gets into
some aspirin.”
c) “I’ll give the medicine if my child gets into
some plant bulbs.”
d) “I’ll give the medicine if my child gets into
some vitamin pills.”
A. Syrup of ipecac is not administered when the
ingested substances is corrosive in nature.
Toilet bowl cleaners, as a collective whole, are
highly corrosive substances. If the ingested
substance “burned” the esophagus going down,
it will “burn” the esophagus coming back up
when the child begins to vomit after
administration of syrup of ipecac.
77. To assess if the cranial nerve VII of the client
was damaged, which changes would not be
expected?
a. Drooling and drooping of the mouth.
b. Inability to open eyelids on operative side.
c. Sagging of the face on the operative side.
d. Inability to close eyelid on operative side.
B. Inability to open eyelids on operative side is
seen with cranial nerve III damage.
78. The community health nurse makes a home visit
to a family. During the visit, the nurse observes that
the mother is beating her child. What is the priority
nursing intervention in this situation?
a. Assess the child’s injuries.
b. Report the incident to protective agencies.
c. Refer the family to appropriate support group.
d. Assist the family to identify stressors and use of
other coping mechanisms to prevent further
incidents.
A. Assessment of physical injuries (like bruises,
lacerations, bleeding and fractures) is the first
priority.
79. The nurse in the neonatal care unit is
supervising the actions of a certified nursing
assistant in giving care to the newborns. The
nursing assistant mistakenly gives a formula feeding
to a newborn that is on water feeding only. The
nurse is responsible for the mistake of the nursing
assistant:
a) Always, as a representative of the institution.
b) Always, because nurses who supervise less-
trained individuals are responsible for their
mistakes.
c) If the nurse failed to determine whether the
nursing assistant was competent to take care
of the client.
d) Only if the nurse agreed that the newborn could
be fed formula.
C. The nurse who is supervising others has a legal
obligation to determine that they are competent
to perform the assignment, as well as legal
obligation to provide adequate supervision.
80. The nurse is assigned to care for a client with
urinary calculi. Fluid intake of 2L/day is
encouraged to the client. the primary reason for this
is to:
a. Reduce the size of existing stones.
b. Prevent crystalline irritation to the ureter.
c. Reduce the size of existing stones
d. Increase the hydrostatic pressure in the
urinary tract.
D. Increasing hydrostatic pressure in the urinary
tract will facilitate passage of the calculi.
81. The nurse is counseling a couple in their mid
30’s who have been unable to conceive for about 6
months. They are concerned that one or both of
them may be infertile. What is the best advice the
nurse could give to the couple?
a) “it is no unusual to take 6-12 months to get
pregnant, especially when the partners are
in their mid-30s. Eat well, exercise, and
avoid stress.”
b) “Start planning adoption. Many couples get
pregnant when they are trying to adopt.”
c) “Consult a fertility specialist and start testing
before you get any older.”
d) “Have sex as often as you can, especially
around the time of ovulation, to increase your
chances of pregnancy.”
A. Infertility is not diagnosed until atleast
12months of unprotected intercourse has failed
to produce a pregnancy. Older couples will
experience a longer time to get pregnant.
82. The nurse is caring for a cient who Is a retired
nurse. A 24-hour urine collection for Creatinine
clearance is to be done. The client tells the nurse, “I
can’t remember what this test is for.” The best
response by the nurse is:
a. “It provides a way to see if you are passing any
protein in your urine.”
b. “It tells how well the kidneys filter wastes
from the blood.”
c. “It tells if your renal insufficiency has affected
your heart.”
d. “The test measures the number of particles the
kidney filters.”
B. Determining how well the kidneys filter wastes
states the purpose of a Creatinine clearance test.
83. The nurse observes the female client in the
psychiatric ward that she is having a hard time
sleeping at night. The nurse asks the client about it
and the client says, “I can’t sleep at night because of
fear of dying.” What is the best initial nursing
response?
a) “It must be frightening for you to feel that
way. Tell me more about it.”
b) “Don’t worry, you won’t die. You are just here
for some test.”
c) “Why are you afraid of dying?”
d) “Try to sleep. You need the rest before
tomorrow’s test.”
A. Acknowledging a feeling tone is the most
therapeutic response and provides a broad
opening for the client to elaborate feelings.
84. In the hospital lobby, the registered nurse
overhears a two staff members discussing about the
health condition of her client. What would be the
appropriate action for the registered nurse to take?
a. Join in the conversation, giving her input about
the case.
b. Ignore them, because they have the right to
discuss anything they want to.
c. Tell them it is not appropriate to discuss
such things.
d. Report this incident to the nursing supervisor.
 C. The behavior should be stopped. The first is to
remind the staff that confidentiality maybe
violated.
85. The client has had a right-sided cerebrovascular
accident. In transferring the client from the
wheelchair to bed, in what position should a client
be placed to facilitate safe transfer?
a) Weakened (L) side of the cient next to bed.
b) Weakened (R) side of the client next to bed.
c) Weakened (L) side of the client away from
bed.
d) Weakened (R) side of the cient away from bed.
C. With a right-sided cerebrovascular accident the
client would have left-sided hemiplegia or
weakness. The client’s good side should be
closest to the bed to facilitate the transfer.
86. The child client has undergone hip surgery and
is in a spica cast. Which of the following toy should
be avoided to be in the child’s bed?
a. A toy gun.
b. A stuffed animal.
c. A ball.
d. Legos.
D. Legos are small plastic building blocks that
could easily slip under the child’s cast and lead
to a break in skin integrity and even infection.
Pencils, backscratchers, and marbles are some
other narrow or small items that could easily
slip under the child’s cast and lead to a break in
skin integrity and infection.
87. The LPN/LVN asks the registered nurse why
oxytocin (Pitocin), 10 units (IV or IM) must be
given to a client after birth fo the fetus. The nurse is
correct to explain that oxytocin:
a) Minimizes discomfort from “afterpains.”
b) Suppresses lactation.
c) Promotes lactation.
d) Maintains uterine tone.
D. Oxytocin (Pitocin) is used to maintain uterine
tone.
88. The nurse in the nursing care unit is aware that
one of the medical staff displays unlikely behaviors
like confusion, agitation, lethargy and unkempt
appearance. This behavior has been reported to the
nurse manager several times, but no changes
observed. The nurse should:
a. Continue to report observations of unusual
behavior until the problem is resolved.
b. Consider that the obligation to protect the
patient from harm has been met by the prior
reports and do nothing further.
c. Discuss the situation with friends who are also
nurses to get ideas .
d. Approach the partner of this medical staff
member with these concerns.
B. The submission of reports about incidents that
expose clients to harm does not remove the
obligation to report ongoing behavior as long
as the risk to the client continues.
89. The physician ordered tetracycline PO qid to a
child client who weights 20kg. The recommended
PO tetracycline dose is 25-50 mg/kg/day. What is
the maximum single dose that can be safely
administered to this child?
a) 1g
b) 500 mg
c) 250 mg
d) 125 mg
C. The recommended dosage of tetracycline is 25-
50mg/kg/day. If the child weighs 20kg and the
maximum dose is 50mg/kg, this would indicate
a total daily dose of 1000mg of tetracycline. In
this case, the child is being given this
medication four times a day. Therefore the
maximum single dose that can be given is
250mg (1000 mg of tetracycline divided by
four doses.)
90. The nurse is completing an obstetric history of a
woman in labor. Which event in the obstetric
history will help the nurse suspects dysfunctional
labor in the current pregnancy?
a. Total time of ruptured membranes was 24
hours with the second birth.
b. First labor lasting 24 hours.
c. Uterine fibroid noted at time of cesarean
delivery.
d. Second birth by cesarean for face presentation.
C. An abnormality in the uterine muscle could
reduce the effectiveness of uterine contractions
and lengthen the duration of subsequent labors.
91. The nurse is planning to talk to the client with
an antisocial personality disorder. What would be
the most therapeutic approach?
a) Provide external controls.
b) Reinforce the client’s self-concept.
c) Give the client opportunities to test reality.
d) Gratify the client’s inner needs.
A. Personality disorders stem from a weak
superego, implying a lack of adequate controls.
92. The nurse is teaching a group of women about
fertility awareness, the nurse should emphasize that
basal body temperature:
a. Can be done with a mercury thermometer but
no a digital one.
b. The average temperature taken each morning.
c. Should be recorded each morning before any
activity.
d. Has a lower degree of accuracy in predicting
ovulation than the cervical mucus test.
C. The basal body temperature is the lowest body
temperature of a healthy person that is taken
immediately after waking and before getting
out of bed. The BBT usually varies from 36.2
ºC to 36.3ºC during menses and for about 5-7
days afterward. About the time of ovulation, a
slight drop in temperature may be seen, after
ovulation in concert with the increasing
progesterone levels of the early luteal phase,
the BBT rises 0.2-0.4 ºC. This elevation
remains until 2-3 days before menstruation, or
if pregnancy has occurred.
93. The nursing applicant has given the chance to
ask questions during a job interview at a local
hospital. What should be the most important
question to ask that can increase chances of
securing a job offer?
a) Begin with questions about client care
assignments, advancement opportunities,
and continuing education.
b) Decline to ask questions, because that is the
responsibility of the interviewer.
c) Ask as many questions about the facility as
possible.
d) Clarify information regarding salary, benefits,
and working hours first, because this will help
in deciding whether or not to take the job.
A. This choice implies concern for client care and
self-improvement.
94. The nurse advised the pregnant woman that
smoking and alcohol should be avoided during
pregnancy. The nurse takes into account that the
developing fetus is most vulnerable to environment
teratogens that cause malformation during:
a. The entire pregnancy.
b. The third trimester.
c. The first trimester.
d. The second trimester.
C. The first trimester is the period of
organogenesis, that is, cell differentiation into
the various organs, tissues, and structures.
95. A male client tells the nurse that there is a big
bug in his bed. The most therapeutic nursing
response would be:
A. Silence.
B. “Where’s the bug? I’ll kill it for you.”
C. “I don’t see a bug in your bed, but you seem
afraid.”
D. “You must be seeing things.”
C. This response does not contradict the client’s
perception, is honest, and shows empathy.
96. A pregnant client in late pregnancy is
complaining of groin pain that seems worse on the
right side. Which of the following is the most likely
cause of it?
a. Beginning of labor.
b. Bladder infection.
c. Constipation.
d. Tension on the round ligament.
D. Tension on round ligament occurs because of
the erect human posture and pressure exerted
by the growing fetus.
97. The nurse is conducting a lecture to a group of
volunteer nurses. The nurse is correct in imparting
the idea that the Good Samaritan law protects the
nurse from a suit for malpractice when:
a) The nurse stops to render emergency aid and
leaves before the ambulance arrives.
b) The nurse acts in an emergency at his or her
place of employment.
c) The nurse refuses to stop for an emergency
outside of the scope of employment.
d) The nurse is grossly negligent at the scene of
an emergency.
D. The Good Samaritan Law does not impose a
duty to stop at the scene of an emergency
outside of the scope of employment, therefore
nurses who do not stop are not liable for suit.
98. A woman is hospitalized with mild
preeclampsia. The nurse is formulating a plan of
care for this client, which nursing care is least likely
to be done?
a. Deep-tendon reflexes once per shift.
b. Vital signs and FHR and rhythm q4h while
awake.
c. Absolute bed rest.
d. Daily weight.
C. Although reducing environment stimuli and
activity is necessary for a woman with mild
preeclampsia, she will most probably have
bathroom privileges.
99. While feeding a newborn with an unrepaired
cardiac defect, the nurse keeps on assessing the
condition of the client. The nurse notes that the
newborn’s respiration is 72 breaths per minute.
What would be the initial nursing action?
a) Burp the newborn.
b) Stop the feeding.
c) Continue the feeding.
d) Notify the physician. PNLE Pediatric
B. A normal respiratory rate for a newborn is 30-
40 breaths per minute.
Nursing Exam
Situation 1: Raphael, a 6 year’s old prep
100. A client who undergone appendectomy 3 days
pupil is seen at the school clinic for
ago is scheduled for discharge today. The nurse
notes that the client is restless, picking at bedclothes growth and development monitoring
and saying, “I am late on my appointment,” and (Questions 1-5)
calling the nurse by the wrong name. The nurse
suspects: 1. Which of the following is characterized the rate
of growth during this period?
a. Panic reaction.
b. Medication overdose. most rapid period of growth
c. Toxic reaction to an antibiotic. a decline in growth rate
d. Delirium tremens. growth spurt
slow uniform growth rate
D. The behavior described is likely to be
symptoms of delirium tremens, or alcohol B. a decline in growth rate. During the
withdrawal (often unsuspected on a surgical Preschooler stage growth is very minimal.
unit.) Weight gain is only 4.5lbs (2kgs) per year and
Height is 3.5in (6-8cm) per year.
Review:
Most rapid growth and development-
Infancy
Slow growth- Toddler hood and
Preschooler
Slower growth- School age
Rapid growth- Adolescence

2. In assessing Raphael’s growth and development,

the nurse is guided by principles of growth and
development. Which is not included?

All individuals follow cephalo-caudal and

proximo-distal
Different parts of the body grows at different rate
All individual follow standard growth rate
Rate and pattern of growth can be modified

D. Rate and pattern of growth can be

modified. Growth and development occurs in
cephalo-caudal meaning development occurs
through out the body’s axis. Example: the child
must be able to lift the head before he is able to
lift his chest. Proximo-distal is development
that progresses from center of the body to the
extremities. Example: a child first develops
arm movement before fine-finger movement.
Different parts of the body grows at different
range because some body tissue mature faster
than the other such as the neurologic tissues
peaks its growth during the first years of life
while the genital tissue doesn’t till puberty.
Also G&D is predictable in the sequence which
a child normally precedes such as motor skills
and behavior. Lastly G&D can never be
modified .
3. What type of play will be ideal for Raphael at this
period?
Make believe
Hide and seek
Peek-a-boo
Building blocks
A. Make believe. Make believe is most appropriate
because it enhances the imitative play and
imagination of the preschooler. C and D are for
infants while letter A is B is recommended for
schoolers because it enhances competitive play.
4. Which of the following information indicate that
Raphael is normal for his age?
Determine own sense self
Develop sense of whether he can trust the world
Has the ability to try new things
Learn basic skills within his culture
C. Has the ability to try new things. Erickson
defines the developmental task of a preschool
period is learning Initiative vs. Guilt. Children
can initiate motor activities of various sorts on
their own and no longer responds to or imitate
the actions of other children or of their
parents.
5. Based on Kohlberg’s theory, what is the stage of
moral development of Raphael?
Punishment-obedience
“good boy-Nice girl”
naïve instrumental orientation
social contact
C. naïve instrumental orientation. According to
Kohlber, a preschooler is under Pre-
conventional where a child learns about
instrumental purpose and exchange, that is they
will something do for another if that that
person does something with the child in return.
Letter A is applicable for Toddlers and letter B
is for a School age child
Situation 2 Baby boy Lacson delivered at
36 weeks gestation weighs 3,400 gm and
height of 59 cm (6-10)
6. Baby boy Lacson’s height is
Long
Short
Average
Too short
A. Long. The average length of full-term babies at
birth is 20 in. (51 cm), although the normal
range is 46 cm (18 in.) to 56 cm (22 in.).
7. Growth and development in a child progresses in
the following ways EXCEPT
From cognitive to psychosexual
From trunk to the tip of the extremities
From head to toe
From general to specific
A. From cognitive to psychosexual. Growth and
development occurs in cephalo-caudal (head to
toe), proximo-distal (trunk to tips of the
extremities and general to specific, but it
doesn’t occurs in cognitive to psychosexual
because they can develop at the same time.
8. As described by Erikson, the major psychosexual
conflict of the above situation is
Autonomy vs. Shame and doubt
Industry vs. Inferiority
Trust vs. mistrust
Initiation vs. guilt
C. Trust vs. mistrust. According to Erikson,
children 0-18 months are under the
developmental task of Trust vs. Mistrust.
9. Which of the following is true about Mongolian
Spots?
Disappears in about a year
Are linked to pathologic conditions
Are managed by tropical steroids
Are indicative of parental abuse
A. Disappears in about a year. Mongolian spots are
stale grey or bluish patches of discoloration
commonly seen across the sacrum or buttocks
due to accumulation of melanocytes and they
disappears in 1 year. They are not linked to
steroid use and pathologic conditions.
10. Signs of cold stress that the nurse must be alert
when caring for a Newborn is:
Hypothermia
Decreased activity level
Shaking
Increased RR
D. Increased RR. Hypothermia is inaccurate cause
normally, temperature of a newborn drop, Also
a child under cold stress will kick and cry to
increase the metabolic rate thereby increasing
heat so B isn’t a good choice. A newborn
doesn’t have the ability to shiver, so letter B
and C is wrong. A newborn will increase its
RR because the NB will need more oxygen
because of too much activity.
Situation 3 Nursing care after delivery
has an important aspect in every stages of
delivery
11. After the baby is delivered, the cord was cut
between two clamps using a sterile scissors and
blade, then the baby is placed at the:
Mother’s breast
Mother’s side
Give it to the grandmother
Baby’s own mat or bed
A. Mother’s breast. Place it at the mother’s breast
for latch-on. (Note: for NSD breast feed ASAP
while for CS delivery, breast feed after 4 hours)
12. The baby’s mother is RH(-). Which of the
following laboratory tests will probably be ordered
for the newborn?
Direct Coomb’s
Indirect Coomb’s
Blood culture
Platelet count
A. Direct Coomb’s. Coomb’s test is the test to
determine if RH antibodies are present. Indirect
Coomb’s is done to the mother and Direct
Coomb’s is the one don’t to the baby. Blood
culture and Platelet count doesn’t help detect
RH antibodies.
13. Hypothermia is common in newborn because of
their inability to control heat. The following would
be an appropriate nursing intervention to prevent
heat loss except:
Place the crib beside the wall
Doing Kangaroo care
By using mechanical pressure
Drying and wrapping the baby
A. Place the crib beside the wall. Placing the crib
beside the wall is inappropriate because it can
provide heat loss by radiation. Doing Kangaroo
care or hugging the baby, mechanical pressure
or incubators and drying and wrapping the
baby will help conserve heat.
14. The following conditions are caused by cold
stress except
Hypoglycemia
Increase ICP
Metabolic acidosis
Cerebral palsy
B. Increase ICP. Hypoglycemia may occur due to
increase metabolic rate, and because of
newborns are born slightly acidic, and they
catabolize brownfat which will produce
ketones which is an acid will cause metabolic
acidosis. Also a NB with severe hypothermia is
in high risk for kernicterus (too much bilirubin
in the brain) can lead to Cerebral palsy. There
is no connection in the increase of ICP with
hypothermia. (NOTE: pathognomonic sign of
Kernicterus in adult- asterexis, or involuntary
flapping of the hand.)
15. During the feto-placental circulation, the shunt
between two atria is called
Ductus venosous
Foramen Magnum
Ductus arteriosus
Foramen Ovale
D. Foramen Ovale. Foramen ovale is opening
between two atria, Ductus venosus is the shunt
from liver to the inferior vena cava, and your
Ductus Arteriosus is the shunt from the
pulmonary artery to the aorta.
16. What would cause the closure of the Foramen
ovale after the baby had been delivered?
Decreased blood flow
Shifting of pressures from right side to the left
side of the heart
Increased PO2
Increased in oxygen saturation
B. Shifting of pressures from right side to the left
side of the heart. During feto-placental
circulation, the pressure in the heart is much
higher in the right side, but once
breathing/crying is established, the pressure
will shift from the R to the L side, and will
facilitate the closure of Foramen Ovale. (Note:
that is why you should position the NB in R
side lying position to increase pressure in the L
side of the heart.)
Review:
Increase PO2-> closure of ductus
arteriosus
Decreased bloodflow -> closure of the
ductus venosus
Circulation in the lungs is initiated by ->
lung expansion and pulmonary
ventilation
What will sustain 1st breath-> decreased
artery pressure
What will complete circulation-> cutting
of the cord
17. Failure of the Foramen Ovale to close will cause
what Congenital Heart Disease?
Total anomalous Pulmunary Artery
Atrial Septal defect
Transposition of great arteries
 Pulmunary Stenosis
B. Atrial Septal defect. Foramen ovale is the
opening between two Atria so, if its will not
close Atrial Septal defect can occur.
Situation 4 Children are vulnerable to
some minor health problems or injuries
hence the nurse should be able to teach
mothers to give appropriate home care.
18. A mother brought her child to the clinic with
nose bleeding. The nurse showed the mother the
most appropriate position for the child which is:
Sitting up
With low back rest
With moderate back rest
Lying semi flat
A. Sitting up. The correct position is making the
child having an upright sitting position with the
head slightly tilted forward. This position will
minimize the amount of blood pressure in nasal
vessels and keep blood moving forward not
back into the nasopharynx, which will have the
choking sensation and increase risk of
aspiration. Choices b, c, d, are inappropriate
cause they can cause blood to enter the
nasopharynx.
19. A common problem in children is the
inflammation of the middle ear. This is related to
the malfunctioning of the:
Tympanic membrane
Eustachian tube
Adenoid
Nasopharynx
B. Eustachian tube. This is because children has
short, horizontal Eustachian tubes. The
dysfunction in the Eustachian tube enables
bacterial invasion of the middle ear and
obstructs drainage of secretions.
20. For acute otitis media, the treatment is prompt
antibiotic therapy. Delayed treatment may result in
complications of:
Tonsillitis
Eardrum Problems
Brain damage
Diabetes mellitus
C. Brain damage. One of the complication of
recurring acute otitis media is risk for having
Meningitis, thereby causing possible brain
damage. That is why patient must follow a
complete treatment regimen and follow up care.
A,B and D are not complications of AOM.
21. When assessing gross motor development in a 3
year old, which of the following activities would the
nurse expect to finds?
Riding a tricycle
Hopping on one foot
Catching a ball
Skipping on alternate foot.
A. Riding a tricycle. Answer is A, riding a tricycle
is appropriate for a 3 y/o child. Hopping on one
foot can be done by a 4 y/o child, as well as
catching and throwing a ball over hand.
Skipping can be done by a 5 y/o.
22. When assessing the weight of a 5-month old,
which of the following indicates healthy growth?
Doubling of birth weight
Tripling of birth weight
Quadrupling of birth weight
Stabilizing of birth weight
A. Doubling of birth weight. During the first 6
months of life the weight from birth will be
doubled and as soon as the baby reaches 1 year,
its birth weight is tripled.
23. An appropriate toy for a 4 year old child is:
Push-pull toys
Card games
Doctor and nurse kits
Books and Crafts
C. Doctor and nurse kits. Letter C is appropriate
because it will enhance the creativity and
imagination of a pre-school child. Letter B and
D are inappropriate because they are too
complex for a 4 y/o. Push-pull toys are
recommended for infants.
24. Which of the following statements would the
nurse expects a 5-year old boy to say whose pet
gerbil just died
“The boogieman got him”
“He’s just a bit dead”
“Ill be good from now own so I wont die like my
gerbil”
“Did you hear the joke about…”
B. “He’s just a bit dead”. A 5 y/o views death in
“degrees”, so the child most likely will say that
“he is just a bit dead”. Personification of death
like boogeyman occurs in ages 7 to 9 as well as
denying death can if they will be good.
Denying death using jokes and attributing life
qualities to death occurs during age 3-5.
25. When assessing the fluid and electrolyte balance
in an infant, which of the following would be
important to remember?
Infant can concentrate urine at an adult level
The metabolic rate of an infant is slower than in
adults
Infants have more intracellular water that adult do
Infant have greater body surface area than
adults
D. Infant have greater body surface area than
adults. Infants have greater body surface area
than adult, increasing their risk to F&E
imbalances. Also infants cant concentrate a
urine at an adult level and their metabolic rate,
also called water turnover, is 2 to 3 times
higher than adult. Plus more fluids of the
infants are at the ECF spaces not in the ICF
spaces.
26. When assessing a child with aspirin overdose,
which of the following will be expected?
Metabolic alkalosis
Respiratory alkalosis
Metabolic acidosis
Respiratory acidosis
C. Metabolic acidosis. Remember that Aspirin is
acid (Acetylsalicylic ACID).
27. Which of the following is not a possible
systemic clinical manifestation of severe burns?
Growth retardation
Hypermetabolism
Sepsis
Blisters and edema
D. Blisters and edema. The question was asking
for a SYSTEMIC clinical manifestation,
Letters A,B and C are systemic manifestations
while Blisters and Edema weren’t.
28. When assessing a family for potential child
abuse risks, the nurse would observe for which of
the following?
Periodic exposure to stress
Low socio-economic status
High level of self esteem
Problematic pregnancies
D. Problematic pregnancies. Typical factors that
may be risk for Child abuse are problematic
pregnancies, chronic exposure to stress not
periodic, low level of self esteem not high level.
Also child abuse can happen in all socio-
economic status not just on low socio-
economic status
29. Which of the following is a possible indicator of
Munchausen syndrome by proxy type of child abuse?
Bruises found at odd locations, with different
stages of healing
STD’s and genital discharges
Unexplained symptoms of diarrhea, vomiting
and apnea with no organic basis
Constant hunger and poor hygiene
C. Unexplained symptoms of diarrhea, vomiting
and apnea with no organic basis. Munchausen
syndrome by Proxy is the fabrication or
inducement of an illness by one person to
another person, usually mother to child. It is
characterized by symptoms such as apnea and
siezures, which may be due to suffocation,
drugs or poisoning, vomiting which can be
induced with poisons and diarrhea with the use
of laxatives. Letter A can be seen in a Physical
abuse, Letter B for sexual abuse and Letter C is
for Physical Neglect.
30. Which of the following is an inappropriate
interventions when caring for a child with HIV?
Teaching family about disease transmission
Offering large amount of fresh fruits and
vegetables
Encouraging child to perform at optimal level
Teach proper hand washing technique
B. Offering large amount of fresh fruits and
vegetables. A child with HIV is
immunocompromised. Fresh fruits and
vegetables, which may be contaminated with
organisms and pesticides can be harmful, if not
fatal to the child, therefore these items should
be avoided.
Situation 5 Agata, 2 years old is rushed to
the ER due to cyanosis precipitated by
crying. Her mother observed that after
playing she gets tired. She was diagnosed
with Tetralogy of Fallot.
31. The goal of nursing care fro Agata is to:
Prevent infection
Promote normal growth and development
Decrease hypoxic spells
Hydrate adequately
C. Decrease hypoxic spells. The correct answer is
letter C. Though letter B would be a good
answer too, this goal is too vague and not
specific. Nursing interventions will not solely
promote normal G&D unless he will undergo
surgical repair. So decreasing Hypoxic Spells
is more SMART. Letter A and D are
inappropriate.
32. The immediate nursing intervention for cyanosis
of Agata is:
Call up the pediatrician
Place her in knee chest position
Administer oxygen inhalation
Transfer her to the PICU
B. Place her in knee chest position. The immediate
intervention would be to place her on knee-
chest or “squatting” position because it traps
blood into the lower extremities. Though also
letter C would be a good choice but the
question is asking for “Immediate” so letter B
is more appropriate. Letter A and D are
incorrect because its normal for a child who
have ToF to have hypoxic or “tets” spells so
there is no need to transfer her to the NICU or
to alert the Pediatrician.
33. Agata was scheduled for a palliative surgery,
which creates anastomosis of the subclavian artery
to the pulmonary artery. This procedure is:
Waterston-Cooley
Raskkind Procedure
Coronary artery bypass
Blalock-Taussig
D. Blalock-Taussig. Blalock-Taussig procedure its
just a temporary or palliative surgery which
creates a shunt between the aorta and
pulmonary artery so that the blood can leave
the aorta and enter the pulmonary artery and
thus oxygenating the lungs and return to the
left side of the heart, then to the aorta then to
the body. This procedure also makes use of the
subclavian vein so pulse is not palpable at the
right arm. The full repair for ToF is called the
Brock procedure. Raskkind is a palliative
surgery for TOGA.
34. Which of the following is not an indicator that
Agata experiences separation anxiety brought about
her hospitalization?
Friendly with the nurse
Prolonged loud crying, consoled only by mother
Occasional temper tantrums and always says NO
Repeatedly verbalizes desire to go home
A. Friendly with the nurse. Because toddlers views
hospitalization is abandonment, separation
anxiety is common. Its has 3 phases: PDD
(parang c puff daddy LOL) 1. Protest 2. despair
3. detachment (or denial). Choices B, C, D are
usually seen in a child with separation anxiety
(usually in the protest stage).
REVIEW:
Separation anxiety begin at: 9 months
Peaks: 18 months
35. When Agata was brought to the OR, her parents
where crying. What would be the most appropriate
nursing diagnosis?
Infective family coping r/t situational crisis
Anxiety r/t powerlessness
Fear r/t uncertain prognosis
Anticipatory grieving r/t gravity of child’s
physical status
D. Anticipatory grieving r/t gravity of child’s
physical status. In this item letter A and be are
inappropriate response so remove them. The
possible answers are C and D. Fear defined as
the perceived threat (real or imagined) that is
consciously recognized as danger (NANDA) is
applicable in the situation but its defining
characteristics are not applicable. Crying per se
can not be a subjective cue to signify fear, and
most of the symptoms of fear in NANDA are
physiological. Anticipatory grieving on the
other hand are intellectual and EMOTIONAL
responses based on a potential loss. And
remember that procedures like this cannot
assure total recovery. So letter D is a more
appropriate Nursing diagnosis
36. Which of the following respiratory condition is
always considered a medical emergency?
Laryngeotracheobronchitis (LTB)
Epiglottitis
Asthma
Cystic Fibrosis
B. Epiglottitis. Acute and sever inflammation of
the epiglottis can cause life threatening airway
obstruction, that is why its always treated as a
medical emergency. NSG intervention :
Prepare tracheostomy set at bed side. LTB, can
also cause airway obstruction but its not an
emergency. Asthma is also not an emergency.
CF is a chronic disease, so its not a medical
emergency
37. Which of the following statements by the family
of a child with asthma indicates a need for
additional teaching?
“We need to identify what things triggers his
attacks”
“He is to use bronchodilator inhaler before steroid
inhaler”
“We’ll make sure he avoids exercise to prevent
asthma attacks”
“he should increase his fluid intake regularly to
thin secretions”
C. “We’ll make sure he avoids exercise to prevent
asthma attacks”. Asthmatic children don’t have
to avoid exercise. They can participate on
physical activities as tolerated. Using a
 bronchodilator before administering steroids is Target setting
correct because steroids are just anti-
inflammatory and they don’t have effects on 42. What does herd immunity means?
the dilation
of the bronchioles. OF course letters A and B are Interruption of transmission
obviously correct. All to be vaccinated
Selected group for vaccination
38. Which of the following would require careful Shorter incubation\
monitoring in the child with ADHD who is
receiving Methylphenidate (Ritalin)? 43. Measles vaccine can be given simultaneously.
What is the combined vaccine to be given to
Dental health children starting at 15 months?
Mouth dryness
Height and weight MCG
Excessive appetite MMR
BCG
C. Height and weight. Dental problems are more BBR
likely to occur in children under going TCA
therapy. Mouth dryness is a expected side B. MMR. MMR or Measles, Mumps, Rubella is a
effects of Ritalin since it activates the SNS. vaccine furnished in one vial and is routinely
Also loss of appetite is more likely to happen, given in one injection (Sub-Q). It can be given
not increase in appetite. The correct answer is at 15 months but can also be given as early as
letter C, because Ritalin can affect the child’s 12th month.
G&D. Intervention: medication “holidays or
vacation”. (This means during weekends or Situation 7: Braguda brought her 5-
holidays or school vacations, where the child
wont be in school, the drug can be withheld.)
month old daughter in the nearest RHU
because her baby sleeps most of the time,
Situation 6 Laura is assigned as the Team with decreased appetite, has colds and
Leader during the immunization day at fever for more than a week. The physician
the RHU diagnosed pneumonia.
39. What program for the DOH is launched at 1976 44. Based on this data given by Braguda, you can
in cooperation with WHO and UNICEF to reduce classify Braguda’s daughter to have:
morbidity and mortality among infants caused by
immunizable disease? Pneumonia: cough and colds
Severe pneumonia
Patak day Very severe pneumonia
Immunization day on Wednesday Pneumonia moderate
Expanded program on immunization
Bakuna ng kabtaan B. Severe pneumonia. For a child aging 2months
up to 5 years old can be classified to have sever
C. Expanded program on immunization pneumonia when he have any of the following
danger signs:
40. One important principle of the immunization Not able to drink
program is based on? Convulsions
Abnormally sleepy or difficult to wake
Statistical occurrence Stridor in calm child or
Epidemiologic situation Severe under-nutrition
Cold chain management
Surveillance study 45. For a 3-month old child to be classified to have
Pneumonia (not severe), you would expect to find
B. Epidemiologic situation. Letters A, C and D are RR of:
not included in the principles of EPI.
60 bpm
41. The main element of immunization program is 40 bpm
one of the following? 70 bpm
50 pbm
Information, education and communication
Assessment and evaluation of the program D. 50 pbm. A child can be classified to have
Research studies Pneumonia (not severe) if:
 the young infant is less than 2 months- 60
bpm or more
if the child is 2 months up to less than 12
months- 50 bpm or more
if the child is 12 months to 4 y/o- 40 bpm or
more
46. You asked Braguda if her baby received all
vaccines under EPI. What legal basis is used in
implementing the UN’s goal on Universal Child
Immunization?
PD no. 996
PD no. 6
PD no. 46
RA 9173
B. PD no. 6 Presidential Proclamation no. 6 (April
3, 1986) is the “Implementing a United Nations
goal on Universal Child Immunization by
1990”. PD 996 (September 16, 1976) is
“providing for compulsory basic immunization
for infants and children below 8 years of age.
PD no. 46 (September 16, 1992) is the
“Reaffirming the commitment of the
Philippines to the universal Child and Mother
goal of the World Health Assembly. RA 9173
is of course the “Nursing act of 2002”
47. Braguda asks you about Vitamin A
supplementation. You responded that giving
Vitamin A starts when the infant reaches 6 months
and the first dose is”
200,000 “IU”
100,000 “IU”
500,000 “IU”
10,000 “IU”
B. 100,000 “IU”. An infant aging 6-11 months will
be given Vitamin supplementation of 100, 000
IU and for Preschoolers ages 12-83 months
200,000 “IU” will be given.
48. As part of CARI program, assessment of the
child is your main responsibility. You could ask the
following question to the mother except:
“How old is the child?”
“IS the child coughing? For how long?”
“Did the child have chest indrawing?”
“Did the child have fever? For how long?”
C. “Did the child have chest indrawing?”. The
CARI program of the DOH includes the “ASK”
and “LOOK, LISTEN” as part of the
assessment of the child who has suspected
Pneumonia. Choices A, B and D are included
in the “ASK” assessment while Chest
indrawings is included in the “LOOK, LISTEN”
and should not be asked to the mother.
49. A newborn’s failure to pass meconium within
24 hours after birth may indicate which of the
following?
Aganglionic Mega colon
Celiac disease
Intussusception
Abdominal wall defect
A. Aganglionic Mega colon. Failure to pass
meconium of Newborn during the first 24
hours of life may indicate Hirschsprung disease
or Congenital Aganglionic Megacolon, an
anomaly resulting in mechanical obstruction
due to inadequate motility in an intestinal
segment. B, C, and D are not associated in the
failure to pass meconium of the newborn
50. The nurse understands that a good snack for a 2
year old with a diagnosis of acute asthma would be:
Grapes
Apple slices
A glass of milk
A glass of cola
B. Apple slices. Grapes is in appropriate because
of its “balat” that can cause choking. A glass of
milk is not a good snack because it’s the most
common cause of Iron-deficiency anemia in
children (milk contains few iron), A glass of
cola is also not appropriate cause it contains
complex sugar. (walang kinalaman ang asthma
dahil ala naman itong diatery restricted foods
na nasa choices.)
51. Which of the following immunizations would
the nurse expect to administer to a child who is HIV
(+) and severely immunocomromised?
Varicella
Rotavirus
MMR
IPV
D. IPV. IPV or Inactivated polio vaccine does not
contain live micro organisms which can be
harmful to an immunocompromised child.
Unlike OPV, IPV is administered via IM route.
52. When assessing a newborn for developmental
dysplasia of the hip, the nurse would expect to
assess which of the following?
Symmetrical gluteal folds
Trendelemburg sign
Ortolani’s sign
Characteristic limp
C. Ortolani’s sign. Correct answer is Ortolani’s
sign; it is the abnormal clicking sound when
the hips are abducted. The sound is produced
when the femoral head enters the acetabulum.
 Letter A is wrong because its should be
“asymmetrical gluteal fold”. Letter B and C are
not applicable for newborns because they are
seen in older children.
53. While assessing a male neonate whose mother
desires him to be circumcised, the nurse observes
that the neonate’s urinary meatus appears to be
located on the ventral surface of the penis. The
physician is notified because the nurse would
suspect which of the following?
Phimosis
Hydrocele
Epispadias
Hypospadias
D. Hypospadias. Hypospadias is a c condition in
which the urethral opening is located below the
glans penis or anywhere along the ventral
surface of the penile shaft. Epispadias, the
urethral meatus is located at the dorsal surface
of the penile shaft. (Para di ka malilto, I-
alphabetesize mo Dorsal, (Above) eh mauuna
sa Ventral (Below) , Epis mauuna sa Hypo.)
54. When teaching a group of parents about seat
belt use, when would the nurse state that the child
be safely restrained in a regular automobile seatbelt?
30 lb and 30 in
35 lb and 3 y/o
40 lb and 40 in
60 lb and 6 y/o
C. 40 lb and 40 in. Basta tandaan ang rule of 4! 4
years old, 40 lbs and 40 in.
55. When assessing a newborn with cleft lip, the
nurse would be alert which of the following will
most likely be compromised?
Sucking ability
Respiratory status
Locomotion
GI function
A. Sucking ability. Because of the defect, the child
will be unable to form the mouth adequately
arounf the nipple thereby requiring special
devices to allow feeding and sucking
gratification. Respiratory status may be
compromised when the child is fed improperly
or during post op period
56. For a child with recurring nephritic syndrome,
which of the following areas of potential
disturbances should be a prime consideration when
planning ongoing nursing care?
Muscle coordination
Sexual maturation
Intellectual development
Body image
D. Body image. Because of edema, associated with
nephroitic syndrome, potential self concept and
body image disturbance related to changes in
appearance and social isolation should be
considered.
57. An inborn error of metabolism that causes
premature destruction of RBC?
G6PD
Hemocystinuria
Phenylketonuria
Celiac Disease
A. G6PD. G6PD is the premature destruction of
RBC when the blood is exposed to antioxidants,
ASA (ano un? Aspirin), legumes and flava
beans.
58. Which of the following would be a diagnostic
test for Phenylketonuria which uses fresh urine
mixed with ferric chloride?
Guthrie Test
Phenestix test
Beutler’s test
Coomb’s test
B. Phenestix test. Phenestix test is a diagnostic test
which uses a fresh urine sample (diapers) and
mixed with ferric chloride. If positive, there
will be a presence of green spots at the diapers.
Guthrie test is another test for PKU and is the
one that mostly used. The specimen used is the
blood and it tests if CHON is converted to
amino acid.
59. Dietary restriction in a child who has
Hemocystenuria will include which of the following
amino acid?
Lysine
Methionine
Isolensine tryptophase
Valine
B. Methionine. Hemocystenuria is the elevated
excretion of the amino acid hemocystiene, and
there is inability to convert the amino acid
methionine or cystiene. So dietary restriction of
this amino acids is advised. This disease can
lead to mental retardation.
60. A milk formula that you can suggest for a child
with Galactosemia:
Lofenalac
Lactum
Neutramigen
Sustagen
C. Neutramigen. Neutramien is suggested for a
child with Galactosemia. Lofenalac is
suggested for a child with PKU.
PNLE Community
Health Nursing Exam
1 industrial
1. Which is the primary goal of community health
nursing?
A. To support and supplement the efforts of the
medical profession in the promotion of health
and prevention of illness
B. To enhance the capacity of individuals,
families and communities to cope with their
health needs
C. To increase the productivity of the people by
providing them with services that will increase
their level of health
D. To contribute to national development through
promotion of family welfare, focusing
particularly on mothers and children.
Answer: (B) To enhance the capacity of
individuals, families and communities to cope
with their health needs
2. CHN is a community-based practice. Which best
explains this statement?
A. The service is provided in the natural
environment of people.
B. The nurse has to conduct community
diagnosis to determine nursing needs and
problems.
C. The services are based on the available
resources within the community.
D. Priority setting is based on the magnitude of
the health problems identified.
Answer: (B) The nurse has to conduct
community diagnosis to determine nursing
needs and problems
3. Population-focused nursing practice requires
which of the following processes?
A. Community organizing
B. Nursing process
C. Community diagnosis
D. Epidemiologic process
Answer: (C) Community diagnosis. Population-
focused nursing care means providing care based on
the greater need of the majority of the population.
The greater need is identified through community
diagnosis.
4. R.A. 1054 is also known as the Occupational
Health Act. Aside from number of employees, what
other factor must be considered in determining the
occupational health privileges to which the workers
will be entitled?
A. Type of occupation: agricultural, commercial,
B. Location of the workplace in relation to
health facilities
C. Classification of the business enterprise based
on net profit
D. Sex and age composition of employees
Answer: (B) Location of the workplace in
relation to health facilities. Based on R.A.
1054, an occupational nurse must be employed
when there are 30 to 100 employees and the
workplace is more than 1 km. away from the
nearest health center
5. A business firm must employ an occupational
health nurse when it has at least how many
employees?
A. 21
B. 101
C. 201
D. 301
Answer: (B) 101. Again, this is based on R.A.
1054
6. When the occupational health nurse employs
ergonomic principles, she is performing which of
her roles?
A. Health care provider
B. Health educator
C. Health care coordinator
D. Environmental manager
Answer: (D) Environmental
manager. Ergonomics is improving efficiency of
workers by improving the worker’s environment
through appropriately designed furniture, for
example
7. A garment factory does not have an occupational
nurse. Who shall provide the occupational health
needs of the factory workers?
A. Occupational health nurse at the Provincial
Health Office
B. Physician employed by the factory
C. Public health nurse of the RHU of their
municipality
D. Rural sanitary inspector of the RHU of their
municipality
 Answer: (C) Public health nurse of the RHU of
their municipality. You’re right! This question is
based on R.A.1054
8. “Public health services are given free of charge.”
Is this statement true or false?
A. The statement is true; it is the responsibility of
government to provide basic services.
B. The statement is false; people pay indirectly
for public health services.
C. The statement may be true or false, depending
on the specific service required.
D. The statement may be true or false, depending
on policies of the government concerned.
Answer: (B) The statement is false; people pay
indirectly for public health services. Community
health services, including public health services, are
pre-paid services, though taxation, for example.
9. According to C.E.Winslow, which of the
following is the goal of Public Health?
A. For people to attain their birthrights of
health and longevity
B. For promotion of health and prevention of
disease
C. For people to have access to basic health
services
D. For people to be organized in their health
efforts
Answer: (A) For people to attain their
birthrights of health and longevity. According to
Winslow, all public health efforts are for people to
realize their birthrights of health and longevity
10. We say that a Filipino has attained longevity
when he is able to reach the average lifespan of
Filipinos. What other statistic may be used to
determine attainment of longevity?
A. Age-specific mortality rate
B. Proportionate mortality rate
C. Swaroop’s index
D. Case fatality rate
Answer: (C) Swaroop’s index. Swaroop’s index is
the percentage of the deaths aged 50 years or older.
Its inverse represents the percentage of untimely
deaths (those who died younger than 50 years
11. 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 catchment 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.
Answer: (D) Public health nursing focuses on
preventive, not curative, services.The catchment
area in PHN consists of a residential community,
many of whom are well individuals who have
greater need for preventive rather than curative
services.
12. According to Margaret Shetland, the philosophy
of public health nursing is based on which of the
following?
A. Health and longevity as birthrights
B. The mandate of the state to protect the
birthrights of its citizens
C. Public health nursing as a specialized field of
nursing
D. The worth and dignity of man
Answer: (D) The worth and dignity of man. This
is a direct quote from Dr. Margaret Shetland’s
statements on Public Health Nursing
13. Which of the following is the mission of the
Department of Health?
A. Health for all Filipinos
B. Ensure the accessibility and quality of
health care
C. Improve the general health status of the
population
D. Health in the hands of the Filipino people by
the year 2020
Answer: (B) Ensure the accessibility and quality
of health care
14. Region IV Hospital is classified as what level of
facility?
A. Primary
B. Secondary
C. Intermediate
D. Tertiary
Answer: (D) Tertiary. Regional hospitals are
tertiary facilities because they serve as training
hospitals for the region.
15. Which is true of primary facilities?
A. They are usually government-run.
B. Their services are provided on an out-
patient basis.
C. They are training facilities for health
professionals.
D. A community hospital is an example of this
level of health facilities.
 Answer: (B) Their services are provided on an Answer: (C) To empower the people and
out-patient basis. Primary facilities government promote their self-reliance. People
and non-government facilities that provide basic empowerment is the basic motivation behind
out-patient services devolution of basic services to LGU’s.

16. Which is an example of the school nurse’s 20. Who is the Chairman of the Municipal Health
health care provider functions? Board?

A. Requesting for BCG from the RHU for school A. Mayor

entrant immunization B. Municipal Health Officer
B. Conducting random classroom inspection C. Public Health Nurse
during a measles epidemic D. Any qualified physician
C. Taking remedial action on an accident hazard
in the school playground Answer: (A) Mayor. The local executive serves as
D. Observing places in the school where pupils the chairman of the Municipal Health Board.
spend their free time
21. Which level of health facility is the usual point
Answer: (B) Conducting random classroom of entry of a client into the health care delivery
inspection during a measles epidemic. Random system?
classroom inspection is assessment of
pupils/students and teachers for signs of a health A. Primary
problem prevalent in the community B. Secondary
C. Intermediate
17. When the nurse determines whether resources D. Tertiary
were maximized in implementing Ligtas Tigdas,
she is evaluating Answer: (A) Primary. The entry of a person into
the health care delivery system is usually through a
A. Effectiveness consultation in out-patient services.
B. Efficiency
C. Adequacy 22. The public health nurse is the supervisor of rural
D. Appropriateness health midwives. Which of the following is a
supervisory function of the public health nurse?
Answer: (B) Efficiency. Efficiency is determining
whether the goals were attained at the least possible A. Referring cases or patients to the midwife
cost. B. Providing technical guidance to the midwife
C. Providing nursing care to cases referred by the
18. You are a new B.S.N. graduate. You want to midwife
become a Public Health Nurse. Where will you D. Formulating and implementing training
apply? programs for midwives

A. Department of Health Answer: (B) Providing technical guidance to the

B. Provincial Health Office midwife. The nurse provides technical guidance to
C. Regional Health Office the midwife in the care of clients, particularly in the
D. Rural Health Unit implementation of management guidelines, as in
Integrated Management of Childhood Illness.
Answer: (D) Rural Health Unit. R.A. 7160
devolved basic health services to local government 23. One of the participants in a hilot training class
units (LGU’s ). The public health nurse is an asked you to whom she should refer a patient in
employee of the LGU. labor who develops a complication. You will
answer, to the
19. R.A. 7160 mandates devolution of basic
services from the national government to local A. Public Health Nurse
government units. Which of the following is the B. Rural Health Midwife
major goal of devolution? C. Municipal Health Officer
D. Any of these health professionals
A. To strengthen local government units
B. To allow greater autonomy to local Answer: (C) Municipal Health Officer. A public
government units health nurse and rural health midwife can provide
C. To empower the people and promote their care during normal childbirth. A physician should
self-reliance attend to a woman with a complication during labor.
D. To make basic services more accessible to the
people
24. You are the public health nurse in a health nurse develops the health capability of
municipality with a total population of about 20,000. people through health education and community
There are 3 rural health midwives among the RHU organizing activities
personnel. How many more midwife items will the
RHU need? 28. Which disease was declared through
Presidential Proclamation No. 4 as a target for
A. 1 eradication in the Philippines?
B. 2
C. 3 A. Poliomyelitis
D. The RHU does not need any more midwife B. Measles
item. C. Rabies
D. Neonatal tetanus
Answer: (A) 1. Each rural health midwife is given a
population assignment of about 5,000. Answer: (B) Measles. Presidential Proclamation No.
4 is on the Ligtas Tigdas Program.
25. If the RHU needs additional midwife items, you
will submit the request for additional midwife items 29. The public health nurse is responsible for
for approval to the presenting the municipal health statistics using
graphs and tables. To compare the frequency of the
A. Rural Health Unit leading causes of mortality in the municipality,
B. District Health Office which graph will you prepare?
C. Provincial Health Office
D. Municipal Health Board A. Line
B. Bar
Answer: (D) Municipal Health Board. As C. Pie
mandated by R.A. 7160, basic health services have D. Scatter diagram
been devolved from the national government to
local government units Answer: (B) Bar. A bar graph is used to present
comparison of values, a line graph for trends over
26. As an epidemiologist, the nurse is responsible time or age, a pie graph for population composition
for reporting cases of notifiable diseases. What law or distribution, and a scatter diagram for correlation
mandates reporting of cases of notifiable diseases? of two variables.

A. Act 3573 30. Which step in community organizing involves

B. R.A. 3753 training of potential leaders in the community?
C. R.A. 1054
D. R.A. 1082 A. Integration
B. Community organization
Answer: (A) Act 3573. Act 3573, the Law on C. Community study
Reporting of Communicable Diseases, enacted in D. Core group formation
1929, mandated the reporting of diseases listed in
the law to the nearest health station Answer: (D) Core group formation. In core group
formation, the nurse is able to transfer the
27. According to Freeman and Heinrich, community technology of community organizing to the
health nursing is a developmental service. Which of potential or informal community leaders through a
the following best illustrates this statement? training program.

A. The community health nurse continuously

develops himself personally and professionally.
PNLE Community
B. Health education and community organizing
are necessary in providing community
health services.
Health Nursing Exam
C. Community health nursing is intended
primarily for health promotion and prevention
and treatment of disease.
2
D. The goal of community health nursing is to 1. In which step are plans formulated for solving
provide nursing services to people in their own community problems?
places of residence.
A. Mobilization
Answer: (B) Health education and community B. Community organization
organizing are necessary in providing C. Follow-up/extension
community health services. The community D. Core group formation
 the terminally ill (those in the terminal stage of a
Answer: (B) Community disease)
organization. Community organization is the step
when community assemblies take place. During 5. Isolation of a child with measles belongs to what
the community assembly, the people may opt to level of prevention?
formalize the community organization and make
plans for community action to resolve a A. Primary
community health problem. B. Secondary
C. Intermediate
2. The public health nurse takes an active role in D. Tertiary
community participation. What is the primary goal
of community organizing? Answer: (A) Primary. The purpose of isolating a
client with a communicable disease is to protect
A. To educate the people regarding community those who are not sick (specific disease
health problems prevention).
B. To mobilize the people to resolve community
health problems 6. On the other hand, Operation Timbang is _____
C. To maximize the community’s resources in prevention.
dealing with health problems
D. To maximize the community’s resources in A. Primary
dealing with health problems B. Secondary
C. Intermediate
Answer: (D) To maximize the community’s D. Tertiary
resources in dealing with health
problems. Community organizing is a Answer: (B) Secondary. Operation Timbang is
developmental service, with the goal of developing done to identify members of the susceptible
the people’s self-reliance in dealing with population who are malnourished. Its purpose is
community health problems. A, B and C are early diagnosis and, subsequently, prompt
objectives of contributory objectives to this goal. treatment.

3. An indicator of success in community organizing 7. Which type of family-nurse contact will provide
is when people are able to you with the best opportunity to observe family
dynamics?
A. Participate in community activities for the
solution of a community problem A. Clinic consultation
B. Implement activities for the solution of the B. Group conference
community problem C. Home visit
C. Plan activities for the solution of the D. Written communication
community problem
D. Identify the health problem as a common Answer: (C) Home visit. Dynamics of family
concern relationships can best be observed in the family’s
natural environment, which is the home.
Answer: (A) Participate in community
activities for the solution of a community 8. The typology of family nursing problems is used
problem. Participation in community activities in the statement of nursing diagnosis in the care of
in resolving a community problem may be in families. The youngest child of the de los Reyes
any of the processes mentioned in the other family has been diagnosed as mentally retarded.
choices This is classified as a:

A. Health threat
4. Tertiary prevention is needed in which stage of B. Health deficit
the natural history of disease? C. Foreseeable crisis
D. Stress point
A. Pre-pathogenesis
B. Pathogenesis Answer: (B) Health deficit. Failure of a family
C. Prodromal member to develop according to what is expected,
D. Terminal as in mental retardation, is a health deficit.

Answer: (D) Terminal. Tertiary prevention 9. The de los Reyes couple have a 6-year old child
involves rehabilitation, prevention of permanent entering school for the first time. The de los Reyes
disability and disability limitation appropriate for family has a:
convalescents, the disabled, complicated cases and
 A. Health threat
B. Health deficit
C. Foreseeable crisis
D. Stress point
Answer: (C) Foreseeable crisis. Entry of the 6-
year old into school is an anticipated period of
unusual demand on the family.
10. Which of the following is an advantage of a
home visit?
A. It allows the nurse to provide nursing care to a
greater number of people.
B. It provides an opportunity to do first hand
appraisal of the home situation.
C. It allows sharing of experiences among people
with similar health problems.
D. It develops the family’s initiative in providing
for health needs of its members.
Answer: (B) It provides an opportunity to do
first hand appraisal of the home
situation.. Choice A is not correct since a home
visit requires that the nurse spend so much time
with the family. Choice C is an advantage of a
group conference, while choice D is true of a clinic
consultation.
11. Which is CONTRARY to the principles in
planning a home visit?
A. A home visit should have a purpose or
objective.
B. The plan should revolve around family health
needs.
C. A home visit should be conducted in the
manner prescribed by the RHU.
D. Planning of continuing care should involve a
responsible family member.
Answer: (C) A home visit should be conducted
in the manner prescribed by the RHU.The home
visit plan should be flexible and practical,
depending on factors, such as the family’s needs
and the resources available to the nurse and the
family.
12. The PHN bag is an important tool in providing
nursing care during a home visit. The most
important principle of bag technique states that it
A. Should save time and effort.
B. Should minimize if not totally prevent the
spread of infection.
C. Should not overshadow concern for the patient
and his family.
D. May be done in a variety of ways depending on
the home situation, etc.
Answer: (B) Should minimize if not totally
prevent the spread of infection. Bag technique is
performed before and after handling a client in the
home to prevent transmission of infection to and
from the client.
13. To maintain the cleanliness of the bag and its
contents, which of the following must the nurse do?
A. Wash his/her hands before and after
providing nursing care to the family
members.
B. In the care of family members, as much as
possible, use only articles taken from the bag.
C. Put on an apron to protect her uniform and fold
it with the right side out before putting it back
into the bag.
D. At the end of the visit, fold the lining on which
the bag was placed, ensuring that the
contaminated side is on the outside.
Answer: (A) Wash his/her hands before and
after providing nursing care to the family
members. Choice B goes against the idea of
utilizing the family’s resources, which is
encouraged in CHN. Choices C and D goes against
the principle of asepsis of confining the
contaminated surface of objects.
14. The public health nurse conducts a study on the
factors contributing to the high mortality rate due to
heart disease in the municipality where she works.
Which branch of epidemiology does the nurse
practice in this situation?
A. Descriptive
B. Analytical
C. Therapeutic
D. Evaluation
Answer: (B) Analytical. Analytical epidemiology
is the study of factors or determinants affecting the
patterns of occurrence and distribution of disease
in a community.
15. Which of the following is a function of
epidemiology?
A. Identifying the disease condition based on
manifestations presented by a client
B. Determining factors that contributed to the
occurrence of pneumonia in a 3 year old
C. Determining the efficacy of the antibiotic used
in the treatment of the 3 year old client with
pneumonia
D. Evaluating the effectiveness of the
implementation of the Integrated
Management of Childhood Illness
Answer: (D) Evaluating the effectiveness of the
implementation of the Integrated Management
of Childhood Illness. Epidemiology is used in the
assessment of a community or evaluation of
interventions in community health practice.

16. Which of the following is an epidemiologic
function of the nurse during an epidemic?
A. Conducting assessment of suspected cases to
detect the communicable disease
B. Monitoring the condition of the cases affected
by the communicable disease
C. Participating in the investigation to
determine the source of the epidemic
D. Teaching the community on preventive
measures against the disease
Answer: (C) Participating in the investigation to
determine the source of the
epidemic. Epidemiology is the study of patterns of
occurrence and distribution of disease in the
community, as well as the factors that affect
disease patterns. The purpose of an epidemiologic
investigation is to identify the source of an
epidemic, i.e., what brought about the epidemic.
17. The primary purpose of conducting an
epidemiologic investigation is to
A. Delineate the etiology of the epidemic
B. Encourage cooperation and support of the
community
C. Identify groups who are at risk of contracting
the disease
D. Identify geographical location of cases of the
disease in the community
Answer: (A) Delineate the etiology of the
epidemic. Delineating the etiology of an epidemic
is identifying its source.
18. Which is a characteristic of person-to-person
propagated epidemics?
A. There are more cases of the disease than
expected.
B. The disease must necessarily be transmitted
through a vector.
C. The spread of the disease can be attributed to a
common vehicle.
D. There is a gradual build up of cases before
the epidemic becomes easily noticeable.
Answer: (D) There is a gradual build up of
cases before the epidemic becomes easily
noticeable. A gradual or insidious onset of the
epidemic is usually observable in person-to-person
propagated epidemics.
19. In the investigation of an epidemic, you
compare the present frequency of the disease with
the usual frequency at this time of the year in this
community. This is done during which stage of the
investigation?
A. Establishing the epidemic
B. Testing the hypothesis
C. Formulation of the hypothesis
D. Appraisal of facts
Answer: (A) Establishing the
epidemic. Establishing the epidemic is
determining whether there is an epidemic or not.
This is done by comparing the present number of
cases with the usual number of cases of the disease
at the same time of the year, as well as establishing
the relatedness of the cases of the disease.
20. The number of cases of Dengue fever usually
increases towards the end of the rainy season. This
pattern of occurrence of Dengue fever is best
described as
A. Epidemic occurrence
B. Cyclical variation
C. Sporadic occurrence
D. Secular variation
Answer: (B) Cyclical variation. A cyclical
variation is a periodic fluctuation in the number of
cases of a disease in the community.
21. In the year 1980, the World Health Organization
declared the Philippines, together with some other
countries in the Western Pacific Region, “free” of
which disease?
A. Pneumonic plague
B. Poliomyelitis
C. Small pox
D. Anthrax
Answer: (C) Small pox. The last documented case
of Small pox was in 1977 at Somalia.
22. In the census of the Philippines in 1995, there
were about 35,299,000 males and about 34,968,000
females. What is the sex ratio?
A. 99.06:100
B. 100.94:100
C. 50.23%
D. 49.76%
Answer: (B) 100.94:100. Sex ratio is the number
of males for every 100 females in the population
23. Primary health care is a total approach to
community development. Which of the following is
an indicator of success in the use of the primary
health care approach?
A. Health services are provided free of charge to
individuals and families.
B. Local officials are empowered as the major
decision makers in matters of health.
C. Health workers are able to provide care based
on identified health needs of the people.
 D. Health programs are sustained according to C. Presidential Decree No. 147
the level of development of the community. D. Presidential Decree 996

Answer: (D) Health programs are sustained
according to the level of development of the
community. Primary health care is essential
health care that can be sustained in all stages of
development of the community.
24. Sputum examination is the major screening tool
for pulmonary tuberculosis. Clients would
sometimes get false negative results in this exam.
This means that the test is not perfect in terms of
which characteristic of a diagnostic examination?
A. Effectiveness
B. Efficacy
C. Specificity
D. Sensitivity
Answer: (D) Sensitivity. Sensitivity is the capacity
of a diagnostic examination to detect cases of the
disease. If a test is 100% sensitive, all the cases
tested will have a positive result, i.e., there will be
no false negative results.
25. Use of appropriate technology requires
knowledge of indigenous technology. Which
medicinal herb is given for fever, headache and
cough?
A. Sambong
B. Tsaang gubat
C. Akapulko
D. Lagundi
Answer: (D) Lagundi. Sambong is used as a
diuretic. Tsaang gubat is used to relieve diarrhea.
Akapulko is used for its antifungal property
26. What law created the Philippine Institute of
Traditional and Alternative Health Care?
Answer: (B) Letter of Instruction No. 949. Letter
of Instruction 949 was issued by then President
Ferdinand Marcos, directing the formerly called
Ministry of Health, now the Department of Health,
to utilize Primary Health Care approach in
planning and implementing health programs
29. Which of the following demonstrates
intersectoral linkages?
A. Two-way referral system
B. Team approach
C. Endorsement done by a midwife to another
midwife
D. Cooperation between the PHN and public
school teacher
Answer: (D) Cooperation between the PHN
and public school teacher. Intersectoral
linkages refer to working relationships between
the health sector and other sectors involved in
community development.
30. The municipality assigned to you has a
population of about 20,000. Estimate the number of
1-4 year old children who will be given Retinol
capsule 200,000 I.U. every 6 months.
A. 1,500
B. 1,800
C. 2,000
D. 2,300
Answer: (D) 2,300. Based on the Philippine
population composition, to estimate the number of
1-4 year old children, multiply total population by
11.5%.

A. R.A. 8423
B. R.A. 4823
C. R.A. 2483
D. R.A. 3482
27. In traditional Chinese medicine, the yielding, PNLE Community
negative and feminine force is termed

A. Yin
Health Nursing Exam
B. Yang
C.
D.
Qi
Chai
3
1. Estimate the number of pregnant women who
Answer: (A) Yin. Yang is the male dominating, will be given tetanus toxoid during an immunization
positive and masculine force. outreach activity in a barangay with a population of
about 1,500.
28. What is the legal basis for Primary Health Care
approach in the Philippines? A. 265
B. 300
A. Alma Ata Declaration on PHC C. 375
B. Letter of Instruction No. 949 D. 400
 6. Which statistic can give the most accurate
Answer: (A) 265. To estimate the number of reflection of the health status of a community?
pregnant women, multiply the total population by
3.5%. A. 1-4 year old age-specific mortality rate
B. Infant mortality rate
2. To describe the sex composition of the C. Swaroop’s index
population, which demographic tool may be used? D. Crude death rate

A. Sex ratio Answer: (C) Swaroop’s index. Swaroop’s

B. Sex proportion index is the proportion of deaths aged 50 years
C. Population pyramid and above. The higher the Swaroop’s index of a
D. Any of these may be used. population, the greater the proportion of the
deaths who were able to reach the age of at least
Answer: (D) Any of these may be used. Sex ratio 50 years, i.e., more people grew old before they
and sex proportion are used to determine the sex died.
composition of a population. A population pyramid
is used to present the composition of a population 7. In the past year, Barangay A had an average
by age and sex. population of 1655. 46 babies were born in that year,
2 of whom died less than 4 weeks after they were
3. Which of the following is a natality rate? born. There were 4 recorded stillbirths. What is the
neonatal mortality rate?
A. Crude birth rate
B. Neonatal mortality rate A. 27.8/1,000
C. Infant mortality rate B. 43.5/1,000
D. General fertility rate C. 86.9/1,000
D. 130.4/1,000
Answer: (A) Crude birth rate. Natality means
birth. A natality rate is a birth rate. Answer: (B) 43.5/1,000. To compute for neonatal
mortality rate, divide the number of babies who
4. You are computing the crude death rate of your died before reaching the age of 28 days by the total
municipality, with a total population of about number of live births, then multiply by 1,000.
18,000, for last year. There were 94 deaths. Among
those who died, 20 died because of diseases of the 8. Which statistic best reflects the nutritional status
heart and 32 were aged 50 years or older. What is of a population?
the crude death rate?
A. 1-4 year old age-specific mortality rate
A. 4.2/1,000 B. Proportionate mortality rate
B. 5.2/1,000 C. Infant mortality rate
C. 6.3/1,000 D. Swaroop’s index
D. 7.3/1,000
Answer: (A) 1-4 year old age-specific mortality
Answer: (B) 5.2/1,000. To compute crude death rate. Since preschoolers are the most susceptible to
rate divide total number of deaths (94) by total the effects of malnutrition, a population with poor
population (18,000) and multiply by 1,000 nutritional status will most likely have a high 1-4
year old age-specific mortality rate, also known as
5. Knowing that malnutrition is a frequent child mortality rate.
community health problem, you decided to conduct
nutritional assessment. What population is 9. What numerator is used in computing general
particularly susceptible to protein energy fertility rate?
malnutrition (PEM)?
A. Estimated midyear population
A. Pregnant women and the elderly B. Number of registered live births
B. Under-5 year old children C. Number of pregnancies in the year
C. 1-4 year old children D. Number of females of reproductive age
D. School age children
Answer: (B) Number of registered live births. To
Answer: (C) 1-4 year old children. Preschoolers compute for general or total fertility rate, divide the
are the most susceptible to PEM because they have number of registered live births by the number of
generally been weaned. Also, this is the population females of reproductive age (15-45 years), then
who, unable to feed themselves, are often the multiply by 1,000.
victims of poor intrafamilial food distribution.
10. You will gather data for nutritional assessment A. P.D. 651
of a purok. You will gather information only from B. Act 3573
families with members who belong to the target C. R.A. 3753
population for PEM. What method of data gathering D. R.A. 3375
is best for this purpose? Answer: (A) P.D. 651. P.D. 651 amended R.A.
3753, requiring the registry of births within 30
A. Census days from their occurrence
B. Survey
C. Record review 15. Which of the following professionals can sign
D. Review of civil registry the birth certificate?

Answer: (B) Survey. A survey, also called sample A. Public health nurse
survey, is data gathering about a sample of the B. Rural health midwife
population C. Municipal health officer
D. Any of these health professionals
11. In the conduct of a census, the method of
population assignment based on the actual physical Answer: (D) Any of these health professionals. D.
location of the people is termed R.A. 3753 states that any birth attendant may sign
the certificate of live birth.
A. De jure
B. De locus 16. Which criterion in priority setting of health
C. De facto problems is used only in community health care?
D. De novo
A. Modifiability of the problem
Answer: (C) De facto. The other method of B. Nature of the problem presented
population assignment, de jure, is based on the C. Magnitude of the health problem
usual place of residence of the people. D. Preventive potential of the health problem

12. The Field Health Services and Information
System (FHSIS) is the recording and reporting
system in public health care in the Philippines. The
Monthly Field Health Service Activity Report is a
form used in which of the components of the FHSIS?
Answer: (C) Magnitude of the health
problem. Magnitude of the problem refers to the
percentage of the population affected by a health
problem. The other choices are criteria considered
in both family and community health care

A. Tally report 17. The Sentrong Sigla Movement has been

B. Output report launched to improve health service delivery. Which
C. Target/client list of the following is/are true of this movement?
D. Individual health record
A. This is a project spearheaded by local
Answer: (A) Tally report. A tally report is government units.
prepared monthly or quarterly by the RHU B. It is a basis for increasing funding from local
personnel and transmitted to the Provincial Health government units.
Office C. It encourages health centers to focus on disease
prevention and control.
13. To monitor clients registered in long-term D. Its main strategy is certification of health
regimens, such as the Multi-Drug Therapy, which centers able to comply with standards.
component will be most useful?
Answer: (D) Its main strategy is certification
A. Tally report of health centers able to comply with
B. Output report standards. Sentrong Sigla Movement is a joint
C. Target/client list project of the DOH and local government units.
D. Individual health record Its main strategy is certification of health
centers that are able to comply with standards
Answer: (C) Target/client list. The MDT Client set by the DOH.
List is a record of clients enrolled in MDT and
other relevant data, such as dates when clients 18. Which of the following women should be
collected their monthly supply of drugs considered as special targets for family planning?

14. Civil registries are important sources of data. A. Those who have two children or more
Which law requires registration of births within 30 B. Those with medical conditions such as anemia
days from the occurrence of the birth? C. Those younger than 20 years and older than 35
years
 D. Those who just had a delivery within the
past 15 months
Answer: (D) Those who just had a delivery
within the past 15 months. The ideal birth
spacing is at least two years. 15 months plus 9
months of pregnancy = 2 years
19. Freedom of choice is one of the policies of the
Family Planning Program of the Philippines. Which
of the following illustrates this principle?
A. Information dissemination about the need for
family planning
B. Support of research and development in family
planning methods
C. Adequate information for couples regarding
the different methods
D. Encouragement of couples to take family
planning as a joint responsibility
Answer: (C) Adequate information forcouples
regarding the different methods. To enable the
couple to choose freely among different methods of
family planning, they must be given full
information regarding the different methods that are
available to them, considering the availability of
quality services that can support their choice.
20. A woman, 6 months pregnant, came to the
center for consultation. Which of the following
substances is contraindicated?
A. Tetanus toxoid
B. Retinol 200,000 IU
C. Ferrous sulfate 200 mg
D. Potassium iodate 200 mg. capsule
Answer: (B) Retinol 200,000 IU. Retinol 200,000
IU is a form of megadose Vitamin A. This may
have a teratogenic effect
21. During prenatal consultation, a client asked you
if she can have her delivery at home. After history
taking and physical examination, you advised her
against a home delivery. Which of the following
findings disqualifies her for a home delivery?
A. Her OB score is G5P3.
B. She has some palmar pallor.
C. Her blood pressure is 130/80.
D. Her baby is in cephalic presentation.
Answer: (A) Her OB score is G5P3. Only women
with less than 5 pregnancies are qualified for a
home delivery. It is also advisable for a
primigravida to have delivery at a childbirth
facility
22. Inadequate intake by the pregnant woman of
which vitamin may cause neural tube defects?
A. Niacin
B. Riboflavin
C. Folic acid
D. Thiamine
Answer: (C) Folic acid. It is estimated that the
incidence of neural tube defects can be reduced
drastically if pregnant women have an adequate
intake of folic acid.
23. You are in a client’s home to attend to a
delivery. Which of the following will you do first?
A. Set up the sterile area.
B. Put on a clean gown or apron.
C. Cleanse the client’s vulva with soap and water.
D. Note the interval, duration and intensity of
labor contractions.
Answer: (D) Note the interval, duration and
intensity of labor contractions.. Assessment
of the woman should be done first to determine
whether she is having true labor and, if so,
what stage of labor she is in.
24. In preparing a primigravida for breastfeeding,
which of the following will you do?
A. Tell her that lactation begins within a day after
delivery.
B. Teach her nipple stretching exercises if her
nipples are everted.
C. Instruct her to wash her nipples before and
after each breastfeeding.
D. Explain to her that putting the baby to breast
will lessen blood loss after delivery.
Answer: (D) Explain to her that putting the baby
to breast will lessen blood loss after
delivery. Suckling of the nipple stimulates the
release of oxytocin by the posterior pituitary gland,
which causes uterine contraction. Lactation begins 1
to 3 days after delivery. Nipple stretching exercises
are done when the nipples are flat or inverted.
Frequent washing dries up the nipples, making them
prone to the formation of fissures.
25. A primigravida is instructed to offer her breast
to the baby for the first time within 30 minutes after
delivery. What is the purpose of offering the breast
this early?
A. To initiate the occurrence of milk letdown
B. To stimulate milk production by the
mammary acini
C. To make sure that the baby is able to get the
colostrum
D. To allow the woman to practice breastfeeding
in the presence of the health worker
Answer: (B) To stimulate milk production by
the mammary acini. Suckling of the nipple
stimulates prolactin reflex (the release of prolactin
 by the anterior pituitary gland), which initiates highly sensitive to heat, requiring storage in the
lactation freezer

26. In a mothers’ class, you discuss proper 30. Unused BCG should be discarded how many
breastfeeding technique. Which is of these is a sign hours after reconstitution?
that the baby has “latched on” to the breast properly?
A. 2
A. The baby takes shallow, rapid sucks. B. 4
B. The mother does not feel nipple pain. C. 6
C. The baby’s mouth is only partly open. D. At the end of the day
D. Only the mother’s nipple is inside the baby’s
mouth. Answer: (B) 4. While the unused portion of
other biologicals in EPI may be given until the
Answer: (B) The mother does not feel nipple end of the day, only BCG is discarded 4 hours
pain.. When the baby has properly latched on to the after reconstitution. This is why BCG
breast, he takes deep, slow sucks; his mouth is wide immunization is scheduled only in the morning.
open; and much of the areola is inside his mouth.
And, you’re right! The mother does not feel nipple
pain.

27. You explain to a breastfeeding mother that

breast milk is sufficient for all of the baby’s nutrient PNLE Community
needs only up to ____.

A. 3 months Health Nursing Exam

B. 6 months
C.
D.
1 year
2 years
4
1. In immunizing school entrants with BCG, you are
Answer: (B) 6 months. After 6 months, the baby’s not obliged to secure parental consent. This is
nutrient needs, especially the baby’s iron because of which legal document?
requirement, can no longer be provided by
mother’s milk alone A. P.D. 996
B. R.A. 7846
28. What is given to a woman within a month after C. Presidential Proclamation No. 6
the delivery of a baby? D. Presidential Proclamation No. 46

A. Malunggay capsule Answer: (A) P.D. 996. Presidential Decree 996,

B. Ferrous sulfate 100 mg. OD enacted in 1976, made immunization in the EPI
C. Retinol 200,000 I.U., 1 capsule compulsory for children under 8 years of age.
D. Potassium iodate 200 mg, 1 capsule Hepatitis B vaccination was made compulsory for
the same age group by R.A. 7846.
Answer: (C) Retinol 200,000 I.U., 1 capsule. A
capsule of Retinol 200,000 IU is given within 1 2. Which immunization produces a permanent scar?
month after delivery. Potassium iodate is given
during pregnancy; malunggay capsule is not A. DPT
routinely administered after delivery; and B. BCG
ferrous sulfate is taken for two months after C. Measles vaccination
delivery. D. Hepatitis B vaccination

29. Which biological used in Expanded Program on Answer: (B) BCG. BCG causes the formation of a
Immunization (EPI) is stored in the freezer? superficial abscess, which begins 2 weeks after
immunization. The abscess heals without treatment,
A. DPT with the formation of a permanent scar
B. Tetanus toxoid
C. Measles vaccine 3. A 4-week old baby was brought to the health
D. Hepatitis B vaccine center for his first immunization. Which can be
given to him?
Answer: (C) Measles vaccine. Among the
biologicals used in the Expanded Program on A. DPT1
Immunization, measles vaccine and OPV are B. OPV1
C. Infant BCG
 D. Hepatitis B vaccine 1
Answer: (C) Infant BCG. Infant BCG may be
given at birth. All the other immunizations
mentioned can be given at 6 weeks of age
4. You will not give DPT 2 if the mother says that
the infant had
A. Seizures a day after DPT 1.
B. Fever for 3 days after DPT 1.
C. Abscess formation after DPT 1.
D. Local tenderness for 3 days after DPT 1.
Answer: (A) Seizures a day after DPT 1. Seizures
within 3 days after administration of DPT is an
indication of hypersensitivity to pertussis vaccine, a
component of DPT. This is considered a specific
contraindication to subsequent doses of DPT.
5. A 2-month old infant was brought to the health
center for immunization. During assessment, the
infant’s temperature registered at 38.1°C. Which is
the best course of action that you will take?
A. Go on with the infant’s immunizations.
B. Give Paracetamol and wait for his fever to
subside.
C. Refer the infant to the physician for further
assessment.
D. Advise the infant’s mother to bring him back
for immunization when he is well.
Answer: (A) Go on with the infant’s
immunizations. In the EPI, fever up to 38.5°C is
not a contraindication to immunization. Mild acute
respiratory tract infection, simple diarrhea and
malnutrition are not contraindications either.
6. A pregnant woman had just received her 4th dose
of tetanus toxoid. Subsequently, her baby will have
protection against tetanus for how long?
A. 1 year
B. 3 years
C. 10 years
D. Lifetime
Answer: (A) 1 year. 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
7. A 4-month old infant was brought to the health
center because of cough. Her respiratory rate is
42/minute. Using the Integrated Management of
Child Illness (IMCI) guidelines of assessment, her
breathing is considered
A. Fast
B. Slow
C. Normal
D. Insignificant
Answer: (C) Normal. In IMCI, a respiratory
rate of 50/minute or more is fast breathing for
an infant aged 2 to 12 months.
8. Which of the following signs will indicate that a
young child is suffering from severe pneumonia?
A. Dyspnea
B. Wheezing
C. Fast breathing
D. Chest indrawing
Answer: (D) Chest indrawing. In IMCI, chest
indrawing is used as the positive sign of dyspnea,
indicating severe pneumonia
9. Using IMCI guidelines, you classify a child as
having severe pneumonia. What is the best
management for the child?
A. Prescribe an antibiotic.
B. Refer him urgently to the hospital.
C. Instruct the mother to increase fluid intake.
D. Instruct the mother to continue breastfeeding.
Answer: (B) Refer him urgently to the
hospital. Severe pneumonia requires urgent referral
to a hospital. Answers A, C and D are done for a
client classified as having pneumonia.
10. A 5-month old infant was brought by his mother
to the health center because of diarrhea occurring 4
to 5 times a day. His skin goes back slowly after a
skin pinch and his 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.
Answer: (B) Some dehydration. 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
11. Based on assessment, you classified a 3-month
old infant with the chief complaint of diarrhea in the
category of SOME DEHYDRATION. Based on
IMCI management guidelines, which of the
following will you do?
A. Bring the infant to the nearest facility where IV
fluids can be given.
B. Supervise the mother in giving 200 to 400 ml.
of Oresol in 4 hours.
 C. Give the infant’s mother instructions on home
management.
D. Keep the infant in your health center for close
observation.
Answer: (B) Supervise the mother in giving 200
to 400 ml. of Oresol in 4 hours. In the IMCI
management guidelines, SOME DEHYDRATION
is treated with the administration of Oresol within a
period of 4 hours. The amount of Oresol is best
computed on the basis of the child’s weight (75
ml/kg body weight). If the weight is unknown, the
amount of Oresol is based on the child’s age.
12. A mother is using Oresol in the management of
diarrhea of her 3-year old child. She asked you what
to do if her child vomits. 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.
Answer: (D) Let the child rest for 10 minutes
then continue giving Oresol more slowly. 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
13. A 1 ½ year old child was classified as having
3rd degree protein energy malnutrition, kwashiorkor.
Which of the following signs will be most apparent
in this child?
A. Voracious appetite
B. Wasting
C. Apathy
D. Edema
Answer: (D) Edema. Edema, a major sign of
kwashiorkor, is caused by decreased colloidal
osmotic pressure of the blood brought about by
hypoalbuminemia. Decreased blood albumin level
is due a protein-deficient diet.
14. Assessment of a 2-year old child revealed
“baggy pants”. Using the IMCI guidelines, how will
you manage this child?
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.
Answer: (A) Refer the child urgently to a
hospital for confinement. “Baggy pants” is a
sign of severe marasmus. The best management
is urgent referral to a hospital.
15. During the physical examination of a young
child, what is the earliest sign of xerophthalmia that
you may observe?
A. Keratomalacia
B. Corneal opacity
C. Night blindness
D. Conjunctival xerosis
Answer: (D) Conjunctival xerosis. The earliest
sign of Vitamin A deficiency (xerophthalmia) is
night blindness. However, this is a functional
change, which is not observable during physical
examination.The earliest visible lesion is
conjunctival xerosis or dullness of the conjunctiva
due to inadequate tear production.
16. To prevent xerophthalmia, young children are
given Retinol capsule every 6 months. What is the
dose given to preschoolers?
A. 10,000 IU
B. 20,000 IU
C. 100,000 IU
D. 200,000 IU
Answer: (D) 200,000 IU. Preschoolers are given
Retinol 200,000 IU every 6 months. 100,000 IU is
given once to infants aged 6 to 12 months. The
dose for pregnant women is 10,000 IU
17. The major sign of iron deficiency anemia is
pallor. What part is best examined for pallor?
A. Palms
B. Nailbeds
C. Around the lips
D. Lower conjunctival sac
Answer: (A) Palms. The anatomic
characteristics of the palms allow a reliable and
convenient basis for examination for pallor.
18. Food fortification is one of the strategies to
prevent micronutrient deficiency conditions. R.A.
8976 mandates fortification of certain food items.
Which of the following is among these food items?
A. Sugar
B. Bread
C. Margarine
D. Filled milk
Answer: (A) Sugar. R.A. 8976 mandates
fortification of rice, wheat flour, sugar and cooking
oil with Vitamin A, iron and/or iodine
19. What is the best course of action when there is a
measles epidemic in a nearby municipality?
A. Give measles vaccine to babies aged 6 to 8
months.
B. Give babies aged 6 to 11 months one dose of
100,000 I.U. of Retinol
C. Instruct mothers to keep their babies at home to
prevent disease transmission.
D. Instruct mothers to feed their babies adequately
to enhance their babies’ resistance.
Answer: (A) Give measles vaccine to babies aged
6 to 8 months. Ordinarily, measles vaccine is given
at 9 months of age. During an impending epidemic,
however, one dose may be given to babies aged 6 to
8 months. The mother is instructed that the baby
needs another dose when the baby is 9 months old.
20. A mother brought her daughter, 4 years old, to
the RHU because of cough and colds. Following the
IMCI assessment guide, which of the following is a
danger sign that indicates the need for urgent
referral to a hospital?
A. Inability to drink
B. High grade fever
C. Signs of severe dehydration
D. Cough for more than 30 days
Answer: (A) Inability to drink. 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
21. Management of a child with measles includes
the administration of which of the following?
A. Gentian violet on mouth lesions
B. Antibiotics to prevent pneumonia
C. Tetracycline eye ointment for corneal opacity
D. Retinol capsule regardless of when the last
dose was given
Answer: (D) Retinol capsule regardless of when
the last dose was given. An infant 6 to 12 months
classified as a case of measles is given Retinol
100,000 IU; a child is given 200,000 IU regardless
of when the last dose was given
22. A mother brought her 10 month old infant for
consultation because of fever, which started 4 days
prior to consultation. To determine malaria risk,
what will you do?
A. Do a tourniquet test.
B. Ask where the family resides.
C. Get a specimen for blood smear.
D. Ask if the fever is present everyday.
Answer: (B) Ask where the family
resides. Because malaria is endemic, the first
question to determine malaria risk is where the
client’s 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 he/she was brought
and whether he/she stayed overnight in that area.
23. The following are strategies implemented by the
Department of Health to prevent mosquito-borne
diseases. Which of these is most effective in the
control of Dengue fever?
A. Stream seeding with larva-eating fish
B. Destroying breeding places of mosquitoes
C. Chemoprophylaxis of non-immune persons
going to endemic areas
D. Teaching people in endemic areas to use
chemically treated mosquito nets
Answer: (B) Destroying breeding places of
mosquitoes. Aedes aegypti, the vector of Dengue
fever, breeds in stagnant, clear water. Its feeding
time is usually during the daytime. It has a cyclical
pattern of occurrence, unlike malaria which is
endemic in certain parts of the country
24. Secondary prevention for malaria includes
A. Planting of neem or eucalyptus trees
B. Residual spraying of insecticides at night
C. Determining whether a place is endemic or
not
D. Growing larva-eating fish in mosquito breeding
places
Answer: (C) Determining whether a place is
endemic or not. This is diagnostic and therefore
secondary level prevention. The other choices are
for primary prevention
25. Scotch tape swab is done to check for which
intestinal parasite?
A. Ascaris
B. Pinworm
C. Hookworm
D. Schistosoma
Answer: (B) Pinworm. Pinworm ova are deposited
around the anal orifice.
26. Which of the following signs indicates the need
for sputum examination for AFB?
A. Hematemesis
B. Fever for 1 week
C. Cough for 3 weeks
D. Chest pain for 1 week
Answer: (C) Cough for 3 weeks. A client is
considered a PTB suspect when he has cough for 2
weeks or more, plus one or more of the following A. 3 skin lesions, negative slit skin smear
signs: fever for 1 month or more; chest pain lasting B. 3 skin lesions, positive slit skin smear
for 2 weeks or more not attributed to other C. 5 skin lesions, negative slit skin smear
conditions; progressive, unexplained weight loss; D. 5 skin lesions, positive slit skin smear
night sweats; and hemoptysis.
Answer: (D) 5 skin lesions, positive slit skin
27. Which clients are considered targets for DOTS smear. A multibacillary leprosy case is one who
Category I? has a positive slit skin smear and at least 5 skin
lesions
A. Sputum negative cavitary cases
B. Clients returning after a default
C. Relapses and failures of previous PTB
PNLE Community
treatment regimens
D. Clients diagnosed for the first time through a
positive sputum exam
Health Nursing Exam
\
Answer: (D) Clients diagnosed for the first time
through a positive sputum exam. Category I is for
5
new clients diagnosed by sputum examination and . In the Philippines, which condition is the most
clients diagnosed to have a serious form of frequent cause of death associated with
extrapulmonary tuberculosis, such as TB schistosomiasis?
osteomyelitis.
A. Liver cancer
28. To improve compliance to treatment, what B. Liver cirrhosis
innovation is being implemented in DOTS? C. Bladder cancer
D. Intestinal perforation
A. Having the health worker follow up the client
at home Answer: (B) Liver cirrhosis. The etiologic agent
B. Having the health worker or a responsible of schistosomiasis in the Philippines is
family member monitor drug intake Schistosoma japonicum, which affects the small
C. Having the patient come to the health center intestine and the liver. Liver damage is a
every month to get his medications consequence of fibrotic reactions to schistosoma
D. Having a target list to check on whether the eggs in the liver
patient has collected his monthly supply of
drugs 2. What is the most effective way of controlling
schistosomiasis in an endemic area?
Answer: (B) Having the health worker or a
responsible family member monitor drug A. Use of molluscicides
intake. Directly Observed Treatment Short Course B. Building of foot bridges
is so-called because a treatment partner, preferably C. Proper use of sanitary toilets
a health worker accessible to the client, monitors D. Use of protective footwear, such as rubber
the client’s compliance to the treatment. boots

29. 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
Answer: (C) Thickened painful nerves. 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
30. Which of the following clients should be
classified as a case of multibacillary leprosy?
Answer: (C) Proper use of sanitary toilets. 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.
3. When residents obtain water from an artesian
well in the neighborhood, the level of this approved
type of water facility is
A. I
B. II
C. III
D. IV
Answer: (B) II. A communal faucet or water
standpost is classified as Level II.
4. For prevention of hepatitis A, you decided to
conduct health education activities. Which of the
following is IRRELEVANT?
A. Use of sterile syringes and needles
B. Safe food preparation and food handling by
vendors
C. Proper disposal of human excreta and personal
hygiene
D. Immediate reporting of water pipe leaks and
illegal water connections
Answer: (A) Use of sterile syringes and
needles. Hepatitis A is transmitted through the fecal
oral route. Hepatitis B is transmitted through
infected body secretions like blood and semen.
5. Which 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
Answer: (A) DPT. 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.
6. You will conduct outreach immunization in a
barangay with a population of about 1500. Estimate
the number of infants in the barangay.
A. 45
B. 50
C. 55
D. 60
Answer: (A) 45. To estimate the number of infants,
multiply total population by 3%
7. In Integrated Management of Childhood Illness,
severe conditions generally require urgent referral
to a hospital. Which of the following severe
conditions DOES NOT always require urgent
referral to a hospital?
A. Mastoiditis
B. Severe dehydration
C. Severe pneumonia
D. Severe febrile disease
Answer: (B) Severe dehydration. 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/nasogastric tube, Oresol/orem.
When the foregoing measures are not possible or
effective, tehn urgent referral to the hospital is done.
8. A client 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
B. 5
C. 8
D. 10
Answer: (A) 3. Adequate blood supply to the area
allows the return of the color of the nailbed within 3
seconds.
9. A 3-year old child was brought by his mother to
the health center because of fever of 4-day duration.
The child had a positive tourniquet test result. In the
absence of other signs, which is the most
appropriate measure that the PHN may carry out to
prevent Dengue shock syndrome?
A. Insert an NGT and give fluids per NGT.
B. Instruct the mother to give the child Oresol.
C. Start the patient on intravenous fluids STAT.
D. Refer the client to the physician for appropriate
management.
Answer: (B) Instruct the mother to give the child
Oresol. Since the child does not manifest any other
danger sign, maintenance of fluid balance and
replacement of fluid loss may be done by giving the
client Oresol.
10. The pathognomonic sign of measles is Koplik’s
spot. You may see Koplik’s spot by inspecting the
_____.
A. Nasal mucosa
B. Buccal mucosa
C. Skin on the abdomen
D. Skin on the antecubital surface
Answer: (B) Buccal mucosa. Koplik’s spot may be
seen on the mucosa of the mouth or the throat.
11. Among the following diseases, which is
airborne?
A. Viral conjunctivitis
B. Acute poliomyelitis
C. Diphtheria
D. Measles
Answer: (D) Measles. Viral conjunctivitis is
transmitted by direct or indirect contact with
discharges from infected eyes. Acute poliomyelitis
is spread through the fecal-oral route and contact
with throat secretions, whereas diphtheria is through
direct and indirect contact with respiratory
secretions.
12. Among children aged 2 months to 3 years, the
most prevalent form of meningitis is caused by
which microorganism?
A. Hemophilus influenzae
B. Morbillivirus
C. Steptococcus pneumoniae
D. Neisseria meningitides
Answer: (A) Hemophilus
influenzae. 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
13. Human beings are the major reservoir of malaria.
Which of the following strategies in malaria control
is based on this fact?
A. Stream seeding
B. Stream clearing
C. Destruction of breeding places
D. Zooprophylaxis
Answer: (D) Zooprophylaxis. Zooprophylaxis is
done by putting animals like cattle or dogs close to
windows or doorways just before nightfall. The
Anopheles mosquito takes his blood meal from the
animal and goes back to its breeding place, thereby
preventing infection of humans
14. The use of larvivorous fish in malaria control is
the basis for which strategy of malaria control?
A. Stream seeding
B. Stream clearing
C. Destruction of breeding places
D. Zooprophylaxis
Answer: (A) Stream seeding. Stream seeding is
done by putting tilapia fry in streams or other
bodies of water identified as breeding places of the
Anopheles mosquito
15. Mosquito-borne diseases are prevented mostly
with the use of mosquito control measures. Which
of the following is NOT appropriate for malaria
control?
A. Use of chemically treated mosquito nets
B. Seeding of breeding places with larva-eating
fish
C. Destruction of breeding places of the
mosquito vector
D. Use of mosquito-repelling soaps, such as those
with basil or citronella
Answer: (C) Destruction of breeding places of
the mosquito vector. Anopheles mosquitoes breed
in slow-moving, clear water, such as mountain
streams.
16. A 4-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
Answer: (B) Cholera. 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.
17. In the Philippines, which specie of schistosoma
is endemic in certain regions?
A. S. mansoni
A.
B. S. malayensis
C. S. haematobium
Answer: (B) S. japonicum. S. mansoni is found
mostly in Africa and South America; S.
haematobium in Africa and the Middle East; and S.
malayensis only in peninsular Malaysia.
18. A 32-year old 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 his
history, which disease condition will you suspect?
A. Hepatitis A
B. Hepatitis B
C. Tetanus
D. Leptospirosis
Answer: (D) Leptospirosis. Leptospirosis is
transmitted through contact with the skin or mucous
membrane with water or moist soil contaminated
with urine of infected animals, like rats.
19. MWSS provides water to Manila and other
cities in Metro Manila. This is an example of which
level of water facility?
A. I
B. II
C. III
 D. IV
Answer: (C) III. Waterworks systems, such as
MWSS, are classified as level III.
20. You are the PHN in the city health center. A
client underwent screening for AIDS using ELISA.
His result was positive. What is the best course of
action that you may take?
A. Get a thorough history of the client, focusing
on the practice of high risk behaviors.
B. Ask the client to be accompanied by a
significant person before revealing the result.
C. Refer the client to the physician since he is the
best person to reveal the result to the client.
D. Refer the client for a supplementary test,
such as Western blot, since the ELISA result
may be false.
Answer: (D) Refer the client for a supplementary
test, such as Western blot, since the ELISA result
may be false. A client having a reactive ELISA
result must undergo a more specific test, such as
Western blot. A negative supplementary test result
means that the ELISA result was false and that,
most probably, the client is not infected.
21. Which is the BEST control measure for AIDS?
A. Being faithful to a single sexual partner
B. Using a condom during each sexual contact
C. Avoiding sexual contact with commercial sex
workers
D. Making sure that one’s sexual partner does not
have signs of AIDS
\ C. Consult at the health center where rubella
Answer: (A) Being faithful to a single sexual
partner. Sexual fidelity rules out the possibility of
getting the disease by sexual contact with another
infected person. Transmission occurs mostly
through sexual intercourse and exposure to blood
or tissues
22. The most frequent causes of death among
clients with AIDS are opportunistic diseases. Which
of the following opportunistic infections is
characterized by tonsillopharyngitis?
A. Respiratory candidiasis
B. Infectious mononucleosis
C. Cytomegalovirus disease
D. Pneumocystis carinii pneumonia
Answer: (B) Infectious
mononucleosis. Cytomegalovirus disease is an
acute viral disease characterized by fever, sore
throat and lymphadenopathy.
23. To determine possible sources of sexually
transmitted infections, which is the BEST method
that may be undertaken by the public health nurse?
A. Contact tracing
B. Community survey
C. Mass screening tests
D. Interview of suspects
Answer: (A) Contact tracing. Contact tracing is
the most practical and reliable method of finding
possible sources of person-to-person transmitted
infections, such as sexually transmitted diseases
24. Antiretroviral agents, such as AZT, are used in
the management of AIDS. Which of the following
is NOT an action expected of these drugs.
A. They prolong the life of the client with AIDS.
B. They reduce the risk of opportunistic infections
C. They shorten the period of communicability of
the disease.
D. They are able to bring about a cure of the
disease condition.
Answer: (D) They are able to bring about a cure
of the disease condition. There is no known
treatment for AIDS. Antiretroviral agents reduce
the risk of opportunistic infections and prolong life,
but does not cure the underlying
immunodeficiency
25. A barangay 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?
A. Advice them on the signs of German measles.
B. Avoid crowded places, such as markets and
moviehouses.
vaccine may be given.
D. Consult a physician who may give them
rubella immunoglobulin.
Answer: (D) Consult a physician who may give
them rubella immunoglobulin. 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.
26. You were invited to be the resource person in a
training class for food handlers. Which of the
following would you emphasize regarding
prevention of staphylococcal food poisoning?
A. All cooking and eating utensils must be
thoroughly washed.
B. Food must be cooked properly to destroy
staphylococcal microorganisms.
C. Food handlers and food servers must have a
negative stool examination result.
D. Proper handwashing during food
preparation is the best way of preventing the
condition.
Answer: (D) Proper handwashing during food
preparation is the best way of preventing the
condition. Symptoms of this food poisoning are
due to staphylococcal enterotoxin, not the
microorganisms themselves. Contamination is by
food handling by persons with staphylococcal skin
or eye infections
27. In a mothers’ class, you 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.
Answer: (A) The older one gets, the more
susceptible he becomes to the complications of
chicken pox. Chicken pox is usually more severe in
adults than in children. Complications, such as
pneumonia, are higher in incidence in adults.
28. Complications to infectious parotitis (mumps)
may be serious in which type of clients?
A. Pregnant women
B. Elderly clients
C. Young adult males
D. Young infants
Answer: (C) Young adult males. Epididymitis and
orchitis are possible complications of mumps. In
post-adolescent males, bilateral inflammation of the
testes and epididymis may cause sterility.
PNLE Medical
Surgical Nursing
Exam 1
SITUATION : Arthur, A registered nurse,
witnessed an old woman hit by a motorcycle while
crossing a train railway. The old woman fell at the
railway. Arthur rushed at the scene.
1. As a registered nurse, Arthur knew that the first
thing that he will do at the scene is
A. Stay with the person, Encourage her to remain
still and Immobilize the leg while While
waiting for the ambulance.
B. Leave the person for a few moments to call for
help.
C. Reduce the fracture manually.
D. Move the person to a safer place.
2. Arthur suspects a hip fracture when he noticed
that the old woman’s leg is
A. A. Lengthened, Abducted and Internally
Rotated.
B. Shortened, Abducted and Externally Rotated.
C. Shortened, Adducted and Internally Rotated.
D. Shortened, Adducted and Externally
Rotated.
3. The old woman complains of pain. John noticed
that the knee is reddened, warm to touch and
swollen. John interprets that this signs and
symptoms are likely related to
A. Infection
B. Thrombophlebitis
C. Inflammation
D. Degenerative disease
4. The old woman told John that she has
osteoporosis; Arthur knew that all of the following
factors would contribute to osteoporosis except
A. Hypothyroidism
B. End stage renal disease
C. Cushing’s Disease
D. Taking Furosemide and Phenytoin.
5. Martha, The old woman was now Immobilized
and brought to the emergency room. The X-ray
shows a fractured femur and pelvis. The ER Nurse
would carefully monitor Martha for which of the
following sign and symptoms?
A. Tachycardia and Hypotension
B. Fever and Bradycardia
C. Bradycardia and Hypertension
 D. Fever and Hypertension B. 5 mm Induration
SITUATION: Mr. D. Rojas, An obese 35 year old C. 10 mm Wheal
MS Professor of OLFU Lagro is admitted due to D. 10 mm Induration
pain in his weight bearing joint. The diagnosis was
Osteoarthritis. 12. The nurse told Alfred to come back after
6. As a nurse, you instructed Mr. Rojas how to use a
cane. Mr. Rojas has a weakness on his right leg due A. a week
to self immobilization and guarding. You plan to B. 48 hours
teach Mr. Rojas to hold the cane C. 1 day
D. 4 days
A. On his left hand, because his right side is weak.
B. On his left hand, because of reciprocal 13. Mang Alfred returns after the Mantoux Test.
motion. The test result read POSITIVE. What should be the
C. On his right hand, to support the right leg. nurse’s next action?
D. On his right hand, because only his right leg is
weak. A. Call the Physician
7. You also told Mr. Rojas to hold the cane B. Notify the radiology dept. for CXR evaluation
C. Isolate the patient
A. 1 Inches in front of the foot. D. Order for a sputum exam
B. 3 Inches at the lateral side of the foot.
C. 6 Inches at the lateral side of the foot. 14. Why is Mantoux test not routinely done in the
D. 12 Inches at the lateral side of the foot. Philippines?

8. Mr. Rojas was discharged and 6 months later, he
came back to the emergency room of the hospital
because he suffered a mild stroke. The right side of
the brain was affected. At the rehabilitative phase of
your nursing care, you observe Mr. Rojas use a cane
and you intervene if you see him
A. Moves the cane when the right leg is moved.
B. Leans on the cane when the right leg swings
through.
C. keeps the cane 6 Inches out to the side of the
right foot.
D. Holds the cane on the right side.
A. It requires a highly skilled nurse to perform a
Mantoux test
B. The sputum culture is the gold standard of PTB
Diagnosis and it will definitively determine the
extent of the cavitary lesions
C. Chest X Ray Can diagnose the specific
microorganism responsible for the lesions
D. Almost all Filipinos will test positive for
Mantoux Test
15. Mang Alfred is now a new TB patient with an
active disease. What is his category according to the
DOH?

SITUATION: Alfred, a 40 year old construction A. I

worker developed cough, night sweats and fever. He B. II
was brought to the nursing unit for diagnostic C. III
studies. He told the nurse he did not receive a BCG D. IV
vaccine during childhood
9. The nurse performs a Mantoux Test. The nurse 16. How long is the duration of the maintenance
knows that Mantoux Test is also known as phase of his treatment?

A. PPD A. 2 months
B. PDP B. 3 months
C. PDD C. 4 months
D. DPP D. 5 months

10. The nurse would inject the solution in what 17. Which of the following drugs is UNLIKELY
route? given to Mang Alfred during the maintenance phase?

A. IM A. Rifampicin
B. IV B. Isoniazid
C. ID C. Ethambutol
D. SC D. Pyridoxine

11. The nurse notes that a positive result for Alfred 18. According to the DOH, the most hazardous
is period for development of clinical disease is during
the first
A. 5 mm wheal
 A. 6-12 months after 25. The maximum height of irrigation solution for
B. 3-6 months after colostomy is
C. 1-2 months after
D. 2-4 weeks after A. 5 inches
B. 12 inches
19. This is the name of the program of the DOH to C. 18 inches
control TB in the country D. 24 inches

A. DOTS 26. Which of the following behavior of the client

B. National Tuberculosis Control Program indicates the best initial step in learning to care for
C. Short Coursed Chemotherapy his colostomy?
D. Expanded Program for Immunization
A. Ask to defer colostomy care to another
20. Susceptibility for the disease [ TB ] is increased individual
markedly in those with the following condition B. Promises he will begin to listen the next day
except C. Agrees to look at the colostomy
D. States that colostomy care is the function of the
A. 23 Year old athlete with diabetes insipidus nurse while he is in the hospital
B. 23 Year old athlete taking long term Decadron
therapy and anabolic steroids 27. While irrigating the client’s colostomy, Michiel
C. 23 Year old athlete taking illegal drugs and suddenly complains of severe cramping. Initially,
abusing substances the nurse would
D. Undernourished and Underweight individual
who undergone gastrectomy A. Stop the irrigation by clamping the tube
B. Slow down the irrigation
21. Direct sputum examination and Chest X ray of C. Tell the client that cramping will subside and is
TB symptomatic is in what level of prevention? normal
D. Notify the physician
A. Primary
B. Secondary 28. The next day, the nurse will assess Michiel’s
C. Tertiary stoma. The nurse noticed that a prolapsed stoma is
D. Quarterly evident if she sees which of the following?

SITUATION: Michiel, A male patient diagnosed A. A sunken and hidden stoma

with colon cancer was newly put in colostomy. B. A dusky and bluish stoma
22. Michiel shows the BEST adaptation with the C. A narrow and flattened stoma
new colostomy if he shows which of the following? D. Protruding stoma with swollen appearance

A. Look at the ostomy site 29. Michiel asked the nurse, what foods will help
B. Participate with the nurse in his daily lessen the odor of his colostomy. The nurse best
ostomy care response would be
C. Ask for leaflets and contact numbers of ostomy
support groups A. Eat eggs
D. Talk about his ostomy openly to the nurse and B. Eat cucumbers
friends C. Eat beet greens and parsley
D. Eat broccoli and spinach
23. The nurse plans to teach Michiel about
colostomy irrigation. As the nurse prepares the 30. The nurse will start to teach Michiel about the
materials needed, which of the following item techniques for colostomy irrigation. Which of the
indicates that the nurse needs further instruction? following should be included in the nurse’s teaching
plan?
A. Plain NSS / Normal Saline
B. K-Y Jelly A. Use 500 ml to 1,000 ml NSS
C. Tap water B. Suspend the irrigant 45 cm above the stoma
D. Irrigation sleeve C. Insert the cone 4 cm in the stoma
24. The nurse should insert the colostomy tube for D. If cramping occurs, slow the irrigation
irrigation at approximately
31. The nurse knew that the normal color of
A. 1-2 inches Michiel’s stoma should be
B. 3-4 inches
C. 6-8 inches A. Brick Red
D. 12-18 inches B. Gray
 C. Blue C. James’ neck veins are not engorged
D. Pale Pink D. Wilma measures the tie from the nose to the tip
SITUATION: James, A 27 basketball player of the earlobe and to the xiphoid process.
sustained inhalation burn that required him to have 38. Wilma knew that James have an adequate
tracheostomy due to massive upper airway edema. respiratory condition if she notices that
32. Wilma, His sister and a nurse is suctioning the
tracheostomy tube of James. Which of the following, A. James’ respiratory rate is 18
if made by Wilma indicates that she is committing B. James’ Oxygen saturation is 91%
an error? C. There are frank blood suction from the tube
D. There are moderate amount of tracheobronchial
A. Hyperventilating James with 100% oxygen secretions
before and after suctioning
B. Instilling 3 to 5 ml normal saline to loosen up 39. Wilma knew that the maximum time when
secretion suctioning James is
C. Applying suction during catheter withdrawal
D. Suction the client every hour A. 10 seconds
B. 20 seconds
33. What size of suction catheter would Wilma use C. 30 seconds
for James, who is 6 feet 5 inches in height and D. 45 seconds
weighing approximately 145 lbs?
SITUATION : Juan Miguel Lopez Zobel Ayala de
A. Fr. 5 Batumbakal was diagnosed with Acute Close Angle
B. Fr. 10 Glaucoma. He is being seen by Nurse Jet.
C. Fr. 12 40. What specific manifestation would nurse Jet see
D. Fr. 18 in Acute close angle glaucoma that she would not
see in an open angle glaucoma?
34. Wilma is using a portable suction unit at home,
What is the amount of suction required by James A. Loss of peripheral vision
using this unit? B. Irreversible vision loss
C. There is an increase in IOP
A. 2-5 mmHg D. Pain
B. 5-10 mmHg
C. 10-15 mmHg 41. Nurse jet knew that Acute close angle glaucoma
D. 20-25 mmHg is caused by

35. If a Wall unit is used, What should be the
suctioning pressure required by James?
A. 50-95 mmHg
B. 95-110 mmHg
C. 100-120 mmHg
D. 155-175 mmHg
36. Wilma was shocked to see that the
Tracheostomy was dislodged. Both the inner and
outer cannulas was removed and left hanging on
James’ neck. What are the 2 equipment’s at james’
bedside that could help Wilma deal with this
situation?
A. New set of tracheostomy tubes and Oxygen
tank
B. Theophylline and Epinephrine
C. Obturator and Kelly clamp
D. Sterile saline dressing
37. Which of the following method if used by
Wilma will best assure that the tracheostomy ties
are not too tightly placed?
A. Wilma places 2 fingers between the tie and
neck
B. The tracheotomy can be pulled slightly away
from the neck
A. Sudden blockage of the anterior angle by the
base of the iris
B. Obstruction in trabecular meshwork
C. Gradual increase of IOP
D. An abrupt rise in IOP from 8 to 15 mmHg
42. Nurse jet performed a TONOMETRY test to Mr.
Batumbakal. What does this test measures
A. It measures the peripheral vision remaining on
the client
B. Measures the Intra Ocular Pressure
C. Measures the Client’s Visual Acuity
D. Determines the Tone of the eye in response to
the sudden increase in IOP.
43. The Nurse notices that Mr. Batumbakal cannot
anymore determine RED from BLUE. The nurse
knew that which part of the eye is affected by this
change?
A. IRIS
B. PUPIL
C. RODS [RETINA]
D. CONES [RETINA]
44. Nurse Jet knows that Aqueous Humor is A. Atropine Sulfate
produce where? B. Pindolol [Visken]
C. Naloxone Hydrochloride [Narcan]
A. In the sub arachnoid space of the meninges D. Mesoridazine Besylate [Serentil]
B. In the Lateral ventricles
C. In the Choroids SITUATION : Wide knowledge about the human
D. In the Ciliary Body ear, it’s parts and it’s functions will help a nurse
assess and analyze changes in the adult client’s
45. Nurse Jet knows that the normal IOP is health.

A. 8-21 mmHg 52. Nurse Anna is doing a caloric testing to his

B. 2-7 mmHg patient, Aida, a 55 year old university professor
C. 31-35 mmHg who recently went into coma after being mauled by
D. 15-30 mmHg her disgruntled 3rd year nursing students whom she
gave a failing mark. After instilling a warm water in
46. Nurse Jet wants to measure Mr. Batumbakal’s the ear, Anna noticed a rotary nystagmus towards
CN II Function. What test would Nurse Jet the irrigated ear. What does this means?
implement to measure CN II’s Acuity? A. Indicates a CN VIII Dysfunction
B. Abnormal
A. Slit lamp C. Normal
B. Snellen’s Chart D. Inconclusive
C. Wood’s light
D. Gonioscopy 53. Ear drops are prescribed to an infant, The most
appropriate method to administer the ear drops is
47. The Doctor orders pilocarpine. Nurse jet knows
that the action of this drug is to A. Pull the pinna up and back and direct the
solution towards the eardrum
A. Contract the Ciliary muscle B. Pull the pinna down and back and direct the
B. Relax the Ciliary muscle solution onto the wall of the canal
C. Dilate the pupils C. Pull the pinna down and back and direct the
D. Decrease production of Aqueous Humor solution towards the eardrum
D. Pull the pinna up and back and direct the
48. The doctor orders timolol [timoptic]. Nurse jet solution onto the wall of the canal
knows that the action of this drug is
54. Nurse Jenny is developing a plan of care for a
A. Reduce production of CSF patient with Menieres disease. What is the priority
B. Reduce production of Aquesous Humor nursing intervention in the plan of care for this
C. Constrict the pupil particular patient?
D. Relaxes the Ciliary muscle
A. Air, Breathing, Circulation
49. When caring for Mr. Batumbakal, Jet teaches B. Love and Belongingness
the client to avoid C. Food, Diet and Nutrition
D. Safety
A. Watching large screen TVs
B. Bending at the waist 55. After mastoidectomy, Nurse John should be
C. Reading books aware that the cranial nerve that is usually damage
D. Going out in the sun after this procedure is

50. Mr. Batumbakal has undergone eye angiography A. CN I

using an Intravenous dye and fluoroscopy. What B. CN II
activity is contraindicated immediately after C. CN VII
procedure? D. CN VI

A. Reading newsprint 56. The physician orders the following for the client
B. Lying down with Menieres disease. Which of the following
C. Watching TV should the nurse question?
D. Listening to the music
A. Dipenhydramine [Benadryl]
51. If Mr. Batumbakal is receiving pilocarpine, B. Atropine sulfate
what drug should always be available in any case C. Out of bed activities and ambulation
systemic toxicity occurs? D. Diazepam [Valium]
57. Nurse Anna is giving dietary instruction to a
client with Menieres disease. Which statement if
made by the client indicates that the teaching has
been successful?
A. I will try to eat foods that are low in sodium
and limit my fluid intake
B. I must drink atleast 3,000 ml of fluids per day
C. I will try to follow a 50% carbohydrate, 30%
fat and 20% protein diet
D. I will not eat turnips, red meat and raddish
58. Peachy was rushed by his father, Steven into the
hospital admission. Peachy is complaining of
something buzzing into her ears. Nurse Joemar
assessed peachy and found out It was an insect.
What should be the first thing that Nurse Joemar
should try to remove the insect out from peachy’s
ear?
A. Use a flashlight to coax the insect out of
peachy’s ear
B. Instill an antibiotic ear drops
C. Irrigate the ear
D. Pick out the insect using a sterile clean forceps
59. Following an ear surgery, which statement if
heard by Nurse Oca from the patient indicates a
correct understanding of the post operative
instructions?
A. Activities are resumed within 5 days
B. I will make sure that I will clean my hair and
face to prevent infection
C. I will use straw for drinking
D. I should avoid air travel for a while
60. Nurse Oca will do a caloric testing to a client
who sustained a blunt injury in the head. He
instilled a cold water in the client’s right ear and he
noticed that nystagmus occurred towards the left ear.
What does this finding indicates?
A. Indicating a Cranial Nerve VIII Dysfunction
B. The test should be repeated again because the
result is vague
C. This is Grossly abnormal and should be
reported to the neurosurgeon
D. This indicates an intact and working
vestibular branch of CN VIII
61. A client with Cataract is about to undergo
surgery. Nurse Oca is preparing plan of care. Which
of the following nursing diagnosis is most
appropriate to address the long term need of this
type of patient?
A. Anxiety R/T to the operation and its outcome
B. Sensory perceptual alteration R/T Lens
extraction and replacement
C. Knowledge deficit R/T the pre operative and
post operative self care
D. Body Image disturbance R/T the eye packing
after surgery
62. Nurse Joseph is performing a WEBERS TEST.
He placed the tuning fork in the patients forehead
after tapping it onto his knee. The client states that
the fork is louder in the LEFT EAR. Which of the
following is a correct conclusion for nurse Josph to
make?
A. He might have a sensory hearing loss in the left
ear
B. Conductive hearing loss is possible in the right
ear
C. He might have a sensory hearing loss in the
right hear, and/or a conductive hearing loss
in the left ear.
D. He might have a conductive hearing loss in the
right ear, and/or a sensory hearing loss in the
left ear.
63. Aling myrna has Menieres disease. What typical
dietary prescription would nurse Oca expect the
doctor to prescribe?
A. A low sodium , high fluid intake
B. A high calorie, high protein dietary intake
C. low fat, low sodium and high calorie intake
D. low sodium and restricted fluid intake
SITUATION : [ From DEC 1991 NLE ] A 45 year
old male construction worker was admitted to a
tertiary hospital for incessant vomiting. Assessment
disclosed: weak rapid pulse, acute weight loss
of .5kg, furrows in his tongue, slow flattening of the
skin was noted when the nurse released her pinch.
Temperature: 35.8 C , BUN Creatinine ratio : 10 :
1, He also complains for postural hypotension.
There was no infection.
64. Which of the following is the appropriate
nursing diagnosis?
A. Fluid volume deficit R/T furrow tongue
B. Fluid volume deficit R/T uncontrolled
vomiting
C. Dehydration R/T subnormal body temperature
D. Dehydration R/T incessant vomiting
65. Approximately how much fluid is lost in acute
weight loss of .5kg?
A. 50 ml
B. 750 ml
C. 500 ml
D. 75 ml
66. Postural Hypotension is
A. A drop in systolic pressure less than 10 mmHg
when patient changes position from lying to
sitting.
 B. A drop in systolic pressure greater than 10 A. Vitamin C rich food
mmHg when patient changes position from B. Vitamin E rich food
lying to sitting C. Thiamine rich food
C. A drop in diastolic pressure less than 10 mmHg D. Vitamin B6 rich food
when patient changes position from lying to
sitting 73. One day, the patient complained of difficulty in
D. A drop in diastolic pressure greater than 10 walking. Your response would be
mmHg when patient changes position from
lying to sitting A. You will need a cane for support
B. Walk erect with eyes on horizon
67. Which of the following measures will not help C. I’ll get you a wheelchair
correct the patient’s condition D. Don’t force yourself to walk

A. Offer large amount of oral fluid intake to SITUATION: Mr. Dela Isla, a client with early
replace fluid lost Dementia exhibits thought process disturbances.
B. Give enteral or parenteral fluid 74. The nurse will assess a loss of ability in which
C. Frequent oral care of the following areas?
D. Give small volumes of fluid at frequent interval
A. Balance
68. After nursing intervention, you will expect the B. Judgment
patient to have C. Speech
D. Endurance
1. Maintain body temperature at 36.5 C
2. Exhibit return of BP and Pulse to normal 75. Mr. Dela Isla said he cannot comprehend what
3. Manifest normal skin turgor of skin and tongue the nurse was saying. He suffers from:
4. Drinks fluids as prescribed
A. 1,3 A. Insomnia
B. 2,4 B. Aphraxia
C. 1,3,4 C. Agnosia
D. 2,3,4 D. Aphasia

SITUATION: A 65 year old woman was admitted 76. The nurse is aware that in communicating with
for Parkinson’s Disease. The charge nurse is going an elderly client, the nurse will
to make an initial assessment.
69. Which of the following is a characteristic of a A. Lean and shout at the ear of the client
patient with advanced Parkinson’s disease? B. Open mouth wide while talking to the client
C. Use a low-pitched voice
A. Disturbed vision D. Use a medium-pitched voice
B. Forgetfulness
C. Mask like facial expression 77. As the nurse talks to the daughter of Mr. Dela
D. Muscle atrophy Isla, which of the following statement of the
daughter will require the nurse to give further
70. The onset of Parkinson’s disease is between 50- teaching?
60 years old. This disorder is caused by
A. I know the hallucinations are parts of the
A. Injurious chemical substances disease
B. Hereditary factors B. I told her she is wrong and I explained to
C. Death of brain cells due to old age her what is right
D. Impairment of dopamine producing cells in C. I help her do some tasks he cannot do for
the brain himself
D. Ill turn off the TV when we go to another room
71. The patient was prescribed with levodopa. What
is the action of this drug? 78. Which of the following is most important
discharge teaching for Mr. Dela Isla
A. Increase dopamine availability
B. Activates dopaminergic receptors in the basal A. Emergency Numbers
ganglia B. Drug Compliance
C. Decrease acetylcholine availability C. Relaxation technique
D. Release dopamine and other catecholamine D. Dietary prescription
from neurological storage sites
72. You are discussing with the dietician what food
to avoid with patients taking levodopa?
SITUATION : Knowledge of the drug
PROPANTHELINE BROMIDE [Probanthine] Is
necessary in treatment of various disorders.
79. What is the action of this drug?
A. Increases glandular secretion for clients
affected with cystic fibrosis
B. Dissolve blockage of the urinary tract due to
obstruction of cystine stones
C. Reduces secretion of the glandular organ of
the body
D. Stimulate peristalsis for treatment of
constipation and obstruction
80. What should the nurse caution the client when
using this medication
A. Avoid hazardous activities like driving,
operating machineries etc.
B. Take the drug on empty stomach
C. Take with a full glass of water in treatment of
Ulcerative colitis
D. I must take double dose if I missed the
previous dose
81. Which of the following drugs are not
compatible when taking Probanthine?
A. Caffeine
B. NSAID
C. Acetaminophen
D. Alcohol
82. What should the nurse tell clients when taking
Probanthine?
A. Avoid hot weathers to prevent heat strokes
B. Never swim on a chlorinated pool
C. Make sure you limit your fluid intake to 1L a
day
D. Avoid cold weathers to prevent hypothermia
83. Which of the following disease would
Probanthine exert the much needed action for
control or treatment of the disorder?
A. Urinary retention
B. Peptic Ulcer Disease
C. Ulcerative Colitis
D. Glaucoma
SITUATION : Mr. Franco, 70 years old, suddenly
could not lift his spoons nor speak at breakfast. He
was rushed to the hospital unconscious. His
diagnosis was CVA.
84. Which of the following is the most important
assessment during the acute stage of an unconscious
patient like Mr. Franco?
A. Level of awareness and response to pain
B. Papillary reflexes and response to sensory
stimuli
C. Coherence and sense of hearing
D. Patency of airway and adequacy of
respiration
85. Considering Mr. Franco’s conditions, which of
the following is most important to include in
preparing Franco’s bedside equipment?
A. Hand bell and extra bed linen
B. Sandbag and trochanter rolls
C. Footboard and splint
D. Suction machine and gloves
86. What is the rationale for giving Mr. Franco
frequent mouth care?
A. He will be thirsty considering that he is doesn’t
drink enough fluids
B. To remove dried blood when tongue is bitten
during a seizure
C. The tactile stimulation during mouth care will
hasten return to consciousness
D. Mouth breathing is used by comatose
patient and it’ll cause oral mucosa dying
and cracking.
87. One of the complications of prolonged bed rest
is decubitus ulcer. Which of the following can best
prevent its occurrence?
A. Massage reddened areas with lotion or oils
B. Turn frequently every 2 hours
C. Use special water mattress
D. Keep skin clean and dry
88. If Mr. Franco’s Right side is weak, What should
be the most accurate analysis by the nurse?
A. Expressive aphasia is prominent on clients
with right sided weakness
B. The affected lobe in the patient is the Right
lobe
C. The client will have problems in judging
distance and proprioception
D. Clients orientation to time and space will be
much affected
SITUATION : a 20 year old college student was
rushed to the ER of PGH after he fainted during
their ROTC drill. Complained of severe right iliac
pain. Upon palpation of his abdomen, Ernie jerks
even on slight pressure. Blood test was ordered.
Diagnosis is acute appendicitis.
89. Which result of the lab test will be significant to
the diagnosis?
A. RBC : 4.5 TO 5 Million / cu. mm.
B. Hgb : 13 to 14 gm/dl.
C. Platelets : 250,000 to 500,000 cu.mm.
D. WBC : 12,000 to 13,000/cu.mm
90. Stat appendectomy was indicated. Pre op care A. When patient requests for it
would include all of the following except? B. Abdomen is soft and patient asks for water
C. Abdomen is soft and flatus has been expelled
A. Consent signed by the father D. B and C only
B. Enema STAT
C. Skin prep of the area including the pubis Situation: Amanda is suffering from chronic
D. Remove the jewelries arteriosclerosis Brain syndrome she fell while
getting out of the bed one morning and was brought
91. Pre-anesthetic med of Demerol and atrophine to the hospital, and she was diagnosed to have
sulfate were ordered to : cerebrovascular thrombosis thus transferred to a
nursing home.
A. Allay anxiety and apprehension 98. What do you call a STROKE that manifests a
B. Reduce pain bizarre behavior?
C. Prevent vomiting
D. Relax abdominal muscle A. Inorganic Stroke
92. Common anesthesia for appendectomy is B. Inorganic Psychoses
C. Organic Stroke
A. Spinal D. Organic Psychoses
B. General
C. Caudal 99. The main difference between chronic and
D. Hypnosis organic brain syndrome is that the former

93. Post op care for appendectomy include the A. Occurs suddenly and reversible
following except B. Is progressive and reversible
C. tends to be progressive and irreversible
A. Early ambulation D. Occurs suddenly and irreversible
B. Diet as tolerated after fully conscious 100. Which behavior results from organic
C. Nasogastric tube connect to suction psychoses?
D. Deep breathing and leg exercise
A. Memory deficit
94. Peritonitis may occur in ruptured appendix and B. Disorientation
may cause serious problems which are C. Impaired Judgement
D. Inappropriate affect
1. Hypovolemia, electrolyte imbalance
2. Elevated temperature, weakness and
diaphoresis
3. Nausea and vomiting, rigidity of the abdominal
wall
4. Pallor and eventually shock
A. 1 and 2
B. 2 and 3
C. 1,2,3
D. All of the above

95. If after surgery the patient’s abdomen becomes

distended and no bowel sounds appreciated, what
would be the most suspected complication?

A. Intussusception
B. Paralytic Ileus
C. Hemorrhage
D. Ruptured colon

96. NGT was connected to suction. In caring for the

patient with NGT, the nurse must

A. Irrigate the tube with saline as ordered

B. Use sterile technique in irrigating the tube
C. advance the tube every hour to avoid kinks
D. Offer some ice chips to wet lips

97. When do you think the NGT tube be removed?


PNLE Medical
Surgical Nursing
Exam 2
1. After a cerebrovascular accident, a 75 yr old
client is admitted to the health care facility. The
client has left-sided weakness and an absent gag
reflex. He’s incontinent and has a tarry stool. His
blood pressure is 90/50 mm Hg, and his hemoglobin
is 10 g/dl. Which of the following is a priority for
this client?
A. checking stools for occult blood
B. performing range-of-motion exercises to the
left side
C. keeping skin clean and dry
D. elevating the head of the bed to 30 degrees
ANS: D
Because the client’s gag reflex is absent,
elevating the head of the bed to 30 degrees
helps minimize the client’s risk of aspiration.
Checking the stools, performing ROM
exercises, and keeping the skin clean and dry
are important, but preventing aspiration
through positioning is the priority
2. The nurse is caring for a client with a colostomy.
The client tells the nurse that he makes small pin
holes in the drainage bag to help relieve gas. The
nurse should teach him that this action:
A. destroys the odor-proof seal
B. wont affect the colostomy system
C. is appropriate for relieving the gas in a
colostomy system
D. destroys the moisture barrier seal
ANS: A
Any hole, no matter how small, will destroy the
odor-proof seal of a drainage bag. Removing the
bag or unclamping it is the only appropriate
method for relieving gas.
3. When assessing the client with celiac disease, the
nurse can expect to find which of the following?
A. steatorrhea
B. jaundiced sclerae
C. clay-colored stools
D. widened pulse pressure
ANS: A
because celiac disease destroys the absorbing
surface of the intestine, fat isn’t absorbed but is
passed in the stool. Steatorrhea is bulky, fatty
stools that have a foul odor. Jaundiced sclerae
result from elevated bilirubin levels. Clay-
colored stools are seen with biliary disease
when bile flow is blocked. Celiac disease
doesn’t cause a widened pulse pressure.
4. A client is hospitalized with a diagnosis of
chronic glomerulonephritis. The client mentions
that she likes salty foods. The nurse should warn her
to avoid foods containing sodium because:
A. reducing sodium promotes urea nitrogen
excretion
B. reducing sodium improves her glomerular
filtration rate
C. reducing sodium increases potassium
absorption
D. reducing sodium decreases edema
ANS: D
Reducing sodium intake reduces fluid retention.
Fluid retention increases blood volume, which
changes blood vessel permeability and allows
plasma to move into interstitial tissue, causing
edema. Urea nitrogen excretion can be increased
only by improved renal function. Sodium intake
doesn’t affect the glomerular filtration rate.
Potassium absorption is improved only by
increasing the glomerular filtration rate; it isn’t
affected by sodium intake.
5. The nurse is caring for a client with a cerebral
injury that impaired his speech and hearing. Most
likely, the client has experienced damage to the:
A. frontal lobe
B. parietal lobe
C. occipital lobe
D. temporal lobe
ANS: D
The portion of the cerebrum that controls speech
and hearing is the temporal lobe. Injury to the
frontal lobe causes personality changes, difficulty
speaking, and disturbance in memory, reasoning,
and concentration. Injury to the parietal lobe
causes sensory alterations and problems with
spatial relationships. Damage to the occipital lobe
causes vision disturbances
6. The nurse is assessing a postcraniotomy client
and finds the urine output from a catheter is 1500
ml for the 1st hour and the same for the 2nd hour.
The nurse should suspect:
A. Cushing’s syndrome
B. Diabetes mellitus
C. Adrenal crisis
D. Diabetes insipidus
ANS: D
Diabetes insipidus is an abrupt onset of
extreme polyuria that commonly occurs in
clients after brain surgery. Cushing’s syndrome
 is excessive glucocorticoid secretion resulting
in sodium and water retention. Diabetes
mellitus is a hyperglycemic state marked by
polyuria, polydipsia, and polyphagia. Adrenal
crisis is undersecretion of glucocorticoids
resulting in profound hypoglycemia,
hypovolemia, and hypotension
7. The nurse is providing postprocedure care for a
client who underwent percutaneous lithotripsy. In
this procedure, an ultrasonic probe inserted through
a nephrostomy tube into the renal pelvis generates
ultra-high-frequency sound waves to shatter renal
calculi. The nurse should instruct the client to:
A. limit oral fluid intake for 1 to 2 weeks
B. report the presence of fine, sandlike particles
through the nephrostomy tube.
C. Notify the physician about cloudy or foul
smelling urine
D. Report bright pink urine within 24 hours after
the procedure
ANS: C
The client should report the presence of
foulsmelling or cloudy urine. Unless
contraindicated, the client should be instructed to
drink large quantities of fluid each day to flush the
kidneys. Sand-like debris is normal because of
residual stone products. Hematuria is common after
lithotripsy.
8. A client with a serum glucose level of 618 mg/dl
is admitted to the facility. He’s awake and oriented,
has hot dry skin, and has the following vital signs:
temperature of 100.6º F (38.1º C), heart rate of 116
beats/minute, and blood pressure of 108/70 mm Hg.
Based on these assessment findings, which nursing
diagnosis takes the highest priority?
A. deficient fluid volume related to osmotic
diuresis
B. decreased cardiac output related to elevated
heart rate
C. imbalanced nutrition: Less than body
requirements related to insulin deficiency
D. ineffective thermoregulation related to
dehydration
ANS: A
A serum glucose level of 618 mg/dl indicates
hyperglycemia, which causes polyuria and deficient
fluid volume. In this client, tachycardia is more
likely to result from deficient fluid volume than
from decreased cardiac output because his blood
pressure is normal. Although the client’s serum
glucose is elevated, food isn’t a priority because
fluids and insulin should be administered to lower
the serum glucose level. Therefore, a diagnosis of
Imbalanced Nutrition: Less then body requirements
isn’t appropriate. A temperature of 100.6º F isn’t
life threatening, eliminating ineffective
thermoregulation as the top priority.
9. Capillary glucose monitoring is being performed
every 4 hours for a client diagnosed with diabetic
ketoacidosis. Insulin is administered using a scale of
regular insulin according to glucose results. At 2
p.m., the client has a capillary glucose level of 250
mg/dl for which he receives 8 U of regular insulin.
The
nurse should expect the dose’s:
A. onset to be at 2 p.m. and its peak at 3 p.m.
B. onset to be at 2:15 p.m. and its peak at 3 p.m.
C. onset to be at 2:30 p.m. and its peak at 4 p.m.
D. onset to be at 4 p.m. and its peak at 6 p.m.
ANS: C
Regular insulin, which is a short-acting insulin, has
an onset of 15 to 30 minutes and a peak of 2 to 4
hours. Because the nurse gave the insulin at 2 p.m.,
the expected onset would be from 2:15 to 2:30 p.m.
and the peak from 4 p.m. to 6 p.m.
10. A client with a head injury is being monitored
for increased intracranial pressure (ICP). His blood
pressure is 90/60 mmHG and the ICP is 18 mmHg;
therefore his cerebral perfusion pressure (CPP) is:
A. 52 mm Hg
B. 88 mm Hg
C. 48 mm Hg
D. 68 mm Hg
ANS: A
CPP is derived by subtracting the ICP from the
mean arterial pressure (MAP). For adequate
cerebral perfusion to take place, the minimum goal
is 70 mmHg. The MAP is derived using the
following formula:
MAP = ((diastolic blood pressure x 2) + systolic
blood pressure) / 3
MAP = ((60 x2) + 90) / 3
MAP = 70 mmHg
To find the CPP, subtract the client’s ICP from the
MAP; in this case , 70 mmHg – 18 mmHg = 52
mmHg.
11. A 52 yr-old female tells the nurse 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 a mobile mass
B. nonmobile mass with irregular edges
C. mobile mass that is oft and easily delineated
D. nonpalpable right axillary lymph nodes
ANS: B
Breast cancer tumors are fixed, hard, and poorly
delineated with irregular edges. Nipple retraction —
not eversion—may be a sign of cancer. A mobile
mass that is soft and easily delineated is most often
a fluid-filled benigned cyst. Axillary lymph nodes
may or may not be palpable on initial detection of a
cancerous mass.
12. A Client is scheduled to have a descending
colostomy. He’s very anxious and has many
questions regarding the surgical procedure, care of
stoma, and lifestyle changes. It would be most
appropriate for the nurse to make a referral to which
member of the health care team?
A. Social worker
B. registered dietician
C. occupational therapist
D. enterostomal nurse therapist
ANS: D
An enterostomal nurse therapist is a registered nurse
who has received advance education in an
accredited program to care for clients with stomas.
The enterostomal nurse therapist can assist with
selection of an appropriate stoma site, teach about
stoma care, and provide emotional support.
13. Ottorrhea and rhinorrhea are most commonly
seen with which type of skull fracture?
A. basilar
B. temporal
C. occipital
D. parietal
ANS: A
Ottorrhea and rhinorrhea are classic signs of
basilar skull fracture. Injury to the dura commonly
occurs with this fracture, resulting in cerebrospinal
fluid (CSF) leaking through the ears and nose. Any
fluid suspected of being CSF should be checked
for glucose or have a halo test done
14. A male client should be taught about testicular
examinations:
A. when sexual activity starts
B. after age 60
C. after age 40
D. before age 20
ANS: D
Testicular cancer commonly occurs in men between
ages 20 and 30. A male client should be taught how
to perform testicular self-examination before age 20,
preferably when he enters his teens.
15. Before weaning a client from a ventilator, which
assessment parameter is most important for the
nurse to review?
A. fluid intake for the last 24 hours
B. baseline arterial blood gas (ABG) levels
C. prior outcomes of weaning
D. electrocardiogram (ECG) results
ANS: B
Before weaning a client from mechanical
ventilation, it’s most important to have a baseline
ABG levels. During the weaning process, ABG
levels will be checked to assess how the client is
tolerating the procedure. Other assessment
parameters are less critical. Measuring fluid volume
intake and output is always important when a client
is being mechanically ventilated. Prior attempts at
weaning and ECG results are documented on the
client’s record, and the nurse can refer to them
before the weaning process begins.
16. The nurse is speaking to a group of women
about early detection of breast cancer. The average
age of the women in the group is 47. Following the
American Cancer Society (ACS) guidelines, the
nurse should recommend that the women:
A. perform breast self-examination annually
B. have a mammogram annually
C. have a hormonal receptor assay annually
D. have a physician conduct a clinical evaluation
every 2 years
ANS: B
According to the ACS guidelines, “Women older
than age 40 should perform breast selfexamination
monthly (not annually).” The hormonal receptor
assay is done on a known breast tumor to determine
whether the tumor is estrogen- or progesterone-
dependent.
17. When caring for a client with esophageal
varices, the nurse knows that bleeding in this
disorder usually stems from:
A. esophageal perforation
B. pulmonary hypertension
C. portal hypertension
D. peptic ulcers
ANS: C
Increased pressure within the portal veins causes
them to bulge, leading to rupture and bleeding into
the lower esophagus. Bleeding associated with
esophageal varices doesn’t stem from esophageal
perforation, pulmonary hypertension, or peptic
ulcers
18. A 49-yer-old client was admitted for surgical
repair of a Colles’ fracture. An external fixator was
placed during surgery. The surgeon explains that
this method of repair:
A. has very low complication rate
 B. maintains reduction and overall hand
function
C. is less bothersome than a cast
D. is best for older people
ANS: B
Complex intra-articular fractures are repaired with
external fixators because they have a better long-
term outcome than those treated with casting. This
is especially true in a young client. The incidence of
complications, such as pin tract infections and
neuritis, is 20% to 60%. Clients must be taught how
to do pin care and assess for development of
neurovascular complications.
19. A client is hospitalized with a diagnosis of
chronic renal failure. An arteriovenous fistula was
created in his left arm for hemodialysis. When
preparing the client for discharge, the nurse should
reinforce which dietary instruction?
A. “Be sure to eat meat at every meal.”
B. “Monitor your fruit intake and eat plenty of
bananas.”
C. “Restrict your salt intake.”
D. “Drink plenty of fluids.”
20. The nurse is caring for a client who has just had
a modified radical mastectomy with immediate
reconstruction. She’s in her 30s and has tow
children. Although she’s worried about her future,
she seems to be adjusting well to her diagnosis.
What should the nurse do to support
her coping?
A. Tell the client’s spouse or partner to be
supportive while she recovers.
B. Encourage the client to proceed with the next
phase of treatment.
C. Recommend that the client remain cheerful for
the sake of her children.
D. Refer the client to the American Cancer
Society’s Reach for Recovery program or
another support program.
21. A 21 year-old male has been seen in the clinic
for a thickening in his right testicle. The physician
ordered a human chorionic gonadotropin (HCG)
level. The nurse’s explanation to the client should
include the fact that:
A. The test will evaluate prostatic function.
B. The test was ordered to identify the site of a
possible infection.
C. The test was ordered because clients who have
testicular cancer has elevated levels of HCG.
D. The test was ordered to evaluate the
testosterone level.
22. A client is receiving captopril (Capoten) for
heart failure. The nurse should notify the physician
that the medication therapy is ineffective if an
assessment reveals:
A. A skin rash.
B. Peripheral edema.
C. A dry cough.
D. Postural hypotension.
23. Which assessment finding indicates dehydration?
A. Tenting of chest skin when pinched.
B. Rapid filling of hand veins.
C. A pulse that isn’t easily obliterated.
D. Neck vein distention
24. The nurse is teaching a client with a 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.
25. For a client newly diagnosed with
radiationinduced thrombocytopenia, the nurse
should include which intervention in the plan of
care?
A. Administer aspirin if the temperature exceeds
38.8º C.
B. Inspect the skin for petechiae once every shift.
C. Provide for frequent periods of rest.
D. Place the client in strict isolation.
26. A client is chronically short of breath and yet
has normal lung ventilation, clear lungs, and an
arterial oxygen saturation (SaO2) 96% or better.
The client most likely has:
A. poor peripheral perfusion
B. a possible Hematologic problem
C. a psychosomatic disorder
D. left-sided heart failure
27. For a client in addisonian crisis, it would be
very risky for a nurse to administer:
A. potassium chloride
B. normal saline solution
C. hydrocortisone
D. fludrocortisone
28. The nurse is reviewing the laboratory report of a
client who underwent a bone marrow biopsy. The
finding that would most strongly support a
diagnosis of acute leukemia is the existence of a
large number of immature:
A. lymphocytes
B. thrombocytes
C. reticulocytes
D. leukocytes
29. The nurse is performing wound care on a foot
ulcer in a client with type 1 diabetes mellitus.
Which technique demonstrates surgical asepsis?
A. Putting on sterile gloves then opening a
container of sterile saline.
B. Cleaning the wound with a circular motion,
moving from outer circles toward the center.
 C. Changing the sterile field after sterile water is
spilled on it.
D. Placing a sterile dressing ½” (1.3 cm) from the
edge of the sterile field.
30. A client with a forceful, pounding heartbeat is
diagnosed with mitral valve prolapse. This client
should avoid which of the following?
A. high volumes of fluid intake
B. aerobic exercise programs
C. caffeine-containing products
D. foods rich in protein
31. A client 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
organ?
A. adrenal cortex
B. pancreas
C. adrenal medulla
D. parathyroid
32. A client has a medical history of rheumatic
fever, type 1 (insulin dependent) diabetes mellitus,
hypertension, pernicious anemia, and appendectomy.
She’s admitted to the hospital and undergoes mitral
valve replacement surgery. After discharge, the
client is scheduled for a tooth extraction. Which
history finding is a major risk factor for infective
endocarditis?
A. appendectomy
B. pernicious anemia
C. diabetes mellitus
D. valve replacement
33. A 62 yr-old client diagnosed with pyelonephritis
and possible septicemia has had five urinary tract
infections over the past two years. She’s fatigued
from lack of sleep; urinates frequently, even during
the night; and has lost weight recently. Test reveal
the following: sodium level 152 mEq/L, osmolarity
340 mOsm/L, glucose level 125 mg/dl, and
potassium level 3.8 mEq/L. which of the following
nursing diagnoses is most appropriate for this client?
A. Deficient fluid volume related to inability to
conserve water
B. Imbalanced nutrition: less than body
requirements related to hypermetabolic state
C. Deficient fluid volume related to osmotic
diuresis induced by hypernatremia
D. Imbalanced nutrition: less than body
requirements related to catabolic effects of
insulin deficiency
34. A 20 yr-old woman has just been diagnosed
with Crohn’s disease. She has lost 10 lb (4.5 kg)
and has cramps and occasional diarrhea. The nurse
should include which of the following when doing a
nutritional assessment?
A. Let the client eat as desired during the
hospitalization.
B. Weight the client daily.
C. Ask the client to list what she eats during a
typical day.
D. Place the client on I & O status and draw blood
for electrolyte levels.
35. When instructions should be included in the
discharge teaching plan for a client after
thyroidectomy for Grave’s disease?
A. Keep an accurate record of intake and output.
B. Use nasal desmopressin acetate DDAVP).
C. Be sure to get regulate follow-up care.
D. Be sure to exercise to improve cardiovascular
fitness.
36. A client comes to the emergency department
with chest pain, dyspnea, and an irregular heartbeat.
An electrocardiogram shows a heart rate of 110
beats/minute (sinus tachycardia) with frequent
premature ventricular contractions. Shortly after
admission, the client has ventricular tachycardia and
becomes unresponsive. After successful
resuscitation, the client is taken to the intensive care
unit. Which nursing diagnosis is appropriate at this
time?
A. Deficient knowledge related to interventions
used to treat acute illness
B. Impaired physical mobility related to complete
bed rest
C. Social isolation related to restricted visiting
hours in the intensive care unit
D. Anxiety related to the threat of death
37. A client is admitted to the health care facility
with active tuberculosis. The nurse should include
which intervention in the plan of care?
A. Putting on a mask when entering the client’s
room.
B. Instructing the client to wear a mask at all
times
C. Wearing a gown and gloves when providing
direct care
D. Keeping the door to the client’s room open to
observe the client
38. The nurse is caring for a client who underwent a
subtotal gastrectomy 24 hours earlier. The client has
a nasogastric (NG) tube. The nurse should:
A. Apply suction to the NG tube every hour.
B. Clamp the NG tube if the client complains of
nausea.
C. Irrigate the NG tube gently with normal saline
solution.
D. Reposition the NG tube if pulled out.
39. Which statement about fluid replacement is
accurate for a client with hyperosmolar
hyperglycemic nonketotic syndrome (HHNS)?
A. administer 2 to 3 L of IV fluid rapidly
B. administer 6 L of IV fluid over the first 24
hours
 C. administer a dextrose solution containing
normal saline solution
D. administer IV fluid slowly to prevent
circulatory overload and collapse
40. Which of the following is an adverse reaction to
glipizide (Glucotrol)?
A. headache
B. constipation
C. hypotension
D. photosensitivity
41. The nurse is caring for four clients on a
stepdown intensive care unit. The client at the
highest risk for developing nosocomial pneumonia
is the one who:
A. has a respiratory infection
B. is intubated and on a ventilator
C. has pleural chest tubes
D. is receiving feedings through a jejunostomy
tube
42. The nurse is teaching a client with chronic
bronchitis about breathing exercises. Which of the
following should the nurse include in the teaching?
A. Make inhalation longer than exhalation.
B. Exhale through an open mouth.
C. Use diaphragmatic breathing.
D. Use chest breathing.
43. A client is admitted to the hospital with an
exacerbation of her chronic systemic lupus
erythematosus (SLE). She gets angry when her call
bell isn’t answered immediately. The most
appropriate response to her would be:
A. “You seem angry. Would you like to talk about
it?”
B. “Calm down. You know that stress will make
your symptoms worse.”
C. “Would you like to talk about the problem with
the nursing supervisor?”
D. “I can see you’re angry. I’ll come back when
you’ve calmed down.”
44. On a routine visit to the physician, a client with
chronic arterial occlusive disease reports stopping
smoking after 34 years. To relive symptoms of
intermittent claudication, a condition associated
with chronic arterial occlusive disease, the nurse
should recommend which additional measure?
A. Taking daily walks.
B. Engaging in anaerobic exercise.
C. Reducing daily fat intake to less than 45% of
total calories
D. Avoiding foods that increase levels of
highdensity lipoproteins (HDLs)
45. A physician orders gastric decompression for a
client with small bowel obstruction. The nurse
should plan for the suction to be:
A. low pressure and intermittent
B. low pressure and continuous
C. high pressure and continuous
D. high pressure and intermittent
46. Which nursing diagnosis is most appropriate for
an elderly client with osteoarthritis?
A. Risk for injury
B. Impaired urinary elimination
C. Ineffective breathing pattern
D. Imbalanced nutrition: less than body
requirements
47. Parathyroid hormone (PTH) has which effects
on the kidney?
A. Stimulation of calcium reabsorption and
phosphate excretion
B. Stimulation of phosphate reabsorption and
calcium excretion
C. Increased absorption of vit D and excretion of
vit E
D. Increased absorption of vit E and excretion of
Vit D
48. A visiting nurse is performing home assessment
for a 59-yr old man recently discharged after hip
replacement surgery. Which home assessment
finding warrants health promotion teaching from the
nurse?
A. A bathroom with grab bars for the tub and
toilet
B. Items stored in the kitchen so that reaching up
and bending down aren’t necessary
C. Many small, unsecured area rugs
D. Sufficient stairwell lighting, with switches to
the top and bottom of the stairs
49. A client with autoimmune thrombocytopenia
and a platelet count of 800/uL develops epistaxis
and melena. Treatment with corticosteroids and
immunoglobulins has been unsuccessful, and the
physician recommends a splenectomy. The client
states, “I don’t need surgery—this will go away on
its own.” In considering her response to the client,
the nurse must depend on the ethical principle of:
A. beneficence
B. autonomy
C. advocacy
D. justice
50. Which of the following is t he most critical
intervention needed for a client with myxedema
coma?
A. Administering and oral dose of levothyroxine
(Synthroid)
B. Warming the client with a warming blanket
C. Measuring and recording accurate intake and
output
D. Maintaining a patent airway
51. Because diet and exercise have failed to control
a 63 yr-old client’s blood glucose level, the client is
prescribed glipizide (Glucotrol). After oral
administration, the onset of action is:
 A. 15 to 30 minutes
B. 30 to 60 minutes
C. 1 to 1 ½ hours
D. 2 to 3 hours
52. A client with pneumonia is receiving
supplemental oxygen, 2 L/min via nasal cannula.
The client’s history includes chronic obstructive
pulmonary disease (COPD) and coronary artery
disease. Because of these findings, the nurse closely
monitors the oxygen flow and the client’s
respiratory status. Which complication may arise if
the client receives a high oxygen concentration?
A. Apnea
B. Anginal pain
C. Respiratory alkalosis
D. Metabolic acidosis
53. A client with type 1 diabetes mellitus has been
on a regimen of multiple daily injection therapy.
He’s being converted to continuous subcutaneous
insulin therapy. While teaching the client bout
continuous subcutaneous insulin therapy, the nurse
would be accurate in telling him the regimen
includes the use of:
A. intermediate and long-acting insulins
B. short and long-acting insulins
C. short-acting only
D. short and intermediate-acting insulins
54. a client who recently had a cerebrovascular
accident requires a cane to ambulate. When
teaching about cane use, the rationale for holding a
cane on the uninvolved side is to:
A. prevent leaning
B. distribute weight away from the involved side
C. maintain stride length
D. prevent edema
55. A client with a history of an anterior wall
myocardial infarction is being transferred from the
coronary care unit (CCU) to the cardiac stepdown
unit (CSU). While giving report to the CSU nurse,
the CCU nurse says, “His pulmonary artery wedge
pressures have been in the high normal range.” The
CSU nurse should be especially observant for:
A. hypertension
B. high urine output
C. dry mucous membranes
D. pulmonary crackles
56. The nurse is caring for a client with a fractures
hip. The client is combative, confused, and trying to
get out of bed. The nurse should:
A. leave the client and get help
B. obtain a physician’s order to restrain the client
C. read the facility’s policy on restraints
D. order soft restraints from the storeroom
57. For the first 72 hours after thyroidectomy
surgery, the nurse would assess the client for
Chvostek’s sign and Trousseau’s sign because they
indicate which of the following?
A. hypocalcemia
B. hypercalcemia
C. hypokalemia
D. Hyperkalemia
58. In a client with enteritis and frequent diarrhea,
the nurse should anticipate an acidbase imbalance
of:
A. respiratory acidosis
B. respiratory alkalosis
C. metabolic acidosis
D. metabolic alkalosis
59. When caring for a client with the nursing
diagnosis Impaired swallowing related to
neuromuscular impairment, the nurse should:
A. position the client in a supine position
B. elevate the head of the bed 90 degrees during
meals
C. encourage the client to remove dentures
D. encourage thin liquids for dietary intake
60. A nurse is caring for a client who has a
tracheostomy and temperature of 39º C. which
intervention will most likely lower the client’s
arterial blood oxygen saturation?
A. Endotracheal suctioning
B. Encouragement of coughing
C. Use of cooling blanket
D. Incentive spirometry
61. A client with a solar burn of the chest, back,
face, and arms is seen in urgent care. The nurse’s
primary concern should be:
A. fluid resuscitation
B. infection
C. body image
D. pain management
62. Which statement is true about crackles?
A. They’re grating sounds.
B. They’re high-pitched, musical squeaks.
C. They’re low-pitched noises that sound like
snoring.
D. They may be fine, medium, or course.
63. A woman whose husband was recently
diagnosed with active pulmonary tuberculosis (TB)
is a tuberculin skin test converter. Management of
her care would include:
A. scheduling her for annual tuberculin skin
testing
B. placing her in quarantine until sputum cultures
are negative
C. gathering a list of persons with whom she has
had recent contact
D. advising her to begin prophylactic therapy with
isoniazid (INH)
64. The nurse is caring for a client who ahs had an
above the knee amputation. The client refuses to
look at the stump. When the nurse attempts to speak
with the client about his surgery, he tells the nurse
that he doesn’t wish to discuss it. The client also
refuses to have his family visit. The nursing
diagnosis that best describes the client’s problem is:
A. Hopelessness
B. Powerlessness
C. Disturbed body image
D. Fear
65. A client with three children who is still I the
child bearing years is admitted for surgical repair of
a prolapsed bladder. The nurse would find that the
client understood the surgeon’s preoperative
teaching when the client states:
A. “If I should become pregnant again, the child
would be delivered by cesarean delivery.”
B. “If I have another child, the procedure may
need to be repeated.”
C. “This surgery may render me incapable of
conceiving another child.”
D. “This procedure is accomplished in two
separate surgeries.”
66. A client experiences problems in body
temperature regulation associated with a skin
impairment. Which gland is most likely involved?
A. Eccrine
B. Sebaceous
C. Apocrine
D. Endocrine
67. A school cafeteria worker comes to the
physician’s office complaining of severe scalp
itching. On inspection, the nurse finds nail marks on
the scalp and small light-colored round specks
attached to the hair shafts close to the scalp. These
findings suggest that the client suffers from:
A. scabies
B. head lice
C. tinea capitis
D. impetigo
68. Following a small-bowel resection, a client
develops fever and anemia. The surface surrounding
the surgical wound is warm to touch and necrotizing
fasciitis is suspected. Another manifestation that
would most suggest necrotizing fasciitis is:
A. erythema
B. leukocytosis
C. pressure-like pain
D. swelling
69. A 28 yr-old nurse has complaints of itching and
a rash of both hands. Contact dermatitis is initially
suspected. The diagnosis is confirmed if the rash
appears:
A. erythematous with raised papules
B. dry and scaly with flaking skin
C. inflamed with weeping and crusting lesions
D. excoriated with multiple fissures
70. When assessing a client with partial thickness
burns over 60% of the body, which of the following
should the nurse report immediately?
A. Complaints of intense thirst
B. Moderate to severe pain
C. Urine output of 70 ml the 1st hour
D. Hoarseness of the voice
71. A client is admitted to the hospital following a
burn injury to the left hand and arm. The client’s
burn is described as white and leathery with no
blisters. Which degree of severity is this burn?
A. first-degree burn
B. second-degree burn
C. third-degree burn
D. fourth-degree burn
72. The nurse is caring for client with a new donor
site that was harvested to treat a new burn. The
nurse position the client to:
A. allow ventilation of the site
B. make the site dependent
C. avoid pressure on the site
D. keep the site fully covered
73. a 45-yr-old auto mechanic comes to the
physician’s office because an exacerbation of his
psoriasis is making it difficult to work. He tells the
nurse that his finger joints are stiff and sore in the
morning. The nurse should respond by:
A. Inquiring further about this problem because
psoriatic arthritis can accompany psoriasis
vulgaris
B. Suggesting he take aspirin for relief because
it’s probably early rheumatoid arthritis
C. Validating his complaint but assuming it’s an
adverse effect of his vocation
D. Asking him if he has been diagnosed or treated
for carpal tunnel syndrome
74. The nurse is providing home care instructions to
a client who has recently had a skin graft. Which
instruction is most important for the client to
remember?
A. Use cosmetic camouflage techniques.
B. Protect the graft from direct sunlight.
C. Continue physical therapy.
D. Apply lubricating lotion to the graft site.
75. a 28 yr-old female nurse is seen in the employee
health department for mild itching and rash of both
hands. Which of the following could be causing this
reaction?
A. possible medication allergies
B. current life stressors she may be experiencing
C. chemicals she may be using and use of latex
gloves
D. recent changes made in laundry detergent or
bath soap.
76. The nurse assesses a client with urticaria. The
nurse understands that urticaria is another name for:
 A. hives
B. a toxin
C. a tubercle
D. a virus
77. A client with psoriasis visits the dermatology
clinic. When inspecting the affected areas, the nurse
expects to see which type of secondary lesion?
A. scale
B. crust
C. ulcer
D. scar
78. The nurse is caring for a bedridden, elderly
adult. To prevent pressure ulcers, which
intervention should the nurse include in the plan of
care?
A. Turn and reposition the client a minimum of
every 8 hours.
B. Vigorously massage lotion into bony
prominences.
C. Post a turning schedule at the client’s bedside.
D. Slide the client, rather than lifting when turning.
79. Following a full-thickeness (3rd degree) burn of
his left arm, a client is treated with artificial skin.
The client understands postoperative care of the
artificial skin when he states that during the first 7
days after the procedure, he’ll restrict:
A. range of motion
B. protein intake
C. going outdoors
D. fluid ingestion
80. A client received burns to his entire back and
left arm. Using the Rule of Nines, the nurse can
calculate that he has sustained burns on what
percentage of his body?
A. 9%
B. 18%
C. 27%
D. 36%
81. The nurse is providing care for a client who has
a sacral pressure ulcer with wet-to-dry dressing.
Which guideline is appropriate for a wet-to-dry
dressing?
A. The wound should remain moist form the
dressing.
B. The wet-to-dry dressing should be tightly
packed into the wound.
C. The dressing should be allowed to dry out
before removal.
D. A plastic sheet-type dressing should cover the
wet dressing.
82. While in skilled nursing facility, a client
contracted scabies, which is diagnosed the day after
discharge. The client is living at her daughter’s
home with six other persons. During her visit to the
clinic, she asks a staff nurse, “What should my
family do?” the most accurate response from the
nurse is:
A. “All family members will need to be treated.”
B. “If someone develops symptoms, tell him to
see a physician right away.”
C. “Just be careful not to share linens and towels
with family members.”
D. “After you’re treated, family members won’t
be at risk for contracting scabies.”
83. In an industrial accident, client who weighs 155
lb (70.3 kg) sustained full-thickness burns over 40%
of his body. He’s in the burn unit receiving fluid
resuscitation. Which observation shows that the
fluid resuscitation is benefiting the client?
A. A urine output consistently above 100 ml/hour.
B. A weight gain of 4 lb (1.8 kg) in 24 hours.
C. Body temperature readings all within normal
limits
D. An electrocardiogram (ECG) showing no
arrhythmias.
84. The nurse is reviewing the laboratory results of
a client with rheumatoid arthritis. Which of the
following laboratory results should the nurse expect
to find?
A. Increased platelet count
B. Elevated erythrocyte sedimentation rate (ESR)
C. Electrolyte imbalance
D. Altered blood urea nitrogen (BUN) and
creatinine levels
85. Which nursing diagnosis takes the highest
priority for a client with Parkinson’s crisis?
A. Imbalanced nutrition: less than body
requirements
B. Ineffective airway clearance
C. Impaired urinary elimination
D. Risk for injury
86. A client with a spinal cord injury and
subsequent urine retention receives intermittent
catheterization every 4 hours. The average
catheterized urine volume has been 550 ml. The
nurse should plan to:
A. Increase the frequency of the catheterizations.
B. Insert an indwelling urinary catheter
C. Place the client on fluid restrictions
D. Use a condom catheter instead of an invasive
one.
87.The nurse is caring for a client who is to undergo
a lumbar puncture to assess for the presence of
blood in the cerebrospinal fluid (CSF) and to
measure CSF pressure. Which result would indicate
n abnormality?
A. The presence of glucose in the CSF.
B. A pressure of 70 to 200 mm H2O
C. The presence of red blood cells (RBCs) in the
first specimen tube
D. A pressure of 00 to 250 mmH2O
88. The nurse is administering eyedrops to a client
with glaucoma. To achieve maximum absorption,
the nurse should instill the eyedrop into the:
 A. conjunctival sac
B. pupil
C. sclera
D. vitreous humor
89. A 52 yr-old married man with two adolescent
children is beginning rehabilitation following a
cerebrovascular accident. As the nurse is planning
the client’s care, the nurse should recognize that his
condition will affect:
A. only himself
B. only his wife and children
C. him and his entire family
D. no one, if he has complete recovery
90. Which action should take the highest priority
when caring for a client with hemiparesis caused by
a cerebrovascular accident (CVA)?
A. Perform passive range-of-motion (ROM)
exercises.
B. Place the client on the affected side.
C. Use hand rolls or pillows for support.
D. Apply antiembolism stockings
91. The nurse is formulating a teaching plan for a
client who has just experienced a transient ischemic
attack (TIA). Which fact should the nurse include in
the teaching plan?
A. TIA symptoms may last 24 to 48 hours.
B. Most clients have residual effects after having
a TIA.
C. TIA may be a warning that the client may have
cerebrovascular accident (CVA)
D. The most common symptom of TIA is the
inability to speak.
92. The nurse has just completed teaching about
postoperative activity to a client who is going to
have a cataract surgery. The nurse knows the
teaching has been effective if the client:
A. coughs and deep breathes postoperatively
B. ties his own shoes
C. asks his wife to pick up his shirt from the floor
after he drops it.
D. States that he doesn’t need to wear an eyepatch
or guard to bed
93. The least serious form of brain trauma,
characterized by a brief loss of consciousness and
period of confusion, is called:
A. contusion
B. concussion
C. coup
D. contrecoup
94. When the nurse performs a neurologic
assessment on Anne Jones, her pupils are dilated
and don’t respond to light.
A. glaucoma
B. damage to the third cranial nerve
C. damage to the lumbar spine
D. Bell’s palsy
95. A 70 yr-old client with a diagnosis of leftsided
cerebrovascular accident is admitted to the facility.
To prevent the development of diffuse osteoporosis,
which of the following objectives is most
appropriate?
A. Maintaining protein levels.
B. Maintaining vitamin levels.
C. Promoting weight-bearing exercises
D. Promoting range-of-motion (ROM) exercises
96. A client is admitted with a diagnosis of
meningitis caused by Neisseria meningitides. The
nurse should institute which type of isolation
precautions?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions
97. A young man was running along an ocean pier,
tripped on an elevated area of the decking, and
struck his head on the pier railing. According to his
friends, “He was unconscious briefly and then
became alert and behaved as though nothing had
happened.” Shortly afterward, he began
complaining of a headache and asked to be taken to
the emergency department. If the client’s
intracranial pressure (ICP) is increasing, the nurse
would expect to observe which of the
following signs first?
A. pupillary asymmetry
B. irregular breathing pattern
C. involuntary posturing
D. declining level of consciousness
98. Emergency medical technicians transport a 28
yr-old iron worker to the emergency department.
They tell the nurse, “He fell from a two-story
building. He has a large contusion on his left chest
and a hematoma in the left parietal area. He has
compound fracture of his left femur and he’s
comatose. We intubated him and he’s maintaining
an arterial oxygen saturation of 92% by pulse
oximeter with a manual-resuscitation bag.” Which
intervention by the nurse has the highest priority?
A. Assessing the left leg
B. Assessing the pupils
C. Placing the client in Trendelenburg’s position
D. Assessing the level of consciousness
99. Alzheimer’s disease is the secondary diagnosis
of a client admitted with myocardial infarction.
Which nursing intervention should appear on this
client’s plan of care?
A. Perform activities of daily living for the client
to decease frustration.
B. Provide a stimulating environment.
C. Establish and maintain a routine.
D. Try to reason with the client as much as
possible.
100. For a client with a head injury whose neck has
been stabilized, the preferred bed position is:
A. Trendelenburg’s
B. 30-degree head elevation
C. flat
D. side-lying
Answers and Rationales
1. ANS: D
Because the client’s gag reflex is absent,
elevating the head of the bed to 30 degrees
helps minimize the client’s risk of aspiration.
Checking the stools, performing ROM
exercises, and keeping the skin clean and dry
are important, but preventing aspiration
through positioning is the priority.
2. ANS: A
Any hole, no matter how small, will destroy
the odor-proof seal of a drainage bag.
Removing the bag or unclamping it is the only
appropriate method for relieving gas.
3. ANS: A
because celiac disease destroys the absorbing
surface of the intestine, fat isn’t absorbed but is
passed in the stool. Steatorrhea is bulky, fatty
stools that have a foul odor. Jaundiced sclerae
result from elevated bilirubin levels. Clay-
colored stools are seen with biliary disease
when bile flow is blocked. Celiac disease
doesn’t cause a widened pulse pressure.
4. ANS: D
Reducing sodium intake reduces fluid retention.
Fluid retention increases blood volume, which
changes blood vessel permeability and allows
plasma to move into interstitial tissue, causing
edema. Urea nitrogen excretion can be
increased only by improved renal function.
Sodium intake doesn’t affect the glomerular
filtration rate. Potassium absorption is
improved only by increasing the glomerular
filtration rate; it isn’t affected by sodium intake.
5. ANS: D
The portion of the cerebrum that controls
speech and hearing is the temporal lobe. Injury
to the frontal lobe causes personality changes,
difficulty speaking, and disturbance in memory,
reasoning, and concentration. Injury to the
parietal lobe causes sensory alterations and
problems with spatial relationships. Damage to
the occipital lobe causes vision disturbances.
6. ANS: D
Diabetes insipidus is an abrupt onset of
extreme polyuria that commonly occurs in
clients after brain surgery. Cushing’s syndrome
is excessive glucocorticoid secretion resulting
in sodium and water retention. Diabetes
mellitus is a hyperglycemic state marked by
polyuria, polydipsia, and polyphagia. Adrenal
crisis is undersecretion of glucocorticoids
resulting in profound hypoglycemia,
hypovolemia, and hypotension.
7. ANS: C
The client should report the presence of
foulsmelling or cloudy urine. Unless
contraindicated, the client should be instructed
to drink large quantities of fluid each day to
flush the kidneys. Sand-like debris is normal
because of residual stone products. Hematuria
is common after lithotripsy.
8. ANS: A
A serum glucose level of 618 mg/dl indicates
hyperglycemia, which causes polyuria and
deficient fluid volume. In this client,
tachycardia is more likely to result from
deficient fluid volume than from decreased
cardiac output because his blood pressure is
normal. Although the client’s serum glucose is
elevated, food isn’t a priority because fluids
and insulin should be administered to lower the
serum glucose level. Therefore, a diagnosis of
Imbalanced Nutrition: Less then body
requirements isn’t appropriate. A temperature
of 100.6º F isn’t life threatening, eliminating
ineffective thermoregulation as the top priority.
9. ANS: C
Regular insulin, which is a short-acting insulin,
has an onset of 15 to 30 minutes and a peak of
2 to 4 hours. Because the nurse gave the insulin
at 2 p.m., the expected onset would be from
2:15 to 2:30 p.m. and the peak from 4 p.m. to 6
p.m.
10. ANS: A
CPP is derived by subtracting the ICP from the
mean arterial pressure (MAP). For adequate
cerebral perfusion to take place, the minimum
goal is 70 mmHg. The MAP is derived using
the following formula:
MAP = ((diastolic blood pressure x 2) +
systolic blood pressure) / 3
MAP = ((60 x2) + 90) / 3
MAP = 70 mmHg
To find the CPP, subtract the client’s ICP from
the MAP; in this case , 70 mmHg – 18 mmHg
= 52 mmHg.
11. ANS: B
Breast cancer tumors are fixed, hard, and
poorly delineated with irregular edges. Nipple
retraction —not eversion—may be a sign of
cancer. A mobile mass that is soft and easily
delineated is most often a fluid-filled benigned
cyst. Axillary lymph nodes may or may not be
palpable on initial detection of a cancerous
mass.
12. ANS: D
An enterostomal nurse therapist is a registered
nurse who has received advance education in
an accredited program to care for clients with
stomas. The enterostomal nurse therapist can
assist with selection of an appropriate stoma
site, teach about stoma care, and provide
emotional support.
13. ANS: A
Ottorrhea and rhinorrhea are classic signs of
 basilar skull fracture. Injury to the dura
commonly occurs with this fracture, resulting
in cerebrospinal fluid (CSF) leaking through
the ears and nose. Any fluid suspected of being
CSF should be checked for glucose or have a
halo test done.
14. ANS: D
Testicular cancer commonly occurs in men
between ages 20 and 30. A male client should
be taught how to perform testicular self-
examination before age 20, preferably when he
enters his teens.
15. ANS: B
Before weaning a client from mechanical
ventilation, it’s most important to have a
baseline ABG levels. During the weaning
process, ABG levels will be checked to assess
how the client is tolerating the procedure.
Other assessment parameters are less critical.
Measuring fluid volume intake and output is
always important when a client is being
mechanically ventilated. Prior attempts at
weaning and ECG results are documented on
the client’s record, and the nurse can refer to
them before the weaning process begins.
16. ANS: B
According to the ACS guidelines, “Women
older than age 40 should perform breast
selfexamination monthly (not annually).” The
hormonal receptor assay is done on a known
breast tumor to determine whether the tumor is
estrogen- or progesterone-dependent.
17. ANS: C
Increased pressure within the portal veins
causes them to bulge, leading to rupture and
bleeding into the lower esophagus. Bleeding
associated with esophageal varices doesn’t
stem from esophageal perforation, pulmonary
hypertension, or peptic ulcers.
18. ANS: B
Complex intra-articular fractures are repaired
with external fixators because they have a
better long-term outcome than those treated
with casting. This is especially true in a young
client. The incidence of complications, such as
pin tract infections and neuritis, is 20% to 60%.
Clients must be taught how to do pin care and
assess for development of neurovascular
complications.
19. ANS: C
In a client with chronic renal failure,
unrestricted intake of sodium, protein,
potassium, and fluids may lead to a dangerous
accumulation of electrolytes and protein
metabolic products, such as amino acids and
ammonia. Therefore, the client must limit his
intake of sodium, meat (high in Protein),
bananas (high in potassium), and fluid because
the kidneys can’t secrete adequate urine.
20. ANS: D
The client isn’t withdrawn or showing other
signs of anxiety or depression. Therefore, the
nurse can probably safely approach her about
talking with others who have had similar
experiences, either through Reach for
Recovery or another formal support group. The
nurse may educate the client’s spouse or
partner to listen to concerns, but the nurse
shouldn’t tell the client’s spouse what to do.
The client must consult with her physician and
make her own decisions
about further treatment. The client needs to
express her sadness, frustration, and fear. She
can’t be expected to be cheerful at all times.
21. ANS: C
HCG is one of the tumor markers for testicular
cancer. The HCG level won’t identify the site
of an infection or evaluate prostatic function or
testosterone level.
22. ANS: B
Peripheral edema is a sign of fluid volume
overload and worsening heart failure. A skin
rash, dry cough, and postural hypotension are
adverse reactions to captopril, but the don’t
indicate that therapy isn’t effective.
23. ANS: A
Tenting of chest skin when pinched indicates
decreased skin elasticity due to dehydration.
Hand veins fill slowly with dehydration, not
rapidly. A pulse that isn’t easily obliterated and
neck vein distention indicate fluid overload,
not dehydration.
24. ANS: B
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.
25. ANS: B
Because thrombocytopenia impairs blood
clotting, the nurse should assess the client
regularly for signs of bleeding, such as
petechiae, purpura, epistaxis, and bleeding
gums. The nurse should avoid administering
aspirin because it can increase the risk of
bleeding. Frequent rest periods are indicated
for clients with anemia, not thrombocytopenia.
Strict isolation is indicated only for clients who
have highly contagious or virulent infections
that are spread by air or physical contact.
26. ANS: B
SaO2 is the degree to which hemoglobin is
saturated with oxygen. It doesn’t indicate the
client’s overall Hgb adequacy. Thus, an
individual with a subnormal Hgb level could
have normal SaO2 and still be short of breath.
In this case, the nurse could assume that the
client has a Hematologic problem. Poor
peripheral perfusion would cause subnormal
SaO2. There isn’t enough data to assume that
the client’s problem is psychosomatic. If the
problem were
left-sided heart failure, the client would exhibit
pulmonary crackles.
27. ANS: A
Addisonian crisis results in Hyperkalemia;
therefore, administering potassium chloride is
contraindicated. Because the client will be
hyponatremic, normal saline solution is
indicated. Hydrocortisone and fludrocortisone
are both useful in replacing deficient adrenal
cortex hormones.
28. ANS: D
Leukemia is manifested by an abnormal
overpopulation of immature leukocytes in the
bone marrow.
29. ANS: C
A sterile field is considered contaminated when
it becomes wet. Moisture can act as a wick,
allowing microorganisms to contaminate the
field. The outside of containers, such as sterile
saline bottles, aren’t sterile. The containers
should be opened before sterile gloves are put
on and the solution poured over the sterile
dressings placed in a sterile basin. Wounds
should be cleaned from the most contaminated
area to the least contaminated area—for
example, from the center outward. The outer
inch of a sterile field shouldn’t be considered
sterile.
30. ANS: C
Caffeine is a stimulant, which can exacerbate
palpitations and should be avoided by a client
with symptomatic mitral valve prolapse. High
fluid intake helps maintain adequate preload
and cardiac output. Aerobic exercise helps in
increase cardiac output and decrease heart rate.
Protein-rich foods aren’t restricted but high
calorie foods are.
31. ANS: A
Excessive 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
cathecolamines—epinephrine and
norepinephrine. The parathyroids secrete
parathyroid hormone.
32. ANS: D
A heart valve prosthesis, such as a mitral valve
replacement, is a major risk factor for infective
endocarditis. Other risk factors include a
history of heart disease (especially mitral valve
prolapse), chronic debilitating disease, IV drug
abuse, and immunosuppression. Although
diabetes mellitus may predispose a person to
cardiovascular disease, it isn’t a major risk
factor for infective endocarditis, nor is an
appendectomy or pernicious anemia.
33. ANS: A
The client has signs and symptoms of diabetes
insipidus, probably caused by the failure of her
renal tubules to respond to antidiuretic
hormone as a consequence of pyelonephritis.
The hypernatremia is secondary to her water
loss. Imbalanced nutrition related to
hypermetabolic state or catabolic effect of
insulin deficiency is an inappropriate nursing
diagnosis for the client.
34. ANS: C
When performing a nutritional assessment, one
of the first things the nurse should do is to
assess what the client typically eats. The client
shouldn’t be permitted to eat as desired.
Weighing the client daily, placing her on I & O
status, and drawing blood to determine
electrolyte level aren’t part of a nutritional
assessment.
35. Ans. C
Regular follow-up care for the client with
Grave’s disease is critical because most cases
eventually result in hypothyroidism. Annual
thyroid-stimulating hormone tests and the
client’s ability to recognize signs and
symptoms of thyroid dysfunction will help
detect thyroid abnormalities early. Intake and
output is important for clients with fluid and
electrolyte imbalances but not thyroid disorders.
DDAVP is used to treat diabetes insipidus.
While exercise to improve cardiovascular
fitness is important, for this client the
importance of regular follow-up is most critical.
36. ANS: D
Anxiety related to the threat of death is an
appropriate nursing diagnosis because the
client’s anxiety can adversely affect hear rate
and rhythm by stimulating the autonomic
nervous system. Also, because the client
required resuscitation, the threat of death is a
real and immediate concern. Unless anxiety is
dealt with first, the client’s emotional state will
impede learning. Client teaching should be
limited to clear concise explanations that
reduce anxiety and promote cooperation. An
anxious client has difficulty learning, so the
deficient knowledge would continue despite
attempts teaching. Impaired physical mobility
and social isolation are necessitated by the
client’s critical condition; therefore, they aren’t
considered problems warranting nursing
diagnoses.
37. ANS: A
Because tuberculosis is transmitted by droplet
nuclei from the respiratory tract, the nurse
should put on a mask when entering the
client’s room. Having the client wear a mask at
all the times would hinder sputum
expectoration and make the mask moist from
respirations. If no contact with the client’s
blood or body fluids is anticipated, the nurse
need not wear a gown or gloves when
providing direct care. A client with
tuberculosis should be in a room with laminar
air flow, and the door should be closed at all
times.
38. ANS: C
The nurse can gently irrigate the tube but must
take care not to reposition it. Repositioning can
cause bleeding. Suction should be applied
continuously, not every hour. The NG tube
shouldn’t be clamped postoperatively because
secretions and gas will accumulate, stressing
the suture line.
39. ANS: A
Regardless of the client’s medical history,
rapid fluid resuscitation is critical for
maintaining cardiovascular integrity. Profound
intravascular depletion requires aggressive
fluid replacement. A typical fluid resuscitation
protocol is 6 L of fluid over the first 12 hours,
with more fluid to follow over the next 24
hours. Various fluids can be used, depending
on the degree of hypovolemia. Commonly
prescribed fluids include dextran (in case of
hypovolemic shock), isotonic normal saline
solution and, when the client is stabilized,
hypotonic half-normal saline solution.
40. ANS: D
Glipizide may cause adverse skin reactions,
such as pruritus, and photosensitivity. It
doesn’t cause headache, constipation, or
hypotension.
41. ANS: B
When clients are on mechanical ventilation, the
artificial airway impairs the gag and cough
reflexes that help keep organisms out of the
lower respiratory tract. The artificial airway
also prevents the upper respiratory system from
humidifying and heating air to enhance
mucociliary clearance. Manipulations of the
artificial airway sometimes allow secretions
into the lower airways. Whit standard
procedures the other choices wouldn’t be at
high risk.
42. ANS: C
In chronic bronchitis, the diaphragmatic is flat
and weak. Diaphragmatic breathing helps to
strengthen the diaphragm and maximizes
ventilation. Exhalation should longer than
inhalation to prevent collapse of the
bronchioles. The client with chronic bronchitis
should exhale through pursed lips to prolong
exhalation, keep the bronchioles from
collapsing, and prevent air trapping.
Diaphragmatic breathing—not chest
breathing—increases lung expansion.
43. ANS: A
Verbalizing the observed behavior is a
therapeutic communication technique in which
the nurse acknowledges what the client is
feeling. Offering to listen to the client express
her anger can help the nurse and the client
understand its cause and begin to deal with it.
Although stress can exacerbate the symptoms
of SLE, telling the client to calm down doesn’t
acknowledge her feelings. Offering to get the
nursing supervisor also doesn’t acknowledge
the client’s feelings. Ignoring the client’s
feelings suggest that the nurse has no interest
in what the client has said.
44. ANS: A
Daily walks relieve symptoms of intermittent
claudication, although the exact mechanism is
unclear. Anaerobic exercise may exacerbate
these symptoms. Clients with chronic arterial
occlusive disease must reduce daily fat intake
to 30% or less of total calories. The client
should limit dietary cholesterol because
hyperlipidemia is associated with
atherosclerosis, a known cause of arterial
occlusive disease. However, HDLs have the
lowest cholesterol concentration,
so this client should eat foods that raise HDL
levels.
45. ANS: A
Gastric decompression is typically low
pressure and intermittent. High pressure and
continuous gastric suctioning predisposes the
gastric mucosa to injury and ulceration.
46. ANS: A
In osteoarthritis, stiffness is common in large,
weight bearing joints such as the hips. This
joint stiffness alters functional ability and
range of motion, placing the client at risk for
falling and injury. Therefore, client safety is in
jeopardy. Osteoporosis doesn’t affect urinary
elimination, breathing, or nutrition.
47. ANS: A
PTH stimulates the kidneys to reabsorb
calcium and excrete phosphate and converts vit
D to its active form: 1 , 25 dihydroxy vitamin
D. PTH doesn’t have a role in the metabolism
of Vit E.
48. ANS: C
The presence of unsecured area rugs poses a
hazard in all homes, particularly in one with a
resident at high risk for falls.
49. ANS: B
Autonomy ascribes the right of the individual
to make his own decisions. In this case, the
client is capable of making his own decision
and the nurse should support his autonomy.
Beneficence and justice aren’t the principles
that directly relate to the situation. Advocacy is
the nurse’s role in supporting the principle of
autonomy.
50. ANS: D
Because respirations are depressed in
myxedema coma, maintaining a patent airway
is the most critical nursing intervention.
Ventilatory support is usually needed. Thyroid
replacement will be administered IV. Although
myxedema coma is associated with severe
hypothermia, a warming blanket shouldn’t be
used because it may cause vasodilation and
shock. Gradual warming blankets would be
appropriate. Intake and output are very
important but aren’t critical
interventions at this time.
51. ANS: A
Glipizide begins to act in 15 to 30 minutes. The
other options are incorrect.
52. ANS: A
Hypoxia is the main breathing stimulus for a
client with COPD. Excessive oxygen
administration may lead to apnea by removing
that stimulus. Anginal pain results from a
reduced myocardial oxygen supply. A client
with COPD may have anginal pain from
generalized vasoconstriction secondary to
hypoxia; however, administering oxygen at any
concentration dilates blood vessels, easing
anginal pain. Respiratory alkalosis results from
alveolar hyperventilation, not excessive oxygen
administration. In a client with COPD, high
oxygen concentrations decrease the ventilatory
drive, leading to respiratory acidosis, not
alkalosis. High oxygen concentrations don’t
cause metabolic acidosis.
53. ANS: C
Continuous subcutaneous insulin regimen uses
a basal rate and boluses of short-acting insulin.
Multiple daily injection therapy uses a
combination of short-acting and intermediate
or long-acting insulins.
54. ANS: B
Holding a cane on the uninvolved side
distributes weight away from the involved side.
Holding the cane close to the body prevents
leaning. Use of a cane won’t maintain stride
length or prevent edema.
55. ANS: D
High pulmonary artery wedge pressures are
diagnostic for left-sided heart failure. With
leftsided heart failure, pulmonary edema can
develop causing pulmonary crackles. In
leftsided heart failure, hypotension may result
and urine output will decline. Dry mucous
membranes aren’t directly associated with
elevated pulmonary artery wedge pressures.
56. ANS: B
It’s mandatory in most settings to have a
physician’s order before restraining a client. A
client should never be left alone while the
nurse summons assistance. All staff members
require annual instruction on the use of
restraints, and the nurse should be familiar with
the facility’s policy.
57. ANS: A
The client who has undergone a thyroidectomy
is t risk for developing hypocalcemia from
inadvertent removal or damage to the
parathyroid gland. The client with
hypocalcemia will exhibit a positive
Chvostek’s sign (facial muscle contraction
when the facial nerve in front of the ear is
tapped) and a positive Trousseau’s sign (carpal
spasm when a blood pressure cuff is inflated
for few minutes). These signs aren’t present
with hypercalcemia, hypokalemia, or
Hyperkalemia.
58. ANS: C
Diarrhea causes a bicarbonate deficit. With loss
of the relative alkalinity of the lower GI tract,
the relative acidity of the upper GI tract
predominates leading to metabolic acidosis.
Diarrhea doesn’t lead to respiratory acid-base
imbalances, such as respiratory acidosis and
respiratory alkalosis. Loss of acid, which
occurs with severe vomiting, may lead to
metabolic alkalosis.
59. ANS: B
The head of the bed must be elevated while the
client is eating. The client should be placed in a
recumbent position—not a supine position—
when lying down to reduce the risk of
aspiration. Encourage the client to wear
properly fitted dentures to enhance his chewing
ability. Thickened liquids, not thin liquids,
decrease aspiration risk.
60. ANS: A
Endotracheal suctioning secretions as well as
gases from the airway and lowers the arterial
oxygen saturation (SaO2) level. Coughing and
incentive spirometry improve oxygenation and
should raise or maintain oxygen saturation.
Because of superficial vasoconstriction, using a
cooling blanket can lower peripheral oxygen
saturation readings, but SaO2 levels wouldn’t
be affected.
61. ANS: D
With a superficial partial thickness burn such
as a solar burn (sunburn), the nurse’s main
concern is pain management. Fluid
resuscitation and infection become concerns if
the burn extends to the dermal and
subcutaneous skin layers. Body image
disturbance is a concern that has a lower
priority than pain management.
62. ANS: D
Crackles result from air moving through
airways that contain fluid. Heard during
inspiration and expiration, crackles are discrete
sounds that vary in pitch and intensity. They’re
classified as fine, medium, or coarse. Pleural
friction rubs have a distinctive grating sound.
As the name indicates, these breath sounds
result when inflamed pleurae rub together.
Continuous, highpitched, musical squeaks,
called wheezes, result when air moves rapidly
through airways narrowed by asthma or
infection or when an airway is partially
obstructed by a tumor or foreign body.
Wheezes, like gurgles, occur on expiration and
sometimes on inspiration. Loud, coarse, low-
pitched sounds resembling snoring are called
gurgles. These sounds develop when thick
secretions partially obstruct airflow through the
large upper airways.
63. Ans. D
Individuals who are tuberculin skin test
converters should begin a 6-month regimen of
an antitubercular drug such as INH, and they
 should never have another skin test. After an
individual has a positive tuberculin skin test,
subsequent skin tests will cause severe skin
reactions but won’t provide new information
about the client’s TB status. The client doesn’t
have active TB, so can’t transmit, or spread,
the bacteria. Therefore, she shouldn’t be
quarantined or asked for information about
recent contacts.
64. ANS: C
Disturbed body image is a negative perception
of the self that makes healthful functioning
more difficult. The defining characteristics for
this nursing diagnosis include undergoing a
change in body structure or function, hiding or
overexposing a body part, not looking at a
body part, and responding verbally or
nonverbally to the actual or perceived change
in structure or function. This client may have
any of the other diagnoses, but the signs and
symptoms described in he case most closely
match the defining characteristics for disturbed
body image.
65. ANS: B
Because the pregnant uterus exerts a lot of
pressure on the urinary bladder, the bladder
repair may need to be repeated. These clients
don’t necessarily have to have a cesarean
delivery if they become pregnant, and this
procedure doesn’t render them sterile. This
procedure is completed in one surgery.
66. ANS: A
Eccrine glands are associated with body
temperature regulation. Sebaceous glands
lubricate the skin and hairs, and apocrine
glands are involved in bacteria decomposition.
Endocrine glands secrete hormones responsible
for the regulation of body processes, such as
metabolism and glucose regulation.
67. ANS: B
The light-colored spots attached to the hair
shafts are nits, which are the eggs of head lice.
They can’t be brushed off the hair shaft like
dandruff. Scabies is a contagious dermatitis
caused by the itch mite, Sacoptes scabiei,
which lives just beneath the skin. Tinea capitis,
or ringworm, causes patchy hair loss and
circular lesions with healing centers. Impetigo
is an infection caused by Staphylococcus or
Sterptococcus, manifested by vesicles or
pustules that form a thick, honey-colored crust.
68. ANS: C
Severe pressure-like pain out of proportion to
visible signs distinguishes necrotizing fasciitis
from cellulites. Erythema, leukocytosis, and
swelling are present in both cellulites and
necrotizing fasciitis.
69. ANS: A
Contact dermatitis is caused by exposure to a
physical or chemical allergen, such as cleaning
products, skin care products, and latex gloves.
Initial symptoms of itching, erythema, and
raised papules occur at the site of the exposure
and can begin within 1 hour of exposure.
Allergic reactions tend to be red and not scaly
or flaky. Weeping, crusting lesions are also
uncommon unless the reaction is quite severe
or has been present for a long time. Excoriation
is more common in skin disorders associated
with a moist environment.
70. ANS: D
Hoarseness indicate injury to the respiratory
system and could indicate the need for
immediate intubation. Thirst following burns is
expected because of the massive fluid shifts
and resultant loss leading to dehydration. Pain,
either severe or moderate, is expected with a
burn injury. The client’s output is adequate.
71. ANS: C
Third-degree burn may appear white, red, or
black and are dry and leathery with no blisters.
There may be little pain because nerve endings
have been destroyed. First-degree burns are
superficial and involve the epidermis only.
There is local pain and redness but no
blistering. Second-degree burn appear red and
moist with blister formation and are painful.
Fourth-degree burns involve underlying muscle
and bone tissue.
72. ANS: C
A universal concern I the care of donor sites
for burn care is to keep the site away from
sources of pressure. Ventilation of the site and
keeping the site fully covered are practices in
some institutions but aren’t hallmarks of donor
site care. Placing the site in a position of
dependence isn’t a justified aspect of donor site
care.
73. ANS: A
Anyone with psoriasis vulgaris who reports
joint pain should be evaluated for psoriaic
arthritis. Approximately 15% to 20% of
individuals with psoriasis will also develop
psoriatic arthritis, which can be painful and
cause deformity. It would be incorrect to
assume that his pain is caused by early
rheumatoid arthritis or his vocation without
asking more questions or performing
diagnostic studies. Carpal tunnel syndrome
causes sensory and motor changes in the
fingers rather than localized pain in the joints.
74. ANS: B
To avoid burning and sloughing, the client
must protect the graft from sunlight. The other
three interventions are all helpful to the client
and his recovery but are less important.
75. ANS: C
Because the itching and rash are localized, an
environmental cause in the workplace should
be suspected. With the advent of universal
precautions, many nurses are experiencing
allergies to latex gloves. Allergies to
medications, laundry detergents, or bath soaps
 or a dermatologic reaction to stress usually
elicit a more generalized or widespread rash.
76. ANS: A
Hives and urticaria are two names for the same
skin lesion. Toxin is a poison. A tubercle is a
tiny round nodule produced by the tuberculosis
bacillus. A virus is an infectious parasite.
77. ANS: A
A scale is the characteristic secondary lesion
occurring in psoriasis. Although crusts, ulcers,
and scars also are secondary lesions in skin
disorders, they don’t accompany psoriasis.
78. ANS: C
A turning schedule with a signing sheet will
help ensure that the client gets turned and thus,
help prevent pressure ulcers. Turning should
occur every 1-2 hours—not every 8 hours—for
clients who are in bed for prolonged periods.
The nurse should apply lotion to keep the skin
moist but should avoid vigorous massage,
which could damage capillaries. When moving
the client, the nurse should lift rather than slide
the client to void shearing.
79. ANS: A
To prevent disruption of the artificial skin’s
adherence to the wound bed, the client should
restrict range of motion of the involved limb.
Protein intake and fluid intake are important
for healing and regeneration and shouldn’t be
restricted. Going outdoors is acceptable as long
as the left arm is protected from direct sunlight.
80. ANS: C
According to the Rule of Nines, the posterior
and anterior trunk, and legs each make up 18%
of the total body surface. The head, neck, and
arms each make up 9% of total body durface,
and the perineum makes up 1%. In this case,
the client received burns to his back (18%) and
one arm (9%), totaling 27%.
81. ANS: A
A wet-to-dry saline dressing should always
keep the wound moist. Tight packing or dry
packing can cause tissue damage and pain. A
dry gauze —not a plastic-sheet-type dressing—
should cover the wet dressing.
82. ANS: A
When someone in a group of persons sharing a
home contracts scabies, each individual in the
same home needs prompt treatment whether
he’s symptomatic or not. Towels and linens
should be washed in hot water. Scabies can be
transmitted from one person to another before
symptoms develop
83. ANS: A
In a client with burns, the goal of fluid
resuscitation is to maintain a mean arterial
blood pressure that provides adequate
perfusion of vital structures. If the kidneys are
adequately perfused, they will produce an
acceptable urine output of at least 0.5
ml/kg/hour. Thus, the expected urine output of
a 155-lb client is 35 ml/hour, and a urine
output consistently above 100 ml/hour is more
than adequate. Weight gain from fluid
resuscitation isn’t a goal. In fact, a 4 lb weight
gain in 24 hours suggests third spacing. Body
temperature readings and ECG interpretations
may demonstrate secondary benefits of fluid
resuscitation but aren’t primary indicators.
84. ANS: B
The ESR test is performed to detect
inflammatory processes in the body. It’s a
nonspecific test, so the health care professional
must view results in conjunction with physical
signs and symptoms. Platelet count,
electrolytes, BUN, and creatinine levels aren’t
usually affected by the inflammatory process.
85. ANS: B
In Parkinson’s crisis, dopamine-related
symptoms are severely exacerbated, virtually
immobilizing the client. A client who is
confined to bed during a crisis is at risk for
aspiration and pneumonia. Also, excessive
drooling increases the risk of airway
obstruction. Because of these concerns,
ineffective airway clearance is the priority
diagnosis for this client. Although imbalanced
nutrition:less than body requirements, impaired
urinary elimination and risk for injury also are
appropriate diagnoses for this client, they
aren’t immediately lifethreatening and thus are
less urgent.
86. ANS: A
As a rule of practice, if intermittent
catheterization for urine retention typically
yields 500 ml or more, the frequency of
catheterization should be increased. Indwelling
catheterization is less preferred because of the
risk of urinary tract infection and the loss of
bladder tone. Fluid restrictions aren’t indicated
for this case; the problem isn’t overhydration,
rather it’s urine retention. A condom catheter
doesn’t help empty the bladder of a client with
urine retention.
87. ANS: D
The normal pressure is 70 to 200 mm H2O are
considered abnormal. The presence of glucose
is an expected finding in CSF, and RBCs
typically occur in the first specimen tube from
the trauma caused by the procedure.
88. ANS: A
The nurse should instill the eyedrop into the
conjunctival sac where absorption can best take
place. The pupil permits light to enter the eye.
The sclera maintains the eye’s shape and size.
The vitreous humor maintains the retina’s
placement and the shape of the eye.
89. ANS: C
According to family theory, any change in a
family member, such as illness, produces role
changes in all family members and affects the
entire family, even if the client eventually
recovers completely.
90. ANS: B
To help prevent airway obstruction and reduce
the risk of aspiration, the nurse should position
a client with hemiparesis on the affected side.
Although performing ROM exercises,
providing pillows for support, and applying
antiembolism stockings can be appropriate for
a client with CVA, the first concern is to
maintain a patent airway.
91. ANS: C
TIA may be a warning that the client will
experience a CVA, or stroke, in the near future.
TIA aymptoms last no longer than 24 hours
and clients usually have complete recovery
after TIA. The most common symptom of TIA
is sudden, painless loss of vision lasting up to
24 hours.
92. ANS: C
Bending to pick up something from the floor
would increase intraocular pressure, as would
bending to tie his shoes. The client needs to
wear eye protection to bed to prevent
accidental injury during sleep.
93. ANS: B
Concussions are considered minor with no
structural signs of injury. A contusion is
bruising of the brain tissue with small
hemorrhages in the tissue. Coup and
contrecoup are type of injuries in which the
damaged area on the brain forms directly
below that site of impact (coup) or at the
site opposite the injury (contrecoup) due to
movement of the brain within the skull.
94. ANS: B
The third cranial nerve (oculomotor) is
responsible for pupil constriction. When there
is damage to the nerve, the pupils remain
dilated and don’t respond to light. Glaucoma,
lumbar spine injury, and Bell’s palsy won’t
affect pupil constriction.
95. ANS: C
When the mechanical stressors of weight
bearing are absent, diffuse osteoporosis can
occur. Therefore, if the client does weight-
bearing exercises, disuse complications can be
prevented. Maintaining protein and vitamins
levels is important, but neither will prevent
osteoporosis. ROM exercises will help prevent
muscle atrophy and contractures.
96. ANS: B
This client requires droplet precautions because
the organism can be transmitted through
airborne droplets when the client coughs,
sneezes, or doesn’t cover his mouth. Airborne
precautions would be instituted for a client
infected with tuberculosis. Standard
precautions would be instituted for a client
when contact with body substances is likely.
Contact precautions would be instituted for a
client infected with an organism that is
transmitted through skin-to-skin
contact.
97. ANS: D
With a brain injury such as an epidural
hematoma (a diagnosis that is most likely
based on this client’s symptoms), the initial
sign of increasing ICP is a change in the level
of consciousness. As neurologic deterioration
progresses, manifestations involving pupillary
symmetry, breathing patterns, and posturing
will
occur.
98. ANS: A
In the scenario, airway and breathing are
established so the nurse’s next priority should
be circulation. With a compound fracture of the
femur, there is a high risk of profuse bleeding;
therefore, the nurse should assess the site.
Neurologic assessment is a secondary concern
to airway, breathing and circulation. The nurse
doesn’t have enough data to warrant putting the
client in Trendelenburg’s position.
99. ANS: C
Establishing and maintaining a routine is
essential to decreasing extraneous stimuli. The
client should participate in daily care as much
as possible. Attempting to reason with such
clients isn’t successful, because they can’t
participate in abstract thinking.
100. ANS: B
For clients with increased intracranial pressure
(ICP), the head of the bed is elevated to
promote venous outflow. Trendelenburg’s
position is contraindicated because it can raise
ICP. Flat or neutral positioning is indicated
when elevating the head of the bed would
increase the risk of neck injury or airway
obstruction. Sidelying isn’t specifically a
therapeutic treatment for increased ICP.
PNLE Medical
Surgical Nursing
Exam 3
1. Lisa is newly diagnosed with asthma and is being
discharged from the hospital after an episode of
status asthmaticus. Discharge teaching should
include which of the following:
A. Limitations in sports that will be imposed by
the illness
B. Specific instructions on staying cal during an
attack
C. The relationship of symptoms and a specific
trigger such as physical exercise
D. Incidence of status asthmaticus in children and
teens
2. Which of the following symptoms is most D. Aneurysm
characteristic of a client with a cancer of the lung? 9. Nurse Fiona is caring a patient with Raynaud’s
disease. Which of the following outcomes
A. air hunger concerning medication regimen is of highest
B. exertional dyspnea priority?
C. cough with night sweats
D. persistent changing cough A. Controlling the pain once vasospasm occur
3. The client has ST segment depression on his 12- B. Relaxing smooth muscle to avoid vasospasms
lead ECG. The nurse determines that this would C. Preventing major disabilities that may occur
indicate the following: D. Avoiding lesions on the feet
10. Mr. Roberto Robles complains of a severe
A. necrosis headache and is extremely anxious. The nurse
B. injury checks his vital signs and finds him to have a heart
C. ischemia rate of 57 bpm and a blood pressure of 230/110
D. nothing significant mmHg. The nurse should also assess for?
4. Red has just returned from the postanesthesia
care unit (PACU) from a hemorrhidectomy. His A. presence of bowel sounds
postoperative orders include sitz baths every B. presence of babinski reflex
morning. The nurse understands that sitz bath is use C. fecal incontinence
for: D. urinary catheter patency
11. A 40n year old male patient is complaining of
A. promote healing chronic progressive and mental deterioration is
B. relive tension admitted to the unit. The nurse recognizes that these
C. lower body temperature characteristics indicate a disease that results in
D. cause swelling degeneration of the basal ganglia and cerebral
5. Trousseau’s sign is associated with which cortex. The disease is called:
electrolyte imbalance?
A. multiple sclerosis
A. hyponatremia B. myasthenia gravis
B. hypocalcemia C. Huntington’s disease
C. hypernatremia D. Guillain-Barre syndrome
D. hypercalcemia 12. Dianne Hizon is a 27 year old woman who has
6. A 36 year old female complains of headache and been admitted to the ER due to severe vomiting.
neck pain. The nurse’s assessments reveal painful Her ABG values are pH= 7.50, PaCO2= 85,
flexion of the neck to the chest. The nurse HCO3= 31, and SaO2= 93%. The nurse
understands that nuchal rigidity is associated with: interpretation of this ABG analysis is:

A. brain tumor A. respiratory acidosis

B. CVA B. respiratory alkalosis
C. meningitis C. metabolic acidosis
D. subdural hematoma D. metabolic alkalosis
7. The nurse teaching the client about behavioral 13. Mr. Perkson has a parkinson’s disease and he
changes, which can affect development of finds the resting tremor he is experiencing in his
atherosclerosis, should discuss which of the right hand very frustrating. The nurse advises him
following as a non-modifiable risk factor for to:
atherosclerosis?
A. take a warm bath
A. cigarette smoking B. hold an object
B. hyperlipidemia C. practice deep breathing
C. female over 55 years of age D. take diazepam as needed
D. sedentary lifestyle 14. A shuffling gait is typically associated with the
8. A 76 year old man enters the ER with complaints patient who has:
of back pain and feeling fatigued. Upon
examination, his blood pressure is 190/100, pulse is A. Parkinson’s disease
118, and hematocrit and hemoglobin are both low. B. Multiple sclerosis
The nurse palpates the abdomen which is soft, non- C. Raynaud’s disease
tender and auscultates an abdominal pulse. The D. Myasthenia gravis
most likely diagnosis is: 15. The priority in preparing the room for a client
with a C7 spinal cord injury is having:
A. Buerger’s disease
B. CHF A. the halo brace device
C. Secondary hypertension B. a catheterization tray
 C. a ventilator on stand by
D. the spinal kinetic bed
16. A 47 year old man with liver failure who has
developed ascites. The nurse understands that
ascites is due to:
A. dehydration
B. protein deficiency
C. bleeding disorders
D. vitamin deficiency
17. A client with rheumatoid arthritis may reveal
which of the following assessment data:
A. Heberden’s nodes
B. Morning stiffness no longer than 30 minutes
C. Asymmetric joint swelling
D. Swan neck deformities
18. Elsa Santos is a 18 year old student admitted to
the ward with a diagnosis of epilepsy. She tells the
nurse that she is experiencing a generalized tingling
sensation and is “smelling roses”. The nurse
understands that Esla is probably experiencing:
A. an acute alcohol withdrawal
B. an acute CVA
C. an aura
D. an olfactory hallucination
19. Mr. Lucas, a 63 year old, went to the clinic
complaining of hoarseness of voice and a cough.
His wife states that his voice has changed in the last
few months. The nurse interprets that Mr. Lucas’s
symptoms are consistent with which of the
following disorders:
A. chronic sinusitis
B. laryngeal cancer
C. gastroesophageal reflux disease
D. coronary artery disease
20. Sarah complains of a nursing sensation,
cramping pain in the top part of her abdomen that
becomes worse in the afternoon and sometimes
awakes her at night. She reports that when she eats,
it helps the pain go away but that pain is now
becoming more intense. Which of the following is
the best condition for the nurse to draw:
A. these symptoms are consistent with an ulcer
B. The client probably has indigestion
C. A snack before going to bed should be advised
D. The client probably developing cholelithiasis
21. Nurse Cynthia is providing a discharge teaching
to a client with chronic cirrhosis. His wife asks her
to explain why there is so much emphasis on
bleeding precautions. Which of the following
provides the most appropriate response?
A. “The low protein diet will result in reduced
clotting.”
B. “The increased production of bile decreases
clotting factors.”
C. “The liver affected by cirrhosis is unable to
produce clotting factors.”
D. “The required medications reduce clotting
factors.”
22. Betty Lee is a 58 year old woman who is being
admitted to the medical ward with trigeminal
neuralgia. The nurse anticipates that Mr. Lee will
demonstrate which of the following major
complaints?
A. excruciating, intermittent, paroxysmal facial
pain
B. unilateral facial droop
C. painless eye spasm
D. mildly painful unilateral eye twitching
23. A 38 year old woman returns from a subtotal
thryroidectomy for the treatment of
hyperthyroidism. Upon assessment, the immediate
priority that the nurse would include is:
A. Assess for pain
B. Assess for neurological status
C. Assess fluid volume status
D. Assess for respiratory distress
24. Nurse Shiela is teaching self-care to a client
with psoriasis. The nurse should encourage which
of the following for his scaled lesion?
A. Importance of follow-up appointments
B. Emollients and moisturizers to soften scales
C. Keep occlusive dressings on the lesions 24
hours a day
D. Use of a clean razor blade each time he shaves
25. A 48 year old woman presents to the hospital
complaining of chest pain, tachycardia and dyspnea.
On exam, heart sounds are muffled. Which of the
following assessment findings would support a
diagnosis of cardiac tamponade?
A. A deviated trachea
B. Absent breath sounds to the lower lobes
C. Pulse 40 with inspiration
D. Blood pressure 140/80
Answers and Rationales
1. C. The relationship of symptoms and a specific
trigger such as physical exercise. COPD clients
have low oxygen and high carbon dioxide
levels. Therefore, hypoxia is the main stimulus
for ventilation is persons with chronic
hypercapnea. Increasing the level of oxygen
would decrease the stimulus to breathe.
2. D. persistent changing cough. The most
common sign of lung cancer is a persistent
cough that changes. Other signs are dyspnea,
bloody sputum and long term pulmonary
infection. Option A is common with asthma,
option B is common with COPD and option C
is common with TB.
3. C. ischemia. Depressed ST segment and
inverted T-waves represent myocardial
ischemia. Injury has a ST segment elevation.
4. A. promote healing. Sitz bath provides moist
heat to the perineal and anal area to clean,
 promote healing and drainage and reduce
soreness to the area. Sitz bath helps healing
with cleaning action and promotion of
circulation, thereby reducing swelling. Sitz
bath usually has no therapeutic value in
lowering body temperature. Although relief of
tension can occur, this effect is secondary to
the promotion of healing.
5. B. hypocalcemia. Trousseau’s sign is a carpal
pedal spasm elicited when a blood pressure
cuff is inflated on the arm of a patient with
hypocalcemia.
6. C. meningitis. A patient with meningitis will
exhibit signs that include photophobia and
nuchal rigidity, which is pain on the flexion of
the chin to chest.
7. C. female over 55 years of age. Lifestyle,
cigarette smoking and hyperlipidemia can be
changed by changing behaviors.
8. D. Aneurysm. The symptoms exhibited by the
client are typical of an abdominal aortic
aneurysm. The most significant sign is the
audible pulse in the abdominal area. If
hemorrhage were present, the abdomen would
be tender and firm.
9. B. Relaxing smooth muscle to avoid
vasospasms. The major task of the health care
team is to medicate the client drugs that
produce smooth muscle relaxation, which will
decrease the vasospasm and increase the
arterial flow to the affected part. The drugs
used are calcium antagonists.
10. D. urinary catheter patency. The patient is
complaining of symptoms of autonomic
dysreflexia, which consists of the triad of
hypertension, bradycardia and a headache.
Major causes of autonomic dysreflexia include
urinary bladder distention and fecal impaction.
Checking the patency of the urinary catheter
will check for bladder distention.
11. C. Huntington’s disease. Huntington’s disease
is a hereditary disease in which degeneration of
the basal ganglia and cerebral cortex causes
chronic progressive chorea (muscle twitching)
and mental deterioration, ending in dementia.
Huntington’s disease usually strikes people
ages 25 to 55.
12. D. metabolic alkalosis. Ms. Hizon’s pH is
above 7.45, which makes it alkalatic, and her
bicarbonate is high which is also makes it basic.
Thus, the diagnosis is metabolic alkalosis.
13. B. hold an object. The resting or non-
intentional tremor may be controlled with
purposeful movement such as holding an
object. A warm bath, deep breathing and
diazepam will promote relaxation but are not
specific interventions for tremor.
14. A. Parkinson’s disease. A shuffling gait from
the musculoskeletal rigidity of the patient with
Parkinson’s disease is common. Patients
experiencing a stroke usually exhibit loss of
voluntary control over motor movements
associated with generalized weakness; a
shuffling gait is usually not observed in stroke
patient.
15. C. a ventilator on stand by. Although a
ventilator is not required for injury below C3,
the innervation of intercostal muscles is
affected. Hemorrhage and cord swelling
extends the level of injury making it likely that
this client will need a ventilator.
16. B. protein deficiency. Protein deficiency allows
fluid to leak out of the vascular system and
third space into the tissues and spaces in the
body such as the peritoneal space. Bleeding
tendencies, dehydration and vitamin deficiency
can occur but don’t cause ascites.
17. D. Swan neck deformities. Swan neck
deformities of the hand are classic deformities
associated with rheumatoid arthritis secondary
to the presence of fibrous connective tissue
within the joint space. Clients with RA do
experience morning stiffness, but it can last
from 30 minutes up to several hours. RA is
characterized by symmetrical joint movement,
and heberden’s nodes are characteristic of
osteoarthritis.
18. C. an aura. An aura frequently precedes an
epileptic seizure and may manifest as vague
physic discomfort or specific aromas. Patients
experiencing auras aren’t having a CVA,
substance withdrawal or hallucination.
19. B. laryngeal cancer. These symptoms, along
with dysphagia, foul-smelling breath, and pain
when drinking hot or acidic, are common signs
of laryngeal cancer.
20. A. these symptoms are consistent with an
ulcer. The description of pain is consistent with
ulcer pain. The pain is epigastric and is worse
when the stomach is empty and is relived by
food.
21. C. “The liver affected by cirrhosis is unable to
produce clotting factors.” When bile
production is reduced, the body has reduced
ability to absorb fat-soluble vitamins. Without
adequate Vitamin K absorption, clotting factors
II, VII, IX, and X are not produced in sufficient
amounts.
22. A. excruciating, intermittent, paroxysmal facial
pain. Trigeminal neuralgia is a syndrome of
excruciating, intermittent, paroxysmal facial
pain. It manifests as intense, periodic pain in
the lips, gums, teeth or chin. The other
symptoms aren’t characteristic of trigeminal
neuralgia.
23. D. Assess for respiratory distress. Though fluid
volume status, neurological status and pain are
all important assessment, the immediate
priority for postoperative is the airway
management. Respiratory distress may result
from hemorrhage, edema, laryngeal damage or
tetany.
24. B. Emollients and moisturizers to soften
scales. Emollients will ease dry skin that
 increases pruritus and causes psoriasis to be
worse. Washing and drying the skin with rough
linens or pressure may cause excoriation.
Constant occlusion may increase the effects of
the medication and increase the risk of
infection.
25. C. Pulse 40 with inspiration. Paradoxical pulse
is a hallmark symptom of cardiac tamponade.
As pressure is exerted on the left ventricle from
fluid, the natural increase in pressure from the
right ventricle during inspiration creates even
more pressure, diminishing cardiac output.
PNLE Medical
Surgical Nursing
Exam 4
1. A patient is admitted to the medical surgical unit
following surgery. Four days after surgery, the
patient spikes a 38.9 degrees C oral temperature and
exhibits a wet, productive cough. The nurse
assesses the patient with understanding that an
infection that is acquired during hospitalization is
known as:
A. a community acquired infection
B. an iatrogenic infection
C. a nosocomial infection
D. an opportunistic infection
2. A client with anemia has a hemoglobin of 6.5
g/dL. The client is experiencing symptoms of
cerebral tissue hypoxia. Which of the following
nursing interventions would be most important in
providing care?
A. Providing rest periods throughout the day
B. Instituting energy conservation techniques
C. Assisting in ambulation to the bathroom
D. Checking temperature of water prior to bathing
3. A client was involved in a motor vehicular
accident in which the seat belt was not worn. The
client is exhibiting crepitus, decrease breath sounds
on the left, complains of shortness of breath, and
has a respiratory rate of 34 breaths per minute.
Which of the following assessment findings would
concern the nurse most?
A. Temperature of 102 degrees F and productive
cough
B. ABG with PaO2 of 92 and PaCO2 of 40
mmHg
C. Trachea deviating to the right
D. Barrel-chested appearance
4. The proper way to open an envelop-wrapped
sterile package after removing the outer package or
tape is to open the first position of the wrapper:
A. away from the body
B. to the left of the body
C. to the right of the body
D. toward the body
5. Assessment of a client with possible
thrombophlebitis to the left leg and a deep vein
thrombosis is done by pulling up on the toes while
gently holding down on the knee. The client
complains of extreme pain in the calf. This should
be documented as:
A. positive tourniquet test
B. positive homan’s sign
C. negative homan’s sign
D. negative tourniquet test
6. Thomas Elison is a 79 year old man who is
admitted with diagnosis of dementia. The doctor
orders a series of laboratory tests to determine
whether Mr. Elison’s dementia is treatable. The
nurse understands that the most common cause of
dementia in this population is:
A. AIDS
B. Alzheimer’s disease
C. Brain tumors
D. Vascular disease
7. Which of the following nursing interventions is
contraindicated in the care of a client with acute
osteomyelitis?
A. Apply heat compress to the affected area
B. Immobilize the affected area
C. Administer narcotic analgesics for pain
D. Administer OTC analgesics for pain
8. A client with congestive heart failure has digoxin
(Lanoxin) ordered everyday. Prior to giving the
medication, the nurse checks the digoxin level
which is therapeutic and ausculates an apical pulse.
The apical pulse is 63 bpm for 1 full minute. The
nurse should:
A. Hold the Lanoxin
B. Give the half dose now, wait an hour and give
the other half
C. Call the physician
D. Give the Lanoxin as ordered
9. Nurse Marian is caring for a client with haital
hernia, which of the following should be included in
her teaching plan regarding causes:
A. To avoid heavy lifting
B. A dietary plan based on soft foods
C. Its prevalence in young adults
D. Its prevalence in fair-skinned individuals
10. Joseph has been diagnosed with hepatic
encephalopathy. The nurse observes flapping
tremors. The nurse understands that flapping
tremors associated with hepatic encephalopathy are
also known as:
A. aphasia
B. ascites
 C. astacia
D. asterixis
11. Hyperkalemia can be treated with
administration of 50% dextrose and insulin. The 50%
dextrose:
A. causes potassium to be excreted
B. causes potassium to move into the cell
C. causes potassium to move into the serum
D. counteracts the effects of insulin
12. Which of the following findings would strongly
indicate the possibility of cirrhosis?
A. dry skin
B. hepatomegaly
C. peripheral edema
D. pruritus
13. Aling Puring has just been diagnosed with
close-angle (narrow-angle) glaucoma. The nurse
assesses the client for which of the following
common presenting symptoms of the disorder?
A. halo vision
B. dull eye pain
C. severe eye and face pain
D. impaired night vision
14. Chvostek’s sign is associated with which
electrolyte impabalnce?
A. Encourage him to maintain bed rest for several
days
B. Monitor temperature every 4 hours
C. Instruct him to avoid sexual contact during
acute phases of illness
D. Encourage him to use antifungal agents
regularly
19. An 8 year old boy is brought to the trauma unit
with a chemical burn to the face. Priority
assessment would include which of the following?
A. Skin integrity
B. BP and pulse
C. Patency of airway
D. Amount of pain
20. A client with anemia due to chemotherapy has a
hemoglobin of 7.0 g/dL. Which of the following
complaints would be indicative of tissue hypoxia
related to anemia?
A. dizziness
B. fatigue relieved by rest
C. skin that is warm and dry to the touch
D. apathy
21. Hazel Murray, 32 years old complains of abrupt
onset of chest and back pain and loss of radial
pulses. The nurse suspects that Mrs. Murray may
have:

A. hypoclacemia A. Acute MI
B. hypokalemia B. CVA
C. hyponatremia C. Dissecting abdominal aorta
D. hypophosphatenia D. Dissecting thoracic aneurysm
15. What laboratory test is a common measure of 22. Nurse Alexandra is establishing a plan of care
the renal function? for a client newly admitted with SIADH. The
priority diagnosis for this client would be which of
A. CBC the following?
B. BUN/Crea
C. Glucose A. Fluid volume deficit
D. Alanine amino transferase (ALT) B. Anxiety related to disease process
16. Nurse Edward is performing discharge teaching C. Fluid volume excess
for a newly diagnosed diabetic patient scheduled for D. Risk for injury
a fasting blood glucose test. The nurse explains to 23. Nursing management of the client with a UTI
the patient that hyperglycemia is defined as a blood should include:
glucose level above:
A. Taking medication until feeling better
A. 100 mg/dl B. Restricting fluids
B. 120 mg/dl C. Decreasing caffeine drinks and alcohol
C. 130 mg/dl D. Douching daily
D. 150 mg/dl 24. Felicia Gomez is 1 day postoperative from
17. Mang Edison is on bed rest has developed an coronary artery bypass surgery. The nurse
ulcer that is full thickness and is penetrating the understands that a postoperative patient who’s
subcutaneous tissue. The nurse documents that this maintained on bed rest is at high risk for developing:
ulcer is in which of the following stages?
A. angina
A. Stage 1 B. arterial bleeding
B. Stage 2 C. deep vein thrombosis (DVT)
C. Stage 3 D. dehiscence of the wound
D. Stage 4 25. Which of the following statement is true
18. A 24 year old male patient comes to the clinic regarding the visual changes associated with
after contracting genital herpes. Which of the cataracts?
following intervention would be most appropriate?
A. Both eyes typically cataracts at the same time
B. The loss of vision is experienced as a painless,
gradual blurring
C. The patient is suddenly blind
D. The patient is typically experiences a painful,
sudden blurring of vision.
Answers and Rationales
1. C. a nosocomial infection. Nosocomial, or
hospital-acquired are infections acquired
during hospitalization for which the patient
isn’t being primarily treated. Community
acquired or opportunistic infections may not be
acquired during hospitalization. An iatrogenic
infection is caused by the doctor or by medical
therapy. And an opportunistic infection affects
a compromised host.
2. C. Assisting in ambulation to the
bathroom. Cerebral tissue hypoxia is
commonly associated with dizziness. The
greatest potential risk to the client with
dizziness is injury, especially with changes in
position. Planning for periods of rest and
conserving energy are important with someone
with anemia because of his or her fatigue level
but most important is safety.
3. C. Trachea deviating to the right. A mediastinal
shift is indicative of a tension pneumothorax
along with the other symptoms in the question.
Since the individual was involved in a MVA,
assessment would be targeted at acute
traumatic injuries to the lungs, heart or chest
wall rather than other conditions indicated in
the other answers. Option A is common with
pneumonia; values in option B are not alarming;
and option D is typical of someone with COPD.
4. A. away from the body. When opening an
envelop-wrapped sterile package, reaching
across the package and using the first motion to
open the top cover away from the body
eliminates the need to later reach across the
steri9le field while opening the package. To
remove equipment from the package, opening
the first portion of the package toward, to the
left, or to the right of the body would require
reaching across a sterile field.
5. B. positive homan’s sign. Pain in the calf while
pulling up on the toes is abnormal and
indicates a positive test. If the client feels
nothing or just feels like the calf muscle is
stretching, it is considered negative. A
tourniquet test is used to measure for varicose
veins.
6. B. Alzheimer’s disease. Alzheimer’s disease is
the most common cause of dementia in the
elderly population. AIDS, brain tumors and
vascular disease are all less common causes of
progressive loss of mental function in elderly
patients.
7. A. Apply heat compress to the affected
area. Options B, C and D are appropriate
nursing interventions when caring for a client
diagnosed with osteomyelitis. The application
of heat can increase edema and pain in the
affected area and spread bacteria through
vasodilation.
8. D. Give the Lanoxin as ordered. The Lanoxin
should be held for a pulse of 60 bpm. Nurses
cannot arbitrarily give half of a dose without a
physician’s order. Unless specific parameters
are given concerning pulse rate, most resources
identify 60 as the reference pulse.
9. A. To avoid heavy lifting. Heavy lifting is one
factor that leads to development of a hiatal
hernia. Dietary factors involve limiting fat
intake, not restricting client to soft foods. It is
more prevalent in individuals who are middle-
aged or older. Fair-skinned individuals are not
prone to this condition.
10. D. asterixis. Flapping tremors associated with
hepatic encephalophaty are asterixis. Aphasia
is the inability to speak. Ascites is an
accumulation of fluid in the peritoneal cavity.
Astacia is the inability to stand or sit still.
11. D. counteracts the effects of insulin. The 50%
dextrose is given to counteract the effects of
insulin. Insulin drives the potassium into the
cell, thereby lowering the serum potassium
levels. The dextrose doesn’t directly cause
potassium excretion or any movement of
potassium.
12. B. hepatomegaly. Although option D is correct,
it is not a strong indicator of cirrhosis. Pruritus
can occur for many reasons. Options A and C
are incorrect, fluid accumulations is usually in
the form of ascites in the abdomen.
Hepatomegaly is an enlarged liver, which is
correct. The spleen may also be enlarged.
13. C. severe eye and face pain. Narrow-angle
glaucoma develops abruptly and manifests with
acute face and eye pain and is a medial
emergency. Halo vision, dull eye pain and
impaired night vision are symptoms associated
with open-angle glaucoma.
14. A. hypoclacemia. Chvostek’s sign is a spasm
of the facial muscles elicited by tapping the
facial nerve and is associated with
hypocalcemia. Clinical signs of hypokalemia
are muscle weakness, leg cramps, fatigue,
nausea and vomiting. Muscle cramps, anorexia,
nausea and vomiting are clinical signs of
hyponatremia. Clinical manifestations
associated with hypophosphatemia include
muscle pain, confusion, seizures and coma.
15. B. BUN/Crea. The BUN is primarily used as
indicator of kidney function because most renal
diseases interfere with its excretion and cause
blood vessels to rise. Creatinine is produced in
relatively constant amounts, according to the
amount of muscle mass and is excreted entirely
by the kidneys making it a good indicator of
renal function.
16. B. 120 mg/dl. Hyperglycemia is defined as a
blood glucose level greater than 120 mg/dl.
 Blood glucose levels of 120 mg/dl, 130 mg/dl
and 150 mg/dl are considered hyperglycemic.
A blood glucose of 100 mg/dl is normal.
17. C. Stage 3. A stage 3 ulcer is full thickness
involving the subcutaneous tissue. A stage 1
ulcer has a defined area of persistent redness in
lightly pigmented skin. A stage 2 ulcer
involves partial thickness skin loss. Stage 4
ulcers extend through the skin and exhibit
tissue necrosis and muscle or bone
involvement.
18. C. Instruct him to avoid sexual contact during
acute phases of illness. Herpes is a virus and is
spread through direct contact. An antifungal
would not be useful; bed rest and temperature
measurement are usually not necessary.
19. C. Patency of airway. A burn face, neck or
chest may cause airway closure because of the
edema that occurs within hours. Remember the
ABC’s: airway, breathing and circulation.
Airway always comes first, even before pain.
The nurse will also assess options B and D, but
these are not the highest priority assessments.
20. A. dizziness. Central tissue hypoxia is
commonly associated with dizziness.
Recognition of cerebral hypoxia is critical
since the body will attempt to shunt
oxygenated blood to vital organs.
21. D. Dissecting thoracic aneurysm. A dissecting
thoracic aneurysm may cause loss of radical
pulses and severe chest and back pain. An MI
typically doesn’t cause loss of radial pulses or
severe back pain. CVA and dissecting
abdominal aneurysm are incorrect responses.
22. C. Fluid volume excess. SIADH results in fluid
retention and hyponatremia. Correction is
aimed at restoring fluid and electrolyte balance.
Anxiety and risk for injury should be addressed
following fluid volume excess.
23. C. Decreasing caffeine drinks and
alcohol. Caffeine and alcohol can increase
PNLE Exam 1
bladder spasms and mucosal irritation, thus 1. A 10 year old who has sustained a head injury is
increase the signs and symptoms of UTI. All brought to the emergency department by his mother.
antibiotics should be taken completely to A diagnosis of a mild concussion is made. At the
prevent resistant strains of organisms. time of discharge, nurse Ron should instruct the
24. C. deep vein thrombosis (DVT). DVT, is the mother to:
most probable complication for postoperative
patients on bed rest. Options A, B and D aren’t A. Withhold food and fluids for 24 hours.
likely complications of the post operative B. Allow him to play outdoors with his friends.
period. C. Arrange for a follow up visit with the child’s
25. B. The loss of vision is experienced as a primary care provider in one week.
painless, gradual blurring. Typically, a patient D. Check for any change in responsiveness every
with cataracts experiences painless, gradual two hours until the follow-up visit.
loss of vision. Although both eyes may develop 2. A male client has suffered a motor accident and
at different rates. is now suffering from hypovolemic shock. Nurse
Helen should frequency assess the client’s vital
signs during the compensatory stage of shock,
because:

A. Arteriolar constriction occurs

B. The cardiac workload decreases
C. Decreased contractility of the heart occurs
 D. The parasympathetic nervous system is
triggered
3. A paranoid male client with schizophrenia is
losing weight, reluctant to eat, and voicing concerns
about being poisoned. The best intervention by
nurse Dina would be to:
A. Allow the client to open canned or pre-
packaged food
B. Restrict the client to his room until 2 lbs are
gained
C. Have a staff member personally taste all of the
client’s food
D. Tell the client the food has been x-rayed by the
staff and is safe
4. One day the mother of a young adult confides to
nurse Frida that she is very troubled by he child’s
emotional illness. The nurse’s most therapeutic
initial response would be:
A. “You may be able to lessen your feelings of
guilt by seeking counseling”
B. “It would be helpful if you become involved in
volunteer work at this time”
C. “I recognize it’s hard to deal with this, but try
to remember that this too shall pass”
D. “Joining a support group of parents who are
coping with this problem can be quite helpful.
5. To check for wound hemorrhage after a client has
had a surgery for the removal of a tumor in the neck,
nurse grace should:
A. Loosen an edge of the dressing and lift it to see
the wound
B. Observe the dressing at the back of the neck for
the presence of blood
C. Outline the blood as it appears on the dressing
to observe any progression
D. Press gently around the incision to express
accumulated blood from the wound
6. A 16-year-old primigravida arrives at the labor
and birthing unit in her 38th week of gestation and
states that she is labor. To verify that the client is in
true labor nurse Trina should:
A. Obtain sides for a fern test
B. Time any uterine contractions
C. Prepare her for a pelvic examination
D. Apply nitrazine paper to moist vaginal tissue
7. As part of the diagnostic workup for pulmonic
stenosis, a child has cardiac catheterization. Nurse
Julius is aware that children with pulmonic stenosis
have increased pressure:
A. In the pulmonary vein
B. In the pulmonary artery
C. On the left side of the heart
D. On the right side of the heart
8. An obese client asks nurse Julius how to lose
weight. Before answering, the nurse should
remember that long-term weight loss occurs best
when:
A. Eating patterns are altered
B. Fats are limited in the diet
C. Carbohydrates are regulated
D. Exercise is a major component
9. As a very anxious female client is talking to the
nurse May, she starts crying. She appears to be
upset that she cannot control her crying. The most
appropriate response by the nurse would be:
A. “Is talking about your problem upsetting you?”
B. “It is Ok to cry; I’ll just stay with you for now”
C. “You look upset; lets talk about why you are
crying.”
D. “Sometimes it helps to get it out of your
system.”
10. A patient has partial-thickness burns to both
legs and portions of his trunk. Which of the
following I.V. fluids is given first?
A. Albumin
B. D5W
C. Lactated Ringer’s solution
D. 0.9% sodium chloride solution with 2 mEq of
potassium per 100 ml
11. During the first 48 hours after a severe burn of
40% of the clients body surface, the nurse’s
assessment should include observations for water
intoxication. Associated adaptations include:
A. Sooty-colored sputum
B. Frothy pink-tinged sputum
C. Twitching and disorientation
D. Urine output below 30ml per hour
12. After a muscle biopsy, nurse Willy should teach
the client to:
A. Change the dressing as needed
B. Resume the usual diet as soon as desired
C. Bathe or shower according to preference
D. Expect a rise in body temperature for 48 hours
13. Before a client whose left hand has been
amputated can be fitted for a prosthesis, nurse Joy is
aware that:
A. Arm and shoulder muscles must be developed
B. Shrinkage of the residual limb must be
completed
C. Dexterity in the other extremity must be
achieved
D. Full adjustment to the altered body image must
have occurred
14. Nurse Cathy applies a fetal monitor to the
abdomen of a client in active labor. When the client
has contractions, the nurse notes a 15 beat per
minute deceleration of the fetal heart rate below the
baseline lasting 15 seconds. Nurse Cathy should:
A. Change the maternal position
B. Prepare for an immediate birth
C. Call the physician immediately
D. Obtain the client’s blood pressure
15. A male client receiving prolonged steroid
therapy complains of always being thirsty and
urinating frequently. The best initial action by the
nurse would be to:
A. Perform a finger stick to test the client’s blood
glucose level
B. Have the physician assess the client for an
enlarged prostate
C. Obtain a urine specimen from the client for
screening purposes
D. Assess the client’s lower extremities for the
presence of pitting edema
16. Nurse Bea recognizes that a pacemaker is
indicated when a client is experiencing:
A. Angina
B. Chest pain
C. Heart block
D. Tachycardia
17. When administering pancrelipase (Pancreases
capsules) to child with cystic fibrosis, nurse Faith
knows they should be given:
A. With meals and snacks
B. Every three hours while awake
C. On awakening, following meals, and at
bedtime
D. After each bowel movement and after postural
draianage
18. A preterm neonate is receiving oxygen by an
overhead hood. During the time the infant is under
the hood, it would be appropriate for nurse Gian to:
A. Hydrate the infant q15 min
B. Put a hat on the infant’s head
C. Keep the oxygen concentration consistent
D. Remove the infant q15 min for stimulation
19. A client’s sputum smears for acid fast bacilli
(AFB) are positive, and transmission-based airborne
precautions are ordered. Nurse Kyle should instruct
visitors to:
A. Limit contact with non-exposed family
members
B. Avoid contact with any objects present in the
client’s room
C. Wear an Ultra-Filter mask when they are in the
client’s room
D. Put on a gown and gloves before going into the
client’s room
20. A client with a head injury has a fixed, dilated
right pupil; responds only to painful stimuli; and
exhibits decorticate posturing. Nurse Kate should
recognize that these are signs of:
A. Meningeal irritation
B. Subdural hemorrhage
C. Medullary compression
D. Cerebral cortex compression
21. After a lateral crushing chest injury, obvious
right-sided paradoxic motion of the client’s chest
demonstrates multiple rib fraactures, resulting in a
flail chest. The complication the nurse should
carefully observe for would be:
A. Mediastinal shift
B. Tracheal laceration
C. Open pneumothorax
D. Pericardial tamponade
22. When planning care for a client at 30-weeks
gestation, admitted to the hospital after vaginal
bleeding secondary to placenta previa, the nurse’s
primary objective would be:
A. Provide a calm, quiet environment
B. Prepare the client for an immediate cesarean
birth
C. Prevent situations that may stimulate the cervix
or uterus
D. Ensure that the client has regular cervical
examinations assess for labor
23. When planning discharge teaching for a young
female client who has had a pneumothorax, it is
important that the nurse include the signs and
symptoms of a pneumothorax and teach the client to
seek medical assistance if she experiences:
A. Substernal chest pain
B. Episodes of palpitation
C. Severe shortness of breath
D. Dizziness when standing up
24. After a laryngectomy, the most important
equipment to place at the client’s bedside would be:
A. Suction equipment
B. Humidified oxygen
C. A nonelectric call bell
D. A cold-stream vaporizer
25. Nurse Oliver interviews a young female client
with anorexia nervosa to obtain information for the
nursing history. The client’s history is likely to
reveal a:
A. Strong desire to improve her body image
B. Close, supportive mother-daughter relationship
C. Satisfaction with and desire to maintain her
present weight
D. Low level of achievement in school, with little
concerns for grades
26. Nurse Bea should plan to assist a client with an
obsessive-compulsive disorder to control the use of
ritualistic behavior by:
A. Providing repetitive activities that require little
thought
B. Attempting to reduce or limit situations that
increase anxiety
C. Getting the client involved with activities that
will provide distraction
D. Suggesting that the client perform menial tasks
to expiate feelings of guilt
27. A 2 ½ year old child undergoes a
ventriculoperitoneal shunt revision. Before
discharge, nurse John, knowing the expected
developmental behaviors for this age group, should
tell the parents to call the physician if the child:
A. Tries to copy all the father’s mannerisms
B. Talks incessantly regardless of the presence of
others
C. Becomes fussy when frustrated and displays a
shortened attention span
D. Frequently starts arguments with playmates by
claiming all toys are “mine”
28. A urinary tract infection is a potential danger
with an indwelling catheter. Nurse Gina can best
plan to avoid this complication by:
A. Assessing urine specific gravity
B. Maintaining the ordered hydration
C. Collecting a weekly urine specimen
D. Emptying the drainage bag frequently
29. A client has sustained a fractured right femur in
a fall on stairs. Nurse Troy with the emergency
response team assess for signs of circulatory
impairment by:
A. Turning the client to side lying position
B. Asking the client to cough and deep breathe
C. Taking the client’s pedal pulse in the affected
limb
D. Instructing the client to wiggle the toes of the
right foot
30. To assess orientation to place in a client
suspected of having dementia of the alzheimers type,
nurse Chris should ask:
A. “Where are you?”
B. “Who brought you here?”
C. “Do you know where you are?”
D. “How long have you been there?”
31. Nurse Mary assesses a postpartum client who
had an abruption placentae and suspects that
disseminated intravascular coagulation (DIC) is
occurring when assessments demonstrate:
A. A boggy uterus
B. Multiple vaginal clots
C. Hypotension and tachycardia
D. Bleeding from the venipuncture site
32. When a client on labor experiences the urge to
push a 9cm dilation, the breathing pattern that nurse
Rhea should instruct the client to use is the:
A. Expulsion pattern
B. Slow paced pattern
C. Shallow chest pattern
D. blowing pattern
33. Nurse Ronald should explain that the most
beneficial between-meal snack for a client who is
recovering from the full-thickness burns would be a:
A. Cheeseburger and a malted
B. Piece of blueberry pie and milk
C. Bacon and tomato sandwich and tea
D. Chicken salad sandwich and soft drink
34. Nurse Wilma recognizes that failure of a
newborn to make the appropriate adaptation to
extrauterine life would be indicated by:
A. flexed extremities
B. Cyanotic lips and face
C. A heart rate of 130 beats per minute
D. A respiratory rate of 40 breath per minute
35. The laboratory calls to state that a client’s
lithium level is 1.9 mEq/L after 10 days of lithium
therapy. Nurse Reese should:
A. Notify the physician of the findings because
the level is dangerously high
B. Monitor the client closely because the level of
lithium in the blood is slightly elevated
C. Continue to administer the medication as
ordered because the level is within the
therapeutic range
D. Report the findings to the physician so the
dosage can be increased because the level is
below therapeutic range
36. A client has a regular 30-day menstrual cycles.
When teaching about the rhythm method, Which the
client and her husband have chosen to use for
family planning, nurse Dianne should emphasize
that the client’s most fertile days are:
A. Days 9 to 11
B. Days 12 to 14
C. Days 15 to 17
D. Days 18 to 20
37. Before an amniocentesis, nurse Alexandra
should:
A. Initiate the intravenous therapy as ordered by
the physiscian
B. Inform the client that the procedure could
precipitate an infection
C. Assure that informed consent has been
obtained from the client
D. Perform a vaginal examination on the client to
assess cervical dilation
38. While a client is on intravenous magnesium
sulfate therapy for preeclampsia, it is essential for
nurse Amy to monitor the client’s deep tendon
reflexes to:
A. Determine her level of consciousness
B. Evaluate the mobility of the extremities
C. Determine her response to painful stimuli
D. Prevent development of respiratory distress
39. A preschooler is admitted to the hospital with a
diagnosis of acute glomerulonephritis. The child’s
history reveals a 5-pound weight gain in one week
and peritoneal edema. For the most accurate
information on the status of the child’s edema,
nursing intervention should include:
A. Obtaining the child’s daily weight
B. Doing a visual inspection of the child
C. Measuring the child’s intake and output
 D. Monitoring the child’s electrolyte values
40. Nurse Mickey is administering dexamethasome
(Decadron) for the early management of a client’s
cerebral edema. This treatment is effective because:
A. Acts as hyperosmotic diuretic
B. Increases tissue resistance to infection
C. Reduces the inflammatory response of tissues
D. Decreases the information of cerebrospinal
fluid
41. During newborn nursing assessment, a positive
Ortolani’s sign would be indicated by:
A. A unilateral droop of hip
B. A broadening of the perineum
C. An apparent shortening of one leg
D. An audible click on hip manipulation
42. When caring for a dying client who is in the
denial stage of grief, the best nursing approach
would be to:
A. Agree and encourage the client’s denial
B. Allow the denial but be available to discuss
death
C. Reassure the client that everything will be OK
D. Leave the client alone to confront the feelings
of impending loss
43. To decrease the symptoms of gastroesophageal
reflux disease (GERD), the physician orders dietary
and medication management. Nurse Helen should
teach the client that the meal alteration that would
be most appropriate would be:
A. Ingest foods while they are hot
B. Divide food into four to six meals a day
C. Eat the last of three meals daily by 8pm
D. Suck a peppermint candy after each meal
44. After a mastectomy or hysterectomy, clients
may feel incomplete as women. The statement that
should alert nurse Gina to this feeling would be:
A. “I can’t wait to see all my friends again”
B. “I feel washed out; there isn’t much left”
C. “I can’t wait to get home to see my grandchild”
D. “My husband plans for me to recuperate at our
daughter’s home”
45. A client with obstruction of the common bile
duct may show a prolonged bleeding and clotting
time because:
A. Vitamin K is not absorbed
B. The ionized calcium levels falls
C. The extrinsic factor is not absorbed
D. Bilirubin accumulates in the plasma
46. Realizing that the hypokalemia is a side effect
of steroid therapy, nurse Monette should monitor a
client taking steroid medication for:
A. Hyperactive reflexes
B. An increased pulse rate
C. Nausea, vomiting, and diarrhea
D. Leg weakness with muscle cramps
47. When assessing a newborn suspected of having
Down syndrome, nurse Rey would expect to
observe:
A. long thin fingers
B. Large, protruding ears
C. Hypertonic neck muscles
D. Simian lines on the hands
48. A 10 year old girl is admitted to the pediatric
unit for recurrent pain and swelling of her joints,
particularly her knees and ankles. Her diagnosis is
juvenile rheumatoid arthritis. Nurse Janah
recognizes that besides joint inflammation, a unique
manifestation of the rheumatoid process involves
the:
A. Ears
B. Eyes
C. Liver
D. Brain
49. A disturbed client is scheduled to begin group
therapy. The client refuses to attend. Nurse Lolit
should:
A. Accept the client’s decision without discussion
B. Have another client to ask the client to consider
C. Tell the client that attendance at the meeting is
required
D. Insist that the client join the group to help the
socialization process
50. Because a severely depressed client has not
responded to any of the antidepressant medications,
the psychiatrist decides to try electroconvulsive
therapy (ECT). Before the treatment the nurse
should:
A. Have the client speak with other clients
receiving ECT
B. Give the client a detailed explanation of the
entire procedure
C. Limit the client’s intake to a light breakfast on
the days of the treatment
D. Provide a simple explanation of the procedure
and continue to reassure the client
51. Nurse Vicky is aware that teaching about
colostomy care is understood when the client states,
“I will contact my physician and report ____”:
A. If I notice a loss of sensation to touch in the
stoma tissue”
B. When mucus is passed from the stoma between
irrigations”
C. The expulsion of flatus while the irrigating
fluid is running out”
D. If I have difficulty in inserting the irrigating
tube into the stoma”
52. The client’s history that alerts nurse Henry to
assess closely for signs of postpartum infection
would be:
A. Three spontaneous abortions
B. negative maternal blood type
 C. Blood loss of 850 ml after a vaginal birth
D. Maternal temperature of 99.9° F 12 hours after
delivery
53. A client is experiencing stomatitis as a result of
chemotherapy. An appropriate nursing intervention
related to this condition would be to:
A. Provide frequent saline mouthwashes
B. Use karaya powder to decrease irritation
C. Increase fluid intake to compensate for the
diarrhea
D. Provide meticulous skin care of the abdomen
with Betadine
54. During a group therapy session, one of the
clients ask a male client with the diagnosis of
antisocial personality disorder why he is in the
hospital. Considering this client’s type of
personality disorder, the nurse might expect him to
respond:
A. “I need a lot of help with my troubles”
B. “Society makes people react in old ways”
C. “I decided that it’s time I own up to my
problems”
D. “My life needs straightening out and this might
help”
55. A child visits the clinic for a 6-week checkup
after a tonsillectomy and adenoidectomy. In
addition to assessing hearing, the nurse should
include an assessment of the child’s:
A. Taste and smell
B. Taste and speech
C. Swallowing and smell
D. Swallowing and speech
56. A client is diagnosed with cancer of the jaw. A
course of radiation therapy is to be followed by
surgery. The client is concerned about the side
effects related to the radiation treaments. Nurse Ria
should explain that the major side effects that will
experienced is:
A. Fatigue
B. Alopecia
C. Vomiting
D. Leucopenia
57. Nurse Katrina prepares an older-adult client for
sleep, actions are taken to help reduce the likelihood
of a fall during the night. Targeting the most
frequent cause of falls, the nurse should:
A. Offer the client assistance to the bathroom
B. Move the bedside table closer to the client’s
bed
C. Encourage the client to take an available
sedative
D. Assist the client to telephone the spouse to say
“goodnight”
58. When evaluating a growth and development of a
6 month old infant, nurse Patty would expect the
infant to be able to:
A. Sit alone, display pincer grasp, wave bye bye
B. Pull self to a standing position, release a toy by
choice, play peek-a-boo
C. Crawl, transfer toy from one hand to the other,
display of fear of strangers
D. Turn completely over, sit momentarily without
support, reach to be picked up
59. A breastfeeding mother asks the nurse what she
can do to ease the discomfort caused by a cracked
nipple. Nurse Tina should instruct the client to:
A. Manually express milk and feed it to the baby
in a bottle
B. Stop breastfeeding for two days to allow the
nipple to heal
C. Use a breast shield to keep the baby from direct
contact with the nipple
D. Feed the baby on the unaffected breast first
until the affected breast heals
60. Nurse Sandy observes that there is blood
coming from the client’s ear after head injury.
Nurse Sandy should:
A. Turn the client to the unaffected side
B. Cleanse the client’s ear with sterile gauze
C. Test the drainage from the client’s ear with
Dextrostix
D. Place sterile cotton loosely in the external ear
of the client
61. Nurse Gio plans a long term care for parents of
children with sickle-cell anemia, which includes
periodic group conferences. Some of the
discussions should be directed towards:
A. Finding special school facilities for the child
B. Making plans for moving to a more therapeutic
climate
C. Choosing a means of birth control to avoid
future pregnancies
D. Airing their feelings regarding the transmission
of the disease to the child
62. The central problem the nurse might face with a
disturbed schizophrenic client is the client’s:
A. Suspicious feelings
B. Continuous pacing
C. Relationship with the family
D. Concern about working with others
63. When planning care with a client during the
postoperative recovery period following an
abdominal hysterectomy and bilateral salpingo-
oophorectomy, nurse Frida should include the
explanation that:
A. Surgical menopause will occur
B. Urinary retention is a common problem
C. Weight gain is expected, and dietary plan are
needed
D. Depression is normal and should be expected
64. An adolescent client with anorexia nervosa
refuses to eat, stating, “I’ll get too fat.” Nurse
Andrea can best respond to this behavior initially by:
 A. Not talking about the fact that the client is not
eating
B. Stopping all of the client’s priviledges until
food is eaten
C. Telling the client that tube feeding will
eventually be necessary
D. Pointing out to the client that death can occur
with malnutrition.
65. A pain scale is used to assess the degree of pain.
The client rates the pain as an 8 on a scale of 10
before medication and a 7 on a scale of 10 after
being medicated. Nurse Glenda determines that the:
A. Client has a low pain tolerance
B. Medication is not adequately effective
C. Medication has sufficiently decreased the pain
level
D. Client needs more education about the use of
the pain scale
66. To enhance a neonate’s behavioral development,
therapeutic nursing measures should include:
A. Keeping the baby awake for longer periods of
time before each feeding
B. Assisting the parents to stimulate their baby
through touch, sound, and sight.
C. Encouraging parental contact for at least one
15-minute period every four hours.
D. Touching and talking to the baby at least
hourly, beginning within two to four hours
after birth
67. Before formulating a plan of care for a 6 year
old boy with attention deficit hyperactivity disorder
(ADHD), nurse Kyla is aware that the initial aim of
therapy is to help the client to:
A. Develop language skills
B. Avoid his own regressive behavior
C. Mainstream into a regular class in school
D. Recognize himself as an independent person of
worth
68. Nurse Wally knows that the most important
aspect of the preoperative care for a child with
Wilms’ tumor would be:
A. Checking the size of the child’s liver
B. Monitoring the child’s blood pressure
C. Maintaining the child in a prone position
D. Collecting the child’s urine for culture and
sensitivity
69. At 11:00 pm the count of hydrocodone (Vicodin)
is incorrect. After several minutes of searching the
medication cart and medication administration
records, no explanation can be found. The primary
nurse should notify the:
A. Nursing unit manager
B. Hospital administrator
C. Quality control manager
D. Physician ordering the medication
70. When caring for the a client with a
pneumothorax, who has a chest tube in place, nurse
Kate should plan to:
A. Administer cough suppressants at appropriate
intervals as ordered
B. Empty and measure the drainage in the
collection chamber each shift
C. Apply clamps below the insertion site when
ever getting the client out of bed
D. Encourage coughing, deep breathing, and range
of motion to the arm on the affected side
71. According to C.E.Winslow, which of the
following is the goal of Public Health?
A. For people to attain their birthrights of health
and longevity
B. For promotion of health and prevention of
disease
C. For people to have access to basic health
services
D. For people to be organized in their health
efforts
72. What other statistic may be used to determine
attainment of longevity?
A. Age-specific mortality rate
B. Proportionate mortality rate
C. Swaroop’s index
D. Case fatality rate
73. 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 catchment 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.
74. Which of the following is the mission of the
Department of Health?
A. Health for all Filipinos
B. Ensure the accessibility and quality of health
care
C. Improve the general health status of the
population
D. Health in the hands of the Filipino people by
the year 2020
75. Nurse Pauline determines whether resources
were maximized in implementing Ligtas Tigdas,
she is evaluating:
A. Effectiveness
B. Efficiency
C. Adequacy
D. Appropriateness
76. Lissa is a B.S.N. graduate. She want to become
a Public Health Nurse. Where will she apply?
 A. Department of Health
B. Provincial Health Office
C. Regional Health Office
D. Rural Health Unit
77. As an epidemiologist, Nurse Celeste is
responsible for reporting cases of notifiable diseases.
What law mandates reporting of cases of notifiable
diseases?
A. Act 3573
B. R.A. 3753
C. R.A. 1054
D. R.A. 1082
78. Nurse Fay is aware that isolation of a child with
measles belongs to what level of prevention?
A. Primary
B. Secondary
C. Intermediate
D. Tertiary
79. Nurse Gina is aware that the following is an
advantage of a home visit?
A. It allows the nurse to provide nursing care to a
greater number of people.
B. It provides an opportunity to do first hand
appraisal of the home situation.
C. It allows sharing of experiences among people
with similar health problems.
D. It develops the family’s initiative in providing
for health needs of its members.
80. The PHN bag is an important tool in providing
nursing care during a home visit. The most
important principle of bag technique states that it:
A. Should save time and effort.
B. Should minimize if not totally prevent the
spread of infection.
C. Should not overshadow concern for the patient
and his family.
D. May be done in a variety of ways depending on
the home situation, etc.
81. Nurse Willy reads about Path Goal theory.
Which of the following behaviors is manifested by
the leader who uses this theory?
A. Recognizes staff for going beyond expectations
by giving them citations
B. Challenges the staff to take individual
accountability for their own practice
C. Admonishes staff for being laggards
D. Reminds staff about the sanctions for non
performance
82. Nurse Cathy learns that some leaders are
transactional leaders. Which of the following does
NOT characterize a transactional leader?
A. Focuses on management tasks
B. Is a caretaker
C. Uses trade-offs to meet goals
D. Inspires others with vision
83. Functional nursing has some advantages, which
one is an EXCEPTION?
A. Psychological and sociological needs are
emphasized.
B. Great control of work activities.
C. Most economical way of delivering nursing
services.
D. Workers feel secure in dependent role
84. Which of the following is the best guarantee that
the patient’s priority needs are met?
A. Checking with the relative of the patient
B. Preparing a nursing care plan in collaboration
with the patient
C. Consulting with the physician
D. Coordinating with other members of the team
85. Nurse Tony stresses the need for all the
employees to follow orders and instructions from
him and not from anyone else. Which of the
following principles does he refer to?
A. Scalar chain
B. Discipline
C. Unity of command
D. Order
86. Nurse Joey discusses the goal of the department.
Which of the following statements is a goal?
A. Increase the patient satisfaction rate
B. Eliminate the incidence of delayed
administration of medications
C. Establish rapport with patients
D. Reduce response time to two minutes
87. Nurse Lou considers shifting to transformational
leadership. Which of the following statements best
describes this type of leadership?
A. Uses visioning as the essence of leadership
B. Serves the followers rather than being served
C. Maintains full trust and confidence in the
subordinates
D. Possesses innate charisma that makes others
feel good in his presence.
88. Nurse Mae tells one of the staff, “I don’t have
time to discuss the matter with you now. See me in
my office later” when the latter asks if they can talk
about an issue. Which of the following conflict
resolution strategies did she use?
A. Smoothing
B. Compromise
C. Avoidance
D. Restriction
89. Nurse Bea plans of assigning competent people
to fill the roles designed in the hierarchy. Which
process refers to this?
A. Staffing
B. Scheduling
C. Recruitment
D. Induction
90. Nurse Linda tries to design an organizational
structure that allows communication to flow in all
directions and involve workers in decision making.
Which form of organizational structure is this?
A. Centralized
B. Decentralized
C. Matrix
D. Informal
91. When documenting information in a client’s
medical record, the nurse should:
A. erase any errors.
B. use a #2 pencil.
C. leave one line blank before each new entry.
D. end each entry with the nurse’s signature and
title.
92. Which of the following factors are major
components of a client’s general background drug
history?
A. Allergies and socioeconomic status
B. Urine output and allergies
C. Gastric reflex and age
D. Bowel habits and allergies
93. Which procedure or practice requires surgical
asepsis?
A. Hand washing
B. Nasogastric tube irrigation
C. I.V. cannula insertion
D. Colostomy irrigation
94. The nurse is performing wound care using
surgical asepsis. Which of the following practices
violates surgical asepsis?
A. Holding sterile objects above the waist
B. Pouring solution onto a sterile field cloth
C. Considering a 1″ (2.5-cm) edge around the
sterile field contaminated
D. Opening the outermost flap of a sterile package
away from the body
95. On admission, a client has the following arterial
blood gas (ABG) values: PaO2, 50 mm Hg; PaCO2,
70 mm Hg; pH, 7.20; HCO3–, 28 mEq/L. Based on
these values,
the nurse should formulate which nursing diagnosis
for this client?
A. Risk for deficient fluid volume
B. Deficient fluid volume
C. Impaired gas exchange
D. Metabolic acidosis
96. The use of larvivorous fish in malaria control is
the basis for which strategy of malaria control?
A. Stream seeding
B. Stream clearing
C. Destruction of breeding places
D. Zooprophylaxis
97. In Integrated Management of Childhood Illness,
severe conditions generally require urgent referral
to a hospital. Which of the following severe
conditions DOES NOT always require urgent
referral to a hospital?
A. Mastoiditis
B. Severe dehydration
C. Severe pneumonia
D. Severe febrile disease
98. A mother brought her daughter, 4 years old, to
the RHU because of cough and colds. Following the
IMCI assessment guide, which of the following is a
danger sign that indicates the need for urgent
referral to a hospital?
A. Inability to drink
B. High grade fever
C. Signs of severe dehydration
D. Cough for more than 30 days
99. Food fortification is one of the strategies to
prevent micronutrient deficiency conditions. R.A.
8976 mandates fortification of certain food items.
Which of the following is among these food items?
A. Sugar
B. Bread
C. Margarine
D. Filled milk
100. The major sign of iron deficiency anemia is
pallor. What part is best examined for pallor?
A. Palms
B. Nailbeds
C. Around the lips
D. Lower conjunctival sac
Answers and Rationales
1. C. Check for any change in responsiveness
every two hours until the follow-up visit. Signs
of an epidural hematoma in children usually do
not appear for 24 hours or more hours; a
follow-up visit usually is arranged for one to
two days after the injury.
2. A. Arteriolar constriction occurs.The early
compensation of shock is cardiovascular and is
seen in changes in pulse, BP, and pulse
pressure; blood is shunted to vital centers,
particularly heart and brain.
3. A. Allow the client to open canned or pre-
packaged food. The client’s comfort, safety,
and nutritional status are the priorities; the
client may feel comfortable to eat if the food
has been sealed before reaching the mental
health facility.
4. D. “Joining a support group of parents who are
coping with this problem can be quite
helpful. Taking with others in similar
circumstances provides support and allows for
sharing of experiences.
5. B. Observe the dressing at the back of the neck
for the presence of blood. Drainage flows by
gravity.
6. C. Prepare her for a pelvic examination. Pelvic
examination would reveal dilation and
effacement
7. D. On the right side of the heart. Pulmonic
stenosis increases resistance to blood flow,
causing right ventricular hyperthropy; with
right ventricular failure there is an increase in
pressure on the right side of the heart.
8. A. Eating patterns are altered. A new dietary
regimen, with a balance of foods from the food
pyramid, must be established and continued for
weight reduction to occur and be maintained.
9. B. “It is Ok to cry; I’ll just stay with you for
now”. This portrays a nonjudgmental attitude
that recognizes the client’s needs.
10. C. Lactated Ringer’s solution. Lactated
Ringer’s solution replaces lost sodium and
corrects metabolic acidosis, both of which
commonly occur following a burn. Albumin is
used as adjunct therapy, not primary fluid
replacement. Dextrose isn’t given to burn
patients during the first 24 hours because it can
cause pseudodiabetes. The patient is
hyperkalemic from the potassium shift from
the intracellular space to the plasma, so
potassium would be detrimental.
11. C. Twitching and disorientation. Excess
extracellular fluid moves into cells (water
intoxication); intracellular fluid excess in
sensitive brain cells causes altered mental
status; other signs include anorexia nervosa,
nausea, vomiting, twitching, sleepiness, and
convulsions.
12. B. Resume the usual diet as soon as desired. As
long as the client has no nausea or vomiting,
there are no dietary restriction.
13. B. Shrinkage of the residual limb must be
completed. Shrinkage of the residual limb,
resulting from reduction of subcutaneous fat
and interstitial fluid, must occur for an
adequate fit between the limb and the
prosthesis.
14. A. Change the maternal position. Stimulation
of the sympathetic nervous system is an initial
response to mild hypoxia that accompanies
partial cord compression (umbilical vein)
during contractions; changing the maternal
position can alleviate the compression.
15. A. Perform a finger stick to test the client’s
blood glucose level. The client has signs of
diabetes, which may result from steroid therapy,
testing the blood glucose level is a method of
screening for diabetes, thus gathering more
data.
16. C. Heart block. This is the primary indication
for a pacemaker because there is an interfere
with the electrical conduction system of the
heart.
17. A. With meals and snacks. Pancreases capsules
must be taken with food and snacks because it
acts on the nutrients and readies them for
absorption.
18. B. Put a hat on the infant’s head. Oxygen has
cooling effect, and the baby should be kept
warm so that metabolic activity and oxygen
demands are not increased.
19. C. Wear an Ultra-Filter mask when they are in
the client’s room. Tubercle bacilli are
transmitted through air currents; therefore
personal protective equipment such as an
Ultra-Filter mask is necessary.
20. D. Cerebral cortex compression. Cerebral
compression affects pyramidal tracts, resulting
in decorticate rigidity and cranial nerve injury,
which cause pupil dilation.
21. A.Mediastinal shift. Mediastinal structures
move toward the uninjured lung, reducing
oxygenation and venous return.
22. C. Prevent situations that may stimulate the
cervix or uterus. Stimulation of the cervix or
uterus may cause bleeding or hemorrhage and
should be avoided.
23. C. Severe shortness of breath. This could
indicate a recurrence of the pneumothorax as
one side of the lung is inadequate to meet the
oxygen demands of the body.
24. A. Suction equipment. Respiratory
complications can occur because of edema of
the glottis or injury to the recurrent laryngeal
nerve.
25. A. Strong desire to improve her body
image. Clients with anorexia nervosa have a
disturbed self image and always see themselves
as fat and needing further reducing.
26. B. Attempting to reduce or limit situations that
increase anxiety. Persons with high anxiety
levels develop various behaviors to relieve
their anxiety; by reducing anxiety, the need for
these obsessive-compulsive action is reduced.
27. C. Becomes fussy when frustrated and displays
a shortened attention span. Shortened attention
span and fussy behavior may indicate a change
in intracranial pressure and/or shunt
malfunction.
28. B. Maintaining the ordered
hydration. Promoting hydration maintains urine
production at a higher rate, which flushes the
bladder and prevents urinary stasis and
possible infection.
29. C. Taking the client’s pedal pulse in the
affected limb. Monitoring a pedal pulse will
assess circulation to the foot.
30. A. “Where are you?”. “Where are you?” is the
best question to elicit information about the
client’s orientation to place because it
encourages a response that can be assessed.
31. D. Bleeding from the venipuncture site. This
indicates a fibrinogenemia; massive clotting in
the area of the separation has resulted in a
lowered circulating fibrinogen.
32. D. blowing pattern. Clients should use a
blowing pattern to overcome the premature
urge to push.
33. A. Cheeseburger and a malted. Of the
selections offered, this is the highest in calories
and protein, which are needed for increased
basal metabolic rate and for tissue repair.
34. B. Cyanotic lips and face. Central cyanosis
(blue lips and face) indicates lowered
oxygenation of the blood, caused by either
decreased lung expansion or right to left
shunting of blood.
35. A. Notify the physician of the findings because
the level is dangerously high. Levels close to 2
mEq/L are dangerously close to the toxic level;
immediate action must be taken.
36. C. Days 15 to 17. Ovulation occurs
approximately 14 days before the next menses,
about the 16th day in 30 day cycle; the 15th to
17th days would be the best time to avoid
sexual intercourse.
37. C. Assure that informed consent has been
obtained from the client. An invasive
procedure such as amniocentesis requires
informed consent.
38. D. Prevent development of respiratory
distress. Respiratory distress or arrest may
occur when the serum level of magnesium
sulfate reaches 12 to 15 mg/dl; deep tendon
reflexes disappear when the serum level is 10
to 12 mg/dl; the drug is withheld in the absence
of deep tendon reflexes; the therapeutic serum
level is 5 to 8 mg/dl.
39. A. Obtaining the child’s daily weight. Weight
monitoring is the most useful means of
assessing fluid balance and changes in the
edematous state; 1 liter of fluid weighs about
2.2 pounds.
40. C. Reduces the inflammatory response of
tissues. Corticosteroids act to decrease
inflammation which decreases edema.
41. D. An audible click on hip manipulation. With
specific manipulation, an audible click may be
heard of felt as he femoral head slips into the
acetabulum.
42. B. Allow the denial but be available to discuss
death. This does not remove client’s only way
of coping, and it permits future movement
through the grieving process when the client is
ready.
43. B. Divide food into four to six meals a
day. The volume of food in the stomach should
be kept small to limit pressure on the cardiac
sphincter.
44. B. “I feel washed out; there isn’t much
left”. The client’s statement infers an emptiness
with an associated loss.
45. A. Vitamin K is not absorbed. Vitamin K, a fat
soluble vitamin, is not absorbed from the GI
tract in the absence of bile; bile enters the
duodenum via the common bile duct.
46. D. Leg weakness with muscle cramps. Impulse
conduction of skeletal muscle is impaired with
decreased potassium levels, muscular weakness
and cramps may occur with hypokalemia.
47. D. Simian lines on the hands. This is
characteristic finding in newborns with Down
syndrome.
48. B. Eyes. Rheumatoid arthritis can cause
inflammation of the iris and ciliary body of the
eyes which may lead to blindness.
49. A. Accept the client’s decision without
discussion. This is all the nurse can do until
trust is established; facing the client to attend
will disrupt the group.
50. D. Provide a simple explanation of the
procedure and continue to reassure the
client. The nurse should offer support and use
clear, simple terms to allay client’s anxiety.
51. D. If I have difficulty in inserting the irrigating
tube into the stoma”. This occurs with stenosis
of the stoma; forcing insertion of the tube
could cause injury.
52. C. Blood loss of 850 ml after a vaginal
birth. Excessive blood loss predisposes the
client to an increased risk of infection because
of decreased maternal resistance; they expected
blood loss is 350 to 500 ml.
53. A. Provide frequent saline mouthwashes. This
is soothing to the oral mucosa and helps
prevent infection.
54. B. “Society makes people react in old
ways”. The client is incapable of accepting
responsibility for self-created problems and
blames society for the behavior.
55. A. Taste and smell. Swelling can obstruct nasal
breathing, interfering with the senses of taste
and smell.
56. A. Fatigue. Fatigue is a major problem caused
by an increase in waste products because of
catabolic processes.
57. A. Offer the client assistance to the
bathroom. Statistics indicate that the most
frequent cause of falls by hospitalized clients is
getting up or attempting to get up to the
bathroom unassisted.
58. D. Turn completely over, sit momentarily
without support, reach to be picked up. These
abilities are age-appropriate for the 6 month
old child.
59. D. Feed the baby on the unaffected breast first
until the affected breast heals. The most
vigorous sucking will occur during the first few
minutes of breastfeeding when the infant
would be on the unaffected breast; later
suckling is less traumatic.
60. D. Place sterile cotton loosely in the external
ear of the client. This would absorb the
drainage without causing further trauma.
61. D. Airing their feelings regarding the
transmission of the disease to the
child. Discussion with parents who have
children with similar problems helps to reduce
some of their discomfort and guilt.
62. A. Suspicious feelings. The nurse must deal
with these feelings and establish basic trust to
promote a therapeutic milieu.
63. A. Surgical menopause will occur. When a
bilateral oophorectomy is performed, both
ovaries are excised, eliminating ovarian
hormones and initiating response.
64. D. Pointing out to the client that death can
occur with malnutrition. The client expects the
nurse to focus on eating, but the emphasis
should be placed on feelings rather than actions.
65. B. Medication is not adequately effective. The
expected effect should be more than a one
point decrease in the pain level.
66. B. Assisting the parents to stimulate their baby
through touch, sound, and sight. Stimuli are
provided via all the senses; since the infant’s
behavioral development is enhanced through
parent-infant interactions, these interactions
should be encouraged.
67. D. Recognize himself as an independent person
of worth. Academic deficits, an inability to
function within constraints required of certain
settings, and negative peer attitudes often lead
to low self-esteem.
68. B. Monitoring the child’s blood
pressure. Because the tumor is of renal origin,
the rennin angiotensin mechanism can be
involved, and blood pressure monitoring is
important.
69. A. Nursing unit manager. Controlled substance
issues for a particular nursing unit are the
responsibility of that unit’s nurse manager.
70. D. Encourage coughing, deep breathing, and
range of motion to the arm on the affected
side. All these interventions promote aeration
of the re-expanding lung and maintenance of
function in the arm and shoulder on the
affected side.
71. A. For people to attain their birthrights of
health and longevity. According to Winslow,
all public health efforts are for people to realize
their birthrights of health and longevity.
72. C. Swaroop’s index. Swaroop’s index is the
percentage of the deaths aged 50 years or older.
Its inverse represents the percentage of
untimely deaths (those who died younger than
50 years).
73. D. Public health nursing focuses on preventive,
not curative, services.. The catchment area in
PHN consists of a residential community,
many of whom are well individuals who have
greater need for preventive rather than curative
services.
74. B. Ensure the accessibility and quality of
health care. Ensuring the accessibility and
quality of health care is the primary mission of
DOH.
75. B. Efficiency. Efficiency is determining
whether the goals were attained at the least
possible cost.
76. D. Rural Health Unit. R.A. 7160 devolved
basic health services to local government units
(LGU’s ). The public health nurse is an
employee of the LGU.
77. A. Act 3573. Act 3573, the Law on Reporting
of Communicable Diseases, enacted in 1929,
mandated the reporting of diseases listed in the
law to the nearest health station.
78. A. Primary. The purpose of isolating a client
with a communicable disease is to protect those
who are not sick (specific disease prevention).
79. B. It provides an opportunity to do first hand
appraisal of the home situation. Choice A is not
correct since a home visit requires that the
nurse spend so much time with the family.
Choice C is an advantage of a group
conference, while choice D is true of a clinic
consultation.
80. B. Should minimize if not totally prevent the
spread of infection. Bag technique is performed
before and after handling a client in the home
to prevent transmission of infection to and
from the client.
81. A. Recognizes staff for going beyond
expectations by giving them citations. Path
Goal theory according to House and associates
rewards good performance so that others would
do the same.
82. D. Inspires others with vision. Inspires others
with a vision is characteristic of a
transformational leader. He is focused more on
the day-to-day operations of the
department/unit.
83. A. Psychological and sociological needs are
emphasized. When the functional method is
used, the psychological and sociological needs
of the patients are neglected; the patients are
regarded as ‘tasks to be done”
84. B. Preparing a nursing care plan in
collaboration with the patient. The best source
of information about the priority needs of the
patient is the patient himself. Hence using a
nursing care plan based on his expressed
priority needs would ensure meeting his needs
effectively.
85. C. Unity of command. The principle of unity of
command means that employees should receive
orders coming from only one manager and not
from two managers. This averts the possibility
of sowing confusion among the members of the
organization.
86. A. Increase the patient satisfaction rate. Goal is
a desired result towards which efforts are
directed. Options AB, C and D are all
objectives which are aimed at specific end.
87. A. Uses visioning as the essence of
leadership. Transformational leadership relies
heavily on visioning as the core of leadership.
88. C. Avoidance. This strategy shuns discussing
the issue head-on and prefers to postpone it to a
later time. In effect the problem remains
unsolved and both parties are in a lose-lose
situation.
89. A. Staffing. Staffing is a management function
involving putting the best people to accomplish
 tasks and activities to attain the goals of the water identified as breeding places of the
organization. Anopheles mosquito.
90. B. Decentralized. Decentralized structures 97. B. Severe dehydration. The order of priority in
allow the staff to make decisions on matters the management of severe dehydration is as
pertaining to their practice and communicate in follows: intravenous fluid therapy, referral to a
downward, upward, lateral and diagonal flow. facility where IV fluids can be initiated within
91. D. end each entry with the nurse’s signature 30 minutes, Oresol/nasogastric tube,
and title. The end of each entry should include Oresol/orem. When the foregoing measures are
the nurse’s signature and title; the signature not possible or effective, tehn urgent referral to
holds the nurse accountable for the recorded the hospital is done.
information. Erasing errors in documentation 98. A. Inability to drink. A sick child aged 2
on a legal document such as a client’s chart months to 5 years must be referred urgently to
isn’t permitted by law. Because a client’s a hospital if he/she has one or more of the
medical record is considered a legal document, following signs: not able to feed or drink,
the nurse should make all entries in ink. The vomits everything, convulsions, abnormally
nurse is accountable for the information sleepy or difficult to awaken.
recorded and therefore shouldn’t leave any 99. A. Sugar. R.A. 8976 mandates fortification of
blank lines in which another health care worker rice, wheat flour, sugar and cooking oil with
could make additions. Vitamin A, iron and/or iodine.
92. A. Allergies and socioeconomic status. General 100. A. Palms. The anatomic characteristics of
background data consist of such components as the palms allow a reliable and convenient basis
allergies, medical history, habits, for examination for pallor.
socioeconomic status, lifestyle, beliefs, and
sensory deficits. Urine output, gastric reflex,
and bowel habits are significant only if a
disease affecting these functions is present.
93. C. I.V. cannula insertion. Caregivers must use
surgical asepsis when performing wound care
or any procedure in which a sterile body cavity
is entered or skin integrity is broken. To
achieve surgical asepsis, objects must be
rendered or kept free of all pathogens. Inserting
an I.V. cannula requires surgical asepsis
because it disrupts skin integrity and involves
entry into a sterile cavity (a vein). The other
options are used to ensure medical asepsis or
clean technique to prevent the spread of
infection. The GI tract isn’t sterile; therefore,
irrigating a nasogastric tube or a colostomy
requires only clean technique.
94. B. Pouring solution onto a sterile field
cloth. Pouring solution onto a sterile field cloth
violates surgical asepsis because moisture
penetrating the cloth can carry microorganisms
to the sterile field via capillary action. The
other options are practices that help ensure
surgical asepsis.
95. C. Impaired gas exchange. The client has a
below-normal value for the partial pressure of
arterial oxygen (PaO2) and an above-normal
value for the partial pressure of arterial carbon
dioxide (PaCO2), supporting the nursing
diagnosis of Impaired gas exchange. ABG
values can’t indicate a diagnosis of Fluid
volume deficit (or excess) or Risk for deficient
fluid volume. Metabolic acidosis is a medical,
not nursing, diagnosis; in any event, these
ABG values indicate respiratory, not metabolic,
acidosis.
96. A. Stream seeding. Stream seeding is done by
putting tilapia fry in streams or other bodies of
 A. WBC count
B. Urinalysis
C. ELISA
D. Peripheral blood smear

PNLE Exam 2
1. A woman in a child bearing age receives a
rubella vaccination. Nurse Joy would give her
which of the following instructions?
A. Refrain from eating eggs or egg products for
24 hours
B. Avoid having sexual intercourse
C. Don’t get pregnant at least 3 months
D. Avoid exposure to sun
7. The Nurse supervisor is planning for patient’s
assignment for the AM shift. The nurse supervisor
avoids assigning which of the following staff
members to a client with herpes zoster?
A. Nurse who never had chicken pox
B. Nurse who never had roseola
C. Nurse who never had german measles
D. Nurse who never had mumps

2. Jonas who is diagnosed with encephalitis is under 8. Clarissa is 7 weeks pregnant. Further
the treatment of Mannitol. Which of the following examination revealed that she is susceptible to
patient outcomes indicate to Nurse Ronald that the rubella. When would be the most appropriate for
treatment of Mannitol has been effective for a her to receive rubella immunization?
patient that has increased intracranial pressure?
A. At once
A. Increased urinary output B. During 2nd trimester
B. Decreased RR C. During 3rd trimester
C. Slowed papillary response D. After the delivery of the baby
D. Decreased level of consciousness
9. A female child with rubella should be isolated
3. Mary asked Nurse Maureen about the incubation from a:
period of rabies. Which statement by the Nurse
Maureen is appropriate? A. 21 year old male cousin living in the same
house
A. Incubation period is 6 months B. 18 year old sister who recently got married
B. Incubation period is 1 week C. 11 year old sister who had rubeola during
C. Incubation period is 1 month childhood
D. Incubation period varies depending on the D. 4 year old girl who lives next door
site of the bite
10. What is the primary prevention of leprosy?

4. Which of the following should Nurse Cherry do A. Nutrition

first in taking care of a male client with rabies? B. Vitamins
C. BCG vaccination
A. Encourage the patient to take a bath D. DPT vaccination
B. Cover IV bottle with brown paper bag 11. A bacteria which causes diphtheria is also
C. Place the patient near the comfort room known as?
D. Place the patient near the door
A. Amoeba
5. Which of the following is the screening test for B. Cholera
dengue hemorrhagic fever? C. Klebs-loeffler bacillus
D. Spirochete
A. Complete blood count 12. Nurse Ron performed mantoux skin test today
B. ELISA (Monday) to a male adult client. Which statement
C. Rumpel-leede test by the client indicates that he understood the
D. Sedimentation rate instruction well?

A. I will come back later

6. Mr. Dela Rosa is suspected to have malaria after B. I will come back next month
a business trip in Palawan. The most important C. I will come back on Friday
diagnostic test in malaria is: D. I will come back on Wednesday, same time, to
read the result
13. A male client had undergone Mantoux skin test. B. OPV
Nurse Ronald notes an 8mm area of indurations at C. Measles
the site of the skin test. The nurse interprets the D. None of the above
result as: 22. EPI is based on?

A. Negative A. Basic health services

B. Uncertain and needs to be repeated
C. Positive
D. Inconclusive
14. Tony will start a 6 month therapy with Isoniazid
(INH). Nurse Trish plans to teach the client to:
B. Scope of community affected
C. Epidemiological situation
D. Research studies
23. TT? provides how many percentage of
protection against tetanus?

A. Use alcohol moderately A. 100

B. Avoid vitamin supplements while o therapy B. 99
C. Incomplete intake of dairy products C. 80
D. May be discontinued if symptoms subsides D. 90
15. Which is the primary characteristic lesion of 24. Temperature of refrigerator to maintain potency
syphilis? of measles and OPV vaccine is:

A. Sore eyes A. -3c to -8c

B. Sore throat B. -15c to -25c
C. Chancroid C. +15c to +25c
D. Chancre D. +3c to +8c
16. What is the fast breathing of Jana who is 3 25. Diptheria is a:
weeks old?
A. Bacterial toxin
A. 60 breaths per minute B. Killed bacteria
B. 40 breaths per minute C. Live attenuated
C. 10 breaths per minute D. Plasma derivatives
D. 20 breaths per minute 26. Budgeting is under in which part of
17. Which of the following signs and symptoms management process?
indicate some dehydration?
A. Directing
A. Drinks eagerly B. Controlling
B. Restless and irritable C. Organizing
C. Unconscious D. Planning
D. A and B 27. Time table showing planned work days and
18. What is the first line for dysentery? shifts of nursing personnel is:

A. Amoxicillin A. Staffing
B. Tetracycline B. Schedule
C. Cefalexin C. Scheduling
D. Cotrimoxazole D. Planning
19. In home made oresol, what is the ratio of salt 28. A force within an individual that influences the
and sugar if you want to prepare with 1 liter of strength of behavior?
water?
A. Motivation
A. 1 tbsp. salt and 8 tbsp. sugar B. Envy
B. 1 tbsp. salt and 8 tsp. sugar C. Reward
C. 1 tsp. salt and 8 tsp. sugar D. Self-esteem
D. 8 tsp. salt and 8 tsp. sugar 29. “To be the leading hospital in the Philippines” is
20. Gentian Violet is used for: best illustrate in:

A. Wound A. Mission
B. Umbilical infections B. Philosophy
C. Ear infections C. Vision
D. Burn D. Objective
21. Which of the following is a live attenuated 30. It is the professionally desired norms against
bacterial vaccine? which a staff performance will be compared?

A. BCG A. Job descriptions

 B. Survey 39. Objective data is also called:
C. Flow chart
D. Standards A. Covert
31. Reprimanding a staff nurse for work that is done B. Overt
incorrectly is an example of what type of C. Inference
reinforcement? D. Evaluation
40. An example of subjective data is:
A. Feedback
B. Positive reinforcement A. Size of wounds
C. Performance appraisal B. VS
D. Negative reinforcement C. Lethargy
32. Questions that are answerable only by choosing D. The statement of patient “My hand is painful”
an option from a set of given alternatives are known 41. What is the best position in palpating the breast?
as?
A. Trendelenburg
A. Survey B. Side lying
B. Close ended C. Supine
C. Questionnaire D. Lithotomy
D. Demographic 42. When is the best time in performing breast self
33. A researcher that makes a generalization based examination?
on observations of an individuals behavior is said to
be which type of reasoning: A. 7 days after menstrual period
B. 7 days before menstrual period
A. Inductive C. 5 days after menstrual period
B. Logical D. 5 days before menstrual period
C. Illogical 43. Which of the following should be given the
D. Deductive highest priority before performing physical
34. The balance of a research’s benefit vs. its risks examination to a patient?
to the subject is:
A. Preparation of the room
A. Analysis B. Preparation of the patient
B. Risk-benefit ratio C. Preparation of the nurse
C. Percentile D. Preparation of environment
D. Maximum risk 44. It is a flip over card usually kept in portable file
35. An individual/object that belongs to a general at nursing station.
population is a/an:
A. Nursing care plan
A. Element B. Medicine and treatment record
B. Subject C. Kardex
C. Respondent D. TPR sheet
D. Author 45. Jose has undergone thoracentesis. The nurse in
36. An illustration that shows how the members of charge is aware that the best position for Jose is:
an organization are connected:
A. Semi fowlers
A. Flowchart B. Low fowlers
B. Bar graph C. Side lying, unaffected side
C. Organizational chart D. Side lying, affected side
D. Line graph 46. The degree of patients abdominal distension
37. The first college of nursing that was established may be determined by:
in the Philippines is:
A. Auscultation
A. Fatima University B. Palpation
B. Far Eastern University C. Inspection
C. University of the East D. Percussion
D. University of Sto. Tomas 47. A male client is addicted with hallucinogen.
38. Florence nightingale is born on: Which physiologic effect should the nurse expect?

A. France A. Bradyprea
B. Britain B. Bradycardia
C. U.S C. Constricted pupils
D. Italy D. Dilated pupils
48. Tristan a 4 year old boy has suffered from full D. Semi-fowlers
thickness burns of the face, chest and neck. What 56. Nurse Hazel knows that Myrna understands her
will be the priority nursing diagnosis? condition well when she remarks that urinary
frequency is caused by:
A. Ineffective airway clearance related to edema
B. Impaired mobility related to pain A. Pressure caused by the ascending uterus
C. Impaired urinary elimination related to fluid B. Water intake of 3L a day
loss C. Effect of cold weather
D. Risk for infection related to epidermal D. Increase intake of fruits and vegetables
disruption 57. How many ml of blood is loss during the first 24
49. In assessing a client’s incision 1 day after the hours post delivery of Myrna?
surgery, Nurse Betty expect to see which of the
following as signs of a local inflammatory response? 100
500
A. Greenish discharge 200
B. Brown exudates at incision edges 400
C. Pallor around sutures 58. Which of the following hormones stimulates the
D. Redness and warmth secretion of milk?
50. Nurse Ronald is aware that the amiotic fluid in
the third trimester weighs approximately: Progesterone
Prolactin
A. 2 kilograms Oxytocin
B. 1 kilograms Estrogen
C. 100 grams 59. Nurse Carla is aware that Myla’s second stage
D. 1.5 kilograms of labor is beginning when the following
51. After delivery of a baby girl. Nurse Gina assessment is noted:
examines the umbilical cord and expects to find a
cord to: Bay of water is broken
Contractions are regular
A. Two arteries and two veins Cervix is completely dilated
B. One artery and one vein Presence of bloody show
C. Two arteries and one vein 60. The leaking fluid is tested with nitrazine paper.
D. One artery and two veins Nurse Kelly confirms that the client’s membrane
52. Myrna a pregnant client reports that her last have ruptures when the paper turns into a:
menstrual cycle is July 11, her expected date of
birth is Pink
Violet
A. November 4 Green
B. November 11 Blue
C. April 4 61. After amniotomy, the priority nursing action is:
D. April 18
53. Which of the following is not a good source of Document the color and consistency of
iron? amniotic fluid
A. Butter Listen the fetal heart tone
B. Pechay Position the mother in her left side
C. Grains Let the mother rest
D. Beef 62. Which is the most frequent reason for
54. Maureen is admitted with a diagnosis of ectopic postpartum hemorrhage?
pregnancy. Which of the following would you
anticipate? Perineal lacerations
Frequent internal examination (IE)
A. NPO CS
B. Bed rest Uterine atomy
C. Immediate surgery 63. On 2nd postpartum day, which height would you
D. Enema expect to find the fundus in a woman who has had a
55. Gina a postpartum client is diagnosed with caesarian birth?
endometritis. Which position would you expect to 1 finger above umbilicus
place her based on this diagnosis? 2 fingers above umbilicus
2 fingers below umbilicus
A. Supine 1 finger below umbilicus
B. Left side lying 64. Which of the following criteria allows Nurse
C. Trendelinburg Kris to perform home deliveries?
 Normal findings during assessment Identify the illness
Previous CS Assess the child
Diabetes history Treat the child
Hypertensive history 73. If a young child has pneumonia when should the
65. Nurse Carla is aware that one of the following mother bring him back for follow up?
vaccines is done by intramuscular (IM) injection?
After 2 days
Measles In the afternoon
OPV After 4 days
BCG After 5 days
Tetanus toxoid 74. It is the certification recognition program that
66. Asin law is on which legal basis: develop and promotes standard for health facilities:

RA 8860 Formula
RA 2777 Tutok gamutan
RI 8172 Sentrong program movement
RR 6610 Sentrong sigla movement
67. Nurse John is aware that the herbal medicine 75. Baby Marie was born May 23, 1984. Nurse John
appropriate for urolithiasis is: will expect finger thumb opposition on:

Akapulco April 1985

Sambong February 1985
Tsaang gubat March 1985
Bayabas June 1985
68. Community/Public health bag is defined as: 76. Baby Reese is a 12 month old child. Nurse
Oliver would anticipate how many teeth?
An essential and indispensable equipment of
the community health nurse during home visit 9
It contains drugs and equipment used by the 7
community health nurse 8
Is a requirement in the health center and for 6
home visit 77. Which of the following is the primary antidote
It is a tool used by the community health nurse for Tylenol poisoning?
in rendering effective procedures during home
visit Narcan
69. TT4 provides how many percentage of Digoxin
protection against tetanus? Acetylcysteine
Flumazenil
70 78. A male child has an intelligence quotient of
80 approximately 40. Which kind of environment and
90 interdisciplinary program most likely to benefit this
99 child would be best described as:
70. Third postpartum visit must be done by public
health nurse: Habit training
Sheltered workshop
Within 24 hours after delivery Custodial
After 2-4 weeks Educational
Within 1 week 79. Nurse Judy is aware that following condition
After 2 months would reflect presence of congenital G.I anomaly?
71. Nurse Candy is aware that the family planning
method that may give 98% protection to another Cord prolapse
pregnancy to women Polyhydramios
Placenta previa
Pills Oligohydramios
Tubal ligation 80. Nurse Christine provides health teaching for the
Lactational Amenorrhea method (LAM) parents of a child diagnosed with celiac disease.
IUD Nurse Christine teaches the parents to include
72. Which of the following is not a part of IMCI which of the following food items in the child’s diet:
case management process
Rye toast
Counsel the mother Oatmeal
 White bread R.A. 7600
Rice R.A. 6700
81. Nurse Randy is planning to administer oral P.D. 996
medication to a 3 year old child. Nurse Randy is 89. Self governance, ability to choose or carry out
aware that the best way to proceed is by: decision without undue pressure or coercion from
anyone:
“Would you like to drink your medicine?”
“If you take your medicine now, I’ll give you Veracity
lollipop” Autonomy
“See the other boy took his medicine? Now it’s Fidelity
your turn.” Beneficence
“Here’s your medicine. Would you like a 90. A male patient complained because his
mango or orange juice?” scheduled surgery was cancelled because of
82. At what age a child can brush her teeth without earthquake. The hospital personnel may be excused
help? because of:

6 years Governance
7 years Respondent superior
5 years Force majeure
8 years Res ipsa loquitor
83. Ribivarin (Virazole) is prescribed for a female 91. Being on time, meeting deadlines and
hospitalized child with RSV. Nurse Judy prepare completing all scheduled duties is what virtue?
this medication via which route?
Fidelity
Intra venous Autonomy
Oral Veracity
Oxygen tent Confidentiality
Subcutaneous 92. This quality is being demonstrated by Nurse
84. The present chairman of the Board of Nursing in Ron who raises the side rails of a confused and
the Philippines is: disoriented patient?

Maria Joanna Cervantes Responsibility

Carmencita Abaquin Resourcefulness
Leonor Rosero Autonomy
Primitiva Paquic Prudence
85. The obligation to maintain efficient ethical 93. Which of the following is formal continuing
standards in the practice of nursing belong to this education?
body:
Conference
BON Enrollment in graduate school
ANSAP Refresher course
PNA Seminar
RN 94. The BSN curriculum prepares the graduates to
86. A male nurse was found guilty of negligence. become?
His license was revoked. Re-issuance of revoked
certificates is after how many years? Nurse generalist
Nurse specialist
1 year Primary health nurse
2 years Clinical instructor
3 years 95. Disposal of medical records in government
4 years hospital/institutions must be done in close
87. Which of the following information cannot be coordination with what agency?
seen in the PRC identification card?
Department of Health
Registration Date Records Management Archives Office
License Number Metro Manila Development Authority
Date of Application Bureau of Internal Revenue
Signature of PRC chairperson 96. Nurse Jolina must see to it that the written
88. Breastfeeding is being enforced by milk code or: consent of mentally ill patients must be taken from:

EO 51 Nurse
 Priest Hallucinogen
Family lawyer Psycho stimulant
Parents/legal guardians Anxiolytic
97. When Nurse Clarence respects the client’s self- Narcotic
disclosure, this is a gauge for the nurses’ 105. In community health nursing, it is the most
important risk factor in the development of mental
Respectfulness illness?
Loyalty
Trustworthiness Separation of parents
Professionalism Political problems
98. The Nurse is aware that the following tasks can Poverty
be safely delegated by the nurse to a non-nurse Sexual abuse
health worker except: 106. All of the following are characteristics of crisis
except
Taking vital signs
Change IV infusions The client may become resistive and active in
Transferring the client from bed to chair stopping the crisis
Irrigation of NGT It is self-limiting for 4-6 weeks
99. During the evening round Nurse Tina saw Mr. It is unique in every individual
Toralba meditating and afterwards started singing It may also affect the family of the client
prayerful hymns. What would be the best response 107. Freud states that temper tantrums is observed
of Nurse Tina? in which of the following:

Call the attention of the client and encourage to Oral

sleep Anal
Report the incidence to head nurse Phallic
Respect the client’s action Latency
Document the situation 108. The nurse is aware that ego development
100. In caring for a dying client, you should begins during:
perform which of the following activities
Toddler period
Do not resuscitate Preschool age
Assist client to perform ADL School age
Encourage to exercise Infancy
Assist client towards a peaceful death 109. Situation: A 19 year old nursing student has
101. The Nurse is aware that the ability to enter into lost 36 lbs for 4 weeks. Her parents brought her to
the life of another person and perceive his current the hospital for medical evaluation. The diagnosis
feelings and their meaning is known: was ANOREXIA NERVOSA. The Primary gain of
a client with anorexia nervosa is:
Belongingness
Genuineness Weight loss
Empathy Weight gain
Respect Reduce anxiety
102. The termination phase of the NPR is best Attractive appearance
described one of the following: 110. The nurse is aware that the primary nursing
diagnosis for the client is:
Review progress of therapy and attainment of
goals Altered nutrition : less than body requirement
Exploring the client’s thoughts, feelings and Altered nutrition : more than body requirement
concerns Impaired tissue integrity
Identifying and solving patients problem Risk for malnutrition
Establishing rapport 111. After 14 days in the hospital, which finding
103. During the process of cocaine withdrawal, the indicates that her condition in improving?
physician orders which of the following:
She tells the nurse that she had no idea that she
Haloperidol (Haldol) is thin
Imipramine (Tofranil) She arrives earlier than scheduled time of
Benztropine (Cogentin) group therapy
Diazepam (Valium) She tells the nurse that she eat 3 times or more
104. The nurse is aware that cocaine is classified as: in a day
She gained 4 lbs in two weeks
112. The nurse is aware that ataractics or psychic 121. Which of the following activity would be best
energizers are also known as: for a depressed client?

Anti manic Chess

Anti depressants Basketball
Antipsychotics Swimming
Anti anxiety Finger painting
113. Known as mood elevators: 122. The nurse is aware that clients with severe
depression, possess which defense mechanism:
Anti depressants
Antipsychotics Introjection
Anti manic Suppression
Anti anxiety Repression
114. The priority of care for a client with Projection
Alzheimer’s disease is 123. Nurse John is aware that self mutilation among
Bipolar disorder patients is a means of:
Help client develop coping mechanism
Encourage to learn new hobbies and interest Overcoming fear of failure
Provide him stimulating environment Overcoming feeling of insecurity
Simplify the environment to eliminate the need Relieving depression
to make chores Relieving anxiety
115. Autism is diagnosed at: 124. Which of the following may cause an increase
in the cystitis symptoms?
Infancy
3 years old Water
5 years old Orange juice
School age Coffee
116. The common characteristic of autism child is: Mango juice
125. In caring for clients with renal calculi, which is
Impulsitivity the priority nursing intervention?
Self destructiveness
Hostility Record vital signs
Withdrawal Strain urine
117. The nurse is aware that the most common Limit fluids
indication in using ECT is: Administer analgesics as prescribed
126. In patient with renal failure, the diet should be:
Schizophrenia
Bipolar Low protein, low sodium, low potassium
Anorexia Nervosa Low protein, high potassium
Depression High carbohydrate, low protein
118. A therapy that focuses on here and now High calcium, high protein
principle to promote self-acceptance? 127. Which of the following cannot be corrected by
dialysis?
Gestalt therapy
Cognitive therapy Hypernatremia
Behavior therapy Hyperkalemia
Personality therapy Elevated creatinine
119. A client has many irrational thoughts. The goal Decreased hemoglobin
of therapy is to change her: 128. Tony with infection is receiving antibiotic
therapy. Later the client complaints of ringing in the
Personality ears. This ototoxicity is damage to:
Communication
Behavior 4th CN
Cognition 8th CN
120. The appropriate nutrition for Bipolar I disorder, 7th CN
in manic phase is: 9th CN
129. Nurse Emma provides teaching to a patient
Low fat, low sodium with recurrent urinary tract infection includes the
Low calorie, high fat following:
Finger foods, high in calorie
Small frequent feedings Increase intake of tea, coffee and colas
 Void every 6 hours per day Call the family
Void immediately after intercourse 138. The ANA recognized nursing informatics
Take tub bath everyday heralding its establishment as a new field in nursing
130. Which assessment finding indicates circulatory during what year?
constriction in a male client with a newly applied
long leg cast? 1994
1992
Blanching or cyanosis of legs 2000
Complaints of pressure or tightness 2001
Inability to move toes 139. When is the first certification of nursing
Numbness of toes informatics given?
131. During acute gout attack, the nurse administer
which of the following drug: 1990-1993
2001-2002
Prednisone (Deltasone) 1994-1996
Colchicines 2005-2008
Aspirin 140. The nurse is assessing a female client with
Allopurinol (Zyloprim) possible diagnosis of osteoarthritis. The most
132. Information in the patients chart is significant risk factor for osteoarthritis is:
inadmissible in court as evidence when:
Obesity
The client objects to its use Race
Handwriting is not legible Job
It has too many unofficial abbreviations Age
The clients parents refuses to use it 141. A male client complains of vertigo. Nurse Bea
133. Nurse Karen is revising a client plan of care. anticipates that the client may have a problem with
During which step of the nursing process does such which portion of the ear?
revision take place?
Tymphanic membranes
Planning Inner ear
Implementation Auricle
Diagnosing External ear
Evaluation 142. When performing Weber’s test, Nurse Rosean
134. When examining a client with abdominal pain, expects that this client will hear
Nurse Hazel should assess:
On unaffected side
Symptomatic quadrant either second or first Longer through bone than air conduction
The symptomatic quadrant last On affected side by bone conduction
The symptomatic quadrant first By neither bone or air conduction
Any quadrant 143. Toy with a tentative diagnosis of myasthenia
135. How long will nurse John obtain an accurate gravis is admitted for diagnostic make up.
reading of temperature via oral route? Myasthenia gravis can confirmed by:

3 minutes Kernigs sign

1 minute Brudzinski’s sign
8 minutes A positive sweat chloride test
15 minutes A positive edrophonium (Tensilon) test
136. The one filing the criminal care against an 144. A male client is hospitalized with Guillain-
accused party is said to be the? Barre Syndrome. Which assessment finding is the
most significant?
Guilty
Accused Even, unlabored respirations
Plaintiff Soft, non distended abdomen
Witness Urine output of 50 ml/hr
137. A male client has a standing DNR order. He Warm skin
then suddenly stopped breathing and you are at his 145. For a female client with suspected intracranial
bedside. You would: pressure (ICP), a most appropriate respiratory goal
is:
Call the physician
Stay with the client and do nothing Maintain partial pressure of arterial oxygen (Pa
Call another nurse O2) above 80mmHg
 Promote elimination of carbon dioxide C. Positive
Lower the PH B. Avoid vitamin supplements while o therapy
Prevent respiratory alkalosis D. Chancre
146. Which nursing assessment would identify the A. 60 breaths per minute
earliest sign of ICP? D. A and B
D. Cotrimoxazole
Change in level of consciousness C. 1 tsp. salt and 8 tsp. sugar
Temperature of over 103°F B. Umbilical infections
Widening pulse pressure A. BCG
Unequal pupils C. Epidemiological situation
147. The greatest danger of an uncorrected atrial D. 90
fibrillation for a male patient will be which of the B. -15c to -25c
following: A. Bacterial toxin
D. Planning
Pulmonary embolism B. Schedule
Cardiac arrest A. Motivation
Thrombus formation C. Vision
Myocardial infarction D. Standards
148. Linda, A 30 year old post hysterectomy client D. Negative reinforcement
has visited the health center. She inquired about B. Close ended
BSE and asked the nurse when BSE should be A. Inductive
performed. You answered that the BSE is best B. Risk-benefit ratio
performed: A. Element
C. Organizational chart
7 days after menstruation D. University of Sto. Tomas
At the same day each month D. Italy
During menstruation B. Overt
Before menstruation D. The statement of patient “My hand is
149. An infant is ordered to recive 500 ml of painful”
D5NSS for 24 hours. The Intravenous drip is C. Supine
running at 60 gtts/min. How many drops per minute A. 7 days after menstrual period
should the flow rate be? B. Preparation of the patient
C. Kardex
60 gtts/min. C. Side lying, unaffected side
21 gtts/min D. Percussion
30 gtts/min D. Dilated pupils
15 gtts/min A. Ineffective airway clearance related to
150. Mr. Gutierrez is to receive 1 liter of D5RL to edema
run for 12 hours. The drop factor of the IV infusion D. Redness and warmth
set is 10 drops per minute. Approximately how B. 1 kilograms
many drops per minutes should the IV be regulated? C. Two arteries and one vein
D. April 18
A. Butter
13-14 drops
C. Immediate surgery
17-18 drops
D. Semi-fowlers
10-12 drops
A. Pressure caused by the ascending uterus
15-16 drops
B. 500
Answers D. Estrogen
C. Don’t get pregnant at least 3 months C. Cervix is completely dilated
A. Increased urinary output D. Blue
D. Incubation period varies depending on the B. Listen the fetal heart tone
site of the bite D. Uterine atomy
B. Cover IV bottle with brown paper bag C. 2 fingers below umbilicus
C. Rumpel-leede test A. Normal findings during assessment
D. Peripheral blood smear D. Tetanus toxoid
A. Nurse who never had chicken pox C. RI 8172
D. After the delivery of the baby B. Sambong
B. 18 year old sister who recently got married A. An essential and indispensable equipment of
C. BCG vaccination the community health nurse during home visit
C. Klebs-loeffler bacillus D. 99
D. I will come back on Wednesday, same time, B. After 2-4 weeks
to read the result C. Lactational Amenorrhea method (LAM)
B. Identify the illness C. Void immediately after intercourse
A. After 2 days A. Blanching or cyanosis of legs
D. Sentrong sigla movement B. Colchicines
B. February 1985 A. The client objects to its use
D. 6 D. Evaluation
C. Acetylcysteine B. The symptomatic quadrant last
A. Habit training A. 3 minutes
B. Polyhydramios C. Plaintiff
D. Rice B. Stay with the client and do nothing
D. “Here’s your medicine. Would you like a A. 1994
mango or orange juice?” B. 2001-2002
A. 6 years D. Age
C. Oxygen tent B. Inner ear
B. Carmencita Abaquin C. On affected side by bone conduction
A. BON D. A positive edrophonium (Tensilon) test
D. 4 years A. Even, unlabored respirations
C. Date of Application B. Promote elimination of carbon dioxide
A. EO 51 A. Change in level of consciousness
B. Autonomy C. Thrombus formation
C. Force majeure B. At the same day each month
A. Fidelity B. 21 gtts/min
D. Prudence A. 13-14 drops
B. Enrollment in graduate school
C. Primary health nurse
A. Department of Health
D. Parents/legal guardians
C. Trustworthiness
B. Change IV infusions
C. Respect the client’s action
D. Assist client towards a peaceful death
C. Empathy
A. Review progress of therapy and attainment
of goals
D. Diazepam (Valium)
B. Psycho stimulant
C. Poverty
A. The client may become resistive and active
in stopping the crisis
B. Anal
D. Infancy
C. Reduce anxiety
A. Altered nutrition : less than body
requirement
D. She gained 4 lbs in two weeks
C. Antipsychotics
A. Anti depressants
D. Simplify the environment to eliminate the
need to make chores
B. 3 years old
D. Withdrawal
D. Depression
A. Gestalt therapy
D. Cognition
C. Finger foods, high in calorie
D. Finger painting
A. Introjection
B. Overcoming feeling of insecurity
C. Coffee
D. Administer analgesics as prescribed
A. Low protein, low sodium, low potassium
D. Decreased hemoglobin
B. 8th CN