PNLE Pre

PNLE Pre-board Preparation Exam 1. Nurse Betty is assigned to the following clients. The client that the nurse would see first after endorsement? a. A 34 year-old post operative appendectomy client of five hours who is complaining of pain. b. A 44 year-old myocardial infarction (MI) client who is complaining of nausea. c. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated. d. A 63 year-old post operative’s abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid. 2. Nurse Gail places a client in a four-point restraint following orders from the physician. The client care plan should include: a. Assess temperature frequently. b. Provide diversional activities. c. Check circulation every 15-30 minutes. d. Socialize with other patients once a shift. 3. A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse In-charge knows the purpose of this therapy is to: a. Prevent stress ulcer b. Block prostaglandin synthesis c. Facilitate protein synthesis. d. Enhance gas exchange 4. The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take? a. Increase the I.V. fluid infusion rate b. Irrigate the indwelling urinary catheter c. Notify the physician d. Continue to monitor and record hourly urine output 5. Tony, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by Tony suggests that ice application has been effective? a. “My ankle looks less swollen now”. b. “My ankle feels warm”. c. “My ankle appears redder now”. d. “I need something stronger for pain relief” 6.The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance? a. Hypernatremia b. Hyperkalemia

c. Hypokalemia d. Hypervolemia 7.She finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors will she exhibit most likely? a. Have condescending trust and confidence in their subordinates. b. Gives economic and ego awards. c. Communicates downward to staffs. d. Allows decision making among subordinates. 8. Nurse Amy is aware that the following is true about functional nursing a. Provides continuous, coordinated and comprehensive nursing services. b. One-to-one nurse patient ratio. c. Emphasize the use of group collaboration. d. Concentrates on tasks and activities. 9.Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?" a. Single order b. Standard written order c. Standing order d. Stat order 10.A female client with a fecal impaction frequently exhibits which clinical manifestation? a. Increased appetite b. Loss of urge to defecate c. Hard, brown, formed stools d. Liquid or semi-liquid stools 11.Nurse Linda prepares to perform an otoscopic examination on a female client. For proper visualization, the nurse should position the client's ear by: a. Pulling the lobule down and back b. Pulling the helix up and forward c. Pulling the helix up and back d. Pulling the lobule down and forward 12. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware that one of the following is unassociated with this condition? a. Excessive fetal activity. b. Larger than normal uterus for gestational age. c. Vaginal bleeding d. Elevated levels of human chorionic gonadotropin. 13. A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is:

a. Urinary output 90 cc in 2 hours. b. Absent patellar reflexes. c. Rapid respiratory rate above 40/min. d. Rapid rise in blood pressure. 14. During vaginal examination of Janah who is in labor, the presenting part is at station plus two. Nurse, correctly interprets it as: a. Presenting part is 2 cm above the plane of the ischial spines. b. Biparietal diameter is at the level of the ischial spines. c. Presenting part in 2 cm below the plane of the ischial spines. d. Biparietal diameter is 2 cm above the ischial spines. 15. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is: a. Contractions every 1 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. 16. Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). A nursing action that must be initiated as the plan of care throughout injection of the drug is: a. Ventilator assistance b. CVP readings c. EKG tracings d. Continuous CPR 17. A trial for vaginal delivery after an earlier caesareans, would likely to be given to a gravida, who had: a. First low transverse cesarean was for active herpes type 2 infections; vaginal culture at 39 weeks pregnancy was positive. b. First and second caesareans were for cephalopelvic disproportion. c. First caesarean through a classic incision as a result of severe fetal distress. d. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation. 18.Nurse Ryan is aware that the best initial approach when trying to take a crying 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. 19.Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the nurse do to prevent trauma to operative site? a. Avoid touching the suture line, even when cleaning.

b. Place the baby in prone position. c. Give the baby a pacifier. d. Place the infant’s arms in soft elbow restraints. 20. Which action should nurse Marian include in the care plan for a 2 month old with heart failure? a. Feed the infant when he cries. b. Allow the infant to rest before feeding. c. Bathe the infant and administer medications before feeding. d. Weigh and bathe the infant before feeding. 21.Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5 months. The nurse should advise her to include which foods in her 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. 22. Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action? a. Call for help and note the time. b. Clear the airway c. Give two sharp thumps to the precordium, and check the pulse. d. Administer two quick blows. 23. Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse should: a. Plan care so the client can receive 8 hours of uninterrupted sleep each night. b. Monitor vital signs every 2 hours. c. Make sure that the client takes food and medications at prescribed intervals. d. Provide milk every 2 to 3 hours. 24. A male client was on warfarin (Coumadin) before admission, and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do? a. Stop the I.V. infusion of heparin and notify the physician. b. Continue treatment as ordered. c. Expect the warfarin to increase the PTT. d. Increase the dosage, because the level is lower than normal. 25. A client undergone ileostomy, when should the drainage appliance be applied to the stoma? a. 24 hours later, when edema has subsided. b. In the operating room. c. After the ileostomy begin to function. d. When the client is able to begin self-care procedures.

26. A client undergone spinal anesthetic, it will be important that the nurse immediately position the client in: a. On the side, to prevent obstruction of airway by tongue. b. Flat on back. c. On the back, with knees flexed 15 degrees. d. Flat on the stomach, with the head turned to the side. 27.While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure? a. Blood pressure is decreased from 160/90 to 110/70. b. Pulse is increased from 87 to 95, with an occasional skipped beat. c. The client is oriented when aroused from sleep, and goes back to sleep immediately. d. The client refuses dinner because of anorexia. 28.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first? a. Altered mental status and dehydration b. Fever and chills c. Hemoptysis and Dyspnea d. Pleuritic chest pain and cough 29. A male client has active tuberculosis (TB). Which of the following symptoms will be exhibit? a. Chest and lower back pain b. Chills, fever, night sweats, and hemoptysis c. Fever of more than 104°F (40°C) and nausea d. Headache and photophobia 30. 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 31. 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 32. A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging? a. Increased elastic recoil of the lungs b. Increased number of functional capillaries in the alveoli c. Decreased residual volume d. Decreased vital capacity 33. Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby should monitor the client for the systemic side effect of: a. Ascites b. Nystagmus c. Leukopenia d. Polycythemia 34. Norma, with recent colostomy expresses concern about the inability to control the passage of gas. Nurse Oliver should suggest that the client plan to: a. Eliminate foods high in cellulose. b. Decrease fluid intake at meal times. c. Avoid foods that in the past caused flatus. d. Adhere to a bland diet prior to social events. 35. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, “I should: a. Lie on my left side while instilling the irrigating solution.” b. Keep the irrigating container less than 18 inches above the stoma.” c. Instill a minimum of 1200 ml of irrigating solution to stimulate evacuation of the bowel.” d. Insert the irrigating catheter deeper into the stoma if cramping occurs during the procedure.” 36. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and electrolyte imbalances. The client is somewhat confused and complains of nausea and muscle weakness. As part of the prescribed therapy to correct this electrolyte imbalance, the nurse would expect to: a. Administer Kayexalate b. Restrict foods high in protein c. Increase oral intake of cheese and milk. d. Administer large amounts of normal saline via I.V. 37. Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:

a. 18 gtt/min b. 28 gtt/min c. 32 gtt/min d. 36 gtt/min 38.Terence suffered form burn injury. Using the rule of nines, which has the largest percent of burns? a. Face and neck b. Right upper arm and penis c. Right thigh and penis d. Upper trunk 39. Herbert, a 45 year old construction engineer is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed: a. Reactive pupils b. A depressed fontanel c. Bleeding from ears d. An elevated temperature 40. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker? a. take the pulse rate once a day, in the morning upon awakening b. May be allowed to use electrical appliances c. Have regular follow up care d. May engage in contact sports 41.The nurse is ware that the most relevant knowledge about oxygen administration to a male client with COPD is a. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. b. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath. c. Oxygen is administered best using a non-rebreathing mask d. Blood gases are monitored using a pulse oximeter. 42.Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Tonny is placed in Fowler's position on either his right side or on his back. The nurse is aware that this position: a. Reduce incisional pain. b. Facilitate ventilation of the left lung. c. Equalize pressure in the pleural space. d. Increase venous return 43. What is Nurse John likely to note in a male client being admitted for alcohol withdrawal?

a. Perceptual disorders. b. Impending coma. c. Recent alcohol intake. d. Depression with mutism. 44. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that it “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. 45. 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 46. In preparing a female client for electroconvulsive therapy (ECT), Nurse Michelle knows that succinylcoline (Anectine) will be administered for which therapeutic effect? a. Short-acting anesthesia b. Decreased oral and respiratory secretions. c. Skeletal muscle paralysis. d. Analgesia. 47. Nurse Gina is aware that the dietary implications for a client in manic phase of bipolar disorder is: a. Serve the client a bowl of soup, buttered French bread, and apple slices. b. Increase calories, decrease fat, and decrease protein. c. Give the client pieces of cut-up steak, carrots, and an apple. d. Increase calories, carbohydrates, and protein. 48.What parental behavior toward a child during an admission procedure should cause Nurse Ron to suspect child abuse? a. Flat affect b. Expressing guilt c. Acting overly solicitous toward the child. d. Ignoring the child. 49.Nurse Lynnette notices that a female client with obsessive-compulsive disorder washes her hands for long periods each day. How should the nurse respond to this compulsive behavior? a. By designating times during which the client can focus on the behavior. b. By urging the client to reduce the frequency of the behavior as rapidly as possible. c. By calling attention to or attempting to prevent the behavior. d. By discouraging the client from verbalizing anxieties.

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

PNLE Pre-board Preparation Exam -Answer and Rationale 1. Answer: (B) A 44 year-old myocardial infarction (MI) client who is complaining of nausea. Rationale: Nausea is a symptom of impending myocardial infarction (MI) and should be assessed immediately so that treatment can be instituted and further damage to the heart is avoided. 2. Answer: (C) Check circulation every 15-30 minutes. Rationale: Restraints encircle the limbs, which place the client at risk for circulation being restricted to the distal areas of the extremities. Checking the client’s circulation every 15-30 minutes will allow the nurse to adjust the restraints before injury from decreased blood flow occurs. 3. Answer: (A) Prevent stress ulcer Rationale: Curling’s ulcer occurs as a generalized stress response in burn patients. This results in a decreased production of mucus and increased secretion of gastric acid. The best treatment for this prophylactic use of antacids and H2 receptor blockers. 4. Answer: (D) Continue to monitor and record hourly urine output Rationale: Normal urine output for an adult is approximately 1 ml/minute (60 ml/hour). Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted. 5. Answer: (A) “My ankle looks less swollen now” Rationale: Ice application decreases pain and swelling. Continued or increased pain, redness, and increased warmth are signs of inflammation that shouldn't occur after ice application 6. Answer: (C) Hypokalemia Rationale: A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia. 7. Answer:(A) Have condescending trust and confidence in their subordinates Rationale: Benevolent-authoritative managers pretentiously show their trust and confidence to their followers. 8. Answer: (A) Provides continuous, coordinated and comprehensive nursing services. Rationale: Functional nursing is focused on tasks and activities and not on the care of the patients. 9. Answer: (B) Standard written order Rationale: This is a standard written order. Prescribers write a single order for medications given only once. A stat order is written for

medications given immediately for an urgent client problem. A standing order, also known as a protocol, establishes guidelines for treating a particular disease or set of symptoms in special care areas such as the coronary care unit. Facilities also may institute medication protocols that specifically designate drugs that a nurse may not give. 10. Answer: (D) Liquid or semi-liquid stools Rationale: Passage of liquid or semi-liquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clients with fecal impaction don't pass hard, brown, formed stools because the feces can't move past the impaction. These clients typically report the urge to defecate (although they can't pass stool) and a decreased appetite. 11. Answer: (C) Pulling the helix up and back Rationale: To perform an otoscopic examination on an adult, the nurse grasps the helix of the ear and pulls it up and back to straighten the ear canal. For a child, the nurse grasps the helix and pulls it down to straighten the ear canal. Pulling the lobule in any direction wouldn't straighten the ear canal for visualization. 12. Answer: (A) Excessive fetal activity. Rationale: The most common signs and symptoms of hydatidiform mole includes elevated levels of human chorionic gonadotropin, vaginal bleeding, larger than normal uterus for gestational age, failure to detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting, and early development of pregnancy-induced hypertension. Fetal activity would not be noted. 13. Answer: (B) Absent patellar reflexes Rationale: Absence of patellar reflexes is an indicator of hypermagnesemia, which requires administration of calcium gluconate. 14. Answer: (C) Presenting part in 2 cm below the plane of the ischial spines. Rationale: Fetus at station plus two indicates that the presenting part is 2 cm below the plane of the ischial spines. 15. Answer: (A) Contractions every 1 ½ minutes lasting 70-80 seconds. Rationale: 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. 16. Answer: (C) EKG tracings Rationale: A potential side effect of calcium gluconate administration is cardiac arrest. Continuous monitoring of cardiac activity (EKG) throught administration of calcium gluconate is an essential part of care. 17. Answer: (D) First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation. Rationale: This type of client has no obstetrical indication for a caesarean section as she did with her first caesarean delivery. 18. Answer: (A) Talk to the mother first and then to the toddler.

Rationale: When dealing with a crying toddler, the best approach is to talk to the mother and ignore the toddler first. This approach helps the toddler get used to the nurse before she attempts any procedures. It also gives the toddler an opportunity to see that the mother trusts the nurse. 19. Answer: (D) Place the infant’s arms in soft elbow restraints. Rationale: Soft restraints from the upper arm to the wrist prevent the infant from touching her lip but allow him to hold a favorite item such as a blanket. Because they could damage the operative site, such as objects as pacifiers, suction catheters, and small spoons 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. 20. Answer: (B) Allow the infant to rest before feeding. Rationale: Because feeding requires so much energy, an infant with heart failure should rest before feeding. 21. Answer: (C) Iron-rich formula only. Rationale: The infants at age 5 months should receive iron-rich formula and that they shouldn’t receive solid food, even baby food until age 6 months.

22. Answer: (A) Call for help and note the time. Rationale: Having established, by stimulating the client, that the client is unconscious rather than sleep, the nurse should immediately call for help. This may be done by dialing the operator from the 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. 23. Answer: (C) Make sure that the client takes food and medications at prescribed intervals. Rationale: Food and drug therapy will prevent the accumulation of hydrochloric acid, or will neutralize and buffer the acid that does accumulate. 24. Answer: (B) Continue treatment as ordered. Rationale: The effects of heparin are monitored by the PTT is normally 30 to 45 seconds; the therapeutic level is 1.5 to 2 times the normal level. 25. Answer: (B) In the operating room. Rationale: The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful, and excoriated. 26. Answer: (B) Flat on back. Rationale: To avoid the complication of a painful spinal headache that can last for several days, the client is kept in flat in a supine position for approximately 4 to 12 hours postoperatively. Headaches are believed to be causes by the seepage of cerebral spinal fluid from the puncture site. By keeping the client flat, cerebral spinal fluid pressures are equalized, which avoids trauma to the neurons.

27. Answer: (C) The client is oriented when aroused from sleep, and goes back to sleep immediately. Rationale: This finding suggest that the level of consciousness is decreasing. 28. Answer: (A) Altered mental status and dehydration Rationale: Fever, chills, hemortysis, dyspnea, cough, and pleuritic chest pain are the common symptoms of pneumonia, but elderly clients may first appear with only an altered lentil status and dehydration due to a blunted immune response. 29. Answer: (B) Chills, fever, night sweats, and hemoptysis Rationale: Typical signs and symptoms are chills, fever, night sweats, and hemoptysis. Chest pain may be present from coughing, but 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. 30. Answer:(A) Acute asthma Rationale: 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. 31. Answer: (B) Respiratory arrest Rationale: 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. 32. Answer: (D) Decreased vital capacity Rationale: Reduction in vital capacity is a normal physiologic changes include decreased elastic recoil of the lungs, fewer functional capillaries in the alveoli, and an increased in residual volume. 33. Answer: (C) Leukopenia Rationale: Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as a result of myelosuppression. 34. Answer: (C) Avoid foods that in the past caused flatus. Rationale: Foods that bothered a person preoperatively will continue to do so after a colostomy. 35. Answer: (B) Keep the irrigating container less than 18 inches above the stoma.” Rationale: This height permits the solution to flow slowly with little force so that excessive peristalsis is not immediately precipitated. 36. Answer: (A) Administer Kayexalate Rationale: Kayexalate,a potassium exchange resin, permits sodium to be exchanged for potassium in the intestine, reducing the serum potassium level. 37. Answer:(B) 28 gtt/min Rationale: This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes) 38. Answer: (D) Upper trunk

Rationale: The percentage designated for each burned part of the body using the rule of nines: Head and neck 9%; Right upper extremity 9%; Left upper extremity 9%; Anterior trunk 18%; Posterior trunk 18%; Right lower extremity 18%; Left lower extremity 18%; Perineum 1%. 39. Answer: (C) Bleeding from ears Rationale: The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation. 40. Answer: (D) may engage in contact sports Rationale: The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator. 41. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. Rationale: COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the client oxygen in low concentrations will maintain the client’s hypoxic drive. 42. Answer: (B) Facilitate ventilation of the left lung. Rationale: Since only a partial pneumonectomy is done, there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side. 43. Answer: (A) Perceptual disorders. Rationale: Frightening visual hallucinations are especially common in clients experiencing alcohol withdrawal. 44. Answer: (D) Suggest that it takes awhile before seeing the results. Rationale: The client needs a specific response; that it takes 2 to 3 weeks (a delayed effect) until the therapeutic blood level is reached. 45. Answer: (C) Superego Rationale: This behavior shows a weak sense of moral consciousness. According to Freudian theory, personality disorders stem from a weak superego. 46. Answer: (C) Skeletal muscle paralysis. Rationale: Anectine is a depolarizing muscle relaxant causing paralysis. It is used to reduce the intensity of muscle contractions during the convulsive stage, thereby reducing the risk of bone fractures or dislocation. 47. Answer: (D) Increase calories, carbohydrates, and protein. Rationale: This client increased protein for tissue building and increased calories to replace what is burned up (usually via carbohydrates). 48. Answer: (C) Acting overly solicitous toward the child. Rationale: This behavior is an example of reaction formation, a coping mechanism. 49. Answer: (A) By designating times during which the client can focus on the behavior.

Rationale: The nurse should designate times during which the client can focus on the compulsive behavior or obsessive thoughts. The nurse should urge the client to reduce the frequency of the compulsive behavior gradually, not rapidly. She shouldn't call attention to or try to prevent the behavior. Trying to prevent the behavior may cause pain and terror in the client. The nurse should encourage the client to verbalize anxieties to help distract attention from the compulsive behavior. 50. Answer: (D) Exploring the meaning of the traumatic event with the client. Rationale: The client with PTSD needs encouragement to examine and understand the meaning of the traumatic event and consequent losses. Otherwise, symptoms may worsen and the client may become depressed or engage in self-destructive behavior such as substance abuse. The client must explore the meaning of the event and won't heal without this, no matter how much time passes. Behavioral techniques, such as relaxation therapy, may help decrease the client's anxiety and induce sleep. The physician may prescribe antianxiety agents or antidepressants cautiously to avoid dependence; sleep medication is rarely appropriate. A special diet isn't indicated unless the client also has an eating disorder or a nutritional problem.

Nursing Practice I -Foundation of Professional Nursing Practice 1. The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a client without checking the client’s pulse. The standard that would be used to determine if the nurse was negligent is: a. The physician’s orders. b. The action of a clinical nurse specialist who is recognized expert in the field. c. The statement in the drug literature about administration of terbutaline. d. The actions of a reasonably prudent nurse with similar education and experience. 2. Nurse Trish is caring for a female client with a history of GI bleeding, sickle cell disease, and a platelet count of 22,000/μl. The female client is dehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hr. The client complains of severe bone pain and is scheduled to receive a dose of morphine sulfate. In administering the medication, Nurse Trish should avoid which route? a. I.V b. I.M c. Oral d. S.C 3. Dr. Garcia writes the following order for the client who has been recently admitted “Digoxin .125 mg P.O. once daily.” To prevent a dosage error, how should the nurse document this order onto the medication administration record? a. “Digoxin .1250 mg P.O. once daily” b. “Digoxin 0.1250 mg P.O. once daily” c. “Digoxin 0.125 mg P.O. once daily” d. “Digoxin .125 mg P.O. once daily” 4. A newly admitted female client was diagnosed with deep vein thrombosis. Which nursing diagnosis should receive the highest priority? a. Ineffective peripheral tissue perfusion related to venous congestion. b. Risk for injury related to edema. c. Excess fluid volume related to peripheral vascular disease. d. Impaired gas exchange related to increased blood flow. 5. Nurse Betty is assigned to the following clients. The client that the nurse would see first after endorsement? a. A 34 year-old post operative appendectomy client of five hours who is complaining of pain. b. A 44 year-old myocardial infarction (MI) client who is complaining of nausea. c. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated. d. A 63 year-old post operative’s abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid. 6. Nurse Gail places a client in a four-point restraint following orders from the physician. The client care plan should include: a. Assess temperature frequently. b. Provide diversional activities.

c. Check circulation every 15-30 minutes. d. Socialize with other patients once a shift. 7. A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse In-charge knows the purpose of this therapy is to: a. Prevent stress ulcer b. Block prostaglandin synthesis c. Facilitate protein synthesis. d. Enhance gas exchange 8. The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take? a. Increase the I.V. fluid infusion rate b. Irrigate the indwelling urinary catheter c. Notify the physician d. Continue to monitor and record hourly urine output 9. Tony, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by Tony suggests that ice application has been effective? a. “My ankle looks less swollen now”. b. “My ankle feels warm”. c. “My ankle appears redder now”. d. “I need something stronger for pain relief” 10.The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance? a. Hypernatremia b. Hyperkalemia c. Hypokalemia d. Hypervolemia 11.She finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors will she exhibit most likely? a. Have condescending trust and confidence in their subordinates. b. Gives economic and ego awards. c. Communicates downward to staffs. d. Allows decision making among subordinates. 12. Nurse Amy is aware that the following is true about functional nursing a. Provides continuous, coordinated and comprehensive nursing services. b. One-to-one nurse patient ratio. c. Emphasize the use of group collaboration. d. Concentrates on tasks and activities. 13.Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"

a. Single order b. Standard written order c. Standing order d. Stat order 14.A female client with a fecal impaction frequently exhibits which clinical manifestation? a. Increased appetite b. Loss of urge to defecate c. Hard, brown, formed stools d. Liquid or semi-liquid stools 15.Nurse Linda prepares to perform an otoscopic examination on a female client. For proper visualization, the nurse should position the client's ear by: a. Pulling the lobule down and back b. Pulling the helix up and forward c. Pulling the helix up and back d. Pulling the lobule down and forward 16. Which instruction should nurse Tom give to a male client who is having external radiation therapy: a. Protect the irritated skin from sunlight. b. Eat 3 to 4 hours before treatment. c. Wash the skin over regularly. d. Apply lotion or oil to the radiated area when it is red or sore. 17.In assisting a female client for immediate surgery, the nurse In-charge is aware that she should: a. Encourage the client to void following preoperative medication. b. Explore the client’s fears and anxieties about the surgery. c. Assist the client in removing dentures and nail polish. d. Encourage the client to drink water prior to surgery. 18. A male client is admitted and diagnosed with acute pancreatitis after a holiday celebration of excessive food and alcohol. Which assessment finding reflects this diagnosis? a. Blood pressure above normal range. b. Presence of crackles in both lung fields. c. Hyperactive bowel sounds d. Sudden onset of continuous epigastric and back pain. 19. Which dietary guidelines are important for nurse Oliver to implement in caring for the client with burns? a. Provide high-fiber, high-fat diet b. Provide high-protein, high-carbohydrate diet.

c. Monitor intake to prevent weight gain. d. Provide ice chips or water intake. 20.Nurse Hazel will administer a unit of whole blood, which priority information should the nurse have about the client? a. Blood pressure and pulse rate. b. Height and weight. c. Calcium and potassium levels d. Hgb and Hct levels. 21. Nurse Michelle witnesses a female client sustain a fall and suspects that the leg may be broken. The nurse takes which priority action? a. Takes a set of vital signs. b. Call the radiology department for X-ray. c. Reassure the client that everything will be alright. d. Immobilize the leg before moving the client. 22.A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladder cancer. The nurse in-charge would take which priority action in the care of this client? a. Place client on reverse isolation. b. Admit the client into a private room. c. Encourage the client to take frequent rest periods. d. Encourage family and friends to visit. 23.A newly admitted female client was diagnosed with agranulocytosis. The nurse formulates which priority nursing diagnosis? a. Constipation b. Diarrhea c. Risk for infection d. Deficient knowledge 24.A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embolism. What is the priority action by the nurse? a. Notify the physician. b. Place the client on the left side in the Trendelenburg position. c. Place the client in high-Fowlers position. d. Stop the total parenteral nutrition. 25.Nurse May attends an educational conference on leadership styles. The nurse is sitting with a nurse employed at a large trauma center who states that the leadership style at the trauma center is taskoriented and directive. The nurse determines that the leadership style used at the trauma center is:

a. Autocratic. b. Laissez-faire. c. Democratic. d. Situational 26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse in-charge is going to hang a 500 cc bag. KCl is supplied 20 mEq/10 cc. How many cc’s of KCl will be added to the IV solution? a. .5 cc b. 5 cc c. 1.5 cc d. 2.5 cc 27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV drip factor is 60. The IV rate that will deliver this amount is: a. 50 cc/ hour b. 55 cc/ hour c. 24 cc/ hour d. 66 cc/ hour 28.The nurse is aware that the most important nursing action when a client returns from surgery is: a. Assess the IV for type of fluid and rate of flow. b. Assess the client for presence of pain. c. Assess the Foley catheter for patency and urine output d. Assess the dressing for drainage. 29. Which of the following vital sign assessments that may indicate cardiogenic shock after myocardial infarction? a. BP – 80/60, Pulse – 110 irregular b. BP – 90/50, Pulse – 50 regular c. BP – 130/80, Pulse – 100 regular d. BP – 180/100, Pulse – 90 irregular 30.Which is the most appropriate nursing action in obtaining a blood pressure measurement? a. Take the proper equipment, place the client in a comfortable position, and record the appropriate information in the client’s chart. b. Measure the client’s arm, if you are not sure of the size of cuff to use. c. Have the client recline or sit comfortably in a chair with the forearm at the level of the heart. d. Document the measurement, which extremity was used, and the position that the client was in during the measurement. 31.Asking the questions to determine if the person understands the health teaching provided by the nurse would be included during which step of the nursing process?

a. Assessment b. Evaluation c. Implementation d. Planning and goals 32.Which of the following item is considered the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person’s needs? a. Diagnostic test results b. Biographical date c. History of present illness d. Physical examination 33.In preventing the development of an external rotation deformity of the hip in a client who must remain in bed for any period of time, the most appropriate nursing action would be to use: a. Trochanter roll extending from the crest of the ileum to the midthigh. b. Pillows under the lower legs. c. Footboard d. Hip-abductor pillow 34.Which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue? a. Stage I b. Stage II c. Stage III d. Stage IV 35.When the method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulations, the wound healing is termed a. Second intention healing b. Primary intention healing c. Third intention healing d. First intention healing 36.An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver learns that the client lives alone and hasn’t been eating or drinking. When assessing him for dehydration, nurse Oliver would expect to find: a. Hypothermia b. Hypertension c. Distended neck veins d. Tachycardia 37.The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as needed, to control a client’s postoperative pain. The package insert is “Meperidine, 100 mg/ml.” How many milliliters of meperidine should the

client receive? a. 0.75 b. 0.6 c. 0.5 d. 0.25 38. A male client with diabetes mellitus is receiving insulin. Which statement correctly describes an insulin unit? a. It’s a common measurement in the metric system. b. It’s the basis for solids in the avoirdupois system. c. It’s the smallest measurement in the apothecary system. d. It’s a measure of effect, not a standard measure of weight or quantity. 39.Nurse Oliver measures a client’s temperature at 102° F. What is the equivalent Centigrade temperature? a. 40.1 °C b. 38.9 °C c. 48 °C d. 38 °C 40.The nurse is assessing a 48-year-old client who has come to the physician’s office for his annual physical exam. One of the first physical signs of aging is: a. Accepting limitations while developing assets. b. Increasing loss of muscle tone. c. Failing eyesight, especially close vision. d. Having more frequent aches and pains. 41.The physician inserts a chest tube into a female client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse in-charge can prevent chest tube air leaks by: a. Checking and taping all connections. b. Checking patency of the chest tube. c. Keeping the head of the bed slightly elevated. d. Keeping the chest drainage system below the level of the chest. 42.Nurse Trish must verify the client’s identity before administering medication. She is aware that the safest way to verify identity is to: a. Check the client’s identification band. b. Ask the client to state his name. c. State the client’s name out loud and wait a client to repeat it. d. Check the room number and the client’s name on the bed.

43.The physician orders dextrose 5 % in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops/ml. Nurse John should run the I.V. infusion at a rate of: a. 30 drops/minute b. 32 drops/minute c. 20 drops/minute d. 18 drops/minute 44.If a central venous catheter becomes disconnected accidentally, what should the nurse in-charge do immediately? a. Clamp the catheter b. Call another nurse c. Call the physician d. Apply a dry sterile dressing to the site. 45.A female client was recently admitted. She has fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, Nurse Hazel inspects the client’s abdomen and notice that it is slightly concave. Additional assessment should proceed in which order: a. Palpation, auscultation, and percussion. b. Percussion, palpation, and auscultation. c. Palpation, percussion, and auscultation. d. Auscultation, percussion, and palpation. 46. Nurse Betty is assessing tactile fremitus in a client with pneumonia. For this examination, nurse Betty should use the: a. Fingertips b. Finger pads c. Dorsal surface of the hand d. Ulnar surface of the hand 47. Which type of evaluation occurs continuously throughout the teaching and learning process? a. Summative b. Informative c. Formative d. Retrospective 48.A 45 year old client, has no family history of breast cancer or other risk factors for this disease. Nurse John should instruct her to have mammogram how often? a. Twice per year b. Once per year

c. Every 2 years d. Once, to establish baseline 49.A male client has the following arterial blood gas values: pH 7.30; Pao2 89 mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. Based on these values, Nurse Patricia should expect which condition? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis 50.Nurse Len refers a female client with terminal cancer to a local hospice. What is the goal of this referral? a. To help the client find appropriate treatment options. b. To provide support for the client and family in coping with terminal illness. c. To ensure that the client gets counseling regarding health care costs. d. To teach the client and family about cancer and its treatment. 51.When caring for a male client with a 3-cm stage I pressure ulcer on the coccyx, which of the following actions can the nurse institute independently? a. Massaging the area with an astringent every 2 hours. b. Applying an antibiotic cream to the area three times per day. c. Using normal saline solution to clean the ulcer and applying a protective dressing as necessary. d. Using a povidone-iodine wash on the ulceration three times per day. 52.Nurse Oliver must apply an elastic bandage to a client’s ankle and calf. He should apply the bandage beginning at the client’s: a. Knee b. Ankle c. Lower thigh d. Foot 53.A 10 year old child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk to this child? a. Hypernatremia b. Hypokalemia c. Hyperphosphatemia d. Hypercalcemia 54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly admitted client. Immediately afterward, the client may experience:

a. Throbbing headache or dizziness b. Nervousness or paresthesia. c. Drowsiness or blurred vision. d. Tinnitus or diplopia. 55.Nurse Michelle hears the alarm sound on the telemetry monitor. The nurse quickly looks at the monitor and notes that a client is in a ventricular tachycardia. The nurse rushes to the client’s room. Upon reaching the client’s bedside, the nurse would take which action first? a. Prepare for cardioversion b. Prepare to defibrillate the client c. Call a code d. Check the client’s level of consciousness 56.Nurse Hazel is preparing to ambulate a female client. The best and the safest position for the nurse in assisting the client is to stand: a. On the unaffected side of the client. b. On the affected side of the client. c. In front of the client. d. Behind the client. 57.Nurse Janah is monitoring the ongoing care given to the potential organ donor who has been diagnosed with brain death. The nurse determines that the standard of care had been maintained if which of the following data is observed? a. Urine output: 45 ml/hr b. Capillary refill: 5 seconds c. Serum pH: 7.32 d. Blood pressure: 90/48 mmHg 58. Nurse Amy has an order to obtain a urinalysis from a male client with an indwelling urinary catheter. The nurse avoids which of the following, which contaminate the specimen? a. Wiping the port with an alcohol swab before inserting the syringe. b. Aspirating a sample from the port on the drainage bag. c. Clamping the tubing of the drainage bag. d. Obtaining the specimen from the urinary drainage bag. 59.Nurse Meredith is in the process of giving a client a bed bath. In the middle of the procedure, the unit secretary calls the nurse on the intercom to tell the nurse that there is an emergency phone call. The appropriate nursing action is to: a. Immediately walk out of the client’s room and answer the phone call. b. Cover the client, place the call light within reach, and answer the phone call. c. Finish the bed bath before answering the phone call. d. Leave the client’s door open so the client can be monitored and the nurse can answer the phone call.

60. Nurse Janah is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. Nurse Janah plans to implement which intervention to obtain the specimen? a. Ask the client to expectorate a small amount of sputum into the emesis basin. b. Ask the client to obtain the specimen after breakfast. c. Use a sterile plastic container for obtaining the specimen. d. Provide tissues for expectoration and obtaining the specimen. 61. Nurse Ron is observing a male client using a walker. The nurse determines that the client is using the walker correctly if the client: a. Puts all the four points of the walker flat on the floor, puts weight on the hand pieces, and then walks into it. b. Puts weight on the hand pieces, moves the walker forward, and then walks into it. c. Puts weight on the hand pieces, slides the walker forward, and then walks into it. d. Walks into the walker, puts weight on the hand pieces, and then puts all four points of the walker flat on the floor. 62.Nurse Amy has documented an entry regarding client care in the client’s medical record. When checking the entry, the nurse realizes that incorrect information was documented. How does the nurse correct this error? a. Erases the error and writes in the correct information. b. Uses correction fluid to cover up the incorrect information and writes in the correct information. c. Draws one line to cross out the incorrect information and then initials the change. d. Covers up the incorrect information completely using a black pen and writes in the correct information 63.Nurse Ron is assisting with transferring a client from the operating room table to a stretcher. To provide safety to the client, the nurse should: a. Moves the client rapidly from the table to the stretcher. b. Uncovers the client completely before transferring to the stretcher. c. Secures the client safety belts after transferring to the stretcher. d. Instructs the client to move self from the table to the stretcher. 64.Nurse Myrna is providing instructions to a nursing assistant assigned to give a bed bath to a client who is on contact precautions. Nurse Myrna instructs the nursing assistant to use which of the following protective items when giving bed bath? a. Gown and goggles b. Gown and gloves c. Gloves and shoe protectors d. Gloves and goggles 65. Nurse Oliver is caring for a client with impaired mobility that occurred as a result of a stroke. The client has right sided arm and leg weakness. The nurse would suggest that the client use which of the

following assistive devices that would provide the best stability for ambulating? a. Crutches b. Single straight-legged cane c. Quad cane d. Walker 66.A male client with a right pleural effusion noted on a chest X-ray is being prepared for thoracentesis. The client experiences severe dizziness when sitting upright. To provide a safe environment, the nurse assists the client to which position for the procedure? a. Prone with head turned toward the side supported by a pillow. b. Sims’ position with the head of the bed flat. c. Right side-lying with the head of the bed elevated 45 degrees. d. Left side-lying with the head of the bed elevated 45 degrees. 67.Nurse John develops methods for data gathering. Which of the following criteria of a good instrument refers to the ability of the instrument to yield the same results upon its repeated administration? a. Validity b. Specificity c. Sensitivity d. Reliability 68.Harry knows that he has to protect the rights of human research subjects. Which of the following actions of Harry ensures anonymity? a. Keep the identities of the subject secret b. Obtain informed consent c. Provide equal treatment to all the subjects of the study. d. Release findings only to the participants of the study 69.Patient’s refusal to divulge information is a limitation because it is beyond the control of Tifanny”. What type of research is appropriate for this study? a. Descriptive- correlational b. Experiment c. Quasi-experiment d. Historical 70.Nurse Ronald is aware that the best tool for data gathering is? a. Interview schedule b. Questionnaire c. Use of laboratory data d. Observation 71.Monica is aware that there are times when only manipulation of study variables is possible and the

elements of control or randomization are not attendant. Which type of research is referred to this? a. Field study b. Quasi-experiment c. Solomon-Four group design d. Post-test only design 72.Cherry notes down ideas that were derived from the description of an investigation written by the person who conducted it. Which type of reference source refers to this? a. Footnote b. Bibliography c. Primary source d. Endnotes 73.When Nurse Trish is providing care to his patient, she must remember that her duty is bound not to do doing any action that will cause the patient harm. This is the meaning of the bioethical principle: a. Non-maleficence b. Beneficence c. Justice d. Solidarity 74.When a nurse in-charge causes an injury to a female patient and the injury caused becomes the proof of the negligent act, the presence of the injury is said to exemplify the principle of: a. Force majeure b. Respondeat superior c. Res ipsa loquitor d. Holdover doctrine 75.Nurse Myrna is aware that the Board of Nursing has quasi-judicial power. An example of this power is: a. The Board can issue rules and regulations that will govern the practice of nursing b. The Board can investigate violations of the nursing law and code of ethics c. The Board can visit a school applying for a permit in collaboration with CHED d. The Board prepares the board examinations 76. When the license of nurse Krina is revoked, it means that she: a. Is no longer allowed to practice the profession for the rest of her life b. Will never have her/his license re-issued since it has been revoked c. May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173 d. Will remain unable to practice professional nursing 77.Ronald plans to conduct a research on the use of a new method of pain assessment scale. Which of

the following is the second step in the conceptualizing phase of the research process? a. Formulating the research hypothesis b. Review related literature c. Formulating and delimiting the research problem d. Design the theoretical and conceptual framework 78. The leader of the study knows that certain patients who are in a specialized research setting tend to respond psychologically to the conditions of the study. This referred to as : a. Cause and effect b. Hawthorne effect c. Halo effect d. Horns effect 79.Mary finally decides to use judgment sampling on her research. Which of the following actions of is correct? a. Plans to include whoever is there during his study. b. Determines the different nationality of patients frequently admitted and decides to get representations samples from each. c. Assigns numbers for each of the patients, place these in a fishbowl and draw 10 from it. d. Decides to get 20 samples from the admitted patients 80. The nursing theorist who developed transcultural nursing theory is: a. Florence Nightingale b. Madeleine Leininger c. Albert Moore d. Sr. Callista Roy 81.Marion is aware that the sampling method that gives equal chance to all units in the population to get picked is: a. Random b. Accidental c. Quota d. Judgment 82.John plans to use a Likert Scale to his study to determine the: a. Degree of agreement and disagreement b. Compliance to expected standards c. Level of satisfaction d. Degree of acceptance 83.Which of the following theory addresses the four modes of adaptation?

a. Madeleine Leininger b. Sr. Callista Roy c. Florence Nightingale d. Jean Watson 84.Ms. Garcia is responsible to the number of personnel reporting to her. This principle refers to: a. Span of control b. Unity of command c. Downward communication d. Leader 85.Ensuring that there is an informed consent on the part of the patient before a surgery is done, illustrates the bioethical principle of: a. Beneficence b. Autonomy c. Veracity d. Non-maleficence 86.Nurse Reese is teaching a female client with peripheral vascular disease about foot care; Nurse Reese should include which instruction? a. Avoid wearing cotton socks. b. Avoid using a nail clipper to cut toenails. c. Avoid wearing canvas shoes. d. Avoid using cornstarch on feet. 87.A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include: a. Fresh orange slices b. Steamed broccoli c. Ice cream d. Ground beef patties 88.The nurse prepares to administer a cleansing enema. What is the most common client position used for this procedure? a. Lithotomy b. Supine c. Prone d. Sims’ left lateral 89.Nurse Marian is preparing to administer a blood transfusion. Which action should the nurse take first?

a. Arrange for typing and cross matching of the client’s blood. b. Compare the client’s identification wristband with the tag on the unit of blood. c. Start an I.V. infusion of normal saline solution. d. Measure the client’s vital signs. 90.A 65 years old male client requests his medication at 9 p.m. instead of 10 p.m. so that he can go to sleep earlier. Which type of nursing intervention is required? a. Independent b. Dependent c. Interdependent d. Intradependent 91.A female client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The Nurse Betty notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process? a. Assessment b. Diagnosis c. Implementation d. Evaluation 92.Nursing care for a female client includes removing elastic stockings once per day. The Nurse Betty is aware that the rationale for this intervention? a. To increase blood flow to the heart b. To observe the lower extremities c. To allow the leg muscles to stretch and relax d. To permit veins in the legs to fill with blood. 93.Which nursing intervention takes highest priority when caring for a newly admitted client who's receiving a blood transfusion? a. Instructing the client to report any itching, swelling, or dyspnea. b. Informing the client that the transfusion usually take 1 ½ to 2 hours. c. Documenting blood administration in the client care record. d. Assessing the client’s vital signs when the transfusion ends. 94.A male client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem? a. Give the feedings at room temperature. b. Decrease the rate of feedings and the concentration of the formula. c. Place the client in semi-Fowler's position while feeding. d. Change the feeding container every 12 hours. 95.Nurse Patricia is reconstituting a powdered medication in a vial. After adding the solution to the

powder, she nurse should: a. Do nothing. b. Invert the vial and let it stand for 3 to 5 minutes. c. Shake the vial vigorously. d. Roll the vial gently between the palms. 96.Which intervention should the nurse Trish use when administering oxygen by face mask to a female client? a. Secure the elastic band tightly around the client's head. b. Assist the client to the semi-Fowler position if possible. c. Apply the face mask from the client's chin up over the nose. d. Loosen the connectors between the oxygen equipment and humidifier. 97.The maximum transfusion time for a unit of packed red blood cells (RBCs) is: a. 6 hours b. 4 hours c. 3 hours d. 2 hours 98.Nurse Monique is monitoring the effectiveness of a client's drug therapy. When should the nurse Monique obtain a blood sample to measure the trough drug level? a. 1 hour before administering the next dose. b. Immediately before administering the next dose. c. Immediately after administering the next dose. d. 30 minutes after administering the next dose. 99.Nurse May is aware that the main advantage of using a floor stock system is: a. The nurse can implement medication orders quickly. b. The nurse receives input from the pharmacist. c. The system minimizes transcription errors. d. The system reinforces accurate calculations. 100. Nurse Oliver is assessing a client's abdomen. Which finding should the nurse report as abnormal? a. Dullness over the liver. b. Bowel sounds occurring every 10 seconds. c. Shifting dullness over the abdomen. d. Vascular sounds heard over the renal arteries

Nursing Practice I-Answers and Rationale 1. Answer: (D) The actions of a reasonably prudent nurse with similar education and experience. Rationale: The standard of care is determined by the average degree of skill, care, and diligence by nurses in similar circumstances. 2. Answer: (B) I.M Rationale: With a platelet count of 22,000/μl, the clients tends to bleed easily. Therefore, the nurse should avoid using the I.M. route because the area is a highly vascular and can bleed readily when penetrated by a needle. The bleeding can be difficult to stop. 3. Answer: (C) “Digoxin 0.125 mg P.O. once daily” Rationale: The nurse should always place a zero before a decimal point so that no one misreads the figure, which could result in a dosage error. The nurse should never insert a zero at the end of a dosage that includes a decimal point because this could be misread, possibly leading to a tenfold increase in the dosage. 4. Answer: (A) Ineffective peripheral tissue perfusion related to venous congestion. Rationale: Ineffective peripheral tissue perfusion related to venous congestion takes the highest priority because venous inflammation and clot formation impede blood flow in a client with deep vein thrombosis. 5. Answer: (B) A 44 year-old myocardial infarction (MI) client who is complaining of nausea. Rationale: Nausea is a symptom of impending myocardial infarction (MI) and should be assessed immediately so that treatment can be instituted and further damage to the heart is avoided. 6. Answer: (C) Check circulation every 15-30 minutes. Rationale: Restraints encircle the limbs, which place the client at risk for circulation being restricted to the distal areas of the extremities. Checking the client’s circulation every 15-30 minutes will allow the nurse to adjust the restraints before injury from decreased blood flow occurs. 7. Answer: (A) Prevent stress ulcer Rationale: Curling’s ulcer occurs as a generalized stress response in burn patients. This results in a decreased production of mucus and increased secretion of gastric acid. The best treatment for this prophylactic use of antacids and H2 receptor blockers. 8. Answer: (D) Continue to monitor and record hourly urine output Rationale: Normal urine output for an adult is approximately 1 ml/minute (60 ml/hour). Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted. 9. Answer: (B) “My ankle feels warm”. Rationale: Ice application decreases pain and swelling. Continued or increased pain, redness, and increased warmth are signs of inflammation that shouldn't occur after ice application 10. Answer: (B) Hyperkalemia Rationale: A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia. 11. Answer:(A) Have condescending trust and confidence in their subordinates

Rationale: Benevolent-authoritative managers pretentiously show their trust and confidence to their followers. 12. Answer: (A) Provides continuous, coordinated and comprehensive nursing services. Rationale: Functional nursing is focused on tasks and activities and not on the care of the patients. 13. Answer: (B) Standard written order Rationale: This is a standard written order. Prescribers write a single order for medications given only once. A stat order is written for medications given immediately for an urgent client problem. A standing order, also known as a protocol, establishes guidelines for treating a particular disease or set of symptoms in special care areas such as the coronary care unit. Facilities also may institute medication protocols that specifically designate drugs that a nurse may not give. 14. Answer: (D) Liquid or semi-liquid stools Rationale: Passage of liquid or semi-liquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clients with fecal impaction don't pass hard, brown, formed stools because the feces can't move past the impaction. These clients typically report the urge to defecate (although they can't pass stool) and a decreased appetite. 15. Answer: (C) Pulling the helix up and back Rationale: To perform an otoscopic examination on an adult, the nurse grasps the helix of the ear and pulls it up and back to straighten the ear canal. For a child, the nurse grasps the helix and pulls it down to straighten the ear canal. Pulling the lobule in any direction wouldn't straighten the ear canal for visualization. 16. Answer: (A) Protect the irritated skin from sunlight. Rationale: Irradiated skin is very sensitive and must be protected with clothing or sunblock. The priority approach is the avoidance of strong sunlight. 17. Answer: (C) Assist the client in removing dentures and nail polish. Rationale: Dentures, hairpins, and combs must be removed. Nail polish must be removed so that cyanosis can be easily monitored by observing the nail beds. 18. Answer: (D) Sudden onset of continuous epigastric and back pain. Rationale: The autodigestion of tissue by the pancreatic enzymes results in pain from inflammation, edema, and possible hemorrhage. Continuous, unrelieved epigastric or back pain reflects the inflammatory process in the pancreas. 19. Answer: (B) Provide high-protein, high-carbohydrate diet. Rationale: A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and resistance to infection. Caloric goals may be as high as 5000 calories per day. 20. Answer: (A) Blood pressure and pulse rate. Rationale: The baseline must be established to recognize the signs of an anaphylactic or hemolytic reaction to the transfusion.

21. Answer: (D) Immobilize the leg before moving the client. Rationale: If the nurse suspects a fracture, splinting the area before moving the client is imperative. The nurse should call for emergency help if the client is not hospitalized and call for a physician for the hospitalized client. 22. Answer: (B) Admit the client into a private room. Rationale: The client who has a radiation implant is placed in a private room and has a limited number of visitors. This reduces the exposure of others to the radiation. 23. Answer: (C) Risk for infection Rationale: Agranulocytosis is characterized by a reduced number of leukocytes (leucopenia) and neutrophils (neutropenia) in the blood. The client is at high risk for infection because of the decreased body defenses against microorganisms. Deficient knowledge related to the nature of the disorder may be appropriate diagnosis but is not the priority. 24. Answer: (B) Place the client on the left side in the Trendelenburg position. Rationale: Lying on the left side may prevent air from flowing into the pulmonary veins. The Trendelenburg position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during aspiration. 25. Answer: (A) Autocratic. Rationale: The autocratic style of leadership is a task-oriented and directive. 26. Answer: (D) 2.5 cc Rationale: 2.5 cc is to be added, because only a 500 cc bag of solution is being medicated instead of a 1 liter. 27. Answer: (A) 50 cc/ hour Rationale: A rate of 50 cc/hr. The child is to receive 400 cc over a period of 8 hours = 50 cc/hr. 28. Answer: (B) Assess the client for presence of pain. Rationale: Assessing the client for pain is a very important measure. Postoperative pain is an indication of complication. The nurse should also assess the client for pain to provide for the client’s comfort. 29. Answer: (A) BP – 80/60, Pulse – 110 irregular Rationale: The classic signs of cardiogenic shock are low blood pressure, rapid and weak irregular pulse, cold, clammy skin, decreased urinary output, and cerebral hypoxia. 30. Answer: (A) Take the proper equipment, place the client in a comfortable position, and record the appropriate information in the client’s chart. Rationale: It is a general or comprehensive statement about the correct procedure, and it includes the basic ideas which are found in the other options 31. Answer: (B) Evaluation Rationale: Evaluation includes observing the person, asking questions, and comparing the patient’s behavioral responses with the expected outcomes.

32. Answer: (C) History of present illness Rationale: The history of present illness is the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person’s needs. 33. Answer: (A) Trochanter roll extending from the crest of the ileum to the mid-thigh. Rationale: A trochanter roll, properly placed, provides resistance to the external rotation of the hip. 34. Answer: (C) Stage III Rationale: Clinically, a deep crater or without undermining of adjacent tissue is noted. 35. Answer: (A) Second intention healing Rationale: When wounds dehisce, they will allowed to heal by secondary intention 36. Answer: (D) Tachycardia Rationale: With an extracellular fluid or plasma volume deficit, compensatory mechanisms stimulate the heart, causing an increase in heart rate. 37. Answer: (A) 0.75 Rationale: To determine the number of milliliters the client should receive, the nurse uses the fraction method in the following equation. 75 mg/X ml = 100 mg/1 ml To solve for X, cross-multiply: 75 mg x 1 ml = X ml x 100 mg 75 = 100X 75/100 = X 0.75 ml (or ¾ ml) = X 38. Answer: (D) It’s a measure of effect, not a standard measure of weight or quantity. Rationale: An insulin unit is a measure of effect, not a standard measure of weight or quantity. Different drugs measured in units may have no relationship to one another in quality or quantity. 39. Answer: (B) 38.9 °C Rationale: To convert Fahrenheit degreed to Centigrade, use this formula °C = (°F – 32) ÷ 1.8 °C = (102 – 32) ÷ 1.8 °C = 70 ÷ 1.8 °C = 38.9 40. Answer: (C) Failing eyesight, especially close vision. Rationale: Failing eyesight, especially close vision, is one of the first signs of aging in middle life (ages 46 to 64). More frequent aches and pains begin in the early late years (ages 65 to 79). Increase in loss of muscle tone occurs in later years (age 80 and older). 41. Answer: (A) Checking and taping all connections Rationale: Air leaks commonly occur if the system isn’t secure. Checking all connections and taping them will prevent air leaks. The chest drainage system is kept lower to promote drainage – not to prevent leaks.

42. Answer: (A) Check the client’s identification band. Rationale: Checking the client’s identification band is the safest way to verify a client’s identity because the band is assigned on admission and isn’t be removed at any time. (If it is removed, it must be replaced). Asking the client’s name or having the client repeated his name would be appropriate only for a client who’s alert, oriented, and able to understand what is being said, but isn’t the safe standard of practice. Names on bed aren’t always reliable 43. Answer: (B) 32 drops/minute Rationale: Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes). Find the number of milliliters per minute as follows: 125/60 minutes = X/1 minute 60X = 125 = 2.1 ml/minute To find the number of drops per minute: 2.1 ml/X gtt = 1 ml/ 15 gtt X = 32 gtt/minute, or 32 drops/minute 44. Answer: (A) Clamp the catheter Rationale: If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp, if available. If a clamp isn’t available, the nurse can place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension and restart the infusion. 45. Answer: (D) Auscultation, percussion, and palpation. Rationale: The correct order of assessment for examining the abdomen is inspection, auscultation, percussion, and palpation. The reason for this approach is that the less intrusive techniques should be performed before the more intrusive techniques. Percussion and palpation can alter natural findings during auscultation. 46. Answer: (D) Ulnar surface of the hand Rationale: The nurse uses the ulnar surface, or ball, of the hand to asses tactile fremitus, thrills, and vocal vibrations through the chest wall. The fingertips and finger pads best distinguish texture and shape. The dorsal surface best feels warmth. 47. Answer: (C) Formative Rationale: Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Summative, or retrospective, evaluation occurs at the conclusion of the teaching and learning session. Informative is not a type of evaluation. 48. Answer: (B) Once per year Rationale: Yearly mammograms should begin at age 40 and continue for as long as the woman is in good health. If health risks, such as family history, genetic tendency, or past breast cancer, exist, more frequent examinations may be necessary. 49. Answer: (A) Respiratory acidosis Rationale: The client has a below-normal (acidic) blood pH value and an above-normal partial pressure of arterial carbon dioxide (Paco2) value, indicating respiratory acidosis. In respiratory alkalosis, the pH

value is above normal and in the Paco2 value is below normal. In metabolic acidosis, the pH and bicarbonate (Hco3) values are below normal. In metabolic alkalosis, the pH and Hco3 values are above normal. 50. Answer: (B) To provide support for the client and family in coping with terminal illness. Rationale: Hospices provide supportive care for terminally ill clients and their families. Hospice care doesn’t focus on counseling regarding health care costs. Most client referred to hospices have been treated for their disease without success and will receive only palliative care in the hospice. 51. Answer: (C) Using normal saline solution to clean the ulcer and applying a protective dressing as necessary. Rationale: Washing the area with normal saline solution and applying a protective dressing are within the nurse’s realm of interventions and will protect the area. Using a povidone-iodine wash and an antibiotic cream require a physician’s order. Massaging with an astringent can further damage the skin. 52. Answer: (D) Foot Rationale: An elastic bandage should be applied form the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client’s foot. Beginning at the ankle, lower thigh, or knee does not promote venous return. 53. Answer: (B) Hypokalemia Rationale: Insulin administration causes glucose and potassium to move into the cells, causing hypokalemia. 54. Answer: (A) Throbbing headache or dizziness Rationale: Headache and dizziness often occur when nitroglycerin is taken at the beginning of therapy. However, the client usually develops tolerance 55. Answer: (D) Check the client’s level of consciousness Rationale: Determining unresponsiveness is the first step assessment action to take. When a client is in ventricular tachycardia, there is a significant decrease in cardiac output. However, checking the unresponsiveness ensures whether the client is affected by the decreased cardiac output. 56. Answer: (B) On the affected side of the client. Rationale: When walking with clients, the nurse should stand on the affected side and grasp the security belt in the midspine area of the small of the back. The nurse should position the free hand at the shoulder area so that the client can be pulled toward the nurse in the event that there is a forward fall. The client is instructed to look up and outward rather than at his or her feet. 57. Answer: (A) Urine output: 45 ml/hr Rationale: Adequate perfusion must be maintained to all vital organs in order for the client to remain visible as an organ donor. A urine output of 45 ml per hour indicates adequate renal perfusion. Low blood pressure and delayed capillary refill time are circulatory system indicators of inadequate perfusion. A serum pH of 7.32 is acidotic, which adversely affects all body tissues. 58. Answer: (D ) Obtaining the specimen from the urinary drainage bag. Rationale: A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag and does not necessarily reflect the current client status. In addition, it may become contaminated with bacteria from opening the system.

59. Answer: (B) Cover the client, place the call light within reach, and answer the phone call. Rationale: Because telephone call is an emergency, the nurse may need to answer it. The other appropriate action is to ask another nurse to accept the call. However, is not one of the options. To maintain privacy and safety, the nurse covers the client and places the call light within the client’s reach. Additionally, the client’s door should be closed or the room curtains pulled around the bathing area. 60. Answer: (C) Use a sterile plastic container for obtaining the specimen. Rationale: Sputum specimens for culture and sensitivity testing need to be obtained using sterile techniques because the test is done to determine the presence of organisms. If the procedure for obtaining the specimen is not sterile, then the specimen is not sterile, then the specimen would be contaminated and the results of the test would be invalid. 61. Answer: (A) Puts all the four points of the walker flat on the floor, puts weight on the hand pieces, and then walks into it. Rationale: When the client uses a walker, the nurse stands adjacent to the affected side. The client is instructed to put all four points of the walker 2 feet forward flat on the floor before putting weight on hand pieces. This will ensure client safety and prevent stress cracks in the walker. The client is then instructed to move the walker forward and walk into it. 62. Answer: (C) Draws one line to cross out the incorrect information and then initials the change. Rationale: To correct an error documented in a medical record, the nurse draws one line through the incorrect information and then initials the error. An error is never erased and correction fluid is never used in the medical record. 63. Answer: (C) Secures the client safety belts after transferring to the stretcher. Rationale: During the transfer of the client after the surgical procedure is complete, the nurse should avoid exposure of the client because of the risk for potential heat loss. Hurried movements and rapid changes in the position should be avoided because these predispose the client to hypotension. At the time of the transfer from the surgery table to the stretcher, the client is still affected by the effects of the anesthesia; therefore, the client should not move self. Safety belts can prevent the client from falling off the stretcher. 64. Answer: (B) Gown and gloves Rationale: Contact precautions require the use of gloves and a gown if direct client contact is anticipated. Goggles are not necessary unless the nurse anticipates the splashes of blood, body fluids, secretions, or excretions may occur. Shoe protectors are not necessary. 65. Answer: (C) Quad cane Rationale: Crutches and a walker can be difficult to maneuver for a client with weakness on one side. A cane is better suited for client with weakness of the arm and leg on one side. However, the quad cane would provide the most stability because of the structure of the cane and because a quad cane has four legs. 66. Answer: (D) Left side-lying with the head of the bed elevated 45 degrees. Rationale: To facilitate removal of fluid from the chest wall, the client is positioned sitting at the edge of the bed leaning over the bedside table with the feet supported on a stool. If the client is unable to sit up, the client is positioned lying in bed on the unaffected side with the head of the bed elevated 30 to 45

degrees. 67. Answer: (D) Reliability Rationale: Reliability is consistency of the research instrument. It refers to the repeatability of the instrument in extracting the same responses upon its repeated administration. 68. Answer: (A) Keep the identities of the subject secret Rationale: Keeping the identities of the research subject secret will ensure anonymity because this will hinder providing link between the information given to whoever is its source. 69. Answer: (A) Descriptive- correlational Rationale: Descriptive- correlational study is the most appropriate for this study because it studies the variables that could be the antecedents of the increased incidence of nosocomial infection. 70. Answer: (C) Use of laboratory data Rationale: Incidence of nosocomial infection is best collected through the use of biophysiologic measures, particularly in vitro measurements, hence laboratory data is essential. 71. Answer: (B) Quasi-experiment Rationale: Quasi-experiment is done when randomization and control of the variables are not possible. 72. Answer: (C) Primary source Rationale: This refers to a primary source which is a direct account of the investigation done by the investigator. In contrast to this is a secondary source, which is written by someone other than the original researcher. 73. Answer: (A) Non-maleficence Rationale: Non-maleficence means do not cause harm or do any action that will cause any harm to the patient/client. To do good is referred as beneficence. 74. Answer: (C) Res ipsa loquitor Rationale: Res ipsa loquitor literally means the thing speaks for itself. This means in operational terms that the injury caused is the proof that there was a negligent act. 75. Answer: (B) The Board can investigate violations of the nursing law and code of ethics Rationale: Quasi-judicial power means that the Board of Nursing has the authority to investigate violations of the nursing law and can issue summons, subpoena or subpoena duces tecum as needed. 76. Answer: (C) May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173 Rationale: RA 9173 sec. 24 states that for equity and justice, a revoked license maybe re-issued provided that the following conditions are met: a) the cause for revocation of license has already been corrected or removed; and, b) at least four years has elapsed since the license has been revoked. 77. Answer: (B) Review related literature Rationale: After formulating and delimiting the research problem, the researcher conducts a review of related literature to determine the extent of what has been done on the study by previous researchers.

78. Answer: (B) Hawthorne effect Rationale: Hawthorne effect is based on the study of Elton Mayo and company about the effect of an intervention done to improve the working conditions of the workers on their productivity. It resulted to an increased productivity but not due to the intervention but due to the psychological effects of being observed. They performed differently because they were under observation. 79. Answer: (B) Determines the different nationality of patients frequently admitted and decides to get representations samples from each. Rationale: Judgment sampling involves including samples according to the knowledge of the investigator about the participants in the study. 80. Answer: (B) Madeleine Leininger Rationale: Madeleine Leininger developed the theory on transcultural theory based on her observations on the behavior of selected people within a culture. 81. Answer: (A) Random Rationale: Random sampling gives equal chance for all the elements in the population to be picked as part of the sample. 82. Answer: (A) Degree of agreement and disagreement Rationale: Likert scale is a 5-point summated scale used to determine the degree of agreement or disagreement of the respondents to a statement in a study 83. Answer: (B) Sr. Callista Roy Rationale: Sr. Callista Roy developed the Adaptation Model which involves the physiologic mode, selfconcept mode, role function mode and dependence mode. 84. Answer: (A) Span of control Rationale: Span of control refers to the number of workers who report directly to a manager. 85. Answer: (B) Autonomy Rationale: Informed consent means that the patient fully understands about the surgery, including the risks involved and the alternative solutions. In giving consent it is done with full knowledge and is given freely. The action of allowing the patient to decide whether a surgery is to be done or not exemplifies the bioethical principle of autonomy. 86. Answer: (C) Avoid wearing canvas shoes. Rationale: The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, which may, in turn, cause skin irritation and breakdown. Both cotton and cornstarch absorb perspiration. The client should be instructed to cut toenails straight across with nail clippers. 87. Answer: (D) Ground beef patties Rationale: Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair.

88. Answer: (D) Sims’ left lateral Rationale: The Sims' left lateral position is the most common position used to administer a cleansing enema because it allows gravity to aid the flow of fluid along the curve of the sigmoid colon. If the client can't assume this position nor has poor sphincter control, the dorsal recumbent or right lateral position may be used. The supine and prone positions are inappropriate and uncomfortable for the client. 89. Answer: (A) Arrange for typing and cross matching of the client’s blood. Rationale: The nurse first arranges for typing and cross matching of the client's blood to ensure compatibility with donor blood. The other options, although appropriate when preparing to administer a blood transfusion, come later. 90. Answer: (A) Independent Rationale: Nursing interventions are classified as independent, interdependent, or dependent. Altering the drug schedule to coincide with the client's daily routine represents an independent intervention, whereas consulting with the physician and pharmacist to change a client's medication because of adverse reactions represents an interdependent intervention. Administering an already-prescribed drug on time is a dependent intervention. An intradependent nursing intervention doesn't exist. 91. Answer: (D) Evaluation Rationale: The nursing actions described constitute evaluation of the expected outcomes. The findings show that the expected outcomes have been achieved. Assessment consists of the client's history, physical examination, and laboratory studies. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. Implementation is the phase of the nursing process where the nurse puts the plan of care into action. 92. Answer: (B) To observe the lower extremities Rationale: Elastic stockings are used to promote venous return. The nurse needs to remove them once per day to observe the condition of the skin underneath the stockings. Applying the stockings increases blood flow to the heart. When the stockings are in place, the leg muscles can still stretch and relax, and the veins can fill with blood. 93. Answer:(A) Instructing the client to report any itching, swelling, or dyspnea. Rationale: Because administration of blood or blood products may cause serious adverse effects such as allergic reactions, the nurse must monitor the client for these effects. Signs and symptoms of lifethreatening allergic reactions include itching, swelling, and dyspnea. Although the nurse should inform the client of the duration of the transfusion and should document its administration, these actions are less critical to the client's immediate health. The nurse should assess vital signs at least hourly during the transfusion. 94. Answer: (B) Decrease the rate of feedings and the concentration of the formula. Rationale: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Decreasing the rate of the feeding and the concentration of the formula should decrease the client's discomfort. Feedings are normally given at room temperature to minimize abdominal cramping. To prevent aspiration during feeding, the head of the client's bed should be elevated at least 30 degrees. Also, to prevent bacterial growth, feeding containers should be routinely changed every 8 to 12 hours. 95. Answer: (D) Roll the vial gently between the palms. Rationale: Rolling the vial gently between the palms produces heat, which helps dissolve the medication.

Doing nothing or inverting the vial wouldn't help dissolve the medication. Shaking the vial vigorously could cause the medication to break down, altering its action. 96. Answer: (B) Assist the client to the semi-Fowler position if possible. Rationale: By assisting the client to the semi-Fowler position, the nurse promotes easier chest expansion, breathing, and oxygen intake. The nurse should secure the elastic band so that the face mask fits comfortably and snugly rather than tightly, which could lead to irritation. The nurse should apply the face mask from the client's nose down to the chin — not vice versa. The nurse should check the connectors between the oxygen equipment and humidifier to ensure that they're airtight; loosened connectors can cause loss of oxygen. 97. Answer: (B) 4 hours Rationale: A unit of packed RBCs may be given over a period of between 1 and 4 hours. It shouldn't infuse for longer than 4 hours because the risk of contamination and sepsis increases after that time. Discard or return to the blood bank any blood not given within this time, according to facility policy. 98. Answer: (B) Immediately before administering the next dose. Rationale: Measuring the blood drug concentration helps determine whether the dosing has achieved the therapeutic goal. For measurement of the trough, or lowest, blood level of a drug, the nurse draws a blood sample immediately before administering the next dose. Depending on the drug's duration of action and half-life, peak blood drug levels typically are drawn after administering the next dose. 99. Answer: (A) The nurse can implement medication orders quickly. Rationale: A floor stock system enables the nurse to implement medication orders quickly. It doesn't allow for pharmacist input, nor does it minimize transcription errors or reinforce accurate calculations. 100. Answer: (C) Shifting dullness over the abdomen. Rationale: Shifting dullness over the abdomen indicates ascites, an abnormal finding. The other options are normal abdominal findings.

Nursing Practice II- Community Health Nursing and Care of the Mother and Child 1. May arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. She also tells the nurse that a home pregnancy test was positive but she began to have mild cramps and is now having moderate vaginal bleeding. During the physical examination of the client, the nurse notes that May has a dilated cervix. The nurse determines that May is experiencing which type of abortion? a. Inevitable b. Incomplete c. Threatened d. Septic 2. Nurse Reese is reviewing the record of a pregnant client for her first prenatal visit. Which of the following data, if noted on the 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 3. Nurse Hazel is preparing to care for a client who is newly admitted to the hospital with a possible diagnosis of ectopic pregnancy. Nurse Hazel develops a plan of care for the client and determines that which of the following nursing actions is the priority? a. Monitoring weight b. Assessing for edema c. Monitoring apical pulse d. Monitoring temperature 4. Nurse Oliver is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy require: a. Decreased caloric intake b. Increased caloric intake c. Decreased Insulin d. Increase Insulin 5. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware that one of the following is unassociated with this condition? a. Excessive fetal activity. b. Larger than normal uterus for gestational age. c. Vaginal bleeding d. Elevated levels of human chorionic gonadotropin.

6. A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is: a. Urinary output 90 cc in 2 hours. b. Absent patellar reflexes. c. Rapid respiratory rate above 40/min. d. Rapid rise in blood pressure. 7. During vaginal examination of Janah who is in labor, the presenting part is at station plus two. Nurse, correctly interprets it as: a. Presenting part is 2 cm above the plane of the ischial spines. b. Biparietal diameter is at the level of the ischial spines. c. Presenting part in 2 cm below the plane of the ischial spines. d. Biparietal diameter is 2 cm above the ischial spines. 8. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is: a. Contractions every 1 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. 9. Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). A nursing action that must be initiated as the plan of care throughout injection of the drug is: a. Ventilator assistance b. CVP readings c. EKG tracings d. Continuous CPR 10. A trial for vaginal delivery after an earlier caesareans, would likely to be given to a gravida, who had: a. First low transverse cesarean was for active herpes type 2 infections; vaginal culture at 39 weeks pregnancy was positive. b. First and second caesareans were for cephalopelvic disproportion. c. First caesarean through a classic incision as a result of severe fetal distress. d. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation. 11.Nurse Ryan is aware that the best initial approach when trying to take a crying 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.

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. 13. Which action should nurse Marian include in the care plan for a 2 month old with heart failure? a. Feed the infant when he cries. b. Allow the infant to rest before feeding. c. Bathe the infant and administer medications before feeding. d. Weigh and bathe the infant before feeding. 14.Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5 months. The nurse should advise her to include which foods in her 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. 15.Mommy Linda is playing with her infant, who is sitting securely alone on the floor of the clinic. The mother hides a toy behind her back and the infant looks for it. The nurse is aware that estimated age of the infant would be: a. 6 months b. 4 months c. 8 months d. 10 months 16.Which of the following is the most prominent feature of public health nursing? a. It involves providing home care to sick people who are not confined in the hospital. b. Services are provided free of charge to people within the catchments area. c. The public health nurse functions as part of a team providing a public health nursing services. d. Public health nursing focuses on preventive, not curative, services. 17.When the nurse determines whether resources were maximized in implementing Ligtas Tigdas, she is evaluating a. Effectiveness b. Efficiency c. Adequacy d. Appropriateness

18.Vangie is a new B.S.N. graduate. She wants to become a Public Health Nurse. Where should she apply? a. Department of Health b. Provincial Health Office c. Regional Health Office d. Rural Health Unit 19.Tony is aware the Chairman of the Municipal Health Board is: a. Mayor b. Municipal Health Officer c. Public Health Nurse d. Any qualified physician 20.Myra is the public health nurse in a municipality with a total population of about 20,000. There are 3 rural health midwives among the RHU personnel. How many more midwife items will the RHU need? a. 1 b. 2 c. 3 d. The RHU does not need any more midwife item. 21.According to Freeman and Heinrich, community health nursing is a developmental service. Which of the following best illustrates this statement? a. The community health nurse continuously develops himself personally and professionally. b. Health education and community organizing are necessary in providing community health services. c. Community health nursing is intended primarily for health promotion and prevention and treatment of disease. d. The goal of community health nursing is to provide nursing services to people in their own places of residence. 22.Nurse Tina is aware that the disease declared through Presidential Proclamation No. 4 as a target for eradication in the Philippines is? a. Poliomyelitis b. Measles c. Rabies d. Neonatal tetanus 23.May knows that the step in community organizing that involves training of potential leaders in the community is: a. Integration b. Community organization c. Community study

d. Core group formation 24.Beth a public health nurse takes an active role in community participation. What is the primary goal of community organizing? a. To educate the people regarding community health problems b. To mobilize the people to resolve community health problems c. To maximize the community’s resources in dealing with health problems. d. To maximize the community’s resources in dealing with health problems. 25.Tertiary prevention is needed in which stage of the natural history of disease? a. Pre-pathogenesis b. Pathogenesis c. Prodromal d. Terminal 26.The nurse is caring for a primigravid client in the labor and delivery area. Which condition would place the client at risk for disseminated intravascular coagulation (DIC)? a. Intrauterine fetal death. b. Placenta accreta. c. Dysfunctional labor. d. Premature rupture of the membranes. 27.A fullterm client is in labor. Nurse Betty is aware that the fetal heart rate would be: a. 80 to 100 beats/minute b. 100 to 120 beats/minute c. 120 to 160 beats/minute d. 160 to 180 beats/minute 28.The skin in the diaper area of a 7 month old infant is excoriated and red. Nurse Hazel should instruct the mother to: a. Change the diaper more often. b. Apply talc powder with diaper changes. c. Wash the area vigorously with each diaper change. d. Decrease the infant’s fluid intake to decrease saturating diapers. 29.Nurse Carla knows that the common cardiac anomalies in children with Down Syndrome (tri-somy 21) is: a. Atrial septal defect b. Pulmonic stenosis c. Ventricular septal defect d. Endocardial cushion defect

30.Malou was diagnosed with severe preeclampsia is now receiving I.V. magnesium sulfate. The adverse effects associated with magnesium sulfate is: a. Anemia b. Decreased urine output c. Hyperreflexia d. Increased respiratory rate 31.A 23 year old client is having her menstrual period every 2 weeks that last for 1 week. This type of menstrual pattern is bets defined by: a. Menorrhagia b. Metrorrhagia c. Dyspareunia d. Amenorrhea 32.Jannah is admitted to the labor and delivery unit. The critical laboratory result for this client would be: a. Oxygen saturation b. Iron binding capacity c. Blood typing d. Serum Calcium 33.Nurse Gina is aware that the most common condition found during the second-trimester of pregnancy is: a. Metabolic alkalosis b. Respiratory acidosis c. Mastitis d. Physiologic anemia 34.Nurse Lynette is working in the triage area of an emergency department. She sees that several pediatric clients arrive simultaneously. The client who needs to be treated first is: a. A crying 5 year old child with a laceration on his scalp. b. A 4 year old child with a barking coughs and flushed appearance. c. A 3 year old child with Down syndrome who is pale and asleep in his mother’s arms. d. A 2 year old infant with stridorous breath sounds, sitting up in his mother’s arms and drooling. 35.Maureen in her third trimester arrives at the emergency room with painless vaginal bleeding. Which of the following conditions is suspected? a. Placenta previa b. Abruptio placentae

c. Premature labor d. Sexually transmitted disease 36.A young child named Richard is suspected of having pinworms. The community nurse collects a stool specimen to confirm the diagnosis. The nurse should schedule the collection of this specimen for: a. Just before bedtime b. After the child has been bathe c. Any time during the day d. Early in the morning 37.In doing a 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 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”. 39.Hypoxia is a common complication of laryngotracheobronchitis. Nurse Oliver should frequently assess a child with laryngotracheobronchitis for: a. Drooling b. Muffled voice c. Restlessness d. Low-grade fever 40.How should Nurse Michelle guide a child who is blind to walk to the playroom? a. Without touching the child, talk continuously as the child walks down the hall. b. Walk one step ahead, with the 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. 41.When assessing a newborn diagnosed with ductus arteriosus, Nurse Olivia should expect that the child most likely would have an: a. Loud, machinery-like murmur. b. Bluish color to the lips.

c. Decreased BP reading in the upper extremities d. Increased BP reading in the upper extremities. 42.The reason nurse May keeps the neonate in a neutral thermal environment is that when a newborn becomes too cool, the neonate requires: a. Less oxygen, and the 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. 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 44.Nurse Carla should know that the most common causative factor of dermatitis in infants and younger children is: a. Baby oil b. Baby lotion c. Laundry detergent d. Powder with cornstarch 45.During tube feeding, how far above an infant’s stomach should the nurse hold the syringe with formula? a. 6 inches b. 12 inches c. 18 inches d. 24 inches 46. In a mothers’ class, Nurse Lhynnete discussed childhood diseases such as chicken pox. Which of the following statements about chicken pox is correct? a. The older one gets, the more susceptible he becomes to the complications of chicken pox. b. A single attack of chicken pox will prevent future episodes, including conditions such as shingles. c. To prevent an outbreak in the community, quarantine may be imposed by health authorities. d. Chicken pox vaccine is best given when there is an impending outbreak in the community. 47.Barangay Pinoy had an outbreak of German measles. To prevent congenital rubella, what is the BEST advice that you can give to women in the first trimester of pregnancy in the barangay Pinoy? a. Advice them on the signs of German measles. b. Avoid crowded places, such as markets and movie houses.

c. Consult at the health center where rubella vaccine may be given. d. Consult a physician who may give them rubella immunoglobulin. 48.Myrna a public health nurse knows that to determine possible sources of sexually transmitted infections, the BEST method that may be undertaken is: a. Contact tracing b. Community survey c. Mass screening tests d. Interview of suspects 49.A 33-year old female client came for consultation at the health center with the chief complaint of fever for a week. Accompanying symptoms were muscle pains and body malaise. A week after the start of fever, the client noted yellowish discoloration of his sclera. History showed that he waded in flood waters about 2 weeks before the onset of symptoms. Based on her history, which disease condition will you suspect? a. Hepatitis A b. Hepatitis B c. Tetanus d. Leptospirosis 50.Mickey a 3-year old client was brought to the health center with the chief complaint of severe diarrhea and the passage of “rice water” stools. The client is most probably suffering from which condition? a. Giardiasis b. Cholera c. Amebiasis d. Dysentery 51.The most prevalent form of meningitis among children aged 2 months to 3 years is caused by which microorganism? a. Hemophilus influenzae b. Morbillivirus c. Steptococcus pneumoniae d. Neisseria meningitidis 52.The student nurse is aware that the pathognomonic sign of measles is 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

53.Angel was diagnosed as having Dengue fever. You will say that there is slow capillary refill when the color of the nailbed that you pressed does not return within how many seconds? a. 3 seconds b. 6 seconds c. 9 seconds d. 10 seconds 54.In Integrated Management of Childhood Illness, the nurse is aware that the severe conditions generally require urgent referral to a hospital. Which of the following severe conditions DOES NOT always require urgent referral to a hospital? a. Mastoiditis b. Severe dehydration c. Severe pneumonia d. Severe febrile disease 55.Myrna a public health nurse will conduct outreach immunization in a barangay Masay with a population of about 1500. The estimated number of infants in the barangay would be: a. 45 infants b. 50 infants c. 55 infants d. 65 infants 56.The community nurse is aware that the biological used in Expanded Program on Immunization (EPI) should NOT be stored in the freezer? a. DPT b. Oral polio vaccine c. Measles vaccine d. MMR 57.It is the most effective way of controlling schistosomiasis in an endemic area? a. Use of molluscicides b. Building of foot bridges c. Proper use of sanitary toilets d. Use of protective footwear, such as rubber boots 58.Several clients is newly admitted and diagnosed with leprosy. Which of the following clients should be classified as a case of multibacillary leprosy? a. 3 skin lesions, negative slit skin smear b. 3 skin lesions, positive slit skin smear c. 5 skin lesions, negative slit skin smear d. 5 skin lesions, positive slit skin smear

59.Nurses are aware that diagnosis of leprosy is highly dependent on recognition of symptoms. Which of the following is an early sign of leprosy? a. Macular lesions b. Inability to close eyelids c. Thickened painful nerves d. Sinking of the nosebridge 60.Marie brought her 10 month old infant for consultation because of fever, started 4 days prior to consultation. In determining malaria risk, what will you do? a. Perform a tourniquet test. b. Ask where the family resides. c. Get a specimen for blood smear. d. Ask if the fever is present everyday. 61.Susie brought her 4 years old daughter to the RHU because of cough and colds. Following the IMCI assessment guide, which of the following is a danger sign that indicates the need for urgent referral to a hospital? a. Inability to drink b. High grade fever c. Signs of severe dehydration d. Cough for more than 30 days 62.Jimmy a 2-year old child revealed “baggy pants”. As a nurse, using the IMCI guidelines, how will you manage Jimmy? a. Refer the child urgently to a hospital for confinement. b. Coordinate with the social worker to enroll the child in a feeding program. c. Make a teaching plan for the mother, focusing on menu planning for her child. d. Assess and treat the child for health problems like infections and intestinal parasitism. 63.Gina is using Oresol in the management of diarrhea of her 3-year old child. She asked you what to do if her child vomits. As a nurse you will tell her to: a. Bring the child to the nearest hospital for further assessment. b. Bring the child to the health center for intravenous fluid therapy. c. Bring the child to the health center for assessment by the physician. d. Let the child rest for 10 minutes then continue giving Oresol more slowly. 64.Nikki a 5-month old infant was brought by his mother to the health center because of diarrhea for 4 to 5 times a day. Her skin goes back slowly after a skin pinch and her eyes are sunken. Using the IMCI guidelines, you will classify this infant in which category? a. No signs of dehydration b. Some dehydration

c. Severe dehydration d. The data is insufficient. 65.Chris a 4-month old infant was brought by her mother to the health center because of cough. His respiratory rate is 42/minute. Using the Integrated Management of Child Illness (IMCI) guidelines of assessment, his breathing is considered as: a. Fast b. Slow c. Normal d. Insignificant 66.Maylene had just received her 4th dose of tetanus toxoid. She is aware that her baby will have protection against tetanus for a. 1 year b. 3 years c. 5 years d. Lifetime 67.Nurse Ron is aware that unused BCG should be discarded after how many hours of reconstitution? a. 2 hours b. 4 hours c. 8 hours d. At the end of the day 68.The nurse explains to a breastfeeding mother that breast milk is sufficient for all of the baby’s nutrient needs only up to: a. 5 months b. 6 months c. 1 year d. 2 years 69.Nurse Ron is aware that the gestational age of a conceptus that is considered viable (able to live outside the womb) is: a. 8 weeks b. 12 weeks c. 24 weeks d. 32 weeks 70.When teaching parents of a neonate the proper position for the 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) 71.Which finding might be seen in baby James a neonate suspected of having an infection? a. Flushed cheeks b. Increased temperature c. Decreased temperature d. Increased activity level 72.Baby Jenny who is small-for-gestation is at increased risk during the transitional period for which complication? a. Anemia probably due to chronic fetal hyposia b. Hyperthermia due to decreased glycogen stores c. Hyperglycemia due to decreased glycogen stores d. Polycythemia probably due to chronic fetal hypoxia 73.Marjorie has just given birth at 42 weeks’ gestation. When the nurse assessing the neonate, which physical finding is expected? a. A sleepy, lethargic baby b. Lanugo covering the body c. Desquamation of the epidermis d. Vernix caseosa covering the body 74.After reviewing the 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 75.Which symptom would indicate the Baby Alexandra was adapting appropriately to extra-uterine life without difficulty? a. Nasal flaring b. Light audible grunting c. Respiratory rate 40 to 60 breaths/minute d. Respiratory rate 60 to 80 breaths/minute 76. When teaching umbilical cord care for Jennifer a new mother, the nurse Jenny would include which information? a. Apply peroxide to the cord with each diaper change b. Cover the cord with petroleum jelly after bathing c. Keep the cord dry and open to air d. Wash the cord with soap and water each day during a tub bath.

77.Nurse John is performing an assessment on a neonate. Which of the following findings is considered common in the healthy neonate? a. Simian crease b. Conjunctival hemorrhage c. Cystic hygroma d. Bulging fontanelle 78.Dr. Esteves decides to artificially rupture the membranes of a mother who is on labor. Following this procedure, the nurse Hazel checks the fetal heart tones for which the following reasons? a. To determine fetal well-being. b. To assess for prolapsed cord c. To assess fetal position d. To prepare for an imminent delivery. 79.Which of the following would be least likely to indicate anticipated bonding behaviors by new parents? a. The parents’ willingness to touch and hold the new born. b. The 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. 80.Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client? a. Applying cold to limit edema during the first 12 to 24 hours. b. Instructing the client to use two or more peripads to cushion the area. c. Instructing the client on the use of sitz baths if ordered. d. Instructing the client about the importance of perineal (kegel) exercises. 81. A pregnant woman accompanied by her husband, seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse Oliver ask her first? a. “Do you have any chronic illnesses?” b. “Do you have any allergies?” c. “What is your expected due date?” d. “Who will be with you during labor?” 82.A neonate begins to gag and turns a dusky color. What should the nurse do first? a. Calm the neonate. b. Notify the physician. c. Provide oxygen via face mask as ordered d. Aspirate the neonate’s nose and mouth with a bulb syringe.

83. When a client states that her "water broke," which of the following actions would be inappropriate for the nurse to do? a. Observing the pooling of straw-colored fluid. b. Checking vaginal discharge with nitrazine paper. c. Conducting a bedside ultrasound for an amniotic fluid index. d. Observing for flakes of vernix in the vaginal discharge. 84. A baby girl is born 8 weeks premature. At birth, she has no spontaneous respirations but is successfully resuscitated. Within several hours she develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. She's diagnosed with respiratory distress syndrome, intubated, and placed on a ventilator. Which nursing action should be included in the baby's plan of care to prevent retinopathy of prematurity? a. Cover his eyes while receiving oxygen. b. Keep her body temperature low. c. Monitor partial pressure of oxygen (Pao2) levels. d. Humidify the oxygen. 85. Which of the following is normal newborn calorie intake? a. 110 to 130 calories per kg. b. 30 to 40 calories per lb of body weight. c. At least 2 ml per feeding d. 90 to 100 calories per kg 86. Nurse John is knowledgeable that usually individual twins will grow appropriately and at the same rate as singletons until how many weeks? a. 16 to 18 weeks b. 18 to 22 weeks c. 30 to 32 weeks d. 38 to 40 weeks 87. Which of the following classifications applies to monozygotic twins for whom the cleavage of the fertilized ovum occurs more than 13 days after fertilization? a. conjoined twins b. diamniotic dichorionic twins c. diamniotic monochorionic twin d. monoamniotic monochorionic twins 88. Tyra experienced painless vaginal bleeding has just been diagnosed as having a placenta previa. Which of the following procedures is usually performed to diagnose placenta previa? a. Amniocentesis b. Digital or speculum examination c. External fetal monitoring

d. Ultrasound 89. Nurse Arnold knows that the following changes in respiratory functioning during pregnancy is considered normal: a. Increased tidal volume b. Increased expiratory volume c. Decreased inspiratory capacity d. Decreased oxygen consumption 90. Emily has gestational diabetes and it is usually managed by which of the following therapy? a. Diet b. Long-acting insulin c. Oral hypoglycemic d. Oral hypoglycemic drug and insulin 91. Magnesium sulfate is given to Jemma with preeclampsia to prevent which of the following condition? a. Hemorrhage b. Hypertension c. Hypomagnesemia d. Seizure 92. Cammile with sickle cell anemia has an increased risk for having a sickle cell crisis during pregnancy. Aggressive management of a sickle cell crisis includes which of the following measures? a. Antihypertensive agents b. Diuretic agents c. I.V. fluids d. Acetaminophen (Tylenol) for pain 93. Which of the following drugs is the antidote for magnesium toxicity? a. Calcium gluconate (Kalcinate) b. Hydralazine (Apresoline) c. Naloxone (Narcan) d. Rho (D) immune globulin (RhoGAM) 94. Marlyn is screened for tuberculosis during her first prenatal visit. An intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is given. She is considered to have a positive test for which of the following results? a. An indurated wheal under 10 mm in diameter appears in 6 to 12 hours. b. An indurated wheal over 10 mm in diameter appears in 48 to 72 hours. c. A flat circumcised area under 10 mm in diameter appears in 6 to 12 hours. d. A flat circumcised area over 10 mm in diameter appears in 48 to 72 hours.

95. Dianne, 24 year-old is 27 weeks’ pregnant arrives at her 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) 96. Rh isoimmunization in a pregnant client develops during which of the following conditions? a. Rh-positive maternal blood crosses into fetal blood, stimulating fetal antibodies. b. Rh-positive fetal blood crosses into maternal blood, stimulating maternal antibodies. c. Rh-negative fetal blood crosses into maternal blood, stimulating maternal antibodies. d. Rh-negative maternal blood crosses into fetal blood, stimulating fetal antibodies. 97. To promote comfort during labor, the nurse John advises a client to assume certain positions and avoid others. Which position may cause maternal hypotension and fetal hypoxia? a. Lateral position b. Squatting position c. Supine position d. Standing position 98. Celeste who used heroin during her pregnancy delivers a neonate. When assessing the neonate, the nurse Lhynnette expects to find: a. Lethargy 2 days after birth. b. Irritability and poor sucking. c. A flattened nose, small eyes, and thin lips. d. Congenital defects such as limb anomalies. 99. The uterus returns to the pelvic cavity in which of the following time frames? a. 7th to 9th day postpartum. b. 2 weeks postpartum. c. End of 6th week postpartum. d. When the lochia changes to alba. 100. Maureen, a primigravida client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin (Pitocin) augmentation. The nurse who's caring for her should stay alert for:

a. Uterine inversion b. Uterine atony c. Uterine involution d. Uterine discomfort Answer and Rationale- Nursing Practice II- Community Health Nursing and Care of the Mother and Child 1. Answer: (A) Inevitable Rationale: An inevitable abortion is termination of pregnancy that cannot be prevented. Moderate to severe bleeding with mild cramping and cervical dilation would be noted in this type of abortion. 2. Answer: (B) History of syphilis Rationale: Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion. 3. Answer: (C) Monitoring apical pulse Rationale: Nursing care for the client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of shock. 4. Answer: (B) Increased caloric intake Rationale: Glucose crosses the placenta, but insulin does not. High fetal demands for glucose, combined with the insulin resistance caused by hormonal changes in the last half of pregnancy can result in elevation of maternal blood glucose levels. This increases the mother’s demand for insulin and is referred to as the diabetogenic effect of pregnancy. 5. Answer: (A) Excessive fetal activity. Rationale: The most common signs and symptoms of hydatidiform mole includes elevated levels of human chorionic gonadotropin, vaginal bleeding, larger than normal uterus for gestational age, failure to detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting, and early development of pregnancy-induced hypertension. Fetal activity would not be noted. 6. Answer: (B) Absent patellar reflexes Rationale: Absence of patellar reflexes is an indicator of hypermagnesemia, which requires administration of calcium gluconate. 7. Answer: (C) Presenting part in 2 cm below the plane of the ischial spines. Rationale: Fetus at station plus two indicates that the presenting part is 2 cm below the plane of the ischial spines. 8. Answer: (A) Contractions every 1 ½ minutes lasting 70-80 seconds. Rationale: 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. Answer: (C) EKG tracings Rationale: A potential side effect of calcium gluconate administration is cardiac arrest. Continuous monitoring of cardiac activity (EKG) throught administration of calcium gluconate is an essential part of care.

10. Answer: (D) First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation. Rationale: This type of client has no obstetrical indication for a caesarean section as she did with her first caesarean delivery. 11. Answer: (A) Talk to the mother first and then to the toddler. Rationale: When dealing with a crying toddler, the best approach is to talk to the mother and ignore the toddler first. This approach helps the toddler get used to the nurse before she attempts any procedures. It also gives the toddler an opportunity to see that the mother trusts the nurse. 12. Answer: (D) Place the infant’s arms in soft elbow restraints. Rationale: Soft restraints from the upper arm to the wrist prevent the infant from touching her lip but allow him to hold a favorite item such as a blanket. Because they could damage the operative site, such as objects as pacifiers, suction catheters, and small spoons 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. Answer: (B) Allow the infant to rest before feeding. Rationale: Because feeding requires so much energy, an infant with heart failure should rest before feeding. 14. Answer: (C) Iron-rich formula only. Rationale: The infants at age 5 months should receive iron-rich formula and that they shouldn’t receive solid food, even baby food until age 6 months. 15. Answer: (D) 10 months Rationale: A 10 month old infant can sit alone and understands object permanence, so he would look for the hidden toy. At age 4 to 6 months, infants can’t sit securely alone. At age 8 months, infants can sit securely alone but cannot understand the permanence of objects. 16. Answer: (D) Public health nursing focuses on preventive, not curative, services. Rationale: The catchments area in PHN consists of a residential community, many of whom are well individuals who have greater need for preventive rather than curative services. 17. Answer: (B) Efficiency Rationale: Efficiency is determining whether the goals were attained at the least possible cost. 18. Answer: (D) Rural Health Unit Rationale: R.A. 7160 devolved basic health services to local government units (LGU’s ). The public health nurse is an employee of the LGU. 19. Answer: (A) Mayor Rationale: The local executive serves as the chairman of the Municipal Health Board. 20. Answer: (A) 1

Rationale: Each rural health midwife is given a population assignment of about 5,000. 21. Answer: (B) Health education and community organizing are necessary in providing community health services. Rationale: The community health nurse develops the health capability of people through health education and community organizing activities. 22. Answer: (B) Measles Rationale: Presidential Proclamation No. 4 is on the Ligtas Tigdas Program. 23. Answer: (D) Core group formation Rationale: In core group formation, the nurse is able to transfer the technology of community organizing to the potential or informal community leaders through a training program. 24. Answer: (D) To maximize the community’s resources in dealing with health problems. Rationale: 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. Answer: (D) Terminal Rationale: Tertiary prevention involves rehabilitation, prevention of permanent disability and disability limitation appropriate for convalescents, the disabled, complicated cases and the terminally ill (those in the terminal stage of a disease). 26. Answer: (A) Intrauterine fetal death. Rationale: Intrauterine fetal death, abruptio placentae, septic shock, and amniotic fluid embolism may trigger normal clotting mechanisms; if clotting factors are depleted, DIC may occur. Placenta accreta, dysfunctional labor, and premature rupture of the membranes aren't associated with DIC. 27. Answer: (C) 120 to 160 beats/minute Rationale: A rate of 120 to 160 beats/minute in the fetal heart appropriate for filling the heart with blood and pumping it out to the system. 28. Answer: (A) Change the diaper more often. Rationale: Decreasing the amount of time the skin comes contact with wet soiled diapers will help heal the irritation. 29. Answer: (D) Endocardial cushion defect Rationale: Endocardial cushion defects are seen most in children with Down syndrome, asplenia, or polysplenia. 30. Answer: (B) Decreased urine output Rationale: Decreased urine output may occur in clients receiving I.V. magnesium and should be monitored closely to keep urine output at greater than 30 ml/hour, because magnesium is excreted through the kidneys and can easily accumulate to toxic levels. 31. Answer: (A) Menorrhagia

Rationale: Menorrhagia is an excessive menstrual period. 32. Answer: (C) Blood typing Rationale: Blood type would be a critical value to have because the risk of blood loss is always a potential complication during the labor and delivery process. Approximately 40% of a woman’s cardiac output is delivered to the uterus, therefore, blood loss can occur quite rapidly in the event of uncontrolled bleeding. 33. Answer: (D) Physiologic anemia Rationale: Hemoglobin values and hematocrit decrease during pregnancy as the increase in plasma volume exceeds the increase in red blood cell production. 34. Answer: (D) A 2 year old infant with stridorous breath sounds, sitting up in his mother’s arms and drooling. Rationale: The infant with the airway emergency should be treated first, because of the risk of epiglottitis. 35. Answer: (A) Placenta previa Rationale: Placenta previa with painless vaginal bleeding. 36. Answer: (D) Early in the morning Rationale: Based on the 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. Answer: (A) Irritability and seizures Rationale: Lead poisoning primarily affects the CNS, causing increased intracranial pressure. This condition results in irritability and changes in level of consciousness, as well as seizure disorders, hyperactivity, and learning disabilities. 38. Answer: (D) “I really need to use the diaphragm and jelly most during the middle of my menstrual cycle”. Rationale: The woman must understand that, although the “fertile” period is approximately mid-cycle, hormonal variations do occur and can result in early or late ovulation. To be effective, the diaphragm should be inserted before every intercourse. 39. Answer: (C) Restlessness Rationale: In a child, restlessness is the earliest sign of hypoxia. Late signs of hypoxia in a child are associated with a change in color, such as pallor or cyanosis. 40. Answer: (B) Walk one step ahead, with the child’s hand on the nurse’s elbow. Rationale: This procedure is generally recommended to follow in guiding a person who is blind. 41. Answer: (A) Loud, machinery-like murmur. Rationale: A loud, machinery-like murmur is a characteristic finding associated with patent ductus arteriosus.

42. Answer: (C) More oxygen, and the newborn’s metabolic rate increases. Rationale: When cold, the infant requires more oxygen and there is an increase in metabolic rate. Nonshievering thermogenesis is a complex process that increases the metabolic rate and rate of oxygen consumption, therefore, the newborn increase heat production. 43. Answer: (D) Voided Rationale: Before administering potassium I.V. to any client, the nurse must first check that the 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. Answer: (c) Laundry detergent Rationale: Eczema or dermatitis is an allergic skin reaction caused by an offending allergen. The topical allergen that is the most common causative factor is laundry detergent. 45. Answer: (A) 6 inches Rationale: This distance allows for easy flow of the formula by gravity, but the flow will be slow enough not to overload the stomach too rapidly. 46. Answer: (A) The older one gets, the more susceptible he becomes to the complications of chicken pox. Rationale: Chicken pox is usually more severe in adults than in children. Complications, such as pneumonia, are higher in incidence in adults. 47. Answer: (D) Consult a physician who may give them rubella immunoglobulin. Rationale: Rubella vaccine is made up of attenuated German measles viruses. This is contraindicated in pregnancy. Immune globulin, a specific prophylactic against German measles, may be given to pregnant women. 48. Answer: (A) Contact tracing Rationale: Contact tracing is the most practical and reliable method of finding possible sources of person-to-person transmitted infections, such as sexually transmitted diseases. 49. Answer: (D) Leptospirosis Rationale: Leptospirosis is transmitted through contact with the skin or mucous membrane with water or moist soil contaminated with urine of infected animals, like rats. 50. Answer: (B) Cholera Rationale: Passage of profuse watery stools is the major symptom of cholera. Both amebic and bacillary dysentery are characterized by the presence of blood and/or mucus in the stools. Giardiasis is characterized by fat malabsorption and, therefore, steatorrhea. 51. Answer: (A) Hemophilus influenzae Rationale: Hemophilus meningitis is unusual over the age of 5 years. In developing countries, the peak incidence is in children less than 6 months of age. Morbillivirus is the etiology of measles. Streptococcus pneumoniae and Neisseria meningitidis may cause meningitis, but age distribution is not specific in young children.

52. Answer: (B) Buccal mucosa Rationale: Koplik’s spot may be seen on the mucosa of the mouth or the throat. 53. Answer: (A) 3 seconds Rationale: Adequate blood supply to the area allows the return of the color of the nailbed within 3 seconds. 54. Answer: (B) Severe dehydration Rationale: The order of priority in the management of severe dehydration is as follows: intravenous fluid therapy, referral to a facility where IV fluids can be initiated within 30 minutes, Oresol or nasogastric tube. When the foregoing measures are not possible or effective, then urgent referral to the hospital is done. 55. Answer: (A) 45 infants Rationale: To estimate the number of infants, multiply total population by 3%. 56. Answer: (A) DPT Rationale: DPT is sensitive to freezing. The appropriate storage temperature of DPT is 2 to 8° C only. OPV and measles vaccine are highly sensitive to heat and require freezing. MMR is not an immunization in the Expanded Program on Immunization. 57. Answer: (C) Proper use of sanitary toilets Rationale: The ova of the parasite get out of the human body together with feces. Cutting the cycle at this stage is the most effective way of preventing the spread of the disease to susceptible hosts. 58. Answer: (D) 5 skin lesions, positive slit skin smear Rationale: A multibacillary leprosy case is one who has a positive slit skin smear and at least 5 skin lesions. 59. Answer: (C) Thickened painful nerves Rationale: The lesion of leprosy is not macular. It is characterized by a change in skin color (either reddish or whitish) and loss of sensation, sweating and hair growth over the lesion. Inability to close the eyelids (lagophthalmos) and sinking of the nosebridge are late symptoms. 60. Answer: (B) Ask where the family resides. Rationale: Because malaria is endemic, the first question to determine malaria risk is where the 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. Answer: (A) Inability to drink Rationale: A sick child aged 2 months to 5 years must be referred urgently to a hospital if he/she has one or more of the following signs: not able to feed or drink, vomits everything, convulsions, abnormally sleepy or difficult to awaken. 62. Answer: (A) Refer the child urgently to a hospital for confinement.

Rationale: “Baggy pants” is a sign of severe marasmus. The best management is urgent referral to a hospital. 63. Answer: (D) Let the child rest for 10 minutes then continue giving Oresol more slowly. Rationale: If the child vomits persistently, that is, he vomits everything that he takes in, he has to be referred urgently to a hospital. Otherwise, vomiting is managed by letting the child rest for 10 minutes and then continuing with Oresol administration. Teach the mother to give Oresol more slowly. 64. Answer: (B) Some dehydration Rationale: Using the assessment guidelines of IMCI, a child (2 months to 5 years old) with diarrhea is classified as having SOME DEHYDRATION if he shows 2 or more of the following signs: restless or irritable, sunken eyes, the skin goes back slow after a skin pinch. 65. Answer: (C) Normal Rationale: In IMCI, a respiratory rate of 50/minute or more is fast breathing for an infant aged 2 to 12 months. 66. Answer: (A) 1 year Rationale: The baby will have passive natural immunity by placental transfer of antibodies. The mother will have active artificial immunity lasting for about 10 years. 5 doses will give the mother lifetime protection. 67. Answer: (B) 4 hours Rationale: While the unused portion of other biologicals in EPI may be given until the end of the day, only BCG is discarded 4 hours after reconstitution. This is why BCG immunization is scheduled only in the morning. 68. Answer: (B) 6 months Rationale: After 6 months, the baby’s nutrient needs, especially the baby’s iron requirement, can no longer be provided by mother’s milk alone. 69. Answer: (C) 24 weeks Rationale: At approximately 23 to 24 weeks’ gestation, the lungs are developed enough to sometimes maintain extrauterine life. The lungs are the most immature system during the gestation period. Medical care for premature labor begins much earlier (aggressively at 21 weeks’ gestation) 70. Answer: (B) Sudden infant death syndrome (SIDS) Rationale: Supine positioning is recommended to reduce the risk of SIDS in infancy. The risk of aspiration is slightly increased with the supine position. Suffocation would be less likely with an infant supine than prone and the position for GER requires the head of the bed to be elevated. 71. Answer: (C) Decreased temperature Rationale: Temperature instability, especially when it results in a low temperature in the neonate, may be a sign of infection. The 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. Answer: (D) Polycythemia probably due to chronic fetal hypoxia Rationale: The small-for-gestation neonate is at risk for developing polycythemia during the transitional period in an attempt to decrease hypoxia. The neonates are also at increased risk for developing hypoglycemia and hypothermia due to decreased glycogen stores. 73. Answer: (C) Desquamation of the epidermis Rationale: Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated. These neonates are usually very alert. Lanugo is missing in the postdate neonate. 74. Answer: (C) Respiratory depression Rationale: Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and bradycardia. The serum blood sugar isn’t affected by magnesium sulfate. The neonate would be floppy, not jittery. 75. Answer: (C) Respiratory rate 40 to 60 breaths/minute Rationale: A respiratory rate 40 to 60 breaths/minute is normal for a neonate during the transitional period. Nasal flaring, respiratory rate more than 60 breaths/minute, and audible grunting are signs of respiratory distress. 76. Answer: (C) Keep the cord dry and open to air Rationale: Keeping the cord dry and open to air helps reduce infection and hastens drying. Infants 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. Answer: (B) Conjunctival hemorrhage Rationale: Conjunctival hemorrhages are commonly seen in neonates secondary to the cranial pressure applied during the birth process. Bulging fontanelles are a sign of intracranial pressure. Simian creases are present in 40% of the neonates with trisomy 21. Cystic hygroma is a neck mass that can affect the airway. 78. Answer: (B) To assess for prolapsed cord Rationale: After a client has an amniotomy, the nurse should assure that the cord isn't prolapsed and that the baby tolerated the procedure well. The most effective way to do this is to check the fetal heart rate. Fetal well-being is assessed via a nonstress test. Fetal position is determined by vaginal examination. Artificial rupture of membranes doesn't indicate an imminent delivery. 79. Answer: (D) The parents’ interactions with each other. Rationale: Parental interaction will provide the nurse with a good assessment of the stability of the family's home life but it has no indication for parental bonding. Willingness to touch and hold the newborn, expressing interest about the newborn's size, and indicating a desire to see the newborn are behaviors indicating parental bonding. 80. Answer: (B) Instructing the client to use two or more peripads to cushion the area Rationale: Using two or more peripads would do little to reduce the pain or promote perineal healing. Cold applications, sitz baths, and Kegel exercises are important measures when the client has a fourth-degree laceration.

81. Answer: (C) “What is your expected due date?” Rationale: When obtaining the history of a client who may be in labor, the nurse's highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illnesses, allergies, and support persons. 82. Answer: (D) Aspirate the neonate’s nose and mouth with a bulb syringe. Rationale: The nurse's first action should be to clear the neonate's airway with a bulb syringe. After the airway is clear and the neonate's color improves, the nurse should comfort and calm the neonate. If the problem recurs or the neonate's color doesn't improve readily, the nurse should notify the physician. Administering oxygen when the airway isn't clear would be ineffective. 83. Answer: (C) Conducting a bedside ultrasound for an amniotic fluid index. Rationale: It isn't within a nurse's scope of practice to perform and interpret a bedside ultrasound under these conditions and without specialized training. Observing for pooling of straw-colored fluid, checking vaginal discharge with nitrazine paper, and observing for flakes of vernix are appropriate assessments for determining whether a client has ruptured membranes. 84. Answer: (C) Monitor partial pressure of oxygen (Pao2) levels. Rationale: Monitoring PaO2 levels and reducing the oxygen concentration to keep PaO2 within normal limits reduces the risk of retinopathy of prematurity in a premature infant receiving oxygen. Covering the infant's eyes and humidifying the oxygen don't reduce the risk of retinopathy of prematurity. Because cooling increases the risk of acidosis, the infant should be kept warm so that his respiratory distress isn't aggravated. 85. Answer: (A) 110 to 130 calories per kg. Rationale: Calories per kg is the accepted way of determined appropriate nutritional intake for a newborn. The recommended calorie requirement is 110 to 130 calories per kg of newborn body weight. This level will maintain a consistent blood glucose level and provide enough calories for continued growth and development. 86. Answer: (C) 30 to 32 weeks Rationale: Individual twins usually grow at the same rate as singletons until 30 to 32 weeks’ gestation, then twins 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. Answer: (A) conjoined twins Rationale: The type of placenta that develops in monozygotic twins depends on the time at which cleavage of the ovum occurs. Cleavage in conjoined twins occurs more than 13 days after fertilization. Cleavage that occurs less than 3 day after fertilization results in diamniotic dicchorionic twins. Cleavage that occurs between days 3 and 8 results in diamniotic monochorionic twins. Cleavage that occurs between days 8 to 13 result in monoamniotic monochorionic twins. 88. Answer: (D) Ultrasound

Rationale: Once the mother and the fetus are stabilized, ultrasound evaluation of the placenta should be done to determine the cause of the bleeding. Amniocentesis is contraindicated in placenta previa. A digital or speculum examination 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. Answer: (A) Increased tidal volume Rationale: A pregnant client breathes deeper, which increases the tidal volume of gas moved in and out of the respiratory tract with each breath. The expiratory volume and residual volume decrease as the pregnancy progresses. The inspiratory capacity increases during pregnancy. The increased oxygen consumption in the pregnant client is 15% to 20% greater than in the nonpregnant state. 90. Answer: (A) Diet Rationale: Clients with gestational diabetes are usually managed by diet alone to control their glucose intolerance. Oral hypoglycemic drugs are contraindicated in pregnancy. Long-acting insulin usually isn’t needed for blood glucose control in the client with gestational diabetes. 91. Answer: (D) Seizure Rationale: The anticonvulsant mechanism of magnesium is believes to depress seizure foci in the brain and peripheral neuromuscular blockade. Hypomagnesemia 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. Answer: (C) I.V. fluids Rationale: A sickle cell crisis during pregnancy is usually managed by exchange transfusion oxygen, and L.V. Fluids. The client usually needs a stronger analgesic than acetaminophen to control the pain of a crisis. Antihypertensive drugs usually aren’t necessary. Diuretic wouldn’t be used unless fluid overload resulted. 93. Answer: (A) Calcium gluconate (Kalcinate) Rationale: Calcium gluconate is the antidote for magnesium toxicity. Ten milliliters of 10% calcium gluconate is given L.V. push over 3 to 5 minutes. Hydralazine is given for sustained elevated blood pressure in preeclamptic clients. Rho (D) immune globulin is given to women with Rh-negative blood to prevent antibody formation from RH-positive conceptions. Naloxone is used to correct narcotic toxicity. 94. Answer: (B) An indurated wheal over 10 mm in diameter appears in 48 to 72 hours. Rationale: A positive PPD result would be an indurated wheal over 10 mm in diameter that appears in 48 to 72 hours. The area must be a raised wheal, not a flat circumcised area to be considered positive. 95. Answer: (C) Pyelonephritis Rational: The symptoms indicate acute pyelonephritis, a serious condition in a pregnant client. UTI symptoms include dysuria, urgency, frequency, and suprapubic tenderness. Asymptomatic bacteriuria doesn’t cause symptoms. Bacterial vaginosis causes milky white vaginal discharge but no systemic symptoms. 96. Answer: (B) Rh-positive fetal blood crosses into maternal blood, stimulating maternal antibodies. Rationale: Rh isoimmunization occurs when Rh-positive fetal blood cells cross into the maternal circulation and stimulate maternal antibody

production. In subsequent pregnancies with Rh-positive fetuses, maternal antibodies may cross back into the fetal circulation and destroy the fetal blood cells. 97. Answer: (C) Supine position Rationale: The supine position causes compression of the client's aorta and inferior vena cava by the fetus. This, in turn, inhibits maternal circulation, leading to maternal hypotension and, ultimately, fetal hypoxia. The other positions promote comfort and aid labor progress. For instance, the lateral, or side-lying, position improves maternal and fetal circulation, enhances comfort, increases maternal relaxation, reduces muscle tension, and eliminates pressure points. The squatting position promotes comfort by taking advantage of gravity. The standing position also takes advantage of gravity and aligns the fetus with the pelvic angle. 98. Answer: (B) Irritability and poor sucking. Rationale: Neonates of heroin-addicted mothers are physically dependent on the drug and experience withdrawal when the drug is no longer supplied. Signs of heroin withdrawal include irritability, poor sucking, and restlessness. Lethargy isn't associated with neonatal heroin addiction. A flattened nose, small eyes, and thin lips are seen in infants with fetal alcohol syndrome. Heroin use during pregnancy hasn't been linked to specific congenital anomalies. 99. Answer: (A) 7th to 9th day postpartum Rationale: The normal involutional process returns the uterus to the pelvic cavity in 7 to 9 days. A significant involutional complication is the failure of the uterus to return to the pelvic cavity within the prescribed time period. This is known as subinvolution. 100. Answer: (B) Uterine atony Rationale: Multiple fetuses, extended labor stimulation with oxytocin, and traumatic delivery commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may precede or follow delivery and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver the placenta manually. Uterine involution and some uterine discomfort are normal after delivery.

NURSING PRACTICE III- Care of Clients with Physiologic and Psychosocial Alterations Nursing 1. Nurse Michelle should know that the drainage is normal 4 days after a sigmoid colostomy when the stool is: a. Green liquid b. Solid formed c. Loose, bloody d. Semiformed 2. Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia? a. On the client’s right side b. On the client’s left side c. Directly in front of the client d. Where the client like 3. A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse? a. Check respiration, circulation, neurological response. b. Align the spine, check pupils, and check for hemorrhage. c. Check respirations, stabilize spine, and check circulation. d. Assess level of consciousness and circulation. 4. In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and relieves angina by: a. Increasing contractility and slowing heart rate. b. Increasing AV conduction and heart rate. c. Decreasing contractility and oxygen consumption. d. Decreasing venous return through vasodilation. 5. Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action? a. Call for help and note the time. b. Clear the airway c. Give two sharp thumps to the precordium, and check the pulse. d. Administer two quick blows. 6. Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse should: a. Plan care so the client can receive 8 hours of uninterrupted sleep each night. b. Monitor vital signs every 2 hours. c. Make sure that the client takes food and medications at prescribed intervals. d. Provide milk every 2 to 3 hours.

7. A male client was on warfarin (Coumadin) before admission, and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do? a. Stop the I.V. infusion of heparin and notify the physician. b. Continue treatment as ordered. c. Expect the warfarin to increase the PTT. d. Increase the dosage, because the level is lower than normal. 8. A client undergone ileostomy, when should the drainage appliance be applied to the stoma? a. 24 hours later, when edema has subsided. b. In the operating room. c. After the ileostomy begin to function. d. When the client is able to begin self-care procedures. 9. A client undergone spinal anesthetic, it will be important that the nurse immediately position the client in: a. On the side, to prevent obstruction of airway by tongue. b. Flat on back. c. On the back, with knees flexed 15 degrees. d. Flat on the stomach, with the head turned to the side. 10.While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure? a. Blood pressure is decreased from 160/90 to 110/70. b. Pulse is increased from 87 to 95, with an occasional skipped beat. c. The client is oriented when aroused from sleep, and goes back to sleep immediately. d. The client refuses dinner because of anorexia.

11.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first? a. Altered mental status and dehydration b. Fever and chills c. Hemoptysis and Dyspnea d. Pleuritic chest pain and cough 12. A male client has active tuberculosis (TB). Which of the following symptoms will be exhibit? a. Chest and lower back pain b. Chills, fever, night sweats, and hemoptysis c. Fever of more than 104°F (40°C) and nausea d. Headache and photophobia

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

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

15. A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging? a. Increased elastic recoil of the lungs b. Increased number of functional capillaries in the alveoli c. Decreased residual volume d. Decreased vital capacity

16. Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to administration of this medication? a. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter. b. Increase in systemic blood pressure. c. Presence of premature ventricular contractions (PVCs) on a cardiac monitor. d. Increase in intracranial pressure (ICP).

17. Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to: a. Report incidents of diarrhea. b. Avoid foods high in vitamin K c. Use a straight razor when shaving. d. Take aspirin to pain relief.

18. Nurse Lhynnette is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by: a. Leaving the hair intact b. Shaving the area c. Clipping the hair in the area d. Removing the hair with a depilatory.

19. Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication: a. Bone fracture b. Loss of estrogen c. Negative calcium balance d. Dowager’s hump

20. Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose of performing the examination is to discover: a. Cancerous lumps b. Areas of thickness or fullness c. Changes from previous examinations. d. Fibrocystic masses

21. When caring for a female client who is being treated for hyperthyroidism, it is important to: a. Provide extra blankets and clothing to keep the client warm. b. Monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy. c. Balance the client’s periods of activity and rest. d. Encourage the client to be active to prevent constipation.

22. Nurse Kris is teaching a client with history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to: a. Avoid focusing on his weight. b. Increase his activity level. c. Follow a regular diet. d. Continue leading a high-stress lifestyle.

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

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

24. A 55-year old client underwent cataract removal with intraocular lens implant. Nurse Oliver is giving the client discharge instructions. These instructions should include which of the following? a. Avoid lifting objects weighing more than 5 lb (2.25 kg). b. Lie on your abdomen when in bed c. Keep rooms brightly lit. d. Avoiding straining during bowel movement or bending at the waist.

25. George should be taught about testicular examinations during: a. when sexual activity starts b. After age 69 c. After age 40 d. Before age 20.

26. A male client undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. Nurse Trish first response is to: a. Call the physician b. Place a saline-soaked sterile dressing on the wound. c. Take a blood pressure and pulse. d. Pull the dehiscence closed.

27. Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During routine assessment, the nurse notices Cheyne- Strokes respirations. Cheyne-strokes respirations are: a. A progressively deeper breaths followed by shallower breaths with apneic periods. b. Rapid, deep breathing with abrupt pauses between each breath. c. Rapid, deep breathing and irregular breathing without pauses. d. Shallow breathing with an increased respiratory rate.

28. Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in clients with heart failure are: a. Tracheal b. Fine crackles c. Coarse crackles d. Friction rubs

29. The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing and breath sounds 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.

30. Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should: a. Place the client on his back remove dangerous objects, and insert a bite block. b. Place the client on his side, remove dangerous objects, and insert a bite block. c. Place the client o his back, remove dangerous objects, and hold down his arms. d. Place the client on his side, remove dangerous objects, and protect his head.

31. After insertion of a cheat tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for? a. Infection of the lung. b. Kinked or obstructed chest tube c. Excessive water in the water-seal chamber d. Excessive chest tube drainage

32. Nurse Maureen is talking to a male client, the client begins choking on his lunch. 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.

33. Nurse Ron is taking a health history of an 84 year old client. Which information will be most useful to the nurse for planning care? a. General health for the last 10 years. b. Current health promotion activities. c. Family history of diseases. d. Marital status.

34. When performing oral care on a comatose client, Nurse Krina should: a. Apply lemon glycerin to the 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.

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

36. Nurse Oliver is working in a out patient clinic. He has been alerted that there is an outbreak of tuberculosis (TB). Which of the following clients entering the clinic today most likely to have TB? a. A 16-year-old female high school student b. A 33-year-old day-care worker c. A 43-yesr-old homeless man with a history of alcoholism d. A 54-year-old businessman

37. Virgie with a positive Mantoux test result will be sent for a chest X-ray. The nurse is aware that which of the following reasons this is done? a. To confirm the diagnosis b. To determine if a repeat skin test is needed c. To determine the extent of lesions d. To determine if this is a primary or secondary infection

38. Kennedy with acute asthma showing inspiratory and expiratory wheezes and a decreased forced expiratory volume should be treated with which of the following classes of medication right away? a. Beta-adrenergic blockers b. Bronchodilators c. Inhaled steroids d. Oral steroids

39. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum, peripheral edema and cyanotic nail beds. Based on this information, he most likely has which of the following conditions? a. Adult respiratory distress syndrome (ARDS) b. Asthma c. Chronic obstructive bronchitis d. Emphysema

Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia. 40. The treatment for patients with leukemia is bone marrow transplantation. Which statement about bone marrow transplantation is not correct? a. The patient is under local anesthesia during the procedure b. The aspirated bone marrow is mixed with heparin. c. The aspiration site is the posterior or anterior iliac crest. d. The recipient receives cyclophosphamide (Cytoxan) for 4 consecutive days before the procedure.

41. After several days of admission, Francis becomes disoriented and complains of frequent headaches. The nurse in-charge first action would be: a. Call the physician b. Document the patient’s status in his charts. c. Prepare oxygen treatment d. Raise the side rails

42. During routine care, Francis asks the nurse, “How can I be anemic if this disease causes increased my white blood cell production?” The nurse in-charge best response would be that the increased number of white blood cells (WBC) is: a. Crowd red blood cells b. Are not responsible for the anemia. c. Uses nutrients from other cells d. Have an abnormally short life span of cells.

43. Diagnostic assessment of Francis would probably not reveal: a. Predominance of lymhoblasts b. Leukocytosis c. Abnormal blast cells in the bone marrow d. Elevated thrombocyte counts

44. Robert, a 57-year-old client with acute arterial occlusion of the left leg undergoes an emergency embolectomy. Six hours later, the nurse 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

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

46. Honey, a 23-year old client complains of substernal chest pain and states that her heart feels like “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

47. A 51-year-old female client tells the nurse in-charge that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client's lump is cancerous? a. Eversion of the right nipple and mobile mass b. Nonmobile mass with irregular edges c. Mobile mass that is soft and easily delineated d. Nonpalpable right axillary lymph nodes

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

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

49. Cristina undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean? a. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis b. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis c. Can't assess tumor or regional lymph nodes and no evidence of metastasis d. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis

50. Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction? a. "Keep the stoma uncovered." b. "Keep the stoma dry." c. "Have a family member perform stoma care initially until you get used to the procedure." d. "Keep the stoma moist."

51. A 37-year-old client with uterine cancer asks the nurse, "Which is the most common type of cancer in women?" The nurse replies that it's breast cancer. Which type of cancer causes the most deaths in women? a. Breast cancer b. Lung cancer c. Brain cancer d. Colon and rectal cancer

52. Antonio with lung cancer develops Horner's syndrome when the tumor invades the ribs and affects the sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse should note: a. miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. b. chest pain, dyspnea, cough, weight loss, and fever. c. arm and shoulder pain and atrophy of arm and hand muscles, both on the affected side. d. hoarseness and dysphagia.

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

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

54. What is the most important postoperative instruction that nurse Kate must give a client who has just returned from the operating room after receiving a subarachnoid block? a. "Avoid drinking liquids until the gag reflex returns." b. "Avoid eating milk products for 24 hours." c. "Notify a nurse if you experience blood in your urine." d. "Remain supine for the time specified by the physician."

55. A male client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis? a. Stool Hematest b. Carcinoembryonic antigen (CEA) c. Sigmoidoscopy d. Abdominal computed tomography (CT) scan

56. During a breast examination, which finding most strongly suggests that the Luz has breast cancer? a. Slight asymmetry of the breasts. b. A fixed nodular mass with dimpling of the overlying skin c. Bloody discharge from the nipple d. Multiple firm, round, freely movable masses that change with the menstrual cycle

57. A female client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis sites for cancer cells? a. Liver b. Colon c. Reproductive tract d. White blood cells (WBCs)

58. Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client? a. The client lies still. b. The client asks questions. c. The client hears thumping sounds.

d. The client wears a watch and wedding band.

59. Nurse Cecile is teaching a female client about preventing osteoporosis. Which of the following teaching points is correct? a. Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss. b. To avoid fractures, the client should avoid strenuous exercise. c. The recommended daily allowance of calcium may be found in a wide variety of foods. d. Obtaining the recommended daily allowance of calcium requires taking a calcium supplement.

60. Before Jacob undergoes arthroscopy, the nurse reviews the assessment findings for contraindications for this procedure. Which finding is a contraindication? a. Joint pain b. Joint deformity c. Joint flexion of less than 50% d. Joint stiffness

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

62. A heparin infusion at 1,500 unit/hour is ordered for a 64-year-old client with stroke in evolution. The infusion contains 25,000 units of heparin in 500 ml of saline solution. How many milliliters per hour should be given? a. 15 ml/hour b. 30 ml/hour c. 45 ml/hour d. 50 ml/hour

63. A 76-year-old male client had a thromboembolic right stroke; his left arm is swollen. Which of the following conditions may cause swelling after a stroke? a. Elbow contracture secondary to spasticity b. Loss of muscle contraction decreasing venous return c. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side d. Hypoalbuminemia due to protein escaping from an inflamed glomerulus

64. 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.

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

66. Mrs. Cruz uses a cane for assistance in walking. Which of the following statements is true about a cane or other assistive devices? a. A walker is a better choice than a cane. b. The cane should be used on the affected side c. The cane should be used on the unaffected side d. A client with osteoarthritis should be encouraged to ambulate without the cane

67. A male client with type 1 diabetes is scheduled to receive 30 U of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client: a. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH). b. 21 U regular insulin and 9 U NPH. c. 10 U regular insulin and 20 U NPH. d. 20 U regular insulin and 10 U NPH.

68. Nurse Len should expect to administer which medication to a client with gout? a. aspirin b. furosemide (Lasix) c. colchicines d. calcium gluconate (Kalcinate)

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

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

70. For a diabetic male client with a foot ulcer, the doctor orders bed rest, a wetto- dry dressing change every shift, and blood glucose monitoring before meals and bedtime. Why are wet-to-dry dressings used for this client? a. They contain exudate and provide a moist wound environment. b. They protect the wound from mechanical trauma and promote healing. c. They debride the wound and promote healing by secondary intention. d. They prevent the entrance of microorganisms and minimize wound discomfort.

71. Nurse Zeny is caring for a client in acute addisonian crisis. Which laboratory data would the nurse expect to find? a. Hyperkalemia b. Reduced blood urea nitrogen (BUN) c. Hypernatremia d. Hyperglycemia

72. A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? a. Infusing I.V. fluids rapidly as ordered b. Encouraging increased oral intake c. Restricting fluids d. Administering glucose-containing I.V. fluids as ordered

73. A female client tells nurse Nikki that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check: a. urine glucose level. b. fasting blood glucose level. c. serum fructosamine level. d. glycosylated hemoglobin level.

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

a. 10:00 am b. Noon c. 4:00 pm d. 10:00 pm

75. The adrenal cortex is responsible for producing which substances? a. Glucocorticoids and androgens b. Catecholamines and epinephrine c. Mineralocorticoids and catecholamines d. Norepinephrine and epinephrine

76. On the third day after a partial thyroidectomy, Proserfina exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a lifethreatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery? a. Hypocalcemia b. Hyponatremia c. Hyperkalemia d. Hypermagnesemia

77. Which laboratory test value is elevated in clients who smoke and can't be used as a general indicator of cancer? a. Acid phosphatase level b. Serum calcitonin level c. Alkaline phosphatase level d. Carcinoembryonic antigen level

78. Francis with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron-deficiency anemia? a. Nights sweats, weight loss, and diarrhea b. Dyspnea, tachycardia, and pallor c. Nausea, vomiting, and anorexia d. Itching, rash, and jaundice

79. In teaching a female client who is HIV-positive about pregnancy, the nurse would know more teaching is necessary when the client says: a. The baby can get the virus from my placenta." b. "I'm planning on starting on birth control pills."

c. "Not everyone who has the virus gives birth to a baby who has the virus." d. "I'll need to have a C-section if I become pregnant and have a baby."

80. When preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction? a. "Put on disposable gloves before bathing." b. "Sterilize all plates and utensils in boiling water." c. "Avoid sharing such articles as toothbrushes and razors." d. "Avoid eating foods from serving dishes shared by other family members."

81. Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client? a. Pallor, bradycardia, and reduced pulse pressure b. Pallor, tachycardia, and a sore tongue c. Sore tongue, dyspnea, and weight gain d. Angina, double vision, and anorexia

82. After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina suspects the client is experiencing anaphylactic shock. What should the nurse do first? a. Page an anesthesiologist immediately and prepare to intubate the client. b. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary. c. Administer the antidote for penicillin, as prescribed, and continue to monitor the client's vital signs. d. Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered.

83. Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include: a. weight gain. b. fine motor tremors. c. respiratory acidosis. d. bilateral hearing loss.

84. A 23-year-old client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that adaptive immunity is provided by which type of white blood cell? a. Neutrophil

b. Basophil c. Monocyte d. Lymphocyte

85. In an individual with Sjögren's syndrome, nursing care should focus on: a. moisture replacement. b. electrolyte balance. c. nutritional supplementation. d. arrhythmia management.

86. During chemotherapy for lymphocytic leukemia, Mathew develops abdominal pain, fever, and "horse barn" smelling diarrhea. It would be most important for the nurse to advise the physician to order: a. enzyme-linked immunosuppressant assay (ELISA) test. b. electrolyte panel and hemogram. c. stool for Clostridium difficile test. d. flat plate X-ray of the abdomen.

87. A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order: a. E-rosette immunofluorescence. b. quantification of T-lymphocytes. c. enzyme-linked immunosorbent assay (ELISA). d. Western blot test with ELISA.

88. A complete blood count is commonly performed before a Joe goes into surgery. What does this test seek to identify? a. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels b. Low levels of urine constituents normally excreted in the urine c. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels d. Electrolyte imbalance that could affect the blood's ability to coagulate properly

89. While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters? a. Platelet count, prothrombin time, and partial thromboplastin time b. Platelet count, blood glucose levels, and white blood cell (WBC) count c. Thrombin time, calcium levels, and potassium levels

d. Fibrinogen level, WBC, and platelet count

90. When taking a dietary history from a newly admitted female client, Nurse Len should remember that which of the following foods is a common allergen? a. Bread b. Carrots c. Orange d. Strawberries

91. Nurse John is caring for clients in the outpatient clinic. Which of the following phone calls should the nurse return first? a. A client with hepatitis A who states, “My arms and legs are itching.” b. A client with cast on the right leg who states, “I have a funny feeling in my right leg.” c. A client with osteomyelitis of the spine who states, “I am so nauseous that I can’t eat.” d. A client with rheumatoid arthritis who states, “I am having trouble sleeping.”

92. Nurse Sarah is caring for clients on the surgical floor and has just received report from the previous shift. Which of the following clients should the nurse see first? a. A 35-year-old admitted three hours ago with a gunshot wound; 1.5 cm area of dark drainage noted on the dressing. b. A 43-year-old who had a mastectomy two days ago; 23 ml of serosanguinous fluid noted in the Jackson-Pratt drain. c. A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous eight hours. d. A 62-year-old who had an abdominal-perineal resection three days ago; client complaints of chills.

93. Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for treatment of 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.

94. Julius is admitted with complaints of severe pain in the lower right quadrant of the abdomen. To assist with pain relief, the nurse should take which of the following actions? a. Encourage the client to change positions frequently in bed. b. Administer Demerol 50 mg IM q 4 hours and PRN. c. Apply warmth to the abdomen with a heating pad. d. Use comfort measures and pillows to position the client.

95. Nurse Tina prepares a client for peritoneal dialysis. Which of the following actions should the nurse take first? a. Assess for a bruit and a thrill. b. Warm the dialysate solution. c. Position the client on the left side. d. Insert a Foley catheter

96. Nurse Jannah teaches an elderly client with right-sided weakness how to use cane. Which of the following behaviors, if demonstrated by the client to the nurse, indicates that the teaching was effective? a. The client holds the cane with his right hand, moves the can forward followed by the right leg, and then moves the left leg. b. The client holds the cane with his right hand, moves the cane forward followed by his left leg, and then moves the right leg. c. The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg. d. The client holds the cane with his left hand, moves the cane forward followed by his left leg, and then moves the right leg.

97. An elderly client is admitted to the nursing home setting. The client is occasionally confused and her gait is often unsteady. Which of the following actions, if taken by the nurse, is most appropriate? a. Ask the 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.

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.

99. Nurse Deric is supervising a group of elderly clients in a residential home setting. The nurse knows that the elderly are at greater risk of developing sensory deprivation for what reason?

a. Increased sensitivity to the side effects of medications. b. Decreased visual, auditory, and gustatory abilities. c. Isolation from their families and familiar surroundings. d. Decrease musculoskeletal function and mobility.

100. A male client with emphysema becomes restless and confused. What step should nurse Jasmine take next? a. Encourage the client to perform pursed lip breathing. b. Check the client’s temperature. c. Assess the client’s potassium level. d. Increase the client’s oxygen flow rate.

Answers and Rationale- NURSING PRACTICE III- Care of Clients with Physiologic and Psychosocial Alterations Nursing 1. Answer: (C) Loose, bloody Rationale: Normal bowel function and soft-formed stool usually do not occur until around the seventh day following surgery. The stool consistency is related to how much water is being absorbed. 2. Answer: (A) On the client’s right side Rationale: The client has left visual field blindness. The client will see only from the right side. 3. Answer: (C) Check respirations, stabilize spine, and check circulation Rationale: Checking the airway would be priority, and a neck injury should be suspected. 4. Answer: (D) Decreasing venous return through vasodilation. Rationale: The significant effect of nitroglycerin is vasodilation and decreased venous return, so the heart does not have to work hard. 5. Answer: (A) Call for help and note the time. Rationale: Having established, by stimulating the client, that the client is unconscious rather than sleep, the nurse should immediately call for help. This may be done by dialing the operator from the 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. Answer: (C) Make sure that the client takes food and medications at prescribed intervals. Rationale: Food and drug therapy will prevent the accumulation of hydrochloric acid, or will neutralize and buffer the acid that does accumulate. 7. Answer: (B) Continue treatment as ordered. Rationale: The effects of heparin are monitored by the PTT is normally 30 to 45 seconds; the therapeutic level is 1.5 to 2 times the normal level.

8. Answer: (B) In the operating room. Rationale: The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful, and excoriated. 9. Answer: (B) Flat on back. Rationale: To avoid the complication of a painful spinal headache that can last for several days, the client is kept in flat in a supine position for approximately 4 to 12 hours postoperatively. Headaches are believed to be causes by the seepage of cerebral spinal fluid from the puncture site. By keeping the client flat, cerebral spinal fluid pressures are equalized, which avoids trauma to the neurons. 10. Answer: (C) The client is oriented when aroused from sleep, and goes back to sleep immediately. Rationale: This finding suggest that the level of consciousness is decreasing. 11. Answer: (A) Altered mental status and dehydration Rationale: Fever, chills, hemortysis, dyspnea, cough, and pleuritic chest pain are the common symptoms of pneumonia, but elderly clients may first appear with only an altered lentil status and dehydration due to a blunted immune response. 12. Answer: (B) Chills, fever, night sweats, and hemoptysis Rationale: Typical signs and symptoms are chills, fever, night sweats, and hemoptysis. Chest pain may be present from coughing, but 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. Answer:(A) Acute asthma Rationale: 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. Answer: (B) Respiratory arrest Rationale: 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. Answer: (D) Decreased vital capacity Rationale: Reduction in vital capacity is a normal physiologic changes include decreased elastic recoil of the lungs, fewer functional capillaries in the alveoli, and an increased in residual volume. 16. Answer: (C) Presence of premature ventricular contractions (PVCs) on a cardiac monitor. Rationale: Lidocaine drips are commonly used to treat clients whose arrhythmias 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. Answer: (B) Avoid foods high in vitamin K Rationale: The client should avoid consuming large amounts of vitamin K because vitamin K can interfere with anticoagulation. The client may need to report diarrhea, but 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. Answer: (C) Clipping the hair in the area Rationale: Hair can be a source of infection and should be removed by clipping. Shaving the area can cause skin abrasions and depilatories can irritate the skin. 19. Answer: (A) Bone fracture Rationale: Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increased the fragility of bones. Estrogen deficiencies result from menopause-not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, But a negative calcium balance isn’t a complication of osteoporosis. Dowager’s hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature. 20. Answer: (C) Changes from previous examinations. Rationale: Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant. 21. Answer: (C) Balance the client’s periods of activity and rest. Rationale: A client with hyperthyroidism needs to be encouraged to balance periods of activity and rest. Many clients with hyperthyroidism are hyperactive and complain of feeling very warm. 22. Answer: (B) Increase his activity level. Rationale: The client should be encouraged to increase his activity level. Maintaining an ideal weight; following a low-cholesterol, low sodium diet; and avoiding stress are all important factors in decreasing the risk of atherosclerosis. 23. Answer: (A) Laminectomy Rationale: The client who has had spinal surgery, such as laminectomy, must be log rolled to keep the spinal column straight when turning. Thoracotomy and cystectomy may turn themselves or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery. 24. Answer: (D) Avoiding straining during bowel movement or bending at the waist. Rationale: The client should avoid straining, lifting heavy objects, and coughing harshly because these activities increase intraocular pressure. Typically, the client is instructed to avoid lifting objects weighing more than 15 lb (7kg) – not 5lb. instruct the client when lying in bed to lie on either the side or back. The client should avoid bright light by wearing sunglasses. 25. Answer: (D) Before age 20. Rationale: Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be taught how to perform testicular selfexamination before age 20, preferably when he enters his teens. 26. Answer: (B) Place a saline-soaked sterile dressing on the wound. Rationale: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the client’s vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it. 27. Answer: (A) A progressively deeper breaths followed by shallower breaths with apneic periods.

Rationale: Cheyne-Strokes respirations are breaths that become progressively deeper fallowed by shallower respirations with apneas periods. 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. Answer: (B) Fine crackles Rationale: Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation. 29. Answer: (B) The airways are so swollen that no air cannot get through Rationale: During an acute attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air 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. Answer: (D) Place the client on his side, remove dangerous objects, and protect his head. Rationale: During the active seizure phase, initiate precautions by placing the client on his side, removing dangerous objects, and protecting his head from injury. A bite block should never be inserted during the active seizure phase. Insertion can break the teeth and lead to aspiration. 31. Answer: (B) Kinked or obstructed chest tube Rationales: Kinking and blockage of the chest tube is a common cause of a tension pneumothorax. Infection and excessive drainage won’t cause a tension pneumothorax. Excessive water won’t affect the chest tube drainage. 32. Answer: (D) Stay with him but not intervene at this time. Rationale: If the client is coughing, he should be able to dislodge the object or cause a complete obstruction. If complete obstruction occurs, the nurse should perform the abdominal thrust maneuver with the client standing. If the client is unconscious, she should lay him down. A nurse should never leave a choking client alone. 33. Answer: (B) Current health promotion activities Rationale: Recognizing an 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. Answer: (C) Place the client in a side lying position, with the head of the bed lowered. Rationale: The client should be positioned in a side-lying position with the head of the bed lowered to prevent aspiration. A small amount of toothpaste should be used and the mouth swabbed or suctioned to remove pooled secretions. Lemon glycerin can be drying if used for extended periods. Brushing the teeth with the client lying supine may lead to aspiration. Hydrogen peroxide is caustic to tissues and should not be used. 35. Answer: (C) Pneumonia

Rationale: Fever productive cough and pleuritic chest pain are common signs and symptoms of pneumonia. The client with ARDS has dyspnea and hypoxia with worsening hypoxia over time, if not treated aggressively. Pleuritic chest pain varies with respiration, unlike the constant chest pain during an MI; so this client most likely isn’t having an MI. the client with TB typically has a cough producing bloodtinged sputum. A sputum culture should be obtained to confirm the nurse’s suspicions. 36. Answer: (C) A 43-yesr-old homeless man with a history of alcoholism Rationale: Clients who are economically disadvantaged, malnourished, and have reduced immunity, such as a client with a history of alcoholism, are at extremely high risk for developing TB. A high school student, daycare worker, and businessman probably have a much low risk of contracting TB. 37. Answer: (C ) To determine the extent of lesions Rationale: If the lesions are large enough, the chest X-ray will show their presence in the lungs. Sputum culture confirms the diagnosis. There can be false-positive and false-negative skin test results. A chest Xray can’t determine if this is a primary or secondary infection. 38. Answer: (B) Bronchodilators Rationale: Bronchodilators are the first line of treatment for asthma because broncho-constriction is the cause of reduced airflow. Beta adrenergic blockers 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. Answer: (C) Chronic obstructive bronchitis Rationale: Because of this extensive smoking history and symptoms the client most likely has chronic obstructive bronchitis. Client with ARDS have acute symptoms of hypoxia and typically need large amounts of oxygen. Clients with asthma and emphysema tend not to have chronic cough or peripheral edema. 40. Answer: (A) The patient is under local anesthesia during the procedure Rationale: Before the procedure, the patient is administered with drugs that would help to prevent infection and rejection of the transplanted cells such as antibiotics, cytotoxic, and corticosteroids. During the transplant, the patient is placed under general anesthesia. 41. Answer: (D) Raise the side rails Rationale: A patient who is disoriented is at risk of falling out of bed. The initial action of the nurse should be raising the side rails to ensure patients safety. 42. Answer: (A) Crowd red blood cells Rationale: The excessive production of white blood cells crowd out red blood cells production which causes anemia to occur. 43. Answer: (B) Leukocytosis Rationale: Chronic Lymphocytic leukemia (CLL) is characterized by increased production of leukocytes and lymphocytes resulting in leukocytosis, and proliferation of these cells within the bone marrow, spleen and liver. 44. Answer: (A) Explain the risks of not having the surgery

Rationale: The best initial response is to explain the risks of not having the surgery. If the client understands the risks but still refuses the nurse should notify the physician and the nurse supervisor and then record the client’s refusal in the nurses’ notes. 45. Answer: (D) The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem) Rationale: The client with atrial fibrillation has the greatest potential to become unstable and is on L.V. medication that requires close monitoring. After assessing this client, the nurse should assess the client with thrombophlebitis who is receiving a heparin infusion, and then the 58- year-old client admitted 2 days ago with heart failure (his signs and symptoms are resolving and 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. Answer: (C) Cocaine Rationale: 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. Answer: (B) Nonmobile mass with irregular edges Rationale: Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. A mobile mass that is soft and easily delineated is most often a fluid-filled benign cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass. Nipple retraction — not eversion — may be a sign of cancer. 48. Answer: (C) Radiation Rationale: The usual treatment for vaginal cancer is external or intravaginal radiation therapy. Less often, surgery is performed. Chemotherapy typically is prescribed only if vaginal cancer is diagnosed in an early stage, which is rare. Immunotherapy isn't used to treat vaginal cancer. 49. Answer: (B) Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis Rationale: TIS, N0, M0 denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis is classified as T0, N0, M0. If the tumor and regional lymph nodes can't be assessed and no evidence of metastasis exists, the lesion is classified as TX, NX, M0. A progressive increase in tumor size, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis is classified as T1, T2, T3, or T4; N0; and M1, M2, or M3. 50. Answer: (D) "Keep the stoma moist." Rationale: The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer of petroleum jelly around the edges, because a dry stoma may become irritated. The nurse should recommend placing a stoma bib over the stoma to filter and warm air before it enters the stoma. The client should begin performing stoma care without assistance as soon as possible to gain independence in self-care activities. 51. Answer: (B) Lung cancer

Rationale: Lung cancer is the most deadly type of cancer in both women and men. Breast cancer ranks second in women, followed (in descending order) by colon and rectal cancer, pancreatic cancer, ovarian cancer, uterine cancer, lymphoma, leukemia, liver cancer, brain cancer, stomach cancer, and multiple myeloma. 52. Answer: (A) miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. Rationale: Horner's syndrome, which occurs when a lung tumor invades the ribs and affects the sympathetic nerve ganglia, is characterized by miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. Chest pain, dyspnea, cough, weight loss, and fever are associated with pleural tumors. Arm and shoulder pain and atrophy of the arm and hand muscles on the affected side suggest Pancoast's tumor, a lung tumor involving the first thoracic and eighth cervical nerves within the brachial plexus. Hoarseness in a client with lung cancer suggests that the tumor has extended to the recurrent laryngeal nerve; dysphagia suggests that the lung tumor is compressing the esophagus. 53. Answer: (A) prostate-specific antigen, which is used to screen for prostate cancer. Rationale: PSA stands for prostate-specific antigen, which is used to screen for prostate cancer. The other answers are incorrect. 54. Answer: (D) "Remain supine for the time specified by the physician." Rationale: The nurse should instruct the client to remain supine for the time specified by the physician. Local anesthetics used in a subarachnoid block don't alter the gag reflex. No interactions between local anesthetics and food occur. Local anesthetics don't cause hematuria. 55. Answer: (C) Sigmoidoscopy Rationale: Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection of two-thirds of all colorectal cancers. Stool Hematest detects blood, which is a sign of colorectal cancer; however, the test doesn't confirm the diagnosis. CEA may be elevated in colorectal cancer but isn't considered a confirming test. An abdominal CT scan is used to stage the presence of colorectal cancer. 56. Answer: (B) A fixed nodular mass with dimpling of the overlying skin Rationale: A fixed nodular mass with dimpling of the overlying skin is common during late stages of breast cancer. Many women have slightly asymmetrical breasts. Bloody nipple discharge is a sign of intraductal papilloma, a benign condition. Multiple firm, round, freely movable masses that change with the menstrual cycle indicate fibrocystic breasts, a benign condition. 57. Answer: (A) Liver Rationale: The liver is one of the five most common cancer metastasis sites. The others are the lymph nodes, lung, bone, and brain. The colon, reproductive tract, and WBCs are occasional metastasis sites. 58. Answer: (D) The client wears a watch and wedding band. Rationale: During an MRI, the client should wear no metal objects, such as jewelry, because the strong magnetic field can pull on them, causing injury to the client and (if they fly off) to others. The client must lie still during the MRI but can talk to those performing the test by way of the microphone inside the scanner tunnel. The client should hear thumping sounds, which are caused by the sound waves thumping on the magnetic field. 59. Answer: (C) The recommended daily allowance of calcium may be found in a wide variety of foods.

Rationale: Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. It's often, though not always, possible to get the recommended daily requirement in the foods we eat. Supplements are available but not always necessary. Osteoporosis doesn't show up on ordinary X-rays until 30% of the bone loss has occurred. Bone densitometry can detect bone loss of 3% or less. This test is sometimes recommended routinely for women over 35 who are at risk. Strenuous exercise won't cause fractures. 60. Answer: (C) Joint flexion of less than 50% Rationale: Arthroscopy is contraindicated in clients with joint flexion of less than 50% because of technical problems in inserting the instrument into the joint to see it clearly. Other contraindications for this procedure include skin and wound infections. Joint pain may be an indication, not a contraindication, for arthroscopy. Joint deformity and joint stiffness aren't contraindications for this procedure. 61. Answer: (D) Gouty arthritis Rationale: Gouty arthritis, a metabolic disease, is characterized by urate deposits and pain in the joints, especially those in the feet and legs. Urate deposits don't occur in septic or traumatic arthritis. Septic arthritis results from bacterial invasion of a joint and leads to inflammation of the synovial lining. Traumatic arthritis results from blunt trauma to a joint or ligament. Intermittent arthritis is a rare, benign condition marked by regular, recurrent joint effusions, especially in the knees. 62. Answer: (B) 30 ml/hou Rationale: An infusion prepared with 25,000 units of heparin in 500 ml of saline solution yields 50 units of heparin per milliliter of solution. The equation is set up as 50 units times X (the unknown quantity) equals 1,500 units/hour, X equals 30 ml/hour. 63. Answer: (B) Loss of muscle contraction decreasing venous return Rationale: In clients with hemiplegia or hemiparesis loss of muscle contraction decreases venous return and may cause swelling of the affected extremity. Contractures, or bony calcifications may occur with a stroke, but 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. Answer: (B) It appears on the distal interphalangeal joint Rationale: 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. Answer: (B) Osteoarthritis is a localized disease rheumatoid arthritis is systemic Rationale: 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. Answer: (C) The cane should be used on the unaffected side Rationale: A cane should be used on the unaffected side. A client with osteoarthritis should be encouraged to ambulate with a cane, walker, or other assistive device as needed; their use takes weight and stress off joints. 67. Answer: (A) a. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).

Rationale: A 70/30 insulin preparation is 70% NPH and 30% regular insulin. Therefore, a correct substitution requires mixing 21 U of NPH and 9 U of regular insulin. The other choices are incorrect dosages for the prescribed insulin. 68. Answer: (C) colchicines Rationale: A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The physician prescribes colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin is used to reduce joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no effect on urate crystal formation. Furosemide, a diuretic, doesn't relieve gout. Calcium gluconate is used to reverse a negative calcium balance and relieve muscle cramps, not to treat gout. 69. Answer: (A) Adrenal cortex Rationale: Excessive secretion of aldosterone in the adrenal cortex is responsible for the client's hypertension. This hormone acts on the renal tubule, where it promotes reabsorption of sodium and excretion of potassium and hydrogen ions. The pancreas mainly secretes hormones involved in fuel metabolism. The adrenal medulla secretes the catecholamines — epinephrine and norepinephrine. The parathyroids secrete parathyroid hormone. 70. Answer: (C) They debride the wound and promote healing by secondary intention Rationale: For this client, wet-to-dry dressings are most appropriate because they clean the foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by secondary intention. Moist, transparent dressings contain exudate and provide a moist wound environment. Hydrocolloid dressings prevent the entrance of microorganisms and minimize wound discomfort. Dry sterile dressings protect the wound from mechanical trauma and promote healing. 71. Answer: (A) Hyperkalemia Rationale: In adrenal insufficiency, the client has hyperkalemia due to reduced aldosterone secretion. BUN increases as the glomerular filtration rate is reduced. Hyponatremia is caused by reduced aldosterone secretion. Reduced cortisol secretion leads to impaired glyconeogenesis and a reduction of glycogen in the liver and muscle, causing hypoglycemia. 72. Answer: (C) Restricting fluids Rationale: To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load. 73. Answer: (D) glycosylated hemoglobin level. Rationale: Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day life span of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months. Fasting blood glucose and urine glucose levels only give information about glucose levels at the point in time when they were obtained. Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks. 74. Answer: (C) 4:00 pm Rationale: NPH is an intermediate-acting insulin that peaks 8 to 12 hours after administration. Because the nurse administered NPH insulin at 7 a.m., the client is at greatest risk for hypoglycemia from 3 p.m. to 7 p.m.

75. Answer: (A) Glucocorticoids and androgens Rationale: The adrenal glands have two divisions, the cortex and medulla. The cortex produces three types of hormones: glucocorticoids, mineralocorticoids, and androgens. The medulla produces catecholamines — epinephrine and norepinephrine. 76. Answer: (A) Hypocalcemia Rationale: Hypocalcemia may follow thyroid surgery if the parathyroid glands were removed accidentally. Signs and symptoms of hypocalcemia may be delayed for up to 7 days after surgery. Thyroid surgery doesn't directly cause serum sodium, potassium, or magnesium abnormalities. Hyponatremia may occur if the client inadvertently received too much fluid; however, this can happen to any surgical client receiving I.V. fluid therapy, not just one recovering from thyroid surgery. Hyperkalemia and hypermagnesemia usually are associated with reduced renal excretion of potassium and magnesium, not thyroid surgery. 77. Answer: (D) Carcinoembryonic antigen level Rationale: In clients who smoke, the level of carcinoembryonic antigen is elevated. Therefore, it can't be used as a general indicator of cancer. However, it is helpful in monitoring cancer treatment because the level usually falls to normal within 1 month if treatment is successful. An elevated acid phosphatase level may indicate prostate cancer. An elevated alkaline phosphatase level may reflect bone metastasis. An elevated serum calcitonin level usually signals thyroid cancer. 78. Answer: (B) Dyspnea, tachycardia, and pallor Rationale: Signs of iron-deficiency anemia include dyspnea, tachycardia, and pallor as well as fatigue, listlessness, irritability, and headache. Night sweats, weight loss, and diarrhea may signal acquired immunodeficiency syndrome (AIDS). Nausea, vomiting, and anorexia may be signs of hepatitis B. Itching, rash, and jaundice may result from an allergic or hemolytic reaction. 79. Answer: (D) "I'll need to have a C-section if I become pregnant and have a baby." Rationale: The human immunodeficiency virus (HIV) is transmitted from mother to child via the transplacental route, but a Cesarean section delivery isn't necessary when the mother is HIV-positive. The use of birth control will prevent the conception of a child who might have HIV. It's true that a mother who's HIV positive can give birth to a baby who's HIV negative. 80. Answer: (C) "Avoid sharing such articles as toothbrushes and razors." Rationale: The human immunodeficiency virus (HIV), which causes AIDS, is most concentrated in the blood. For this reason, the client shouldn't share personal articles that may be blood-contaminated, such as toothbrushes and razors, with other family members. HIV isn't transmitted by bathing or by eating from plates, utensils, or serving dishes used by a person with AIDS. 81. Answer: (B) Pallor, tachycardia, and a sore tongue Rationale: Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision aren't characteristic findings in pernicious anemia. 82. Answer: (B) Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.

Rationale: To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent bronchodilator as prescribed. The physician is likely to order additional medications, such as antihistamines and corticosteroids; if these medications don't relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client. No antidote for penicillin exists; however, the nurse should continue to monitor the client's vital signs. A client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring; however, administering epinephrine is the first priority. 83. Answer: (D) bilateral hearing loss. Rationale: Prolonged use of aspirin and other salicylates sometimes causes bilateral hearing loss of 30 to 40 decibels. Usually, this adverse effect resolves within 2 weeks after the therapy is discontinued. Aspirin doesn't lead to weight gain or fine motor tremors. Large or toxic salicylate doses may cause respiratory alkalosis, not respiratory acidosis. 84. Answer: (D) Lymphocyte Rationale: The lymphocyte provides adaptive immunity — recognition of a foreign antigen and formation of memory cells against the antigen. Adaptive immunity is mediated by B and T lymphocytes and can be acquired actively or passively. The neutrophil is crucial to phagocytosis. The basophil plays an important role in the release of inflammatory mediators. The monocyte functions in phagocytosis and monokine production. 85. Answer: (A) moisture replacement. Rationale: Sjogren's syndrome is an autoimmune disorder leading to progressive loss of lubrication of the skin, GI tract, ears, nose, and vagina. Moisture replacement is the mainstay of therapy. Though malnutrition and electrolyte imbalance may occur as a result of Sjogren's syndrome's effect on the GI tract, it isn't the predominant problem. Arrhythmias aren't a problem associated with Sjogren's syndrome. 86. Answer: (C) stool for Clostridium difficile test. Rationale: Immunosuppressed clients — for example, clients receiving chemotherapy, — are at risk for infection with C. difficile, which causes "horse barn" smelling diarrhea. Successful treatment begins with an accurate diagnosis, which includes a stool test. The ELISA test is diagnostic for human immunodeficiency virus (HIV) and isn't indicated in this case. An electrolyte panel and hemogram may be useful in the overall evaluation of a client but aren't diagnostic for specific causes of diarrhea. A flat plate of the abdomen may provide useful information about bowel function but isn't indicated in the case of "horse barn" smelling diarrhea. 87. Answer: (D) Western blot test with ELISA. Rationale: HIV infection is detected by analyzing blood for antibodies to HIV, which form approximately 2 to 12 weeks after exposure to HIV and denote infection. The Western blot test — electrophoresis of antibody proteins — is more than 98% accurate in detecting HIV antibodies when used in conjunction with the ELISA. It isn't specific when used alone. Erosette immunofluorescence is used to detect viruses in general; it doesn't confirm HIV infection. Quantification of T-lymphocytes is a useful monitoring test but isn't diagnostic for HIV. The ELISA test detects HIV antibody particles but may yield inaccurate results; a positive ELISA result must be confirmed by the Western blot test. 88. Answer: (C) Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels

Rationale: Low preoperative HCT and Hb levels indicate the client may require a blood transfusion before surgery. If the HCT and Hb levels decrease during surgery because of blood loss, the potential need for a transfusion increases. Possible renal failure is indicated by elevated BUN or creatinine levels. Urine constituents aren't found in the blood. Coagulation is determined by the presence of appropriate clotting factors, not electrolytes. 89. Answer: (A) Platelet count, prothrombin time, and partial thromboplastin time Rationale: The diagnosis of DIC is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, and fibrinogen level as well as client history and other assessment factors. Blood glucose levels, WBC count, calcium levels, and potassium levels aren't used to confirm a diagnosis of DIC. 90. Answer: (D) Strawberries Rationale: Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots, and oranges rarely cause allergic reactions. 91. Answer: (B) A client with cast on the right leg who states, “I have a funny feeling in my right leg.” Rationale: It may indicate neurovascular compromise, requires immediate assessment. 92. Answer: (D) A 62-year-old who had an abdominal-perineal resection three days ago; client complaints of chills. Rationale: The client is at risk for peritonitis; should be assessed for further symptoms and infection. 93. Answer: (C) The client spontaneously flexes his wrist when the blood pressure is obtained. Rationale: Carpal spasms indicate hypocalcemia. 94. Answer: (D) Use comfort measures and pillows to position the client. Rationale: Using comfort measures and pillows to position the client is a non-pharmacological methods of pain relief. 95. Answer: (B) Warm the dialysate solution. Rationale: Cold dialysate increases discomfort. The solution should be warmed to body temperature in warmer or heating pad; don’t use microwave oven. 96. Answer: (C) The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg. Rationale: The cane acts as a support and aids in weight bearing for the weaker right leg. 97. Answer: (A) Ask the woman’s family to provide personal items such as photos or mementos. Rationale: Photos and mementos provide visual stimulation to reduce sensory deprivation. 98. Answer: (B) The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward. Rationale: A walker needs to be picked up, placed down on all legs. 99. Answer: (C) Isolation from their families and familiar surroundings. Rationale: Gradual loss of sight, hearing, and taste interferes with normal functioning.

100. Answer: (A) Encourage the client to perform pursed lip breathing. Rationale: Purse lip breathing prevents the collapse of lung unit and helps client control rate and depth of breathing.

Practice Test IV- Psychiatric Nursing 1. Marco approached Nurse Trish asking for advice on how to deal with his alcohol addiction. Nurse Trish should tell the client that the only effective treatment for alcoholism is: a. Psychotherapy b. Alcoholics anonymous (A.A.) c. Total abstinence d. Aversion Therapy

2. Nurse Hazel is caring for a male client who experience false sensory perceptions with no basis in reality. This perception is known as: a. Hallucinations b. Delusions c. Loose associations d. Neologisms

3. Nurse Monet is caring for a female client who has suicidal tendency. When accompanying the client to the restroom, Nurse Monet should… a. Give her privacy b. Allow her to urinate c. Open the window and allow her to get some fresh air d. Observe her

4. Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. Which action should the nurse include in the plan? a. Provide privacy during meals b. Set-up a strict eating plan for the client c. Encourage client to exercise to reduce anxiety d. Restrict visits with the family

5. A client is experiencing anxiety attack. The most appropriate nursing intervention should include? a. Turning on the television b. Leaving the client alone

c. Staying with the client and speaking in short sentences d. Ask the client to play with other clients

6. A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects a belief that one is: a. Being Killed b. Highly famous and important c. Responsible for evil world d. Connected to client unrelated to oneself

7. A 20 year old client was diagnosed with dependent personality disorder. Which behavior is not likely to be evidence of ineffective individual coping? a. Recurrent self-destructive behavior b. Avoiding relationship c. Showing interest in solitary activities d. Inability to make choices and decision without advise

8. A male client is diagnosed with schizotypal personality disorder. Which signs would this client exhibit during social situation? a. Paranoid thoughts b. Emotional affect c. Independence need d. Aggressive behavior

9. Nurse Claire is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is? a. Encourage to avoid foods b. Identify anxiety causing situations c. Eat only three meals a day d. Avoid shopping plenty of groceries

10. Nurse Tony was caring for a 41 year old female client. Which behavior by the client indicates adult cognitive development? a. Generates new levels of awareness b. Assumes responsibility for her actions c. Has maximum ability to solve problems and learn new skills d. Her perception are based on reality

11.A neuromuscular blocking agent is administered to a client before ECT therapy. The Nurse should carefully observe the client for? a. Respiratory difficulties b. Nausea and vomiting c. Dizziness d. Seizures

12.A 75 year old client is admitted to the hospital with the diagnosis of dementia of the 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

13.Nurse Trish is working in a mental health facility; the nurse priority nursing intervention for a newly admitted client with bulimia nervosa would be to? a. Teach client to measure I & O b. Involve client in planning daily meal c. Observe client during meals d. Monitor client continuously

14.Nurse Patricia is aware that the major health complication associated with intractable anorexia nervosa would be? a. Cardiac dysrhythmias resulting to cardiac arrest b. Glucose intolerance resulting in protracted hypoglycemia c. Endocrine imbalance causing cold amenorrhea d. Decreased metabolism causing cold intolerance

15.Nurse Anna can minimize agitation in a disturbed client by? a. Increasing stimulation b. limiting unnecessary interaction c. increasing appropriate sensory perception d. ensuring constant client and staff contact

16.A 39 year old mother with obsessive-compulsive disorder has become immobilized by her elaborate

hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C. disorder is often: a. Problems with being too conscientious b. Problems with anger and remorse c. Feelings of guilt and inadequacy d. Feeling of unworthiness and hopelessness

17.Mario is complaining to other clients about not being allowed by staff to keep food in his room. Which of the following interventions would be most appropriate? a. Allowing a snack to be kept in his room b. Reprimanding the client c. Ignoring the clients behavior d. Setting limits on the behavior

18.Conney with borderline personality disorder who is to be discharge soon threatens to “do something” to herself if discharged. Which of the following actions by the nurse would be most important? a. Ask a family member to stay with the client at home temporarily b. Discuss the meaning of the 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

19.Joey a client with antisocial personality disorder belches loudly. A staff member asks Joey, “Do you know why people find you repulsive?” this statement most likely would elicit which of the following client reaction? a. Depensiveness b. Embarrassment c. Shame d. Remorsefulness

20.Which of the following approaches would be most appropriate to use with a client suffering from narcissistic personality disorder when discrepancies exist between what the client states and what actually exist? a. Rationalization b. Supportive confrontation c. Limit setting d. Consistency

21.Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis and hyperactivity. Blood

pressure is 190/87 mmhg and pulse is 92 bpm. Which of the medications would the nurse expect to administer? a. Naloxone (Narcan) b. Benzlropine (Cogentin) c. Lorazepam (Ativan) d. Haloperidol (Haldol)

22.Which of the following foods would the nurse Trish eliminate from the diet of a client in alcohol withdrawal? a. Milk b. Orange Juice c. Soda d. Regular Coffee

23.Which of the following would Nurse Hazel expect to assess for a client who is exhibiting late signs of heroin withdrawal? a. Yawning & diaphoresis b. Restlessness & Irritability c. Constipation & steatorrhea d. Vomiting and Diarrhea

24.To establish open and trusting relationship with a female client who has been hospitalized with severe anxiety, the nurse in charge should? a. Encourage the staff to have frequent interaction with the client b. Share an activity with the client c. Give client feedback about behavior d. Respect client’s need for personal space

25. Nurse Monette recognizes that the focus of environmental (MILIEU) therapy is to: a. Manipulate the environment to bring about positive changes in behavior b. Allow the client’s freedom to determine whether or not they will be involved in activities c. Role play life events to meet individual needs d. Use natural remedies rather than drugs to control behavior

26.Nurse Trish would expect a child with a diagnosis of reactive attachment disorder to: a. Have more positive relation with the father than the mother b. Cling to mother & cry on separation

c. Be able to develop only superficial relation with the others d. Have been physically abuse

27.When teaching parents about childhood depression Nurse Trina should say? a. It may appear acting out behavior b. Does not respond to conventional treatment c. Is short in duration & resolves easily d. Looks almost identical to adult depression

28.Nurse Perry is aware that language development in autistic child resembles: a. Scanning speech b. Speech lag c. Shuttering d. Echolalia

29.A 60 year old female client who lives alone tells the nurse at the community health center “I really don’t need anyone to talk to”. The TV is my best friend. The nurse recognizes that the client is using the defense mechanism known as? a. Displacement b. Projection c. Sublimation d. Denial

30.When working with a male client suffering phobia about black cats, Nurse Trish should anticipate that a problem for this client would be? a. Anxiety when discussing phobia b. Anger toward the feared object c. Denying that the phobia exist d. Distortion of reality when completing daily routines

31.Linda is pacing the floor and appears extremely anxious. The duty nurse approaches in an attempt to alleviate 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

32.Nurse Penny is aware that the symptoms that distinguish post traumatic stress disorder from other anxiety disorder would be:

a. Avoidance of situation & certain activities that resemble the stress b. Depression and a blunted affect when discussing the traumatic situation c. Lack of interest in family & others d. Re-experiencing the trauma in dreams or flashback

33.Nurse Benjie is communicating with a male client with substance-induced persisting dementia; the client cannot remember facts and fills in the gaps with imaginary information. Nurse Benjie is aware that this is typical of? a. Flight of ideas b. Associative looseness c. Confabulation d. Concretism

34.Nurse Joey is aware that the signs & symptoms that would be most specific for diagnosis anorexia are? a. Excessive weight loss, amenorrhea & abdominal distension b. Slow pulse, 10% weight loss & alopecia c. Compulsive behavior, excessive fears & nausea d. Excessive activity, memory lapses & an increased pulse

35.A characteristic that would suggest to Nurse Anne that an adolescent may have bulimia would be: a. Frequent regurgitation & re-swallowing of food b. Previous history of gastritis c. Badly stained teeth d. Positive body image

36.Nurse Monette is aware that extremely depressed clients seem to do best in settings where they have: a. Multiple stimuli b. Routine Activities c. Minimal decision making d. Varied Activities

37.To further assess a 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

38.A nursing care plan for a male client with bipolar I disorder should include: a. Providing a structured environment b. Designing activities that will require the client to maintain contact with reality c. Engaging the client in conversing about current affairs d. Touching the client provide assurance

39.When planning care for a female client using ritualistic behavior, Nurse Gina must recognize that the ritual: a. Helps the client focus on the inability to deal with reality b. Helps the client control the anxiety c. Is under the client’s conscious control d. Is used by the client primarily for secondary gains

40.A 32 year old male graduate student, who has become increasingly withdrawn and neglectful of his work and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed assessment, a diagnosis of schizophrenia is made. It is unlikely that the client will demonstrate: a. Low self esteem b. Concrete thinking c. Effective self boundaries d. Weak ego

41.A 23 year old client has been admitted with a diagnosis of schizophrenia says to the nurse “Yes, its march, March is little woman”. That’s literal you know”. These statement illustrate: a. Neologisms b. Echolalia c. Flight of ideas d. Loosening of association

42.A long term goal for a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs would be to help the client develop:

a. Insight into his behavior b. Better self control c. Feeling of self worth d. Faith in his wife

43.A male client who is experiencing disordered thinking about food being poisoned is admitted to the mental health unit. The nurse uses which communication technique to encourage the client to eat dinner? a. Focusing on self-disclosure of own food preference b. Using open ended question and silence c. Offering opinion about the need to eat d. Verbalizing reasons that the client may not choose to eat

44.Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina enters the client’s room, the client is found lying on the bed with a body pulled into a fetal position. Nurse Nina should? a. Ask the client direct questions to encourage talking b. Rake the client into the dayroom to be with other clients c. Sit beside the client in silence and occasionally ask open-ended question d. Leave the client alone and continue with providing care to the other clients

45.Nurse Tina is caring for a client with delirium and states that “look at the spiders on the wall”. What should the nurse respond to the client? a. “You’re having hallucination, there are no spiders in this room at all” b. “I can see the spiders on the wall, but they are not going to hurt you” c. “Would you like me to kill the spiders” d. “I know you are frightened, but I do not see spiders on the wall”

46.Nurse Jonel is providing information to a community group about violence in the family. Which statement by a group member would indicate a need to provide additional information? a. “Abuse occurs more in low-income families” b. “Abuser Are often jealous or self-centered” c. “Abuser use fear and intimidation” d. “Abuser usually have poor self-esteem”

47.During electroconvulsive therapy (ECT) the client receives oxygen by mask via positive pressure ventilation. The nurse assisting with this procedure knows that positive pressure ventilation is necessary because?

a. Anesthesia is administered during the procedure b. Decrease oxygen to the brain increases confusion and disorientation c. Grand mal seizure activity depresses respirations d. Muscle relaxations given to prevent injury during seizure activity depress respirations.

48.When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of the discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care requiring evaluation? a. The client eliminates all anxiety from daily situations b. The client ignores feelings of anxiety c. The client identifies anxiety producing situations d. The client maintains contact with a crisis counselor

49.Nurse Tina is caring for a client with depression who has not responded to antidepressant medication. The nurse anticipates that what treatment procedure may be prescribed. a. Neuroleptic medication b. Short term seclusion c. Psychosurgery d. Electroconvulsive therapy

50.Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of prescribed antipsychotic medication. The most important piece of information the nurse in charge should obtain initially is the: a. Length of time on the med. b. Name of the ingested medication & the amount ingested c. Reason for the suicide attempt d. Name of the nearest relative & their phone number

Answer and Rationale- Practice Test IV- Psychiatric Nursing 1. C . Total abstinence is the only effective treatment for alcoholism 2. A . Hallucinations are visual, auditory, gustatory, tactile or olfactory perceptions that have no basis in reality. 3. D . The Nurse has a responsibility to observe continuously the acutely suicidal client. The Nurse should watch for clues, such as communicating suicidal thoughts, and messages; hoarding medications and talking about death. 4. B . Establishing a consistent eating plan and monitoring client’s weight are important to this disorder. 5. C . Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm and medicating as needed. 6. B . Delusion of grandeur is a false belief that one is highly famous and important. 7. D . Individual with dependent personality disorder typically shows indecisiveness submissiveness and clinging behavior so that others will make decisions with them. 8. A . Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts 9. B . Bulimia disorder generally is a maladaptive coping response to stress and underlying issues. The client should identify anxiety causing situation that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. 10. A . An adult age 31 to 45 generates new level of awareness. 11. A . Neuromuscular Blocker, such as SUCCINYLCHOLINE (Anectine) produces respiratory depression because it inhibits contractions of respiratory muscles. 12. C . With depression, there is little or no emotional involvement therefore little alteration in affect. 13. D . These clients often hide food or force vomiting; therefore they must be carefully monitored. 14. A . These clients have severely depleted levels of sodium and potassium because of their starvation diet and energy expenditure, these electrolytes are necessary for cardiac functioning. 15. B . Limiting unnecessary interaction will decrease stimulation and agitation. 16. C . Ritualistic behavior seen in this disorder is aimed at controlling guilt and inadequacy by

maintaining an absolute set pattern of behavior. 17. D . The nurse needs to set limits in the client’s manipulative behavior to help the client control dysfunctional behavior. A consistent approach by the staff is necessary to decrease manipulation. 18. B . Any suicidal statement must be assessed by the nurse. The nurse should discuss the client’s statement with her to determine its meaning in terms of suicide. 19. A . When the staff member ask the client if he wonders why others find him repulsive, the client is likely to feel defensive because the question is belittling. The natural tendency is to counterattack the threat to self image. 20. B . The nurse would specifically use supportive confrontation with the client to point out discrepancies between what the client states and what actually exists to increase responsibility for self. 21. C . The nurse would most likely administer benzodiazepine, such as lorazepan (ativan) to the client who is experiencing symptom: The client’s experiences symptoms of withdrawal because of the rebound phenomenon when the sedation of the CNS from alcohol begins to decrease. 22. D . Regular coffee contains caffeine which acts as psychomotor stimulants and leads to feelings of anxiety and agitation. Serving coffee top the client may add to tremors or wakefulness. 23. D . Vomiting and diarrhea are usually the late signs of heroin withdrawal, along with muscle spasm, fever, nausea, repetitive, abdominal cramps and backache. 24. D . Moving to a client’s personal space increases the feeling of threat, which increases anxiety. 25. A . Environmental (MILIEU) therapy aims at having everything in the client’s surrounding area toward helping the client. 26. C . Children who have experienced attachment difficulties with primary caregiver are not able to trust others and therefore relate superficially 27. A . Children have difficulty verbally expressing their feelings, acting out behavior, such as temper tantrums, may indicate underlying depression. 28. D . The autistic child repeat sounds or words spoken by others. 29. D . The client statement is an example of the use of denial, a defense that blocks problem by unconscious refusing to admit they exist 30. A . Discussion of the feared object triggers an emotional response to the object.

31. B . The nurse presence may provide the client with support & feeling of control. 32. D . Experiencing the actual trauma in dreams or flashback is the major symptom that distinguishes post traumatic stress disorder from other anxiety disorder. 33. C . Confabulation or the filling in of memory gaps with imaginary facts is a defense mechanism used by people experiencing memory deficits. 34. A . These are the major signs of anorexia nervosa. Weight loss is excessive (15% of expected weight) 35. C . Dental enamel erosion occurs from repeated self-induced vomiting. 36. B . Depression usually is both emotional & physical. A simple daily routine is the best, least stressful and least anxiety producing. 37. D . The expression of these feeling may indicate that this client is unable to continue the struggle of life. 38. A . Structure tends to decrease agitation and anxiety and to increase the client’s feeling of security. 39. B . The rituals used by a client with obsessive compulsive disorder help control the anxiety level by maintaining a set pattern of action. 40. C . A person with this disorder would not have adequate self-boundaries 41. D . Loose associations are thoughts that are presented without the logical connections usually necessary for the listening to interpret the message. 42. C . Helping the client to develop feeling of self worth would reduce the client’s need to use pathologic defenses. 43. B . Open ended questions and silence are strategies used to encourage clients to discuss their problem in descriptive manner. 44. C . Clients who are withdrawn may be immobile and mute, and require consistent, repeated interventions. Communication with withdrawn clients requires much patience from the nurse. The nurse facilitates communication with the client by sitting in silence, asking open-ended question and pausing to provide opportunities for the client to respond. 45. D . When hallucination is present, the nurse should reinforce reality with the client. 46. A . Personal characteristics of abuser include low self-esteem, immaturity, dependence, insecurity and jealousy.

47. D . A short acting skeletal muscle relaxant such as succinylcholine (Anectine) is administered during this procedure to prevent injuries during seizure. 48. C . Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus. 49. D . Electroconvulsive therapy is an effective treatment for depression that has not responded to medication 50. B . In an emergency, lives saving facts are obtained first. The name and the amount of medication ingested are of outmost important in treating this potentially life threatening situation.

Board Exam Nursing Test IV NLE The scope of this Nursing Test IV is parallel to the NP4 NLE Coverage:



Medical Surgical Nursing

1. Following spinal injury, the nurse should encourage the client to drink fluids to avoid: A) Urinary tract infection. B) Fluid and electrolyte imbalance. C) Dehydration. D) Skin breakdown.

2. The client is transferred from the operating room to recovery room after an open-heart surgery. The nurse assigned is taking the vital signs of the client. The nurse notified the physician when the temperature of the client rises to 38.8 ºC or 102 ºF because elevated temperatures: A) May be a forerunner of hemorrhage. B) Are related to diaphoresis and possible chilling. C) May indicate cerebral edema. D) Increase the cardiac output.

3. After radiation therapy for cancer of the prostate, the client experienced irritation in the bladder. Which of the following sign of bladder irritability is correct? A) Hematuria B) Dysuria

C) Polyuria D) Dribbling

4. A client is diagnosed with a brain tumor in the occipital lobe. Which of the following will the client most likely experience? A) Visual hallucinations. B) Receptive aphasia. C) Hemiparesis. D) Personality changes.

5. A client with Addison’s disease has a blood pressure of 65/60. The nurse understands that decreased blood pressure of the client with Addison’s disease involves a disturbance in the production of: A) Androgens B) Glucocorticoids C) Mineralocorticoids D) Estrogen

6. The nurse is planning to teach the client about a spontaneous pneumothorax. The nurse would base the teaching on the understanding that: A) Inspired air will move from the lung into the pleural space. B) There is greater negative pressure within the chest cavity. C) The heart and great vessels shift to the affected side. D) The other lung will collapse if not treated immediately.

7. During an assessment, the nurse recognizes that the client has an increased risk for developing cancer of the tongue. Which of the following health history will be a concern? A) Heavy consumption of alcohol. B) Frequent gum chewing. C) Nail biting. D) Poor dental habits.

8. The client in the orthopedic unit asks the nurse the reason behind why compact bone is stronger than cancellous bone. Which of the following is the correct response of the nurse? A) Compact bone is stronger than cancellous bone because of its greater size. B) Compact bone is stronger than cancellous bone because of its greater weight. C) Compact bone is stronger than cancellous bone because of its greater volume. D) Compact bone is stronger than cancellous bone because of its greater density.

9. The nurse is reviewing the laboratory results of the client. In reviewing the results of the RBC count, the nurse understands that the higher the red blood cell count, the : A) Greater the blood viscosity. B) Higher the blood pH. C) Less it contributes to immunity. D) Lower the hematocrit.

10. The physician advised the client with Hemiparesis to use a cane. The client asks the nurse why cane will be needed. The nurse explains to the client that cane is advised specifically to: A) Aid in controlling involuntary muscle movements. B) Relieve pressure on weight-bearing joints. C) Maintain balance and improve stability. D) Prevent further injury to weakened muscles.

11. The nurse is conducting a discharge teaching regarding the prevention of further problems to a client who undergone surgery for carpal tunnel syndrome of the right hand. Which of the following instruction will the nurse includes? A) Learn to type using your left hand only. B) Avoid typing in a long period of time. C) Avoid carrying heavy things using the right hand. D) Do manual stretching exercise during breaks.

12. A female client is admitted because of recurrent urinary tract infections. The client asks the nurse why she is prone to this disease. The nurse states that the client is most susceptible because of: A) Continuity of the mucous membrane. B) Inadequate fluid intake. C) The length of the urethra. D) Poor hygienic practices.

13. A 55-year-old client is admitted with chest pain that radiates to the neck, jaw and shoulders that occurs at rest, with high body temperature, weak with generalized sweating and with decreased blood pressure. A myocardial infarction is diagnosed. The nurse knows that the most accurate explanation for one of these presenting adaptations is: A) Catecholamines released at the site of the infarction causes intermittent localized pain. B) Parasympathetic reflexes from the infarcted myocardium causes diaphoresis. C) Constriction of central and peripheral blood vessels causes a decrease in blood pressure. D) Inflammation in the myocardium causes a rise in the systemic body temperature.

14. Following an amputation of a lower limb to a male client, the nurse provides an instruction on how to prevent a hip flexion contracture. The nurse should instruct the client to:. A) Perform quadriceps muscle setting exercises twice a day. B) Sit in a chair for 30 minutes three times a day. C) Lie on the abdomen 30 minutes every four hours. D) Turn from side to side every 2 hours.

15. The physician scheduled the client with rheumatoid arthritis for the injection of hydrocortisone into the knee joint. The client asks the nurse why there is a need for this injection. The nurse explains that the most important reason for doing this is to: A) Lubricate the joint. B) Prevent ankylosis of the joint. C) Reduce inflammation. D) Provide physiotherapy.

16. The nurse is assigned to care for a 57-year-old female client who had a cataract surgery an hour ago. The nurse should: A) Advise the client to refrain from vigorous brushing of teeth and hair. B) Instruct the client to avoid driving for 2 weeks. C) Encourage eye exercises to strengthen the ocular musculature. D) Teach the client coughing and deep-breathing techniques.

17. A client with AIDS develops bacterial pneumonia is admitted in the emergency department. The 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.

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.”

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.

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.

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.”.

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.

23. A 75-year-old male client tells the nurse that his wife has osteoporosis and asks what chances he had

of getting also osteoporosis like his wife. Which of the following is the correct response of the nurse? A) “This is only a problem for women.” B) “You are not at risk because of your small frame.” C) “You might think about having a bone density test,” D) “Exercise is a good way to prevent this problem.”

24. An older adult client with acute pain is admitted in the hospital. The nurse understands that in managing acute pain of the client during the first 24 hours, the nurse should ensure that: A) Ordered PRN analgesics are administered on a scheduled basis. B) Patient controlled analgesia is avoided in this population. C) Pain medication is ordered via the intramuscular route. D) An order for meperidine (Demerol) is secured for pain relief.

25. A nurse is caring to an older adult with presbycusis. In formulating nursing care plan for this client, the nurse should expect that hearing loss of the client that is caused by aging to have: A) Overgrowth of the epithelial auditory lining. B) Copious, moist cerumen. C) Difficulty hearing women’s voices. D) Tears in the tympanic membrane.

26. The nurse is reviewing the client’s chart about the ordered medication. The nurse must observe for signs of hyperkalemia when administering: A) Furosemide (Lasix) B) Hydrochlorothiazide (HydroDIURIL) C) Metolazone (Zaroxolyn) D) Spironolactone (Aldactone)

27. The physician prescribed Albuterol (Proventil) to the client with severe asthma. After the administration of the medication the nurse should monitor the client for: A) Palpitation B) Visual disturbance C) Decreased pulse rate D) Lethargy

28. A client is receiving diltiazem (Cardizem). What should the nurse include in a teaching plan aimed at reducing the side effects of this medication?

A) Take the drug with an antacid. B) Lie down after meals. C) Avoid dairy products in diet. D) Change positions slowly.

29. A client is receiving simvastatin (Zocor). The nurse is aware that this medication is effective when there is decrease in: A) The triglycerides B) The INR C) Chest pain D) Blood pressure

30. A client is taking nitroglycerine tablets, the nurse should teach the client the importance of: A) Increasing the number of tablets if dizziness or hypertension occurs. B) Limiting the number of tablets to 4 per day. C) Making certain the medication is stored in a dark container. D) Discontinuing the medication if a headache develops.

31. The physician prescribes Ibuprofen (Motrin) and hydroxychloroquine sulfate (Plaquenil) for a 58year-old male client with arthritis. The nurse provides information about toxicity of the hydroxychloroquine. The nurse can determine if the information is clearly understood if the client states: A) “I will contact the physician immediately if I develop blurred vision.” B) “I will contact the physician immediately if I develop urinary retention.” C) “I will contact the physician immediately if I develop swallowing difficulty.” D) “I will contact the physician immediately if I develop feelings of irritability.”

32. The client with an acute myocardial infarction is hospitalized for almost one week. The client experiences nausea and loss of appetite. The nurse caring for the client recognizes that these symptoms may indicate the: A) Adverse effects of spironolactone (Aldactone) B) Adverse effects of digoxin (Lanoxin) C) Therapeutic effects of propranolol (Indiral) D) Therapeutic effects of furosemide (Lasix)

33. A client with a partial occlusion of the left common carotid artery is scheduled for discharge. The client is still receiving Coumadin. The nurse provided a discharge instruction to the client regarding adverse effects of Coumadin. The nurse should tell the client to consult with the physician if:

A) Swelling of the ankles increases. B) Blood appears in the urine. C) Increased transient Ischemic attacks occur. D) The ability to concentrate diminishes.

34. Levodopa is ordered for a client with 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.

35. In making a diagnosis of myasthenia gravis Edrophonium HCI (Tensilon) is used. The nurse knows that this drug will cause a temporary increase in: A) Muscle strength B) Symptoms C) Blood pressure D) Consciousness

36. The nurse can determine the effectiveness of carbamazepine (Tegretol) in the management of trigeminal neuralgia by monitoring the client’s: A) Seizure activity B) Liver function C) Cardiac output D) Pain relief

37. Administration of potassium iodide solution is ordered to the client who will undergo a subtotal thyroidectomy. The nurse understands that this medication is given to: A) Ablate the cells of the thyroid gland that produce T4. B) Decrease the total basal metabolic rate. C) Decrease the size and vascularity of the thyroid. D) Maintain function of the parathyroid gland.

38. A client with 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.

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

40. A client with recurrent urinary tract infections is to be discharged. The client will be taking nitrofurantoin (Macrobid) 50 mg po every evening at home. The nurse provides discharge instructions to the client. Which of the following instructions will be correct? A) Strain urine for crystals and stones B) Increase fluid intake. C) Stop the drug if the urinary output increases D) Maintain the exact time schedule for drug taking.

41. A client with cancer of the lung is receiving chemotherapy. The physician orders antibiotic therapy for the client. The nurse understands that chemotherapy destroys rapidly growing leukocytes in the: A) Bone marrow B) Liver C) Lymph nodes D) Blood

42. The physician reduced the 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

43. The nurse is assigned to care for a client with diarrhea. Excessive fluid loss is expected. The nurse is aware that fluid deficit can most accurately be assessed by: A) The presence of dry skin B) A change in body weight

C) An altered general appearance D) A decrease in blood pressure

44. Which of the following is the most important electrolyte of intracellular fluid? A) Potassium B) Sodium C) Chloride D) Calcium

45. Which of the following client has a high risk for developing hyperkalemia? A) Crohn’s disease B) End-Stage renal disease C) Cushing’s syndrome D) Chronic heart failure

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

47. Potassium chloride, 20 mEq, is ordered and to be added in the IV solution of a client in a diabetic ketoacidosis. The primary reason for administering this drug is: A) Replacement of excessive losses B) Treatment of hyperpnea C) Prevention of flaccid paralysis D) Treatment of cardiac dysrhythmias

48. A female client is brought to the emergency unit. The client is complaining of abdominal cramps. On assessment, client is experiencing anorexia and weight is reduced. The 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.

49. The client is to receive an IV piggyback medication. When preparing the medication the nurse should be aware that it is very important to: A) Use strict sterile technique B) Use exactly 100mL of fluid to mix the medication C) Change the needle just before adding the medication D) Rotate the bag after adding the medication

50. The nurse is reviewing the laboratory result of the client. An arterial blood gas report indicates the 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 and Rationale: Board Exam Nursing Test IV NLE 100.4o F c. Assess for sore throat, cough, or burning with urination. d. Gather the supplies to prepare the room for protective isolation. e. Report superinfections, such as candidiasis f. Practice good handwashing technique. 24.A primary nursing responsibility is the prevention of lung cancer by assisting patients in smoking/tobacco cessation. Which tasks would be appropriate to delegate to the LPN/LVN? a. Develop a “quit plan” b. Explain the application of a nicotine patch c. Discuss strategies to avoid relapse d. Suggest ways to deal with urges for a tobacco

Answer and Rationale - Cancer RATIONALE CANCER 1. ANSWER A – Oral hygiene is within the scope of responsibilities of the nursing assistant. It is the responsibility of the nurse to observe response to treatments and to help the patient deal with loss or anxiety. The nursing assistant can be directed to weigh the patient, but should not be expected to know when to initiate that measurement. 2. ANSWER D – The patient’s physical condition is currently stable, but emotional needs are affecting his or her ability to receive the information required to make an informed decision. The other diagnoses are relevant, but if the patient leaves the clinic for interventions may be delayed or ignored.

3. ANSWER A – Pancreatic cancer is more common in blacks, males, and smokers. Other links include alcohol, diabetes, obesity, history of pancreatitis, organic chemicals, a high-fat diet, and previous abdominal radiation. 4. ANSWER C, D, B, E, A – This classification system is based on the extent of the disease rather than the histological changes, Stage 0: cancer in situ, stage I: tumor limited to tissue of origin, stage II: limited local spread, stage III: extensive local and regional spread, stage IV: metastasis. 5. ANSWER B – Administering enemas and antibiotics is within the scope of practice for LPN/LVNs. Although some states may allow the LPN/LVN to administer blood, in general, blood administration, pre-operative teaching, and assisting with central line insertion are the responsibilities of the RN> 6. ANSWER A. Nurse Practitioner, B. Nutritionist, C. LPN/LVN, D. Nurse Practitioner, E. RN – The nurse practitioner is often the provider who performs the physical examinations and recommends diagnostic testing. The nutritionist can give information about diet. The LPN/LVN will know the standard seven warning signs and can educate through standard teaching programs in some states. However, the RN has primary responsibility for educating people about risk factors. 7. ANSWER B – The physician has described a treatment for controlling cancer that is not curable. When the goal is cure, the patient will be deemed free of disease after treatments. In palliation, the treatment is given primarily for pain relief. Permanent remission is another term to describe cure. 8. ANSWER C – The nursing assistant can observe the amount that patient eats (or what is gone from the tray) and report to the nurse. Assessing patterns of fatigue or skin reaction is the responsibility of the RN. The initial recommendation for exercise should come from the physician. 9. ANSWER C – Paresthesia is a side effect associated with some chemotherapy drugs such as vincristine (Oncovin). The physician can modify the dose or discontinue the drug. Fatigue, nausea, vomiting, and anorexia are common side effects for many chemotherapy medications. The nurse can assist the patient by planning for rest periods, giving antiemetics as ordered, and encouraging small meals with high-protein and high-calorie foods. 10. ANSWER A – WBC count is especially important because chemotherapy can cause decreases in WBCs, particularly neutrophils, which leaves the patient vulnerable to infection. The other tests are important in the total management, but less directly specific to chemotherapy.

11. ANSWER C – Giving medications is within the scope of practice for the LPN/LVN. Assisting the patient to brush and floss should be delegated to the nursing assistant. Explaining contraindications is the responsibility of the RN. Recommendations for saliva substitutes should come from the physician or pharmacist. 12. ANSWER A – Ideally, chemotherapy drugs should be given by nurses who have received additional training in how to safely prepare and deliver the drugs and protect themselves from exposure. The other options are a concern but the general principles of drug administration apply. 13. ANSWER A, C, B, D – Tumor lysis syndrome is an emergency of electrolyte imbalances and potential renal failure. A patient scheduled for surgery should be assessed and prepared for surgery. A patient with breakthrough pain needs assessment and the physician may need to be contacted for a change of dose or medication. Anticipatory nausea and vomiting has a psychogenic component that requires assessment, teaching, reassurance, and antiemetics. 14. ANSWER A – Back pain is an early sign occurring in 95% of patients. The other symptoms are later signs. 15. ANSWER B, C, D, A – Induction is the initial aggressive treatment to destroy leukemia cells. Intensification starts immediately after induction, lasting for several months and targeting persistent, undetected leukemia cells. Consolidation occurs after remission to eliminate any remaining leukemia cells. Maintenance involves lower doses to keep the body free of leukemia cells. 16. ANSWER D – T (tumor) 0-4 signifies tumors increasing size. N (regional lymph nodes) 0-3 signifies increasing involvement of lymph nodes. M (metastasis) 0 signifies no metastasis and 1 signifies distal metastasis. 17. ANSWER B – Potentially life-threatening hypercalcemia can occur in cancers with destruction of bone. Other laboratory values are pertinent for overall patient management but are less specific to bone cancers. 18. ANSWER B, D – Debulking of tumor and laminectomy are palliative procedures. These patients can be placed in the same room. The patient with low neutrophil count and the patient who has had a bone marrow harvest need protective isolation. 19. ANSWER A – Cigarette smoking is associated with 80-90% of lung cancers. Occupational exposure coupled with cigarette smoking increases risks. ETS increases risk by 35%. Cigar

smoking provides higher risk than pipe smoking, but both are lower risks than cigarette smoking. 20. ANSWER B – Tumor lysis syndrome can result in severe electrolyte imbalances and potential renal failure. The other laboratory values are important to monitor for general chemotherapy side effects, but are less pertinent to tumor lysis syndrome. 21. ANSWER A, C – After age 18, females should annual Pap smears, regardless of sexual activity. African-American males should begin prostate-specific antigen testing at age 45. Annual mammograms are recommended for women over the age of 40. Annual fecal occult blood testing is recommended starting at age 50. 22. ANSWER B – Hyponatremia is a concern; therefore, fluid restrictions would be ordered. Urinalysis is less pertinent; however, the nurse should monitor for increased urine specific gravity. The diet may need to include sodium supplements. Fluid bolus is unlikely to be ordered for SIADH. 23. ANSWER A, B, D,F – Vital signs and reporting on specific parameters, good hand washing, and gathering equipment are within the scope of duties for an nursing assistant. Assessing for symptoms of infection/superinfections is the responsibility of the RN. 24. ANSWER B – The LPN/LVN is versed in medication administration and able to teach patients standardized information. The other options require more in-depth assessment, planning, and teaching, which should be performed by the RN.

Medical-Surgical Emergencies 1. You are the charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment? a. An advanced practice nurse and an experienced LPN/LVN b. An experienced LPN/LVN and an inexperienced RN c. An experienced RN and an inexperienced RN d. An experienced RN and a nursing assistant 2. You are working in the triage area of an ED, and four patients approach the triage desk at the same time. List the order in which you will assess these patients. a. An ambulatory, dazed 25-year-old male with a bandaged head wound b. An irritable infant with a fever, petechiae, and nuchal rigidity c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity d. A 50-year-old female with moderate abdominal pain and occasional vomiting _____, _____, _____, _____ 3. In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? a. Complete set of vital signs b. Palpation and auscultation of the abdomen c. Brief neurologic assessment d. Initiation of pulse oximetry 4. A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and dizziness. This patient should be prioritized into which category? a. High urgent b. Urgent c. Non-urgent d. Emergent 5. The physician has ordered cooling measures for a child with fever who is likely to be discharged when the temperature comes down. Which of the following would be appropriate to delegate to the nursing assistant? a. Assist the child to remove outer clothing. b. Advise the parent to use acetaminophen instead of aspirin. c. Explain the need for cool fluids. d. Prepare and administer a tepid bath. 6. It is the summer season, and patients with signs and symptoms of heat-related illness

present in the ED. Which patient needs attention first? a. An elderly person complains of dizziness and syncope after standing in the sun for several hours to view a parade b. A marathon runner complains of severe leg cramps and nausea. Tachycardia, diaphoresis, pallor, and weakness are observed. c. A previously healthy homemaker reports broken air conditioner for days. Tachypnea, hypotension, fatigue, and profuse diaphoresis are observed. d. A homeless person, poor historian, presents with altered mental status, poor muscle coordination, and hot, dry, ashen skin. Duration of exposure is unknown. 7. You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform. a. Perform the chin lift or jaw thrust maneuver. b. Establish unresponsiveness. c. Initiate cardiopulmonary resuscitation (CPR). d. Call for help and activate the code team. e. Instruct a nursing assistant to get the crash cart. _____, _____, _____, _____, _____ 8. The emergency medical service (EMS) has transported a patient with severe chest pain. As the patient is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the nursing assistant? a. Chest compressions b. Bag-valve mask ventilation c. Assisting with oral intubation d. Placing the defibrillator pads 9. An anxious 24-year-old college student complains of tingling sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are noted. What priority nursing action should you take? a. Notify the physician immediately. b. Administer supplemental oxygen. c. Have the student breathe into a paper bag. d. Obtain an order for an anxiolytic medication. 10.An experienced traveling nurse has been assigned to work in the ED; however, this is the nurse’s first week on the job. Which area of the ED is the most appropriate assignment for the nurse? a. Trauma team b. Triage c. Ambulatory or fats track clinic d. Pediatric medicine team

11.A tearful parent brings a child to the ED for taking an unknown amount of children’s chewable vitamins at an unknown time. The child is currently alert and asymptomatic. What information should be immediately reported to the physician? a. The ingested children’s chewable vitamins contain iron. b. The child has been treated several times for ingestion of toxic substances. c. The child has been treated several times for accidental injuries. d. The child was nauseated and vomited once at home. 12.In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN? a. Assess immediate emotional state and physical injuries b. Collect hair samples, saliva swabs, and scrapings beneath fingernails. c. Provide emotional support and supportive communication. d. Ensure that the “chain of custody” is maintained. 13.You are caring for a victim of frostbite to the feet. Place the following interventions in the correct order. a. Apply a loose, sterile, bulky dressing. b. Give pain medication. c. Remove the victim from the cold environment. d. Immerse the feet in warm water 100o F to 105o F (40.6o C to 46.1o C) _____, _____, _____, _____ 14.A patient sustains an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to the LPN/LVN? a. Gently cleanse the amputated digits with Betadine solution. b. Place the amputated digits directly into ice slurry. c. Wrap the amputated digits in sterile gauze moistened with saline. d. Store the amputated digits in a solution of sterile normal saline. 15.A 36-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the physician will order which drug for status epilepticus? a. PO phenytoin and carbamazepine b. IV lorazepam (Ativan) c. IV carbamazepam d. IV magnesium sulfate 16.You are preparing a child for IV conscious sedation prior to repair of a facial laceration.

What information should you immediately report to the physician? a. The parent is unsure about the child’s tetanus immunization status. b. The child is upset and pulls out the IV. c. The parent declines the IV conscious sedation. d. The parent wants information about the IV conscious sedation. 17.An intoxicated patient presents with slurred speech, mild confusion, and uncooperative behavior. The patient is a poor historian but admits to “drinking a few on the weekend.” What is the priority nursing action for this patient? a. Obtain an order for a blood alcohol level. b. Contact the family to obtain additional history and baseline information. c. Administer naloxone (Narcan) 2 - 4 mg as ordered. d. Administer IV fluid support with supplemental thiamine as ordered. 18.When an unexpected death occurs in the ED, which of the following tasks is most appropriate to delegate to the nursing assistant? a. Escort the family to a place of privacy. b. Go with the organ donor specialist to talk to the family. c. Assist with postmortem care. d. Assist the family to collect belongings. 19.Following emergency endotracheal intubation, you must verify tube placement and secure the tube. List in order the steps that are required to perform this function? a. Obtain an order for a chest x-ray to document tube placement. b. Secure the tube in place. c. Auscultate the chest during assisted ventilation. d. Confirm that the breath sounds are equal and bilateral. _____, _____, _____, _____ 20.A teenager arrives by private car. He is alert and ambulatory, but this shirt and pants are covered with blood. He and his hysterical friends are yelling and trying to explain that that they were goofing around and he got poked in the abdomen with a stick. Which of the following comments should be given first consideration? a. “There was a lot of blood and we used three bandages.” b. “He pulled the stick out, just now, because it was hurting him.” c. “The stick was really dirty and covered with mud.” d. “He’s a diabetic, so he needs attention right away.” 21.A prisoner, with a known history of alcohol abuse, has been in police custody for 48 hours. Initially, anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyper-reactivity are observed. The medical diagnosis is

delirium tremens. What is the priority nursing diagnosis? a. Risk for Injury related to seizures b. Risk for Other-Directed Violence related to hallucinations c. Risk for Situational Low Self-esteem related to police custody d. Risk for Nutritional Deficit related to chronic alcohol abuse 22.You are assigned to telephone triage. A patient who was stung by a common honey bee calls for advice, reports pain and localized swelling, but denies any respiratory distress or other systemic signs of anaphylaxis. What is the action that you should direct the caller to perform? a. Call 911. b. Remove the stinger by scraping. c. Apply a cool compress. d. Take an oral antihistamine. 23.In relation to submersion injuries, which task is most appropriate to delegate to an LPN/LVN? a. Talk to a community group about water safety issues. b. Stabilize the cervical spine for an unconscious drowning victim. c. Remove wet clothing and cover the victim with a warm blanket. d. Monitor an asymptomatic near-drowning victim. 24.You are assessing a patient who has sustained a cat bite to the left hand. The cat is upto-date immunizations. The date of the patient’s last tetanus shot is unknown. Which of the following is the priority nursing diagnosis? a. Risk for Infection related to organisms specific to cat bites b. Impaired Skin Integrity related to puncture wounds c. Ineffective Health Maintenance related to immunization status d. Risk for Impaired Mobility related to potential tendon damage 25.These patients present to the ED complaining of acute abdominal pain. Prioritize them in order of severity. a. A 35-year-old male complaining of severe, intermittent cramps with three episodes of watery diarrhea, 2 hours after eating b. A 11-year-old boy with a low-grade fever, left lower quadrant tenderness, nausea, and anorexia for the past 2 days c. A 40-year-old female with moderate left upper quadrant pain, vomiting small amounts of yellow bile, and worsening symptoms over the past week d. A 56-year-old male with a pulsating abdominal mass and sudden onset of pressure-like pain in the abdomen and flank within the past hour _____, _____, _____, _____

26.The nursing manager decides to form a committee to address the issue of violence against ED personnel. Which combination of employees is best suited to fulfill this assignment? a. ED physicians and charge nurses b. Experienced RNs and experienced paramedics c. RNs, LPN/LVNs, and nursing assistants d. At least one representative from each group of ED personnel 27.In a multiple-trauma victim, which assessment finding signals the most serious and lifethreatening condition? a. A deviated trachea b. Gross deformity in a lower extremity c. Decreased bowel sounds d. Hematuria 28.A patient in a one-car rollover presents with multiple injuries. Prioritize the interventions that must be initiated for this patient. a. Secure/start two large-bore IVs with normal saline b. Use the chin lift or jaw thrust method to open the airway. c. Assess for spontaneous respirations d. Give supplemental oxygen per mask. e. Obtain a full set of vital signs. f. Remove patient’s clothing. g. Insert a Foley catheter if not contraindicated. _____, _____, _____, _____, ____, ____, ____ 29.In the work setting, what is your primary responsibility in preparing for disaster management that includes natural disasters or bioterrorism incidents? a. Knowledge of the agency’s emergency response plan b. Awareness of the signs and symptoms for potential agnets of bioterrorism c. Knowledge of how and what to report to the CDC d. Ethical decision-making about exposing self to potentially lethal substances 30.You are giving discharge instructions to a woman who has been treated for contusions and bruises sustained during an episode of domestic violence. What is your priority intervention for this patient? a. Transportation arrangements to a safe house b. Referral to a counselor c. Advise about contacting the police d. Follow-up appointment for injuries

Answer and Rationale - Medical-Surgical Emergencies