You are on page 1of 43

1.

A pregnant woman who is at term is admitted to the

6. Which of the following is the most frequent cause of

birthing unit in active labor. The client has only progressed

noncompliance to the medical treatment of open-angle

from 2cm to 3 cm in 8 hours. She is diagnosed with

glaucoma?

hypotonic dystocia and the physician ordered Oxytocin


(Pitocin) to augment her contractions. Which of the following

A. The frequent nausea and vomiting accompanying use of

is the most important aspect of nursing intervention at this

miotic drug.

time?

B. Loss of mobility due to severe driving restrictions.


C. Decreased light and near-vision accommodation due to

A. Timing and recording length of contractions.

miotic effects of pilocarpine.

B. Monitoring.

D. The painful and insidious progression of this type of

C. Preparing for an emergency cesarean birth.

glaucoma.

D. Checking the perineum for bulging.


7. In the morning shift, the nurse is making rounds in the
2. A client who hallucinates is not in touch with reality. It is

nursing care units. The nurse enters in a clients room and

important for the nurse to:

notes that the clients tube has become disconnected from


the Pleurovac. What would be the initial nursing action?

A. Isolate the client from other patients.


B. Maintain a safe environment.

A. Apply pressure directly over the incision site.

C. Orient the client to time, place, and person.

B. Clamp the chest tube near the incision site.

D. Establish a trusting relationship.

C. Clamp the chest tube closer to the drainage system.


D. Reconnect the chest tube to the Pleurovac.

3. The nurse is caring to a child client who has had a


tonsillectomy. The child complains of having dryness of the

8. Which of the following complications during a breech birth

throat. Which of the following would the nurse give to the

the nurse needs to be alarmed?

child?
A. Abruption placenta.
A. Cola with ice

B. Caput succedaneum.

B. Yellow noncitrus Jello

C. Pathological hyperbilirubinemia.

C. Cool cherry Kool-Aid

D. Umbilical cord prolapse.

D. A glass of milk
9. The nurse is caring to a client diagnosed with severe
4. The physician ordered Phenylephrine (Neo-Synephrine)

depression. Which of the following nursing approach is

nasal spray to a 13-year-old client. The nurse caring to the

important in depression?

client provides instructions that the nasal spray must be used


exactly as directed to prevent the development of:

A. Protect the client against harm to others.


B. Provide the client with motor outlets for aggressive, hostile

A. Increased nasal congestion.

feelings.

B. Nasal polyps.

C. Reduce interpersonal contacts.

C. Bleeding tendencies.

D. Deemphasizing preoccupation with elimination,

D. Tinnitus and diplopia.

nourishment, and sleep.

5. A client with tuberculosis is to be admitted in the hospital.

10. A 3-month-old client is in the pediatric unit. During

The nurse who will be assigned to care for the client must

assessment, the nurse is suspecting that the baby may have

institute appropriate precautions. The nurse should:

hypothyroidism when mother states that her baby does not:

A. Place the client in a private room.

A. Sit up.

B. Wear an N 95 respirator when caring for the client.

B. Pick up and hold a rattle.

C. Put on a gown every time when entering the room.

C. Roll over.

D. Don a surgical mask with a face shield when entering the

D. Hold the head up.

room.
11. The physician calls the nursing unit to leave an order.
The senior nurse had conversation with the other staff. The

newly hired nurse answers the phone so that the senior

15. The nurse is assigned to care for a child client admitted

nurses may continue their conversation. The new nurse does

in the pediatrics unit. The client is receiving digoxin. Which of

not knowthe physician or the client to whom the order

the following questions will be asked by the nurse to the

pertains. The nurse should:

parents of the child in order to assess the clients risk for


digoxin toxicity?

A. Ask the physician to call back after the nurse has read the
hospital policy manual.

A. Has he been exposed to any childhood communicable

B. Take the telephone order.

diseases in the past 2-3 weeks?

C. Refuse to take the telephone order.

B. Has he been taking diuretics at home?

D. Ask the charge nurse or one of the other senior staff

C. Do any of his brothers and sisters have history of cardiac

nurses to take the telephone order.

problems?
D. Has he been going to school regularly?

12. The staff nurse on the labor and delivery unit is assigned
to care to a primigravida in transition complicated by

16. The nurse noticed that the signed consent form has an

hypertension. A new pregnant woman in active labor is

error. The form states, Amputation of the right leg instead of

admitted in the same unit. The nurse manager assigned the

the left leg that is to be amputated. The nurse has

same nurse to the second client. The nurse feels that the

administered already the preoperative medications. What

client with hypertension requires one-to-one care. What

should the nurse do?

would be the initial actionof the nurse?


A. Call the physician to reschedule the surgery.
A. Accept the new assignment and complete an incident

B. Call the nearest relative to come in to sign a new form.

report describing a shortage of nursing staff.

C. Cross out the error and initial the form.

B. Report the incident to the nursing supervisor and request

D. Have the client sign another form.

to be floated.
C. Report the nursing assessment of the client in transitional

17. The nurse in the nursing care unit checks the fluctuation

labor to the nurse manager and discuss misgivings about the

in the water-seal compartment of a closed chest drainage

new assignment.

system. The fluctuation has stopped, the nurse would:

D. Accept the new assignment and provide the best care.


A. Vigorously strip the tube to dislodge a clot.
13. A newborn infant with Down syndrome is to be

B. Raise the apparatus above the chest to move fluid.

discharged today. The nurse is preparing to give the

C. Increase wall suction above 20 cm H2O pressure.

discharge teaching regarding the proper care at home. The

D. Ask the client to cough and take a deep breath.

nurse would anticipate that the mother is probably at the:


18. The pediatric nurse in the neonatal unit was informed
A. 40 years of age.

that the baby that is brought to the mother in the hospital

B. 20 years of age.

room is wrong. The nurse determines that two babies were

C. 35 years of age.

placed in the wrong cribs. The most appropriate nursing

D. 20 years of age.

action would be to:

14. The emergency department has shortage of staff. The

A. Determine who is responsible for the mistake and

nurse manager informs the staff nurse in the critical care unit

terminate his or her employment.

that she has to float to the emergency department. What

B. Record the event in an incident/variance report and notify

should the staff nurse expect under these conditions?

the nursing supervisor.


C. Reassure both mothers, report to the charge nurse, and

A. The float staff nurse will be informed of the situation

do not record.

before the shift begins.

D. Record detailed notes of the event on the mothers

B. The staff nurse will be able to negotiate the assignments

medical record.

in the emergency department.


C. Cross training will be available for the staff nurse.

19. Before the administration of digoxin, the nurse completes

D. Client assignments will be equally divided among the

an assessment to a toddler client for signs and symptoms of

nurses.

digoxin toxicity. Which of the following is the earliest and


most significant sign of digoxin toxicity?

A. Tinnitus

24. The nurse is providing an orientation regarding case

B. Nausea and vomiting

management to the nursing students. Which characteristics

C. Vision problem

should the nurse include in the discussion in understanding

D. Slowing in the heart rate

case management?

20. Which of the following treatment modality is appropriate

A. Main objective is a written plan that combines discipline-

for a client with paranoid tendency?

specific processes used to measure outcomes of care.


B. Main purpose is to identify expected client, family and staff

A. Activity therapy.

performance against the timeline for clients with the same

B. Individual therapy.

diagnosis.

C. Group therapy.

C. Main focus is comprehensive coordination of client care,

D. Family therapy.

avoid unnecessary duplication of services, improve resource


utilization and decrease cost.

21. The client with rheumatoid arthritis is for discharge. In

D. Primary goal is to understand why predicted outcomes

preparing the client for discharge on prednisone therapy, the

have not been met and the correction of identified problems.

nurse should advise the client to:


25. The physician orders a dose of IV phenytoin to a child
A. Wear sunglasses if exposed to bright light for an extended

client. In preparing in the administration of the drug, which

period of time.

nursing action is not correct?

B. Take oral preparations of prednisone before meals.


C. Have periodic complete blood counts while on the

A. Infuse the phenytoin into a smaller vein to prevent purple

medication.

glove syndrome.

D. Never stop or change the amount of the medication

B. Check the phenytoin solution to be sure it is clear or light

without medical advice.

yellow in color, never cloudy.


C. Plan to give phenytoin over 30-60 minutes, using an in-

22. A pregnant client tells the nurse that she is worried about

line filter.

having urinary frequency. What will be the most appropriate

D. Flush the IV tubing with normal saline before starting

nursing response?

phenytoin.

A. Try using Kegel (perineal) exercises and limiting fluids

26. The pregnant woman visits the clinic for check up.

before bedtime. If you have frequency associated with fever,

Which assessment findings will help the nurse determine

pain on voiding, or blood in the urine, call your doctor/nurse-

that the client is in 8-week gestation?

midwife.
B. Placental progesterone causes irritability of the bladder

A. Leopold maneuvers.

sphincter. Your symptoms will go away after the baby

B. Fundal height.

comes.

C. Positive radioimmunoassay test (RIA test).

C. Pregnant women urinate frequently to get rid of fetal

D. Auscultation of fetal heart tones.

wastes. Limit fluids to 1L/daily.


D. Frequency is due to bladder irritation from concentrate

27. Which of the following nursing intervention is essential

urine and is normal in pregnancy. Increase your daily fluid

for the client who had pneumonectomy?

intake to 3L.
A. Medicate for pain only when needed.
23. Which of the following will help the nurse determine that

B. Connect the chest tube to water-seal drainage.

the expression of hostility is useful?

C. Notify the physician if the chest drainage exceeds


100mL/hr.

A. Expression of anger dissipates the energy.

D. Encourage deep breathing and coughing.

B. Energy from anger is used to accomplish what needs to


be done.

28. The nurse is providing a health teaching to a group of

C. Expression intimidates others.

parents regarding Chlamydia trachomatis. The nurse is

D. Degree of hostility is less than the provocation.

correct in the statement, Chlamydia trachomatis is not only


an intracellular bacterium that causes neonatal conjunctivitis,
but it also can cause:

A. Discoloration of baby and adult teeth.

house fire. While waiting for the ambulance, the nurse will

B. Pneumonia in the newborn.

anticipate emergency care to include assessment for:

C. Snuffles and rhagades in the newborn.


D. Central hearing defects in infancy.

A. Gas exchange impairment.


B. Hypoglycemia.

29. The nurse is assigned to care to a 17-year-old male

C. Hyperthermia.

client with a history of substance abuse. The client asks the

D. Fluid volume excess.

nurse, Have you ever tried or used drugs? The most


correct response of the nurse would be:

34. Most couples are using natural family planning


methods. Most accidental pregnancies in couples preferred

A. Yes, once I tried grass.

to use this method have been related to unprotected

B. No, I dont think so.

intercourse before ovulation. Which of the following factor

C. Why do you want to know that?

explains why pregnancy may be achieved by unprotected

D. How will my answer help you?

intercourse during the preovulatory period?

30. Which of the following describes a health care team with

A. Ovum viability.

the principles of participative leadership?

B. Tubal motility.
C. Spermatozoal viability.

A. Each member of the team can independently make

D. Secretory endometrium.

decisions regarding the clients care without necessarily


consulting the other members.

35. An older adult client wakes up at 2 oclock in the morning

B. The physician makes most of the decisions regarding the

and comes to the nurses station saying, I am having

clients care.

difficulty in sleeping. What is the best nursing response to

C. The team uses the expertise of its members to influence

the client?

the decisions regarding the clients care.


D. Nurses decide nursing care; physicians decide medical

A. Ill give you a sleeping pill to help you get more sleep

and other treatment for the client.

now.
B. Perhaps youd like to sit here at the nurses station for a

31. A nurse is giving a health teaching to a woman who

while.

wants to breastfeed her newborn baby. Which hormone,

C. Would you like me to show you where the bathroom is?

normally secreted during the postpartum period, influences

D. What woke you up?

both the milk ejection reflex and uterine involution?


36. The nurse is taking care of a multipara who is at 42
A. Oxytocin.

weeks of gestation and in active labor, her membranes

B. Estrogen.

ruptured spontaneously 2 hours ago. While auscultating for

C. Progesterone.

the point of maximum intensity of fetal heart tones before

D. Relaxin.

applying an external fetal monitor, the nurse counts 100


beats per minute. The immediate nursing action is to:

32. One staff nurse is assigned to a group of 5 patients for


the 12-hour shift. The nurse is responsible for the overall

A. Start oxygen by mask to reduce fetal distress.

planning, giving and evaluating care during the entire shift.

B. Examine the woman for signs of a prolapsed cord.

After the shift, same responsibility will be endorsed to the

C. Turn the woman on her left side to increase placental

next nurse in charge. This describes nursing care delivered

perfusion.

via the:

D. Take the womans radial pulse while still auscultating the


FHR.

A. Primary nursing method.


B. Case method.

37. The nurse must instruct a client with glaucoma to avoid

C. Functional method.

taking over-the-counter medications like:

D. Team method.
A. Antihistamines.
33. The ambulance team calls the emergency department
that they are going to bring a client who sustained burns in a

B. NSAIDs.

C. Antacids.

A. Suture set.

D. Salicylates.

B. Tracheostomy set.
C. Suction equipment.

38. A male client is brought to the emergency department

D. Wire cutters.

due to motor vehicle accident. While monitoring the client,


the nurse suspects increasing intracranial pressure when:

43. A mother is in the third stage of labor. Which of the


following signs will help the nurse determine the signs of

A. Client is oriented when aroused from sleep, and goes

placental separation?

back to sleep immediately.


B. Blood pressure is decreased from 160/90 to 110/70.

A. The uterus becomes globular.

C. Client refuses dinner because of anorexia.

B. The umbilical cord is shortened.

D. Pulse is increased from 88-96 with occasional skipped

C. The fundus appears at the introitus.

beat.

D. Mucoid discharge is increased.

39. The nurse is conducting a lecture to a class of nursing

44. After therapy with the thrombolytic alteplase (t-PA. , what

students about advance directives to preoperative clients.

observation will the nurse report to the physician?

Which of the following statement by the nurse js correct?


A. 3+ peripheral pulses.
A. The spouse, but not the rest of the family, may override

B. Change in level of consciousness and headache.

the advance directive.

C. Occasional dysrhythmias.

B. An advance directive is required for a do not resuscitate

D. Heart rate of 100/bpm.

order.
C. A durable power of attorney, a form of advance directive,

45. A client who undergone left nephrectomy has a large

may only be held by a blood relative.

flank incision. Which of the following nursing action will

D. The advance directive may be enforced even in the face

facilitate deep breathing and coughing?

of opposition by the spouse.


A. Push fluid administration to loosen respiratory secretions.
40. A client diagnosed with schizophrenia is shouting and

B. Have the client lie on the unaffected side.

banging on the door leading to the outside, saying, I need to

C. Maintain the client in high Fowlers position.

go to an appointment. What is the appropriate nursing

D. Coordinate breathing and coughing exercise with

intervention?

administration of analgesics.

A. Tell the client that he cannot bang on the door.

46. The community nurse is teaching the group of mothers

B. Ignore this behavior.

about the cervical mucus method of natural family planning.

C. Escort the client going back into the room.

Which characteristics are typical of the cervical mucus

D. Ask the client to move away from the door.

during the fertile period of the menstrual cycle?

41. Which of the following action is an accurate tracheal

A. Absence of ferning.

suctioning technique?

B. Thin, clear, good spinnbarkeit.


C. Thick, cloudy.

A. 25 seconds of continuous suction during catheter

D. Yellow and sticky.

insertion.
B. 20 seconds of continuous suction during catheter

47. A client with ruptured appendix had surgery an hour ago

insertion.

and is transferred to the nursing care unit. The nurse placed

C. 10 seconds of intermittent suction during catheter

the client in a semi-Fowlers position primarily to:

withdrawal.
D. 15 seconds of intermittent suction during catheter

A. Facilitate movement and reduce complications from

withdrawal.

immobility.
B. Fully aerate the lungs.

42. The clients jaw and cheekbone is sutured and wired.

C. Splint the wound.

The nurse anticipates that the most important thing that must

D. Promote drainage and prevent subdiaphragmatic

be ready at the bedside is:

abscesses.

48. Which of the following will best describe a management

A. Stand with legs apart and touch hands to floor three times

function?

per day.
B. Ten minutes of walking per day with an emphasis on good

A. Writing a letter to the editor of a nursing journal.

posture.

B. Negotiating labor contracts.

C. Ten minutes of swimming or leg kicking in pool per day.

C. Directing and evaluating nursing staff members.

D. Pelvic rock exercise and squats three times a day.

D. Explaining medication side effects to a client.


54. A client with obsessive-compulsive behavior is admitted
49. The parents of an infant client ask the nurse to teach

in the psychiatric unit. The nurse taking care of the client

them how to administer Cortisporin eye drops. The nurse is

knows that the primary treatment goal is to:

correct in advising the parents to place the drops:


A. Provide distraction.
A. In the middle of the lower conjunctival sac of the infants

B. Support but limit the behavior.

eye.

C. Prohibit the behavior.

B. Directly onto the infants sclera.

D. Point out the behavior.

C. In the outer canthus of the infants eye.


D. In the inner canthus of the infants eye.

55. After ileostomy, the nurse expects that the drainage


appliance will be applied to the stoma:

50. The nurse is assessing on the client who is admitted due


to vehicle accident. Which of the following findings will help

A. When the client is able to begin self-care procedures.

the nurse that there is internal bleeding?

B. 24 hours later, when the swelling subsided.


C. In the operating room after the ileostomy procedure.

A. Frank blood on the clothing.

D. After the ileostomy begins to function.

B. Thirst and restlessness.


C. Abdominal pain.

56. A female client who has a 28-day menstrual cycle asks

D. Confusion and altered of consciousness.

the community health nurse when she get pregnant during


her cycle. What will be the best nursing response?

51. The nurse is completing an assessment to a newborn


baby boy. The nurse observes that the skin of the newborn is

A. It is impossible to determine the fertile period reliably. So it

dry and flaking and there are several areas of an apparent

is best to assume that a woman is always fertile.

macular rash. The nurse charts this as:

B. In a 28-day cycle, ovulation occurs at or about day 14.


The egg lives for about 24 hours and the sperm live for about

A. Icterus neonatorum

72 hours. The fertile period would be approximately between

B. Multiple hemangiomas

day 11 and day 15.

C. Erythema toxicum

C. In a 28- day cycle, ovulation occurs at or about day 14.

D. Milia

The egg lives for about 72 hours and the sperm live for about
24 hours. The fertile period would be approximately between

52. The client is brought to the emergency department

day 13 and 17.

because of serious vehicle accident. After an hour, the client

D. In a 28-day cycle, ovulation occurs 8 days before the next

has been declared brain dead. The nurse who has been with

period or at about day 20. The fertile period is between day

the client must now talk to the family about organ donation.

20 and the beginning of the next period.

Which of the following consideration is necessary?


57. Which of the following statement describes the role of a
A. Include as many family members as possible.

nurse as a client advocate?

B. Take the family to the chapel.


C. Discuss life support systems.

A. A nurse may override clients wishes for their own good.

D. Clarify the familys understanding of brain death.

B. A nurse has the moral obligation to prevent harm and do


well for clients.

53. The nurse is teaching exercises that are good for

C. A nurse helps clients gain greater independence and self-

pregnant women increasing tone and fitness and decreasing

determination.

lower backache. Which of the following should the nurse

D. A nurse measures the risk and benefits of various health

exclude in the exercise program?

situations while factoring in cost.

58. A community health nurse is providing a health teaching

C. New admitted client with chest pain.

to a woman infected with herpes simplex 2. Which of the

D. A client with diabetes who has a glucoscan reading of

following health teaching must the nurse include to reduce

180.

the chances of transmission of herpes simplex 2?


63. A couple seeks medical advice in the community health
A. Abstain from intercourse until lesions heal.

care unit. A couple has been unable to conceive; the man is

B. Therapy is curative.

being evaluated for possible problems. The physician

C. Penicillin is the drug of choice for treatment.

ordered semen analysis. Which of the following instructions

D. The organism is associated with later development of

is correct regarding collection of a sperm specimen?

hydatidiform mole.
A. Collect a specimen at the clinic, place in iced container,
59. The nurse in the psychiatric ward informed the male

and give to laboratory personnel immediately.

client that he will be attending the 9:00 AM group therapy

B. Collect specimen after 48-72 hours of abstinence and

sessions. The client tells the nurse that he must wash his

bring to clinic within 2 hours.

hands from 9:00 to 9:30 AM each day and therefore he

C. Collect specimen in the morning after 24 hours of

cannot attend. Which concept does the nursing staff need to

abstinence and bring to clinic immediately.

keep in mind in planning nursing intervention for this client?

D. Collect specimen at night, refrigerate, and bring to clinic


the next morning.

A. Depression underlines ritualistic behavior.


B. Fear and tensions are often expressed in disguised form

64. The physician ordered Betamethasone to a pregnant

through symbolic processes.

woman at 34 weeks of gestation with sign of preterm labor.

C. Ritualistic behavior makes others uncomfortable.

The nurse expects that the drug will:

D. Unmet needs are discharged through ritualistic behavior.


A. Treat infection.
10. The nurse assesses the health condition of the female

B. Suppress labor contraction.

client. The client tells the nurse that she discovered a lump in

C. Stimulate the production of surfactant.

the breast last year and hesitated to seek medical advice.

D. Reduce the risk of hypertension.

The nurse understands that, women who tend to delay


seeking medical advice after discovering the disease are

65. A tracheostomy cuff is to be deflated, which of the

displaying what common defense mechanism?

following nursing intervention should be implemented before


starting the procedures?

A. Intellectualization.
B. Suppression.

A. Suction the trachea and mouth.

C. Repression.

B. Have the obdurator available.

D. Denial.

C. Encourage deep breathing and coughing.


D. Do a pulse oximetry reading.

61. Which of the following situations cannot be delegated by


the registered nurse to the nursing assistant?

66. A client is diagnosed with Tuberculosis and respiratory


isolation is initiated. This means that:

A. A postoperative client who is stable needs to ambulate.


B. Client in soft restraint who is very agitated and crying.

A. Gloves are worn when handling the clients tissue,

C. A confused elderly woman who needs assistance with

excretions, and linen.

eating.

B. Both client and attending nurse must wear masks at all

D. Routine temperature check that must be done for a client

times.

at end of shift.

C. Nurse and visitors must wear masks until chemotherapy


is begun. Client is instructed in cough and tissue techniques.

62. In the admission care unit, which of the following client

D. Full isolation; that is, caps and gowns are required during

would the nurse give immediate attention?

the period of contagion.

A. A client who is 3 days postoperative with left calf pain.

67. A client with lung cancer is admitted in the nursing care

B. A client who is postoperative hip pinning who is

unit. The husband wants to know the condition of his wife.

complaining of pain.

How should the nurse respond to the husband?

A. Find out what information he already has.

72. The nurse is assessing the newborn boy. Apgar scores

B. Suggest that he discuss it with his wife.

are 7 and 9. The newborn becomes slightly cyanotic. What is

C. Refer him to the doctor.

the initial nursing action?

D. Refer him to the nurse in charge.


A. Elevate his head to promote gravity drainage of
68. A hospitalized client cannot find his handkerchief and

secretions.

accuses other cient in the room and the nurse of stealing

B. Wrap him in another blanket, to reduce heat loss.

them. Which is the most therapeutic approach to this client?

C. Stimulate him to cry,, to increase oxygenation.


D. Aspirate his mouth and nose with bulb syringe.

A. Divert the clients attention.


B. Listen without reinforcing the clients belief.

73. The nurse is formulating a plan of care to a client with a

C. Inject humor to defuse the intensity.

somatoform disorder. The nurse needs to have knowledge of

D. Logically point out that the client is jumping to

which psychodynamic principle?

conclusions.

A. The symptoms of a somatoform disorder are an attempt to


adjust to painful life situations or to cope with conflicting

69. After a cystectomy and formation of an ileal conduit, the

sexual, aggressive, or dependent feelings.

nurse provides instruction regarding prevention of leakage of

B. The major fundamental mechanism is regression.

the pouch and backflow of the urine. The nurse is correct to

C. The clients symptoms are imaginary and the suffering is

include in the instruction to empty the urine pouch:

faked.
D. An extensive, prolonged study of the symptoms will be

A. Every 3-4 hours.

reassuring to the client, who seeks sympathy, attention and

B. Every hour.

love.

C. Twice a day.
D. Once before bedtime.

74. An infant is brought to the health care clinic for three


immunizations at the same time. The nurse knows that

70. Which telephone call from a students mother should the

hepatitis B, DPT, and Haemophilus influenzae type B

school nurse take care of at once?

immunizations should:
A. Be drawn in the same syringe and given in one injection.

A. A telephone call notifying the school nurse that the child

B. Be mixed and inject in the same sites.

pediatrician has informed the mother that the child will need

C. Not be mixed and the nurse must give three injections in

cardiac repair surgery within the next few weeks.

three sites.

B. A telephone call notifying the school nurse that the childs

D. Be mixed and the nurse must give the injection in three

pediatrician has informed the mother that the child has head

sites.

lice.
C. A telephone call notifying the school nurse that a child has

75. A female client with cancer has radium implants. The

a temperature of 102F and a rash covering the trunk and

nurse wants to maintain the implants in the correct position.

upper extremities of the body.

The nurse should position the client:

D. A telephone call notifying the school nurse that a child


underwent an emergency appendectomy during the previous

A. Flat in bed.

night.

B. On the side only.


C. With the foot of the bed elevated.

71. Which of the following signs and symptoms that require

D. With the head elevated 45-degrees (semi-Fowlers).

immediate attention and may indicate most serious


complications during pregnancy?

76. The nurse wants to know if the mother of a toddler


understands the instructions regarding the administration of

A. Severe abdominal pain or fluid discharge from the vagina.

syrup of ipecac. Which of the following statement will help

B. Excessive saliva, bumps around the areolae, and

the nurse to know that the mother needs additional

increased vaginal mucus.

teaching?

C. Fatigue, nausea, and urinary frequency at any time during


pregnancy.

A. Ill give the medicine if my child gets into some toilet bowl

D. Ankle edema, enlarging varicosities, and heartburn.

cleaner.
B. Ill give the medicine if my child gets into some aspirin.

C. Ill give the medicine if my child gets into some plant

A. it is no unusual to take 6-12 months to get pregnant,

bulbs.

especially when the partners are in their mid-30s. Eat well,

D. Ill give the medicine if my child gets into some vitamin

exercise, and avoid stress.

pills.

B. Start planning adoption. Many couples get pregnant


when they are trying to adopt.

77. To assess if the cranial nerve VII of the client was

C. Consult a fertility specialist and start testing before you

damaged, which changes would not be expected?

get any older.


D. Have sex as often as you can, especially around the time

A. Drooling and drooping of the mouth.

of ovulation, to increase your chances of pregnancy.

B. Inability to open eyelids on operative side.


C. Sagging of the face on the operative side.

82. The nurse is caring for a cient who Is a retired nurse. A

D. Inability to close eyelid on operative side.

24-hour urine collection for Creatinine clearance is to be


done. The client tells the nurse, I cant remember what this

78. The community health nurse makes a home visit to a

test is for. The best response by the nurse is:

family. During the visit, the nurse observes that the mother is
beating her child. What is the priority nursing intervention in

A. It provides a way to see if you are passing any protein in

this situation?

your urine.
B. It tells how well the kidneys filter wastes from the blood.

A. Assess the childs injuries.

C. It tells if your renal insufficiency has affected your heart.

B. Report the incident to protective agencies.

D. The test measures the number of particles the kidney

C. Refer the family to appropriate support group.

filters.

D. Assist the family to identify stressors and use of other


coping mechanisms to prevent further incidents.

83. The nurse observes the female client in the psychiatric


ward that she is having a hard time sleeping at night. The

79. The nurse in the neonatal care unit is supervising the

nurse asks the client about it and the client says, I cant

actions of a certified nursing assistant in giving care to the

sleep at night because of fear of dying. What is the best

newborns. The nursing assistant mistakenly gives a formula

initial nursing response?

feeding to a newborn that is on water feeding only. The nurse


is responsible for the mistake of the nursing assistant:

A. It must be frightening for you to feel that way. Tell me


more about it.

A. Always, as a representative of the institution.

B. Dont worry, you wont die. You are just here for some

B. Always, because nurses who supervise less-trained

test.

individuals are responsible for their mistakes.

C. Why are you afraid of dying?

C. If the nurse failed to determine whether the nursing

D. Try to sleep. You need the rest before tomorrows test.

assistant was competent to take care of the client.


D. Only if the nurse agreed that the newborn could be fed

84. In the hospital lobby, the registered nurse overhears a

formula.

two staff members discussing about the health condition of


her client. What would be the appropriate action for the

80. The nurse is assigned to care for a client with urinary

registered nurse to take?

calculi. Fluid intake of 2L/day is encouraged to the client. the


primary reason for this is to:

A. Join in the conversation, giving her input about the case.


B. Ignore them, because they have the right to discuss

A. Reduce the size of existing stones.

anything they want to.

B. Prevent crystalline irritation to the ureter.

C. Tell them it is not appropriate to discuss such things.

C. Reduce the size of existing stones

D. Report this incident to the nursing supervisor.

D. Increase the hydrostatic pressure in the urinary tract.


85. The client has had a right-sided cerebrovascular
81. The nurse is counseling a couple in their mid 30s who

accident. In transferring the client from the wheelchair to

have been unable to conceive for about 6 months. They are

bed, in what position should a client be placed to facilitate

concerned that one or both of them may be infertile. What is

safe transfer?

the best advice the nurse could give to the couple?

A. Weakened (L) side of the cient next to bed.

90. The nurse is completing an obstetric history of a woman

B. Weakened (R) side of the client next to bed.

in labor. Which event in the obstetric history will help the

C. Weakened (L) side of the client away from bed.

nurse suspects dysfunctional labor in the current pregnancy?

D. Weakened (R) side of the cient away from bed.


A. Total time of ruptured membranes was 24 hours with the
86. The child client has undergone hip surgery and is in a

second birth.

spica cast. Which of the following toy should be avoided to

B. First labor lasting 24 hours.

be in the childs bed?

C. Uterine fibroid noted at time of cesarean delivery.


D. Second birth by cesarean for face presentation.

A. A toy gun.
B. A stuffed animal.

91. The nurse is planning to talk to the client with an

C. A ball.

antisocial personality disorder. What would be the most

D. Legos.

therapeutic approach?

87. The LPN/LVN asks the registered nurse why oxytocin

A. Provide external controls.

(Pitocin), 10 units (IV or IM) must be given to a client after

B. Reinforce the clients self-concept.

birth fo the fetus. The nurse is correct to explain that

C. Give the client opportunities to test reality.

oxytocin:

D. Gratify the clients inner needs.

A. Minimizes discomfort from afterpains.

92. The nurse is teaching a group of women about fertility

B. Suppresses lactation.

awareness, the nurse should emphasize that basal body

C. Promotes lactation.

temperature:

D. Maintains uterine tone.


A. Can be done with a mercury thermometer but no a digital
88. The nurse in the nursing care unit is aware that one of

one.

the medical staff displays unlikely behaviors like confusion,

B. The average temperature taken each morning.

agitation, lethargy and unkempt appearance. This behavior

C. Should be recorded each morning before any activity.

has been reported to the nurse manager several times, but

D. Has a lower degree of accuracy in predicting ovulation

no changes observed. The nurse should:

than the cervical mucus test.

A. Continue to report observations of unusual behavior until

93. The nursing applicant has given the chance to ask

the problem is resolved.

questions during a job interview at a local hospital. What

B. Consider that the obligation to protect the patient from

should be the most important question to ask that can

harm has been met by the prior reports and do nothing

increase chances of securing a job offer?

further.
C. Discuss the situation with friends who are also nurses to

A. Begin with questions about client care assignments,

get ideas .

advancement opportunities, and continuing education.

D. Approach the partner of this medical staff member with

B. Decline to ask questions, because that is the

these concerns.

responsibility of the interviewer.


C. Ask as many questions about the facility as possible.

89. The physician ordered tetracycline PO qid to a child

D. Clarify information regarding salary, benefits, and working

client who weights 20kg. The recommended PO tetracycline

hours first, because this will help in deciding whether or not

dose is 25-50 mg/kg/day. What is the maximum single dose

to take the job.

that can be safely administered to this child?


94. The nurse advised the pregnant woman that smoking
A. 1 g

and alcohol should be avoided during pregnancy. The nurse

B. 500 mg

takes into account that the developing fetus is most

C. 250 mg

vulnerable to environment teratogens that cause

D. 125 mg

malformation during:
A. The entire pregnancy.
B. The third trimester.

C. The first trimester.

100. A client who undergone appendectomy 3 days ago is

D. The second trimester.

scheduled for discharge today. The nurse notes that the


client is restless, picking at bedclothes and saying, I am late

95. A male client tells the nurse that there is a big bug in his

on my appointment, and calling the nurse by the wrong

bed. The most therapeutic nursing response would be:

name. The nurse suspects:

A. Silence.

A. Panic reaction.

B. Wheres the bug? Ill kill it for you.

B. Medication overdose.

C. I dont see a bug in your bed, but you seem afraid.

C. Toxic reaction to an antibiotic.

D. You must be seeing things.

D. Delirium tremens.

96. A pregnant client in late pregnancy is complaining of


groin pain that seems worse on the right side. Which of the
following is the most likely cause of it?

[divider] Answers & Rationale


1. A. The oxytocic effect of Pitocin increases the intensity
and durations of contractions; prolonged contractions will

A. Beginning of labor.

jeopardize the safetyof the fetus and necessitate

B. Bladder infection.

discontinuing the drug.

C. Constipation.
D. Tension on the round ligament.

2. B. It is of paramount importance to prevent the client from


hurting himself or herself or others.

97. The nurse is conducting a lecture to a group of volunteer


nurses. The nurse is correct in imparting the idea that the

3. B. After tonsillectomy, clear, cool liquids should be given.

Good Samaritan law protects the nurse from a suit for

Citrus, carbonated, and hot or cold liquids should be avoided

malpractice when:

because they may irritate the throat. Red liquids should be


avoided because they give the appearance of blood if the

A. The nurse stops to render emergency aid and leaves

child vomits. Milk and milk products including pudding are

before the ambulance arrives.

avoided because they coat the throat, cause the child to

B. The nurse acts in an emergency at his or her place of

clear the throat, and increase the risk of bleeding.

employment.
C. The nurse refuses to stop for an emergency outside of the

4. A. Phenylephrine, with frequent and continued use, can

scope of employment.

cause rebound congestion of mucous membranes.

D. The nurse is grossly negligent at the scene of an


emergency.

5. B. The N 95 respirator is a high-particulate filtration mask


that meets the CDC performance criteria for a tuberculosis

98. A woman is hospitalized with mild preeclampsia. The

respirator.

nurse is formulating a plan of care for this client, which


nursing care is least likely to be done?

6. C. The most frequent cause of noncompliance to the


treatment of chronic, or open-angle glaucoma is the miotic

A. Deep-tendon reflexes once per shift.

effects of pilocarpine. Pupillary constriction impedes normal

B. Vital signs and FHR and rhythm q4h while awake.

accommodation, making night driving difficult and

C. Absolute bed rest.

hazardous, reducing the clients ability to read for extended

D. Daily weight.

periods and making participation in games with fast-moving


objects impossible.

99. While feeding a newborn with an unrepaired cardiac


defect, the nurse keeps on assessing the condition of the

7. B. This stops the sucking of air through the tube and

client. The nurse notes that the newborns respiration is 72

prevents the entry of contaminants. In addition, clamping

breaths per minute. What would be the initial nursing action?

near the chest wall provides for some stability and may
prevent the clamp from pulling on the chest tube.

A. Burp the newborn.


B. Stop the feeding.

8. D. Because umbilical cords insertion site is born before

C. Continue the feeding.

the fetal head, the cord may be compressed by the after-

D. Notify the physician.

coming head in a breech birth.

9. B. It is important to externalize the anger away from self.

19. D. One of the earliest signs of digoxin toxicity is


Bradycardia. For a toddler, any heart rate that falls below the

10. D. Development normally proceeds cephalocaudally; so

norm of about 100-120 bpm would indicate Bradycardia and

the first major developmental milestone that the infant

would necessitate holding the medication and notifying the

achieves is the ability to hold the head up within the first 8-12

physician.

weeks of life. In hypothyroidism, the infants muscle tone


would be poor and the infant would not be able to achieve

20. B. This option is least threatening.

this milestone.
21. D. In preparing the client for discharge that is receiving
11. D. Get a senior nurse who know s the policies, the client,

prednisone, the nurse should caution the client to (A. take

and the doctor. Generally speaking, a nurse should not

oral preparations after meals; (B. remember that routine

accept telephone orders. However, if it is necessary to take

checks of vital signs, weight, and lab studies are critical; (C.

one, follow the hospitals policy regarding telephone orders.

NEVER STOP OR CHANGE THE AMOUNT OF

Failure to followhospital policy could be considered

MEDICATION WITHOUT MEDICAL ADVICE; (D. store the

negligence. In this case, the nurse was new and did not

medication in a light-resistant container.

know the hospitals policy concerning telephone orders. The


nurse was also unfamiliar with the doctor and the client.

22. A. Progesterone also reduces smooth muscle motility in

Therefore the nurse should not take the order unless A. no

the urinary tract and predisposes the pregnant woman to

one else is available and B. it is an emergency situation.

urinary tract infections. Women should contact their doctors


if they exhibit signs of infection. Kegel exercise will help

12. C. The nurse is obligated to inform the nurse manager

strengthen the perineal muscles; limiting fluids at bedtime

about changes in the condition of the client, which may

reduces the possibility of being awakened by the necessity of

change the decision made by the nurse manager.

voiding.

13. A. Perinatal risk factors for the development of Down

23. B. This is the proper use of anger.

syndrome include advanced maternal age, especially with


the first pregnancy.

24. C. There are several models of case management, but


the commonality is comprehensive coordination of care to

14. B. Assignments should be based on scope of practice

better predict needs of high-risk clients, decrease

and expertise.

exacerbations and continually monitor progress overtime.

15. B. The child who is concurrently taking digoxin and

25. A. Phenytoin should be infused or injected into larger

diuretics is at increased risk for digoxin toxicity due to the

veins to avoid the discoloration know as purple glove

loss of potassium. The child and parents should be taught

syndrome; infusing into a smaller vein is not appropriate.

what foods are high in potassium, and the child should be


encouraged to eat a high-potassium diet. In addition, the

26. C. Serum radioimmunoassay (RIA. is accurate within

childs serum potassium level should be carefully monitored.

7days of conception. This test is specific for HCG, and


accuracy is not compromised by confusion with LH.

16. A. The responsible for an accurate informed consent is


the physician. An exception to this answer would be a life-

27. D. Surgery and anesthesia can increase mucus

threatening emergency, but there are no data to support

production. Deep breathing and coughing are essential to

another response.

prevent atelectasis and pneumonia in the clients only


remaining lung.

17. D. Asking the client to cough and take a deep breath will
help determine if the chest tube is kinked or if the lungs has

28. B. Newborns can get pneumonia (tachypnea, mild

reexpanded.

hypoxia, cough, eosinophiliA. and conjunctivitis from


Chlamydia.

18. B. Every event that exposes a client to harm should be


recorded in an incident report, as well as reported to the

29. D. The client may perceive this as avoidance, but it is

appropriate supervisors in order to resolve the current

more important to redirect back to the client, especially in

problems and permit the institution to prevent the problem

light of the manipulative behavior of drug abusers and

from happening again.

adolescents.

30. C. It describes a democratic process in which all

is an adverse effect. Monitor clotting times and signs of any

members have input in the clients care.

gastrointestinal or internal bleeding.

31. A. Contraction of the milk ducts and let-down reflex occur

45. D. Because flank incision in nephrectomy is directly

under the stimulation of oxytocin released by the posterior

below the diaphragm, deep breathing is painful. Additionally,

pituitary gland.

there is a greater incisional pull each time the person moves


than there is with abdominal surgery. Incisional pain

32. B. In case management, the nurse assumes total

following nephrectomy generally requires analgesics

responsibility for meeting the needs of the client during the

administration every 3-4 hours for 24-48 hours after surgery.

entire time on duty.

Therefore, turning, coughing and deep-breathing exercises


should be planned to maximize the analgesic effects.

33. A. Smoke inhalation affects gas exchange.


46. B. Under high estrogen levels, during the period
34. C. Sperm deposited during intercourse may remain

surrounding ovulation, the cervical mucus becomes thin,

viable for about 3 days. If ovulation occurs during this period,

clear, and elastic (spinnbarkeit), facilitating sperm passage.

conception may result.


47. D. After surgery for a ruptured appendix, the client
35. B. This option shows acceptance (key concept) of this

should be placed in a semi-Fowlers position to promote

age-typical sleep pattern (that of waking in the early

drainage and to prevent possible complications.

morning).
48. C. Directing and evaluation of staff is a major
36. D. Taking the mothers pulse while listening to the FHR

responsibility of a nursing manager.

will differentiate between the maternal and fetal heart rates


and rule out fetal Bradycardia.

49. A. The recommended procedure for administering


eyedrops to any client calls for the drops to be placed in the

37. A. Antihistamines cause pupil dilation and should be

middle of the lower conjunctival sac.

avoided with glaucoma.


50. B. Thirst and restlessness indicate hypovolemia and
38. A. This suggests that the level of consciousness is

hypoxemia. Internal bleeding is difficult to recognized and

decreasing.

evaluate because it is not apparent.

39. D. An advance directive is a form of informed consent,

51. C. Erythema toxicum is the normal, nonpathological

and only a competent adult or the holder of a durable power

macular newborn rash.

of attorney has the right to consent or refuse treatment. If the


spouse does not hold the power of attorney, the decisions of

52. D. The family needs to understand what brain death is

the holder, even if opposed by the spouse, are enforced.

before talking about organ donation. They need time to


accept the death of their family member. An environment

40. C. Gentle but firm guidance and nonverbal direction is

conducive to discussing an emotional issue is needed.

needed to intervene when a client with schizophrenic


symptoms is being disruptive.

53. A. Bending from the waist in pregnancy tends to make


backache worse.

41. C. Suctioning is only done for 10 seconds, intermittently,


as the catheter is being withdrawn.

54. B. Support and limit setting decrease anxiety and provide


external control.

42. D. The priority for this client is being able to establish an


airway.

55. C. The stoma drainage bag is applied in the operating


room. Drainage from the ileostomy contains secretions that

43. A. Signs of placental separation include a change in the

are rich in digestive enzymes and highly irritating to the skin.

shape of the uterus from ovoid to globular.

Protection of the skin from the effects of these enzymes is


begun at once. Skin exposed to these enzymes even for a

44. B. This could indicate intracranial bleeding. Alteplase is a


thrombolytic enzyme that lyses thrombi and emboli. Bleeding

short time becomes reddened, painful and excoriated.

56. B. It is the most accurate statement of physiological facts

is in attendance. Client should be in a well-ventilated room,

for a 28-day menstrual cycle: ovulation at day 14, egg life

without air recirculation, to prevent air contamination.

span 24 hours, sperm life span of 72 hours. Fertilization


could occur from sperm deposited before ovulation.

67. A. It is best to establish baseline information first.

57. C. An advocate role encourage freedom of choice,

68. B. Listening is probably the most effective response of

includes speaking out for the client, and supports the clients

the four choices.

best interests.
69. A. Urine flow is continuous. The pouch has an outlet
58. A. Abstinence will eliminate any unnecessary pain during

valve for easy drainage every 3-4 hours. (the pouch should

intercourse and will reduce the possibility of transmitting

be changed every 3-5 days, or sooner if the adhesive is

infection to ones sexual partner.

loose).

59. B. Anxiety is generated by group therapy at 9:00 AM.

70. C. A high fever accompanied by a body rash could

The ritualistic behavioral defense of hand washing

indicate that the child has a communicable disease and

decreases anxiety by avoiding group therapy.

would have exposed other students to the infection. The


school nurse would want to investigate this telephone call

60. D. Denial is a very strong defense mechanism used to

immediately so that plans could be instituted to control the

allay the emotional effects of discovering a potential threat.

spread of such infection.

Although denial has been found to be an effective


mechanism for survival in some instances, such as during

71. A. Severe abdominal pain may indicate complications of

natural disasters, it may in greater pathology in a woman

pregnancy such as abortion, ectopic pregnancy, or abruption

with potential breast carcinoma.

placenta; fluid discharge from the vagina may indicate


premature rupture of the membrane.

61. B. The registered nurse cannot delegate the


responsibility for assessment and evaluation of clients. The

72. D. Gentle aspiration of mucus helps maintain a patent

status of the client in restraint requires further assessment to

airway, required for effective gas exchange.

determine if there are additional causes for the behavior.


73. A. Somatoform disorders provide a way of coping with
62. C. The client with chest pain may be having a myocardial

conflicts.

infarction, and immediate assessment and intervention is a


priority.

74. C. Immunization should never be mixed together in a


syringe, thus necessitating three separate injections in three

63. B. Is correct because semen analysis requires that a

sites. Note: some manufacturers make a premixed

freshly masturbated specimen be obtained after a rest

combination of immunization that is safe and effective.

(abstinence) period of 48-72 hours.


75. A. Clients with radioactive implants should be positioned
64. C. Betamethasone, a form of cortisone, acts on the fetal

flat in bed to prevent dislodgement of the vaginal packing.

lungs to produce surfactant.

The client may roll to the side for meals but the upper body
should not be raised more than 20 degrees.

65. A. Secretions may have pooled above the tracheostomy


cuff. If these are not suctioned before deflation, the

76. A. Syrup of ipecac is not administered when the ingested

secretions may be aspirated.

substances is corrosive in nature. Toilet bowl cleaners, as a


collective whole, are highly corrosive substances. If the

66. C. Proper handling of sputum is essential to allay droplet

ingested substance burned the esophagus going down, it

transference of bacilli in the air. Clients need to be taught to

will burn the esophagus coming back up when the child

cover their nose and mouth with tissues when sneezing or

begins to vomit after administration of syrup of ipecac.

coughing. Chemotherapy generally renders the client


noninfectious within days to a few weeks, usually before

77. B. Inability to open eyelids on operative side is seen with

cultures for tubercle bacilli are negative. Until chemical

cranial nerve III damage.

isolation is established, many institutions require the client to


wear a mask when visitors are in the room or when the nurse

78. A. Assessment of physical injuries (like bruises,

90. C. An abnormality in the uterine muscle could reduce the

lacerations, bleeding and fractures) is the first priority.

effectiveness of uterine contractions and lengthen the


duration of subsequent labors.

79. C. The nurse who is supervising others has a legal


obligation to determine that they are competent to perform

91. A. Personality disorders stem from a weak superego,

the assignment, as well as legal obligation to provide

implying a lack of adequate controls.

adequate supervision.
92. C. The basal body temperature is the lowest body
80. D. Increasing hydrostatic pressure in the urinary tract will

temperature of a healthy person that is taken immediately

facilitate passage of the calculi.

after waking and before getting out of bed. The BBT usually
varies from 36.2 C to 36.3C during menses and for about

81. A. Infertility is not diagnosed until atleast 12months of

5-7 days afterward. About the time of ovulation, a slight drop

unprotected intercourse has failed to produce a pregnancy.

in temperature may be seen, after ovulation in concert with

Older couples will experience a longer time to get pregnant.

the increasing progesterone levels of the early luteal phase,


the BBT rises 0.2-0.4 C. This elevation remains until 2-3

82. B. Determining how well the kidneys filter wastes states

days before menstruation, or if pregnancy has occurred.

the purpose of a Creatinine clearance test.


93. A. This choice implies concern for client care and self83. A. Acknowledging a feeling tone is the most therapeutic

improvement.

response and provides a broad opening for the client to


elaborate feelings.

94. C. The first trimester is the period of organogenesis, that


is, cell differentiation into the various organs, tissues, and

84. C. The behavior should be stopped. The first is to remind

structures.

the staff that confidentiality maybe violated.


95. C. This response does not contradict the clients
85. C. With a right-sided cerebrovascular accident the client

perception, is honest, and shows empathy.

would have left-sided hemiplegia or weakness. The clients


good side should be closest to the bed to facilitate the

96. D. Tension on round ligament occurs because of the

transfer.

erect human posture and pressure exerted by the growing


fetus.

86. D. Legos are small plastic building blocks that could


easily slip under the childs cast and lead to a break in skin

97. D. The Good Samaritan Law does not impose a duty to

integrity and even infection. Pencils, backscratchers, and

stop at the scene of an emergency outside of the scope of

marbles are some other narrow or small items that could

employment, therefore nurses who do not stop are not liable

easily slip under the childs cast and lead to a break in skin

for suit.

integrity and infection.


98. C. Although reducing environment stimuli and activity is
87. D. Oxytocin (Pitocin) is used to maintain uterine tone.

necessary for a woman with mild preeclampsia, she will


most probably have bathroom privileges.

88. B. The submission of reports about incidents that expose


clients to harm does not remove the obligation to report

99. B. A normal respiratory rate for a newborn is 30-40

ongoing behavior as long as the risk to the client continues.

breaths per minute.

89. C. The recommended dosage of tetracycline is 25-

100. D. The behavior described is likely to be symptoms of

50mg/kg/day. If the child weighs 20kg and the maximum

delirium tremens, or alcohol withdrawal (often unsuspected

dose is 50mg/kg, this would indicate a total daily dose of

on a surgical unit.)

1000mg of tetracycline. In this case, the child is being given


this medication four times a day. Therefore the maximum
single dose that can be given is 250mg (1000 mg of
tetracycline divided by four doses.)

1. A 10 year old who has sustained a head injury is brought

presence of blood

to the emergency department by his mother. A diagnosis of a

C. Outline the blood as it appears on the dressing to observe

mild concussion is made. At the time of discharge, nurse

any progression

Ron should instruct the mother to:

D. Press gently around the incision to express accumulated


blood from the wound

A. Withhold food and fluids for 24 hours.


B. Allow him to play outdoors with his friends.

6. A 16-year-old primigravida arrives at the labor and birthing

C. Arrange for a follow up visit with the childs primary care

unit in her 38th week of gestation and states that she is

provider in one week.

labor. To verify that the client is in true labor nurse Trina

C. Check for any change in responsiveness every two hours

should:

until the follow-up visit.


A. Obtain sides for a fern test
2. A male client has suffered a motor accident and is now

B. Time any uterine contractions

suffering from hypovolemic shock. Nurse Helen should

C. Prepare her for a pelvic examination

frequency assess the clients vital signs during the

D. Apply nitrazine paper to moist vaginal tissue

compensatory stage of shock, because:


7. As part of the diagnostic workup for pulmonic stenosis, a
A. Arteriolar constriction occurs

child has cardiac catheterization. Nurse Julius is aware that

B. The cardiac workload decreases

children with pulmonic stenosis have increased pressure:

C. Decreased contractility of the heart occurs


D. The parasympathetic nervous system is triggered

A. In the pulmonary vein


B. In the pulmonary artery

3. A paranoid male client with schizophrenia is losing weight,

C. On the left side of the heart

reluctant to eat, and voicing concerns about being poisoned.

D. On the right side of the heart

The best intervention by nurse Dina would be to:


8. An obese client asks nurse Julius how to lose weight.
A. Allow the client to open canned or pre-packaged food

Before answering, the nurse should remember that long-term

B. Restrict the client to his room until 2 lbs are gained

weight loss occurs best when:

C. Have a staff member personally taste all of the clients


food

A. Eating patterns are altered

D. Tell the client the food has been x-rayed by the staff and is

B. Fats are limited in the diet

safe

C. Carbohydrates are regulated


D. Exercise is a major component

4. One day the mother of a young adult confides to nurse


Frida that she is very troubled by he childs emotional illness.

9. As a very anxious female client is talking to the nurse May,

The nurses most therapeutic initial response would be:

she starts crying. She appears to be upset that she cannot


control her crying. The most appropriate response by the

A. You may be able to lessen your feelings of guilt by

nurse would be:

seeking counseling
B. It would be helpful if you become involved in volunteer

A. Is talking about your problem upsetting you?

work at this time

B. It is Ok to cry; Ill just stay with you for now

C. I recognize its hard to deal with this, but try to remember

C. You look upset; lets talk about why you are crying.

that this too shall pass

D. Sometimes it helps to get it out of your system.

D. Joining a support group of parents who are coping with


this problem can be quite helpful.

10. A patient has partial-thickness burns to both legs and


portions of his trunk. Which of the following I.V. fluids is given

5. To check for wound hemorrhage after a client has had a

first?

surgery for the removal of a tumor in the neck, nurse grace


should:

A. Albumin
B. D5W

A. Loosen an edge of the dressing and lift it to see the

C. Lactated Ringers solution

wound

D. 0.9% sodium chloride solution with 2 mEq of potassium

B. Observe the dressing at the back of the neck for the

per 100 ml

11. During the first 48 hours after a severe burn of 40% of

A. Angina

the clients body surface, the nurses assessment should

B. Chest pain

include observations for water intoxication. Associated

C. Heart block

adaptations include:

D. Tachycardia

A. Sooty-colored sputum

17. When administering pancrelipase (Pancreases capsules)

B. Frothy pink-tinged sputum

to child with cystic fibrosis, nurse Faith knows they should be

C. Twitching and disorientation

given:

D. Urine output below 30ml per hour


A. With meals and snacks
12. After a muscle biopsy, nurse Willy should teach the client

B. Every three hours while awake

to:

C. On awakening, following meals, and at bedtime


C. After each bowel movement and after postural draianage

A. Change the dressing as needed


B. Resume the usual diet as soon as desired

18. A preterm neonate is receiving oxygen by an overhead

C. Bathe or shower according to preference

hood. During the time the infant is under the hood, it would

D. Expect a rise in body temperature for 48 hours

be appropriate for nurse Gian to:

13. Before a client whose left hand has been amputated can

A. Hydrate the infant q15 min

be fitted for a prosthesis, nurse Joy is aware that:

B. Put a hat on the infants head


C. Keep the oxygen concentration consistent

A. Arm and shoulder muscles must be developed

D. Remove the infant q15 min for stimulation

B. Shrinkage of the residual limb must be completed


C. Dexterity in the other extremity must be achieved

19. A clients sputum smears for acid fast bacilli (AFB) are

D. Full adjustment to the altered body image must have

positive, and transmission-based airborne precautions are

occurred

ordered. Nurse Kyle should instruct visitors to:

14. Nurse Cathy applies a fetal monitor to the abdomen of a

A.Limit contact with non-exposed family members

client in active labor. When the client has contractions, the

B. Avoid contact with any objects present in the clients room

nurse notes a 15 beat per minute deceleration of the fetal

C. Wear an Ultra-Filter mask when they are in the clients

heart rate below the baseline lasting 15 seconds. Nurse

room

Cathy should:

D. Put on a gown and gloves before going into the clients


room

A. Change the maternal position


B. Prepare for an immediate birth

20. A client with a head injury has a fixed, dilated right pupil;

C. Call the physician immediately

responds only to painful stimuli; and exhibits decorticate

D. Obtain the clients blood pressure

posturing. Nurse Kate should recognize that these are signs


of:

15. A male client receiving prolonged steroid therapy


complains of always being thirsty and urinating frequently.

A. Meningeal irritation

The best initial action by the nurse would be to:

B. Subdural hemorrhage
C. Medullary compression

A. Perform a finger stick to test the clients blood glucose

D. Cerebral cortex compression

level
B. Have the physician assess the client for an enlarged

21. After a lateral crushing chest injury, obvious right-sided

prostate

paradoxic motion of the clients chest demonstrates multiple

C. Obtain a urine specimen from the client for screening

rib fraactures, resulting in a flail chest. The complication the

purposes

nurse should carefully observe for would be:

D. Assess the clients lower extremities for the presence of


pitting edema

A. Mediastinal shift
B. Tracheal laceration

16. Nurse Bea recognizes that a pacemaker is indicated

C. Open pneumothorax

when a client is experiencing:

D. Pericardial tamponade

22. When planning care for a client at 30-weeks gestation,

27. A 2 year old child undergoes a ventriculoperitoneal

admitted to the hospital after vaginal bleeding secondary to

shunt revision. Before discharge, nurse John, knowing the

placenta previa, the nurses primary objective would be:

expected developmental behaviors for this age group, should


tell the parents to call the physician if the child:

A. Provide a calm, quiet environment


B. Prepare the client for an immediate cesarean birth

A. Tries to copy all the fathers mannerisms

C. Prevent situations that may stimulate the cervix or uterus

B. Talks incessantly regardless of the presence of others

D. Ensure that the client has regular cervical examinations

C. Becomes fussy when frustrated and displays a shortened

assess for labor

attention span
D. Frequently starts arguments with playmates by claiming

23. When planning discharge teaching for a young female

all toys are mine

client who has had a pneumothorax, it is important that the


nurse include the signs and symptoms of a pneumothorax

28. A urinary tract infection is a potential danger with an

and teach the client to seek medical assistance if she

indwelling catheter. Nurse Gina can best plan to avoid this

experiences:

complication by:

A. Substernal chest pain

A. Assessing urine specific gravity

B. Episodes of palpitation

B. Maintaining the ordered hydration

C. Severe shortness of breath

C. Collecting a weekly urine specimen

D. Dizziness when standing up

D. Emptying the drainage bag frequently

24. After a laryngectomy, the most important equipment to

29. A client has sustained a fractured right femur in a fall on

place at the clients bedside would be:

stairs. Nurse Troy with the emergency response team assess


for signs of circulatory impairment by:

A. Suction equipment
B. Humidified oxygen

A. Turning the client to side lying position

C. A nonelectric call bell

B. Asking the client to cough and deep breathe

D. A cold-stream vaporizer

C. Taking the clients pedal pulse in the affected limb


D. Instructing the client to wiggle the toes of the right foot

25. Nurse Oliver interviews a young female client with


anorexia nervosa to obtain information for the nursing

30. To assess orientation to place in a client suspected of

history. The clients history is likely to reveal a:

having dementia of the alzheimers type, nurse Chris should


ask:

A. Strong desire to improve her body image


B. Close, supportive mother-daughter relationship

A. Where are you?

C. Satisfaction with and desire to maintain her present

B. Who brought you here?

weight

C. Do you know where you are?

D. Low level of achievement in school, with little concerns for

D. How long have you been there?

grades
31. Nurse Mary assesses a postpartum client who had an
26. Nurse Bea should plan to assist a client with an

abruption placentae and suspects that disseminated

obsessive-compulsive disorder to control the use of ritualistic

intravascular coagulation (DIC) is occurring when

behavior by:

assessments demonstrate:

A. Providing repetitive activities that require little thought

A. A boggy uterus

B. Attempting to reduce or limit situations that increase

B. Multiple vaginal clots

anxiety

C. Hypotension and tachycardia

C. Getting the client involved with activities that will provide

D. Bleeding from the venipuncture site

distraction
D. Suggesting that the client perform menial tasks to expiate

32. When a client on labor experiences the urge to push a

feelings of guilt

9cm dilation, the breathing pattern that nurse Rhea should


instruct the client to use is the:

A. Expulsion pattern

C. Assure that informed consent has been obtained from the

B. Slow paced pattern

client

C. Shallow chest pattern

D. Perform a vaginal examination on the client to assess

D. blowing pattern

cervical dilation

33. Nurse Ronald should explain that the most beneficial

38. While a client is on intravenous magnesium sulfate

between-meal snack for a client who is recovering from the

therapy for preeclampsia, it is essential for nurse Amy to

full-thickness burns would be a:

monitor the clients deep tendon reflexes to:

A. Cheeseburger and a malted

A. Determine her level of consciousness

B. Piece of blueberry pie and milk

B. Evaluate the mobility of the extremities

C. Bacon and tomato sandwich and tea

C. Determine her response to painful stimuli

D. Chicken salad sandwich and soft drink

D. Prevent development of respiratory distress

34. Nurse Wilma recognizes that failure of a newborn to

39. A preschooler is admitted to the hospital with a diagnosis

make the appropriate adaptation to extrauterine life would be

of acute glomerulonephritis. The childs history reveals a 5-

indicated by:

pound weight gain in one week and peritoneal edema. For


the most accurate information on the status of the childs

A. flexed extremities

edema, nursing intervention should include:

B. Cyanotic lips and face


C. A heart rate of 130 beats per minute

A. Obtaining the childs daily weight

D. A respiratory rate of 40 breath per minute

B. Doing a visual inspection of the child


C. Measuring the childs intake and output

35. The laboratory calls to state that a clients lithium level is

D. Monitoring the childs electrolyte values

1.9 mEq/L after 10 days of lithium therapy. Nurse Reese


should:

40. Nurse Mickey is administering dexamethasome


(Decadron) for the early management of a clients cerebral

A. Notify the physician of the findings because the level is

edema. This treatment is effective because:

dangerously high
B. Monitor the client closely because the level of lithium in

A. Acts as hyperosmotic diuretic

the blood is slightly elevated

B. Increases tissue resistance to infection

C. Continue to administer the medication as ordered

C. Reduces the inflammatory response of tissues

because the level is within the therapeutic range

D. Decreases the information of cerebrospinal fluid

D. Report the findings to the physician so the dosage can be


increased because the level is below therapeutic range

41. During newborn nursing assessment, a positive


Ortolanis sign would be indicated by:

36. A client has a regular 30-day menstrual cycles. When


teaching about the rhythm method, Which the client and her

A. A unilateral droop of hip

husband have chosen to use for family planning, nurse

B. A broadening of the perineum

Dianne should emphasize that the clients most fertile days

C. An apparent shortening of one leg

are:

D. An audible click on hip manipulation

A. Days 9 to 11

42. When caring for a dying client who is in the denial stage

B. Days 12 to 14

of grief, the best nursing approach would be to:

C. Days 15 to 17
D. Days 18 to 20

A. Agree and encourage the clients denial


B. Allow the denial but be available to discuss death

37. Before an amniocentesis, nurse Alexandra should:

C. Reassure the client that everything will be OK


D. Leave the client alone to confront the feelings of

A. Initiate the intravenous therapy as ordered by the

impending loss

physiscian
B. Inform the client that the procedure could precipitate an

43. To decrease the symptoms of gastroesophageal reflux

infection

disease (GERD), the physician orders dietary and

medication management. Nurse Helen should teach the

C. Liver

client that the meal alteration that would be most appropriate

D. Brain

would be:
49. A disturbed client is scheduled to begin group therapy.
A. Ingest foods while they are hot

The client refuses to attend. Nurse Lolit should:

B. Divide food into four to six meals a day


C.Eat the last of three meals daily by 8pm

A. Accept the clients decision without discussion

D. Suck a peppermint candy after each meal

B. Have another client to ask the client to consider


C. Tell the client that attendance at the meeting is required

44. After a mastectomy or hysterectomy, clients may feel

D. Insist that the client join the group to help the socialization

incomplete as women. The statement that should alert nurse

process

Gina to this feeling would be:


50. Because a severely depressed client has not responded
A. I cant wait to see all my friends again

to any of the antidepressant medications, the psychiatrist

B. I feel washed out; there isnt much left

decides to try electroconvulsive therapy (ECT). Before the

C. I cant wait to get home to see my grandchild

treatment the nurse should:

D. My husband plans for me to recuperate at our daughters


home

A. Have the client speak with other clients receiving ECT


B. Give the client a detailed explanation of the entire

45. A client with obstruction of the common bile duct may

procedure

show a prolonged bleeding and clotting time because:

C. Limit the clients intake to a light breakfast on the days of


the treatment

A. Vitamin K is not absorbed

D. Provide a simple explanation of the procedure and

B. The ionized calcium levels falls

continue to reassure the client

C. The extrinsic factor is not absorbed


D. Bilirubin accumulates in the plasma

51. Nurse Vicky is aware that teaching about colostomy care


is understood when the client states, I will contact my

46. Realizing that the hypokalemia is a side effect of steroid

physician and report ____:

therapy, nurse Monette should monitor a client taking steroid


medication for:

A. If I notice a loss of sensation to touch in the stoma tissue


B. When mucus is passed from the stoma between

A. Hyperactive reflexes

irrigations

B. An increased pulse rate

C. The expulsion of flatus while the irrigating fluid is running

C. Nausea, vomiting, and diarrhea

out

D. Leg weakness with muscle cramps

D. If I have difficulty in inserting the irrigating tube into the


stoma

47. When assessing a newborn suspected of having Down


syndrome, nurse Rey would expect to observe:

52. The clients history that alerts nurse Henry to assess


closely for signs of postpartum infection would be:

A. long thin fingers


B. Large, protruding ears

A. Three spontaneous abortions

C. Hypertonic neck muscles

B. negative maternal blood type

D. Simian lines on the hands

C. Blood loss of 850 ml after a vaginal birth


D. Maternal temperature of 99.9 F 12 hours after delivery

48. A 10 year old girl is admitted to the pediatric unit for


recurrent pain and swelling of her joints, particularly her

53. A client is experiencing stomatitis as a result of

knees and ankles. Her diagnosis is juvenile rheumatoid

chemotherapy. An appropriate nursing intervention related to

arthritis. Nurse Janah recognizes that besides joint

this condition would be to:

inflammation, a unique manifestation of the rheumatoid


process involves the:

A. Provide frequent saline mouthwashes


B. Use karaya powder to decrease irritation

A. Ears
B. Eyes

C. Increase fluid intake to compensate for the diarrhea

D. Provide meticulous skin care of the abdomen with

fear of strangers

Betadine

D. Turn completely over, sit momentarily without support,


reach to be picked up

54. During a group therapy session, one of the clients ask a


male client with the diagnosis of antisocial personality

59. A breastfeeding mother asks the nurse what she can do

disorder why he is in the hospital. Considering this clients

to ease the discomfort caused by a cracked nipple. Nurse

type of personality disorder, the nurse might expect him to

Tina should instruct the client to:

respond:
A. Manually express milk and feed it to the baby in a bottle
A. I need a lot of help with my troubles

B. Stop breastfeeding for two days to allow the nipple to heal

B. Society makes people react in old ways

C. Use a breast shield to keep the baby from direct contact

C. I decided that its time I own up to my problems

with the nipple

D. My life needs straightening out and this might help

D. Feed the baby on the unaffected breast first until the


affected breast heals

55. A child visits the clinic for a 6-week checkup after a


tonsillectomy and adenoidectomy. In addition to assessing

60. Nurse Sandy observes that there is blood coming from

hearing, the nurse should include an assessment of the

the clients ear after head injury. Nurse Sandy should:

childs:
A. Turn the client to the unaffected side
A. Taste and smell

B. Cleanse the clients ear with sterile gauze

B. Taste and speech

C. Test the drainage from the clients ear with Dextrostix

C. Swallowing and smell

D. Place sterile cotton loosely in the external ear of the client

D. Swallowing and speech


61. Nurse Gio plans a long term care for parents of children
56. A client is diagnosed with cancer of the jaw. A course of

with sickle-cell anemia, which includes periodic group

radiation therapy is to be followed by surgery. The client is

conferences. Some of the discussions should be directed

concerned about the side effects related to the radiation

towards:

treaments. Nurse Ria should explain that the major side


effects that will experienced is:

A. Finding special school facilities for the child


B. Making plans for moving to a more therapeutic climate

A. Fatigue

C. Choosing a means of birth control to avoid future

B. Alopecia

pregnancies

C. Vomiting

D. Airing their feelings regarding the transmission of the

D. Leucopenia

disease to the child

57. Nurse Katrina prepares an older-adult client for sleep,

62. The central problem the nurse might face with a

actions are taken to help reduce the likelihood of a fall during

disturbed schizophrenic client is the clients:

the night. Targeting the most frequent cause of falls, the


nurse should:

A. Suspicious feelings
B. Continuous pacing

A. Offer the client assistance to the bathroom

C. Relationship with the family

B. Move the bedside table closer to the clients bed

D. Concern about working with others

C. Encourage the client to take an available sedative


D. Assist the client to telephone the spouse to say

63. When planning care with a client during the

goodnight

postoperative recovery period following an abdominal


hysterectomy and bilateral salpingo-oophorectomy, nurse

58. When evaluating a growth and development of a 6 month

Frida should include the explanation that:

old infant, nurse Patty would expect the infant to be able to:
A. Surgical menopause will occur
A. Sit alone, display pincer grasp, wave bye bye

B. Urinary retention is a common problem

B. Pull self to a standing position, release a toy by choice,

C. Weight gain is expected, and dietary plan are needed

play peek-a-boo

D. Depression is normal and should be expected

C. Crawl, transfer toy from one hand to the other, display of

64. An adolescent client with anorexia nervosa refuses to

cart and medication administration records, no explanation

eat, stating, Ill get too fat. Nurse Andrea can best respond

can be found. The primary nurse should notify the:

to this behavior initially by:


A. Nursing unit manager
A. Not talking about the fact that the client is not eating

B. Hospital administrator

B. Stopping all of the clients privileges until food is eaten

C. Quality control manager

C. Telling the client that tube feeding will eventually be

D. Physician ordering the medication

necessary
D. Pointing out to the client that death can occur with

70. When caring for the a client with a pneumothorax, who

malnutrition.

has a chest tube in place, nurse Kate should plan to:

65. A pain scale is used to assess the degree of pain. The

A. Administer cough suppressants at appropriate intervals as

client rates the pain as an 8 on a scale of 10 before

ordered

medication and a 7 on a scale of 10 after being medicated.

B. Empty and measure the drainage in the collection

Nurse Glenda determines that the:

chamber each shift


C. Apply clamps below the insertion site when ever getting

A. Client has a low pain tolerance

the client out of bed

B. Medication is not adequately effective

D. Encourage coughing, deep breathing, and range of

C. Medication has sufficiently decreased the pain level

motion to the arm on the affected side

D. Client needs more education about the use of the pain


scale

71. According to C.E.Winslow, which of the following is the


goal of Public Health?

66. To enhance a neonates behavioral development,


therapeutic nursing measures should include:

A. For people to attain their birthrights of health and longevity


B. For promotion of health and prevention of disease

A. Keeping the baby awake for longer periods of time before

C. For people to have access to basic health services

each feeding

D. For people to be organized in their health efforts

B. Assisting the parents to stimulate their baby through


touch, sound, and sight.

72. What other statistic may be used to determine attainment

C. Encouraging parental contact for at least one 15-minute

of longevity?

period every four hours.


D. Touching and talking to the baby at least hourly, beginning

A. Age-specific mortality rate

within two to four hours after birth

B. Proportionate mortality rate


C. Swaroops index

67. Before formulating a plan of care for a 6 year old boy with

D. Case fatality rate

attention deficit hyperactivity disorder (ADHD), nurse Kyla is


aware that the initial aim of therapy is to help the client to:

73. Which of the following is the most prominent feature of


public health nursing?

A. Develop language skills


B. Avoid his own regressive behavior

A. It involves providing home care to sick people who are not

C. Mainstream into a regular class in school

confined in the hospital

D. Recognize himself as an independent person of worth

B. Services are provided free of charge to people within the


catchment area.

68. Nurse Wally knows that the most important aspect of the

C. The public health nurse functions as part of a team

preoperative care for a child with Wilms tumor would be:

providing a public health nursing services.


D. Public health nursing focuses on preventive, not curative,

A. Checking the size of the childs liver

services.

B. Monitoring the childs blood pressure


C. Maintaining the child in a prone position

74. Which of the following is the mission of the Department

D. Collecting the childs urine for culture and sensitivity

of Health?

69. At 11:00 pm the count of hydrocodone (Vicodin) is

A. Health for all Filipinos

incorrect. After several minutes of searching the medication

B. Ensure the accessibility and quality of health care

C. Improve the general health status of the population

A. Should save time and effort.

D. Health in the hands of the Filipino people by the year

B. Should minimize if not totally prevent the spread of

2020

infection.
C. Should not overshadow concern for the patient and his

75. Nurse Pauline determines whether resources were

family.

maximized in implementing Ligtas Tigdas, she is evaluating:

D. May be done in a variety of ways depending on the home


situation, etc.

A. Effectiveness
B. Efficiency

81. Nurse Willy reads about Path Goal theory. Which of the

C. Adequacy

following behaviors is manifested by the leader who uses this

D. Appropriateness

theory?

76. Lissa is a B.S.N. graduate. She want to become a Public

A. Recognizes staff for going beyond expectations by giving

Health Nurse. Where will she apply?

them citations
B. Challenges the staff to take individual accountability for

A. Department of Health

their own practice

B. Provincial Health Office

C. Admonishes staff for being laggards

C. Regional Health Office

D. Reminds staff about the sanctions for non performance

D. Rural Health Unit


82. Nurse Cathy learns that some leaders are transactional
77. As an epidemiologist, Nurse Celeste is responsible for

leaders. Which of the following does NOT characterize a

reporting cases of notifiable diseases. What law mandates

transactional leader?

reporting of cases of notifiable diseases?


A. Focuses on management tasks
A. Act 3573

B. Is a caretaker

B. R.A. 3753

C. Uses trade-offs to meet goals

C. R.A. 1054

D. Inspires others with vision

D. R.A. 1082
83. Functional nursing has some advantages, which one is
78. Nurse Fay is aware that isolation of a child with measles

an EXCEPTION?

belongs to what level of prevention?


A. Psychological and sociological needs are emphasized.
A. Primary

B. Great control of work activities.

B. Secondary

C. Most economical way of delivering nursing services.

C. Intermediate

D. Workers feel secure in dependent role

D. Tertiary
84. Which of the following is the best guarantee that the
79. Nurse Gina is aware that the following is an advantage of

patients priority needs are met?

a home visit?
A. Checking with the relative of the patient
A. It allows the nurse to provide nursing care to a greater

B. Preparing a nursing care plan in collaboration with the

number of people.

patient

B. It provides an opportunity to do first hand appraisal of the

C. Consulting with the physician

home situation.

D. Coordinating with other members of the team

C. It allows sharing of experiences among people with


similar health problems.

85. Nurse Tony stresses the need for all the employees to

D. It develops the familys initiative in providing for health

follow orders and instructions from him and not from anyone

needs of its members.

else. Which of the following principles does he refer to?

80. The PHN bag is an important tool in providing nursing

A. Scalar chain

care during a home visit. The most important principle of bag

B. Discipline

technique states that it:

C. Unity of command
D. Order

86. Nurse Joey discusses the goal of the department. Which

C. leave one line blank before each new entry.

of the following statements is a goal?

D. end each entry with the nurses signature and title.

A. Increase the patient satisfaction rate

92. Which of the following factors are major components of a

B. Eliminate the incidence of delayed administration of

clients general background drug history?

medications
C. Establish rapport with patients

A. Allergies and socioeconomic status

D. Reduce response time to two minutes

B. Urine output and allergies


C. Gastric reflex and age

87. Nurse Lou considers shifting to transformational

D. Bowel habits and allergies

leadership. Which of the following statements best describes


this type of leadership?

93. Which procedure or practice requires surgical asepsis?

A. Uses visioning as the essence of leadership

A. Hand washing

B. Serves the followers rather than being served

B. Nasogastric tube irrigation

C. Maintains full trust and confidence in the subordinates

C. I.V. cannula insertion

D. Possesses innate charisma that makes others feel good

D. Colostomy irrigation

in his presence.
94. The nurse is performing wound care using surgical
88. Nurse Mae tells one of the staff, I dont have time to

asepsis. Which of the following practices violates surgical

discuss the matter with you now. See me in my office later

asepsis?

when the latter asks if they can talk about an issue. Which of
the following conflict resolution strategies did she use?

A. Holding sterile objects above the waist


B. Pouring solution onto a sterile field cloth

A. Smoothing

C. Considering a 1 (2.5-cm) edge around the sterile field

B. Compromise

contaminated

C. Avoidance

D. Opening the outermost flap of a sterile package away

D. Restriction

from the body

89. Nurse Bea plans of assigning competent people to fill the

95. On admission, a client has the following arterial blood

roles designed in the hierarchy. Which process refers to this?

gas (ABG) values: PaO2, 50 mm Hg; PaCO2, 70 mm Hg;


pH, 7.20; HCO3, 28 mEq/L. Based on these values,

A. Staffing

the nurse should formulate which nursing diagnosis for this

B. Scheduling

client?

C. Recruitment
D. Induction

A. Risk for deficient fluid volume


B. Deficient fluid volume

90. Nurse Linda tries to design an organizational structure

C. Impaired gas exchange

that allows communication to flow in all directions and

D. Metabolic acidosis

involve workers in decision making. Which form of


organizational structure is this?

96. The use of larvivorous fish in malaria control is the basis


for which strategy of malaria control?

A. Centralized
B. Decentralized

A. Stream seeding

C. Matrix

B. Stream clearing

D. Informal

C. Destruction of breeding places


D. Zooprophylaxis

91. When documenting information in a clients medical


record, the nurse should:

97. In Integrated Management of Childhood Illness, severe


conditions generally require urgent referral to a hospital.

A. erase any errors.

Which of the following severe conditions DOES NOT always

B. use a #2 pencil.

require urgent referral to a hospital?

A. Mastoiditis

4. D. Joining a support group of parents who are

B. Severe dehydration

coping with this problem can be quite helpful.

C. Severe pneumonia

Taking with others in similar circumstances provides support

D. Severe febrile disease

and allows for sharing of experiences.

98. A mother brought her daughter, 4 years old, to the RHU

5. B. Observe the dressing at the back of the neck for

because of cough and colds. Following the IMCI assessment

the presence of blood

guide, which of the following is a danger sign that indicates

Drainage flows by gravity.

the need for urgent referral to a hospital?


6. C. Prepare her for a pelvic examination
A. Inability to drink

Pelvic examination would reveal dilation and effacement

B. High grade fever


C. Signs of severe dehydration

7. D. On the right side of the heart

D. Cough for more than 30 days

Pulmonic stenosis increases resistance to blood flow,


causing right ventricular hypertrophy; with right ventricular

99. Food fortification is one of the strategies to prevent

failure there is an increase in pressure on the right side of

micronutrient deficiency conditions. R.A. 8976 mandates

the heart.

fortification of certain food items. Which of the following is


among these food items?

8. A. Eating patterns are altered


A new dietary regimen, with a balance of foods from the food

A. Sugar

pyramid, must be established and continued for weight

B. Bread

reduction to occur and be maintained.

C. Margarine
D. Filled milk

9. B. It is ok to cry; Ill just stay with you for now


This portrays a nonjudgmental attitude that recognizes the

100. The major sign of iron deficiency anemia is pallor. What

clients needs.

part is best examined for pallor?


10. C. Lactated Ringers solution
A. Palms

Lactated Ringers solution replaces lost sodium and corrects

B. Nailbeds

metabolic acidosis, both of which commonly occur following

C. Around the lips

a burn. Albumin is used as adjunct therapy, not primary fluid

D. Lower conjunctival sac

replacement. Dextrose isnt given to burn patients during the


first 24 hours because it can cause pseudodiabetes. The

[divider] Answers & Rationale

patient is hyperkalemic from the potassium shift from the


intracellular space to the plasma, so potassium would be

1. C. Check for any change in responsiveness every two

detrimental.

hours until the follow-up visit


Signs of an epidural hematoma in children usually do not

11. C. Twitching and disorientation

appear for 24 hours or more hours; a follow-up visit usually is

Excess extracellular fluid moves into cells (water

arranged for one to two days after the injury.

intoxication); intracellular fluid excess in sensitive brain cells


causes altered mental status; other signs include anorexia

2. A. Arteriolar constriction occurs

nervosa, nausea, vomiting, twitching, sleepiness, and

The early compensation of shock is cardiovascular and is

convulsions.

seen in changes in pulse, BP, and pulse pressure; blood is


shunted to vital centers, particularly heart and brain.

12. B. Resume the usual diet as soon as desired


As long as the client has no nausea or vomiting, there are no

3. A. Allow the client to open canned or pre-packaged

dietary restriction.

food
The clients comfort, safety, and nutritional status are the

13. B. Shrinkage of the residual limb must be completed

priorities; the client may feel comfortable to eat if the food

Shrinkage of the residual limb, resulting from reduction of

has been sealed before reaching the mental health facility.

subcutaneous fat and interstitial fluid, must occur for an


adequate fit between the limb and the prosthesis.

14. A. Change the maternal position

24. A. Suction equipment

Stimulation of the sympathetic nervous system is an initial

Respiratory complications can occur because of edema of

response to mild hypoxia that accompanies partial cord

the glottis or injury to the recurrent laryngeal nerve.

compression (umbilical vein) during contractions; changing


the maternal position can alleviate the compression.

25. A. Strong desire to improve her body image


Clients with anorexia nervosa have a disturbed self image

15. A. Perform a finger stick to test the clients blood

and always see themselves as fat and needing further

glucose level

reducing.

The client has signs of diabetes, which may result from


steroid therapy, testing the blood glucose level is a method of

26. B. Attempting to reduce or limit situations that

screening for diabetes, thus gathering more data.

increase anxiety
Persons with high anxiety levels develop various behaviors

16. C. Heart block

to relieve their anxiety; by reducing anxiety, the need for

This is the primary indication for a pacemaker because there

these obsessive-compulsive action is reduced.

is an interfere with the electrical conduction system of the


heart.

27. C. Becomes fussy when frustrated and displays a


shortened attention span

17. A. With meals and snacks

Shortened attention span and fussy behavior may indicate a

Pancreases capsules must be taken with food and snacks

change in intracranial pressure and/or shunt malfunction.

because it acts on the nutrients and readies them for


absorption.

28. B. Maintaining the ordered hydration


Promoting hydration maintains urine production at a higher

18. B. Put a hat on the infants head

rate, which flushes the bladder and prevents urinary stasis

Oxygen has cooling effect, and the baby should be kept

and possible infection.

warm so that metabolic activity and oxygen demands are not


increased.

29. C. Taking the clients pedal pulse in the affected limb


Monitoring a pedal pulse will assess circulation to the foot.

19. C. Wear an Ultra-Filter mask when they are in the


clients room

30. A. Where are you?

Tubercle bacilli are transmitted through air currents; therefore

Where are you? is the best question to elicit information

personal protective equipment such as an Ultra-Filter mask

about the clients orientation to place because it encourages

is necessary.

a response that can be assessed.

20. D. Cerebral cortex compression

31. D. Bleeding from the venipuncture site

Cerebral compression affects pyramidal tracts, resulting in

This indicates a fibrinogenemia; massive clotting in the area

decorticate rigidity and cranial nerve injury, which cause

of the separation has resulted in a lowered circulating

pupil dilation.

fibrinogen.

21. A. Mediastinal shift

32. D. blowing pattern

Mediastinal structures move toward the uninjured lung,

Clients should use a blowing pattern to overcome the

reducing oxygenation and venous return.

premature urge to push.

22. C. Prevent situations that may stimulate the cervix or

33. A. Cheeseburger and a malted

uterus

Of the selections offered, this is the highest in calories and

Stimulation of the cervix or uterus may cause bleeding or

protein, which are needed for increased basal metabolic rate

hemorrhage and should be avoided.

and for tissue repair.

23. C. Severe shortness of breath

34. B. Cyanotic lips and face

This could indicate a recurrence of the pneumothorax as one

Central cyanosis (blue lips and face) indicates lowered

side of the lung is inadequate to meet the oxygen demands

oxygenation of the blood, caused by either decreased lung

of the body.

expansion or right to left shunting of blood.

35. A. Notify the physician of the findings because the

46. D. Leg weakness with muscle cramps

level is dangerously high

Impulse conduction of skeletal muscle is impaired with

Levels close to 2 mEq/L are dangerously close to the toxic

decreased potassium levels, muscular weakness and

level; immediate action must be taken.

cramps may occur with hypokalemia.

36. C. Days 15 to 17

47. D. Simian lines on the hands

Ovulation occurs approximately 14 days before the next

This is characteristic finding in newborns with Down

menses, about the 16th day in 30 day cycle; the 15th to 17th

syndrome.

days would be the best time to avoid sexual intercourse.


48. B. Eyes
37. C. Assure that informed consent has been obtained

Rheumatoid arthritis can cause inflammation of the iris and

from the client

ciliary body of the eyes which may lead to blindness.

An invasive procedure such as amniocentesis requires


informed consent.

49. A. Accept the clients decision without discussion


This is all the nurse can do until trust is established; facing

38. D. Prevent development of respiratory distress

the client to attend will disrupt the group.

Respiratory distress or arrest may occur when the serum


level of magnesium sulfate reaches 12 to 15 mg/dl; deep

50. D. Provide a simple explanation of the procedure and

tendon reflexes disappear when the serum level is 10 to 12

continue to reassure the client

mg/dl; the drug is withheld in the absence of deep tendon

The nurse should offer support and use clear, simple terms

reflexes; the therapeutic serum level is 5 to 8 mg/dl.

to allay clients anxiety.

39. A. Obtaining the childs daily weight

51. D. If I have difficulty in inserting the irrigating tube

Weight monitoring is the most useful means of assessing

into the stoma

fluid balance and changes in the edematous state; 1 liter of

This occurs with stenosis of the stoma; forcing insertion of

fluid weighs about 2.2 pounds.

the tube could cause injury.

40. C. Reduces the inflammatory response of tissues

52. C. Blood loss of 850 ml after a vaginal birth

Corticosteroids act to decrease inflammation which

Excessive blood loss predisposes the client to an increased

decreases edema.

risk of infection because of decreased maternal resistance;


they expected blood loss is 350 to 500 ml.

41. D. An audible click on hip manipulation


With specific manipulation, an audible click may be heard of

53. A. Provide frequent saline mouthwashes

felt as he femoral head slips into the acetabulum.

This is soothing to the oral mucosa and helps prevent


infection.

42. B. Allow the denial but be available to discuss death


This does not remove clients only way of coping, and it

54. B. Society makes people react in old ways

permits future movement through the grieving process when

The client is incapable of accepting responsibility for self-

the client is ready.

created problems and blames society for the behavior.

43. B. Divide food into four to six meals a day

55. A. Taste and smell

The volume of food in the stomach should be kept small to

Swelling can obstruct nasal breathing, interfering with the

limit pressure on the cardiac sphincter.

senses of taste and smell.

44. B. I feel washed out; there isnt much left

56. A. Fatigue

The clients statement infers an emptiness with an

Fatigue is a major problem caused by an increase in waste

associated loss.

products because of catabolic processes.

45. A. Vitamin K is not absorbed

57. A. Offer the client assistance to the bathroom

Vitamin K, a fat soluble vitamin, is not absorbed from the GI

Statistics indicate that the most frequent cause of falls by

tract in the absence of bile; bile enters the duodenum via the

hospitalized clients is getting up or attempting to get up to

common bile duct.

the bathroom unassisted.

58. D. Turn completely over, sit momentarily without

mechanism can be involved, and blood pressure monitoring

support, reach to be picked up

is important.

These abilities are age-appropriate for the 6 month old child.


69. A. Nursing unit manager
59. D. Feed the baby on the unaffected breast first until

Controlled substance issues for a particular nursing unit are

the affected breast heals

the responsibility of that units nurse manager.

The most vigorous sucking will occur during the first few
minutes of breastfeeding when the infant would be on the

70. D. Encourage coughing, deep breathing, and range

unaffected breast; later suckling is less traumatic.

of motion to the arm on the affected side


All these interventions promote aeration of the re-expanding

60. D. Place sterile cotton loosely in the external ear of

lung and maintenance of function in the arm and shoulder on

the client

the affected side.

This would absorb the drainage without causing further


trauma.

71. A. For people to attain their birthrights of health and


longevity

61. D. Airing their feelings regarding the transmission of

According to Winslow, all public health efforts are for people

the disease to the child

to realize their birthrights of health and longevity.

Discussion with parents who have children with similar


problems helps to reduce some of their discomfort and guilt.

72. C. Swaroops index


Swaroops index is the percentage of the deaths aged 50

62. A. Suspicious feelings

years or older. Its inverse represents the percentage of

The nurse must deal with these feelings and establish basic

untimely deaths (those who died younger than 50 years).

trust to promote a therapeutic milieu.


73. D. Public health nursing focuses on preventive, not
63. A. Surgical menopause will occur

curative, services.

When a bilateral oophorectomy is performed, both ovaries

The catchment area in PHN consists of a residential

are excised, eliminating ovarian hormones and initiating

community, many of whom are well individuals who have

response.

greater need for preventive rather than curative services.

64. D. Pointing out to the client that death can occur with

74. B. Ensure the accessibility and quality of health care

malnutrition.

Ensuring the accessibility and quality of health care is the

The client expects the nurse to focus on eating, but the

primary mission of DOH.

emphasis should be placed on feelings rather than actions.


75. B. Efficiency
65. B. Medication is not adequately effective

Efficiency is determining whether the goals were attained at

The expected effect should be more than a one point

the least possible cost.

decrease in the pain level.


76. D. Rural Health Unit
66. B. Assisting the parents to stimulate their baby

R.A. 7160 devolved basic health services to local

through touch, sound, and sight.

government units (LGUs ). The public health nurse is an

Stimuli are provided via all the senses; since the infants

employee of the LGU.

behavioral development is enhanced through parent-infant


interactions, these interactions should be encouraged.

77. A. Act 3573


Act 3573, the Law on Reporting of Communicable Diseases,

67. D. Recognize himself as an independent person of

enacted in 1929, mandated the reporting of diseases listed in

worth

the law to the nearest health station.

Academic deficits, an inability to function within constraints


required of certain settings, and negative peer attitudes often

78. A. Primary

lead to low self-esteem.

The purpose of isolating a client with a communicable


disease is to protect those who are not sick (specific disease

68. B. Monitoring the childs blood pressure


Because the tumor is of renal origin, the rennin angiotensin

prevention).

79. B. It provides an opportunity to do first hand

88. C. Avoidance

appraisal of the home situation.

This strategy shuns discussing the issue head-on and

Choice A is not correct since a home visit requires that the

prefers to postpone it to a later time. In effect the problem

nurse spend so much time with the family. Choice C is an

remains unsolved and both parties are in a lose-lose

advantage of a group conference, while choice D is true of a

situation.

clinic consultation.
89. A. Staffing
80. B. Should minimize if not totally prevent the spread

Staffing is a management function involving putting the best

of infection.

people to accomplish tasks and activities to attain the goals

Bag technique is performed before and after handling a

of the organization.

client in the home to prevent transmission of infection to and


from the client.

90. B. Decentralized
Decentralized structures allow the staff to make decisions on

81. A. Bag technique is performed before and after

matters pertaining to their practice and communicate in

handling a client in the home to prevent transmission of

downward, upward, lateral and diagonal flow.

infection to and from the client.


Path Goal theory according to House and associates

91. D. end each entry with the nurses signature and

rewards good performance so that others would do the

title.

same.

The end of each entry should include the nurses signature


and title; the signature holds the nurse accountable for the

82. D. Inspires others with vision

recorded information. Erasing errors in documentation on a

Inspires others with a vision is characteristic of a

legal document such as a clients chart isnt permitted by law.

transformational leader. He is focused more on the day-to-

Because a clients medical record is considered a legal

day operations of the department/unit.

document, the nurse should make all entries in ink. The


nurse is accountable for the information recorded and

83. A. Psychological and sociological needs are

therefore shouldnt leave any blank lines in which another

emphasized.

health care worker could make additions.

When the functional method is used, the psychological and


sociological needs of the patients are neglected; the patients

92. A. Allergies and socioeconomic status

are regarded as tasks to be done

General background data consist of such components as


allergies, medical history, habits, socioeconomic status,

84. B. Preparing a nursing care plan in collaboration

lifestyle, beliefs, and sensory deficits. Urine output, gastric

with the patient

reflex, and bowel habits are significant only if a disease

The best source of information about the priority needs of the

affecting these functions is present.

patient is the patient himself. Hence using a nursing care


plan based on his expressed priority needs would ensure

93. C. I.V. cannula insertion

meeting his needs effectively.

Caregivers must use surgical asepsis when performing


wound care or any procedure in which a sterile body cavity is

85. C. Unity of command

entered or skin integrity is broken. To achieve surgical

The principle of unity of command means that employees

asepsis, objects must be rendered or kept free of all

should receive orders coming from only one manager and

pathogens. Inserting an I.V. cannula requires surgical

not from two managers. This averts the possibility of sowing

asepsis because it disrupts skin integrity and involves entry

confusion among the members of the organization.

into a sterile cavity (a vein). The other options are used to


ensure medical asepsis or clean technique to prevent the

86. A. Increase the patient satisfaction rate

spread of infection. The GI tract isnt sterile; therefore,

Goal is a desired result towards which efforts are directed.

irrigating a nasogastric tube or a colostomy requires only

Options AB, C and D are all objectives which are aimed at

clean technique.

specific end.
94. B. Pouring solution onto a sterile field cloth
87. A. Uses visioning as the essence of leadership

Pouring solution onto a sterile field cloth violates surgical

Transformational leadership relies heavily on visioning as the

asepsis because moisture penetrating the cloth can carry

core of leadership.

microorganisms to the sterile field via capillary action. The


other options are practices that help ensure surgical asepsis.

95. C. Impaired gas exchange


The client has a below-normal value for the partial pressure
of arterial oxygen (PaO2) and an above-normal value for the
partial pressure of arterial carbon dioxide (PaCO2),
supporting the nursing diagnosis of Impaired gas exchange.
ABG values cant indicate a diagnosis of Fluid volume deficit
(or excess) or Risk for deficient fluid volume. Metabolic
acidosis is a medical, not nursing, diagnosis; in any event,
these ABG values indicate respiratory, not metabolic,
acidosis.
96. A. Stream seeding
Stream seeding is done by putting tilapia fry in streams or
other bodies of water identified as breeding places of the
Anopheles mosquito.
97. B. Severe dehydration
The order of priority in the management of severe
dehydration is as follows: intravenous fluid therapy, referral to
a facility where IV fluids can be initiated within 30 minutes,
Oresol/nasogastric tube, Oresol/orem. When the foregoing
measures are not possible or effective, tehn urgent referral to
the hospital is done.
98. A. Inability to drink
A sick child aged 2 months to 5 years must be referred
urgently to a hospital if he/she has one or more of the
following signs: not able to feed or drink, vomits everything,
convulsions, abnormally sleepy or difficult to awaken.
99. A. Sugar
R.A. 8976 mandates fortification of rice, wheat flour, sugar
and cooking oil with Vitamin A, iron and/or iodine.
100. A. Palms
The anatomic characteristics of the palms allow a reliable
and convenient basis for examination for pallor.

1. A woman in a child bearing age receives a rubella


vaccination. Nurse Joy would give her which of the following
instructions?
a. Refrain from eating eggs or egg products for 24 hours
b. Avoid having sexual intercourse
c. Dont get pregnant at least 3 months
d. Avoid exposure to sun
2. Jonas who is diagnosed with encephalitis is under the
treatment of Mannitol. Which of the following patient
outcomes indicate to Nurse Ronald that the treatment of
Mannitol has been effective for a patient that has increased
intracranial pressure?
a. Increased urinary output
b. Decreased RR
c. Slowed pupillary response
d. Decreased level of consciousness
3. Mary asked Nurse Maureen about the incubation period of
rabies. Which statement by the Nurse Maureen is
appropriate?
a. Incubation period is 6 months
b. Incubation period is 1 week
c. Incubation period is 1 month
d. Incubation period varies depending on the site of the bite
4. Which of the following should Nurse Cherry do first in
taking care of a male client with rabies?

a. Encourage the patient to take a bath

c. BCG vaccination

b. Cover IV bottle with brown paper bag

d. DPT vaccination

c. Place the patient near the comfort room


d. Place the patient near the door

11. A bacteria which causes diphtheria is also known as?

5. Which of the following is the screening test for dengue

a. Amoeba

hemorrhagic fever?

b. Cholera
c. Klebs-loeffler bacillus

a. Complete blood count

d. Spirochete

b. ELISA
c. Rumpel-leede test

12. Nurse Ron performed mantoux skin test today (Monday)

d. Sedimentation rate

to a male adult client. Which statement by the client indicates


that he understood the instruction well?

6. Mr. Dela Rosa is suspected to have malaria after a


business trip in Palawan. The most important diagnostic test

a. I will come back later

in malaria is:

b. I will come back next month


c. I will come back on Friday

a. WBC count

d. I will come back on Wednesday, same time, to read the

b. Urinalysis

result

c. ELISA
d. Peripheral blood smear

13. A male client had undergone Mantoux skin test. Nurse


Ronald notes an 8mm area of indurations at the site of the

7. The Nurse supervisor is planning for patients assignment

skin test. The nurse interprets the result as:

for the AM shift. The nurse supervisor avoids assigning


which of the following staff members to a client with herpes

a. Negative

zoster?

b. Uncertain and needs to be repeated


c. Positive

a. Nurse who never had chicken pox

d. Inconclusive

b. Nurse who never had roseola


c. Nurse who never had german measles

14. Tony will start a 6 month therapy with Isoniazid (INH).

d. Nurse who never had mumps

Nurse Trish plans to teach the client to:

8. Clarissa is 7 weeks pregnant. Further examination

a. Use alcohol moderately

revealed that she is susceptible to rubella. When would be

b. Avoid vitamin supplements while o therapy

the most appropriate for her to receive rubella immunization?

c. Incomplete intake of dairy products


d. May be discontinued if symptoms subsides

a. At once
b. During 2nd trimester

15. Which is the primary characteristic lesion of syphilis?

c. During 3rd trimester


d. After the delivery of the baby

a. Sore eyes
b. Sore throat

9. A female child with rubella should be isolated from a:

c. Chancroid
d. Chancre

a. 21 year old male cousin living in the same house


b. 18 year old sister who recently got married

16. What is the fast breathing of Jana who is 3 weeks old?

c. 11 year old sister who had rubeola during childhood


d. 4 year old girl who lives next door

a. 60 breaths per minute


b. 40 breaths per minute

10. What is the primary prevention of leprosy?

c. 10 breaths per minute


d. 20 breaths per minute

a. Nutrition
b. Vitamins

17. Which of the following signs and symptoms indicate

24. Temperature of refrigerator to maintain potency of

some dehydration?

measles and OPV vaccine is:

a. Drinks eagerly

a. -3c to -8c

b. Restless and irritable

b. -15c to -25c

c. Unconscious

c. +15c to +25c

d. A and B

d. +3c to +8c

18. What is the first line for dysentery?

25. Diptheria is a:

a. Amoxicillin

a. Bacterial toxin

b. Tetracycline

b. Killed bacteria

c. Cefalexin

c. Live attenuated

d. Cotrimoxazole

d. Plasma derivatives

19. In home made oresol, what is the ratio of salt and sugar

26. Budgeting is under in which part of management

if you want to prepare with 1 liter of water?

process?

a. 1 tbsp. salt and 8 tbsp. sugar

a. Directing

b. 1 tbsp. salt and 8 tsp. sugar

b. Controlling

c. 1 tsp. salt and 8 tsp. sugar

c. Organizing

d. 8 tsp. salt and 8 tsp. sugar

d. Planning

20. Gentian Violet is used for:

27. Time table showing planned work days and shifts of


nursing personnel is:

a. Wound
b. Umbilical infections

a. Staffing

c. Ear infections

b. Schedule

d. Burn

c. Scheduling
d. Planning

21. Which of the following is a live attenuated bacterial


vaccine?

28. A force within an individual that influences the strength of


behavior?

a. BCG
b. OPV

a. Motivation

c. Measles

b. Envy

d. None of the above

c. Reward
d. Self-esteem

22. EPI is based on?


29. To be the leading hospital in the Philippines is best
a. Basic health services

illustrate in:

b. Scope of community affected


c. Epidemiological situation

a. Mission

d. Research studies

b. Philosophy
c. Vision

23. TT2 provides how many percentage of protection against

d. Objective

tetanus?
30. It is the professionally desired norms against which a
a. 100

staff performance will be compared?

b. 99
c. 80

a. Job descriptions

d. 90

b. Survey

c. Flow chart

37. The first college of nursing that was established in the

d. Standards

Philippines is:

31. Reprimanding a staff nurse for work that is done

a. Fatima University

incorrectly is an example of what type of reinforcement?

b. Far Eastern University


c. University of the East

a. Feedback

d. University of Sto. Tomas

b. Positive reinforcement
c. Performance appraisal

38. Florence nightingale is born on:

d. Negative reinforcement
a. France
32. Questions that are answerable only by choosing an

b. Britain

option from a set of given alternatives are known as?

c. U.S
d. Italy

a. Survey
b. Close ended

39. Objective data is also called:

c. Questionnaire
d. Demographic

a. Covert
b. Overt

33. A researcher that makes a generalization based on

c. Inference

observations of an individuals behavior is said to be which

d. Evaluation

type of reasoning:
40. An example of subjective data is:
a. Inductive
b. Logical

a. Size of wounds

c. Illogical

b. VS

d. Deductive

c. Lethargy
d. The statement of patient My hand is painful

34. The balance of a researchs benefit vs. its risks to the


subject is:

41. What is the best position in palpating the breast?

a. Analysis

a. Trendelenburg

b. Risk-benefit ratio

b. Side lying

c. Percentile

c. Supine

d. Maximum risk

d. Lithotomy

35. An individual/object that belongs to a general population

42. When is the best time in performing breast self

is a/an:

examination?

a. Element

a. 7 days after menstrual period

b. Subject

b. 7 days before menstrual period

c. Respondent

c. 5 days after menstrual period

d. Author

d. 5 days before menstrual period

36. An illustration that shows how the members of an

43. Which of the following should be given the highest

organization are connected:

priority before performing physical examination to a patient?

a. Flowchart

a. Preparation of the room

b. Bar graph

b. Preparation of the patient

c. Organizational chart

c. Preparation of the nurse

d. Line graph

d. Preparation of environment

44. It is a flip over card usually kept in portable file at nursing

a. 2 kilograms

station.

b. 1 kilograms
c. 100 grams

a. Nursing care plan

d. 1.5 kilograms

b. Medicine and treatment record


c. Kardex

51. After delivery of a baby girl. Nurse Gina examines the

d. TPR sheet

umbilical cord and expects to find a cord to:

45. Jose has undergone thoracentesis. The nurse in charge

a. Two arteries and two veins

is aware that the best position for Jose is:

b. One artery and one vein


c. Two arteries and one vein

a. Semi fowlers

d. One artery and two veins

b. Low fowlers
c. Side lying, unaffected side

52. Myrna a pregnant client reports that her last menstrual

d. Side lying, affected side

cycle is July 11, her expected date of birth is

46. The degree of patients abdominal distension may be

a. November 4

determined by:

b. November 11
c. April 4

a. Auscultation

d. April 18

b. Palpation
c. Inspection

53. Which of the following is not a good source of iron?

d. Percussion
a. Butter
47. A male client is addicted with hallucinogen. Which

b. Pechay

physiologic effect should the nurse expect?

c. Grains
d. Beef

a. Bradyprea
b. Bradycardia

54. Maureen is admitted with a diagnosis of ectopic

c. Constricted pupils

pregnancy. Which of the following would you anticipate?

d. Dilated pupils
a. NPO
48. Tristan a 4 year old boy has suffered from full thickness

b. Bed rest

burns of the face, chest and neck. What will be the priority

c. Immediate surgery

nursing diagnosis?

d. Enema

a. Ineffective airway clearance related to edema

55. Gina a postpartum client is diagnosed with endometritis.

b. Impaired mobility related to pain

Which position would you expect to place her based on this

c. Impaired urinary elimination related to fluid loss

diagnosis?

d. Risk for infection related to epidermal disruption


a. Supine
49. In assessing a clients incision 1 day after the surgery,

b. Left side lying

Nurse Betty expect to see which of the following as signs of

c. Trendelinburg

a local inflammatory response?

d. Semi-fowlers

a. Greenish discharge

56. Nurse Hazel knows that Myrna understands her

b. Brown exudates at incision edges

condition well when she remarks that urinary frequency is

c. Pallor around sutures

caused by:

d. Redness and warmth


a. Pressure caused by the ascending uterus
50. Nurse Ronald is aware that the amniotic fluid in the third
trimester weighs approximately:

b. Water intake of 3L a day

c. Effect of cold weather

63. On 2nd postpartum day, which height would you expect

d. Increase intake of fruits and vegetables

to find the fundus in a woman who has had a caesarian


birth?

57. How many ml of blood is loss during the first 24 hours


post delivery of Myrna?

a. 1 finger above umbilicus


b. 2 fingers above umbilicus

a. 100

c. 2 fingers below umbilicus

b. 500

d. 1 finger below umbilicus

c. 200
d. 400

64. Which of the following criteria allows Nurse Kris to


perform home deliveries?

58. Which of the following hormones stimulates the secretion


of milk?

a. Normal findings during assessment


b. Previous CS

a. Progesterone

c. Diabetes history

b. Prolactin

d. Hypertensive history

c. Oxytocin
d. Estrogen

65. Nurse Carla is aware that one of the following vaccines is


done by intramuscular (IM) injection?

59. Nurse Carla is aware that Mylas second stage of labor is


beginning when the following assessment is noted:

a. Measles
b. OPV

a. Bay of water is broken

c. BCG

b. Contractions are regular

d. Tetanus toxoid

c. Cervix is completely dilated


d. Presence of bloody show

66. Asin law is on which legal basis:

60. The leaking fluid is tested with nitrazine paper. Nurse

a. RA 8860

Kelly confirms that the clients membrane have ruptures

b. RA 2777

when the paper turns into a:

c. RI 8172
d. RR 6610

a. Pink
b. Violet

67. Nurse John is aware that the herbal medicine

c. Green

appropriate for urolithiasis is:

d. Blue
a. Akapulko
61. After amniotomy, the priority nursing action is:

b. Sambong
c. Tsaang gubat

a. Document the color and consistency of amniotic fluid

d. Bayabas

b. Listen the fetal heart tone


c. Position the mother in her left side

68. Community/Public health bag is defined as:

d. Let the mother rest


a. An essential and indispensable equipment of the
62. Which is the most frequent reason for postpartum

community health nurse during home visit

hemorrhage?

b. It contains drugs and equipment used by the community


health nurse

a. Perineal lacerations

c. Is a requirement in the health center and for home visit

b. Frequent internal examination (IE)

d. It is a tool used by the community health nurse in

c. CS

rendering effective procedures during home visit

d. Uterine atony
69. TT4 provides how many percentage of protection against
tetanus?

a. 70

c. March 1985

b. 80

d. June 1985

c. 90
d. 99

76. Baby Reese is a 12 month old child. Nurse Oliver would


anticipate how many teeth?

70. Third postpartum visit must be done by public health


nurse:

a. 9
b. 7

a. Within 24 hours after delivery

c. 8

b. After 2-4 weeks

d. 6

c. Within 1 week
d. After 2 months

77. Which of the following is the primary antidote for Tylenol


poisoning?

71. Nurse Candy is aware that the family planning method


that may give 98% protection to another pregnancy to

a. Narcan

women

b. Digoxin
c. Acetylcysteine

a. Pills

d. Flumazenil

b. Tubal ligation
c. Lactational Amenorrhea method (LAM)

78. A male child has an intelligence quotient of

d. IUD

approximately 40. Which kind of environment and


interdisciplinary program most likely to benefit this child

72. Which of the following is not a part of IMCI case

would be best described as:

management process
a. Habit training
a. Counsel the mother

b. Sheltered workshop

b. Identify the illness

c. Custodial

c. Assess the child

d. Educational

d. Treat the child


79. Nurse Judy is aware that following condition would reflect
73. If a young child has pneumonia when should the mother

presence of congenital G.I anomaly?

bring him back for follow up?


a. Cord prolapse
a. After 2 days

b. Polyhydramios

b. In the afternoon

c. Placenta previa

c. After 4 days

d. Oligohydramnios

d. After 5 days
80. Nurse Christine provides health teaching for the parents
74. It is the certification recognition program that develop

of a child diagnosed with celiac disease. Nurse Christine

and promotes standard for health facilities:

teaches the parents to include which of the following food


items in the childs diet:

a. Formula
b. Tutok gamutan

a. Rye toast

c. Sentrong program movement

b. Oatmeal

d. Sentrong sigla movement

c. White bread
d. Rice

75. Baby Marie was born May 23, 1984. Nurse John will
expect finger thumb opposition on:

81. Nurse Randy is planning to administer oral medication to


a 3 year old child. Nurse Randy is aware that the best way to

a. April 1985
b. February 1985

proceed is by:

a. Would you like to drink your medicine?

c. Date of Application

b. If you take your medicine now, Ill give you lollipop

d. Signature of PRC chairperson

c. See the other boy took his medicine? Now its your turn.
d. Heres your medicine. Would you like a mango or orange

88. Breastfeeding is being enforced by milk code or:

juice?
a. EO 51
82. At what age a child can brush her teeth without help?

b. R.A. 7600
c. R.A. 6700

a. 6 years

d. P.D. 996

b. 7 years
c. 5 years

89. Self governance, ability to choose or carry out decision

d. 8 years

without undue pressure or coercion from anyone:

83. Ribivarin (Virazole) is prescribed for a female

a. Veracity

hospitalized child with RSV. Nurse Judy prepare this

b. Autonomy

medication via which route?

c. Fidelity
d. Beneficence

a. Intravenous
b. Oral

90. A male patient complained because his scheduled

c. Oxygen tent

surgery was cancelled because of earthquake. The hospital

d. Subcutaneous

personnel may be excused because of:

84. The present chairman of the Board of Nursing in the

a. Governance

Philippines is:

b. Respondeat superior
c. Force majeure

a. Maria Joanna Cervantes

d. Res ipsa loquitur

b. Carmencita Abaquin
c. Leonor Rosero

91. Being on time, meeting deadlines and completing all

d. Primitiva Paquic

scheduled duties is what virtue?

85. The obligation to maintain efficient ethical standards in

a. Fidelity

the practice of nursing belong to this body:

b. Autonomy
c. Veracity

a. BON

d. Confidentiality

b. ANSAP
c. PNA

92. This quality is being demonstrated by Nurse Ron who

d. RN

raises the side rails of a confused and disoriented patient?

86. A male nurse was found guilty of negligence. His license

a. Responsibility

was revoked. Re-issuance of revoked certificates is after how

b. Resourcefulness

many years?

c. Autonomy
d. Prudence

a. 1 year
b. 2 years

93. Which of the following is formal continuing education?

c. 3 years
d. 4 years

a. Conference
b. Enrollment in graduate school

87. Which of the following information cannot be seen in the

c. Refresher course

PRC identification card?

d. Seminar

a. Registration Date

94. The BSN curriculum prepares the graduates to become?

b. License Number

a. Nurse generalist

c. Encourage to exercise

b. Nurse specialist

d. Assist client towards a peaceful death

c. Primary health nurse


d. Clinical instructor

101. The Nurse is aware that the ability to enter into the life
of another person and perceive his current feelings and their

95. Disposal of medical records in government

meaning is known:

hospital/institutions must be done in close coordination with


what agency?

a. Belongingness
b. Genuineness

a. Department of Health

c. Empathy

b. Records Management Archives Office

d. Respect

c. Metro Manila Development Authority


d. Bureau of Internal Revenue

102. The termination phase of the NPR is best described


one of the following:

96. Nurse Jolina must see to it that the written consent of


mentally ill patients must be taken from:

a. Review progress of therapy and attainment of goals


b. Exploring the clients thoughts, feelings and concerns

a. Nurse

c. Identifying and solving patients problem

b. Priest

d. Establishing rapport

c. Family lawyer
d. Parents/legal guardians

103. During the process of cocaine withdrawal, the physician


orders which of the following:

97. When Nurse Clarence respects the clients selfdisclosure, this is a gauge for the nurses:

a. Haloperidol (Haldol)
b. Imipramine (Tofranil)

a. Respectfulness

c. Benztropine (Cogentin)

b. Loyalty

d. Diazepam (Valium)

c. Trustworthiness
d. Professionalism

104. The nurse is aware that cocaine is classified as:

98. The Nurse is aware that the following tasks can be safely

a. Hallucinogen

delegated by the nurse to a non-nurse health worker except:

b. Psycho stimulant
c. Anxiolytic

a. Taking vital signs

d. Narcotic

b. Change IV infusions
c. Transferring the client from bed to chair

105. In community health nursing, it is the most important

d. Irrigation of NGT

risk factor in the development of mental illness?

99. During the evening round Nurse Tina saw Mr. Toralba

a. Separation of parents

meditating and afterwards started singing prayerful hymns.

b. Political problems

What would be the best response of Nurse Tina?

c. Poverty
d. Sexual abuse

a. Call the attention of the client and encourage to sleep


b. Report the incidence to head nurse

106. All of the following are characteristics of crisis except

c. Respect the clients action


d. Document the situation

a. The client may become resistive and active in stopping the


crisis

100. In caring for a dying client, you should perform which of

b. It is self-limiting for 4-6 weeks

the following activities

c. It is unique in every individual


d. It may also affect the family of the client

a. Do not resuscitate
b. Assist client to perform ADL

107. Freud states that temper tantrums is observed in which

a. Anti depressants

of the following:

b. Antipsychotics
c. Anti manic

a. Oral

d. Anti anxiety

b. Anal
c. Phallic

114. The priority of care for a client with Alzheimers disease

d. Latency

is

108. The nurse is aware that ego development begins

a. Help client develop coping mechanism

during:

b. Encourage to learn new hobbies and interest


c. Provide him stimulating environment

a. Toddler period

d. Simplify the environment to eliminate the need to make

b. Preschool age

chores

c. School age
d. Infancy

115. Autism is diagnosed at:

109. Situation: A 19 year old nursing student has lost 36 lbs

a. Infancy

for 4 weeks. Her parents brought her to the hospital for

b. 3 years old

medical evaluation. The diagnosis was ANOREXIA

c. 5 years old

NERVOSA. The Primary gain of a client with anorexia

d. School age

nervosa is:
116. The common characteristic of autism child is:
a. Weight loss
b. Weight gain

a. Impulsivity

c. Reduce anxiety

b. Self destructiveness

d. Attractive appearance

c. Hostility
d. Withdrawal

110. The nurse is aware that the primary nursing diagnosis


for the client is:

117. The nurse is aware that the most common indication in


using ECT is:

a. Altered nutrition : less than body requirement


b. Altered nutrition : more than body requirement

a. Schizophrenia

c. Impaired tissue integrity

b. Bipolar

d. Risk for malnutrition

c. Anorexia Nervosa
d. Depression

111. After 14 days in the hospital, which finding indicates


that her condition in improving?

118. A therapy that focuses on here and now principle to


promote self-acceptance?

a. She tells the nurse that she had no idea that she is thin
b. She arrives earlier than scheduled time of group therapy

a. Gestalt therapy

c. She tells the nurse that she eat 3 times or more in a day

b. Cognitive therapy

d. She gained 4 lbs in two weeks

c. Behavior therapy
d. Personality therapy

112. The nurse is aware that ataractics or psychic energizers


are also known as:

119. A client has many irrational thoughts. The goal of


therapy is to change her:

a. Anti manic
b. Anti depressants

a. Personality

c. Antipsychotics

b. Communication

d. Anti anxiety

c. Behavior
d. Cognition

113. Known as mood elevators:

120. The appropriate nutrition for Bipolar I disorder, in manic

c. High carbohydrate, low protein

phase is:

d. High calcium, high protein

a. Low fat, low sodium

127. Which of the following cannot be corrected by dialysis?

b. Low calorie, high fat


c. Finger foods, high in calorie

a. Hypernatremia

d. Small frequent feedings

b. Hyperkalemia
c. Elevated creatinine

121. Which of the following activity would be best for a

d. Decreased hemoglobin

depressed client?
128. Tony with infection is receiving antibiotic therapy. Later
a. Chess

the client complaints of ringing in the ears. This ototoxicity is

b. Basketball

damage to:

c. Swimming
d. Finger painting

a. 4th CN
b. 8th CN

122. The nurse is aware that clients with severe depression,

c. 7th CN

possess which defense mechanism:

d. 9th CN

a. Introjection

129. Nurse Emma provides teaching to a patient with

b. Suppression

recurrent urinary tract infection includes the following:

c. Repression
d. Projection

a. Increase intake of tea, coffee and colas


b. Void every 6 hours per day

123. Nurse John is aware that self mutilation among Bipolar

c. Void immediately after intercourse

disorder patients is a means of:

d. Take tub bath everyday

a. Overcoming fear of failure

130. Which assessment finding indicates circulatory

b. Overcoming feeling of insecurity

constriction in a male client with a newly applied long leg

c. Relieving depression

cast?

d. Relieving anxiety
a. Blanching or cyanosis of legs
124. Which of the following may cause an increase in the

b. Complaints of pressure or tightness

cystitis symptoms?

c. Inability to move toes


d. Numbness of toes

a. Water
b. Orange juice

131. During acute gout attack, the nurse administer which of

c. Coffee

the following drug:

d. Mango juice
a. Prednisone (Deltasone)
125. In caring for clients with renal calculi, which is the

b. Colchicines

priority nursing intervention?

c. Aspirin
d. Allopurinol (Zyloprim)

a. Record vital signs


b. Strain urine

132. Information in the patients chart is inadmissible in court

c. Limit fluids

as evidence when:

d. Administer analgesics as prescribed


a. The client objects to its use
126. In patient with renal failure, the diet should be:

b. Handwriting is not legible


c. It has too many unofficial abbreviations

a. Low protein, low sodium, low potassium


b. Low protein, high potassium

d. The clients parents refuses to use it

133. Nurse Karen is revising a client plan of care. During

a. 1990-1993

which step of the nursing process does such revision take

b. 2001-2002

place?

c. 1994-1996
d. 2005-2008

a. Planning
b. Implementation

140. The nurse is assessing a female client with possible

c. Diagnosing

diagnosis of osteoarthritis. The most significant risk factor for

d. Evaluation

osteoarthritis is:

134. When examining a client with abdominal pain, Nurse

a. Obesity

Hazel should assess:

b. Race
c. Job

a. Symptomatic quadrant either second or first

d. Age

b. The symptomatic quadrant last


c. The symptomatic quadrant first

141. A male client complains of vertigo. Nurse Bea

d. Any quadrant

anticipates that the client may have a problem with which


portion of the ear?

135. How long will nurse John obtain an accurate reading of


temperature via oral route?

a. Tymphanic membranes
b. Inner ear

a. 3 minutes

c. Auricle

b. 1 minute

d. External ear

c. 8 minutes
d. 15 minutes

142. When performing Webers test, Nurse Rosean expects


that this client will hear

136. The one filing the criminal care against an accused


party is said to be the?

a. On unaffected side
b. Longer through bone than air conduction

a. Guilty

c. On affected side by bone conduction

b. Accused

d. By neither bone or air conduction

c. Plaintiff
d. Witness

143. Toy with a tentative diagnosis of myasthenia gravis is


admitted for diagnostic make up. Myasthenia gravis can

137. A male client has a standing DNR order. He then

confirmed by:

suddenly stopped breathing and you are at his bedside. You


would:

a. Kernigs sign
b. Brudzinskis sign

a. Call the physician

c. A positive sweat chloride test

b. Stay with the client and do nothing

d. A positive edrophonium (Tensilon) test

c. Call another nurse


d. Call the family

144. A male client is hospitalized with Guillain-Barre


Syndrome. Which assessment finding is the most

138. The ANA recognized nursing informatics heralding its

significant?

establishment as a new field in nursing during what year?


a. Even, unlabored respirations
a. 1994

b. Soft, non distended abdomen

b. 1992

c. Urine output of 50 ml/hr

c. 2000

d. Warm skin

d. 2001
145. For a female client with suspected intracranial pressure
139. When is the first certification of nursing informatics
given?

(ICP), a most appropriate respiratory goal is:

a. Maintain partial pressure of arterial oxygen (Pa O2) above

1c

80mmHg

2a

b. Promote elimination of carbon dioxide

3d

c. Lower the PH

4b

d. Prevent respiratory alkalosis

5c
6d

146. Which nursing assessment would identify the earliest

7a

sign of ICP?

8d
9b

a. Change in level of consciousness

10 c

b. Temperature of over 103F

11 c

c. Widening pulse pressure

12 d

d. Unequal pupils

13 c
14 b

147. The greatest danger of an uncorrected atrial fibrillation

15 d

for a male patient will be which of the following:

16 a
17 d

a. Pulmonary embolism

18 d

b. Cardiac arrest

19 c

c. Thrombus formation

20 b

d. Myocardial infarction

21 a
22 c

148. Linda, A 30 year old post hysterectomy client has visited

23 d

the health center. She inquired about BSE and asked the

24 b

nurse when BSE should be performed. You answered that

25 a

the BSE is best performed:

26 d
27 b

a. 7 days after menstruation

28 a

b. At the same day each month

29 c

c. During menstruation

30 d

d. Before menstruation

31 d
32 b

149. An infant is ordered to recive 500 ml of D5NSS for 24

33 a

hours. The Intravenous drip is running at 60 gtts/min. How

34 b

many drops per minute should the flow rate be?

35 a
36 c

a. 60 gtts/min.

37 d

b. 21 gtts/min

38 d

c. 30 gtts/min

39 b

d. 15 gtts/min

40 d
41 c

150. Mr. Gutierrez is to receive 1 liter of D5RL to run for 12

42 a

hours. The drop factor of the IV infusion set is 10 drops per

43 b

minute. Approximately how many drops per minutes should

44 c

the IV be regulated?

45 c
46 d

a. 13-14 drops

47 d

b. 17-18 drops

48 a

c. 10-12 drops

49 d

d. 15-16 drops

50 b

[divider] Answers

51 c

101 c

52 d

102 a

53 a

103 d

54 c

104 b

55 d

105 c

56 a

106 a

57 b

107 b

58 d

108 d

59 c

109 c

60 d

110 a

61 b

111 d

62 d

112 c

63 c

113 a

64 a

114 d

65 d

115 b

66 c

116 d

67 b

117 d

68 a

118 a

69 d

119 d

70 b

120 c

71 c

121 d

72 b

122 a

73 a

123 b

74 d

124 c

75 b

125 d

76 d

126 a

77 c

127 d

78 a

128 b

79 b

129 c

80 d

130 a

81 d

131 b

82 a

132 a

83 c

133 d

84 b

134 b

85 a

135 a

86 d

136 c

87 c

137 b

88 a

138 a

89 b

139 b

90 c

140 d

91 a

141 b

92 d

142 c

93 b

143 d

94 c

144 a

95 a

145 b

96 d

146 a

97 c

147 c

98 b

148 b

99 c

149 b

100 d

150 a

You might also like