PNLE Exam 1

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8182838485
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Text Mode

Text Mode – Text version of the exam

1. A 10 year old who has sustained a head injury is brought to the emergency department by his mother. A diagnosis of a mild concussion is made. At the time of discharge, nurse Ron should instruct the mother to:

  1. Withhold food and fluids for 24 hours.
  2. Allow him to play outdoors with his friends.
  3. Arrange for a follow up visit with the child’s primary care provider in one week.
  4. Check for any change in responsiveness every two hours until the follow-up visit.

2. A male client has suffered a motor accident and is now suffering from hypovolemic shock. Nurse Helen should frequency assess the client’s vital signs during the compensatory stage of shock, because:

  1. Arteriolar constriction occurs
  2. The cardiac workload decreases
  3. Decreased contractility of the heart occurs
  4. The parasympathetic nervous system is triggered

3. A paranoid male client with schizophrenia is losing weight, reluctant to eat, and voicing concerns about being poisoned. The best intervention by nurse Dina would be to:

  1. Allow the client to open canned or pre-packaged food
  2. Restrict the client to his room until 2 lbs are gained
  3. Have a staff member personally taste all of the client’s food
  4. Tell the client the food has been x-rayed by the staff and is safe

4. One day the mother of a young adult confides to nurse Frida that she is very troubled by he child’s emotional illness. The nurse’s most therapeutic initial response would be:

  1. “You may be able to lessen your feelings of guilt by seeking counseling”
  2. “It would be helpful if you become involved in volunteer work at this time”
  3. “I recognize it’s hard to deal with this, but try to remember that this too shall pass”
  4. “Joining a support group of parents who are coping with this problem can be quite helpful.

5. To check for wound hemorrhage after a client has had a surgery for the removal of a tumor in the neck, nurse grace should:

  1. Loosen an edge of the dressing and lift it to see the wound
  2. Observe the dressing at the back of the neck for the presence of blood
  3. Outline the blood as it appears on the dressing to observe any progression
  4. Press gently around the incision to express accumulated blood from the wound

6. A 16-year-old primigravida arrives at the labor and birthing unit in her 38th week of gestation and states that she is labor. To verify that the client is in true labor nurse Trina should:

  1. Obtain sides for a fern test
  2. Time any uterine contractions
  3. Prepare her for a pelvic examination
  4. Apply nitrazine paper to moist vaginal tissue

7. As part of the diagnostic workup for pulmonic stenosis, a child has cardiac catheterization. Nurse Julius is aware that children with pulmonic stenosis have increased pressure:

  1. In the pulmonary vein
  2. In the pulmonary artery
  3. On the left side of the heart
  4. On the right side of the heart

8. An obese client asks nurse Julius how to lose weight. Before answering, the nurse should remember that long-term weight loss occurs best when:

  1. Eating patterns are altered
  2. Fats are limited in the diet
  3. Carbohydrates are regulated
  4. Exercise is a major component

9. As a very anxious female client is talking to the nurse May, she starts crying. She appears to be upset that she cannot control her crying. The most appropriate response by the nurse would be:

  1. “Is talking about your problem upsetting you?”
  2. “It is Ok to cry; I’ll just stay with you for now”
  3. “You look upset; lets talk about why you are crying.”
  4. “Sometimes it helps to get it out of your system.”

10. A patient has partial-thickness burns to both legs and portions of his trunk. Which of the following I.V. fluids is given first?

  1. Albumin
  2. D5W
  3. Lactated Ringer’s solution
  4. 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml

11. During the first 48 hours after a severe burn of 40% of the clients body surface, the nurse’s assessment should include observations for water intoxication. Associated adaptations include:

  1. Sooty-colored sputum
  2. Frothy pink-tinged sputum
  3. Twitching and disorientation
  4. Urine output below 30ml per hour

12. After a muscle biopsy, nurse Willy should teach the client to:

  1. Change the dressing as needed
  2. Resume the usual diet as soon as desired
  3. Bathe or shower according to preference
  4. Expect a rise in body temperature for 48 hours

13. Before a client whose left hand has been amputated can be fitted for a prosthesis, nurse Joy is aware that:

  1. Arm and shoulder muscles must be developed
  2. Shrinkage of the residual limb must be completed
  3. Dexterity in the other extremity must be achieved
  4. Full adjustment to the altered body image must have occurred

14. Nurse Cathy applies a fetal monitor to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beat per minute deceleration of the fetal heart rate below the baseline lasting 15 seconds. Nurse Cathy should:

  1. Change the maternal position
  2. Prepare for an immediate birth
  3. Call the physician immediately
  4. Obtain the client’s blood pressure

15. A male client receiving prolonged steroid therapy complains of always being thirsty and urinating frequently. The best initial action by the nurse would be to:

  1. Perform a finger stick to test the client’s blood glucose level
  2. Have the physician assess the client for an enlarged prostate
  3. Obtain a urine specimen from the client for screening purposes
  4. Assess the client’s lower extremities for the presence of pitting edema

16. Nurse Bea recognizes that a pacemaker is indicated when a client is experiencing:

  1. Angina
  2. Chest pain
  3. Heart block
  4. Tachycardia

17. When administering pancrelipase (Pancreases capsules) to child with cystic fibrosis, nurse Faith knows they should be given:

  1. With meals and snacks
  2. Every three hours while awake
  3. On awakening, following meals, and at bedtime
  4. After each bowel movement and after postural draianage

18. A preterm neonate is receiving oxygen by an overhead hood. During the time the infant is under the hood, it would be appropriate for nurse Gian to:

  1. Hydrate the infant q15 min
  2. Put a hat on the infant’s head
  3. Keep the oxygen concentration consistent
  4. Remove the infant q15 min for stimulation

19. A client’s sputum smears for acid fast bacilli (AFB) are positive, and transmission-based airborne precautions are ordered. Nurse Kyle should instruct visitors to:

  1. Limit contact with non-exposed family members
  2. Avoid contact with any objects present in the client’s room
  3. Wear an Ultra-Filter mask when they are in the client’s room
  4. Put on a gown and gloves before going into the client’s room

20. A client with a head injury has a fixed, dilated right pupil; responds only to painful stimuli; and exhibits decorticate posturing. Nurse Kate should recognize that these are signs of:

  1. Meningeal irritation
  2. Subdural hemorrhage
  3. Medullary compression
  4. Cerebral cortex compression

21. After a lateral crushing chest injury, obvious right-sided paradoxic motion of the client’s chest demonstrates multiple rib fraactures, resulting in a flail chest. The complication the nurse should carefully observe for would be:

  1. Mediastinal shift
  2. Tracheal laceration
  3. Open pneumothorax
  4. Pericardial tamponade

22. When planning care for a client at 30-weeks gestation, admitted to the hospital after vaginal bleeding secondary to placenta previa, the nurse’s primary objective would be:

  1. Provide a calm, quiet environment
  2. Prepare the client for an immediate cesarean birth
  3. Prevent situations that may stimulate the cervix or uterus
  4. Ensure that the client has regular cervical examinations assess for labor

23. When planning discharge teaching for a young female client who has had a pneumothorax, it is important that the nurse include the signs and symptoms of a pneumothorax and teach the client to seek medical assistance if she experiences:

  1. Substernal chest pain
  2. Episodes of palpitation
  3. Severe shortness of breath
  4. Dizziness when standing up

24. After a laryngectomy, the most important equipment to place at the client’s bedside would be:

  1. Suction equipment
  2. Humidified oxygen
  3. A nonelectric call bell
  4. A cold-stream vaporizer

25. Nurse Oliver interviews a young female client with anorexia nervosa to obtain information for the nursing history. The client’s history is likely to reveal a:

  1. Strong desire to improve her body image
  2. Close, supportive mother-daughter relationship
  3. Satisfaction with and desire to maintain her present weight
  4. Low level of achievement in school, with little concerns for grades
26. Nurse Bea should plan to assist a client with an obsessive-compulsive disorder to control the use of ritualistic behavior by:
  1. Providing repetitive activities that require little thought
  2. Attempting to reduce or limit situations that increase anxiety
  3. Getting the client involved with activities that will provide distraction
  4. Suggesting that the client perform menial tasks to expiate feelings of guilt

27. A 2 ½ year old child undergoes a ventriculoperitoneal shunt revision. Before discharge, nurse John, knowing the expected developmental behaviors for this age group, should tell the parents to call the physician if the child:

  1. Tries to copy all the father’s mannerisms
  2. Talks incessantly regardless of the presence of others
  3. Becomes fussy when frustrated and displays a shortened attention span
  4. Frequently starts arguments with playmates by claiming all toys are “mine”

28. A urinary tract infection is a potential danger with an indwelling catheter. Nurse Gina can best plan to avoid this complication by:

  1. Assessing urine specific gravity
  2. Maintaining the ordered hydration
  3. Collecting a weekly urine specimen
  4. Emptying the drainage bag frequently

29. A client has sustained a fractured right femur in a fall on stairs. Nurse Troy with the emergency response team assess for signs of circulatory impairment by:

  1. Turning the client to side lying position
  2. Asking the client to cough and deep breathe
  3. Taking the client’s pedal pulse in the affected limb
  4. Instructing the client to wiggle the toes of the right foot

30. To assess orientation to place in a client suspected of having dementia of the alzheimers type, nurse Chris should ask:

  1. “Where are you?”
  2. “Who brought you here?”
  3. “Do you know where you are?”
  4. “How long have you been there?”

31. Nurse Mary assesses a postpartum client who had an abruption placentae and suspects that disseminated intravascular coagulation (DIC) is occurring when assessments demonstrate:

  1. A boggy uterus
  2. Multiple vaginal clots
  3. Hypotension and tachycardia
  4. Bleeding from the venipuncture site

32. When a client on labor experiences the urge to push a 9cm dilation, the breathing pattern that nurse Rhea should instruct the client to use is the:

  1. Expulsion pattern
  2. Slow paced pattern
  3. Shallow chest pattern
  4. blowing pattern

33. Nurse Ronald should explain that the most beneficial between-meal snack for a client who is recovering from the full-thickness burns would be a:

  1. Cheeseburger and a malted
  2. Piece of blueberry pie and milk
  3. Bacon and tomato sandwich and tea
  4. Chicken salad sandwich and soft drink

34. Nurse Wilma recognizes that failure of a newborn to make the appropriate adaptation to extrauterine life would be indicated by:

  1. flexed extremities
  2. Cyanotic lips and face
  3. A heart rate of 130 beats per minute
  4. A respiratory rate of 40 breath per minute

35. The laboratory calls to state that a client’s lithium level is 1.9 mEq/L after 10 days of lithium therapy. Nurse Reese should:

  1. Notify the physician of the findings because the level is dangerously high
  2. Monitor the client closely because the level of lithium in the blood is slightly elevated
  3. Continue to administer the medication as ordered because the level is within the therapeutic range
  4. Report the findings to the physician so the dosage can be increased because the level is below therapeutic range

36. A client has a regular 30-day menstrual cycles. When teaching about the rhythm method, Which the client and her husband have chosen to use for family planning, nurse Dianne should emphasize that the client’s most fertile days are:

  1. Days 9 to 11
  2. Days 12 to 14
  3. Days 15 to 17
  4. Days 18 to 20

37. Before an amniocentesis, nurse Alexandra should:

  1. Initiate the intravenous therapy as ordered by the physiscian
  2. Inform the client that the procedure could precipitate an infection
  3. Assure that informed consent has been obtained from the client
  4. Perform a vaginal examination on the client to assess cervical dilation

38. While a client is on intravenous magnesium sulfate therapy for preeclampsia, it is essential for nurse Amy to monitor the client’s deep tendon reflexes to:

  1. Determine her level of consciousness
  2. Evaluate the mobility of the extremities
  3. Determine her response to painful stimuli
  4. Prevent development of respiratory distress

39. A preschooler is admitted to the hospital with a diagnosis of acute glomerulonephritis. The child’s history reveals a 5-pound weight gain in one week and peritoneal edema. For the most accurate information on the status of the child’s edema, nursing intervention should include:

  1. Obtaining the child’s daily weight
  2. Doing a visual inspection of the child
  3. Measuring the child’s intake and output
  4. Monitoring the child’s electrolyte values

40. Nurse Mickey is administering dexamethasome (Decadron) for the early management of a client’s cerebral edema. This treatment is effective because:

  1. Acts as hyperosmotic diuretic
  2. Increases tissue resistance to infection
  3. Reduces the inflammatory response of tissues
  4. Decreases the information of cerebrospinal fluid

41. During newborn nursing assessment, a positive Ortolani’s sign would be indicated by:

  1. A unilateral droop of hip
  2. A broadening of the perineum
  3. An apparent shortening of one leg
  4. An audible click on hip manipulation

42. When caring for a dying client who is in the denial stage of grief, the best nursing approach would be to:

  1. Agree and encourage the client’s denial
  2. Allow the denial but be available to discuss death
  3. Reassure the client that everything will be OK
  4. Leave the client alone to confront the feelings of impending loss

43. To decrease the symptoms of gastroesophageal reflux disease (GERD), the physician orders dietary and medication management. Nurse Helen should teach the client that the meal alteration that would be most appropriate would be:

  1. Ingest foods while they are hot
  2. Divide food into four to six meals a day
  3. Eat the last of three meals daily by 8pm
  4. Suck a peppermint candy after each meal

44. After a mastectomy or hysterectomy, clients may feel incomplete as women. The statement that should alert nurse Gina to this feeling would be:

  1. “I can’t wait to see all my friends again”
  2. “I feel washed out; there isn’t much left”
  3. “I can’t wait to get home to see my grandchild”
  4. “My husband plans for me to recuperate at our daughter’s home”

45. A client with obstruction of the common bile duct may show a prolonged bleeding and clotting time because:

  1. Vitamin K is not absorbed
  2. The ionized calcium levels falls
  3. The extrinsic factor is not absorbed
  4. Bilirubin accumulates in the plasma

46. Realizing that the hypokalemia is a side effect of steroid therapy, nurse Monette should monitor a client taking steroid medication for:

  1. Hyperactive reflexes
  2. An increased pulse rate
  3. Nausea, vomiting, and diarrhea
  4. Leg weakness with muscle cramps

47. When assessing a newborn suspected of having Down syndrome, nurse Rey would expect to observe:

  1. long thin fingers
  2. Large, protruding ears
  3. Hypertonic neck muscles
  4. Simian lines on the hands

48. A 10 year old girl is admitted to the pediatric unit for recurrent pain and swelling of her joints, particularly her knees and ankles. Her diagnosis is juvenile rheumatoid arthritis. Nurse Janah recognizes that besides joint inflammation, a unique manifestation of the rheumatoid process involves the:

  1. Ears
  2. Eyes
  3. Liver
  4. Brain

49. A disturbed client is scheduled to begin group therapy. The client refuses to attend. Nurse Lolit should:

  1. Accept the client’s decision without discussion
  2. Have another client to ask the client to consider
  3. Tell the client that attendance at the meeting is required
  4. Insist that the client join the group to help the socialization process

50. Because a severely depressed client has not responded to any of the antidepressant medications, the psychiatrist decides to try electroconvulsive therapy (ECT). Before the treatment the nurse should:

  1. Have the client speak with other clients receiving ECT
  2. Give the client a detailed explanation of the entire procedure
  3. Limit the client’s intake to a light breakfast on the days of the treatment
  4. Provide a simple explanation of the procedure and continue to reassure the client

51. Nurse Vicky is aware that teaching about colostomy care is understood when the client states, “I will contact my physician and report ____”:

  1. If I notice a loss of sensation to touch in the stoma tissue”
  2. When mucus is passed from the stoma between irrigations”
  3. The expulsion of flatus while the irrigating fluid is running out”
  4. If I have difficulty in inserting the irrigating tube into the stoma”

52. The client’s history that alerts nurse Henry to assess closely for signs of postpartum infection would be:

  1. Three spontaneous abortions
  2. negative maternal blood type
  3. Blood loss of 850 ml after a vaginal birth
  4. Maternal temperature of 99.9° F 12 hours after delivery

53. A client is experiencing stomatitis as a result of chemotherapy. An appropriate nursing intervention related to this condition would be to:

  1. Provide frequent saline mouthwashes
  2. Use karaya powder to decrease irritation
  3. Increase fluid intake to compensate for the diarrhea
  4. Provide meticulous skin care of the abdomen with Betadine

54. During a group therapy session, one of the clients ask a male client with the diagnosis of antisocial personality disorder why he is in the hospital. Considering this client’s type of personality disorder, the nurse might expect him to respond:

  1. “I need a lot of help with my troubles”
  2. “Society makes people react in old ways”
  3. “I decided that it’s time I own up to my problems”
  4. “My life needs straightening out and this might help”

55. A child visits the clinic for a 6-week checkup after a tonsillectomy and adenoidectomy. In addition to assessing hearing, the nurse should include an assessment of the child’s:

  1. Taste and smell
  2. Taste and speech
  3. Swallowing and smell
  4. Swallowing and speech

56. A client is diagnosed with cancer of the jaw. A course of radiation therapy is to be followed by surgery. The client is concerned about the side effects related to the radiation treaments. Nurse Ria should explain that the major side effects that will experienced is:

  1. Fatigue
  2. Alopecia
  3. Vomiting
  4. Leucopenia

57. Nurse Katrina prepares an older-adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. Targeting the most frequent cause of falls, the nurse should:

  1. Offer the client assistance to the bathroom
  2. Move the bedside table closer to the client’s bed
  3. Encourage the client to take an available sedative
  4. Assist the client to telephone the spouse to say “goodnight”

58. When evaluating a growth and development of a 6 month old infant, nurse Patty would expect the infant to be able to:

  1. Sit alone, display pincer grasp, wave bye bye
  2. Pull self to a standing position, release a toy by choice, play peek-a-boo
  3. Crawl, transfer toy from one hand to the other, display of fear of strangers
  4. Turn completely over, sit momentarily without support, reach to be picked up

59. A breastfeeding mother asks the nurse what she can do to ease the discomfort caused by a cracked nipple. Nurse Tina should instruct the client to:

  1. Manually express milk and feed it to the baby in a bottle
  2. Stop breastfeeding for two days to allow the nipple to heal
  3. Use a breast shield to keep the baby from direct contact with the nipple
  4. Feed the baby on the unaffected breast first until the affected breast heals

60. Nurse Sandy observes that there is blood coming from the client’s ear after head injury. Nurse Sandy should:

  1. Turn the client to the unaffected side
  2. Cleanse the client’s ear with sterile gauze
  3. Test the drainage from the client’s ear with Dextrostix
  4. Place sterile cotton loosely in the external ear of the client

61. Nurse Gio plans a long term care for parents of children with sickle-cell anemia, which includes periodic group conferences. Some of the discussions should be directed towards:

  1. Finding special school facilities for the child
  2. Making plans for moving to a more therapeutic climate
  3. Choosing a means of birth control to avoid future pregnancies
  4. Airing their feelings regarding the transmission of the disease to the child

62. The central problem the nurse might face with a disturbed schizophrenic client is the client’s:

  1. Suspicious feelings
  2. Continuous pacing
  3. Relationship with the family
  4. Concern about working with others

63. When planning care with a client during the postoperative recovery period following an abdominal hysterectomy and bilateral salpingo-oophorectomy, nurse Frida should include the explanation that:

  1. Surgical menopause will occur
  2. Urinary retention is a common problem
  3. Weight gain is expected, and dietary plan are needed
  4. Depression is normal and should be expected

64. An adolescent client with anorexia nervosa refuses to eat, stating, “I’ll get too fat.” Nurse Andrea can best respond to this behavior initially by:

  1. Not talking about the fact that the client is not eating
  2. Stopping all of the client’s priviledges until food is eaten
  3. Telling the client that tube feeding will eventually be necessary
  4. Pointing out to the client that death can occur with malnutrition.

65. A pain scale is used to assess the degree of pain. The client rates the pain as an 8 on a scale of 10 before medication and a 7 on a scale of 10 after being medicated. Nurse Glenda determines that the:

  1. Client has a low pain tolerance
  2. Medication is not adequately effective
  3. Medication has sufficiently decreased the pain level
  4. Client needs more education about the use of the pain scale

66. To enhance a neonate’s behavioral development, therapeutic nursing measures should include:

  1. Keeping the baby awake for longer periods of time before each feeding
  2. Assisting the parents to stimulate their baby through touch, sound, and sight.
  3. Encouraging parental contact for at least one 15-minute period every four hours.
  4. Touching and talking to the baby at least hourly, beginning within two to four hours after birth

67. Before formulating a plan of care for a 6 year old boy with attention deficit hyperactivity disorder (ADHD), nurse Kyla is aware that the initial aim of therapy is to help the client to:

  1. Develop language skills
  2. Avoid his own regressive behavior
  3. Mainstream into a regular class in school
  4. Recognize himself as an independent person of worth

68. Nurse Wally knows that the most important aspect of the preoperative care for a child with Wilms’ tumor would be:

  1. Checking the size of the child’s liver
  2. Monitoring the child’s blood pressure
  3. Maintaining the child in a prone position
  4. Collecting the child’s urine for culture and sensitivity

69. At 11:00 pm the count of hydrocodone (Vicodin) is incorrect. After several minutes of searching the medication cart and medication administration records, no explanation can be found. The primary nurse should notify the:

  1. Nursing unit manager
  2. Hospital administrator
  3. Quality control manager
  4. Physician ordering the medication

70. When caring for the a client with a pneumothorax, who has a chest tube in place, nurse Kate should plan to:

  1. Administer cough suppressants at appropriate intervals as ordered
  2. Empty and measure the drainage in the collection chamber each shift
  3. Apply clamps below the insertion site when ever getting the client out of bed
  4. Encourage coughing, deep breathing, and range of motion to the arm on the affected side

71. According to C.E.Winslow, which of the following is the goal of Public Health?

  1. For people to attain their birthrights of health and longevity
  2. For promotion of health and prevention of disease
  3. For people to have access to basic health services
  4. For people to be organized in their health efforts

72. What other statistic may be used to determine attainment of longevity?

  1. Age-specific mortality rate
  2. Proportionate mortality rate
  3. Swaroop’s index
  4. Case fatality rate

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

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

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

  1. Health for all Filipinos
  2. Ensure the accessibility and quality of health care
  3. Improve the general health status of the population
  4. Health in the hands of the Filipino people by the year 2020

75. Nurse Pauline determines whether resources were maximized in implementing Ligtas Tigdas, she is evaluating:

  1. Effectiveness
  2. Efficiency
  3. Adequacy
  4. Appropriateness

76. Lissa is a B.S.N. graduate. She want to become a Public Health Nurse. Where will she apply?

  1. Department of Health
  2. Provincial Health Office
  3. Regional Health Office
  4. Rural Health Unit

77. As an epidemiologist, Nurse Celeste is responsible for reporting cases of notifiable diseases. What law mandates reporting of cases of notifiable diseases?

  1. Act 3573
  2. R.A. 3753
  3. R.A. 1054
  4. R.A. 1082

78. Nurse Fay is aware that isolation of a child with measles belongs to what level of prevention?

  1. Primary
  2. Secondary
  3. Intermediate
  4. Tertiary

79. Nurse Gina is aware that the following is an advantage of a home visit?

  1. It allows the nurse to provide nursing care to a greater number of people.
  2. It provides an opportunity to do first hand appraisal of the home situation.
  3. It allows sharing of experiences among people with similar health problems.
  4. It develops the family’s initiative in providing for health needs of its members.

80. The PHN bag is an important tool in providing nursing care during a home visit. The most important principle of bag technique states that it:

  1. Should save time and effort.
  2. Should minimize if not totally prevent the spread of infection.
  3. Should not overshadow concern for the patient and his family.
  4. May be done in a variety of ways depending on the home situation, etc.

81. Nurse Willy reads about Path Goal theory. Which of the following behaviors is manifested by the leader who uses this theory?

  1. Recognizes staff for going beyond expectations by giving them citations
  2. Challenges the staff to take individual accountability for their own practice
  3. Admonishes staff for being laggards
  4. Reminds staff about the sanctions for non performance

82. Nurse Cathy learns that some leaders are transactional leaders. Which of the following does NOT characterize a transactional leader?

  1. Focuses on management tasks
  2. Is a caretaker
  3. Uses trade-offs to meet goals
  4. Inspires others with vision

83. Functional nursing has some advantages, which one is an EXCEPTION?

  1. Psychological and sociological needs are emphasized.
  2. Great control of work activities.
  3. Most economical way of delivering nursing services.
  4. Workers feel secure in dependent role

84. Which of the following is the best guarantee that the patient’s priority needs are met?

  1. Checking with the relative of the patient
  2. Preparing a nursing care plan in collaboration with the patient
  3. Consulting with the physician
  4. Coordinating with other members of the team

85. Nurse Tony stresses the need for all the employees to follow orders and instructions from him and not from anyone else. Which of the following principles does he refer to?

  1. Scalar chain
  2. Discipline
  3. Unity of command
  4. Order

86. Nurse Joey discusses the goal of the department. Which of the following statements is a goal?

  1. Increase the patient satisfaction rate
  2. Eliminate the incidence of delayed administration of medications
  3. Establish rapport with patients
  4. Reduce response time to two minutes

87. Nurse Lou considers shifting to transformational leadership. Which of the following statements best describes this type of leadership?

  1. Uses visioning as the essence of leadership
  2. Serves the followers rather than being served
  3. Maintains full trust and confidence in the subordinates
  4. Possesses innate charisma that makes others feel good in his presence.

88. Nurse Mae tells one of the staff, “I don’t have time to discuss the matter with you now. See me in my office later” when the latter asks if they can talk about an issue. Which of the following conflict resolution strategies did she use?

  1. Smoothing
  2. Compromise
  3. Avoidance
  4. Restriction

89. Nurse Bea plans of assigning competent people to fill the roles designed in the hierarchy. Which process refers to this?

  1. Staffing
  2. Scheduling
  3. Recruitment
  4. Induction

90. Nurse Linda tries to design an organizational structure that allows communication to flow in all directions and involve workers in decision making. Which form of organizational structure is this?

  1. Centralized
  2. Decentralized
  3. Matrix
  4. Informal

91. When documenting information in a client’s medical record, the nurse should:

  1. erase any errors.
  2. use a #2 pencil.
  3. leave one line blank before each new entry.
  4. end each entry with the nurse’s signature and title.

92. Which of the following factors are major components of a client’s general background drug history?

  1. Allergies and socioeconomic status
  2. Urine output and allergies
  3. Gastric reflex and age
  4. Bowel habits and allergies

93. Which procedure or practice requires surgical asepsis?

  1. Hand washing
  2. Nasogastric tube irrigation
  3. I.V. cannula insertion
  4. Colostomy irrigation

94. The nurse is performing wound care using surgical asepsis. Which of the following practices violates surgical asepsis?

  1. Holding sterile objects above the waist
  2. Pouring solution onto a sterile field cloth
  3. Considering a 1″ (2.5-cm) edge around the sterile field contaminated
  4. Opening the outermost flap of a sterile package away from the body

95. On admission, a client has the following arterial blood gas (ABG) values: PaO2, 50 mm Hg; PaCO2, 70 mm Hg; pH, 7.20; HCO3–, 28 mEq/L. Based on these values,
the nurse should formulate which nursing diagnosis for this client?

  1. Risk for deficient fluid volume
  2. Deficient fluid volume
  3. Impaired gas exchange
  4. Metabolic acidosis

96. The use of larvivorous fish in malaria control is the basis for which strategy of malaria control?

  1. Stream seeding
  2. Stream clearing
  3. Destruction of breeding places
  4. Zooprophylaxis

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

  1. Mastoiditis
  2. Severe dehydration
  3. Severe pneumonia
  4. Severe febrile disease

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

  1. Inability to drink
  2. High grade fever
  3. Signs of severe dehydration
  4. Cough for more than 30 days

99. Food fortification is one of the strategies to prevent micronutrient deficiency conditions. R.A. 8976 mandates fortification of certain food items. Which of the following is among these food items?

  1. Sugar
  2. Bread
  3. Margarine
  4. Filled milk

100. The major sign of iron deficiency anemia is pallor. What part is best examined for pallor?

  1. Palms
  2. Nailbeds
  3. Around the lips
  4. Lower conjunctival sac
Answers and Rationales
  1. C. Check for any change in responsiveness every two hours until the follow-up visit. Signs of an epidural hematoma in children usually do not appear for 24 hours or more hours; a follow-up visit usually is arranged for one to two days after the injury.
  2. A. Arteriolar constriction occurs.The early compensation of shock is cardiovascular and is seen in changes in pulse, BP, and pulse pressure; blood is shunted to vital centers, particularly heart and brain.
  3. A. Allow the client to open canned or pre-packaged food. The client’s comfort, safety, and nutritional status are the priorities; the client may feel comfortable to eat if the food has been sealed before reaching the mental health facility.
  4. D. “Joining a support group of parents who are coping with this problem can be quite helpful. Taking with others in similar circumstances provides support and allows for sharing of experiences.
  5. B. Observe the dressing at the back of the neck for the presence of blood. Drainage flows by gravity.
  6. C. Prepare her for a pelvic examination. Pelvic examination would reveal dilation and effacement
  7. D. On the right side of the heart. Pulmonic stenosis increases resistance to blood flow, causing right ventricular hyperthropy; with right ventricular failure there is an increase in pressure on the right side of the heart.
  8. A. Eating patterns are altered. A new dietary regimen, with a balance of foods from the food pyramid, must be established and continued for weight reduction to occur and be maintained.
  9. B. “It is Ok to cry; I’ll just stay with you for now”. This portrays a nonjudgmental attitude that recognizes the client’s needs.
  10. C. Lactated Ringer’s solution. Lactated Ringer’s solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not primary fluid replacement. Dextrose isn’t given to burn patients during the first 24 hours because it can cause pseudodiabetes. The patient is hyperkalemic from the potassium shift from the intracellular space to the plasma, so potassium would be detrimental.
  11. C. Twitching and disorientation. Excess extracellular fluid moves into cells (water intoxication); intracellular fluid excess in sensitive brain cells causes altered mental status; other signs include anorexia nervosa, nausea, vomiting, twitching, sleepiness, and convulsions.
  12. B. Resume the usual diet as soon as desired. As long as the client has no nausea or vomiting, there are no dietary restriction.
  13. B. Shrinkage of the residual limb must be completed. Shrinkage of the residual limb, resulting from reduction of subcutaneous fat and interstitial fluid, must occur for an adequate fit between the limb and the prosthesis.
  14. A. Change the maternal position. Stimulation of the sympathetic nervous system is an initial response to mild hypoxia that accompanies partial cord compression (umbilical vein) during contractions; changing the maternal position can alleviate the compression.
  15. A. Perform a finger stick to test the client’s blood glucose level. The client has signs of diabetes, which may result from steroid therapy, testing the blood glucose level is a method of screening for diabetes, thus gathering more data.
  16. C. Heart block. This is the primary indication for a pacemaker because there is an interfere with the electrical conduction system of the heart.
  17. A. With meals and snacks. Pancreases capsules must be taken with food and snacks because it acts on the nutrients and readies them for absorption.
  18. B. Put a hat on the infant’s head. Oxygen has cooling effect, and the baby should be kept warm so that metabolic activity and oxygen demands are not increased.
  19. C. Wear an Ultra-Filter mask when they are in the client’s room. Tubercle bacilli are transmitted through air currents; therefore personal protective equipment such as an Ultra-Filter mask is necessary.
  20. D. Cerebral cortex compression. Cerebral compression affects pyramidal tracts, resulting in decorticate rigidity and cranial nerve injury, which cause pupil dilation.
  21. A.Mediastinal shift. Mediastinal structures move toward the uninjured lung, reducing oxygenation and venous return.
  22. C. Prevent situations that may stimulate the cervix or uterus. Stimulation of the cervix or uterus may cause bleeding or hemorrhage and should be avoided.
  23. C. Severe shortness of breath. This could indicate a recurrence of the pneumothorax as one side of the lung is inadequate to meet the oxygen demands of the body.
  24. A. Suction equipment. Respiratory complications can occur because of edema of the glottis or injury to the recurrent laryngeal nerve.
  25. A. Strong desire to improve her body image. Clients with anorexia nervosa have a disturbed self image and always see themselves as fat and needing further reducing.
  26. B. Attempting to reduce or limit situations that increase anxiety. Persons with high anxiety levels develop various behaviors to relieve their anxiety; by reducing anxiety, the need for these obsessive-compulsive action is reduced.
  27. C. Becomes fussy when frustrated and displays a shortened attention span. Shortened attention span and fussy behavior may indicate a change in intracranial pressure and/or shunt malfunction.
  28. B. Maintaining the ordered hydration. Promoting hydration maintains urine production at a higher rate, which flushes the bladder and prevents urinary stasis and possible infection.
  29. C. Taking the client’s pedal pulse in the affected limb. Monitoring a pedal pulse will assess circulation to the foot.
  30. A.  “Where are you?”. “Where are you?” is the best question to elicit information about the client’s orientation to place because it encourages a response that can be assessed.
  31. D. Bleeding from the venipuncture site. This indicates a fibrinogenemia; massive clotting in the area of the separation has resulted in a lowered circulating fibrinogen.
  32. D. blowing pattern. Clients should use a blowing pattern to overcome the premature urge to push.
  33. A. Cheeseburger and a malted. Of the selections offered, this is the highest in calories and protein, which are needed for increased basal metabolic rate and for tissue repair.
  34. B. Cyanotic lips and face. Central cyanosis (blue lips and face) indicates lowered oxygenation of the blood, caused by either decreased lung expansion or right to left shunting of blood.
  35. A. Notify the physician of the findings because the level is dangerously high. Levels close to 2 mEq/L are dangerously close to the toxic level; immediate action must be taken.
  36. C. Days 15 to 17. Ovulation occurs approximately 14 days before the next menses, about the 16th day in 30 day cycle; the 15th to 17th days would be the best time to avoid sexual intercourse.
  37. C. Assure that informed consent has been obtained from the client. An invasive procedure such as amniocentesis requires informed consent.
  38. D. Prevent development of respiratory distress. Respiratory distress or arrest may occur when the serum level of magnesium sulfate reaches 12 to 15 mg/dl; deep tendon reflexes disappear when the serum level is 10 to 12 mg/dl; the drug is withheld in the absence of deep tendon reflexes; the therapeutic serum level is 5 to 8 mg/dl.
  39. A. Obtaining the child’s daily weight. Weight monitoring is the most useful means of assessing fluid balance and changes in the edematous state; 1 liter of fluid weighs about 2.2 pounds.
  40. C. Reduces the inflammatory response of tissues. Corticosteroids act to decrease inflammation which decreases edema.
  41. D. An audible click on hip manipulation. With specific manipulation, an audible click may be heard of felt as he femoral head slips into the acetabulum.
  42. B. Allow the denial but be available to discuss death. This does not remove client’s only way of coping, and it permits future movement through the grieving process when the client is ready.
  43. B. Divide food into four to six meals a day. The volume of food in the stomach should be kept small to limit pressure on the cardiac sphincter.
  44. B. “I feel washed out; there isn’t much left”. The client’s statement infers an emptiness with an associated loss.
  45. A. Vitamin K is not absorbed. Vitamin K, a fat soluble vitamin, is not absorbed from the GI tract in the absence of bile; bile enters the duodenum via the common bile duct.
  46. D. Leg weakness with muscle cramps. Impulse conduction of skeletal muscle is impaired with decreased potassium levels, muscular weakness and cramps may occur with hypokalemia.
  47. D. Simian lines on the hands. This is characteristic finding in newborns with Down syndrome.
  48. B. Eyes. Rheumatoid arthritis can cause inflammation of the iris and ciliary body of the eyes which may lead to blindness.
  49. A. Accept the client’s decision without discussion. This is all the nurse can do until trust is established; facing the client to attend will disrupt the group.
  50. D. Provide a simple explanation of the procedure and continue to reassure the client. The nurse should offer support and use clear, simple terms to allay client’s anxiety.
  51. D. If I have difficulty in inserting the irrigating tube into the stoma”. This occurs with stenosis of the stoma; forcing insertion of the tube could cause injury.
  52. C. Blood loss of 850 ml after a vaginal birth. Excessive blood loss predisposes the client to an increased risk of infection because of decreased maternal resistance; they expected blood loss is 350 to 500 ml.
  53. A. Provide frequent saline mouthwashes. This is soothing to the oral mucosa and helps prevent infection.
  54. B. “Society makes people react in old ways”. The client is incapable of accepting responsibility for self-created problems and blames society for the behavior.
  55. A. Taste and smell. Swelling can obstruct nasal breathing, interfering with the senses of taste and smell.
  56. A. Fatigue. Fatigue is a major problem caused by an increase in waste products because of catabolic processes.
  57. A. Offer the client assistance to the bathroom. Statistics indicate that the most frequent cause of falls by hospitalized clients is getting up or attempting to get up to the bathroom unassisted.
  58. D. Turn completely over, sit momentarily without support, reach to be picked up. These abilities are age-appropriate for the 6 month old child.
  59. D. Feed the baby on the unaffected breast first until the affected breast heals. The most vigorous sucking will occur during the first few minutes of breastfeeding when the infant would be on the unaffected breast; later suckling is less traumatic.
  60. D. Place sterile cotton loosely in the external ear of the client. This would absorb the drainage without causing further trauma.
  61. D. Airing their feelings regarding the transmission of the disease to the child. Discussion with parents who have children with similar problems helps to reduce some of their discomfort and guilt.
  62. A. Suspicious feelings. The nurse must deal with these feelings and establish basic trust to promote a therapeutic milieu.
  63. A. Surgical menopause will occur. When a bilateral oophorectomy is performed, both ovaries are excised, eliminating ovarian hormones and initiating response.
  64. D. Pointing out to the client that death can occur with malnutrition. The client expects the nurse to focus on eating, but the emphasis should be placed on feelings rather than actions.
  65. B. Medication is not adequately effective. The expected effect should be more than a one point decrease in the pain level.
  66. B. Assisting the parents to stimulate their baby through touch, sound, and sight. Stimuli are provided via all the senses; since the infant’s behavioral development is enhanced through parent-infant interactions, these interactions should be encouraged.
  67. D. Recognize himself as an independent person of worth. Academic deficits, an inability to function within constraints required of certain settings, and negative peer attitudes often lead to low self-esteem.
  68. B. Monitoring the child’s blood pressure. Because the tumor is of renal origin, the rennin angiotensin mechanism can be involved, and blood pressure monitoring is important.
  69. A. Nursing unit manager. Controlled substance issues for a particular nursing unit are the responsibility of that unit’s nurse manager.
  70. D. Encourage coughing, deep breathing, and range of motion to the arm on the affected side. All these interventions promote aeration of the re-expanding lung and maintenance of function in the arm and shoulder on the affected side.
  71. A. For people to attain their birthrights of health and longevity. According to Winslow, all public health efforts are for people to realize their birthrights of health and longevity.
  72. C. Swaroop’s index. Swaroop’s index is the percentage of the deaths aged 50 years or older. Its inverse represents the percentage of untimely deaths (those who died younger than 50 years).
  73. D. Public health nursing focuses on preventive, not curative, services.. The catchment area in PHN consists of a residential community, many of whom are well individuals who have greater need for preventive rather than curative services.
  74. B. Ensure the accessibility and quality of health care. Ensuring the accessibility and quality of health care is the primary mission of DOH.
  75. B. Efficiency. Efficiency is determining whether the goals were attained at the least possible cost.
  76. D. Rural Health Unit. R.A. 7160 devolved basic health services to local government units (LGU’s ). The public health nurse is an employee of the LGU.
  77. A. Act 3573. Act 3573, the Law on Reporting of Communicable Diseases, enacted in 1929, mandated the reporting of diseases listed in the law to the nearest health station.
  78. A. Primary. The purpose of isolating a client with a communicable disease is to protect those who are not sick (specific disease prevention).
  79. B. It provides an opportunity to do first hand appraisal of the home situation. Choice A is not correct since a home visit requires that the nurse spend so much time with the family. Choice C is an advantage of a group conference, while choice D is true of a clinic consultation.
  80. B. Should minimize if not totally prevent the spread of infection. Bag technique is performed before and after handling a client in the home to prevent transmission of infection to and from the client.
  81. A. Recognizes staff for going beyond expectations by giving them citationsPath Goal theory according to House and associates rewards good performance so that others would do the same.
  82. D. Inspires others with vision. Inspires others with a vision is characteristic of a transformational leader. He is focused more on the day-to-day operations of the department/unit.
  83. A. Psychological and sociological needs are emphasized. When the functional method is used, the psychological and sociological needs of the patients are neglected; the patients are regarded as ‘tasks to be done”
  84. B. Preparing a nursing care plan in collaboration with the patient. The best source of information about the priority needs of the patient is the patient himself. Hence using a nursing care plan based on his expressed priority needs would ensure meeting his needs effectively.
  85. C. Unity of command. The principle of unity of command means that employees should receive orders coming from only one manager and not from two managers. This averts the possibility of sowing confusion among the members of the organization.
  86. A. Increase the patient satisfaction rate. Goal is a desired result towards which efforts are directed. Options AB, C and D are all objectives which are aimed at specific end.
  87. A. Uses visioning as the essence of leadership. Transformational leadership relies heavily on visioning as the core of leadership.
  88. C. Avoidance. This strategy shuns discussing the issue head-on and prefers to postpone it to a later time. In effect the problem remains unsolved and both parties are in a lose-lose situation.
  89. A. Staffing. Staffing is a management function involving putting the best people to accomplish tasks and activities to attain the goals of the organization.
  90. B. Decentralized. Decentralized structures allow the staff to make decisions on matters pertaining to their practice and communicate in downward, upward, lateral and diagonal flow.
  91. D. end each entry with the nurse’s signature and title. The end of each entry should include the nurse’s signature and title; the signature holds the nurse accountable for the recorded information. Erasing errors in documentation on a legal document such as a client’s chart isn’t permitted by law. Because a client’s medical record is considered a legal document, the nurse should make all entries in ink. The nurse is accountable for the information recorded and therefore shouldn’t leave any blank lines in which another health care worker could make additions.
  92. A. Allergies and socioeconomic status. General background data consist of such components as allergies, medical history, habits, socioeconomic status, lifestyle, beliefs, and sensory deficits. Urine output, gastric reflex, and bowel habits are significant only if a disease affecting these functions is present.
  93. C. I.V. cannula insertion. Caregivers must use surgical asepsis when performing wound care or any procedure in which a sterile body cavity is entered or skin integrity is broken. To achieve surgical asepsis, objects must be rendered or kept free of all pathogens. Inserting an I.V. cannula requires surgical asepsis because it disrupts skin integrity and involves entry into a sterile cavity (a vein). The other options are used to ensure medical asepsis or clean technique to prevent the spread of infection. The GI tract isn’t sterile; therefore, irrigating a nasogastric tube or a colostomy requires only clean technique.
  94. B. Pouring solution onto a sterile field cloth. Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis.
  95. C. Impaired gas exchange. The client has a below-normal value for the partial pressure of arterial oxygen (PaO2) and an above-normal value for the partial pressure of arterial carbon dioxide (PaCO2), supporting the nursing diagnosis of Impaired gas exchange. ABG values can’t indicate a diagnosis of Fluid volume deficit (or excess) or Risk for deficient fluid volume. Metabolic acidosis is a medical, not nursing, diagnosis; in any event, these ABG values indicate respiratory, not metabolic, acidosis.
  96. A. Stream seeding. Stream seeding is done by putting tilapia fry in streams or other bodies of 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.

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