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PNLE : Maternal and Child Health Nursing Exam 3 (PM)
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Question 1
The nurse must instruct a client with glaucoma to avoid taking over-the-counter medications like:
A
Salicylates.
B
Antihistamines.
C
Antacids.
D
NSAIDs.
Question 1 Explanation:
Antihistamines cause pupil dilation and should be avoided with glaucoma.
Question 2
The nurse in the nursing care unit checks the fluctuation in the water-seal compartment of a closed chest drainage system. The fluctuation has stopped, the nurse would:
A
Vigorously strip the tube to dislodge a clot.
B
Raise the apparatus above the chest to move fluid.
C
Increase wall suction above 20 cm H2O pressure.
D
Ask the client to cough and take a deep breath.
Question 2 Explanation:
Asking the client to cough and take a deep breath will help determine if the chest tube is kinked or if the lungs has reexpanded.
Question 3
A client with lung cancer is admitted in the nursing care unit. The husband wants to know the condition of his wife. How should the nurse respond to the husband?
A
Suggest that he discuss it with his wife.
B
Refer him to the doctor.
C
Find out what information he already has.
D
Refer him to the nurse in charge.
Question 3 Explanation:
It is best to establish baseline information first.
Question 4
The nurse is caring for a cient who Is a retired nurse. A 24-hour urine collection for Creatinine clearance is to be done. The client tells the nurse, “I can’t remember what this test is for.” The best response by the nurse is:
A
“The test measures the number of particles the kidney filters.”
B
“It tells how well the kidneys filter wastes from the blood.”
C
“It provides a way to see if you are passing any protein in your urine.”
D
“It tells if your renal insufficiency has affected your heart.”
Question 4 Explanation:
Determining how well the kidneys filter wastes states the purpose of a Creatinine clearance test.
Question 5
The emergency department has shortage of staff. The nurse manager informs the staff nurse in the critical care unit that she has to float to the emergency department. What should the staff nurse expect under these conditions?
A
Client assignments will be equally divided among the nurses.
B
Cross training will be available for the staff nurse.
C
The staff nurse will be able to negotiate the assignments in the emergency department.
D
The float staff nurse will be informed of the situation before the shift begins.
Question 5 Explanation:
Assignments should be based on scope of practice and expertise.
Question 6
In the morning shift, the nurse is making rounds in the nursing care units. The nurse enters in a client’s room and notes that the client’s tube has become disconnected from the Pleurovac. What would be the initial nursing action?
A
Apply pressure directly over the incision site.
B
Clamp the chest tube closer to the drainage system.
C
Reconnect the chest tube to the Pleurovac.
D
Clamp the chest tube near the incision site.
Question 6 Explanation:
This stops the sucking of air through the tube and prevents the entry of contaminants. In addition, clamping near the chest wall provides for some stability and may prevent the clamp from pulling on the chest tube.
Question 7
The nurse is taking care of a multipara who is at 42 weeks of gestation and in active labor, her membranes ruptured spontaneously 2 hours ago. While auscultating for the point of maximum intensity of fetal heart tones before applying an external fetal monitor, the nurse counts 100 beats per minute. The immediate nursing action is to:
A
Turn the woman on her left side to increase placental perfusion.
B
Start oxygen by mask to reduce fetal distress.
C
Take the woman’s radial pulse while still auscultating the FHR.
D
Examine the woman for signs of a prolapsed cord.
Question 7 Explanation:
Taking the mother’s pulse while listening to the FHR will differentiate between the maternal and fetal heart rates and rule out fetal Bradycardia.
Question 8
The nurse is completing an obstetric history of a woman in labor. Which event in the obstetric history will help the nurse suspects dysfunctional labor in the current pregnancy?
A
First labor lasting 24 hours.
B
Uterine fibroid noted at time of cesarean delivery.
C
Second birth by cesarean for face presentation.
D
Total time of ruptured membranes was 24 hours with the second birth.
Question 8 Explanation:
An abnormality in the uterine muscle could reduce the effectiveness of uterine contractions and lengthen the duration of subsequent labors.
Question 9
Before the administration of digoxin, the nurse completes an assessment to a toddler client for signs and symptoms of digoxin toxicity. Which of the following is the earliest and most significant sign of digoxin toxicity?
A
Nausea and vomiting
B
Tinnitus
C
Slowing in the heart rate
D
Vision problem
Question 9 Explanation:
One of the earliest signs of digoxin toxicity is Bradycardia. For a toddler, any heart rate that falls below the norm of about 100-120 bpm would indicate Bradycardia and would necessitate holding the medication and notifying the physician.
Question 10
Which of the following will best describe a management function?
A
Explaining medication side effects to a client.
B
Negotiating labor contracts.
C
Directing and evaluating nursing staff members.
D
Writing a letter to the editor of a nursing journal.
Question 10 Explanation:
Directing and evaluation of staff is a major responsibility of a nursing manager.
Question 11
An older adult client wakes up at 2 o’clock in the morning and comes to the nurse’s station saying, “I am having difficulty in sleeping.” What is the best nursing response to the client?
A
“I’ll give you a sleeping pill to help you get more sleep now.”
B
“Perhaps you’d like to sit here at the nurse’s station for a while.”
C
“Would you like me to show you where the bathroom is?”
D
“What woke you up?”
Question 11 Explanation:
This option shows acceptance (key concept) of this age-typical sleep pattern (that of waking in the early morning).
Question 12
Which of the following action is an accurate tracheal suctioning technique?
A
15 seconds of intermittent suction during catheter withdrawal.
B
10 seconds of intermittent suction during catheter withdrawal.
C
25 seconds of continuous suction during catheter insertion.
D
20 seconds of continuous suction during catheter insertion.
Question 12 Explanation:
Suctioning is only done for 10 seconds, intermittently, as the catheter is being withdrawn.
Question 13
The nurse is counseling a couple in their mid 30’s who have been unable to conceive for about 6 months. They are concerned that one or both of them may be infertile. What is the best advice the nurse could give to the couple?
A
“Consult a fertility specialist and start testing before you get any older.”
B
“Start planning adoption. Many couples get pregnant when they are trying to adopt.”
C
“Have sex as often as you can, especially around the time of ovulation, to increase your chances of pregnancy.”
D
“it is no unusual to take 6-12 months to get pregnant, especially when the partners are in their mid-30s. Eat well, exercise, and avoid stress.”
Question 13 Explanation:
Infertility is not diagnosed until atleast 12months of unprotected intercourse has failed to produce a pregnancy. Older couples will experience a longer time to get pregnant.
Question 14
The staff nurse on the labor and delivery unit is assigned to care to a primigravida in transition complicated by hypertension. A new pregnant woman in active labor is admitted in the same unit. The nurse manager assigned the same nurse to the second client. The nurse feels that the client with hypertension requires one-to-one care. What would be the initial action of the nurse?
A
Accept the new assignment and complete an incident report describing a shortage of nursing staff.
B
Report the nursing assessment of the client in transitional labor to the nurse manager and discuss misgivings about the new assignment.
C
Accept the new assignment and provide the best care.
D
Report the incident to the nursing supervisor and request to be floated.
Question 14 Explanation:
The nurse is obligated to inform the nurse manager about changes in the condition of the client, which may change the decision made by the nurse manager.
Question 15
A client who undergone left nephrectomy has a large flank incision. Which of the following nursing action will facilitate deep breathing and coughing?
A
Have the client lie on the unaffected side.
B
Coordinate breathing and coughing exercise with administration of analgesics.
C
Maintain the client in high Fowler’s position.
D
Push fluid administration to loosen respiratory secretions.
Question 15 Explanation:
Because flank incision in nephrectomy is directly below the diaphragm, deep breathing is painful. Additionally, there is a greater incisional pull each time the person moves than there is with abdominal surgery. Incisional pain following nephrectomy generally requires analgesics administration every 3-4 hours for 24-48 hours after surgery. Therefore, turning, coughing and deep-breathing exercises should be planned to maximize the analgesic effects.
Question 16
Most couples are using “natural” family planning methods. Most accidental pregnancies in couples preferred to use this method have been related to unprotected intercourse before ovulation. Which of the following factor explains why pregnancy may be achieved by unprotected intercourse during the preovulatory period?
A
Spermatozoal viability.
B
Ovum viability.
C
Secretory endometrium.
D
Tubal motility.
Question 16 Explanation:
Sperm deposited during intercourse may remain viable for about 3 days. If ovulation occurs during this period, conception may result.
Question 17
The nurse in the neonatal care unit is supervising the actions of a certified nursing assistant in giving care to the newborns. The nursing assistant mistakenly gives a formula feeding to a newborn that is on water feeding only. The nurse is responsible for the mistake of the nursing assistant:
A
Only if the nurse agreed that the newborn could be fed formula.
B
Always, as a representative of the institution.
C
Always, because nurses who supervise less-trained individuals are responsible for their mistakes.
D
If the nurse failed to determine whether the nursing assistant was competent to take care of the client.
Question 17 Explanation:
The nurse who is supervising others has a legal obligation to determine that they are competent to perform the assignment, as well as legal obligation to provide adequate supervision.
Question 18
A female client with cancer has radium implants. The nurse wants to maintain the implants in the correct position. The nurse should position the client:
A
With the head elevated 45-degrees (semi-Fowler’s).
B
On the side only.
C
Flat in bed.
D
With the foot of the bed elevated.
Question 18 Explanation:
Clients with radioactive implants should be positioned flat in bed to prevent dislodgement of the vaginal packing. The client may roll to the side for meals but the upper body should not be raised more than 20 degrees.
Question 19
The physician orders a dose of IV phenytoin to a child client. In preparing in the administration of the drug, which nursing action is not correct?
A
Flush the IV tubing with normal saline before starting phenytoin.
B
Infuse the phenytoin into a smaller vein to prevent purple glove syndrome.
C
Check the phenytoin solution to be sure it is clear or light yellow in color, never cloudy.
D
Plan to give phenytoin over 30-60 minutes, using an in-line filter.
Question 19 Explanation:
Phenytoin should be infused or injected into larger veins to avoid the discoloration know as purple glove syndrome; infusing into a smaller vein is not appropriate.
Question 20
The nurse is conducting a lecture to a class of nursing students about advance directives to preoperative clients. Which of the following statement by the nurse js correct?
A
“The advance directive may be enforced even in the face of opposition by the spouse.”
B
“An advance directive is required for a “do not resuscitate” order.”
C
“A durable power of attorney, a form of advance directive, may only be held by a blood relative.”
D
“The spouse, but not the rest of the family, may override the advance directive.”
Question 20 Explanation:
An advance directive is a form of informed consent, and only a competent adult or the holder of a durable power of attorney has the right to consent or refuse treatment. If the spouse does not hold the power of attorney, the decisions of the holder, even if opposed by the spouse, are enforced.
Question 21
Which of the following is the most frequent cause of noncompliance to the medical treatment of open-angle glaucoma?
A
The frequent nausea and vomiting accompanying use of miotic drug.
B
Loss of mobility due to severe driving restrictions.
C
The painful and insidious progression of this type of glaucoma.
D
Decreased light and near-vision accommodation due to miotic effects of pilocarpine.
Question 21 Explanation:
The most frequent cause of noncompliance to the treatment of chronic, or open-angle glaucoma is the miotic effects of pilocarpine. Pupillary constriction impedes normal accommodation, making night driving difficult and hazardous, reducing the client’s ability to read for extended periods and making participation in games with fast-moving objects impossible.
Question 22
The nurse is caring to a child client who has had a tonsillectomy. The child complains of having dryness of the throat. Which of the following would the nurse give to the child?
A
Cola with ice
B
Cool cherry Kool-Aid
C
Yellow noncitrus Jello
D
A glass of milk
Question 22 Explanation:
After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and hot or cold liquids should be avoided because they may irritate the throat. Red liquids should be avoided because they give the appearance of blood if the child vomits. Milk and milk products including pudding are avoided because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding.
Question 23
To assess if the cranial nerve VII of the client was damaged, which changes would not be expected?
A
Inability to open eyelids on operative side.
B
Drooling and drooping of the mouth.
C
Sagging of the face on the operative side.
D
Inability to close eyelid on operative side.
Question 23 Explanation:
Inability to open eyelids on operative side is seen with cranial nerve III damage.
Question 24
A community health nurse is providing a health teaching to a woman infected with herpes simplex 2. Which of the following health teaching must the nurse include to reduce the chances of transmission of herpes simplex 2?
A
“Therapy is curative.”
B
“The organism is associated with later development of hydatidiform mole.
C
“Penicillin is the drug of choice for treatment.”
D
“Abstain from intercourse until lesions heal.”
Question 24 Explanation:
Abstinence will eliminate any unnecessary pain during intercourse and will reduce the possibility of transmitting infection to one’s sexual partner.
Question 25
The pediatric nurse in the neonatal unit was informed that the baby that is brought to the mother in the hospital room is wrong. The nurse determines that two babies were placed in the wrong cribs. The most appropriate nursing action would be to:
A
Record the event in an incident/variance report and notify the nursing supervisor.
B
Determine who is responsible for the mistake and terminate his or her employment.
C
Record detailed notes of the event on the mother’s medical record.
D
Reassure both mothers, report to the charge nurse, and do not record.
Question 25 Explanation:
Every event that exposes a client to harm should be recorded in an incident report, as well as reported to the appropriate supervisors in order to resolve the current problems and permit the institution to prevent the problem from happening again.
Question 26
The nurse is assigned to care for a child client admitted in the pediatrics unit. The client is receiving digoxin. Which of the following questions will be asked by the nurse to the parents of the child in order to assess the client’s risk for digoxin toxicity?
A
“Do any of his brothers and sisters have history of cardiac problems?”
B
“Has he been taking diuretics at home?”
C
“Has he been going to school regularly?”
D
“Has he been exposed to any childhood communicable diseases in the past 2-3 weeks?”
Question 26 Explanation:
The child who is concurrently taking digoxin and diuretics is at increased risk for digoxin toxicity due to the loss of potassium. The child and parents should be taught what foods are high in potassium, and the child should be encouraged to eat a high-potassium diet. In addition, the child’s serum potassium level should be carefully monitored.
Question 27
Which of the following will help the nurse determine that the expression of hostility is useful?
A
Expression of anger dissipates the energy.
B
Expression intimidates others.
C
Energy from anger is used to accomplish what needs to be done.
D
Degree of hostility is less than the provocation.
Question 27 Explanation:
This is the proper use of anger.
Question 28
A nurse is giving a health teaching to a woman who wants to breastfeed her newborn baby. Which hormone, normally secreted during the postpartum period, influences both the milk ejection reflex and uterine involution?
A
Progesterone.
B
Oxytocin.
C
Relaxin.
D
Estrogen.
Question 28 Explanation:
Contraction of the milk ducts and let-down reflex occur under the stimulation of oxytocin released by the posterior pituitary gland.
Question 29
A client diagnosed with schizophrenia is shouting and banging on the door leading to the outside, saying, “I need to go to an appointment.” What is the appropriate nursing intervention?
A
Escort the client going back into the room.
B
Ignore this behavior.
C
Ask the client to move away from the door.
D
Tell the client that he cannot bang on the door.
Question 29 Explanation:
Gentle but firm guidance and nonverbal direction is needed to intervene when a client with schizophrenic symptoms is being disruptive.
Question 30
An infant is brought to the health care clinic for three immunizations at the same time. The nurse knows that hepatitis B, DPT, and Haemophilus influenzae type B immunizations should:
A
Be mixed and inject in the same sites.
B
Be mixed and the nurse must give the injection in three sites.
C
Be drawn in the same syringe and given in one injection.
D
Not be mixed and the nurse must give three injections in three sites.
Question 30 Explanation:
Immunization should never be mixed together in a syringe, thus necessitating three separate injections in three sites. Note: some manufacturers make a premixed combination of immunization that is safe and effective.
Question 31
The nurse advised the pregnant woman that smoking and alcohol should be avoided during pregnancy. The nurse takes into account that the developing fetus is most vulnerable to environment teratogens that cause malformation during:
A
The entire pregnancy.
B
The first trimester.
C
The second trimester.
D
The third trimester.
Question 31 Explanation:
The first trimester is the period of organogenesis, that is, cell differentiation into the various organs, tissues, and structures.
Question 32
The client has had a right-sided cerebrovascular accident. In transferring the client from the wheelchair to bed, in what position should a client be placed to facilitate safe transfer?
A
Weakened (R) side of the client next to bed.
B
Weakened (R) side of the cient away from bed.
C
Weakened (L) side of the cient next to bed.
D
Weakened (L) side of the client away from bed.
Question 32 Explanation:
With a right-sided cerebrovascular accident the client would have left-sided hemiplegia or weakness. The client’s good side should be closest to the bed to facilitate the transfer.
Question 33
A client with ruptured appendix had surgery an hour ago and is transferred to the nursing care unit. The nurse placed the client in a semi-Fowler’s position primarily to:
A
Promote drainage and prevent subdiaphragmatic abscesses.
B
Splint the wound.
C
Fully aerate the lungs.
D
Facilitate movement and reduce complications from immobility.
Question 33 Explanation:
After surgery for a ruptured appendix, the client should be placed in a semi-Fowler’s position to promote drainage and to prevent possible complications.
Question 34
The nurse is providing an orientation regarding case management to the nursing students. Which characteristics should the nurse include in the discussion in understanding case management?
A
Main purpose is to identify expected client, family and staff performance against the timeline for clients with the same diagnosis.
B
Main focus is comprehensive coordination of client care, avoid unnecessary duplication of services, improve resource utilization and decrease cost.
C
Main objective is a written plan that combines discipline-specific processes used to measure outcomes of care.
D
Primary goal is to understand why predicted outcomes have not been met and the correction of identified problems.
Question 34 Explanation:
There are several models of case management, but the commonality is comprehensive coordination of care to better predict needs of high-risk clients, decrease exacerbations and continually monitor progress overtime.
Question 35
A 3-month-old client is in the pediatric unit. During assessment, the nurse is suspecting that the baby may have hypothyroidism when mother states that her baby does not:
A
Hold the head up.
B
Pick up and hold a rattle.
C
Roll over.
D
Sit up.
Question 35 Explanation:
Development normally proceeds cephalocaudally; so the first major developmental milestone that the infant achieves is the ability to hold the head up within the first 8-12 weeks of life. In hypothyroidism, the infant’s muscle tone would be poor and the infant would not be able to achieve this milestone.
Question 36
Which of the following statement describes the role of a nurse as a client advocate?
A
A nurse measures the risk and benefits of various health situations while factoring in cost.
B
A nurse has the moral obligation to prevent harm and do well for clients.
C
A nurse helps clients gain greater independence and self-determination.
D
A nurse may override clients’ wishes for their own good.
Question 36 Explanation:
An advocate role encourage freedom of choice, includes speaking out for the client, and supports the client’s best interests.
Question 37
The nursing applicant has given the chance to ask questions during a job interview at a local hospital. What should be the most important question to ask that can increase chances of securing a job offer?
A
Begin with questions about client care assignments, advancement opportunities, and continuing education.
B
Clarify information regarding salary, benefits, and working hours first, because this will help in deciding whether or not to take the job.
C
Decline to ask questions, because that is the responsibility of the interviewer.
D
Ask as many questions about the facility as possible.
Question 37 Explanation:
This choice implies concern for client care and self-improvement.
Question 38
The nurse assesses the health condition of the female client. The client tells the nurse that she discovered a lump in the breast last year and hesitated to seek medical advice. The nurse understands that, women who tend to delay seeking medical advice after discovering the disease are displaying what common defense mechanism?
A
Denial.
B
Repression.
C
Suppression.
D
Intellectualization.
Question 38 Explanation:
Denial is a very strong defense mechanism used to allay the emotional effects of discovering a potential threat. Although denial has been found to be an effective mechanism for survival in some instances, such as during natural disasters, it may in greater pathology in a woman with potential breast carcinoma.
Question 39
After ileostomy, the nurse expects that the drainage appliance will be applied to the stoma:
A
When the client is able to begin self-care procedures.
B
In the operating room after the ileostomy procedure.
C
After the ileostomy begins to function.
D
24 hours later, when the swelling subsided.
Question 39 Explanation:
The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful and excoriated.
Question 40
A client is diagnosed with Tuberculosis and respiratory isolation is initiated. This means that:
A
Full isolation; that is, caps and gowns are required during the period of contagion.
B
Both client and attending nurse must wear masks at all times.
C
Gloves are worn when handling the client’s tissue, excretions, and linen.
D
Nurse and visitors must wear masks until chemotherapy is begun. Client is instructed in cough and tissue techniques.
Question 40 Explanation:
Proper handling of sputum is essential to allay droplet transference of bacilli in the air. Clients need to be taught to cover their nose and mouth with tissues when sneezing or coughing. Chemotherapy generally renders the client noninfectious within days to a few weeks, usually before cultures for tubercle bacilli are negative. Until chemical isolation is established, many institutions require the client to wear a mask when visitors are in the room or when the nurse is in attendance. Client should be in a well-ventilated room, without air recirculation, to prevent air contamination.
Question 41
The LPN/LVN asks the registered nurse why oxytocin (Pitocin), 10 units (IV or IM) must be given to a client after birth fo the fetus. The nurse is correct to explain that oxytocin:
A
Suppresses lactation.
B
Promotes lactation.
C
Minimizes discomfort from “afterpains.”
D
Maintains uterine tone.
Question 41 Explanation:
Oxytocin (Pitocin) is used to maintain uterine tone.
Question 42
The parents of an infant client ask the nurse to teach them how to administer Cortisporin eye drops. The nurse is correct in advising the parents to place the drops:
A
In the middle of the lower conjunctival sac of the infant’s eye.
B
In the inner canthus of the infant’s eye.
C
In the outer canthus of the infant’s eye.
D
Directly onto the infant’s sclera.
Question 42 Explanation:
The recommended procedure for administering eyedrops to any client calls for the drops to be placed in the middle of the lower conjunctival sac.
Question 43
In the hospital lobby, the registered nurse overhears a two staff members discussing about the health condition of her client. What would be the appropriate action for the registered nurse to take?
A
Report this incident to the nursing supervisor.
B
Ignore them, because they have the right to discuss anything they want to.
C
Tell them it is not appropriate to discuss such things.
D
Join in the conversation, giving her input about the case.
Question 43 Explanation:
The behavior should be stopped. The first is to remind the staff that confidentiality maybe violated.
Question 44
While feeding a newborn with an unrepaired cardiac defect, the nurse keeps on assessing the condition of the client. The nurse notes that the newborn’s respiration is 72 breaths per minute. What would be the initial nursing action?
A
Stop the feeding.
B
Continue the feeding.
C
Notify the physician.
D
Burp the newborn.
Question 44 Explanation:
A normal respiratory rate for a newborn is 30-40 breaths per minute.
Question 45
A client who hallucinates is not in touch with reality. It is important for the nurse to:
A
Orient the client to time, place, and person
B
Establish a trusting relationship.
C
Isolate the client from other patients.
D
Maintain a safe environment.
Question 45 Explanation:
It is of paramount importance to prevent the client from hurting himself or herself or others.
Question 46
After a cystectomy and formation of an ileal conduit, the nurse provides instruction regarding prevention of leakage of the pouch and backflow of the urine. The nurse is correct to include in the instruction to empty the urine pouch:
A
Every hour.
B
Twice a day.
C
Once before bedtime.
D
Every 3-4 hours.
Question 46 Explanation:
Urine flow is continuous. The pouch has an outlet valve for easy drainage every 3-4 hours. (the pouch should be changed every 3-5 days, or sooner if the adhesive is loose).
Question 47
A mother is in the third stage of labor. Which of the following signs will help the nurse determine the signs of placental separation?
A
The fundus appears at the introitus.
B
The uterus becomes globular.
C
The umbilical cord is shortened.
D
Mucoid discharge is increased.
Question 47 Explanation:
Signs of placental separation include a change in the shape of the uterus from ovoid to globular.
Question 48
The child client has undergone hip surgery and is in a spica cast. Which of the following toy should be avoided to be in the child’s bed?
A
Legos.
B
A toy gun.
C
A ball.
D
A stuffed animal.
Question 48 Explanation:
Legos are small plastic building blocks that could easily slip under the child’s cast and lead to a break in skin integrity and even infection. Pencils, backscratchers, and marbles are some other narrow or small items that could easily slip under the child’s cast and lead to a break in skin integrity and infection.
Question 49
The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year-old client. The nurse caring to the client provides instructions that the nasal spray must be used exactly as directed to prevent the development of:
A
Bleeding tendencies.
B
Tinnitus and diplopia.
C
Nasal polyps
D
Increased nasal congestion.
Question 49 Explanation:
Phenylephrine, with frequent and continued use, can cause rebound congestion of mucous membranes.
Question 50
The nurse is providing a health teaching to a group of parents regarding Chlamydia trachomatis. The nurse is correct in the statement, “Chlamydia trachomatis is not only an intracellular bacterium that causes neonatal conjunctivitis, but it also can cause:
A
Discoloration of baby and adult teeth.
B
Central hearing defects in infancy.
C
Snuffles and rhagades in the newborn.
D
Pneumonia in the newborn.
Question 50 Explanation:
Newborns can get pneumonia (tachypnea, mild hypoxia, cough, eosinophilia) and conjunctivitis from Chlamydia.
Question 51
The nurse is formulating a plan of care to a client with a somatoform disorder. The nurse needs to have knowledge of which psychodynamic principle?
A
The major fundamental mechanism is regression.
B
The symptoms of a somatoform disorder are an attempt to adjust to painful life situations or to cope with conflicting sexual, aggressive, or dependent feelings.
C
An extensive, prolonged study of the symptoms will be reassuring to the client, who seeks sympathy, attention and love.
D
The client’s symptoms are imaginary and the suffering is faked.
Question 51 Explanation:
Somatoform disorders provide a way of coping with conflicts.
Question 52
A couple seeks medical advice in the community health care unit. A couple has been unable to conceive; the man is being evaluated for possible problems. The physician ordered semen analysis. Which of the following instructions is correct regarding collection of a sperm specimen?
A
Collect specimen after 48-72 hours of abstinence and bring to clinic within 2 hours.
B
Collect specimen at night, refrigerate, and bring to clinic the next morning.
C
Collect specimen in the morning after 24 hours of abstinence and bring to clinic immediately.
D
Collect a specimen at the clinic, place in iced container, and give to laboratory personnel immediately.
Question 52 Explanation:
Is correct because semen analysis requires that a freshly masturbated specimen be obtained after a rest (abstinence) period of 48-72 hours.
Question 53
The nurse is assigned to care for a client with urinary calculi. Fluid intake of 2L/day is encouraged to the client. the primary reason for this is to:
A
Increase the hydrostatic pressure in the urinary tract.
B
Prevent crystalline irritation to the ureter.
C
Reduce the size of existing stones
D
Reduce the size of existing stones.
Question 53 Explanation:
Increasing hydrostatic pressure in the urinary tract will facilitate passage of the calculi.
Question 54
The nurse is teaching a group of women about fertility awareness, the nurse should emphasize that basal body temperature:
A
Can be done with a mercury thermometer but no a digital one.
B
Should be recorded each morning before any activity.
C
Has a lower degree of accuracy in predicting ovulation than the cervical mucus test.
D
The average temperature taken each morning.
Question 54 Explanation:
The basal body temperature is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2 ºC to 36.3ºC during menses and for about 5-7 days afterward. About the time of ovulation, a slight drop in temperature may be seen, after ovulation in concert with the increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 ºC. This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred.
Question 55
A male client tells the nurse that there is a big bug in his bed. The most therapeutic nursing response would be:
A
“I don’t see a bug in your bed, but you seem afraid.”
B
Silence
C
“Where’s the bug? I’ll kill it for you.”
D
“You must be seeing things.”
Question 55 Explanation:
This response does not contradict the client’s perception, is honest, and shows empathy.
Question 56
Which of the following describes a health care team with the principles of participative leadership?
A
The physician makes most of the decisions regarding the client’s care.
B
Each member of the team can independently make decisions regarding the client’s care without necessarily consulting the other members.
C
The team uses the expertise of its members to influence the decisions regarding the client’s care.
D
Nurses decide nursing care; physicians decide medical and other treatment for the client.
Question 56 Explanation:
It describes a democratic process in which all members have input in the client’s care.
Question 57
The physician ordered tetracycline PO qid to a child client who weights 20kg. The recommended PO tetracycline dose is 25-50 mg/kg/day. What is the maximum single dose that can be safely administered to this child?
A
1 g
B
500 mg
C
250 mg
D
125 mg
Question 57 Explanation:
The recommended dosage of tetracycline is 25-50mg/kg/day. If the child weighs 20kg and the maximum dose is 50mg/kg, this would indicate a total daily dose of 1000mg of tetracycline. In this case, the child is being given this medication four times a day. Therefore the maximum single dose that can be given is 250mg (1000 mg of tetracycline divided by four doses.)
Question 58
The nurse in the nursing care unit is aware that one of the medical staff displays unlikely behaviors like confusion, agitation, lethargy and unkempt appearance. This behavior has been reported to the nurse manager several times, but no changes observed. The nurse should:
A
Consider that the obligation to protect the patient from harm has been met by the prior reports and do nothing further.
B
Discuss the situation with friends who are also nurses to get ideas .
C
Continue to report observations of unusual behavior until the problem is resolved.
D
Approach the partner of this medical staff member with these concerns.
Question 58 Explanation:
The submission of reports about incidents that expose clients to harm does not remove the obligation to report ongoing behavior as long as the risk to the client continues.
Question 59
The community nurse is teaching the group of mothers about the cervical mucus method of natural family planning. Which characteristics are typical of the cervical mucus during the “fertile” period of the menstrual cycle?
A
Thin, clear, good spinnbarkeit.
B
Absence of ferning.
C
Yellow and sticky.
D
Thick, cloudy.
Question 59 Explanation:
Under high estrogen levels, during the period surrounding ovulation, the cervical mucus becomes thin, clear, and elastic (spinnbarkeit), facilitating sperm passage.
Question 60
The client’s jaw and cheekbone is sutured and wired. The nurse anticipates that the most important thing that must be ready at the bedside is:
A
Tracheostomy set.
B
Suture set.
C
Suction equipment.
D
Wire cutters.
Question 60 Explanation:
The priority for this client is being able to establish an airway.
Question 61
Which of the following situations cannot be delegated by the registered nurse to the nursing assistant?
A
A confused elderly woman who needs assistance with eating.
B
Client in soft restraint who is very agitated and crying.
C
A postoperative client who is stable needs to ambulate.
D
Routine temperature check that must be done for a client at end of shift.
Question 61 Explanation:
The registered nurse cannot delegate the responsibility for assessment and evaluation of clients. The status of the client in restraint requires further assessment to determine if there are additional causes for the behavior.
Question 62
The client with rheumatoid arthritis is for discharge. In preparing the client for discharge on prednisone therapy, the nurse should advise the client to:
A
Take oral preparations of prednisone before meals.
B
Never stop or change the amount of the medication without medical advice.
C
Have periodic complete blood counts while on the medication.
D
Wear sunglasses if exposed to bright light for an extended period of time.
Question 62 Explanation:
In preparing the client for discharge that is receiving prednisone, the nurse should caution the client to (a) take oral preparations after meals; (b) remember that routine checks of vital signs, weight, and lab studies are critical; (c) NEVER STOP OR CHANGE THE AMOUNT OF MEDICATION WITHOUT MEDICAL ADVICE; (d) store the medication in a light-resistant container.
Question 63
A pregnant client tells the nurse that she is worried about having urinary frequency. What will be the most appropriate nursing response?
A
“Frequency is due to bladder irritation from concentrate urine and is normal in pregnancy. Increase your daily fluid intake to 3L.”
B
“Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you have frequency associated with fever, pain on voiding, or blood in the urine, call your doctor/nurse-midwife.
C
“Placental progesterone causes irritability of the bladder sphincter. Your symptoms will go away after the baby comes.”
D
“Placental progesterone causes irritability of the bladder sphincter. Your symptoms will go away after the baby comes.”
Question 63 Explanation:
Progesterone also reduces smooth muscle motility in the urinary tract and predisposes the pregnant woman to urinary tract infections. Women should contact their doctors if they exhibit signs of infection. Kegel exercise will help strengthen the perineal muscles; limiting fluids at bedtime reduces the possibility of being awakened by the necessity of voiding.
Question 64
The nurse is completing an assessment to a newborn baby boy. The nurse observes that the skin of the newborn is dry and flaking and there are several areas of an apparent macular rash. The nurse charts this as:
A
Milia
B
Icterus neonatorum
C
Erythema toxicum
D
Multiple hemangiomas
Question 64 Explanation:
Erythema toxicum is the normal, nonpathological macular newborn rash.
Question 65
Which telephone call from a student’s mother should the school nurse take care of at once?
A
A telephone call notifying the school nurse that the child’s pediatrician has informed the mother that the child has head lice.
B
A telephone call notifying the school nurse that a child has a temperature of 102ºF and a rash covering the trunk and upper extremities of the body.
C
A telephone call notifying the school nurse that a child underwent an emergency appendectomy during the previous night.
D
A telephone call notifying the school nurse that the child’ pediatrician has informed the mother that the child will need cardiac repair surgery within the next few weeks.
Question 65 Explanation:
A high fever accompanied by a body rash could indicate that the child has a communicable disease and would have exposed other students to the infection. The school nurse would want to investigate this telephone call immediately so that plans could be instituted to control the spread of such infection.
Question 66
In the admission care unit, which of the following client would the nurse give immediate attention?
A
A client who is 3 days postoperative with left calf pain.
B
A client with diabetes who has a glucoscan reading of 180.
C
A client who is postoperative hip pinning who is complaining of pain.
D
New admitted client with chest pain
Question 66 Explanation:
The client with chest pain may be having a myocardial infarction, and immediate assessment and intervention is a priority.
Question 67
The physician ordered Betamethasone to a pregnant woman at 34 weeks of gestation with sign of preterm labor. The nurse expects that the drug will:
A
Suppress labor contraction.
B
Stimulate the production of surfactant.
C
Reduce the risk of hypertension.
D
Treat infection.
Question 67 Explanation:
Betamethasone, a form of cortisone, acts on the fetal lungs to produce surfactant.
Question 68
The physician calls the nursing unit to leave an order. The senior nurse had conversation with the other staff. The newly hired nurse answers the phone so that the senior nurses may continue their conversation. The new nurse does not know the physician or the client to whom the order pertains. The nurse should:
A
Ask the charge nurse or one of the other senior staff nurses to take the telephone order.
B
Take the telephone order.
C
Refuse to take the telephone order.
D
Ask the physician to call back after the nurse has read the hospital policy manual.
Question 68 Explanation:
Get a senior nurse who know s the policies, the client, and the doctor. Generally speaking, a nurse should not accept telephone orders. However, if it is necessary to take one, follow the hospital’s policy regarding telephone orders. Failure to follow hospital policy could be considered negligence. In this case, the nurse was new and did not know the hospital’s policy concerning telephone orders. The nurse was also unfamiliar with the doctor and the client. Therefore the nurse should not take the order unless a) no one else is available and b) it is an emergency situation.
Question 69
A tracheostomy cuff is to be deflated, which of the following nursing intervention should be implemented before starting the procedures?
A
Suction the trachea and mouth.
B
Encourage deep breathing and coughing.
C
Have the obdurator available.
D
Do a pulse oximetry reading.
Question 69 Explanation:
Secretions may have pooled above the tracheostomy cuff. If these are not suctioned before deflation, the secretions may be aspirated.
Question 70
A pregnant client in late pregnancy is complaining of groin pain that seems worse on the right side. Which of the following is the most likely cause of it?
A
Tension on the round ligament.
B
Bladder infection.
C
Constipation.
D
Beginning of labor.
Question 70 Explanation:
Tension on round ligament occurs because of the erect human posture and pressure exerted by the growing fetus.
Question 71
A client with obsessive-compulsive behavior is admitted in the psychiatric unit. The nurse taking care of the client knows that the primary treatment goal is to:
A
Point out the behavior.
B
Support but limit the behavior.
C
Prohibit the behavior.
D
Provide distraction.
Question 71 Explanation:
Support and limit setting decrease anxiety and provide external control.
Question 72
The pregnant woman visits the clinic for check –up. Which assessment findings will help the nurse determine that the client is in 8-week gestation?
A
Auscultation of fetal heart tones.
B
Leopold maneuvers.
C
Fundal height.
D
Positive radioimmunoassay test (RIA test).
Question 72 Explanation:
Serum radioimmunoassay (RIA) is accurate within 7days of conception. This test is specific for HCG, and accuracy is not compromised by confusion with LH.
Question 73
A newborn infant with Down syndrome is to be discharged today. The nurse is preparing to give the discharge teaching regarding the proper care at home. The nurse would anticipate that the mother is probably at the:
A
20 years of age.
B
40 years of age
C
35 years of age.
D
20 years of age.
Question 73 Explanation:
Perinatal risk factors for the development of Down syndrome include advanced maternal age, especially with the first pregnancy.
Question 74
A pregnant woman who is at term is admitted to the birthing unit in active labor. The client has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her contractions. Which of the following is the most important aspect of nursing intervention at this time?
A
Timing and recording length of contractions.
B
Monitoring.
C
Checking the perineum for bulging.
D
Preparing for an emergency cesarean birth.
Question 74 Explanation:
The oxytocic effect of Pitocin increases the intensity and durations of contractions; prolonged contractions will jeopardize the safety of the fetus and necessitate discontinuing the drug.
Question 75
After therapy with the thrombolytic alteplase (t-PA), what observation will the nurse report to the physician?
A
Change in level of consciousness and headache.
B
Occasional dysrhythmias.
C
3+ peripheral pulses.
D
Heart rate of 100/bpm.
Question 75 Explanation:
This could indicate intracranial bleeding. Alteplase is a thrombolytic enzyme that lyses thrombi and emboli. Bleeding is an adverse effect. Monitor clotting times and signs of any gastrointestinal or internal bleeding.
Question 76
Which of the following signs and symptoms that require immediate attention and may indicate most serious complications during pregnancy?
A
Severe abdominal pain or fluid discharge from the vagina.
B
Fatigue, nausea, and urinary frequency at any time during pregnancy.
C
Excessive saliva, “bumps around the areolae, and increased vaginal mucus.
D
Ankle edema, enlarging varicosities, and heartburn.
Question 76 Explanation:
Severe abdominal pain may indicate complications of pregnancy such as abortion, ectopic pregnancy, or abruption placenta; fluid discharge from the vagina may indicate premature rupture of the membrane.
Question 77
The nurse wants to know if the mother of a toddler understands the instructions regarding the administration of syrup of ipecac. Which of the following statement will help the nurse to know that the mother needs additional teaching?
A
“I’ll give the medicine if my child gets into some plant bulbs.”
B
“I’ll give the medicine if my child gets into some toilet bowl cleaner.”
C
“I’ll give the medicine if my child gets into some aspirin.”
D
“I’ll give the medicine if my child gets into some vitamin pills.
Question 77 Explanation:
Syrup of ipecac is not administered when the ingested substances is corrosive in nature. Toilet bowl cleaners, as a collective whole, are highly corrosive substances. If the ingested substance “burned” the esophagus going down, it will “burn” the esophagus coming back up when the child begins to vomit after administration of syrup of ipecac.
Question 78
The nurse is assessing the newborn boy. Apgar scores are 7 and 9. The newborn becomes slightly cyanotic. What is the initial nursing action?
A
Aspirate his mouth and nose with bulb syringe.
B
Stimulate him to cry,, to increase oxygenation.
C
Elevate his head to promote gravity drainage of secretions.
D
Wrap him in another blanket, to reduce heat loss.
Question 78 Explanation:
Gentle aspiration of mucus helps maintain a patent airway, required for effective gas exchange.
Question 79
A woman is hospitalized with mild preeclampsia. The nurse is formulating a plan of care for this client, which nursing care is least likely to be done?
A
Deep-tendon reflexes once per shift.
B
Daily weight.
C
Absolute bed rest.
D
Vital signs and FHR and rhythm q4h while awake.
Question 79 Explanation:
Although reducing environment stimuli and activity is necessary for a woman with mild preeclampsia, she will most probably have bathroom privileges.
Question 80
One staff nurse is assigned to a group of 5 patients for the 12-hour shift. The nurse is responsible for the overall planning, giving and evaluating care during the entire shift. After the shift, same responsibility will be endorsed to the next nurse in charge. This describes nursing care delivered via the:
A
Functional method.
B
Primary nursing method.
C
Case method.
D
Team method.
Question 80 Explanation:
In case management, the nurse assumes total responsibility for meeting the needs of the client during the entire time on duty.
Question 81
The community health nurse makes a home visit to a family. During the visit, the nurse observes that the mother is beating her child. What is the priority nursing intervention in this situation?
A
Assist the family to identify stressors and use of other coping mechanisms to prevent further incidents.
B
Report the incident to protective agencies.
C
Assess the child’s injuries.
D
Refer the family to appropriate support group.
Question 81 Explanation:
Assessment of physical injuries (like bruises, lacerations, bleeding and fractures) is the first priority.
Question 82
The nurse is caring to a client diagnosed with severe depression. Which of the following nursing approach is important in depression?
A
Reduce interpersonal contacts.
B
Deemphasizing preoccupation with elimination, nourishment, and sleep.
C
Protect the client against harm to others.
D
Provide the client with motor outlets for aggressive, hostile feelings.
Question 82 Explanation:
It is important to externalize the anger away from self.
Question 83
The nurse is conducting a lecture to a group of volunteer nurses. The nurse is correct in imparting the idea that the Good Samaritan law protects the nurse from a suit for malpractice when:
A
The nurse is grossly negligent at the scene of an emergency.
B
The nurse acts in an emergency at his or her place of employment.
C
The nurse refuses to stop for an emergency outside of the scope of employment.
D
The nurse stops to render emergency aid and leaves before the ambulance arrives.
Question 83 Explanation:
The Good Samaritan Law does not impose a duty to stop at the scene of an emergency outside of the scope of employment, therefore nurses who do not stop are not liable for suit.
Question 84
The nurse is planning to talk to the client with an antisocial personality disorder. What would be the most therapeutic approach?
A
Provide external controls.
B
Gratify the client’s inner needs.
C
Reinforce the client’s self-concept.
D
Give the client opportunities to test reality.
Question 84 Explanation:
Personality disorders stem from a weak superego, implying a lack of adequate controls.
Question 85
Which of the following treatment modality is appropriate for a client with paranoid tendency?
A
Family therapy.
B
Individual therapy.
C
Group therapy.
D
Activity therapy.
Question 85 Explanation:
This option is least threatening.
Question 86
The client is brought to the emergency department because of serious vehicle accident. After an hour, the client has been declared brain dead. The nurse who has been with the client must now talk to the family about organ donation. Which of the following consideration is necessary?
A
Take the family to the chapel.
B
Clarify the family’s understanding of brain death.
C
Discuss life support systems.
D
Include as many family members as possible.
Question 86 Explanation:
The family needs to understand what brain death is before talking about organ donation. They need time to accept the death of their family member. An environment conducive to discussing an emotional issue is needed.
Question 87
The nurse is assessing on the client who is admitted due to vehicle accident. Which of the following findings will help the nurse that there is internal bleeding?
A
Confusion and altered of consciousness.
B
Abdominal pain.
C
Frank blood on the clothing.
D
Thirst and restlessness.
Question 87 Explanation:
Thirst and restlessness indicate hypovolemia and hypoxemia. Internal bleeding is difficult to recognized and evaluate because it is not apparent.
Question 88
Which of the following complications during a breech birth the nurse needs to be alarmed?
A
Caput succedaneum.
B
Umbilical cord prolapse
C
Abruption placenta.
D
Pathological hyperbilirubinemia.
Question 88 Explanation:
Because umbilical cord’s insertion site is born before the fetal head, the cord may be compressed by the after-coming head in a breech birth.
Question 89
The nurse in the psychiatric ward informed the male client that he will be attending the 9:00 AM group therapy sessions. The client tells the nurse that he must wash his hands from 9:00 to 9:30 AM each day and therefore he cannot attend. Which concept does the nursing staff need to keep in mind in planning nursing intervention for this client?
A
Unmet needs are discharged through ritualistic behavior.
B
Ritualistic behavior makes others uncomfortable.
C
Depression underlines ritualistic behavior.
D
Fear and tensions are often expressed in disguised form through symbolic processes.
Question 89 Explanation:
Anxiety is generated by group therapy at 9:00 AM. The ritualistic behavioral defense of hand washing decreases anxiety by avoiding group therapy.
Question 90
The nurse is assigned to care to a 17-year-old male client with a history of substance abuse. The client asks the nurse, “Have you ever tried or used drugs?” The most correct response of the nurse would be:
A
“Why do you want to know that?”
B
“No, I don’t think so.”
C
“How will my answer help you?”
D
“Yes, once I tried grass.”
Question 90 Explanation:
The client may perceive this as avoidance, but it is more important to redirect back to the client, especially in light of the manipulative behavior of drug abusers and adolescents.
Question 91
A male client is brought to the emergency department due to motor vehicle accident. While monitoring the client, the nurse suspects increasing intracranial pressure when:
A
Pulse is increased from 88-96 with occasional skipped beat.
B
Client is oriented when aroused from sleep, and goes back to sleep immediately.
C
Client refuses dinner because of anorexia.
D
Blood pressure is decreased from 160/90 to 110/70.
Question 91 Explanation:
This suggests that the level of consciousness is decreasing.
Question 92
The ambulance team calls the emergency department that they are going to bring a client who sustained burns in a house fire. While waiting for the ambulance, the nurse will anticipate emergency care to include assessment for:
A
Hyperthermia.
B
Hypoglycemia.
C
Gas exchange impairment
D
Fluid volume excess.
Question 92 Explanation:
Smoke inhalation affects gas exchange.
Question 93
Which of the following nursing intervention is essential for the client who had pneumonectomy?
A
Encourage deep breathing and coughing.
B
Medicate for pain only when needed.
C
Notify the physician if the chest drainage exceeds 100mL/hr.
D
Connect the chest tube to water-seal drainage.
Question 93 Explanation:
Surgery and anesthesia can increase mucus production. Deep breathing and coughing are essential to prevent atelectasis and pneumonia in the client’s only remaining lung.
Question 94
A hospitalized client cannot find his handkerchief and accuses other cient in the room and the nurse of stealing them. Which is the most therapeutic approach to this client?
A
Inject humor to defuse the intensity.
B
Listen without reinforcing the client’s belief.
C
Logically point out that the client is jumping to conclusions.
D
Divert the client’s attention.
Question 94 Explanation:
Listening is probably the most effective response of the four choices.
Question 95
A female client who has a 28-day menstrual cycle asks the community health nurse when she get pregnant during her cycle. What will be the best nursing response?
A
In a 28- day cycle, ovulation occurs at or about day 14. The egg lives for about 72 hours and the sperm live for about 24 hours. The fertile period would be approximately between day 13 and 17.
B
In a 28-day cycle, ovulation occurs at or about day 14. The egg lives for about 24 hours and the sperm live for about 72 hours. The fertile period would be approximately between day 11 and day 15.
C
In a 28-day cycle, ovulation occurs 8 days before the next period or at about day 20. The fertile period is between day 20 and the beginning of the next period.
D
It is impossible to determine the fertile period reliably. So it is best to assume that a woman is always fertile.
Question 95 Explanation:
It is the most accurate statement of physiological facts for a 28-day menstrual cycle: ovulation at day 14, egg life span 24 hours, sperm life span of 72 hours. Fertilization could occur from sperm deposited before ovulation.
Question 96
The nurse observes the female client in the psychiatric ward that she is having a hard time sleeping at night. The nurse asks the client about it and the client says, “I can’t sleep at night because of fear of dying.” What is the best initial nursing response?
A
“Don’t worry, you won’t die. You are just here for some test.”
B
“It must be frightening for you to feel that way. Tell me more about it.”
C
“Why are you afraid of dying?”
D
“Try to sleep. You need the rest before tomorrow’s test.”
Question 96 Explanation:
Acknowledging a feeling tone is the most therapeutic response and provides a broad opening for the client to elaborate feelings.
Question 97
A client who undergone appendectomy 3 days ago is scheduled for discharge today. The nurse notes that the client is restless, picking at bedclothes and saying, “I am late on my appointment,” and calling the nurse by the wrong name. The nurse suspects:
A
Medication overdose.
B
Panic reaction.
C
Toxic reaction to an antibiotic.
D
Delirium tremens.
Question 97 Explanation:
The behavior described is likely to be symptoms of delirium tremens, or alcohol withdrawal (often unsuspected on a surgical unit.)
Question 98
A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned to care for the client must institute appropriate precautions. The nurse should:
A
Don a surgical mask with a face shield when entering the room.
B
Put on a gown every time when entering the room.
C
Place the client in a private room.
D
Wear an N 95 respirator when caring for the client.
Question 98 Explanation:
The N 95 respirator is a high-particulate filtration mask that meets the CDC performance criteria for a tuberculosis respirator.
Question 99
The nurse noticed that the signed consent form has an error. The form states, “Amputation of the right leg” instead of the left leg that is to be amputated. The nurse has administered already the preoperative medications. What should the nurse do?
A
Call the physician to reschedule the surgery.
B
Call the nearest relative to come in to sign a new form.
C
Cross out the error and initial the form.
D
Have the client sign another form.
Question 99 Explanation:
The responsible for an accurate informed consent is the physician. An exception to this answer would be a life-threatening emergency, but there are no data to support another response.
Question 100
The nurse is teaching exercises that are good for pregnant women increasing tone and fitness and decreasing lower backache. Which of the following should the nurse exclude in the exercise program?
A
Ten minutes of swimming or leg kicking in pool per day.
B
Pelvic rock exercise and squats three times a day.
C
Stand with legs apart and touch hands to floor three times per day.
D
Ten minutes of walking per day with an emphasis on good posture.
Question 100 Explanation:
Bending from the waist in pregnancy tends to make backache worse.
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PNLE : Maternal and Child Health Nursing Exam 3 (EM)
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Question 1
The nurse is caring to a child client who has had a tonsillectomy. The child complains of having dryness of the throat. Which of the following would the nurse give to the child?
A
A glass of milk
B
Cool cherry Kool-Aid
C
Yellow noncitrus Jello
D
Cola with ice
Question 1 Explanation:
After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and hot or cold liquids should be avoided because they may irritate the throat. Red liquids should be avoided because they give the appearance of blood if the child vomits. Milk and milk products including pudding are avoided because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding.
Question 2
The nurse is caring for a cient who Is a retired nurse. A 24-hour urine collection for Creatinine clearance is to be done. The client tells the nurse, “I can’t remember what this test is for.” The best response by the nurse is:
A
“It provides a way to see if you are passing any protein in your urine.”
B
“It tells if your renal insufficiency has affected your heart.”
C
“The test measures the number of particles the kidney filters.”
D
“It tells how well the kidneys filter wastes from the blood.”
Question 2 Explanation:
Determining how well the kidneys filter wastes states the purpose of a Creatinine clearance test.
Question 3
The child client has undergone hip surgery and is in a spica cast. Which of the following toy should be avoided to be in the child’s bed?
A
A ball.
B
A stuffed animal.
C
A toy gun.
D
Legos.
Question 3 Explanation:
Legos are small plastic building blocks that could easily slip under the child’s cast and lead to a break in skin integrity and even infection. Pencils, backscratchers, and marbles are some other narrow or small items that could easily slip under the child’s cast and lead to a break in skin integrity and infection.
Question 4
The parents of an infant client ask the nurse to teach them how to administer Cortisporin eye drops. The nurse is correct in advising the parents to place the drops:
A
In the outer canthus of the infant’s eye.
B
Directly onto the infant’s sclera.
C
In the inner canthus of the infant’s eye.
D
In the middle of the lower conjunctival sac of the infant’s eye.
Question 4 Explanation:
The recommended procedure for administering eyedrops to any client calls for the drops to be placed in the middle of the lower conjunctival sac.
Question 5
Which of the following will help the nurse determine that the expression of hostility is useful?
A
Energy from anger is used to accomplish what needs to be done.
B
Expression intimidates others.
C
Expression of anger dissipates the energy.
D
Degree of hostility is less than the provocation.
Question 5 Explanation:
This is the proper use of anger.
Question 6
One staff nurse is assigned to a group of 5 patients for the 12-hour shift. The nurse is responsible for the overall planning, giving and evaluating care during the entire shift. After the shift, same responsibility will be endorsed to the next nurse in charge. This describes nursing care delivered via the:
A
Functional method.
B
Primary nursing method.
C
Team method.
D
Case method.
Question 6 Explanation:
In case management, the nurse assumes total responsibility for meeting the needs of the client during the entire time on duty.
Question 7
A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned to care for the client must institute appropriate precautions. The nurse should:
A
Put on a gown every time when entering the room.
B
Don a surgical mask with a face shield when entering the room.
C
Place the client in a private room.
D
Wear an N 95 respirator when caring for the client.
Question 7 Explanation:
The N 95 respirator is a high-particulate filtration mask that meets the CDC performance criteria for a tuberculosis respirator.
Question 8
Which of the following nursing intervention is essential for the client who had pneumonectomy?
A
Encourage deep breathing and coughing.
B
Medicate for pain only when needed.
C
Connect the chest tube to water-seal drainage.
D
Notify the physician if the chest drainage exceeds 100mL/hr.
Question 8 Explanation:
Surgery and anesthesia can increase mucus production. Deep breathing and coughing are essential to prevent atelectasis and pneumonia in the client’s only remaining lung.
Question 9
The physician calls the nursing unit to leave an order. The senior nurse had conversation with the other staff. The newly hired nurse answers the phone so that the senior nurses may continue their conversation. The new nurse does not know the physician or the client to whom the order pertains. The nurse should:
A
Ask the physician to call back after the nurse has read the hospital policy manual.
B
Take the telephone order.
C
Ask the charge nurse or one of the other senior staff nurses to take the telephone order.
D
Refuse to take the telephone order.
Question 9 Explanation:
Get a senior nurse who know s the policies, the client, and the doctor. Generally speaking, a nurse should not accept telephone orders. However, if it is necessary to take one, follow the hospital’s policy regarding telephone orders. Failure to follow hospital policy could be considered negligence. In this case, the nurse was new and did not know the hospital’s policy concerning telephone orders. The nurse was also unfamiliar with the doctor and the client. Therefore the nurse should not take the order unless a) no one else is available and b) it is an emergency situation.
Question 10
A female client with cancer has radium implants. The nurse wants to maintain the implants in the correct position. The nurse should position the client:
A
With the head elevated 45-degrees (semi-Fowler’s).
B
On the side only.
C
Flat in bed.
D
With the foot of the bed elevated.
Question 10 Explanation:
Clients with radioactive implants should be positioned flat in bed to prevent dislodgement of the vaginal packing. The client may roll to the side for meals but the upper body should not be raised more than 20 degrees.
Question 11
The community health nurse makes a home visit to a family. During the visit, the nurse observes that the mother is beating her child. What is the priority nursing intervention in this situation?
A
Assist the family to identify stressors and use of other coping mechanisms to prevent further incidents.
B
Assess the child’s injuries.
C
Report the incident to protective agencies.
D
Refer the family to appropriate support group.
Question 11 Explanation:
Assessment of physical injuries (like bruises, lacerations, bleeding and fractures) is the first priority.
Question 12
The nurse is formulating a plan of care to a client with a somatoform disorder. The nurse needs to have knowledge of which psychodynamic principle?
A
The symptoms of a somatoform disorder are an attempt to adjust to painful life situations or to cope with conflicting sexual, aggressive, or dependent feelings.
B
An extensive, prolonged study of the symptoms will be reassuring to the client, who seeks sympathy, attention and love.
C
The client’s symptoms are imaginary and the suffering is faked.
D
The major fundamental mechanism is regression.
Question 12 Explanation:
Somatoform disorders provide a way of coping with conflicts.
Question 13
The nurse in the neonatal care unit is supervising the actions of a certified nursing assistant in giving care to the newborns. The nursing assistant mistakenly gives a formula feeding to a newborn that is on water feeding only. The nurse is responsible for the mistake of the nursing assistant:
A
Only if the nurse agreed that the newborn could be fed formula.
B
Always, because nurses who supervise less-trained individuals are responsible for their mistakes.
C
Always, as a representative of the institution.
D
If the nurse failed to determine whether the nursing assistant was competent to take care of the client.
Question 13 Explanation:
The nurse who is supervising others has a legal obligation to determine that they are competent to perform the assignment, as well as legal obligation to provide adequate supervision.
Question 14
A tracheostomy cuff is to be deflated, which of the following nursing intervention should be implemented before starting the procedures?
A
Suction the trachea and mouth.
B
Do a pulse oximetry reading.
C
Encourage deep breathing and coughing.
D
Have the obdurator available.
Question 14 Explanation:
Secretions may have pooled above the tracheostomy cuff. If these are not suctioned before deflation, the secretions may be aspirated.
Question 15
A newborn infant with Down syndrome is to be discharged today. The nurse is preparing to give the discharge teaching regarding the proper care at home. The nurse would anticipate that the mother is probably at the:
A
40 years of age
B
20 years of age.
C
35 years of age.
D
20 years of age.
Question 15 Explanation:
Perinatal risk factors for the development of Down syndrome include advanced maternal age, especially with the first pregnancy.
Question 16
The nurse is planning to talk to the client with an antisocial personality disorder. What would be the most therapeutic approach?
A
Give the client opportunities to test reality.
B
Provide external controls.
C
Reinforce the client’s self-concept.
D
Gratify the client’s inner needs.
Question 16 Explanation:
Personality disorders stem from a weak superego, implying a lack of adequate controls.
Question 17
The nurse in the nursing care unit checks the fluctuation in the water-seal compartment of a closed chest drainage system. The fluctuation has stopped, the nurse would:
A
Increase wall suction above 20 cm H2O pressure.
B
Vigorously strip the tube to dislodge a clot.
C
Raise the apparatus above the chest to move fluid.
D
Ask the client to cough and take a deep breath.
Question 17 Explanation:
Asking the client to cough and take a deep breath will help determine if the chest tube is kinked or if the lungs has reexpanded.
Question 18
The nurse must instruct a client with glaucoma to avoid taking over-the-counter medications like:
A
NSAIDs.
B
Salicylates.
C
Antacids.
D
Antihistamines.
Question 18 Explanation:
Antihistamines cause pupil dilation and should be avoided with glaucoma.
Question 19
The nurse is providing a health teaching to a group of parents regarding Chlamydia trachomatis. The nurse is correct in the statement, “Chlamydia trachomatis is not only an intracellular bacterium that causes neonatal conjunctivitis, but it also can cause:
A
Pneumonia in the newborn.
B
Central hearing defects in infancy.
C
Snuffles and rhagades in the newborn.
D
Discoloration of baby and adult teeth.
Question 19 Explanation:
Newborns can get pneumonia (tachypnea, mild hypoxia, cough, eosinophilia) and conjunctivitis from Chlamydia.
Question 20
A 3-month-old client is in the pediatric unit. During assessment, the nurse is suspecting that the baby may have hypothyroidism when mother states that her baby does not:
A
Roll over.
B
Sit up.
C
Hold the head up.
D
Pick up and hold a rattle.
Question 20 Explanation:
Development normally proceeds cephalocaudally; so the first major developmental milestone that the infant achieves is the ability to hold the head up within the first 8-12 weeks of life. In hypothyroidism, the infant’s muscle tone would be poor and the infant would not be able to achieve this milestone.
Question 21
A nurse is giving a health teaching to a woman who wants to breastfeed her newborn baby. Which hormone, normally secreted during the postpartum period, influences both the milk ejection reflex and uterine involution?
A
Progesterone.
B
Relaxin.
C
Estrogen.
D
Oxytocin.
Question 21 Explanation:
Contraction of the milk ducts and let-down reflex occur under the stimulation of oxytocin released by the posterior pituitary gland.
Question 22
A client with lung cancer is admitted in the nursing care unit. The husband wants to know the condition of his wife. How should the nurse respond to the husband?
A
Suggest that he discuss it with his wife.
B
Find out what information he already has.
C
Refer him to the nurse in charge.
D
Refer him to the doctor.
Question 22 Explanation:
It is best to establish baseline information first.
Question 23
The nurse is assigned to care for a client with urinary calculi. Fluid intake of 2L/day is encouraged to the client. the primary reason for this is to:
A
Prevent crystalline irritation to the ureter.
B
Increase the hydrostatic pressure in the urinary tract.
C
Reduce the size of existing stones.
D
Reduce the size of existing stones
Question 23 Explanation:
Increasing hydrostatic pressure in the urinary tract will facilitate passage of the calculi.
Question 24
Which of the following will best describe a management function?
A
Explaining medication side effects to a client.
B
Directing and evaluating nursing staff members.
C
Negotiating labor contracts.
D
Writing a letter to the editor of a nursing journal.
Question 24 Explanation:
Directing and evaluation of staff is a major responsibility of a nursing manager.
Question 25
An older adult client wakes up at 2 o’clock in the morning and comes to the nurse’s station saying, “I am having difficulty in sleeping.” What is the best nursing response to the client?
A
“Would you like me to show you where the bathroom is?”
B
“I’ll give you a sleeping pill to help you get more sleep now.”
C
“Perhaps you’d like to sit here at the nurse’s station for a while.”
D
“What woke you up?”
Question 25 Explanation:
This option shows acceptance (key concept) of this age-typical sleep pattern (that of waking in the early morning).
Question 26
The client has had a right-sided cerebrovascular accident. In transferring the client from the wheelchair to bed, in what position should a client be placed to facilitate safe transfer?
A
Weakened (R) side of the cient away from bed.
B
Weakened (L) side of the cient next to bed.
C
Weakened (L) side of the client away from bed.
D
Weakened (R) side of the client next to bed.
Question 26 Explanation:
With a right-sided cerebrovascular accident the client would have left-sided hemiplegia or weakness. The client’s good side should be closest to the bed to facilitate the transfer.
Question 27
A mother is in the third stage of labor. Which of the following signs will help the nurse determine the signs of placental separation?
A
The uterus becomes globular.
B
The umbilical cord is shortened.
C
Mucoid discharge is increased.
D
The fundus appears at the introitus.
Question 27 Explanation:
Signs of placental separation include a change in the shape of the uterus from ovoid to globular.
Question 28
Which of the following treatment modality is appropriate for a client with paranoid tendency?
A
Group therapy.
B
Individual therapy.
C
Activity therapy.
D
Family therapy.
Question 28 Explanation:
This option is least threatening.
Question 29
The physician ordered tetracycline PO qid to a child client who weights 20kg. The recommended PO tetracycline dose is 25-50 mg/kg/day. What is the maximum single dose that can be safely administered to this child?
A
500 mg
B
250 mg
C
1 g
D
125 mg
Question 29 Explanation:
The recommended dosage of tetracycline is 25-50mg/kg/day. If the child weighs 20kg and the maximum dose is 50mg/kg, this would indicate a total daily dose of 1000mg of tetracycline. In this case, the child is being given this medication four times a day. Therefore the maximum single dose that can be given is 250mg (1000 mg of tetracycline divided by four doses.)
Question 30
A male client tells the nurse that there is a big bug in his bed. The most therapeutic nursing response would be:
A
“Where’s the bug? I’ll kill it for you.”
B
“You must be seeing things.”
C
“I don’t see a bug in your bed, but you seem afraid.”
D
Silence
Question 30 Explanation:
This response does not contradict the client’s perception, is honest, and shows empathy.
Question 31
Most couples are using “natural” family planning methods. Most accidental pregnancies in couples preferred to use this method have been related to unprotected intercourse before ovulation. Which of the following factor explains why pregnancy may be achieved by unprotected intercourse during the preovulatory period?
A
Tubal motility.
B
Secretory endometrium.
C
Spermatozoal viability.
D
Ovum viability.
Question 31 Explanation:
Sperm deposited during intercourse may remain viable for about 3 days. If ovulation occurs during this period, conception may result.
Question 32
An infant is brought to the health care clinic for three immunizations at the same time. The nurse knows that hepatitis B, DPT, and Haemophilus influenzae type B immunizations should:
A
Be mixed and inject in the same sites.
B
Be drawn in the same syringe and given in one injection.
C
Be mixed and the nurse must give the injection in three sites.
D
Not be mixed and the nurse must give three injections in three sites.
Question 32 Explanation:
Immunization should never be mixed together in a syringe, thus necessitating three separate injections in three sites. Note: some manufacturers make a premixed combination of immunization that is safe and effective.
Question 33
The nurse in the psychiatric ward informed the male client that he will be attending the 9:00 AM group therapy sessions. The client tells the nurse that he must wash his hands from 9:00 to 9:30 AM each day and therefore he cannot attend. Which concept does the nursing staff need to keep in mind in planning nursing intervention for this client?
A
Fear and tensions are often expressed in disguised form through symbolic processes.
B
Depression underlines ritualistic behavior.
C
Ritualistic behavior makes others uncomfortable.
D
Unmet needs are discharged through ritualistic behavior.
Question 33 Explanation:
Anxiety is generated by group therapy at 9:00 AM. The ritualistic behavioral defense of hand washing decreases anxiety by avoiding group therapy.
Question 34
Before the administration of digoxin, the nurse completes an assessment to a toddler client for signs and symptoms of digoxin toxicity. Which of the following is the earliest and most significant sign of digoxin toxicity?
A
Nausea and vomiting
B
Vision problem
C
Tinnitus
D
Slowing in the heart rate
Question 34 Explanation:
One of the earliest signs of digoxin toxicity is Bradycardia. For a toddler, any heart rate that falls below the norm of about 100-120 bpm would indicate Bradycardia and would necessitate holding the medication and notifying the physician.
Question 35
A couple seeks medical advice in the community health care unit. A couple has been unable to conceive; the man is being evaluated for possible problems. The physician ordered semen analysis. Which of the following instructions is correct regarding collection of a sperm specimen?
A
Collect specimen after 48-72 hours of abstinence and bring to clinic within 2 hours.
B
Collect a specimen at the clinic, place in iced container, and give to laboratory personnel immediately.
C
Collect specimen at night, refrigerate, and bring to clinic the next morning.
D
Collect specimen in the morning after 24 hours of abstinence and bring to clinic immediately.
Question 35 Explanation:
Is correct because semen analysis requires that a freshly masturbated specimen be obtained after a rest (abstinence) period of 48-72 hours.
Question 36
The client with rheumatoid arthritis is for discharge. In preparing the client for discharge on prednisone therapy, the nurse should advise the client to:
A
Never stop or change the amount of the medication without medical advice.
B
Wear sunglasses if exposed to bright light for an extended period of time.
C
Take oral preparations of prednisone before meals.
D
Have periodic complete blood counts while on the medication.
Question 36 Explanation:
In preparing the client for discharge that is receiving prednisone, the nurse should caution the client to (a) take oral preparations after meals; (b) remember that routine checks of vital signs, weight, and lab studies are critical; (c) NEVER STOP OR CHANGE THE AMOUNT OF MEDICATION WITHOUT MEDICAL ADVICE; (d) store the medication in a light-resistant container.
Question 37
A client who undergone left nephrectomy has a large flank incision. Which of the following nursing action will facilitate deep breathing and coughing?
A
Maintain the client in high Fowler’s position.
B
Have the client lie on the unaffected side.
C
Coordinate breathing and coughing exercise with administration of analgesics.
D
Push fluid administration to loosen respiratory secretions.
Question 37 Explanation:
Because flank incision in nephrectomy is directly below the diaphragm, deep breathing is painful. Additionally, there is a greater incisional pull each time the person moves than there is with abdominal surgery. Incisional pain following nephrectomy generally requires analgesics administration every 3-4 hours for 24-48 hours after surgery. Therefore, turning, coughing and deep-breathing exercises should be planned to maximize the analgesic effects.
Question 38
A pregnant woman who is at term is admitted to the birthing unit in active labor. The client has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her contractions. Which of the following is the most important aspect of nursing intervention at this time?
A
Preparing for an emergency cesarean birth.
B
Timing and recording length of contractions.
C
Checking the perineum for bulging.
D
Monitoring.
Question 38 Explanation:
The oxytocic effect of Pitocin increases the intensity and durations of contractions; prolonged contractions will jeopardize the safety of the fetus and necessitate discontinuing the drug.
Question 39
The nursing applicant has given the chance to ask questions during a job interview at a local hospital. What should be the most important question to ask that can increase chances of securing a job offer?
A
Clarify information regarding salary, benefits, and working hours first, because this will help in deciding whether or not to take the job.
B
Decline to ask questions, because that is the responsibility of the interviewer.
C
Ask as many questions about the facility as possible.
D
Begin with questions about client care assignments, advancement opportunities, and continuing education.
Question 39 Explanation:
This choice implies concern for client care and self-improvement.
Question 40
While feeding a newborn with an unrepaired cardiac defect, the nurse keeps on assessing the condition of the client. The nurse notes that the newborn’s respiration is 72 breaths per minute. What would be the initial nursing action?
A
Burp the newborn.
B
Stop the feeding.
C
Continue the feeding.
D
Notify the physician.
Question 40 Explanation:
A normal respiratory rate for a newborn is 30-40 breaths per minute.
Question 41
A community health nurse is providing a health teaching to a woman infected with herpes simplex 2. Which of the following health teaching must the nurse include to reduce the chances of transmission of herpes simplex 2?
A
“Therapy is curative.”
B
“Penicillin is the drug of choice for treatment.”
C
“The organism is associated with later development of hydatidiform mole.
D
“Abstain from intercourse until lesions heal.”
Question 41 Explanation:
Abstinence will eliminate any unnecessary pain during intercourse and will reduce the possibility of transmitting infection to one’s sexual partner.
Question 42
The nurse assesses the health condition of the female client. The client tells the nurse that she discovered a lump in the breast last year and hesitated to seek medical advice. The nurse understands that, women who tend to delay seeking medical advice after discovering the disease are displaying what common defense mechanism?
A
Intellectualization.
B
Suppression.
C
Denial.
D
Repression.
Question 42 Explanation:
Denial is a very strong defense mechanism used to allay the emotional effects of discovering a potential threat. Although denial has been found to be an effective mechanism for survival in some instances, such as during natural disasters, it may in greater pathology in a woman with potential breast carcinoma.
Question 43
The nurse is taking care of a multipara who is at 42 weeks of gestation and in active labor, her membranes ruptured spontaneously 2 hours ago. While auscultating for the point of maximum intensity of fetal heart tones before applying an external fetal monitor, the nurse counts 100 beats per minute. The immediate nursing action is to:
A
Examine the woman for signs of a prolapsed cord.
B
Take the woman’s radial pulse while still auscultating the FHR.
C
Turn the woman on her left side to increase placental perfusion.
D
Start oxygen by mask to reduce fetal distress.
Question 43 Explanation:
Taking the mother’s pulse while listening to the FHR will differentiate between the maternal and fetal heart rates and rule out fetal Bradycardia.
Question 44
A client who undergone appendectomy 3 days ago is scheduled for discharge today. The nurse notes that the client is restless, picking at bedclothes and saying, “I am late on my appointment,” and calling the nurse by the wrong name. The nurse suspects:
A
Medication overdose.
B
Toxic reaction to an antibiotic.
C
Delirium tremens.
D
Panic reaction.
Question 44 Explanation:
The behavior described is likely to be symptoms of delirium tremens, or alcohol withdrawal (often unsuspected on a surgical unit.)
Question 45
The nurse is teaching exercises that are good for pregnant women increasing tone and fitness and decreasing lower backache. Which of the following should the nurse exclude in the exercise program?
A
Ten minutes of swimming or leg kicking in pool per day.
B
Pelvic rock exercise and squats three times a day.
C
Stand with legs apart and touch hands to floor three times per day.
D
Ten minutes of walking per day with an emphasis on good posture.
Question 45 Explanation:
Bending from the waist in pregnancy tends to make backache worse.
Question 46
In the hospital lobby, the registered nurse overhears a two staff members discussing about the health condition of her client. What would be the appropriate action for the registered nurse to take?
A
Tell them it is not appropriate to discuss such things.
B
Ignore them, because they have the right to discuss anything they want to.
C
Join in the conversation, giving her input about the case.
D
Report this incident to the nursing supervisor.
Question 46 Explanation:
The behavior should be stopped. The first is to remind the staff that confidentiality maybe violated.
Question 47
The LPN/LVN asks the registered nurse why oxytocin (Pitocin), 10 units (IV or IM) must be given to a client after birth fo the fetus. The nurse is correct to explain that oxytocin:
A
Promotes lactation.
B
Suppresses lactation.
C
Maintains uterine tone.
D
Minimizes discomfort from “afterpains.”
Question 47 Explanation:
Oxytocin (Pitocin) is used to maintain uterine tone.
Question 48
The pregnant woman visits the clinic for check –up. Which assessment findings will help the nurse determine that the client is in 8-week gestation?
A
Positive radioimmunoassay test (RIA test).
B
Fundal height.
C
Leopold maneuvers.
D
Auscultation of fetal heart tones.
Question 48 Explanation:
Serum radioimmunoassay (RIA) is accurate within 7days of conception. This test is specific for HCG, and accuracy is not compromised by confusion with LH.
Question 49
A client who hallucinates is not in touch with reality. It is important for the nurse to:
A
Establish a trusting relationship.
B
Maintain a safe environment.
C
Isolate the client from other patients.
D
Orient the client to time, place, and person
Question 49 Explanation:
It is of paramount importance to prevent the client from hurting himself or herself or others.
Question 50
The nurse is completing an assessment to a newborn baby boy. The nurse observes that the skin of the newborn is dry and flaking and there are several areas of an apparent macular rash. The nurse charts this as:
A
Milia
B
Multiple hemangiomas
C
Icterus neonatorum
D
Erythema toxicum
Question 50 Explanation:
Erythema toxicum is the normal, nonpathological macular newborn rash.
Question 51
The nurse is assessing on the client who is admitted due to vehicle accident. Which of the following findings will help the nurse that there is internal bleeding?
A
Frank blood on the clothing.
B
Abdominal pain.
C
Confusion and altered of consciousness.
D
Thirst and restlessness.
Question 51 Explanation:
Thirst and restlessness indicate hypovolemia and hypoxemia. Internal bleeding is difficult to recognized and evaluate because it is not apparent.
Question 52
Which of the following signs and symptoms that require immediate attention and may indicate most serious complications during pregnancy?
A
Fatigue, nausea, and urinary frequency at any time during pregnancy.
B
Ankle edema, enlarging varicosities, and heartburn.
C
Excessive saliva, “bumps around the areolae, and increased vaginal mucus.
D
Severe abdominal pain or fluid discharge from the vagina.
Question 52 Explanation:
Severe abdominal pain may indicate complications of pregnancy such as abortion, ectopic pregnancy, or abruption placenta; fluid discharge from the vagina may indicate premature rupture of the membrane.
Question 53
The client’s jaw and cheekbone is sutured and wired. The nurse anticipates that the most important thing that must be ready at the bedside is:
A
Wire cutters.
B
Suction equipment.
C
Suture set.
D
Tracheostomy set.
Question 53 Explanation:
The priority for this client is being able to establish an airway.
Question 54
The nurse is conducting a lecture to a group of volunteer nurses. The nurse is correct in imparting the idea that the Good Samaritan law protects the nurse from a suit for malpractice when:
A
The nurse stops to render emergency aid and leaves before the ambulance arrives.
B
The nurse is grossly negligent at the scene of an emergency.
C
The nurse acts in an emergency at his or her place of employment.
D
The nurse refuses to stop for an emergency outside of the scope of employment.
Question 54 Explanation:
The Good Samaritan Law does not impose a duty to stop at the scene of an emergency outside of the scope of employment, therefore nurses who do not stop are not liable for suit.
Question 55
The nurse is completing an obstetric history of a woman in labor. Which event in the obstetric history will help the nurse suspects dysfunctional labor in the current pregnancy?
A
Second birth by cesarean for face presentation.
B
Uterine fibroid noted at time of cesarean delivery.
C
First labor lasting 24 hours.
D
Total time of ruptured membranes was 24 hours with the second birth.
Question 55 Explanation:
An abnormality in the uterine muscle could reduce the effectiveness of uterine contractions and lengthen the duration of subsequent labors.
Question 56
The nurse is caring to a client diagnosed with severe depression. Which of the following nursing approach is important in depression?
A
Reduce interpersonal contacts.
B
Provide the client with motor outlets for aggressive, hostile feelings.
C
Deemphasizing preoccupation with elimination, nourishment, and sleep.
D
Protect the client against harm to others.
Question 56 Explanation:
It is important to externalize the anger away from self.
Question 57
The nurse is assigned to care for a child client admitted in the pediatrics unit. The client is receiving digoxin. Which of the following questions will be asked by the nurse to the parents of the child in order to assess the client’s risk for digoxin toxicity?
A
“Has he been exposed to any childhood communicable diseases in the past 2-3 weeks?”
B
“Has he been going to school regularly?”
C
“Do any of his brothers and sisters have history of cardiac problems?”
D
“Has he been taking diuretics at home?”
Question 57 Explanation:
The child who is concurrently taking digoxin and diuretics is at increased risk for digoxin toxicity due to the loss of potassium. The child and parents should be taught what foods are high in potassium, and the child should be encouraged to eat a high-potassium diet. In addition, the child’s serum potassium level should be carefully monitored.
Question 58
Which of the following complications during a breech birth the nurse needs to be alarmed?
A
Caput succedaneum.
B
Abruption placenta.
C
Pathological hyperbilirubinemia.
D
Umbilical cord prolapse
Question 58 Explanation:
Because umbilical cord’s insertion site is born before the fetal head, the cord may be compressed by the after-coming head in a breech birth.
Question 59
The physician ordered Betamethasone to a pregnant woman at 34 weeks of gestation with sign of preterm labor. The nurse expects that the drug will:
A
Stimulate the production of surfactant.
B
Reduce the risk of hypertension.
C
Treat infection.
D
Suppress labor contraction.
Question 59 Explanation:
Betamethasone, a form of cortisone, acts on the fetal lungs to produce surfactant.
Question 60
After therapy with the thrombolytic alteplase (t-PA), what observation will the nurse report to the physician?
A
Change in level of consciousness and headache.
B
Heart rate of 100/bpm.
C
3+ peripheral pulses.
D
Occasional dysrhythmias.
Question 60 Explanation:
This could indicate intracranial bleeding. Alteplase is a thrombolytic enzyme that lyses thrombi and emboli. Bleeding is an adverse effect. Monitor clotting times and signs of any gastrointestinal or internal bleeding.
Question 61
The nurse wants to know if the mother of a toddler understands the instructions regarding the administration of syrup of ipecac. Which of the following statement will help the nurse to know that the mother needs additional teaching?
A
“I’ll give the medicine if my child gets into some aspirin.”
B
“I’ll give the medicine if my child gets into some toilet bowl cleaner.”
C
“I’ll give the medicine if my child gets into some plant bulbs.”
D
“I’ll give the medicine if my child gets into some vitamin pills.
Question 61 Explanation:
Syrup of ipecac is not administered when the ingested substances is corrosive in nature. Toilet bowl cleaners, as a collective whole, are highly corrosive substances. If the ingested substance “burned” the esophagus going down, it will “burn” the esophagus coming back up when the child begins to vomit after administration of syrup of ipecac.
Question 62
Which of the following describes a health care team with the principles of participative leadership?
A
Nurses decide nursing care; physicians decide medical and other treatment for the client.
B
The physician makes most of the decisions regarding the client’s care.
C
Each member of the team can independently make decisions regarding the client’s care without necessarily consulting the other members.
D
The team uses the expertise of its members to influence the decisions regarding the client’s care.
Question 62 Explanation:
It describes a democratic process in which all members have input in the client’s care.
Question 63
A client with obsessive-compulsive behavior is admitted in the psychiatric unit. The nurse taking care of the client knows that the primary treatment goal is to:
A
Provide distraction.
B
Support but limit the behavior.
C
Point out the behavior.
D
Prohibit the behavior.
Question 63 Explanation:
Support and limit setting decrease anxiety and provide external control.
Question 64
Which telephone call from a student’s mother should the school nurse take care of at once?
A
A telephone call notifying the school nurse that a child has a temperature of 102ºF and a rash covering the trunk and upper extremities of the body.
B
A telephone call notifying the school nurse that the child’s pediatrician has informed the mother that the child has head lice.
C
A telephone call notifying the school nurse that the child’ pediatrician has informed the mother that the child will need cardiac repair surgery within the next few weeks.
D
A telephone call notifying the school nurse that a child underwent an emergency appendectomy during the previous night.
Question 64 Explanation:
A high fever accompanied by a body rash could indicate that the child has a communicable disease and would have exposed other students to the infection. The school nurse would want to investigate this telephone call immediately so that plans could be instituted to control the spread of such infection.
Question 65
The nurse is assigned to care to a 17-year-old male client with a history of substance abuse. The client asks the nurse, “Have you ever tried or used drugs?” The most correct response of the nurse would be:
A
“How will my answer help you?”
B
“Why do you want to know that?”
C
“No, I don’t think so.”
D
“Yes, once I tried grass.”
Question 65 Explanation:
The client may perceive this as avoidance, but it is more important to redirect back to the client, especially in light of the manipulative behavior of drug abusers and adolescents.
Question 66
In the admission care unit, which of the following client would the nurse give immediate attention?
A
A client who is 3 days postoperative with left calf pain.
B
New admitted client with chest pain
C
A client with diabetes who has a glucoscan reading of 180.
D
A client who is postoperative hip pinning who is complaining of pain.
Question 66 Explanation:
The client with chest pain may be having a myocardial infarction, and immediate assessment and intervention is a priority.
Question 67
A male client is brought to the emergency department due to motor vehicle accident. While monitoring the client, the nurse suspects increasing intracranial pressure when:
A
Client refuses dinner because of anorexia.
B
Blood pressure is decreased from 160/90 to 110/70.
C
Pulse is increased from 88-96 with occasional skipped beat.
D
Client is oriented when aroused from sleep, and goes back to sleep immediately.
Question 67 Explanation:
This suggests that the level of consciousness is decreasing.
Question 68
A pregnant client in late pregnancy is complaining of groin pain that seems worse on the right side. Which of the following is the most likely cause of it?
A
Bladder infection.
B
Constipation.
C
Tension on the round ligament.
D
Beginning of labor.
Question 68 Explanation:
Tension on round ligament occurs because of the erect human posture and pressure exerted by the growing fetus.
Question 69
A client with ruptured appendix had surgery an hour ago and is transferred to the nursing care unit. The nurse placed the client in a semi-Fowler’s position primarily to:
A
Fully aerate the lungs.
B
Promote drainage and prevent subdiaphragmatic abscesses.
C
Splint the wound.
D
Facilitate movement and reduce complications from immobility.
Question 69 Explanation:
After surgery for a ruptured appendix, the client should be placed in a semi-Fowler’s position to promote drainage and to prevent possible complications.
Question 70
The ambulance team calls the emergency department that they are going to bring a client who sustained burns in a house fire. While waiting for the ambulance, the nurse will anticipate emergency care to include assessment for:
A
Gas exchange impairment
B
Fluid volume excess.
C
Hypoglycemia.
D
Hyperthermia.
Question 70 Explanation:
Smoke inhalation affects gas exchange.
Question 71
A client is diagnosed with Tuberculosis and respiratory isolation is initiated. This means that:
A
Both client and attending nurse must wear masks at all times.
B
Gloves are worn when handling the client’s tissue, excretions, and linen.
C
Nurse and visitors must wear masks until chemotherapy is begun. Client is instructed in cough and tissue techniques.
D
Full isolation; that is, caps and gowns are required during the period of contagion.
Question 71 Explanation:
Proper handling of sputum is essential to allay droplet transference of bacilli in the air. Clients need to be taught to cover their nose and mouth with tissues when sneezing or coughing. Chemotherapy generally renders the client noninfectious within days to a few weeks, usually before cultures for tubercle bacilli are negative. Until chemical isolation is established, many institutions require the client to wear a mask when visitors are in the room or when the nurse is in attendance. Client should be in a well-ventilated room, without air recirculation, to prevent air contamination.
Question 72
The community nurse is teaching the group of mothers about the cervical mucus method of natural family planning. Which characteristics are typical of the cervical mucus during the “fertile” period of the menstrual cycle?
A
Thick, cloudy.
B
Absence of ferning.
C
Thin, clear, good spinnbarkeit.
D
Yellow and sticky.
Question 72 Explanation:
Under high estrogen levels, during the period surrounding ovulation, the cervical mucus becomes thin, clear, and elastic (spinnbarkeit), facilitating sperm passage.
Question 73
The nurse is counseling a couple in their mid 30’s who have been unable to conceive for about 6 months. They are concerned that one or both of them may be infertile. What is the best advice the nurse could give to the couple?
A
“it is no unusual to take 6-12 months to get pregnant, especially when the partners are in their mid-30s. Eat well, exercise, and avoid stress.”
B
“Consult a fertility specialist and start testing before you get any older.”
C
“Start planning adoption. Many couples get pregnant when they are trying to adopt.”
D
“Have sex as often as you can, especially around the time of ovulation, to increase your chances of pregnancy.”
Question 73 Explanation:
Infertility is not diagnosed until atleast 12months of unprotected intercourse has failed to produce a pregnancy. Older couples will experience a longer time to get pregnant.
Question 74
The nurse is assessing the newborn boy. Apgar scores are 7 and 9. The newborn becomes slightly cyanotic. What is the initial nursing action?
A
Wrap him in another blanket, to reduce heat loss.
B
Stimulate him to cry,, to increase oxygenation.
C
Aspirate his mouth and nose with bulb syringe.
D
Elevate his head to promote gravity drainage of secretions.
Question 74 Explanation:
Gentle aspiration of mucus helps maintain a patent airway, required for effective gas exchange.
Question 75
The pediatric nurse in the neonatal unit was informed that the baby that is brought to the mother in the hospital room is wrong. The nurse determines that two babies were placed in the wrong cribs. The most appropriate nursing action would be to:
A
Reassure both mothers, report to the charge nurse, and do not record.
B
Determine who is responsible for the mistake and terminate his or her employment.
C
Record the event in an incident/variance report and notify the nursing supervisor.
D
Record detailed notes of the event on the mother’s medical record.
Question 75 Explanation:
Every event that exposes a client to harm should be recorded in an incident report, as well as reported to the appropriate supervisors in order to resolve the current problems and permit the institution to prevent the problem from happening again.
Question 76
The nurse is conducting a lecture to a class of nursing students about advance directives to preoperative clients. Which of the following statement by the nurse js correct?
A
“An advance directive is required for a “do not resuscitate” order.”
B
“The advance directive may be enforced even in the face of opposition by the spouse.”
C
“A durable power of attorney, a form of advance directive, may only be held by a blood relative.”
D
“The spouse, but not the rest of the family, may override the advance directive.”
Question 76 Explanation:
An advance directive is a form of informed consent, and only a competent adult or the holder of a durable power of attorney has the right to consent or refuse treatment. If the spouse does not hold the power of attorney, the decisions of the holder, even if opposed by the spouse, are enforced.
Question 77
The client is brought to the emergency department because of serious vehicle accident. After an hour, the client has been declared brain dead. The nurse who has been with the client must now talk to the family about organ donation. Which of the following consideration is necessary?
A
Discuss life support systems.
B
Take the family to the chapel.
C
Clarify the family’s understanding of brain death.
D
Include as many family members as possible.
Question 77 Explanation:
The family needs to understand what brain death is before talking about organ donation. They need time to accept the death of their family member. An environment conducive to discussing an emotional issue is needed.
Question 78
To assess if the cranial nerve VII of the client was damaged, which changes would not be expected?
A
Sagging of the face on the operative side.
B
Inability to open eyelids on operative side.
C
Inability to close eyelid on operative side.
D
Drooling and drooping of the mouth.
Question 78 Explanation:
Inability to open eyelids on operative side is seen with cranial nerve III damage.
Question 79
Which of the following is the most frequent cause of noncompliance to the medical treatment of open-angle glaucoma?
A
Loss of mobility due to severe driving restrictions.
B
The painful and insidious progression of this type of glaucoma.
C
The frequent nausea and vomiting accompanying use of miotic drug.
D
Decreased light and near-vision accommodation due to miotic effects of pilocarpine.
Question 79 Explanation:
The most frequent cause of noncompliance to the treatment of chronic, or open-angle glaucoma is the miotic effects of pilocarpine. Pupillary constriction impedes normal accommodation, making night driving difficult and hazardous, reducing the client’s ability to read for extended periods and making participation in games with fast-moving objects impossible.
Question 80
Which of the following action is an accurate tracheal suctioning technique?
A
20 seconds of continuous suction during catheter insertion.
B
10 seconds of intermittent suction during catheter withdrawal.
C
25 seconds of continuous suction during catheter insertion.
D
15 seconds of intermittent suction during catheter withdrawal.
Question 80 Explanation:
Suctioning is only done for 10 seconds, intermittently, as the catheter is being withdrawn.
Question 81
A pregnant client tells the nurse that she is worried about having urinary frequency. What will be the most appropriate nursing response?
A
“Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you have frequency associated with fever, pain on voiding, or blood in the urine, call your doctor/nurse-midwife.
B
“Placental progesterone causes irritability of the bladder sphincter. Your symptoms will go away after the baby comes.”
C
“Frequency is due to bladder irritation from concentrate urine and is normal in pregnancy. Increase your daily fluid intake to 3L.”
D
“Placental progesterone causes irritability of the bladder sphincter. Your symptoms will go away after the baby comes.”
Question 81 Explanation:
Progesterone also reduces smooth muscle motility in the urinary tract and predisposes the pregnant woman to urinary tract infections. Women should contact their doctors if they exhibit signs of infection. Kegel exercise will help strengthen the perineal muscles; limiting fluids at bedtime reduces the possibility of being awakened by the necessity of voiding.
Question 82
In the morning shift, the nurse is making rounds in the nursing care units. The nurse enters in a client’s room and notes that the client’s tube has become disconnected from the Pleurovac. What would be the initial nursing action?
A
Reconnect the chest tube to the Pleurovac.
B
Clamp the chest tube near the incision site.
C
Clamp the chest tube closer to the drainage system.
D
Apply pressure directly over the incision site.
Question 82 Explanation:
This stops the sucking of air through the tube and prevents the entry of contaminants. In addition, clamping near the chest wall provides for some stability and may prevent the clamp from pulling on the chest tube.
Question 83
A client diagnosed with schizophrenia is shouting and banging on the door leading to the outside, saying, “I need to go to an appointment.” What is the appropriate nursing intervention?
A
Ignore this behavior.
B
Tell the client that he cannot bang on the door.
C
Escort the client going back into the room.
D
Ask the client to move away from the door.
Question 83 Explanation:
Gentle but firm guidance and nonverbal direction is needed to intervene when a client with schizophrenic symptoms is being disruptive.
Question 84
A woman is hospitalized with mild preeclampsia. The nurse is formulating a plan of care for this client, which nursing care is least likely to be done?
A
Absolute bed rest.
B
Deep-tendon reflexes once per shift.
C
Vital signs and FHR and rhythm q4h while awake.
D
Daily weight.
Question 84 Explanation:
Although reducing environment stimuli and activity is necessary for a woman with mild preeclampsia, she will most probably have bathroom privileges.
Question 85
The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year-old client. The nurse caring to the client provides instructions that the nasal spray must be used exactly as directed to prevent the development of:
A
Tinnitus and diplopia.
B
Bleeding tendencies.
C
Increased nasal congestion.
D
Nasal polyps
Question 85 Explanation:
Phenylephrine, with frequent and continued use, can cause rebound congestion of mucous membranes.
Question 86
The nurse is providing an orientation regarding case management to the nursing students. Which characteristics should the nurse include in the discussion in understanding case management?
A
Main focus is comprehensive coordination of client care, avoid unnecessary duplication of services, improve resource utilization and decrease cost.
B
Main purpose is to identify expected client, family and staff performance against the timeline for clients with the same diagnosis.
C
Main objective is a written plan that combines discipline-specific processes used to measure outcomes of care.
D
Primary goal is to understand why predicted outcomes have not been met and the correction of identified problems.
Question 86 Explanation:
There are several models of case management, but the commonality is comprehensive coordination of care to better predict needs of high-risk clients, decrease exacerbations and continually monitor progress overtime.
Question 87
Which of the following statement describes the role of a nurse as a client advocate?
A
A nurse may override clients’ wishes for their own good.
B
A nurse helps clients gain greater independence and self-determination.
C
A nurse has the moral obligation to prevent harm and do well for clients.
D
A nurse measures the risk and benefits of various health situations while factoring in cost.
Question 87 Explanation:
An advocate role encourage freedom of choice, includes speaking out for the client, and supports the client’s best interests.
Question 88
The nurse advised the pregnant woman that smoking and alcohol should be avoided during pregnancy. The nurse takes into account that the developing fetus is most vulnerable to environment teratogens that cause malformation during:
A
The entire pregnancy.
B
The third trimester.
C
The first trimester.
D
The second trimester.
Question 88 Explanation:
The first trimester is the period of organogenesis, that is, cell differentiation into the various organs, tissues, and structures.
Question 89
After a cystectomy and formation of an ileal conduit, the nurse provides instruction regarding prevention of leakage of the pouch and backflow of the urine. The nurse is correct to include in the instruction to empty the urine pouch:
A
Every 3-4 hours.
B
Every hour.
C
Once before bedtime.
D
Twice a day.
Question 89 Explanation:
Urine flow is continuous. The pouch has an outlet valve for easy drainage every 3-4 hours. (the pouch should be changed every 3-5 days, or sooner if the adhesive is loose).
Question 90
The staff nurse on the labor and delivery unit is assigned to care to a primigravida in transition complicated by hypertension. A new pregnant woman in active labor is admitted in the same unit. The nurse manager assigned the same nurse to the second client. The nurse feels that the client with hypertension requires one-to-one care. What would be the initial action of the nurse?
A
Accept the new assignment and provide the best care.
B
Report the incident to the nursing supervisor and request to be floated.
C
Accept the new assignment and complete an incident report describing a shortage of nursing staff.
D
Report the nursing assessment of the client in transitional labor to the nurse manager and discuss misgivings about the new assignment.
Question 90 Explanation:
The nurse is obligated to inform the nurse manager about changes in the condition of the client, which may change the decision made by the nurse manager.
Question 91
The nurse in the nursing care unit is aware that one of the medical staff displays unlikely behaviors like confusion, agitation, lethargy and unkempt appearance. This behavior has been reported to the nurse manager several times, but no changes observed. The nurse should:
A
Discuss the situation with friends who are also nurses to get ideas .
B
Approach the partner of this medical staff member with these concerns.
C
Consider that the obligation to protect the patient from harm has been met by the prior reports and do nothing further.
D
Continue to report observations of unusual behavior until the problem is resolved.
Question 91 Explanation:
The submission of reports about incidents that expose clients to harm does not remove the obligation to report ongoing behavior as long as the risk to the client continues.
Question 92
The nurse observes the female client in the psychiatric ward that she is having a hard time sleeping at night. The nurse asks the client about it and the client says, “I can’t sleep at night because of fear of dying.” What is the best initial nursing response?
A
“Why are you afraid of dying?”
B
“It must be frightening for you to feel that way. Tell me more about it.”
C
“Try to sleep. You need the rest before tomorrow’s test.”
D
“Don’t worry, you won’t die. You are just here for some test.”
Question 92 Explanation:
Acknowledging a feeling tone is the most therapeutic response and provides a broad opening for the client to elaborate feelings.
Question 93
A hospitalized client cannot find his handkerchief and accuses other cient in the room and the nurse of stealing them. Which is the most therapeutic approach to this client?
A
Inject humor to defuse the intensity.
B
Divert the client’s attention.
C
Logically point out that the client is jumping to conclusions.
D
Listen without reinforcing the client’s belief.
Question 93 Explanation:
Listening is probably the most effective response of the four choices.
Question 94
A female client who has a 28-day menstrual cycle asks the community health nurse when she get pregnant during her cycle. What will be the best nursing response?
A
In a 28- day cycle, ovulation occurs at or about day 14. The egg lives for about 72 hours and the sperm live for about 24 hours. The fertile period would be approximately between day 13 and 17.
B
In a 28-day cycle, ovulation occurs at or about day 14. The egg lives for about 24 hours and the sperm live for about 72 hours. The fertile period would be approximately between day 11 and day 15.
C
It is impossible to determine the fertile period reliably. So it is best to assume that a woman is always fertile.
D
In a 28-day cycle, ovulation occurs 8 days before the next period or at about day 20. The fertile period is between day 20 and the beginning of the next period.
Question 94 Explanation:
It is the most accurate statement of physiological facts for a 28-day menstrual cycle: ovulation at day 14, egg life span 24 hours, sperm life span of 72 hours. Fertilization could occur from sperm deposited before ovulation.
Question 95
Which of the following situations cannot be delegated by the registered nurse to the nursing assistant?
A
A confused elderly woman who needs assistance with eating.
B
Client in soft restraint who is very agitated and crying.
C
A postoperative client who is stable needs to ambulate.
D
Routine temperature check that must be done for a client at end of shift.
Question 95 Explanation:
The registered nurse cannot delegate the responsibility for assessment and evaluation of clients. The status of the client in restraint requires further assessment to determine if there are additional causes for the behavior.
Question 96
The nurse is teaching a group of women about fertility awareness, the nurse should emphasize that basal body temperature:
A
Should be recorded each morning before any activity.
B
The average temperature taken each morning.
C
Has a lower degree of accuracy in predicting ovulation than the cervical mucus test.
D
Can be done with a mercury thermometer but no a digital one.
Question 96 Explanation:
The basal body temperature is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2 ºC to 36.3ºC during menses and for about 5-7 days afterward. About the time of ovulation, a slight drop in temperature may be seen, after ovulation in concert with the increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 ºC. This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred.
Question 97
After ileostomy, the nurse expects that the drainage appliance will be applied to the stoma:
A
When the client is able to begin self-care procedures.
B
In the operating room after the ileostomy procedure.
C
After the ileostomy begins to function.
D
24 hours later, when the swelling subsided.
Question 97 Explanation:
The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful and excoriated.
Question 98
The physician orders a dose of IV phenytoin to a child client. In preparing in the administration of the drug, which nursing action is not correct?
A
Check the phenytoin solution to be sure it is clear or light yellow in color, never cloudy.
B
Infuse the phenytoin into a smaller vein to prevent purple glove syndrome.
C
Plan to give phenytoin over 30-60 minutes, using an in-line filter.
D
Flush the IV tubing with normal saline before starting phenytoin.
Question 98 Explanation:
Phenytoin should be infused or injected into larger veins to avoid the discoloration know as purple glove syndrome; infusing into a smaller vein is not appropriate.
Question 99
The nurse noticed that the signed consent form has an error. The form states, “Amputation of the right leg” instead of the left leg that is to be amputated. The nurse has administered already the preoperative medications. What should the nurse do?
A
Have the client sign another form.
B
Cross out the error and initial the form.
C
Call the nearest relative to come in to sign a new form.
D
Call the physician to reschedule the surgery.
Question 99 Explanation:
The responsible for an accurate informed consent is the physician. An exception to this answer would be a life-threatening emergency, but there are no data to support another response.
Question 100
The emergency department has shortage of staff. The nurse manager informs the staff nurse in the critical care unit that she has to float to the emergency department. What should the staff nurse expect under these conditions?
A
Cross training will be available for the staff nurse.
B
The float staff nurse will be informed of the situation before the shift begins.
C
The staff nurse will be able to negotiate the assignments in the emergency department.
D
Client assignments will be equally divided among the nurses.
Question 100 Explanation:
Assignments should be based on scope of practice and expertise.
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1. A pregnant woman who is at term is admitted to the birthing unit in active labor. The client has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her contractions. Which of the following is the most important aspect of nursing intervention at this time?
Timing and recording length of contractions.
Monitoring.
Preparing for an emergency cesarean birth.
Checking the perineum for bulging.
2. A client who hallucinates is not in touch with reality. It is important for the nurse to:
Isolate the client from other patients.
Maintain a safe environment.
Orient the client to time, place, and person.
Establish a trusting relationship.
3. The nurse is caring to a child client who has had a tonsillectomy. The child complains of having dryness of the throat. Which of the following would the nurse give to the child?
Cola with ice
Yellow noncitrus Jello
Cool cherry Kool-Aid
A glass of milk
4. The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year-old client. The nurse caring to the client provides instructions that the nasal spray must be used exactly as directed to prevent the development of:
Increased nasal congestion.
Nasal polyps.
Bleeding tendencies.
Tinnitus and diplopia.
5. A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned to care for the client must institute appropriate precautions. The nurse should:
Place the client in a private room.
Wear an N 95 respirator when caring for the client.
Put on a gown every time when entering the room.
Don a surgical mask with a face shield when entering the room.
6. Which of the following is the most frequent cause of noncompliance to the medical treatment of open-angle glaucoma?
The frequent nausea and vomiting accompanying use of miotic drug.
Loss of mobility due to severe driving restrictions.
Decreased light and near-vision accommodation due to miotic effects of pilocarpine.
The painful and insidious progression of this type of glaucoma.
7. In the morning shift, the nurse is making rounds in the nursing care units. The nurse enters in a client’s room and notes that the client’s tube has become disconnected from the Pleurovac. What would be the initial nursing action?
Apply pressure directly over the incision site.
Clamp the chest tube near the incision site.
Clamp the chest tube closer to the drainage system.
Reconnect the chest tube to the Pleurovac.
8. Which of the following complications during a breech birth the nurse needs to be alarmed?
Abruption placenta.
Caput succedaneum.
Pathological hyperbilirubinemia.
Umbilical cord prolapse.
9. The nurse is caring to a client diagnosed with severe depression. Which of the following nursing approach is important in depression?
Protect the client against harm to others.
Provide the client with motor outlets for aggressive, hostile feelings.
Reduce interpersonal contacts.
Deemphasizing preoccupation with elimination, nourishment, and sleep.
10. A 3-month-old client is in the pediatric unit. During assessment, the nurse is suspecting that the baby may have hypothyroidism when mother states that her baby does not:
Sit up.
Pick up and hold a rattle.
Roll over.
Hold the head up.
11. The physician calls the nursing unit to leave an order. The senior nurse had conversation with the other staff. The newly hired nurse answers the phone so that the senior nurses may continue their conversation. The new nurse does not knowthe physician or the client to whom the order pertains. The nurse should:
Ask the physician to call back after the nurse has read the hospital policy manual.
Take the telephone order.
Refuse to take the telephone order.
Ask the charge nurse or one of the other senior staff nurses to take the telephone order.
12. The staff nurse on the labor and delivery unit is assigned to care to a primigravida in transition complicated by hypertension. A new pregnant woman in active labor is admitted in the same unit. The nurse manager assigned the same nurse to the second client. The nurse feels that the client with hypertension requires one-to-one care. What would be the initial actionof the nurse?
Accept the new assignment and complete an incident report describing a shortage of nursing staff.
Report the incident to the nursing supervisor and request to be floated.
Report the nursing assessment of the client in transitional labor to the nurse manager and discuss misgivings about the new assignment.
Accept the new assignment and provide the best care.
13. A newborn infant with Down syndrome is to be discharged today. The nurse is preparing to give the discharge teaching regarding the proper care at home. The nurse would anticipate that the mother is probably at the:
40 years of age.
20 years of age.
35 years of age.
20 years of age.
14. The emergency department has shortage of staff. The nurse manager informs the staff nurse in the critical care unit that she has to float to the emergency department. What should the staff nurse expect under these conditions?
The float staff nurse will be informed of the situation before the shift begins.
The staff nurse will be able to negotiate the assignments in the emergency department.
Cross training will be available for the staff nurse.
Client assignments will be equally divided among the nurses.
15. The nurse is assigned to care for a child client admitted in the pediatrics unit. The client is receiving digoxin. Which of the following questions will be asked by the nurse to the parents of the child in order to assess the client’s risk for digoxin toxicity?
“Has he been exposed to any childhood communicable diseases in the past 2-3 weeks?”
“Has he been taking diuretics at home?”
“Do any of his brothers and sisters have history of cardiac problems?”
“Has he been going to school regularly?”
16. The nurse noticed that the signed consent form has an error. The form states, “Amputation of the right leg” instead of the left leg that is to be amputated. The nurse has administered already the preoperative medications. What should the nurse do?
Call the physician to reschedule the surgery.
Call the nearest relative to come in to sign a new form.
Cross out the error and initial the form.
Have the client sign another form.
17. The nurse in the nursing care unit checks the fluctuation in the water-seal compartment of a closed chest drainage system. The fluctuation has stopped, the nurse would:
Vigorously strip the tube to dislodge a clot.
Raise the apparatus above the chest to move fluid.
Increase wall suction above 20 cm H2O pressure.
Ask the client to cough and take a deep breath.
18. The pediatric nurse in the neonatal unit was informed that the baby that is brought to the mother in the hospital room is wrong. The nurse determines that two babies were placed in the wrong cribs. The most appropriate nursing action would be to:
Determine who is responsible for the mistake and terminate his or her employment.
Record the event in an incident/variance report and notify the nursing supervisor.
Reassure both mothers, report to the charge nurse, and do not record.
Record detailed notes of the event on the mother’s medical record.
19. Before the administration of digoxin, the nurse completes an assessment to a toddler client for signs and symptoms of digoxin toxicity. Which of the following is the earliest and most significant sign of digoxin toxicity?
Tinnitus
Nausea and vomiting
Vision problem
Slowing in the heart rate
20. Which of the following treatment modality is appropriate for a client with paranoid tendency?
Activity therapy.
Individual therapy.
Group therapy.
Family therapy.
21. The client with rheumatoid arthritis is for discharge. In preparing the client for discharge on prednisone therapy, the nurse should advise the client to:
Wear sunglasses if exposed to bright light for an extended period of time.
Take oral preparations of prednisone before meals.
Have periodic complete blood counts while on the medication.
Never stop or change the amount of the medication without medical advice.
22. A pregnant client tells the nurse that she is worried about having urinary frequency. What will be the most appropriate nursing response?
“Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you have frequency associated with fever, pain on voiding, or blood in the urine, call your doctor/nurse-midwife.
“Placental progesterone causes irritability of the bladder sphincter. Your symptoms will go away after the baby comes.”
“Pregnant women urinate frequently to get rid of fetal wastes. Limit fluids to 1L/daily.”
“Frequency is due to bladder irritation from concentrate urine and is normal in pregnancy. Increase your daily fluid intake to 3L.”
23. Which of the following will help the nurse determine that the expression of hostility is useful?
Expression of anger dissipates the energy.
Energy from anger is used to accomplish what needs to be done.
Expression intimidates others.
Degree of hostility is less than the provocation.
24. The nurse is providing an orientation regarding case management to the nursing students. Which characteristics should the nurse include in the discussion in understanding case management?
Main objective is a written plan that combines discipline-specific processes used to measure outcomes of care.
Main purpose is to identify expected client, family and staff performance against the timeline for clients with the same diagnosis.
Main focus is comprehensive coordination of client care, avoid unnecessary duplication of services, improve resource utilization and decrease cost.
Primary goal is to understand why predicted outcomes have not been met and the correction of identified problems.
25. The physician orders a dose of IV phenytoin to a child client. In preparing in the administration of the drug, which nursing action is not correct?
Infuse the phenytoin into a smaller vein to prevent purple glove syndrome.
Check the phenytoin solution to be sure it is clear or light yellow in color, never cloudy.
Plan to give phenytoin over 30-60 minutes, using an in-line filter.
Flush the IV tubing with normal saline before starting phenytoin.
26. The pregnant woman visits the clinic for check –up. Which assessment findings will help the nurse determine that the client is in 8-week gestation?
Leopold maneuvers.
Fundal height.
Positive radioimmunoassay test (RIA test).
Auscultation of fetal heart tones.
27. Which of the following nursing intervention is essential for the client who had pneumonectomy?
Medicate for pain only when needed.
Connect the chest tube to water-seal drainage.
Notify the physician if the chest drainage exceeds 100mL/hr.
Encourage deep breathing and coughing.
28. The nurse is providing a health teaching to a group of parents regarding Chlamydia trachomatis. The nurse is correct in the statement, “Chlamydia trachomatis is not only an intracellular bacterium that causes neonatal conjunctivitis, but it also can cause:
Discoloration of baby and adult teeth.
Pneumonia in the newborn.
Snuffles and rhagades in the newborn.
Central hearing defects in infancy.
29. The nurse is assigned to care to a 17-year-old male client with a history of substance abuse. The client asks the nurse, “Have you ever tried or used drugs?” The most correct response of the nurse would be:
“Yes, once I tried grass.”
“No, I don’t think so.”
“Why do you want to know that?”
“How will my answer help you?”
30. Which of the following describes a health care team with the principles of participative leadership?
Each member of the team can independently make decisions regarding the client’s care without necessarily consulting the other members.
The physician makes most of the decisions regarding the client’s care.
The team uses the expertise of its members to influence the decisions regarding the client’s care.
Nurses decide nursing care; physicians decide medical and other treatment for the client.
31. A nurse is giving a health teaching to a woman who wants to breastfeed her newborn baby. Which hormone, normally secreted during the postpartum period, influences both the milk ejection reflex and uterine involution?
Oxytocin.
Estrogen.
Progesterone.
Relaxin.
32. One staff nurse is assigned to a group of 5 patients for the 12-hour shift. The nurse is responsible for the overall planning, giving and evaluating care during the entire shift. After the shift, same responsibility will be endorsed to the next nurse in charge. This describes nursing care delivered via the:
Primary nursing method.
Case method.
Functional method.
Team method.
33. The ambulance team calls the emergency department that they are going to bring a client who sustained burns in a house fire. While waiting for the ambulance, the nurse will anticipate emergency care to include assessment for:
Gas exchange impairment.
Hypoglycemia.
Hyperthermia.
Fluid volume excess.
34. Most couples are using “natural” family planning methods. Most accidental pregnancies in couples preferred to use this method have been related to unprotected intercourse before ovulation. Which of the following factor explains why pregnancy may be achieved by unprotected intercourse during the preovulatory period?
Ovum viability.
Tubal motility.
Spermatozoal viability.
Secretory endometrium.
35. An older adult client wakes up at 2 o’clock in the morning and comes to the nurse’s station saying, “I am having difficulty in sleeping.” What is the best nursing response to the client?
“I’ll give you a sleeping pill to help you get more sleep now.”
“Perhaps you’d like to sit here at the nurse’s station for a while.”
“Would you like me to show you where the bathroom is?”
“What woke you up?”
36. The nurse is taking care of a multipara who is at 42 weeks of gestation and in active labor, her membranes ruptured spontaneously 2 hours ago. While auscultating for the point of maximum intensity of fetal heart tones before applying an external fetal monitor, the nurse counts 100 beats per minute. The immediate nursing action is to:
Start oxygen by mask to reduce fetal distress.
Examine the woman for signs of a prolapsed cord.
Turn the woman on her left side to increase placental perfusion.
Take the woman’s radial pulse while still auscultating the FHR.
37. The nurse must instruct a client with glaucoma to avoid taking over-the-counter medications like:
Antihistamines.
NSAIDs.
Antacids.
Salicylates.
38. A male client is brought to the emergency department due to motor vehicle accident. While monitoring the client, the nurse suspects increasing intracranial pressure when:
Client is oriented when aroused from sleep, and goes back to sleep immediately.
Blood pressure is decreased from 160/90 to 110/70.
Client refuses dinner because of anorexia.
Pulse is increased from 88-96 with occasional skipped beat.
39. The nurse is conducting a lecture to a class of nursing students about advance directives to preoperative clients. Which of the following statement by the nurse js correct?
“The spouse, but not the rest of the family, may override the advance directive.”
“An advance directive is required for a “do not resuscitate” order.”
“A durable power of attorney, a form of advance directive, may only be held by a blood relative.”
“The advance directive may be enforced even in the face of opposition by the spouse.”
40. A client diagnosed with schizophrenia is shouting and banging on the door leading to the outside, saying, “I need to go to an appointment.” What is the appropriate nursing intervention?
Tell the client that he cannot bang on the door.
Ignore this behavior.
Escort the client going back into the room.
Ask the client to move away from the door.
41. Which of the following action is an accurate tracheal suctioning technique?
25 seconds of continuous suction during catheter insertion.
20 seconds of continuous suction during catheter insertion.
10 seconds of intermittent suction during catheter withdrawal.
15 seconds of intermittent suction during catheter withdrawal.
42. The client’s jaw and cheekbone is sutured and wired. The nurse anticipates that the most important thing that must be ready at the bedside is:
Suture set.
Tracheostomy set.
Suction equipment.
Wire cutters.
43. A mother is in the third stage of labor. Which of the following signs will help the nurse determine the signs of placental separation?
The uterus becomes globular.
The umbilical cord is shortened.
The fundus appears at the introitus.
Mucoid discharge is increased.
44. After therapy with the thrombolytic alteplase (t-PA), what observation will the nurse report to the physician?
3+ peripheral pulses.
Change in level of consciousness and headache.
Occasional dysrhythmias.
Heart rate of 100/bpm.
45. A client who undergone left nephrectomy has a large flank incision. Which of the following nursing action will facilitate deep breathing and coughing?
Push fluid administration to loosen respiratory secretions.
Have the client lie on the unaffected side.
Maintain the client in high Fowler’s position.
Coordinate breathing and coughing exercise with administration of analgesics.
46. The community nurse is teaching the group of mothers about the cervical mucus method of natural family planning. Which characteristics are typical of the cervical mucus during the “fertile” period of the menstrual cycle?
Absence of ferning.
Thin, clear, good spinnbarkeit.
Thick, cloudy.
Yellow and sticky.
47. A client with ruptured appendix had surgery an hour ago and is transferred to the nursing care unit. The nurse placed the client in a semi-Fowler’s position primarily to:
Facilitate movement and reduce complications from immobility.
Fully aerate the lungs.
Splint the wound.
Promote drainage and prevent subdiaphragmatic abscesses.
48. Which of the following will best describe a management function?
Writing a letter to the editor of a nursing journal.
Negotiating labor contracts.
Directing and evaluating nursing staff members.
Explaining medication side effects to a client.
49. The parents of an infant client ask the nurse to teach them how to administer Cortisporin eye drops. The nurse is correct in advising the parents to place the drops:
In the middle of the lower conjunctival sac of the infant’s eye.
Directly onto the infant’s sclera.
In the outer canthus of the infant’s eye.
In the inner canthus of the infant’s eye.
50. The nurse is assessing on the client who is admitted due to vehicle accident. Which of the following findings will help the nurse that there is internal bleeding?
Frank blood on the clothing.
Thirst and restlessness.
Abdominal pain.
Confusion and altered of consciousness.
51. The nurse is completing an assessment to a newborn baby boy. The nurse observes that the skin of the newborn is dry and flaking and there are several areas of an apparent macular rash. The nurse charts this as:
Icterus neonatorum
Multiple hemangiomas
Erythema toxicum
Milia
52. The client is brought to the emergency department because of serious vehicle accident. After an hour, the client has been declared brain dead. The nurse who has been with the client must now talk to the family about organ donation. Which of the following consideration is necessary?
Include as many family members as possible.
Take the family to the chapel.
Discuss life support systems.
Clarify the family’s understanding of brain death.
53. The nurse is teaching exercises that are good for pregnant women increasing tone and fitness and decreasing lower backache. Which of the following should the nurse exclude in the exercise program?
Stand with legs apart and touch hands to floor three times per day.
Ten minutes of walking per day with an emphasis on good posture.
Ten minutes of swimming or leg kicking in pool per day.
Pelvic rock exercise and squats three times a day.
54. A client with obsessive-compulsive behavior is admitted in the psychiatric unit. The nurse taking care of the client knows that the primary treatment goal is to:
Provide distraction.
Support but limit the behavior.
Prohibit the behavior.
Point out the behavior.
55. After ileostomy, the nurse expects that the drainage appliance will be applied to the stoma:
When the client is able to begin self-care procedures.
24 hours later, when the swelling subsided.
In the operating room after the ileostomy procedure.
After the ileostomy begins to function.
56. A female client who has a 28-day menstrual cycle asks the community health nurse when she get pregnant during her cycle. What will be the best nursing response?
It is impossible to determine the fertile period reliably. So it is best to assume that a woman is always fertile.
In a 28-day cycle, ovulation occurs at or about day 14. The egg lives for about 24 hours and the sperm live for about 72 hours. The fertile period would be approximately between day 11 and day 15.
In a 28- day cycle, ovulation occurs at or about day 14. The egg lives for about 72 hours and the sperm live for about 24 hours. The fertile period would be approximately between day 13 and 17.
In a 28-day cycle, ovulation occurs 8 days before the next period or at about day 20. The fertile period is between day 20 and the beginning of the next period.
57. Which of the following statement describes the role of a nurse as a client advocate?
A nurse may override clients’ wishes for their own good.
A nurse has the moral obligation to prevent harm and do well for clients.
A nurse helps clients gain greater independence and self-determination.
A nurse measures the risk and benefits of various health situations while factoring in cost.
58. A community health nurse is providing a health teaching to a woman infected with herpes simplex 2. Which of the following health teaching must the nurse include to reduce the chances of transmission of herpes simplex 2?
“Abstain from intercourse until lesions heal.”
“Therapy is curative.”
“Penicillin is the drug of choice for treatment.”
“The organism is associated with later development of hydatidiform mole.
59. The nurse in the psychiatric ward informed the male client that he will be attending the 9:00 AM group therapy sessions. The client tells the nurse that he must wash his hands from 9:00 to 9:30 AM each day and therefore he cannot attend. Which concept does the nursing staff need to keep in mind in planning nursing intervention for this client?
Depression underlines ritualistic behavior.
Fear and tensions are often expressed in disguised form through symbolic processes.
Ritualistic behavior makes others uncomfortable.
Unmet needs are discharged through ritualistic behavior.
60. The nurse assesses the health condition of the female client. The client tells the nurse that she discovered a lump in the breast last year and hesitated to seek medical advice. The nurse understands that, women who tend to delay seeking medical advice after discovering the disease are displaying what common defense mechanism?
Intellectualization.
Suppression.
Repression.
Denial.
61. Which of the following situations cannot be delegated by the registered nurse to the nursing assistant?
A postoperative client who is stable needs to ambulate.
Client in soft restraint who is very agitated and crying.
A confused elderly woman who needs assistance with eating.
Routine temperature check that must be done for a client at end of shift.
62. In the admission care unit, which of the following client would the nurse give immediate attention?
A client who is 3 days postoperative with left calf pain.
A client who is postoperative hip pinning who is complaining of pain.
New admitted client with chest pain.
A client with diabetes who has a glucoscan reading of 180.
63. A couple seeks medical advice in the community health care unit. A couple has been unable to conceive; the man is being evaluated for possible problems. The physician ordered semen analysis. Which of the following instructions is correct regarding collection of a sperm specimen?
Collect a specimen at the clinic, place in iced container, and give to laboratory personnel immediately.
Collect specimen after 48-72 hours of abstinence and bring to clinic within 2 hours.
Collect specimen in the morning after 24 hours of abstinence and bring to clinic immediately.
Collect specimen at night, refrigerate, and bring to clinic the next morning.
64. The physician ordered Betamethasone to a pregnant woman at 34 weeks of gestation with sign of preterm labor. The nurse expects that the drug will:
Treat infection.
Suppress labor contraction.
Stimulate the production of surfactant.
Reduce the risk of hypertension.
65. A tracheostomy cuff is to be deflated, which of the following nursing intervention should be implemented before starting the procedures?
Suction the trachea and mouth.
Have the obdurator available.
Encourage deep breathing and coughing.
Do a pulse oximetry reading.
66. A client is diagnosed with Tuberculosis and respiratory isolation is initiated. This means that:
Gloves are worn when handling the client’s tissue, excretions, and linen.
Both client and attending nurse must wear masks at all times.
Nurse and visitors must wear masks until chemotherapy is begun. Client is instructed in cough and tissue techniques.
Full isolation; that is, caps and gowns are required during the period of contagion.
67. A client with lung cancer is admitted in the nursing care unit. The husband wants to know the condition of his wife. How should the nurse respond to the husband?
Find out what information he already has.
Suggest that he discuss it with his wife.
Refer him to the doctor.
Refer him to the nurse in charge.
68. A hospitalized client cannot find his handkerchief and accuses other cient in the room and the nurse of stealing them. Which is the most therapeutic approach to this client?
Divert the client’s attention.
Listen without reinforcing the client’s belief.
Inject humor to defuse the intensity.
Logically point out that the client is jumping to conclusions.
69. After a cystectomy and formation of an ileal conduit, the nurse provides instruction regarding prevention of leakage of the pouch and backflow of the urine. The nurse is correct to include in the instruction to empty the urine pouch:
Every 3-4 hours.
Every hour.
Twice a day.
Once before bedtime.
70. Which telephone call from a student’s mother should the school nurse take care of at once?
A telephone call notifying the school nurse that the child’ pediatrician has informed the mother that the child will need cardiac repair surgery within the next few weeks.
A telephone call notifying the school nurse that the child’s pediatrician has informed the mother that the child has head lice.
A telephone call notifying the school nurse that a child has a temperature of 102ºF and a rash covering the trunk and upper extremities of the body.
A telephone call notifying the school nurse that a child underwent an emergency appendectomy during the previous night.
71. Which of the following signs and symptoms that require immediate attention and may indicate most serious complications during pregnancy?
Severe abdominal pain or fluid discharge from the vagina.
Excessive saliva, “bumps around the areolae, and increased vaginal mucus.
Fatigue, nausea, and urinary frequency at any time during pregnancy.
Ankle edema, enlarging varicosities, and heartburn.
72. The nurse is assessing the newborn boy. Apgar scores are 7 and 9. The newborn becomes slightly cyanotic. What is the initial nursing action?
Elevate his head to promote gravity drainage of secretions.
Wrap him in another blanket, to reduce heat loss.
Stimulate him to cry,, to increase oxygenation.
Aspirate his mouth and nose with bulb syringe.
73. The nurse is formulating a plan of care to a client with a somatoform disorder. The nurse needs to have knowledge of which psychodynamic principle?
The symptoms of a somatoform disorder are an attempt to adjust to painful life situations or to cope with conflicting sexual, aggressive, or dependent feelings.
The major fundamental mechanism is regression.
The client’s symptoms are imaginary and the suffering is faked.
An extensive, prolonged study of the symptoms will be reassuring to the client, who seeks sympathy, attention and love.
74. An infant is brought to the health care clinic for three immunizations at the same time. The nurse knows that hepatitis B, DPT, and Haemophilus influenzae type B immunizations should:
Be drawn in the same syringe and given in one injection.
Be mixed and inject in the same sites.
Not be mixed and the nurse must give three injections in three sites.
Be mixed and the nurse must give the injection in three sites.
75. A female client with cancer has radium implants. The nurse wants to maintain the implants in the correct position. The nurse should position the client:
Flat in bed.
On the side only.
With the foot of the bed elevated.
With the head elevated 45-degrees (semi-Fowler’s).
76. The nurse wants to know if the mother of a toddler understands the instructions regarding the administration of syrup of ipecac. Which of the following statement will help the nurse to know that the mother needs additional teaching?
“I’ll give the medicine if my child gets into some toilet bowl cleaner.”
“I’ll give the medicine if my child gets into some aspirin.”
“I’ll give the medicine if my child gets into some plant bulbs.”
“I’ll give the medicine if my child gets into some vitamin pills.”
77. To assess if the cranial nerve VII of the client was damaged, which changes would not be expected?
Drooling and drooping of the mouth.
Inability to open eyelids on operative side.
Sagging of the face on the operative side.
Inability to close eyelid on operative side.
78. The community health nurse makes a home visit to a family. During the visit, the nurse observes that the mother is beating her child. What is the priority nursing intervention in this situation?
Assess the child’s injuries.
Report the incident to protective agencies.
Refer the family to appropriate support group.
Assist the family to identify stressors and use of other coping mechanisms to prevent further incidents.
79. The nurse in the neonatal care unit is supervising the actions of a certified nursing assistant in giving care to the newborns. The nursing assistant mistakenly gives a formula feeding to a newborn that is on water feeding only. The nurse is responsible for the mistake of the nursing assistant:
Always, as a representative of the institution.
Always, because nurses who supervise less-trained individuals are responsible for their mistakes.
If the nurse failed to determine whether the nursing assistant was competent to take care of the client.
Only if the nurse agreed that the newborn could be fed formula.
80. The nurse is assigned to care for a client with urinary calculi. Fluid intake of 2L/day is encouraged to the client. the primary reason for this is to:
Reduce the size of existing stones.
Prevent crystalline irritation to the ureter.
Reduce the size of existing stones
Increase the hydrostatic pressure in the urinary tract.
81. The nurse is counseling a couple in their mid 30’s who have been unable to conceive for about 6 months. They are concerned that one or both of them may be infertile. What is the best advice the nurse could give to the couple?
“it is no unusual to take 6-12 months to get pregnant, especially when the partners are in their mid-30s. Eat well, exercise, and avoid stress.”
“Start planning adoption. Many couples get pregnant when they are trying to adopt.”
“Consult a fertility specialist and start testing before you get any older.”
“Have sex as often as you can, especially around the time of ovulation, to increase your chances of pregnancy.”
82. The nurse is caring for a cient who Is a retired nurse. A 24-hour urine collection for Creatinine clearance is to be done. The client tells the nurse, “I can’t remember what this test is for.” The best response by the nurse is:
“It provides a way to see if you are passing any protein in your urine.”
“It tells how well the kidneys filter wastes from the blood.”
“It tells if your renal insufficiency has affected your heart.”
“The test measures the number of particles the kidney filters.”
83. The nurse observes the female client in the psychiatric ward that she is having a hard time sleeping at night. The nurse asks the client about it and the client says, “I can’t sleep at night because of fear of dying.” What is the best initial nursing response?
“It must be frightening for you to feel that way. Tell me more about it.”
“Don’t worry, you won’t die. You are just here for some test.”
“Why are you afraid of dying?”
“Try to sleep. You need the rest before tomorrow’s test.”
84. In the hospital lobby, the registered nurse overhears a two staff members discussing about the health condition of her client. What would be the appropriate action for the registered nurse to take?
Join in the conversation, giving her input about the case.
Ignore them, because they have the right to discuss anything they want to.
Tell them it is not appropriate to discuss such things.
Report this incident to the nursing supervisor.
85. The client has had a right-sided cerebrovascular accident. In transferring the client from the wheelchair to bed, in what position should a client be placed to facilitate safe transfer?
Weakened (L) side of the cient next to bed.
Weakened (R) side of the client next to bed.
Weakened (L) side of the client away from bed.
Weakened (R) side of the cient away from bed.
86. The child client has undergone hip surgery and is in a spica cast. Which of the following toy should be avoided to be in the child’s bed?
A toy gun.
A stuffed animal.
A ball.
Legos.
87. The LPN/LVN asks the registered nurse why oxytocin (Pitocin), 10 units (IV or IM) must be given to a client after birth fo the fetus. The nurse is correct to explain that oxytocin:
Minimizes discomfort from “afterpains.”
Suppresses lactation.
Promotes lactation.
Maintains uterine tone.
88. The nurse in the nursing care unit is aware that one of the medical staff displays unlikely behaviors like confusion, agitation, lethargy and unkempt appearance. This behavior has been reported to the nurse manager several times, but no changes observed. The nurse should:
Continue to report observations of unusual behavior until the problem is resolved.
Consider that the obligation to protect the patient from harm has been met by the prior reports and do nothing further.
Discuss the situation with friends who are also nurses to get ideas .
Approach the partner of this medical staff member with these concerns.
89. The physician ordered tetracycline PO qid to a child client who weights 20kg. The recommended PO tetracycline dose is 25-50 mg/kg/day. What is the maximum single dose that can be safely administered to this child?
1 g
500 mg
250 mg
125 mg
90. The nurse is completing an obstetric history of a woman in labor. Which event in the obstetric history will help the nurse suspects dysfunctional labor in the current pregnancy?
Total time of ruptured membranes was 24 hours with the second birth.
First labor lasting 24 hours.
Uterine fibroid noted at time of cesarean delivery.
Second birth by cesarean for face presentation.
91. The nurse is planning to talk to the client with an antisocial personality disorder. What would be the most therapeutic approach?
Provide external controls.
Reinforce the client’s self-concept.
Give the client opportunities to test reality.
Gratify the client’s inner needs.
92. The nurse is teaching a group of women about fertility awareness, the nurse should emphasize that basal body temperature:
Can be done with a mercury thermometer but no a digital one.
The average temperature taken each morning.
Should be recorded each morning before any activity.
Has a lower degree of accuracy in predicting ovulation than the cervical mucus test.
93. The nursing applicant has given the chance to ask questions during a job interview at a local hospital. What should be the most important question to ask that can increase chances of securing a job offer?
Begin with questions about client care assignments, advancement opportunities, and continuing education.
Decline to ask questions, because that is the responsibility of the interviewer.
Ask as many questions about the facility as possible.
Clarify information regarding salary, benefits, and working hours first, because this will help in deciding whether or not to take the job.
94. The nurse advised the pregnant woman that smoking and alcohol should be avoided during pregnancy. The nurse takes into account that the developing fetus is most vulnerable to environment teratogens that cause malformation during:
The entire pregnancy.
The third trimester.
The first trimester.
The second trimester.
95. A male client tells the nurse that there is a big bug in his bed. The most therapeutic nursing response would be:
Silence.
“Where’s the bug? I’ll kill it for you.”
“I don’t see a bug in your bed, but you seem afraid.”
“You must be seeing things.”
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?
Beginning of labor.
Bladder infection.
Constipation.
Tension on the round ligament.
97. The nurse is conducting a lecture to a group of volunteer nurses. The nurse is correct in imparting the idea that the Good Samaritan law protects the nurse from a suit for malpractice when:
The nurse stops to render emergency aid and leaves before the ambulance arrives.
The nurse acts in an emergency at his or her place of employment.
The nurse refuses to stop for an emergency outside of the scope of employment.
The nurse is grossly negligent at the scene of an emergency.
98. A woman is hospitalized with mild preeclampsia. The nurse is formulating a plan of care for this client, which nursing care is least likely to be done?
Deep-tendon reflexes once per shift.
Vital signs and FHR and rhythm q4h while awake.
Absolute bed rest.
Daily weight.
99. While feeding a newborn with an unrepaired cardiac defect, the nurse keeps on assessing the condition of the client. The nurse notes that the newborn’s respiration is 72 breaths per minute. What would be the initial nursing action?
Burp the newborn.
Stop the feeding.
Continue the feeding.
Notify the physician.
100. A client who undergone appendectomy 3 days ago is scheduled for discharge today. The nurse notes that the client is restless, picking at bedclothes and saying, “I am late on my appointment,” and calling the nurse by the wrong name. The nurse suspects:
Panic reaction.
Medication overdose.
Toxic reaction to an antibiotic.
Delirium tremens.
Answers and Rationales
A. The oxytocic effect of Pitocin increases the intensity and durations of contractions; prolonged contractions will jeopardize the safetyof the fetus and necessitate discontinuing the drug.
B. It is of paramount importance to prevent the client from hurting himself or herself or others.
B. After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and hot or cold liquids should be avoided because they may irritate the throat. Red liquids should be avoided because they give the appearance of blood if the child vomits. Milk and milk products including pudding are avoided because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding.
A. Phenylephrine, with frequent and continued use, can cause rebound congestion of mucous membranes.
B. The N 95 respirator is a high-particulate filtration mask that meets the CDC performance criteria for a tuberculosis respirator.
C. The most frequent cause of noncompliance to the treatment of chronic, or open-angle glaucoma is the miotic effects of pilocarpine. Pupillary constriction impedes normal accommodation, making night driving difficult and hazardous, reducing the client’s ability to read for extended periods and making participation in games with fast-moving objects impossible.
B. This stops the sucking of air through the tube and prevents the entry of contaminants. In addition, clamping near the chest wall provides for some stability and may prevent the clamp from pulling on the chest tube.
D. Because umbilical cord’s insertion site is born before the fetal head, the cord may be compressed by the after-coming head in a breech birth.
B. It is important to externalize the anger away from self.
D. Development normally proceeds cephalocaudally; so the first major developmental milestone that the infant achieves is the ability to hold the head up within the first 8-12 weeks of life. In hypothyroidism, the infant’s muscle tone would be poor and the infant would not be able to achieve this milestone.
D. Get a senior nurse who know s the policies, the client, and the doctor. Generally speaking, a nurse should not accept telephone orders. However, if it is necessary to take one, follow the hospital’s policy regarding telephone orders. Failure to followhospital policy could be considered negligence. In this case, the nurse was new and did not know the hospital’s policy concerning telephone orders. The nurse was also unfamiliar with the doctor and the client. Therefore the nurse should not take the order unless a) no one else is available and b) it is an emergency situation.
C. The nurse is obligated to inform the nurse manager about changes in the condition of the client, which may change the decision made by the nurse manager.
A. Perinatal risk factors for the development of Down syndrome include advanced maternal age, especially with the first pregnancy.
B. Assignments should be based on scope of practice and expertise.
B. The child who is concurrently taking digoxin and diuretics is at increased risk for digoxin toxicity due to the loss of potassium. The child and parents should be taught what foods are high in potassium, and the child should be encouraged to eat a high-potassium diet. In addition, the child’s serum potassium level should be carefully monitored.
A. The responsible for an accurate informed consent is the physician. An exception to this answer would be a life-threatening emergency, but there are no data to support another response.
D. Asking the client to cough and take a deep breath will help determine if the chest tube is kinked or if the lungs has reexpanded.
B. Every event that exposes a client to harm should be recorded in an incident report, as well as reported to the appropriate supervisors in order to resolve the current problems and permit the institution to prevent the problem from happening again.
D. One of the earliest signs of digoxin toxicity is Bradycardia. For a toddler, any heart rate that falls below the norm of about 100-120 bpm would indicate Bradycardia and would necessitate holding the medication and notifying the physician.
B. This option is least threatening.
D. In preparing the client for discharge that is receiving prednisone, the nurse should caution the client to (a) take oral preparations after meals; (b) remember that routine checks of vital signs, weight, and lab studies are critical; (c) NEVER STOP OR CHANGE THE AMOUNT OF MEDICATION WITHOUT MEDICAL ADVICE; (d) store the medication in a light-resistant container.
A. Progesterone also reduces smooth muscle motility in the urinary tract and predisposes the pregnant woman to urinary tract infections. Women should contact their doctors if they exhibit signs of infection. Kegel exercise will help strengthen the perineal muscles; limiting fluids at bedtime reduces the possibility of being awakened by the necessity of voiding.
B. This is the proper use of anger.
C. There are several models of case management, but the commonality is comprehensive coordination of care to better predict needs of high-risk clients, decrease exacerbations and continually monitor progress overtime.
A. Phenytoin should be infused or injected into larger veins to avoid the discoloration know as purple glove syndrome; infusing into a smaller vein is not appropriate.
C. Serum radioimmunoassay (RIA) is accurate within 7days of conception. This test is specific for HCG, and accuracy is not compromised by confusion with LH.
D. Surgery and anesthesia can increase mucus production. Deep breathing and coughing are essential to prevent atelectasis and pneumonia in the client’s only remaining lung.
B. Newborns can get pneumonia (tachypnea, mild hypoxia, cough, eosinophilia) and conjunctivitis from Chlamydia.
D. The client may perceive this as avoidance, but it is more important to redirect back to the client, especially in light of the manipulative behavior of drug abusers and adolescents.
C. It describes a democratic process in which all members have input in the client’s care.
A. Contraction of the milk ducts and let-down reflex occur under the stimulation of oxytocin released by the posterior pituitary gland.
B. In case management, the nurse assumes total responsibility for meeting the needs of the client during the entire time on duty.
A. Smoke inhalation affects gas exchange.
C. Sperm deposited during intercourse may remain viable for about 3 days. If ovulation occurs during this period, conception may result.
B. This option shows acceptance (key concept) of this age-typical sleep pattern (that of waking in the early morning).
D. Taking the mother’s pulse while listening to the FHR will differentiate between the maternal and fetal heart rates and rule out fetal Bradycardia.
A. Antihistamines cause pupil dilation and should be avoided with glaucoma.
A. This suggests that the level of consciousness is decreasing.
D. An advance directive is a form of informed consent, and only a competent adult or the holder of a durable power of attorney has the right to consent or refuse treatment. If the spouse does not hold the power of attorney, the decisions of the holder, even if opposed by the spouse, are enforced.
C. Gentle but firm guidance and nonverbal direction is needed to intervene when a client with schizophrenic symptoms is being disruptive.
C. Suctioning is only done for 10 seconds, intermittently, as the catheter is being withdrawn.
D. The priority for this client is being able to establish an airway.
A. Signs of placental separation include a change in the shape of the uterus from ovoid to globular.
B. This could indicate intracranial bleeding. Alteplase is a thrombolytic enzyme that lyses thrombi and emboli. Bleeding is an adverse effect. Monitor clotting times and signs of any gastrointestinal or internal bleeding.
D. Because flank incision in nephrectomy is directly below the diaphragm, deep breathing is painful. Additionally, there is a greater incisional pull each time the person moves than there is with abdominal surgery. Incisional pain following nephrectomy generally requires analgesics administration every 3-4 hours for 24-48 hours after surgery. Therefore, turning, coughing and deep-breathing exercises should be planned to maximize the analgesic effects.
B. Under high estrogen levels, during the period surrounding ovulation, the cervical mucus becomes thin, clear, and elastic (spinnbarkeit), facilitating sperm passage.
D. After surgery for a ruptured appendix, the client should be placed in a semi-Fowler’s position to promote drainage and to prevent possible complications.
C. Directing and evaluation of staff is a major responsibility of a nursing manager.
A. The recommended procedure for administering eyedrops to any client calls for the drops to be placed in the middle of the lower conjunctival sac.
B. Thirst and restlessness indicate hypovolemia and hypoxemia. Internal bleeding is difficult to recognized and evaluate because it is not apparent.
C. Erythema toxicum is the normal, nonpathological macular newborn rash.
D. The family needs to understand what brain death is before talking about organ donation. They need time to accept the death of their family member. An environment conducive to discussing an emotional issue is needed.
A. Bending from the waist in pregnancy tends to make backache worse.
B. Support and limit setting decrease anxiety and provide external control.
C. The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful and excoriated.
B. It is the most accurate statement of physiological facts for a 28-day menstrual cycle: ovulation at day 14, egg life span 24 hours, sperm life span of 72 hours. Fertilization could occur from sperm deposited before ovulation.
C. An advocate role encourage freedom of choice, includes speaking out for the client, and supports the client’s best interests.
A. Abstinence will eliminate any unnecessary pain during intercourse and will reduce the possibility of transmitting infection to one’s sexual partner.
B. Anxiety is generated by group therapy at 9:00 AM. The ritualistic behavioral defense of hand washing decreases anxiety by avoiding group therapy.
D. Denial is a very strong defense mechanism used to allay the emotional effects of discovering a potential threat. Although denial has been found to be an effective mechanism for survival in some instances, such as during natural disasters, it may in greater pathology in a woman with potential breast carcinoma.
B. The registered nurse cannot delegate the responsibility for assessment and evaluation of clients. The status of the client in restraint requires further assessment to determine if there are additional causes for the behavior.
C. The client with chest pain may be having a myocardial infarction, and immediate assessment and intervention is a priority.
B. Is correct because semen analysis requires that a freshly masturbated specimen be obtained after a rest (abstinence) period of 48-72 hours.
C. Betamethasone, a form of cortisone, acts on the fetal lungs to produce surfactant.
A. Secretions may have pooled above the tracheostomy cuff. If these are not suctioned before deflation, the secretions may be aspirated.
C. Proper handling of sputum is essential to allay droplet transference of bacilli in the air. Clients need to be taught to cover their nose and mouth with tissues when sneezing or coughing. Chemotherapy generally renders the client noninfectious within days to a few weeks, usually before cultures for tubercle bacilli are negative. Until chemical isolation is established, many institutions require the client to wear a mask when visitors are in the room or when the nurse is in attendance. Client should be in a well-ventilated room, without air recirculation, to prevent air contamination.
A. It is best to establish baseline information first.
B. Listening is probably the most effective response of the four choices.
A. Urine flow is continuous. The pouch has an outlet valve for easy drainage every 3-4 hours. (the pouch should be changed every 3-5 days, or sooner if the adhesive is loose).
C. A high fever accompanied by a body rash could indicate that the child has a communicable disease and would have exposed other students to the infection. The school nurse would want to investigate this telephone call immediately so that plans could be instituted to control the spread of such infection.
A. Severe abdominal pain may indicate complications of pregnancy such as abortion, ectopic pregnancy, or abruption placenta; fluid discharge from the vagina may indicate premature rupture of the membrane.
D. Gentle aspiration of mucus helps maintain a patent airway, required for effective gas exchange.
A. Somatoform disorders provide a way of coping with conflicts.
C. Immunization should never be mixed together in a syringe, thus necessitating three separate injections in three sites. Note: some manufacturers make a premixed combination of immunization that is safe and effective.
A. Clients with radioactive implants should be positioned flat in bed to prevent dislodgement of the vaginal packing. The client may roll to the side for meals but the upper body should not be raised more than 20 degrees.
A. Syrup of ipecac is not administered when the ingested substances is corrosive in nature. Toilet bowl cleaners, as a collective whole, are highly corrosive substances. If the ingested substance “burned” the esophagus going down, it will “burn” the esophagus coming back up when the child begins to vomit after administration of syrup of ipecac.
B. Inability to open eyelids on operative side is seen with cranial nerve III damage.
A. Assessment of physical injuries (like bruises, lacerations, bleeding and fractures) is the first priority.
C. The nurse who is supervising others has a legal obligation to determine that they are competent to perform the assignment, as well as legal obligation to provide adequate supervision.
D. Increasing hydrostatic pressure in the urinary tract will facilitate passage of the calculi.
A. Infertility is not diagnosed until atleast 12months of unprotected intercourse has failed to produce a pregnancy. Older couples will experience a longer time to get pregnant.
B. Determining how well the kidneys filter wastes states the purpose of a Creatinine clearance test.
A. Acknowledging a feeling tone is the most therapeutic response and provides a broad opening for the client to elaborate feelings.
C. The behavior should be stopped. The first is to remind the staff that confidentiality maybe violated.
C. With a right-sided cerebrovascular accident the client would have left-sided hemiplegia or weakness. The client’s good side should be closest to the bed to facilitate the transfer.
D. Legos are small plastic building blocks that could easily slip under the child’s cast and lead to a break in skin integrity and even infection. Pencils, backscratchers, and marbles are some other narrow or small items that could easily slip under the child’s cast and lead to a break in skin integrity and infection.
D. Oxytocin (Pitocin) is used to maintain uterine tone.
B. The submission of reports about incidents that expose clients to harm does not remove the obligation to report ongoing behavior as long as the risk to the client continues.
C. The recommended dosage of tetracycline is 25-50mg/kg/day. If the child weighs 20kg and the maximum dose is 50mg/kg, this would indicate a total daily dose of 1000mg of tetracycline. In this case, the child is being given this medication four times a day. Therefore the maximum single dose that can be given is 250mg (1000 mg of tetracycline divided by four doses.)
C. An abnormality in the uterine muscle could reduce the effectiveness of uterine contractions and lengthen the duration of subsequent labors.
A. Personality disorders stem from a weak superego, implying a lack of adequate controls.
C. The basal body temperature is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2 ºC to 36.3ºC during menses and for about 5-7 days afterward. About the time of ovulation, a slight drop in temperature may be seen, after ovulation in concert with the increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 ºC. This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred.
A. This choice implies concern for client care and self-improvement.
C. The first trimester is the period of organogenesis, that is, cell differentiation into the various organs, tissues, and structures.
C. This response does not contradict the client’s perception, is honest, and shows empathy.
D. Tension on round ligament occurs because of the erect human posture and pressure exerted by the growing fetus.
D. The Good Samaritan Law does not impose a duty to stop at the scene of an emergency outside of the scope of employment, therefore nurses who do not stop are not liable for suit.
C. Although reducing environment stimuli and activity is necessary for a woman with mild preeclampsia, she will most probably have bathroom privileges.
B. A normal respiratory rate for a newborn is 30-40 breaths per minute.
D. The behavior described is likely to be symptoms of delirium tremens, or alcohol withdrawal (often unsuspected on a surgical unit.)