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REVALIDA EXAM (200 ITEMS) Name:_________________________ Yr/Sec:_____________ Date:_________ Score:______

INSTRUCTIONS: Encircle the letter of the correct answer. 1. A pregnant woman who is at term is admitted to the birthing unit in active labor. The client has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her contractions. Which of the following is the most important aspect of nursing intervention at this time? A) Timing and recording length of contractions. B) Monitoring. C) Preparing for an emergency cesarean birth. D) Checking the perineum for bulging. 2. A client who hallucinates is not in touch with reality. It is important for the nurse to: A) Isolate the client from other patients. B) Maintain a safe environment. C) Orient the client to time, place, and person. D) Establish a trusting relationship. 3. The nurse is caring to a child client who has had a tonsillectomy. The child complains of having dryness of the throat. Which of the following would the nurse give to the child? A) Cola with ice B) Yellow noncitrus Jello C) Cool cherry Kool-Aid D) A glass of milk 4. The physician ordered Phenylephrine (NeoSynephrine) nasal spray to a 13-year-old client. The nurse caring to the client provides instructions that the nasal spray must be used exactly as directed to prevent the development of: A) Increased nasal congestion. B) Nasal polyps. C) Bleeding tendencies. D) Tinnitus and diplopia. 5. A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned to care for the client must institute appropriate precautions. The nurse should: A) Place the client in a private room. B) Wear an N 95 respirator when caring for the client. C) Put on a gown every time when entering the room. D) Don a surgical mask with a face shield when entering the room. 6. Which of the following is the most frequent cause of noncompliance to the medical treatment of openangle glaucoma? A) The frequent nausea and vomiting accompanying use of miotic drug. B) Loss of mobility due to severe driving restrictions. C) Decreased light and near-vision accommodation due to miotic effects of pilocarpine. D) The painful and insidious progression of this type of glaucoma. 7. In the morning shift, the nurse is making rounds in the nursing care units. The nurse enters in a clients room and notes that the clients tube has become disconnected from the Pleurovac. What would be the initial nursing action? A) Apply pressure directly over the incision site. B) Clamp the chest tube near the incision site. C) Clamp the chest tube closer to the drainage system. D) Reconnect the chest tube to the Pleurovac. 8. Which of the following complications during a breech birth the nurse needs to be alarmed? A) Abruption placenta. B) Caput succedaneum. C) Pathological hyperbilirubinemia. D) Umbilical cord prolapse. 9. The nurse is caring to a client diagnosed with severe depression. Which of the following nursing approach is important in depression? A) Protect the client against harm to others. B) Provide the client with motor outlets for aggressive, hostile feelings. C) Reduce interpersonal contacts. D) Deemphasizing preoccupation with elimination, nourishment, and sleep. 10. A 3-month-old client is in the pediatric unit. During assessment, the nurse is suspecting that the baby may have hypothyroidism when mother states that her baby does not: A) Sit up. B) Pick up and hold a rattle. C) Roll over. D) Hold the head up.

11. The physician calls the nursing unit to leave an order. The senior nurse had conversation with the other staff. The newly hired nurse answers the phone so that the senior nurses may continue their conversation. The new nurse does not knowthe physician or the client to whom the order pertains. The nurse should: A) Ask the physician to call back after the nurse has read the hospital policy manual. B) Take the telephone order. C) Refuse to take the telephone order. D) Ask the charge nurse or one of the other senior staff nurses to take the telephone order. 12. The staff nurse on the labor and delivery unit is assigned to care to a primigravida in transition complicated by hypertension. A new pregnant woman in active labor is admitted in the same unit. The nurse manager assigned the same nurse to the second client. The nurse feels that the client with hypertension requires one-to-one care. What would be the initial actionof the nurse? A) Accept the new assignment and complete an incident report describing a shortage of nursing staff. B) Report the incident to the nursing supervisor and request to be floated. C) Report the nursing assessment of the client in transitional labor to the nurse manager and discuss misgivings about the new assignment. D) 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: A) 40 years of age. B) 20 years of age. C) 35 years of age. D) 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? A) The float staff nurse will be informed of the situation before the shift begins. B) The staff nurse will be able to negotiate the assignments in the emergency department. C) Cross training will be available for the staff nurse. D) Client assignments will be equally divided among the nurses.

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 clients risk for digoxin toxicity? A) Has he been exposed to any childhood communicable diseases in the past 2-3 weeks? B) Has he been taking diuretics at home? C) Do any of his brothers and sisters have history of cardiac problems? D) Has he been going to school regularly? 16. The nurse noticed that the signed consent form has an error. The form states, Amputation of the right leg instead of the left leg that is to be amputated. The nurse has administered already the preoperative medications. What should the nurse do? A) Call the physician to reschedule the surgery. B) Call the nearest relative to come in to sign a new form. C) Cross out the error and initial the form. D) Have the client sign another form. 17. The nurse in the nursing care unit checks the fluctuation in the water-seal compartment of a closed chest drainage system. The fluctuation has stopped, the nurse would: A) Vigorously strip the tube to dislodge a clot. B) Raise the apparatus above the chest to move fluid. C) Increase wall suction above 20 cm H2O pressure. D) Ask the client to cough and take a deep breath. 18. The pediatric nurse in the neonatal unit was informed that the baby that is brought to the mother in the hospital room is wrong. The nurse determines that two babies were placed in the wrong cribs. The most appropriate nursing action would be to: A) Determine who is responsible for the mistake and terminate his or her employment. B) Record the event in an incident/variance report and notify the nursing supervisor. C) Reassure both mothers, report to the charge nurse, and do not record. D) Record detailed notes of the event on the mothers 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? A) Tinnitus B) Nausea and vomiting C) Vision problem D) Slowing in the heart rate

20. Which of the following treatment modality is appropriate for a client with paranoid tendency? A) Activity therapy. B) Individual therapy. C) Group therapy. D) Family therapy. 21. The client with rheumatoid arthritis is for discharge. In preparing the client for discharge on prednisone therapy, the nurse should advise the client to: A) Wear sunglasses if exposed to bright light for an extended period of time. B) Take oral preparations of prednisone before meals. C) Have periodic complete blood counts while on the medication. D) Never stop or change the amount of the medication without medical advice. 22. A pregnant client tells the nurse that she is worried about having urinary frequency. What will be the most appropriate nursing response? A) Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you have frequency associated with fever, pain on voiding, or blood in the urine, call your doctor/nurse-midwife. B) Placental progesterone causes irritability of the bladder sphincter. Your symptoms will go away after the baby comes. C) Pregnant women urinate frequently to get rid of fetal wastes. Limit fluids to 1L/daily. D) Frequency is due to bladder irritation from concentrate urine and is normal in pregnancy. Increase your daily fluid intake to 3L. 23. Which of the following will help the nurse determine that the expression of hostility is useful? A) Expression of anger dissipates the energy. B) Energy from anger is used to accomplish what needs to be done. C) Expression intimidates others. D) Degree of hostility is less than the provocation. 24. The nurse is providing an orientation regarding case management to the nursing students. Which characteristics should the nurse include in the discussion in understanding case management? A) Main objective is a written plan that combines discipline-specific processes used to measure outcomes of care. B) Main purpose is to identify expected client, family and staff performance against the timeline for clients with the same diagnosis. C) Main focus is comprehensive coordination of client care, avoid unnecessary duplication of services, improve resource utilization and decrease cost. D) Primary goal is to understand why predicted

outcomes have not been met and the correction of identified problems. 25. The physician orders a dose of IV phenytoin to a child client. In preparing in the administration of the drug, which nursing action is not correct? A) Infuse the phenytoin into a smaller vein to prevent purple glove syndrome. B) Check the phenytoin solution to be sure it is clear or light yellow in color, never cloudy. C) Plan to give phenytoin over 30-60 minutes, using an in-line filter. D) Flush the IV tubing with normal saline before starting phenytoin. 26. The pregnant woman visits the clinic for check up. Which assessment findings will help the nurse determine that the client is in 8-week gestation? A) Leopold maneuvers. B) Fundal height. C) Positive radioimmunoassay test (RIA test). D) Auscultation of fetal heart tones. 27. Which of the following nursing intervention is essential for the client who had pneumonectomy? A) Medicate for pain only when needed. B) Connect the chest tube to water-seal drainage. C) Notify the physician if the chest drainage exceeds 100mL/hr. D) Encourage deep breathing and coughing. 28. The nurse is providing a health teaching to a group of parents regarding Chlamydia trachomatis. The nurse is correct in the statement, Chlamydia trachomatis is not only an intracellular bacterium that causes neonatal conjunctivitis, but it also can cause: A) Discoloration of baby and adult teeth. B) Pneumonia in the newborn. C) Snuffles and rhagades in the newborn. D) Central hearing defects in infancy. 29. The nurse is assigned to care to a 17-year-old male client with a history of substance abuse. The client asks the nurse, Have you ever tried or used drugs? The most correct response of the nurse would be: A) Yes, once I tried grass. B) No, I dont think so. C) Why do you want to know that? D) How will my answer help you? 30. Which of the following describes a health care team with the principles of participative leadership? A) Each member of the team can independently make decisions regarding the clients care without necessarily consulting the other members. B) The physician makes most of the decisions regarding the clients care. C) The team uses the expertise of its members to

influence the decisions regarding the clients care. D) 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? A) Oxytocin. B) Estrogen. C) Progesterone. D) 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: A) Primary nursing method. B) Case method. C) Functional method. D) 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: A) Gas exchange impairment. B) Hypoglycemia. C) Hyperthermia. D) 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? A) Ovum viability. B) Tubal motility. C) Spermatozoal viability. D) Secretory endometrium. 35. An older adult client wakes up at 2 oclock in the morning and comes to the nurses station saying, I am having difficulty in sleeping. What is the best nursing response to the client? A) Ill give you a sleeping pill to help you get more sleep now. B) Perhaps youd like to sit here at the nurses station for a while. C) Would you like me to show you where the bathroom is? D) 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: A) Start oxygen by mask to reduce fetal distress. B) Examine the woman for signs of a prolapsed cord. C) Turn the woman on her left side to increase placental perfusion. D) Take the womans radial pulse while still auscultating the FHR. 37. The nurse must instruct a client with glaucoma to avoid taking over-the-counter medications like: A) Antihistamines. B) NSAIDs. C) Antacids. D) Salicylates. 38. A male client is brought to the emergency department due to motor vehicle accident. While monitoring the client, the nurse suspects increasing intracranial pressure when: A) Client is oriented when aroused from sleep, and goes back to sleep immediately. B) Blood pressure is decreased from 160/90 to 110/70. C) Client refuses dinner because of anorexia. D) Pulse is increased from 88-96 with occasional skipped beat. 39. The nurse is conducting a lecture to a class of nursing students about advance directives to preoperative clients. Which of the following statement by the nurse js correct? A) The spouse, but not the rest of the family, may override the advance directive. B) An advance directive is required for a do not resuscitate order. C) A durable power of attorney, a form of advance directive, may only be held by a blood relative. D) The advance directive may be enforced even in the face of opposition by the spouse. 40. A client diagnosed with schizophrenia is shouting and banging on the door leading to the outside, saying, I need to go to an appointment. What is the appropriate nursing intervention? A) Tell the client that he cannot bang on the door. B) Ignore this behavior. C) Escort the client going back into the room. D) Ask the client to move away from the door.

41. Which of the following action is an accurate tracheal suctioning technique? A) 25 seconds of continuous suction during catheter insertion. B) 20 seconds of continuous suction during catheter insertion. C) 10 seconds of intermittent suction during catheter withdrawal. D) 15 seconds of intermittent suction during catheter withdrawal. 42. The clients jaw and cheekbone is sutured and wired. The nurse anticipates that the most important thing that must be ready at the bedside is: A) Suture set. B) Tracheostomy set. C) Suction equipment. D) Wire cutters. 43. A mother is in the third stage of labor. Which of the following signs will help the nurse determine the signs of placental separation? A) The uterus becomes globular. B) The umbilical cord is shortened. C) The fundus appears at the introitus. D) Mucoid discharge is increased. 44. After therapy with the thrombolytic alteplase (tPA), what observation will the nurse report to the physician? A) 3+ peripheral pulses. B) Change in level of consciousness and headache. C) Occasional dysrhythmias. D) Heart rate of 100/bpm. 45. A client who undergone left nephrectomy has a large flank incision. Which of the following nursing action will facilitate deep breathing and coughing? A) Push fluid administration to loosen respiratory secretions. B) Have the client lie on the unaffected side. C) Maintain the client in high Fowlers position. D) 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? A) Absence of ferning. B) Thin, clear, good spinnbarkeit. C) Thick, cloudy. D) 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-Fowlers position primarily to:

A) Facilitate movement and reduce complications from immobility. B) Fully aerate the lungs. C) Splint the wound. D) Promote drainage and prevent subdiaphragmatic abscesses. 48. Which of the following will best describe a management function? A) Writing a letter to the editor of a nursing journal. B) Negotiating labor contracts. C) Directing and evaluating nursing staff members. D) Explaining medication side effects to a client. 49. The parents of an infant client ask the nurse to teach them how to administer Cortisporin eye drops. The nurse is correct in advising the parents to place the drops: A) In the middle of the lower conjunctival sac of the infants eye. B) Directly onto the infants sclera. C) In the outer canthus of the infants eye. D) In the inner canthus of the infants 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? A) Frank blood on the clothing. B) Thirst and restlessness. C) Abdominal pain. D) 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: A) Icterus neonatorum B) Multiple hemangiomas C) Erythema toxicum D) 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? A) Include as many family members as possible. B) Take the family to the chapel. C) Discuss life support systems. D) Clarify the familys 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? A) Stand with legs apart and touch hands to floor three times per day. B) Ten minutes of walking per day with an emphasis on good posture. C) Ten minutes of swimming or leg kicking in pool per day. D) Pelvic rock exercise and squats three times a day. 54. A client with obsessive-compulsive behavior is admitted in the psychiatric unit. The nurse taking care of the client knows that the primary treatment goal is to: A) Provide distraction. B) Support but limit the behavior. C) Prohibit the behavior. D) Point out the behavior. 55. After ileostomy, the nurse expects that the drainage appliance will be applied to the stoma: A) When the client is able to begin self-care procedures. B) 24 hours later, when the swelling subsided. C) In the operating room after the ileostomy procedure. D) After the ileostomy begins to function. 56. A female client who has a 28-day menstrual cycle asks the community health nurse when she get pregnant during her cycle. What will be the best nursing response? A) It is impossible to determine the fertile period reliably. So it is best to assume that a woman is always fertile. B) In a 28-day cycle, ovulation occurs at or about day 14. The egg lives for about 24 hours and the sperm live for about 72 hours. The fertile period would be approximately between day 11 and day 15. C) In a 28- day cycle, ovulation occurs at or about day 14. The egg lives for about 72 hours and the sperm live for about 24 hours. The fertile period would be approximately between day 13 and 17. D) In a 28-day cycle, ovulation occurs 8 days before the next period or at about day 20. The fertile period is between day 20 and the beginning of the next period. 57. Which of the following statement describes the role of a nurse as a client advocate? A) A nurse may override clients wishes for their own good. B) A nurse has the moral obligation to prevent harm and do well for clients. C) A nurse helps clients gain greater independence and self-determination.

D) A nurse measures the risk and benefits of various health situations while factoring in cost. 58. A community health nurse is providing a health teaching to a woman infected with herpes simplex 2. Which of the following health teaching must the nurse include to reduce the chances of transmission of herpes simplex 2? A) Abstain from intercourse until lesions heal. B) Therapy is curative. C) Penicillin is the drug of choice for treatment. D) The organism is associated with later development of hydatidiform mole. 59. The nurse in the psychiatric ward informed the male client that he will be attending the 9:00 AM group therapy sessions. The client tells the nurse that he must wash his hands from 9:00 to 9:30 AM each day and therefore he cannot attend. Which concept does the nursing staff need to keep in mind in planning nursing intervention for this client? A) Depression underlines ritualistic behavior. B) Fear and tensions are often expressed in disguised form through symbolic processes. C) Ritualistic behavior makes others uncomfortable. D) Unmet needs are discharged through ritualistic behavior. 60. The nurse assesses the health condition of the female client. The client tells the nurse that she discovered a lump in the breast last year and hesitated to seek medical advice. The nurse understands that, women who tend to delay seeking medical advice after discovering the disease are displaying what common defense mechanism? A) Intellectualization. B) Suppression. C) Repression. D) Denial. 61. Which of the following situations cannot be delegated by the registered nurse to the nursing assistant? A) A postoperative client who is stable needs to ambulate. B) Client in soft restraint who is very agitated and crying. C) A confused elderly woman who needs assistance with eating. D) Routine temperature check that must be done for a client at end of shift. 62. In the admission care unit, which of the following client would the nurse give immediate attention? A) A client who is 3 days postoperative with left calf pain. B) A client who is postoperative hip pinning who is complaining of pain. C) New admitted client with chest pain.

D) A client with diabetes who has a glucoscan reading of 180. 63. A couple seeks medical advice in the community health care unit. A couple has been unable to conceive; the man is being evaluated for possible problems. The physician ordered semen analysis. Which of the following instructions is correct regarding collection of a sperm specimen? A) Collect a specimen at the clinic, place in iced container, and give to laboratory personnel immediately. B) Collect specimen after 48-72 hours of abstinence and bring to clinic within 2 hours. C) Collect specimen in the morning after 24 hours of abstinence and bring to clinic immediately. D) Collect specimen at night, refrigerate, and bring to clinic the next morning. 64. The physician ordered Betamethasone to a pregnant woman at 34 weeks of gestation with sign of preterm labor. The nurse expects that the drug will: A) Treat infection. B) Suppress labor contraction. C) Stimulate the production of surfactant. D) Reduce the risk of hypertension. 65. A tracheostomy cuff is to be deflated, which of the following nursing intervention should be implemented before starting the procedures? A) Suction the trachea and mouth. B) Have the obdurator available. C) Encourage deep breathing and coughing. D) Do a pulse oximetry reading. 66. A client is diagnosed with Tuberculosis and respiratory isolation is initiated. This means that: A) Gloves are worn when handling the clients tissue, excretions, and linen. B) Both client and attending nurse must wear masks at all times. C) Nurse and visitors must wear masks until chemotherapy is begun. Client is instructed in cough and tissue techniques. D) Full isolation; that is, caps and gowns are required during the period of contagion. 67. A client with lung cancer is admitted in the nursing care unit. The husband wants to know the condition of his wife. How should the nurse respond to the husband? A) Find out what information he already has. B) Suggest that he discuss it with his wife. C) Refer him to the doctor. D) Refer him to the nurse in charge. 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?

A) Divert the clients attention. B) Listen without reinforcing the clients belief. C) Inject humor to defuse the intensity. D) 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: A) Every 3-4 hours. B) Every hour. C) Twice a day. D) Once before bedtime. 70. Which telephone call from a students mother should the school nurse take care of at once? A) A telephone call notifying the school nurse that the child pediatrician has informed the mother that the child will need cardiac repair surgery within the next few weeks. B) A telephone call notifying the school nurse that the childs pediatrician has informed the mother that the child has head lice. C) A telephone call notifying the school nurse that a child has a temperature of 102F and a rash covering the trunk and upper extremities of the body. D) A telephone call notifying the school nurse that a child underwent an emergency appendectomy during the previous night. 71. 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) Excessive saliva, bumps around the areolae, and increased vaginal mucus. C) Fatigue, nausea, and urinary frequency at any time during pregnancy. D) 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? A) Elevate his head to promote gravity drainage of secretions. B) Wrap him in another blanket, to reduce heat loss. C) Stimulate him to cry,, to increase oxygenation. D) Aspirate his mouth and nose with bulb syringe.

73. The nurse is formulating a plan of care to a client with a somatoform disorder. The nurse needs to have knowledge of which psychodynamic principle? A) The symptoms of a somatoform disorder are an attempt to adjust to painful life situations or to cope with conflicting sexual, aggressive, or dependent feelings. B) The major fundamental mechanism is regression. C) The clients symptoms are imaginary and the suffering is faked. D) An extensive, prolonged study of the symptoms will be reassuring to the client, who seeks sympathy, attention and love. 74. An infant is brought to the health care clinic for three immunizations at the same time. The nurse knows that hepatitis B, DPT, and Haemophilus influenzae type B immunizations should: A) Be drawn in the same syringe and given in one injection. B) Be mixed and inject in the same sites. C) Not be mixed and the nurse must give three injections in three sites. D) Be mixed and the nurse must give the injection in three sites. 75. A female client with cancer has radium implants. The nurse wants to maintain the implants in the correct position. The nurse should position the client: A) Flat in bed. B) On the side only. C) With the foot of the bed elevated. D) With the head elevated 45-degrees (semiFowlers). 76. The nurse wants to know if the mother of a toddler understands the instructions regarding the administration of syrup of ipecac. Which of the following statement will help the nurse to know that the mother needs additional teaching? A) Ill give the medicine if my child gets into some toilet bowl cleaner. B) Ill give the medicine if my child gets into some aspirin. C) Ill give the medicine if my child gets into some plant bulbs. D) Ill 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? A) Drooling and drooping of the mouth. B) Inability to open eyelids on operative side. C) Sagging of the face on the operative side. D) Inability to close eyelid on operative side.

78. The community health nurse makes a home visit to a family. During the visit, the nurse observes that the mother is beating her child. What is the priority nursing intervention in this situation? A) Assess the childs injuries. B) Report the incident to protective agencies. C) Refer the family to appropriate support group. D) Assist the family to identify stressors and use of other coping mechanisms to prevent further incidents. 79. The nurse in the neonatal care unit is supervising the actions of a certified nursing assistant in giving care to the newborns. The nursing assistant mistakenly gives a formula feeding to a newborn that is on water feeding only. The nurse is responsible for the mistake of the nursing assistant: A) Always, as a representative of the institution. B) Always, because nurses who supervise lesstrained individuals are responsible for their mistakes. C) If the nurse failed to determine whether the nursing assistant was competent to take care of the client. D) Only if the nurse agreed that the newborn could be fed formula. 80. The nurse is assigned to care for a client with urinary calculi. Fluid intake of 2L/day is encouraged to the client. the primary reason for this is to: A) Reduce the size of existing stones. B) Prevent crystalline irritation to the ureter. C) Reduce the size of existing stones D) Increase the hydrostatic pressure in the urinary tract. 81. The nurse is counseling a couple in their mid 30s who have been unable to conceive for about 6 months. They are concerned that one or both of them may be infertile. What is the best advice the nurse could give to the couple? A) it is no unusual to take 6-12 months to get pregnant, especially when the partners are in their mid-30s. Eat well, exercise, and avoid stress. B) Start planning adoption. Many couples get pregnant when they are trying to adopt. C) Consult a fertility specialist and start testing before you get any older. D) Have sex as often as you can, especially around the time of ovulation, to increase your chances of pregnancy.

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 cant remember what this test is for. The best response by the nurse is: A) It provides a way to see if you are passing any protein in your urine. B) It tells how well the kidneys filter wastes from the blood. C) It tells if your renal insufficiency has affected your heart. D) The test measures the number of particles the kidney filters. 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 cant sleep at night because of fear of dying. What is the best initial nursing response? A) It must be frightening for you to feel that way. Tell me more about it. B) Dont worry, you wont die. You are just here for some test. C) Why are you afraid of dying? D) Try to sleep. You need the rest before tomorrows 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? A) Join in the conversation, giving her input about the case. B) Ignore them, because they have the right to discuss anything they want to. C) Tell them it is not appropriate to discuss such things. D) Report this incident to the nursing supervisor. 85. The client has had a right-sided cerebrovascular accident. In transferring the client from the wheelchair to bed, in what position should a client be placed to facilitate safe transfer? A) Weakened (L) side of the cient next to bed. B) Weakened (R) side of the client next to bed. C) Weakened (L) side of the client away from bed. D) Weakened (R) side of the cient away from bed. 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 childs bed? A) A toy gun. B) A stuffed animal. C) A ball. D) Lego.

87. The LPN/LVN asks the registered nurse why oxytocin (Pitocin), 10 units (IV or IM) must be given to a client after birth for the fetus. The nurse is correct to explain that oxytocin: A) Minimizes discomfort from afterpains. B) Suppresses lactation. C) Promotes lactation. D) Maintains uterine tone. 88. The nurse in the nursing care unit is aware that one of the medical staff displays unlikely behaviors like confusion, agitation, lethargy and unkempt appearance. This behavior has been reported to the nurse manager several times, but no changes observed. The nurse should: A) Continue to report observations of unusual behavior until the problem is resolved. B) Consider that the obligation to protect the patient from harm has been met by the prior reports and do nothing further. C) Discuss the situation with friends who are also nurses to get ideas . D) Approach the partner of this medical staff member with these concerns. 89. The physician ordered tetracycline PO qid to a child client who weights 20kg. The recommended PO tetracycline dose is 25-50 mg/kg/day. What is the maximum single dose that can be safely administered to this child? A) 1 g B) 500 mg C) 250 mg D) 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? A) Total time of ruptured membranes was 24 hours with the second birth. B) First labor lasting 24 hours. C) Uterine fibroid noted at time of cesarean delivery. D) Second birth by cesarean for face presentation. 91. The nurse is planning to talk to the client with an antisocial personality disorder. What would be the most therapeutic approach? A) Provide external controls. B) Reinforce the clients self-concept. C) Give the client opportunities to test reality. D) Gratify the clients inner needs.

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92. The nurse is teaching a group of women about fertility awareness, the nurse should emphasize that basal body temperature: A) Can be done with a mercury thermometer but no a digital one. B) The average temperature taken each morning. C) Should be recorded each morning before any activity. D) Has a lower degree of accuracy in predicting ovulation than the cervical mucus test. 93. The nursing applicant has given the chance to ask questions during a job interview at a local hospital. What should be the most important question to ask that can increase chances of securing a job offer? A) Begin with questions about client care assignments, advancement opportunities, and continuing education. B) Decline to ask questions, because that is the responsibility of the interviewer. C) Ask as many questions about the facility as possible. D) Clarify information regarding salary, benefits, and working hours first, because this will help in deciding whether or not to take the job. 94. The nurse advised the pregnant woman that smoking and alcohol should be avoided during pregnancy. The nurse takes into account that the developing fetus is most vulnerable to environment teratogens that cause malformation during: A) The entire pregnancy. B) The third trimester. C) The first trimester. D) The second trimester. 95. A male client tells the nurse that there is a big bug in his bed. The most therapeutic nursing response would be: A) Silence. B) Wheres the bug? Ill kill it for you. C) I dont see a bug in your bed, but you seem afraid. D) 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? A) Beginning of labor. B) Bladder infection. C) Constipation. D) 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: A) The nurse stops to render emergency aid and leaves before the ambulance arrives.

B) The nurse acts in an emergency at his or her place of employment. C) The nurse refuses to stop for an emergency outside of the scope of employment. D) The nurse is grossly negligent at the scene of an emergency. 98. A woman is hospitalized with mild preeclampsia. The nurse is formulating a plan of care for this client, which nursing care is least likely to be done? A) Deep-tendon reflexes once per shift. B) Vital signs and FHR and rhythm q4h while awake. C) Absolute bed rest. D) Daily weight. 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 newborns 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. 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: A) Panic reaction. B) Medication overdose. C) Toxic reaction to an antibiotic. D) Delirium tremens.
110. As a registered nurse, Dervid knew that the first thing that he will do at the scene is A. Stay with the person, Encourage her to remain still and Immobilize the leg while waiting for the ambulance. B. Leave the person for a few moments to call for help. C. Reduce the fracture manually. D. Move the person to a safer place. 102. Dervid suspects a hip fracture when he noticed that the old womans leg is A. Lengthened, Abducted and Internally Rotated. B. Shortened, Abducted and Externally Rotated. C. Shortened, Adducted and Internally Rotated. D. Shortened, Adducted and Externally Rotated.

11 103. The old woman complains of pain. John noticed that the knee is reddened, warm to touch and swollen. John interprets that this signs and symptoms are likely related to: A. Infection C. Thrombophlebitis B. Inflammation D. Degenerative disease 104. The old woman told John that she has osteoporosis; Dervid knew that all of the following factors would contribute to osteoporosis except A. Hypothyroidism B. End stage renal disease C. Cushings Disease D. Taking Furosemide and Phenytoin. 105. Martha, The old woman was now Immobilized and brought to the emergency room. The X-ray shows a fractured femur and pelvis. The ER Nurse would carefully monitor Martha for which of the following sign and symptoms? A. Tachycardia and Hypotension B. Fever and Bradycardia C. Bradycardia and Hypertension D. Fever and Hypertension SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of OLFU Lagro is admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis. 106. As a nurse, you instructed Mr. Rojas how to use a cane. Mr. Rojas has a weakness on his right leg due to self immobilization and guarding. You plan to teach Mr. Rojas to hold the cane A. On his left hand, because his right side is weak. B. On his left hand, because of reciprocal motion. C. On his right hand, to support the right leg. D. On his right hand, because only his right leg is weak. 107. You also told Mr. Rojas to hold the cane A. 1 Inches in front of the foot. B. 3 Inches at the lateral side of the foot. c. 6 Inches at the lateral side of the foot. D. 12 Inches at the lateral side of the foot. 108. Mr. Rojas was discharged and 6 months later, he came back to the emergency room of the hospital because he suffered a mild stroke. The right side of the brain was affected. At the rehabilitative phase of your nursing care, you observe Mr. Rojas use a cane and you intervene if you see him A. Moves the cane when the right leg is moved. B. Leans on the cane when the right leg swings through. C. keeps the cane 6 Inches out to the side of the right foot. D. Holds the cane on the right side. SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood 109. The nurse performs a Mantoux Test. The nurse knows that Mantoux Test is also known as A. PPD B. PDP C. PDD D. DPP 110. The nurse would inject the solution in what route? A. IM B. IV C. ID D. SC 111. The nurse notes that a positive result for Alfred is A. 5 mm wheal B. 5 mm Induration C. 10 mm Wheal D. 10 mm Induration 112. The nurse told Alfred to come back after A. a week B. 48 hours C. 1 day D. 4 days 113. Mang Alfred returns after the Mantoux Test. The test result read POSITIVE. What should be the nurses next action? A. Call the Physician B. Notify the radiology dept. for CXR evaluation C. Isolate the patient D. Order for a sputum exam 114. Why is Mantoux test not routinely done in the Philippines? A. It requires a highly skilled nurse to perform a Mantoux test B. The sputum culture is the gold standard of PTB Diagnosis and it will definitively determine the extent of the cavitary lesions C. Chest X Ray Can diagnose the specific microorganism responsible for the lesions D. Almost all Filipinos will test positive for Mantoux Test

12 115. Mang Alfred is now a new TB patient with an active disease. What is his category according to the DOH? A. I B. II C. III D. IV 116. How long is the duration of the maintenance phase of his treatment? A. 2 months B. 3 months C. 4 months D. 5 months 117. Which of the following drugs is UNLIKELY given to Mang Alfred during the maintenance phase? A. Rifampicin B. Isoniazid C. Ethambutol D. Pyridoxine 118. According to the DOH, the most hazardous period for development of clinical disease is during the first A. 6-12 months after B. 3-6 months after C. 1-2 months after D. 2-4 weeks after 119. This is the name of the program of the DOH to control TB in the country A. DOTS B. National Tuberculosis Control Program C. Short Coursed Chemotherapy D. Expanded Program for Immunization 120. Susceptibility for the disease [ TB ] is increased markedly in those with the following condition except A. 23 Year old athlete with diabetes insipidus B. 23 Year old athlete taking long term Decadron therapy and anabolic steroids C. 23 Year old athlete taking illegal drugs and abusing substances D. Undernourished and Underweight individual who undergone gastrectomy 121. Direct sputum examination and Chest X ray of TB symptomatic is in what level of prevention? A. Primary B. Secondary C. Tertiary D. Quarterly SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy. 122. Michiel shows the BEST adaptation with the new colostomy if he shows which of the following? A. Look at the ostomy site B. Participate with the nurse in his daily ostomy care C. Ask for leaflets and contact numbers of ostomy support groups D. Talk about his ostomy openly to the nurse and friends 123. The nurse plans to teach Michiel about colostomy irrigation. As the nurse prepares the materials needed, which of the following item indicates that the nurse needs further instruction? A. Plain NSS / Normal Saline B. K-Y Jelly C. Tap water D. Irrigation sleeve 124. The nurse should insert the colostomy tube for irrigation at approximately A. 1-2 inches B. 3-4 inches C. 6-8 inches D. 12-18 inches 125. The maximum height of irrigation solution for colostomy is A. 5 inches B. 12 inches C. 18 inches D. 24 inches 126. Which of the following behavior of the client indicates the best initial step in learning to care for his colostomy? A. Ask to defer colostomy care to another individual B. Promises he will begin to listen the next day C. Agrees to look at the colostomy D. States that colostomy care is the function of the nurse while he is in the hospital 127. While irrigating the clients colostomy, Michiel suddenly complains of severe cramping. Initially, the nurse would A. Stop the irrigation by clamping the tube B. Slow down the irrigation C. Tell the client that cramping will subside and is normal D. Notify the physician 128. The next day, the nurse will assess Michiels stoma. The nurse noticed that a prolapsed stoma is evident if she sees which of the following? A. A sunken and hidden stoma B. A dusky and bluish stoma C. A narrow and flattened stoma

13 D. Protruding stoma with swollen appearance 129. Michiel asked the nurse, what foods will help lessen the odor of his colostomy. The nurse best response would be A. Eat eggs B. Eat cucumbers C. Eat beet greens and parsley D. Eat broccoli and spinach 130. The nurse will start to teach Michiel about the techniques for colostomy irrigation. Which of the following should be included in the nurses teaching plan? A. Use 500 ml to 1,000 ml NSS B. Suspend the irrigant 45 cm above the stoma C. Insert the cone 4 cm in the stoma D. If cramping occurs, slow the irrigation 131. The nurse knew that the normal color of Michiels stoma should be A. Brick Red B. Gray C. Blue D. Pale Pink SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema. 132. Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error? A. Hyperventilating James with 100% oxygen before and after suctioning B. Instilling 3 to 5 ml normal saline to loosen up secretion C. Applying suction during catheter withdrawal D. Suction the client every hour 133. What size of suction catheter would Wilma use for James, who is 6 feet 5 inches in height and weighing approximately 145 lbs? A. Fr. 5 B. Fr. 10 C. Fr. 12 D. Fr. 18 134. Wilma is using a portable suction unit at home, What is the amount of suction required by James using this unit? A. 2-5 mmHg B. 5-10 mmHg C. 10-15 mmHg D. 20-25 mmHg 135. If a Wall unit is used, What should be the suctioning pressure required by James? A. 50-95 mmHg B. 95-110 mmHg C. 100-120 mmHg D. 155-175 mmHg 136. Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner and outer cannulas was removed and left hanging on James neck. What are the 2 equipments at james bedside that could help Wilma deal with this situation? A. New set of tracheostomy tubes and Oxygen tank B. Theophylline and Epinephrine C. Obturator and Kelly clamp D. Sterile saline dressing 137. Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed? A. Wilma places 2 fingers between the tie and neck B. The tracheotomy can be pulled slightly away from the neck C. James neck veins are not engorged D. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process. 138. Wilma knew that James have an adequate respiratory condition if she notices that A. James respiratory rate is 18 B. James Oxygen saturation is 91% C. There are frank blood suction from the tube D. There are moderate amount of tracheobronchial secretions 139. Wilma knew that the maximum time when suctioning James is A. 10 seconds B. 20 seconds C. 30 seconds D. 45 seconds SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet. 140. What specific manifestation would nurse Jet see in Acute close angle glaucoma that she would not see in an open angle glaucoma? A. Loss of peripheral vision B. Irreversible vision loss C. There is an increase in IOP D. Pain 141. Nurse jet knew that Acute close angle glaucoma is caused by A. Sudden blockage of the anterior angle by the base of the iris

14 B. Obstruction in trabecular meshwork C. Gradual increase of IOP D. An abrupt rise in IOP from 8 to 15 mmHg 142. Nurse jet performed a TONOMETRY test to Mr. Batumbakal. What does this test measures A. It measures the peripheral vision remaining on the client B. Measures the Intra Ocular Pressure C. Measures the Clients Visual Acuity D. Determines the Tone of the eye in response to the sudden increase in IOP. 143. The Nurse notices that Mr. Batumbakal cannot anymore determine RED from BLUE. The nurse knew that which part of the eye is affected by this change? A. IRIS B. PUPIL c. RODS [RETINA] D. CONES [RETINA] 144. Nurse Jet knows that Aqueous Humor is produce where? A. In the sub arachnoid space of the meninges B. In the Lateral ventricles C. In the Choroids D. In the Ciliary Body 145. Nurse Jet knows that the normal IOP is A. 8-21 mmHg B. 2-7 mmHg c. 31-35 mmHg D. 15-30 mmHg 146. Nurse Jet wants to measure Mr. Batumbakals CN II Function. What test would Nurse Jet implement to measure CN IIs Acuity? A. Slit lamp B. Snellens Chart C. Woods light D. Gonioscopy 147. The Doctor orders pilocarpine. Nurse jet knows that the action of this drug is to A. Contract the Ciliary muscle B. Relax the Ciliary muscle C. Dilate the pupils D. Decrease production of Aqueous Humor 148. The doctor orders timolol [timoptic]. Nurse jet knows that the action of this drug is A. Reduce production of CSF B. Reduce production of Aqueous Humor C. Constrict the pupil D. Relaxes the Ciliary muscle 149. When caring for Mr. Batumbakal, Jet teaches the client to avoid A. Watching large screen TVs B. Bending at the waist C. Reading books D. Going out in the sun 150. Mr. Batumbakal has undergone eye angiography using an Intravenous dye and fluoroscopy. What activity is contraindicated immediately after procedure? A. Reading newsprint B. Lying down C. Watching TV D. Listening to the music

151. Accompanied by her husband, a patient seeks admission to the labor and delivery area. The client states that she is in labor, and says she attended the hospital clinic for prenatal care. Which question should the nurse ask her first? a. Do you have any chronic illness? b. Do you have any allergies? c. What is your expected due date? d. Who will be with you during labor? 152. A patient is in the second stage of labor. During this stage, how frequently should the nurse in charge assess her uterine contractions? a. Every 5 minutes b. Every 15 minutes c. Every 30 minutes d. Every 60 minutes 153. A patient is in last trimester of pregnancy. Nurse Jane should instruct her to notify her primary health care provider immediately if she notices: a. Blurred vision b. Hemorrhoids c. Increased vaginal mucus d. Shortness of breath on exertion 154. The nurse in charge is reviewing a patients prenatal history. Which finding indicates a genetic risk factor? a. The patient is 25 years old b. The patient has a child with cystic fibrosis c. The patient was exposed to rubella at 36 weeks gestation d. The patient has a history of preterm labor at 32 weeks gestation 155. A adult female patient is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by;

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a. Return preovulatory basal body temperature b. Basal body temperature increase of 0.1 degrees to 0.2 degrees on the 2nd or 3rd day of cycle c. 3 full days of elevated basal body temperature and clear, thin cervical mucus d. Breast tenderness and mittelschmerz 156. During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal movement, making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, the nurse in charge should instruct the client to push the control button at which time? a. At the beginning of each fetal movement b. At the beginning of each contraction c. After every three fetal movements d. At the end of fetal movement 157. When evaluating a clients knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse in charge that the client understands the information given to her? a. Ill report increased frequency of urination. b. If I have blurred or double vision, I should call the clinic immediately. c. If I feel tired after resting, I should report it immediately. d. Nausea should be reported immediately. 158. When assessing a client during her first prenatal visit, the nurse discovers that the client had a reduction mammoplasty. The mother indicates she wants to breast-feed. What information should the nurse give to this mother regarding breast-feeding success? a. Its contraindicated for you to breast-feed following this type of surgery. b. I support your commitment; however, you may have to supplement each feeding with formula. c. You should check with your surgeon to determine whether breast-feeding would be possible. d. You should be able to breast-feed without difficulty. 159. Following a precipitous delivery, examination of the clients vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client? a. Applying cold to limit edema during the first 12 to 24 hours b. Instructing the client to use two or more peripads to cushion the area c. Instructing the client on the use of sitz baths if ordered

d. Instructing the client about the importance of perineal (Kegel) exercises 160. A client makes a routine visit to the prenatal clinic. Although shes 14 weeks pregnant, the size of her uterus approximates that in an 18- to 20-week pregnancy. Dr. Diaz diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal: a. an empty gestational sac. b. grapelike clusters. c. a severely malformed fetus. d. an extrauterine pregnancy. 161. After completing a second vaginal examination of a client in labor, the nursemidwife determines that the fetus is in the right occiput anterior position and at 1 station. Based on these findings, the nurse-midwife knows that the fetal presenting part is: a. 1 cm below the ischial spines. b. directly in line with the ischial spines. c. 1 cm above the ischial spines. d. in no relationship to the ischial spines. 162. Which of the following would be inappropriate to assess in a mother whos breast-feeding? a. The attachment of the baby to the breast. b. The mothers comfort level with positioning the baby. c. Audible swallowing. d. The babys lips smacking 163. During a prenatal visit at 4 months gestation, a pregnant client asks whether tests can be done to identify fetal abnormalities. Between 18 and 40 weeks gestation, which procedure is used to detect fetal anomalies? a. Amniocentesis. b. Chorionic villi sampling. c. Fetoscopy. d. Ultrasound 164. A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of her fetus. Her BPP score is 8. What does this score indicate? a. The fetus should be delivered within 24 hours. b. The client should repeat the test in 24 hours. c. The fetus isnt in distress at this time. d. The client should repeat the test in 1 week. 165. A client whos 36 weeks pregnant comes to the clinic for a prenatal checkup. To assess the clients preparation for parenting, the nurse might ask which question? a. Are you planning to have epidural anesthesia?

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b. Have you begun prenatal classes? c. What changes have you made at home to get ready for the baby? d. Can you tell me about the meals you typically eat each day? 166. A client whos admitted to labor and delivery has the following assessment findings: gravida 2 para 1, estimated 40 weeks gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which of the following would be the priority at this time? a. Placing the client in bed to begin fetal monitoring. b. Preparing for immediate delivery. c. Checking for ruptured membranes. d. Providing comfort measures. 167. Nurse Roy is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first? a. Change the clients position. b. Prepare for emergency cesarean section. c. Check for placenta previa. d. Administer oxygen. 168. The nurse in charge is caring for a postpartum client who had a vaginal delivery with a midline episiotomy. Which nursing diagnosis takes priority for this client? a. Risk for deficient fluid volume related to hemorrhage b. Risk for infection related to the type of delivery c. Pain related to the type of incision d. Urinary retention related to periurethral edema 169. Which change would the nurse identify as a progressive physiological change in postpartum period? a. Lactation b. Lochia c. Uterine involution d. Diuresis 170. A 39-year-old at 37 weeks gestation is admitted to the hospital with complaints of vaginal bleeding following the use of cocaine 1 hour earlier. Which complication is most likely causing the clients complaint of vaginal bleeding? a. Placenta previa b. Abruptio placentae c. Ectopic pregnancy d. Spontaneous abortion

171. A client with type 1 diabetes mellitus whos a multigravida visits the clinic at 27 weeks gestation. The nurse should instruct the client that for most pregnant women with type 1 diabetes mellitus: a. Weekly fetal movement counts are made by the mother. b. Contraction stress testing is performed weekly. c. Induction of labor is begun at 34 weeks gestation. d. Nonstress testing is performed weekly until 32 weeks gestation 172. When administering magnesium sulfate to a client with preeclampsia, the nurse understands that this drug is given to: a. Prevent seizures b. Reduce blood pressure c. Slow the process of labor d. Increase dieresis 173. Whats the approximate time that the blastocyst spends traveling to the uterus for implantation? a. 2 days b. 7 days c. 10 days d. 14 weeks 174. After teaching a pregnant woman who is in labor about the purpose of the episiotomy, which of the following purposes stated by the client would indicate to the nurse that the teaching was effective? a. Shortens the second stage of labor b. Enlarges the pelvic inlet c. Prevents perineal edema d. Ensures quick placenta delivery 175. A primigravida client at about 35 weeks gestation in active labor has had no prenatal care and admits to cocaine use during the pregnancy. Which of the following persons must the nurse notify? a. Nursing unit manager so appropriate agencies can be notified b. Head of the hospitals security department c. Chaplain in case the fetus dies in utero d. Physician who will attend the delivery of the infant 176. When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse in charge should include which of the following? a. The vaccine prevents a future fetus from developing congenital anomalies b. Pregnancy should be avoided for 3 months after the immunization c. The client should avoid contact with children

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diagnosed with rubella d. The injection will provide immunity against the 7-day measles. 177. A client with eclampsia begins to experience a seizure. Which of the following would the nurse in charge do first? a. Pad the side rails b. Place a pillow under the left buttock c. Insert a padded tongue blade into the mouth d. Maintain a patent airway 178. While caring for a multigravida client in early labor in a birthing center, which of the following foods would be best if the client requests a snack? a. Yogurt b. Cereal with milk c. Vegetable soup d. Peanut butter cookies 179. The multigravida mother with a history of rapid labor who us in active labor calls out to the nurse, The baby is coming! which of the following would be the nurses first action? a. Inspect the perineum b. Time the contractions c. Auscultate the fetal heart rate d. Contact the birth attendant 180. While assessing a primipara during the immediate postpartum period, the nurse in charge plans to use both hands to assess the clients fundus to: a. Prevent uterine inversion b. Promote uterine involution c. Hasten the puerperium period d. Determine the size of the fundus 181. What is the purpose of tunneling (inserting the catheter 2-4 inches under the skin) when the surgeon inserts a Hickman central catheter device? Tunneling: a. Increases the patients comfort level. b. Decreases the risk of infection. c. Prevents the patients clothes from having contact with the catheter d. Makes the catheter less visible to other people. 182. The primary complication of a central venous access device (CVAD) is: a. Thrombus formation in the vein. b. Pain and discomfort. c. Infection. d. Occlusion of the catheter as the result of an intra-lumen clot. 183. Nurse Blessy is doing some patient education related to a patients central venous

access device. Which of the following statements will the nurse make to the patient? a. These type of devices are essentially risk free. b. These devices seldom work for more than a week or two necessitating replacement. c. The dressing should only the changed by your doctor. d. Heparin in instilled into the lumen of the catheter to decrease the risk of clotting. 184. The chemotherapeutic DNA alkylating agents such as nitrogen mustards are effective because they: a. Cross-link DNA strands with covalent bonds between alkyl groups on the drug and guanine bases on DNA. b. Have few, if any, side effects. c. Are used to treat multiple types of cancer. d. Are cell cycle-specific agents. 185. Hormonal agents are used to treat some cancers. An example would be: a. Thyroxine to treat thyroid cancer. b. ACTH to treat adrenal carcinoma. c. Estrogen antagonists to treat breast cancer. d. Glucagon to treat pancreatic carcinoma. 186. Chemotherapeutic agents often produce a certain degree of myelosuppression including leukopenia. Leukopenia does not present immediately but is delayed several days to weeks because: a. The patients hemoglobin and hematocrit are normal. b. Red blood cells are affected first. c. Folic acid levels are normal. d. The current white cell count is not affected by chemotherapy. 187. Currently, there is no way to prevent myelosuppression. However, there are medications available to elicit a more rapid bone marrow recovery. An example is: a. Epoetin alfa (Epogen, Procrit). b. Glucagon. c. Fenofibrate (Tricor). d. Lamotrigine (Lamictal). 188. Estrogen antagonists are used to treat estrogen hormone-dependent cancer, such as breast carcinoma. Androgen antagonists block testosterone stimulation of androgendependent cancers. An example of an androgen-dependent cancer would be: a. Prostate cancer. b. Thyroid cancer. c. Renal carcinoma. d. neuroblastoma.

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189. Serotonin release stimulates vomiting following chemotherapy. Therefore, serotonin antagonists are effective in preventing and treating nausea and vomiting related to chemotherapy. An example of an effective serotonin antagonist antiemetic is: a. ondansetron (Zofran). b. fluoxetine (Prozac). c. paroxetine (Paxil). d. sertraline (Zoloft). 190. Methotrexate, the most widely used antimetabolite in cancer chemotherapy does not penetrate the central nervous system (CNS). To treat CNS disease this drug must be administered: a. Intravenously. b. Subcutaneously. c. Intrathecally. d. By inhalation. 191. Methotrexate is a folate antagonist. It inhibits enzymes required for DNA base synthesis. To prevent harm to normal cells, a fully activated form of folic acid known as leucovorin (folinic acid; citrovorum factor) can be administered. Administration of leucovorin is known as: a. Induction therapy. b. Consolidation therapy. c. Pulse therapy. d. Rescue therapy. 192. A male Patient is undergoing chemotherapy may also be given the drug allopurinol (Zyloprim, Aloprim). Allopurinol inhibits the synthesis of uric acid. Concomitant administration of allopurinol prevents: a. Myelosuppression. b. Gout and hyperuricemia. c. Pancytopenia. d. Cancer cell growth and replication 193. Superficial bladder cancer can be treated by direct instillation of the antineoplastic antibiotic agent mitomycin (Mutamycin). This process is termed: a. Intraventricular administration. b. Intravesical administration. c. Intravascular administration. d. Intrathecal administration. 194. The most common dose-limiting toxicity of chemotherapy is: a. Nausea and vomiting. b. Bloody stools. c. Myelosuppression. d. Inability to ingest food orally due to stomatitis and mucositis.

195. Chemotherapy induces vomiting by: a. Stimulating neuroreceptors in the medulla. b. Inhibiting the release of catecholamines. c. Autonomic instability. d. Irritating the gastric mucosa. 196. Myeloablation using chemotherapeutic agents is useful in cancer treatment because: a. It destroys the myelocytes (muscle cells). b. It reduces the size of the cancer tumor. c. After surgery, it reduces the amount of chemotherapy needed. d. It destroys the bone marrow prior to transplant. 197. Anticipatory nausea and vomiting associated with chemotherapy occurs: a. Within the first 24 hours after chemotherapy. b. 1-5 days after chemotherapy. c. Before chemotherapy administration. d. While chemotherapy is being administered. 198. Medications bound to protein have the following effect: a. Enhancement of drug availability. b. Rapid distribution of the drug to receptor sites. c. The more drug bound to protein, the less available for desired effect. d. Increased metabolism of the drug by the liver. 199. Some drugs are excreted into bile and delivered to the intestines. Prior to elimination from the body, the drug may be absorbed. This process is known as: a. Hepatic clearance. b. Total clearance. c. Enterohepatic cycling. d. First-pass effect. 200. An adult patient has been taking a drug (Drug A) that is highly metabolized by the cytochrome p-450 system. He has been on this medication for 6 months. At this time, he is started on a second medication (Drug B) that is an inducer of the cytochrome p-450 system. You should monitor this patient for: a. Increased therapeutic effects of Drug A. b. Increased adverse effects of Drug B. c. Decreased therapeutic effects of Drug A. d. Decreased therapeutic effects of Drug B.