Professional Documents
Culture Documents
Reviewer NLE
Reviewer NLE
Table of Contents
Part 1 Mock Board Examination
Test Scope/Coverage
Nursing Practice I Foundation of Nursing, Nursing Research, Professional
Adjustment, Leadership and Management
Nursing Practice II Maternal and Child Health, Community Health Nursing,
Communicable Diseases, Integrated Management of
Childhood Illness
Nursing Practice III Medical and Surgical Nursing
Nursing Practice IV Medical and Surgical Nursing
Nursing Practice V Psychiatric Nursing
Part 2
Nursing Practice I-V Answers and Rationale
Part 3 Selected Practice Test from Nursing Cribs website
Practice Test 1 Foundation of Nursing
Answers and Rationale
Practice Test 2 Maternal and Child Health
Answers and Rationale
Practice Test 3 Medical Surgical Nursing
Answers and Rationale
Practice Test 4 Psychiatric Nursing
Answers and Rationale
Nursing Crib Student Nurses Community 4
PART I
NURSING PRACTICE I
Foundation of Professional Nursing
Practice
Nursing Crib Student Nurses Community 5
TEST I - Foundation of Professional Nursing Practice
1. The nurse In-charge in labor and delivery unit administered a dose of
terbutaline to a client without checking the clients pulse. The standard that
would be used to determine if the nurse was negligent is:
a. The physicians orders.
b. The action of a clinical nurse specialist who is recognized expert in
the field.
c. The statement in the drug literature about administration of
terbutaline.
d. The actions of a reasonably prudent nurse with similar education
and experience.
2. Nurse Trish is caring for a female client with a history of GI bleeding,
sickle cell disease, and a platelet count of 22,000/l. The female client is
b. Stage II
c. Stage III
d. Stage IV
35.When the method of wound healing is one in which wound edges are not
surgically approximated and integumentary continuity is restored by
granulations, the wound healing is termed
a. Second intention healing
b. Primary intention healing
c. Third intention healing
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d. First intention healing
36.An 80-year-old male client is admitted to the hospital with a diagnosis of
pneumonia. Nurse Oliver learns that the client lives alone and hasnt been
eating or drinking. When assessing him for dehydration, nurse Oliver
would expect to find:
a. Hypothermia
b. Hypertension
c. Distended neck veins
d. Tachycardia
37.The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours
as needed, to control a clients postoperative pain. The package insert is
Meperidine, 100 mg/ml. How many milliliters of meperidine should the
client receive?
a. 0.75
b. 0.6
c. 0.5
d. 0.25
38. A male client with diabetes mellitus is receiving insulin. Which statement
correctly describes an insulin unit?
a. Its a common measurement in the metric system.
b. Its the basis for solids in the avoirdupois system.
c. Its the smallest measurement in the apothecary system.
d. Its a measure of effect, not a standard measure of weight or
quantity.
39.Nurse Oliver measures a clients temperature at 102 F. What is the
equivalent Centigrade temperature?
a. 40.1 C
b. 38.9 C
c. 48 C
d. 38 C
40.The nurse is assessing a 48-year-old client who has come to the
physicians office for his annual physical exam. One of the first physical
signs of aging is:
a. Accepting limitations while developing assets.
b. Increasing loss of muscle tone.
c. Failing eyesight, especially close vision.
b. Informative
c. Formative
d. Retrospective
48.A 45 year old client, has no family history of breast cancer or other risk
factors for this disease. Nurse John should instruct her to have
mammogram how often?
a. Twice per year
b. Once per year
c. Every 2 years
d. Once, to establish baseline
49.A male client has the following arterial blood gas values: pH 7.30; Pao2 89
mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. Based on these values,
Nurse Patricia should expect which condition?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
50.Nurse Len refers a female client with terminal cancer to a local hospice.
What is the goal of this referral?
a. To help the client find appropriate treatment options.
b. To provide support for the client and family in coping with terminal
illness.
c. To ensure that the client gets counseling regarding health care
costs.
d. To teach the client and family about cancer and its treatment.
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51.When caring for a male client with a 3-cm stage I pressure ulcer on the
coccyx, which of the following actions can the nurse institute
independently?
a. Massaging the area with an astringent every 2 hours.
b. Applying an antibiotic cream to the area three times per day.
c. Using normal saline solution to clean the ulcer and applying a
protective dressing as necessary.
d. Using a povidone-iodine wash on the ulceration three times per
day.
52.Nurse Oliver must apply an elastic bandage to a clients ankle and calf. He
should apply the bandage beginning at the clients:
a. Knee
b. Ankle
c. Lower thigh
d. Foot
53.A 10 year old child with type 1 diabetes develops diabetic ketoacidosis
and receives a continuous insulin infusion. Which condition represents the
greatest risk to this child?
a. Hypernatremia
b. Hypokalemia
c. Hyperphosphatemia
d. Hypercalcemia
54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly
admitted client. Immediately afterward, the client may experience:
a. Throbbing headache or dizziness
b. Nervousness or paresthesia.
c. Drowsiness or blurred vision.
d. Tinnitus or diplopia.
55.Nurse Michelle hears the alarm sound on the telemetry monitor. The nurse
quickly looks at the monitor and notes that a client is in a ventricular
tachycardia. The nurse rushes to the clients room. Upon reaching the
clients bedside, the nurse would take which action first?
a. Prepare for cardioversion
b. Prepare to defibrillate the client
c. Call a code
d. Check the clients level of consciousness
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56.Nurse Hazel is preparing to ambulate a female client. The best and the
safest position for the nurse in assisting the client is to stand:
a. On the unaffected side of the client.
b. On the affected side of the client.
c. In front of the client.
d. Behind the client.
57.Nurse Janah is monitoring the ongoing care given to the potential organ
donor who has been diagnosed with brain death. The nurse determines
that the standard of care had been maintained if which of the following
data is observed?
a. Urine output: 45 ml/hr
b. Capillary refill: 5 seconds
c. Serum pH: 7.32
d. Blood pressure: 90/48 mmHg
58. Nurse Amy has an order to obtain a urinalysis from a male client with an
indwelling urinary catheter. The nurse avoids which of the following, which
contaminate the specimen?
a. Wiping the port with an alcohol swab before inserting the syringe.
b. Aspirating a sample from the port on the drainage bag.
c. Clamping the tubing of the drainage bag.
d. Obtaining the specimen from the urinary drainage bag.
59.Nurse Meredith is in the process of giving a client a bed bath. In the
middle of the procedure, the unit secretary calls the nurse on the intercom
to tell the nurse that there is an emergency phone call. The appropriate
nursing action is to:
a. Immediately walk out of the clients room and answer the phone
call.
b. Cover the client, place the call light within reach, and answer the
phone call.
a. Field study
b. Quasi-experiment
c. Solomon-Four group design
d. Post-test only design
72.Cherry notes down ideas that were derived from the description of an
investigation written by the person who conducted it. Which type of
reference source refers to this?
a. Footnote
b. Bibliography
c. Primary source
d. Endnotes
73.When Nurse Trish is providing care to his patient, she must remember that
her duty is bound not to do doing any action that will cause the patient
harm. This is the meaning of the bioethical principle:
a. Non-maleficence
b. Beneficence
c. Justice
d. Solidarity
74.When a nurse in-charge causes an injury to a female patient and the injury
caused becomes the proof of the negligent act, the presence of the injury
is said to exemplify the principle of:
a. Force majeure
b. Respondeat superior
c. Res ipsa loquitor
d. Holdover doctrine
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75.Nurse Myrna is aware that the Board of Nursing has quasi-judicial power.
An example of this power is:
a. The Board can issue rules and regulations that will govern the
practice of nursing
b. The Board can investigate violations of the nursing law and code of
ethics
c. The Board can visit a school applying for a permit in collaboration
with CHED
d. The Board prepares the board examinations
76. When the license of nurse Krina is revoked, it means that she:
a. Is no longer allowed to practice the profession for the rest of her life
b. Will never have her/his license re-issued since it has been revoked
c. May apply for re-issuance of his/her license based on certain
conditions stipulated in RA 9173
d. Will remain unable to practice professional nursing
77.Ronald plans to conduct a research on the use of a new method of pain
assessment scale. Which of the following is the second step in the
conceptualizing phase of the research process?
a. Formulating the research hypothesis
b. Review related literature
d. Evaluation
92.Nursing care for a female client includes removing elastic stockings once
per day. The Nurse Betty is aware that the rationale for this intervention?
a. To increase blood flow to the heart
b. To observe the lower extremities
c. To allow the leg muscles to stretch and relax
d. To permit veins in the legs to fill with blood.
93.Which nursing intervention takes highest priority when caring for a newly
admitted client who's receiving a blood transfusion?
a. Instructing the client to report any itching, swelling, or dyspnea.
b. Informing the client that the transfusion usually take 1 . to 2 hours.
c. Documenting blood administration in the client care record.
d. Assessing the clients vital signs when the transfusion ends.
94.A male client complains of abdominal discomfort and nausea while
receiving tube feedings. Which intervention is most appropriate for this
problem?
a. Give the feedings at room temperature.
b. Decrease the rate of feedings and the concentration of the formula.
c. Place the client in semi-Fowler's position while feeding.
d. Change the feeding container every 12 hours.
95.Nurse Patricia is reconstituting a powdered medication in a vial. After
adding the solution to the powder, she nurse should:
a. Do nothing.
b. Invert the vial and let it stand for 3 to 5 minutes.
c. Shake the vial vigorously.
d. Roll the vial gently between the palms.
96.Which intervention should the nurse Trish use when administering oxygen
by face mask to a female client?
a. Secure the elastic band tightly around the client's head.
b. Assist the client to the semi-Fowler position if possible.
c. Apply the face mask from the client's chin up over the nose.
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d. Loosen the connectors between the oxygen equipment and
humidifier.
97.The maximum transfusion time for a unit of packed red blood cells (RBCs)
is:
a. 6 hours
b. 4 hours
c. 3 hours
d. 2 hours
98.Nurse Monique is monitoring the effectiveness of a client's drug therapy.
When should the nurse Monique obtain a blood sample to measure the
trough drug level?
a. 1 hour before administering the next dose.
b. Immediately before administering the next dose.
c. Immediately after administering the next dose.
NURSING PRACTICE II
Community Health Nursing and Care
of the Mother and Child
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TEST II - Community Health Nursing and Care of the Mother and Child
1. May arrives at the health care clinic and tells the nurse that her last
menstrual period was 9 weeks ago. She also tells the nurse that a home
pregnancy test was positive but she began to have mild cramps and is
now having moderate vaginal bleeding. During the physical examination of
the client, the nurse notes that May has a dilated cervix. The nurse
determines that May is experiencing which type of abortion?
a. Inevitable
b. Incomplete
c. Threatened
d. Septic
2. Nurse Reese is reviewing the record of a pregnant client for her first
prenatal visit. Which of the following data, if noted on the clients record,
would alert the nurse that the client is at risk for a spontaneous abortion?
a. Age 36 years
b. History of syphilis
c. History of genital herpes
d. History of diabetes mellitus
3. Nurse Hazel is preparing to care for a client who is newly admitted to the
hospital with a possible diagnosis of ectopic pregnancy. Nurse Hazel
develops a plan of care for the client and determines that which of the
following nursing actions is the priority?
a. Monitoring weight
a. It involves providing home care to sick people who are not confined
in the hospital.
b. Services are provided free of charge to people within the
catchments area.
c. The public health nurse functions as part of a team providing a
public health nursing services.
d. Public health nursing focuses on preventive, not curative, services.
17.When the nurse determines whether resources were maximized in
implementing Ligtas Tigdas, she is evaluating
a. Effectiveness
b. Efficiency
c. Adequacy
d. Appropriateness
18.Vangie is a new B.S.N. graduate. She wants to become a Public Health
Nurse. Where should she apply?
a. Department of Health
b. Provincial Health Office
c. Regional Health Office
d. Rural Health Unit
19.Tony is aware the Chairman of the Municipal Health Board is:
a. Mayor
b. Municipal Health Officer
c. Public Health Nurse
d. Any qualified physician
20.Myra is the public health nurse in a municipality with a total population of
about 20,000. There are 3 rural health midwives among the RHU
personnel. How many more midwife items will the RHU need?
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a. 1
b. 2
c. 3
d. The RHU does not need any more midwife item.
21.According to Freeman and Heinrich, community health nursing is a
developmental service. Which of the following best illustrates this
statement?
a. The community health nurse continuously develops himself
personally and professionally.
b. Health education and community organizing are necessary in
providing community health services.
c. Community health nursing is intended primarily for health promotion
and prevention and treatment of disease.
d. The goal of community health nursing is to provide nursing services
to people in their own places of residence.
22.Nurse Tina is aware that the disease declared through Presidential
Proclamation No. 4 as a target for eradication in the Philippines is?
a. Poliomyelitis
b. Measles
c. Rabies
d. Neonatal tetanus
23.May knows that the step in community organizing that involves training of
potential leaders in the community is:
a. Integration
b. Community organization
c. Community study
d. Core group formation
24.Beth a public health nurse takes an active role in community participation.
What is the primary goal of community organizing?
a. To educate the people regarding community health problems
b. To mobilize the people to resolve community health problems
c. To maximize the communitys resources in dealing with health
problems.
d. To maximize the communitys resources in dealing with health
problems.
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25.Tertiary prevention is needed in which stage of the natural history of
disease?
a. Pre-pathogenesis
b. Pathogenesis
c. Prodromal
d. Terminal
26.The nurse is caring for a primigravid client in the labor and delivery area.
Which condition would place the client at risk for disseminated
intravascular coagulation (DIC)?
a. Intrauterine fetal death.
b. Placenta accreta.
c. Dysfunctional labor.
d. Premature rupture of the membranes.
27.A fullterm client is in labor. Nurse Betty is aware that the fetal heart rate
would be:
a. 80 to 100 beats/minute
b. 100 to 120 beats/minute
c. 120 to 160 beats/minute
d. 160 to 180 beats/minute
28.The skin in the diaper area of a 7 month old infant is excoriated and red.
Nurse Hazel should instruct the mother to:
a. Change the diaper more often.
b. Apply talc powder with diaper changes.
c. Wash the area vigorously with each diaper change.
d. Decrease the infants fluid intake to decrease saturating diapers.
29.Nurse Carla knows that the common cardiac anomalies in children with
Down Syndrome (tri-somy 21) is:
a. Atrial septal defect
b. Pulmonic stenosis
c. Ventricular septal defect
d. Endocardial cushion defect
30.Malou was diagnosed with severe preeclampsia is now receiving I.V.
magnesium sulfate. The adverse effects associated with magnesium
sulfate is:
a. Anemia
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b. Decreased urine output
c. Hyperreflexia
d. Increased respiratory rate
31.A 23 year old client is having her menstrual period every 2 weeks that last
for 1 week. This type of menstrual pattern is bets defined by:
a. Menorrhagia
b. Metrorrhagia
c. Dyspareunia
d. Amenorrhea
32.Jannah is admitted to the labor and delivery unit. The critical laboratory
result for this client would be:
a. Oxygen saturation
b. Iron binding capacity
c. Blood typing
d. Serum Calcium
33.Nurse Gina is aware that the most common condition found during the
second-trimester of pregnancy is:
a. Metabolic alkalosis
b. Respiratory acidosis
c. Mastitis
d. Physiologic anemia
34.Nurse Lynette is working in the triage area of an emergency department.
She sees that several pediatric clients arrive simultaneously. The client
who needs to be treated first is:
a. A crying 5 year old child with a laceration on his scalp.
b. A 4 year old child with a barking coughs and flushed appearance.
c. A 3 year old child with Down syndrome who is pale and asleep in
his mothers arms.
d. A 2 year old infant with stridorous breath sounds, sitting up in his
mothers arms and drooling.
35.Maureen in her third trimester arrives at the emergency room with painless
vaginal bleeding. Which of the following conditions is suspected?
a. Placenta previa
b. Abruptio placentae
c. Premature labor
d. Sexually transmitted disease
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36.A young child named Richard is suspected of having pinworms. The
d. Interview of suspects
49.A 33-year old female client came for consultation at the health center with
the chief complaint of fever for a week. Accompanying symptoms were
muscle pains and body malaise. A week after the start of fever, the client
noted yellowish discoloration of his sclera. History showed that he waded
in flood waters about 2 weeks before the onset of symptoms. Based on
her history, which disease condition will you suspect?
a. Hepatitis A
b. Hepatitis B
c. Tetanus
d. Leptospirosis
50.Mickey a 3-year old client was brought to the health center with the chief
complaint of severe diarrhea and the passage of rice water stools. The
client is most probably suffering from which condition?
a. Giardiasis
b. Cholera
c. Amebiasis
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d. Dysentery
51.The most prevalent form of meningitis among children aged 2 months to 3
years is caused by which microorganism?
a. Hemophilus influenzae
b. Morbillivirus
c. Steptococcus pneumoniae
d. Neisseria meningitidis
52.The student nurse is aware that the pathognomonic sign of measles is
Kopliks spot and you may see Kopliks spot by inspecting the:
a. Nasal mucosa
b. Buccal mucosa
c. Skin on the abdomen
d. Skin on neck
53.Angel was diagnosed as having Dengue fever. You will say that there is
slow capillary refill when the color of the nailbed that you pressed does not
return within how many seconds?
a. 3 seconds
b. 6 seconds
c. 9 seconds
d. 10 seconds
54.In Integrated Management of Childhood Illness, the nurse is aware that
the severe conditions generally require urgent referral to a hospital. Which
of the following severe conditions DOES NOT always require urgent
referral to a hospital?
a. Mastoiditis
b. Severe dehydration
c. Severe pneumonia
d. Severe febrile disease
c. 8 hours
d. At the end of the day
68.The nurse explains to a breastfeeding mother that breast milk is sufficient
for all of the babys nutrient needs only up to:
a. 5 months
b. 6 months
c. 1 year
d. 2 years
69.Nurse Ron is aware that the gestational age of a conceptus that is
considered viable (able to live outside the womb) is:
a. 8 weeks
b. 12 weeks
c. 24 weeks
d. 32 weeks
70.When teaching parents of a neonate the proper position for the neonates
sleep, the nurse Patricia stresses the importance of placing the neonate
on his back to reduce the risk of which of the following?
a. Aspiration
b. Sudden infant death syndrome (SIDS)
c. Suffocation
d. Gastroesophageal reflux (GER)
71.Which finding might be seen in baby James a neonate suspected of
having an infection?
a. Flushed cheeks
b. Increased temperature
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c. Decreased temperature
d. Increased activity level
72.Baby Jenny who is small-for-gestation is at increased risk during the
transitional period for which complication?
a. Anemia probably due to chronic fetal hyposia
b. Hyperthermia due to decreased glycogen stores
c. Hyperglycemia due to decreased glycogen stores
d. Polycythemia probably due to chronic fetal hypoxia
73.Marjorie has just given birth at 42 weeks gestation. When the nurse
assessing the neonate, which physical finding is expected?
a. A sleepy, lethargic baby
b. Lanugo covering the body
c. Desquamation of the epidermis
d. Vernix caseosa covering the body
74.After reviewing the Myrnas maternal history of magnesium sulfate during
labor, which condition would nurse Richard anticipate as a potential
problem in the neonate?
a. Hypoglycemia
b. Jitteriness
c. Respiratory depression
d. Tachycardia
75.Which symptom would indicate the Baby Alexandra was adapting
appropriately to extra-uterine life without difficulty?
a. Nasal flaring
b. Light audible grunting
c. Respiratory rate 40 to 60 breaths/minute
d. Respiratory rate 60 to 80 breaths/minute
76. When teaching umbilical cord care for Jennifer a new mother, the nurse
Jenny would include which information?
a. Apply peroxide to the cord with each diaper change
b. Cover the cord with petroleum jelly after bathing
c. Keep the cord dry and open to air
d. Wash the cord with soap and water each day during a tub bath.
77.Nurse John is performing an assessment on a neonate. Which of the
following findings is considered common in the healthy neonate?
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a. Simian crease
b. Conjunctival hemorrhage
c. Cystic hygroma
d. Bulging fontanelle
78.Dr. Esteves decides to artificially rupture the membranes of a mother who
is on labor. Following this procedure, the nurse Hazel checks the fetal
heart tones for which the following reasons?
a. To determine fetal well-being.
b. To assess for prolapsed cord
c. To assess fetal position
d. To prepare for an imminent delivery.
79.Which of the following would be least likely to indicate anticipated bonding
behaviors by new parents?
a. The parents willingness to touch and hold the new born.
b. The parents expression of interest about the size of the new born.
c. The parents indication that they want to see the newborn.
d. The parents interactions with each other.
80.Following a precipitous delivery, examination of the client's vagina reveals
a fourth-degree laceration. Which of the following would be
contraindicated when caring for this client?
a. Applying cold to limit edema during the first 12 to 24 hours.
b. Instructing the client to use two or more peripads to cushion the
area.
c. Instructing the client on the use of sitz baths if ordered.
d. Instructing the client about the importance of perineal (kegel)
exercises.
81. A pregnant woman accompanied by her husband, seeks admission to the
labor and delivery area. She states that she's in labor and says she attended the
facility clinic for prenatal care. Which question should the nurse Oliver ask her
first?
intervals.
d. Provide milk every 2 to 3 hours.
7. A male client was on warfarin (Coumadin) before admission, and has
been receiving heparin I.V. for 2 days. The partial thromboplastin time
(PTT) is 68 seconds. What should Nurse Carla do?
a. Stop the I.V. infusion of heparin and notify the physician.
b. Continue treatment as ordered.
c. Expect the warfarin to increase the PTT.
d. Increase the dosage, because the level is lower than normal.
8. A client undergone ileostomy, when should the drainage appliance be
applied to the stoma?
a. 24 hours later, when edema has subsided.
b. In the operating room.
c. After the ileostomy begin to function.
d. When the client is able to begin self-care procedures.
9. A client undergone spinal anesthetic, it will be important that the nurse
immediately position the client in:
a. On the side, to prevent obstruction of airway by tongue.
b. Flat on back.
c. On the back, with knees flexed 15 degrees.
d. Flat on the stomach, with the head turned to the side.
10.While monitoring a male client several hours after a motor vehicle
accident, which assessment data suggest increasing intracranial
pressure?
a. Blood pressure is decreased from 160/90 to 110/70.
b. Pulse is increased from 87 to 95, with an occasional skipped beat.
c. The client is oriented when aroused from sleep, and goes back to
sleep immediately.
d. The client refuses dinner because of anorexia.
11.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the
following symptoms may appear first?
a. Altered mental status and dehydration
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b. Fever and chills
c. Hemoptysis and Dyspnea
d. Pleuritic chest pain and cough
12. A male client has active tuberculosis (TB). Which of the following symptoms
will be exhibit?
a. Chest and lower back pain
b. Chills, fever, night sweats, and hemoptysis
c. Fever of more than 104F (40C) and nausea
d. Headache and photophobia
13. Mark, a 7-year-old client is brought to the emergency department. Hes
tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has
a nonproductive cough. He recently had a cold. Form this history; the client may
have which of the following conditions?
a. Acute asthma
b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease (COPD)
d. Emphysema
14. Marichu was given morphine sulfate for pain. She is sleeping and her
respiratory rate is 4 breaths/minute. If action isnt taken quickly, she might have
which of the following reactions?
a. Asthma attack
b. Respiratory arrest
c. Seizure
d. Wake up on his own
15. A 77-year-old male client is admitted for elective knee surgery. Physical
examination reveals shallow respirations but no sign of respiratory distress.
Which of the following is a normal physiologic change related to aging?
a. Increased elastic recoil of the lungs
b. Increased number of functional capillaries in the alveoli
c. Decreased residual volume
d. Decreased vital capacity
16. Nurse John is caring for a male client receiving lidocaine I.V. Which factor is
the most relevant to administration of this medication?
a. Decrease in arterial oxygen saturation (SaO2) when measured with a
pulse oximeter.
b. Increase in systemic blood pressure.
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c. Presence of premature ventricular contractions (PVCs) on a cardiac
monitor.
d. Increase in intracranial pressure (ICP).
17. Nurse Ron is caring for a male client taking an anticoagulant. The nurse
should teach the client to:
a. Report incidents of diarrhea.
b. Avoid foods high in vitamin K
c. Use a straight razor when shaving.
d. Take aspirin to pain relief.
18. Nurse Lhynnette is preparing a site for the insertion of an I.V. catheter. The
nurse should treat excess hair at the site by:
a. Leaving the hair intact
b. Shaving the area
c. Clipping the hair in the area
d. Removing the hair with a depilatory.
19. Nurse Michelle is caring for an elderly female with osteoporosis. When
teaching the client, the nurse should include information about which major
complication:
a. Bone fracture
b. Loss of estrogen
c. Negative calcium balance
d. Dowagers hump
20. Nurse Len is teaching a group of women to perform BSE. The nurse should
explain that the purpose of performing the examination is to discover:
a. Cancerous lumps
b. Areas of thickness or fullness
c. Changes from previous examinations.
d. Fibrocystic masses
21. When caring for a female client who is being treated for hyperthyroidism, it is
important to:
a. Provide extra blankets and clothing to keep the client warm.
b. Monitor the client for signs of restlessness, sweating, and excessive
weight loss during thyroid replacement therapy.
c. Balance the clients periods of activity and rest.
d. Encourage the client to be active to prevent constipation.
Nursing Crib Student Nurses Community 51
22. Nurse Kris is teaching a client with history of atherosclerosis. To decrease
the risk of atherosclerosis, the nurse should encourage the client to:
a. Avoid focusing on his weight.
b. Increase his activity level.
c. Follow a regular diet.
d. Continue leading a high-stress lifestyle.
23. Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client
following a:
a. Laminectomy
b. Thoracotomy
c. Hemorrhoidectomy
d. Cystectomy.
24. A 55-year old client underwent cataract removal with intraocular lens implant.
Nurse Oliver is giving the client discharge instructions. These instructions should
include which of the following?
a. Avoid lifting objects weighing more than 5 lb (2.25 kg).
b. Lie on your abdomen when in bed
c. Keep rooms brightly lit.
d. Avoiding straining during bowel movement or bending at the waist.
25. George should be taught about testicular examinations during:
a. when sexual activity starts
b. After age 69
c. After age 40
d. Before age 20.
26. A male client undergone a colon resection. While turning him, wound
dehiscence with evisceration occurs. Nurse Trish first response is to:
a. Call the physician
b. Place a saline-soaked sterile dressing on the wound.
c. Take a blood pressure and pulse.
d. Pull the dehiscence closed.
27. Nurse Audrey is caring for a client who has suffered a severe
cerebrovascular accident. During routine assessment, the nurse notices Cheyne-
33. Nurse Ron is taking a health history of an 84 year old client. Which
information will be most useful to the nurse for planning care?
a. General health for the last 10 years.
b. Current health promotion activities.
c. Family history of diseases.
d. Marital status.
34. When performing oral care on a comatose client, Nurse Krina should:
a. Apply lemon glycerin to the clients lips at least every 2 hours.
b. Brush the teeth with client lying supine.
c. Place the client in a side lying position, with the head of the bed
lowered.
d. Clean the clients mouth with hydrogen peroxide.
35. A 77-year-old male client is admitted with a diagnosis of dehydration and
change in mental status. Hes being hydrated with L.V. fluids. When the nurse
takes his vital signs, she notes he has a fever of 103F (39.4C) a cough
producing yellow sputum and pleuritic chest pain. The nurse suspects this client
may have which of the following conditions?
a. Adult respiratory distress syndrome (ARDS)
b. Myocardial infarction (MI)
c. Pneumonia
d. Tuberculosis
36. Nurse Oliver is working in a out patient clinic. He has been alerted that there
is an outbreak of tuberculosis (TB). Which of the following clients entering the
clinic today most likely to have TB?
a. A 16-year-old female high school student
b. A 33-year-old day-care worker
c. A 43-yesr-old homeless man with a history of alcoholism
d. A 54-year-old businessman
37. Virgie with a positive Mantoux test result will be sent for a chest X-ray. The
nurse is aware that which of the following reasons this is done?
a. To confirm the diagnosis
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b. To determine if a repeat skin test is needed
c. To determine the extent of lesions
d. To determine if this is a primary or secondary infection
38. Kennedy with acute asthma showing inspiratory and expiratory wheezes and
a decreased forced expiratory volume should be treated with which of the
following classes of medication right away?
a. Beta-adrenergic blockers
b. Bronchodilators
c. Inhaled steroids
d. Oral steroids
39. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two
packs of cigarettes per day has a chronic cough producing thick sputum,
peripheral edema and cyanotic nail beds. Based on this information, he most
likely has which of the following conditions?
minute.
b. The 89-year-old client with end-stage right-sided heart failure, blood
pressure of 78/50 mm Hg, and a do not resuscitate order
c. The 62-year-old client who was admitted 1 day ago with
thrombophlebitis and is receiving L.V. heparin
d. The 75-year-old client who was admitted 1 hour ago with new-onset
atrial fibrillation and is receiving L.V. dilitiazem (Cardizem)
46. Honey, a 23-year old client complains of substernal chest pain and states
that her heart feels like its racing out of the chest. She reports no history of
cardiac disorders. The nurse attaches her to a cardiac monitor and notes sinus
tachycardia with a rate of 136beats/minutes. Breath sounds are clear and the
respiratory rate is 26 breaths/minutes. Which of the following drugs should the
nurse question the client about using?
a. Barbiturates
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b. Opioids
c. Cocaine
d. Benzodiazepines
47. A 51-year-old female client tells the nurse in-charge that she has found a
painless lump in her right breast during her monthly self-examination. Which
assessment finding would strongly suggest that this client's lump is cancerous?
a. Eversion of the right nipple and mobile mass
b. Nonmobile mass with irregular edges
c. Mobile mass that is soft and easily delineated
d. Nonpalpable right axillary lymph nodes
48. A 35-year-old client with vaginal cancer asks the nurse, "What is the usual
treatment for this type of cancer?" Which treatment should the nurse name?
a. Surgery
b. Chemotherapy
c. Radiation
d. Immunotherapy
49. Cristina undergoes a biopsy of a suspicious lesion. The biopsy report
classifies the lesion according to the TNM staging system as follows: TIS, N0,
M0. What does this classification mean?
a. No evidence of primary tumor, no abnormal regional lymph nodes, and
no evidence of distant metastasis
b. Carcinoma in situ, no abnormal regional lymph nodes, and no
evidence of distant metastasis
c. Can't assess tumor or regional lymph nodes and no evidence of
metastasis
d. Carcinoma in situ, no demonstrable metastasis of the regional lymph
nodes, and ascending degrees of distant metastasis
50. Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching
the client how to care for the neck stoma, the nurse should include which
instruction?
a. "Keep the stoma uncovered."
d. 50 ml/hour
63. A 76-year-old male client had a thromboembolic right stroke; his left arm is
swollen. Which of the following conditions may cause swelling after a stroke?
a. Elbow contracture secondary to spasticity
b. Loss of muscle contraction decreasing venous return
c. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side
d. Hypoalbuminemia due to protein escaping from an inflamed
glomerulus
64. Heberdens nodes are a common sign of osteoarthritis. Which of the following
statement is correct about this deformity?
a. It appears only in men
b. It appears on the distal interphalangeal joint
c. It appears on the proximal interphalangeal joint
d. It appears on the dorsolateral aspect of the interphalangeal joint.
65. Which of the following statements explains the main difference between
rheumatoid arthritis and osteoarthritis?
a. Osteoarthritis is gender-specific, rheumatoid arthritis isnt
b. Osteoarthritis is a localized disease rheumatoid arthritis is systemic
c. Osteoarthritis is a systemic disease, rheumatoid arthritis is localized
d. Osteoarthritis has dislocations and subluxations, rheumatoid arthritis
doesnt
66. Mrs. Cruz uses a cane for assistance in walking. Which of the following
statements is true about a cane or other assistive devices?
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a. A walker is a better choice than a cane.
b. The cane should be used on the affected side
c. The cane should be used on the unaffected side
d. A client with osteoarthritis should be encouraged to ambulate without
the cane
67. A male client with type 1 diabetes is scheduled to receive 30 U of 70/30
insulin. There is no 70/30 insulin available. As a substitution, the nurse may give
the client:
a. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).
b. 21 U regular insulin and 9 U NPH.
c. 10 U regular insulin and 20 U NPH.
d. 20 U regular insulin and 10 U NPH.
68. Nurse Len should expect to administer which medication to a client with
gout?
a. aspirin
b. furosemide (Lasix)
c. colchicines
d. calcium gluconate (Kalcinate)
69. Mr. Domingo with a history of hypertension is diagnosed with primary
hyperaldosteronism. This diagnosis indicates that the client's hypertension is
caused by excessive hormone secretion from which of the following glands?
a. Adrenal cortex
b. Pancreas
c. Adrenal medulla
d. Parathyroid
70. For a diabetic male client with a foot ulcer, the doctor orders bed rest, a wettodry dressing change every shift, and blood glucose monitoring before meals
and bedtime. Why are wet-to-dry dressings used for this client?
a. They contain exudate and provide a moist wound environment.
b. They protect the wound from mechanical trauma and promote healing.
c. They debride the wound and promote healing by secondary intention.
d. They prevent the entrance of microorganisms and minimize wound
discomfort.
71. Nurse Zeny is caring for a client in acute addisonian crisis. Which laboratory
data would the nurse expect to find?
a. Hyperkalemia
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b. Reduced blood urea nitrogen (BUN)
c. Hypernatremia
d. Hyperglycemia
72. A client is admitted for treatment of the syndrome of inappropriate antidiuretic
hormone (SIADH). Which nursing intervention is appropriate?
a. Infusing I.V. fluids rapidly as ordered
b. Encouraging increased oral intake
c. Restricting fluids
d. Administering glucose-containing I.V. fluids as ordered
73. A female client tells nurse Nikki that she has been working hard for the last 3
months to control her type 2 diabetes mellitus with diet and exercise. To
determine the effectiveness of the client's efforts, the nurse should check:
a. urine glucose level.
b. fasting blood glucose level.
c. serum fructosamine level.
d. glycosylated hemoglobin level.
74. Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to a
diabetic client at 7 a.m. At what time would the nurse expect the client to be most
at risk for a hypoglycemic reaction?
a. 10:00 am
b. Noon
c. 4:00 pm
d. 10:00 pm
75. The adrenal cortex is responsible for producing which substances?
a. Glucocorticoids and androgens
b. Catecholamines and epinephrine
c. Mineralocorticoids and catecholamines
d. Norepinephrine and epinephrine
76. On the third day after a partial thyroidectomy, Proserfina exhibits muscle
twitching and hyperirritability of the nervous system. When questioned, the client
reports numbness and tingling of the mouth and fingertips. Suspecting a lifethreatening
NURSING PRACTICE IV
Care of Clients with Physiologic and
Psychosocial Alterations
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TEST IV - Care of Clients with Physiologic and Psychosocial Alterations
1. Randy has undergone kidney transplant, what assessment would prompt
Nurse Katrina to suspect organ rejection?
a. Sudden weight loss
b. Polyuria
c. Hypertension
d. Shock
2. The immediate objective of nursing care for an overweight, mildly
hypertensive male client with ureteral colic and hematuria is to decrease:
a. Pain
b. Weight
c. Hematuria
d. Hypertension
3. Matilda, with hyperthyroidism is to receive Lugols iodine solution before a
subtotal thyroidectomy is performed. The nurse is aware that this
medication is given to:
a. Decrease the total basal metabolic rate.
b. Maintain the function of the parathyroid glands.
c. Block the formation of thyroxine by the thyroid gland.
d. Decrease the size and vascularity of the thyroid gland.
4. Ricardo, was diagnosed with type I diabetes. The nurse is aware that
acute hypoglycemia also can develop in the client who is diagnosed with:
a. Liver disease
b. Hypertension
c. Type 2 diabetes
d. Hyperthyroidism
5. Tracy is receiving combination chemotherapy for treatment of metastatic
carcinoma. Nurse Ruby should monitor the client for the systemic side
effect of:
a. Ascites
b. Nystagmus
c. Leukopenia
d. Polycythemia
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6. Norma, with recent colostomy expresses concern about the inability to
control the passage of gas. Nurse Oliver should suggest that the client
plan to:
a. Eliminate foods high in cellulose.
b. Decrease fluid intake at meal times.
c. Avoid foods that in the past caused flatus.
d. Adhere to a bland diet prior to social events.
7. Nurse Ron begins to teach a male client how to perform colostomy
irrigations. The nurse would evaluate that the instructions were
understood when the client states, I should:
a. Lie on my left side while instilling the irrigating solution.
b. Keep the irrigating container less than 18 inches above the stoma.
c. Instill a minimum of 1200 ml of irrigating solution to stimulate
evacuation of the bowel.
d. Insert the irrigating catheter deeper into the stoma if cramping
occurs during the procedure.
8. Patrick is in the oliguric phase of acute tubular necrosis and is
experiencing fluid and electrolyte imbalances. The client is somewhat
confused and complains of nausea and muscle weakness. As part of the
prescribed therapy to correct this electrolyte imbalance, the nurse would
expect to:
a. Administer Kayexalate
b. Restrict foods high in protein
c. Increase oral intake of cheese and milk.
d. Administer large amounts of normal saline via I.V.
9. Mario has burn injury. After Forty48 hours, the physician orders for Mario
2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is
10 gtt/ml. The nurse should set the flow to provide:
a. 18 gtt/min
b. 28 gtt/min
c. 32 gtt/min
d. 36 gtt/min
10.Terence suffered form burn injury. Using the rule of nines, which has the
largest percent of burns?
a. Face and neck
b. hypokalemia.
c. hyperkalemia.
d. hypercalcemia.
17.Ms. X has just been diagnosed with condylomata acuminata (genital
warts). What information is appropriate to tell this client?
a. This condition puts her at a higher risk for cervical cancer;
therefore, she should have a Papanicolaou (Pap) smear annually.
b. The most common treatment is metronidazole (Flagyl), which
should eradicate the problem within 7 to 10 days.
c. The potential for transmission to her sexual partner will be
eliminated if condoms are used every time they have sexual
intercourse.
d. The human papillomavirus (HPV), which causes condylomata
acuminata, can't be transmitted during oral sex.
18.Maritess was recently diagnosed with a genitourinary problem and is
being examined in the emergency department. When palpating the her
kidneys, the nurse should keep which anatomical fact in mind?
a. The left kidney usually is slightly higher than the right one.
b. The kidneys are situated just above the adrenal glands.
c. The average kidney is approximately 5 cm (2") long and 2 to 3 cm
(." to 1-1/8") wide.
d. The kidneys lie between the 10th and 12th thoracic vertebrae.
19.Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The
nurse is aware that the diagnostic test are consistent with CRF if the result
is:
a. Increased pH with decreased hydrogen ions.
b. Increased serum levels of potassium, magnesium, and calcium.
c. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/
dl.
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d. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP)
excretion 75%.
20. Katrina has an abnormal result on a Papanicolaou test. After admitting
that she read her chart while the nurse was out of the room, Katrina asks
what dysplasia means. Which definition should the nurse provide?
a. Presence of completely undifferentiated tumor cells that don't
resemble cells of the tissues of their origin.
b. Increase in the number of normal cells in a normal arrangement in
a tissue or an organ.
c. Replacement of one type of fully differentiated cell by another in
tissues where the second type normally isn't found.
d. Alteration in the size, shape, and organization of differentiated cells.
21. During a routine checkup, Nurse Mariane assesses a male client with
acquired immunodeficiency syndrome (AIDS) for signs and symptoms of
cancer. What is the most common AIDS-related cancer?
a. Squamous cell carcinoma
b. Multiple myeloma
c. Leukemia
d. Kaposi's sarcoma
22.Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans
to use a spinal (subarachnoid) block during surgery. In the operating
room, the nurse positions the client according to the anesthesiologist's
instructions. Why does the client require special positioning for this type of
anesthesia?
a. To prevent confusion
b. To prevent seizures
c. To prevent cerebrospinal fluid (CSF) leakage
d. To prevent cardiac arrhythmias
23.A male client had a nephrectomy 2 days ago and is now complaining of
abdominal pressure and nausea. The first nursing action should be to:
a. Auscultate bowel sounds.
b. Palpate the abdomen.
c. Change the client's position.
d. Insert a rectal tube.
24.Wilfredo with a recent history of rectal bleeding is being prepared for a
colonoscopy. How should the nurse Patricia position the client for this test
initially?
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a. Lying on the right side with legs straight
b. Lying on the left side with knees bent
c. Prone with the torso elevated
d. Bent over with hands touching the floor
25.A male client with inflammatory bowel disease undergoes an ileostomy.
On the first day after surgery, Nurse Oliver notes that the client's stoma
appears dusky. How should the nurse interpret this finding?
a. Blood supply to the stoma has been interrupted.
b. This is a normal finding 1 day after surgery.
c. The ostomy bag should be adjusted.
d. An intestinal obstruction has occurred.
26.Anthony suffers burns on the legs, which nursing intervention helps
prevent contractures?
a. Applying knee splints
b. Elevating the foot of the bed
c. Hyperextending the client's palms
d. Performing shoulder range-of-motion exercises
27.Nurse Ron is assessing a client admitted with second- and third-degree
burns on the face, arms, and chest. Which finding indicates a potential
problem?
a. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
b. Urine output of 20 ml/hour.
c. White pulmonary secretions.
d. Rectal temperature of 100.6 F (38 C).
28. Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too
weak to move on his own. To help the client avoid pressure ulcers, Nurse
Celia should:
a. Turn him frequently.
b. Perform passive range-of-motion (ROM) exercises.
c. Reduce the client's fluid intake.
d. Encourage the client to use a footboard.
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29.Nurse Maria plans to administer dexamethasone cream to a female client
who has dermatitis over the anterior chest. How should the nurse apply
this topical agent?
a. With a circular motion, to enhance absorption.
b. With an upward motion, to increase blood supply to the affected
area
c. In long, even, outward, and downward strokes in the direction of
hair growth
d. In long, even, outward, and upward strokes in the direction opposite
hair growth
30.Nurse Kate is aware that one of the following classes of medication
protect the ischemic myocardium by blocking catecholamines and
sympathetic nerve stimulation is:
a. Beta -adrenergic blockers
b. Calcium channel blocker
c. Narcotics
d. Nitrates
31.A male client has jugular distention. On what position should the nurse
place the head of the bed to obtain the most accurate reading of jugular
vein distention?
a. High Fowlers
b. Raised 10 degrees
c. Raised 30 degrees
d. Supine position
32.The nurse is aware that one of the following classes of medications
maximizes cardiac performance in clients with heart failure by increasing
ventricular contractility?
a. Beta-adrenergic blockers
b. Calcium channel blocker
c. Diuretics
d. Inotropic agents
33.A male client has a reduced serum high-density lipoprotein (HDL) level
and an elevated low-density lipoprotein (LDL) level. Which of the following
dietary modifications is not appropriate for this client?
a. Fiber intake of 25 to 30 g daily
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b. Less than 30% of calories form fat
c. Cholesterol intake of less than 300 mg daily
46. Nurse Patricia is aware that the average length of time from human
immunodeficiency virus (HIV) infection to the development of acquired
immunodeficiency syndrome (AIDS)?
a. Less than 5 years
b. 5 to 7 years
c. 10 years
d. More than 10 years
47. An 18-year-old male client admitted with heat stroke begins to show signs of
disseminated intravascular coagulation (DIC). Which of the following laboratory
findings is most consistent with DIC?
a. Low platelet count
b. Elevated fibrinogen levels
c. Low levels of fibrin degradation products
d. Reduced prothrombin time
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48. Mario comes to the clinic complaining of fever, drenching night sweats, and
unexplained weight loss over the past 3 months. Physical examination reveals a
single enlarged supraclavicular lymph node. Which of the following is the most
probable diagnosis?
a. Influenza
b. Sickle cell anemia
c. Leukemia
d. Hodgkins disease
49. A male client with a gunshot wound requires an emergency blood
transfusion. His blood type is AB negative. Which blood type would be the safest
for him to receive?
a. AB Rh-positive
b. A Rh-positive
c. A Rh-negative
d. O Rh-positive
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and
beginning chemotherapy.
50. Stacy is discharged from the hospital following her chemotherapy treatments.
Which statement of Stacys mother indicated that she understands when she will
contact the physician?
a. I should contact the physician if Stacy has difficulty in sleeping.
b. I will call my doctor if Stacy has persistent vomiting and diarrhea.
c. My physician should be called if Stacy is irritable and unhappy.
d. Should Stacy have continued hair loss, I need to call the doctor.
51. Stacys mother states to the nurse that it is hard to see Stacy with no hair.
The best response for the nurse is:
a. Stacy looks very nice wearing a hat.
b. You should not worry about her hair, just be glad that she is alive.
c. Yes it is upsetting. But try to cover up your feelings when you are with her
or else she may be upset.
d. This is only temporary; Stacy will re-grow new hair in 3-6 months, but
a. Asthma attack
b. Pulmonary embolism
c. Respiratory failure
d. Rheumatoid arthritis
Situation: Mr. Gonzales was admitted to the hospital with ascites and
jaundice. To rule out cirrhosis of the liver:
59. Which laboratory test indicates liver cirrhosis?
a. Decreased red blood cell count
b. Decreased serum acid phosphate level
c. Elevated white blood cell count
d. Elevated serum aminotransferase
60.The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales
is at increased risk for excessive bleeding primarily because of:
a. Impaired clotting mechanism
b. Varix formation
c. Inadequate nutrition
d. Trauma of invasive procedure
61. Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation
is most common with this condition?
a. Increased urine output
b. Altered level of consciousness
c. Decreased tendon reflex
d. Hypotension
62. When Mr. Gonzales regained consciousness, the physician orders 50 ml of
Lactose p.o. every 2 hours. Mr. Gozales develops diarrhea. The nurse best
action would be:
a. Ill see if your physician is in the hospital.
b. Maybe your reacting to the drug; I will withhold the next dose.
Nursing Crib Student Nurses Community 82
c. Ill lower the dosage as ordered so the drug causes only 2 to 4 stools
a day.
d. Frequently, bowel movements are needed to reduce sodium level.
63. Which of the following groups of symptoms indicates a ruptured abdominal
aortic aneurysm?
a. Lower back pain, increased blood pressure, decreased re blood cell
(RBC) count, increased white blood (WBC) count.
b. Severe lower back pain, decreased blood pressure, decreased
RBC count, increased WBC count.
c. Severe lower back pain, decreased blood pressure, decreased
RBC count, decreased RBC count, decreased WBC count.
d. Intermitted lower back pain, decreased blood pressure, decreased
RBC count, increased WBC count.
64. After undergoing a cardiac catheterization, Tracy has a large puddle of blood
under his buttocks. Which of the following steps should the nurse take first?
a. Call for help.
b. Obtain vital signs
hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following
responses best describes the result?
a. Appropriate; lowering carbon dioxide (CO2) reduces intracranial
pressure (ICP)
b. Emergent; the client is poorly oxygenated
c. Normal
d. Significant; the client has alveolar hypoventilation
72. When prioritizing care, which of the following clients should the nurse Olivia
assess first?
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a. A 17-year-old clients 24-hours postappendectomy
b. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome
c. A 50-year-old client 3 days postmyocardial infarction
d. A 50-year-old client with diverticulitis
73. JP has been diagnosed with gout and wants to know why colchicine is used
in the treatment of gout. Which of the following actions of colchicines explains
why its effective for gout?
a. Replaces estrogen
b. Decreases infection
c. Decreases inflammation
d. Decreases bone demineralization
74. Norma asks for information about osteoarthritis. Which of the following
statements about osteoarthritis is correct?
a. Osteoarthritis is rarely debilitating
b. Osteoarthritis is a rare form of arthritis
c. Osteoarthritis is the most common form of arthritis
d. Osteoarthritis afflicts people over 60
75. Ruby is receiving thyroid replacement therapy develops the flu and forgets to
take her thyroid replacement medicine. The nurse understands that skipping this
medication will put the client at risk for developing which of the following lifethreatening
complications?
a. Exophthalmos
b. Thyroid storm
c. Myxedema coma
d. Tibial myxedema
76. Nurse Sugar is assessing a client with Cushing's syndrome. Which
observation should the nurse report to the physician immediately?
a. Pitting edema of the legs
b. An irregular apical pulse
c. Dry mucous membranes
d. Frequent urination
77. Cyrill with severe head trauma sustained in a car accident is admitted to the
intensive care unit. Thirty-six hours later, the client's urine output suddenly rises
above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which
laboratory findings support the nurse's suspicion of diabetes insipidus?
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cavity?
a. The space remains filled with air only
b. The surgeon fills the space with a gel
c. Serous fluids fills the space and consolidates the region
d. The tissue from the other lung grows over to the other side
95. Hemoptysis may be present in the client with a pulmonary embolism because
of which of the following reasons?
a. Alveolar damage in the infracted area
b. Involvement of major blood vessels in the occluded area
c. Loss of lung parenchyma
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d. Loss of lung tissue
96. Aldo with a massive pulmonary embolism will have an arterial blood gas
analysis performed to determine the extent of hypoxia. The acid-base disorder
that may be present is?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
97. After a motor vehicle accident, Armand an 22-year-old client is admitted with
a pneumothorax. The surgeon inserts a chest tube and attaches it to a chest
drainage system. Bubbling soon appears in the water seal chamber. Which of the
following is the most likely cause of the bubbling?
a. Air leak
b. Adequate suction
c. Inadequate suction
d. Kinked chest tube
98. Nurse Michelle calculates the IV flow rate for a postoperative client. The
client receives 3,000 ml of Ringers lactate solution IV to run over 24 hours. The
IV infusion set has a drop factor of 10 drops per milliliter. The nurse should
regulate the clients IV to deliver how many drops per minute?
a. 18
b. 21
c. 35
d. 40
99. Mickey, a 6-year-old child with a congenital heart disorder is admitted with
congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The
bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount
should the nurse administer to the child?
a. 1.2 ml
b. 2.4 ml
c. 3.5 ml
d. 4.2 ml
100. Nurse Alexandra teaches a client about elastic stockings. Which of the
following statements, if made by the client, indicates to the nurse that the
teaching was successful?
NURSING PRACTICE V
Care of Clients with Physiologic and
Psychosocial Alterations
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TEST V - Care of Clients with Physiologic and Psychosocial Alterations
1. Mr. Marquez reports of losing his job, not being able to sleep at night, and
feeling upset with his wife. Nurse John responds to the client, You may
want to talk about your employment situation in group today. The Nurse is
using which therapeutic technique?
a. Observations
b. Restating
c. Exploring
d. Focusing
2. Tony refuses his evening dose of Haloperidol (Haldol), then becomes
extremely agitated in the dayroom while other clients are watching
television. He begins cursing and throwing furniture. Nurse Oliver first
action is to:
a. Check the clients medical record for an order for an as-needed I.M.
dose of medication for agitation.
b. Place the client in full leather restraints.
c. Call the attending physician and report the behavior.
d. Remove all other clients from the dayroom.
3. Tina who is manic, but not yet on medication, comes to the drug treatment
center. The nurse would not let this client join the group session because:
a. The client is disruptive.
b. The client is harmful to self.
c. The client is harmful to others.
d. The client needs to be on medication first.
4. Dervid, an adolescent boy was admitted for substance abuse and
hallucinations. The clients mother asks Nurse Armando to talk with his
husband when he arrives at the hospital. The mother says that she is
afraid of what the father might say to the boy. The most appropriate
nursing intervention would be to:
a. Inform the mother that she and the father can work through this
problem themselves.
b. Refer the mother to the hospital social worker.
c. Agree to talk with the mother and the father together.
14 to 30 days.
b. A warning about the incidence of neuroleptic malignant syndrome
(NMS).
c. A reminder of the need to schedule blood work in 1 week to check
blood levels of the drug.
d. A warning that immediate sedation can occur with a resultant drop
in pulse.
16.Richard with agoraphobia has been symptom-free for 4 months. Classic
signs and symptoms of phobias include:
a. Insomnia and an inability to concentrate.
b. Severe anxiety and fear.
c. Depression and weight loss.
d. Withdrawal and failure to distinguish reality from fantasy.
17.Which medications have been found to help reduce or eliminate panic
attacks?
a. Antidepressants
b. Anticholinergics
c. Antipsychotics
d. Mood stabilizers
18.A client seeks care because she feels depressed and has gained weight.
To treat her atypical depression, the physician prescribes tranylcypromine
sulfate (Parnate), 10 mg by mouth twice per day. When this drug is used
to treat atypical depression, what is its onset of action?
a. 1 to 2 days
b. 3 to 5 days
c. 6 to 8 days
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d. 10 to 14 days
19. A 65 years old client is in the first stage of Alzheimer's disease. Nurse
Patricia should plan to focus this client's care on:
a. Offering nourishing finger foods to help maintain the client's
nutritional status.
b. Providing emotional support and individual counseling.
c. Monitoring the client to prevent minor illnesses from turning into
major problems.
d. Suggesting new activities for the client and family to do together.
20.The nurse is assessing a client who has just been admitted to the
emergency department. Which signs would suggest an overdose of an
antianxiety agent?
a. Combativeness, sweating, and confusion
b. Agitation, hyperactivity, and grandiose ideation
c. Emotional lability, euphoria, and impaired memory
d. Suspiciousness, dilated pupils, and increased blood pressure
21.The nurse is caring for a client diagnosed with antisocial personality
disorder. The client has a history of fighting, cruelty to animals, and
stealing. Which of the following traits would the nurse be most likely to
a. Withdrawal
b. Logical thinking
c. Repression
d. Denial
28.Richard is admitted with a diagnosis of schizotypal personality disorder.
Which signs would this client exhibit during social situations?
a. Aggressive behavior
b. Paranoid thoughts
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c. Emotional affect
d. Independence needs
29. Nurse Mickey is caring for a client diagnosed with bulimia. The most
appropriate initial goal for a client diagnosed with bulimia is to:
a. Avoid shopping for large amounts of food.
b. Control eating impulses.
c. Identify anxiety-causing situations
d. Eat only three meals per day.
30.Rudolf is admitted for an overdose of amphetamines. When assessing the
client, the nurse should expect to see:
a. Tension and irritability
b. Slow pulse
c. Hypotension
d. Constipation
31.Nicolas is experiencing hallucinations tells the nurse, The voices are
telling me Im no good. The client asks if the nurse hears the voices. The
most appropriate response by the nurse would be:
a. It is the voice of your conscience, which only you can control.
b. No, I do not hear your voices, but I believe you can hear them.
c. The voices are coming from within you and only you can hear
them.
d. Oh, the voices are a symptom of your illness; dont pay any
attention to them.
32.The nurse is aware that the side effect of electroconvulsive therapy that a
client may experience:
a. Loss of appetite
b. Postural hypotension
c. Confusion for a time after treatment
d. Complete loss of memory for a time
33.A dying male client gradually moves toward resolution of feelings
regarding impending death. Basing care on the theory of Kubler-Ross,
Nurse Trish plans to use nonverbal interventions when assessment
reveals that the client is in the:
a. Anger stage
b. Denial stage
c. Bargaining stage
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d. Acceptance stage
34.The outcome that is unrelated to a crisis state is:
a. Learning more constructive coping skills
b. Decompensation to a lower level of functioning.
c. Adaptation and a return to a prior level of functioning.
d. A higher level of anxiety continuing for more than 3 months.
35.Miranda a psychiatric client is to be discharged with orders for haloperidol
(haldol) therapy. When developing a teaching plan for discharge, the
nurse should include cautioning the client against:
a. Driving at night
b. Staying in the sun
c. Ingesting wines and cheeses
d. Taking medications containing aspirin
36.Jen a nursing student is anxious about the upcoming board examination
but is able to study intently and does not become distracted by a
roommates talking and loud music. The students ability to ignore
distractions and to focus on studying demonstrates:
a. Mild-level anxiety
b. Panic-level anxiety
c. Severe-level anxiety
d. Moderate-level anxiety
37.When assessing a premorbid personality characteristics of a client with a
major depression, it would be unusual for the nurse to find that this client
demonstrated:
a. Rigidity
b. Stubbornness
c. Diverse interest
d. Over meticulousness
38.Nurse Krina recognizes that the suicidal risk for depressed client is
greatest:
a. As their depression begins to improve
b. When their depression is most severe
c. Before nay type of treatment is started
d. As they lose interest in the environment
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39.Nurse Kate would expect that a client with vascular dementis would
experience:
a. Loss of remote memory related to anoxia
b. Loss of abstract thinking related to emotional state
c. Inability to concentrate related to decreased stimuli
d. Disturbance in recalling recent events related to cerebral hypoxia.
40.Josefina is to be discharged on a regimen of lithium carbonate. In the
teaching plan for discharge the nurse should include:
a. Advising the client to watch the diet carefully
b. Suggesting that the client take the pills with milk
c. Reminding the client that a CBC must be done once a month.
therapy."
c. "Your cursing is interrupting the activity. Take time out in your room
for 10 minutes."
d. "I'm disappointed in you. You can't control yourself even for a few
minutes."
48.Nurse Maureen knows that the nonantipsychotic medication used to treat
some clients with schizoaffective disorder is:
a. phenelzine (Nardil)
b. chlordiazepoxide (Librium)
c. lithium carbonate (Lithane)
d. imipramine (Tofranil)
49.Which information is most important for the nurse Trinity to include in a
teaching plan for a male schizophrenic client taking clozapine (Clozaril)?
a. Monthly blood tests will be necessary.
b. Report a sore throat or fever to the physician immediately.
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c. Blood pressure must be monitored for hypertension.
d. Stop the medication when symptoms subside.
50.Ricky with chronic schizophrenia takes neuroleptic medication is admitted
to the psychiatric unit. Nursing assessment reveals rigidity, fever,
hypertension, and diaphoresis. These findings suggest which lifethreatening
reaction:
a. Tardive dyskinesia.
b. Dystonia.
c. Neuroleptic malignant syndrome.
d. Akathisia.
51.Which nursing intervention would be most appropriate if a male client
develop orthostatic hypotension while taking amitriptyline (Elavil)?
a. Consulting with the physician about substituting a different type of
antidepressant.
b. Advising the client to sit up for 1 minute before getting out of bed.
c. Instructing the client to double the dosage until the problem
resolves.
d. Informing the client that this adverse reaction should disappear
within 1 week.
52.Mr. Cruz visits the physician's office to seek treatment for depression,
feelings of hopelessness, poor appetite, insomnia, fatigue, low selfesteem,
poor concentration, and difficulty making decisions. The client
states that these symptoms began at least 2 years ago. Based on this
report, the nurse Tyfany suspects:
a. Cyclothymic disorder.
b. Atypical affective disorder.
c. Major depression.
d. Dysthymic disorder.
53. After taking an overdose of phenobarbital (Barbita), Mario is admitted to
the emergency department. Dr. Trinidad prescribes activated charcoal
c. Triangulation
d. Splitting
78.An 83year-old male client is in extended care facility is anxious most of the
time and frequently complains of a number of vague symptoms that
interfere with his ability to eat. These symptoms indicate which of the
following disorders?
a. Conversion disorder
b. Hypochondriasis
c. Severe anxiety
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d. Sublimation
79. Charina, a college student who frequently visited the health center during the
past year with multiple vague complaints of GI symptoms before course
examinations. Although physical causes have been eliminated, the student
continues to express her belief that she has a serious illness. These symptoms
are typically of which of the following disorders?
a. Conversion disorder
b. Depersonalization
c. Hypochondriasis
d. Somatization disorder
80. Nurse Daisy is aware that the following pharmacologic agents are sedativehypnotic
medication is used to induce sleep for a client experiencing a sleep
disorder is:
a. Triazolam (Halcion)
b. Paroxetine (Paxil)\
c. Fluoxetine (Prozac)
d. Risperidone (Risperdal)
81. Aldo, with a somatoform pain disorder may obtain secondary gain. Which of
the following statement refers to a secondary gain?
a. It brings some stability to the family
b. It decreases the preoccupation with the physical illness
c. It enables the client to avoid some unpleasant activity
d. It promotes emotional support or attention for the client
82. Dervid is diagnosed with panic disorder with agoraphobia is talking with the
nurse in-charge about the progress made in treatment. Which of the following
statements indicates a positive client response?
a. I went to the mall with my friends last Saturday
b. Im hyperventilating only when I have a panic attack
c. Today I decided that I can stop taking my medication
d. Last night I decided to eat more than a bowl of cereal
83. The effectiveness of monoamine oxidase (MAO) inhibitor drug therapy in a
client with posttraumatic stress disorder can be demonstrated by which of the
following client self reports?
a. Im sleeping better and dont have nightmares
b. Im not losing my temper as much
c. Ive lost my craving for alcohol
90. Which of the following descriptions of a clients experience and behavior can
be assessed as an illusion?
a. The client tries to hit the nurse when vital signs must be taken
b. The client says, I keep hearing a voice telling me to run away
c. The client becomes anxious whenever the nurse leaves the
bedside
d. The client looks at the shadow on a wall and tells the nurse she
sees frightening faces on the wall.
91. During conversation of Nurse John with a client, he observes that the client
shift from one topic to the next on a regular basis. Which of the following terms
describes this disorder?
a. Flight of ideas
b. Concrete thinking
c. Ideas of reference
d. Loose association
92. Francis tells the nurse that her coworkers are sabotaging the computer.
When the nurse asks questions, the client becomes argumentative. This
behavior shows personality traits associated with which of the following
personality disorder?
a. Antisocial
b. Histrionic
c. Paranoid
d. Schizotypal
93. Which of the following interventions is important for a Cely experiencing with
paranoid personality disorder taking olanzapine (Zyprexa)?
a. Explain effects of serotonin syndrome
b. Teach the client to watch for extrapyramidal adverse reaction
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c. Explain that the drug is less affective if the client smokes
d. Discuss the need to report paradoxical effects such as euphoria
94. Nurse Alexandra notices other clients on the unit avoiding a client diagnosed
with antisocial personality disorder. When discussing appropriate behavior in
group therapy, which of the following comments is expected about this client by
his peers?
a. Lack of honesty
b. Belief in superstition
c. Show of temper tantrums
d. Constant need for attention
95. Tommy, with dependent personality disorder is working to increase his selfesteem.
Which of the following statements by the Tommy shows teaching was
successful?
a. Im not going to look just at the negative things about myself
b. Im most concerned about my level of competence and progress
c. Im not as envious of the things other people have as I used to be
d. I find I cant stop myself from taking over things other should be
doing
PART II
ANSWERS
&
RATIONALE
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TEST I
Answers and Rationale Foundation of Professional Nursing Practice
1. Answer: (D) The actions of a reasonably prudent nurse with similar
education and experience.
Rationale: The standard of care is determined by the average degree of
skill, care, and diligence by nurses in similar circumstances.
2. Answer: (B) I.M
Rationale: With a platelet count of 22,000/l, the clients tends to bleed
easily. Therefore, the nurse should avoid using the I.M. route because the
area is a highly vascular and can bleed readily when penetrated by a
needle. The bleeding can be difficult to stop.
3. Answer: (C) Digoxin 0.125 mg P.O. once daily
Rationale: The nurse should always place a zero before a decimal point
so that no one misreads the figure, which could result in a dosage error.
The nurse should never insert a zero at the end of a dosage that includes
a decimal point because this could be misread, possibly leading to a
tenfold increase in the dosage.
4. Answer: (A) Ineffective peripheral tissue perfusion related to venous
congestion.
Rationale: Ineffective peripheral tissue perfusion related to venous
congestion takes the highest priority because venous inflammation and
clot formation impede blood flow in a client with deep vein thrombosis.
5. Answer: (B) A 44 year-old myocardial infarction (MI) client who is
complaining of nausea.
Rationale: Nausea is a symptom of impending myocardial infarction (MI)
and should be assessed immediately so that treatment can be instituted
and further damage to the heart is avoided.
6. Answer: (C) Check circulation every 15-30 minutes.
Rationale: Restraints encircle the limbs, which place the client at risk for
circulation being restricted to the distal areas of the extremities. Checking
the clients circulation every 15-30 minutes will allow the nurse to adjust
the restraints before injury from decreased blood flow occurs.
7. Answer: (A) Prevent stress ulcer
Rationale: Curlings ulcer occurs as a generalized stress response in burn
patients. This results in a decreased production of mucus and increased
secretion of gastric acid. The best treatment for this prophylactic use of
antacids and H2 receptor blockers.
the more intrusive techniques. Percussion and palpation can alter natural
findings during auscultation.
46. Answer: (D) Ulnar surface of the hand
Rationale: The nurse uses the ulnar surface, or ball, of the hand to asses
tactile fremitus, thrills, and vocal vibrations through the chest wall. The
fingertips and finger pads best distinguish texture and shape. The dorsal
surface best feels warmth.
47. Answer: (C) Formative
Rationale: Formative (or concurrent) evaluation occurs continuously
throughout the teaching and learning process. One benefit is that the
nurse can adjust teaching strategies as necessary to enhance learning.
Summative, or retrospective, evaluation occurs at the conclusion of the
teaching and learning session. Informative is not a type of evaluation.
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48. Answer: (B) Once per year
Rationale: Yearly mammograms should begin at age 40 and continue for
as long as the woman is in good health. If health risks, such as family
history, genetic tendency, or past breast cancer, exist, more frequent
examinations may be necessary.
49. Answer: (A) Respiratory acidosis
Rationale: The client has a below-normal (acidic) blood pH value and an
above-normal partial pressure of arterial carbon dioxide (Paco2) value,
indicating respiratory acidosis. In respiratory alkalosis, the pH value is
above normal and in the Paco2 value is below normal. In metabolic
acidosis, the pH and bicarbonate (Hco3) values are below normal. In
metabolic alkalosis, the pH and Hco3 values are above normal.
50. Answer: (B) To provide support for the client and family in coping with
terminal illness.
Rationale: Hospices provide supportive care for terminally ill clients and
their families. Hospice care doesnt focus on counseling regarding health
care costs. Most client referred to hospices have been treated for their
disease without success and will receive only palliative care in the
hospice.
51. Answer: (C) Using normal saline solution to clean the ulcer and applying
a protective dressing as necessary.
Rationale: Washing the area with normal saline solution and applying a
protective dressing are within the nurses realm of interventions and will
protect the area. Using a povidone-iodine wash and an antibiotic cream
require a physicians order. Massaging with an astringent can further
damage the skin.
52. Answer: (D) Foot
Rationale: An elastic bandage should be applied form the distal area to
the proximal area. This method promotes venous return. In this case, the
nurse should begin applying the bandage at the clients foot. Beginning at
the ankle, lower thigh, or knee does not promote venous return.
53. Answer: (B) Hypokalemia
Rationale: The Sims' left lateral position is the most common position
used to administer a cleansing enema because it allows gravity to aid the
flow of fluid along the curve of the sigmoid colon. If the client can't assume
this position nor has poor sphincter control, the dorsal recumbent or right
lateral position may be used. The supine and prone positions are
inappropriate and uncomfortable for the client.
89. Answer: (A) Arrange for typing and cross matching of the clients blood.
Rationale: The nurse first arranges for typing and cross matching of the
client's blood to ensure compatibility with donor blood. The other options,
although appropriate when preparing to administer a blood transfusion,
come later.
90. Answer: (A) Independent
Rationale: Nursing interventions are classified as independent,
interdependent, or dependent. Altering the drug schedule to coincide with
the client's daily routine represents an independent intervention, whereas
consulting with the physician and pharmacist to change a client's
medication because of adverse reactions represents an interdependent
intervention. Administering an already-prescribed drug on time is a
dependent intervention. An intradependent nursing intervention doesn't
exist.
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91. Answer: (D) Evaluation
Rationale: The nursing actions described constitute evaluation of the
expected outcomes. The findings show that the expected outcomes have
been achieved. Assessment consists of the client's history, physical
examination, and laboratory studies. Analysis consists of considering
assessment information to derive the appropriate nursing diagnosis.
Implementation is the phase of the nursing process where the nurse puts
the plan of care into action.
92. Answer: (B) To observe the lower extremities
Rationale: Elastic stockings are used to promote venous return. The
nurse needs to remove them once per day to observe the condition of the
skin underneath the stockings. Applying the stockings increases blood
flow to the heart. When the stockings are in place, the leg muscles can still
stretch and relax, and the veins can fill with blood.
93. Answer:(A) Instructing the client to report any itching, swelling, or
dyspnea.
Rationale: Because administration of blood or blood products may cause
serious adverse effects such as allergic reactions, the nurse must monitor
the client for these effects. Signs and symptoms of life-threatening allergic
reactions include itching, swelling, and dyspnea. Although the nurse
should inform the client of the duration of the transfusion and should
document its administration, these actions are less critical to the client's
immediate health. The nurse should assess vital signs at least hourly
during the transfusion.
94. Answer: (B) Decrease the rate of feedings and the concentration of the
formula.
Rationale: Complaints of abdominal discomfort and nausea are common
in clients receiving tube feedings. Decreasing the rate of the feeding and
the concentration of the formula should decrease the client's discomfort.
Feedings are normally given at room temperature to minimize abdominal
cramping. To prevent aspiration during feeding, the head of the client's
bed should be elevated at least 30 degrees. Also, to prevent bacterial
growth, feeding containers should be routinely changed every 8 to 12
hours.
95. Answer: (D) Roll the vial gently between the palms.
Rationale: Rolling the vial gently between the palms produces heat,
which helps dissolve the medication. Doing nothing or inverting the vial
wouldn't help dissolve the medication. Shaking the vial vigorously could
cause the medication to break down, altering its action.
96. Answer: (B) Assist the client to the semi-Fowler position if possible.
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Rationale: By assisting the client to the semi-Fowler position, the nurse
promotes easier chest expansion, breathing, and oxygen intake. The
nurse should secure the elastic band so that the face mask fits
comfortably and snugly rather than tightly, which could lead to irritation.
The nurse should apply the face mask from the client's nose down to the
chin not vice versa. The nurse should check the connectors between
the oxygen equipment and humidifier to ensure that they're airtight;
loosened connectors can cause loss of oxygen.
97. Answer: (B) 4 hours
Rationale: A unit of packed RBCs may be given over a period of between
1 and 4 hours. It shouldn't infuse for longer than 4 hours because the risk
of contamination and sepsis increases after that time. Discard or return to
the blood bank any blood not given within this time, according to facility
policy.
98. Answer: (B) Immediately before administering the next dose.
Rationale: Measuring the blood drug concentration helps determine
whether the dosing has achieved the therapeutic goal. For measurement
of the trough, or lowest, blood level of a drug, the nurse draws a blood
sample immediately before administering the next dose. Depending on the
drug's duration of action and half-life, peak blood drug levels typically are
drawn after administering the next dose.
99. Answer: (A) The nurse can implement medication orders quickly.
Rationale: A floor stock system enables the nurse to implement
medication orders quickly. It doesn't allow for pharmacist input, nor does it
minimize transcription errors or reinforce accurate calculations.
100. Answer: (C) Shifting dullness over the abdomen.
Rationale: Shifting dullness over the abdomen indicates ascites, an
abnormal finding. The other options are normal abdominal findings.
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TEST II
Rationale: When dealing with a crying toddler, the best approach is to talk
to the mother and ignore the toddler first. This approach helps the toddler
get used to the nurse before she attempts any procedures. It also gives
the toddler an opportunity to see that the mother trusts the nurse.
12. Answer: (D) Place the infants arms in soft elbow restraints.
Rationale: Soft restraints from the upper arm to the wrist prevent the
infant from touching her lip but allow him to hold a favorite item such as a
blanket. Because they could damage the operative site, such as objects
as pacifiers, suction catheters, and small spoons shouldnt be placed in a
babys mouth after cleft repair. A baby in a prone position may rub her
face on the sheets and traumatize the operative site. The suture line
should be cleaned gently to prevent infection, which could interfere with
healing and damage the cosmetic appearance of the repair.
13. Answer: (B) Allow the infant to rest before feeding.
Rationale: Because feeding requires so much energy, an infant with heart
failure should rest before feeding.
14. Answer: (C) Iron-rich formula only.
Rationale: The infants at age 5 months should receive iron-rich formula
and that they shouldnt receive solid food, even baby food until age 6
months.
15. Answer: (D) 10 months
Rationale: A 10 month old infant can sit alone and understands object
permanence, so he would look for the hidden toy. At age 4 to 6 months,
infants cant sit securely alone. At age 8 months, infants can sit securely
alone but cannot understand the permanence of objects.
16. Answer: (D) Public health nursing focuses on preventive, not curative,
services.
Rationale: The catchments area in PHN consists of a residential
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community, many of whom are well individuals who have greater need for
preventive rather than curative services.
17. Answer: (B) Efficiency
Rationale: Efficiency is determining whether the goals were attained at
the least possible cost.
18. Answer: (D) Rural Health Unit
Rationale: R.A. 7160 devolved basic health services to local government
units (LGUs ). The public health nurse is an employee of the LGU.
19. Answer: (A) Mayor
Rationale: The local executive serves as the chairman of the Municipal
Health Board.
20. Answer: (A) 1
Rationale: Each rural health midwife is given a population assignment of
about 5,000.
21. Answer: (B) Health education and community organizing are necessary in
providing community health services.
Rationale: The community health nurse develops the health capability of
the uterus, therefore, blood loss can occur quite rapidly in the event of
uncontrolled bleeding.
33. Answer: (D) Physiologic anemia
Rationale: Hemoglobin values and hematocrit decrease during pregnancy
as the increase in plasma volume exceeds the increase in red blood cell
production.
34. Answer: (D) A 2 year old infant with stridorous breath sounds, sitting up in
his mothers arms and drooling.
Rationale: The infant with the airway emergency should be treated first,
because of the risk of epiglottitis.
35. Answer: (A) Placenta previa
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Rationale: Placenta previa with painless vaginal bleeding.
36. Answer: (D) Early in the morning
Rationale: Based on the nurses knowledge of microbiology, the
specimen should be collected early in the morning. The rationale for this
timing is that, because the female worm lays eggs at night around the
perineal area, the first bowel movement of the day will yield the best
results. The specific type of stool specimen used in the diagnosis of
pinworms is called the tape test.
37. Answer: (A) Irritability and seizures
Rationale: Lead poisoning primarily affects the CNS, causing increased
intracranial pressure. This condition results in irritability and changes in
level of consciousness, as well as seizure disorders, hyperactivity, and
learning disabilities.
38. Answer: (D) I really need to use the diaphragm and jelly most during the
middle of my menstrual cycle.
Rationale: The woman must understand that, although the fertile period
is approximately mid-cycle, hormonal variations do occur and can result in
early or late ovulation. To be effective, the diaphragm should be inserted
before every intercourse.
39. Answer: (C) Restlessness
Rationale: In a child, restlessness is the earliest sign of hypoxia. Late
signs of hypoxia in a child are associated with a change in color, such as
pallor or cyanosis.
40. Answer: (B) Walk one step ahead, with the childs hand on the nurses
elbow.
Rationale: This procedure is generally recommended to follow in guiding
a person who is blind.
41. Answer: (A) Loud, machinery-like murmur.
Rationale: A loud, machinery-like murmur is a characteristic finding
associated with patent ductus arteriosus.
42. Answer: (C) More oxygen, and the newborns metabolic rate increases.
Rationale: When cold, the infant requires more oxygen and there is an
increase in metabolic rate. Non-shievering thermogenesis is a complex
process that increases the metabolic rate and rate of oxygen
laceration.
81. Answer: (C) What is your expected due date?
Rationale: When obtaining the history of a client who may be in labor, the
nurse's highest priority is to determine her current status, particularly her
due date, gravidity, and parity. Gravidity and parity affect the duration of
labor and the potential for labor complications. Later, the nurse should ask
about chronic illnesses, allergies, and support persons.
82. Answer: (D) Aspirate the neonates nose and mouth with a bulb syringe.
Rationale: The nurse's first action should be to clear the neonate's airway
with a bulb syringe. After the airway is clear and the neonate's color
improves, the nurse should comfort and calm the neonate. If the problem
recurs or the neonate's color doesn't improve readily, the nurse should
notify the physician. Administering oxygen when the airway isn't clear
would be ineffective.
83. Answer: (C) Conducting a bedside ultrasound for an amniotic fluid index.
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Rationale: It isn't within a nurse's scope of practice to perform and
interpret a bedside ultrasound under these conditions and without
specialized training. Observing for pooling of straw-colored fluid, checking
vaginal discharge with nitrazine paper, and observing for flakes of vernix
are appropriate assessments for determining whether a client has
ruptured membranes.
84. Answer: (C) Monitor partial pressure of oxygen (Pao2) levels.
Rationale: Monitoring PaO2 levels and reducing the oxygen
concentration to keep PaO2 within normal limits reduces the risk of
retinopathy of prematurity in a premature infant receiving oxygen.
Covering the infant's eyes and humidifying the oxygen don't reduce the
risk of retinopathy of prematurity. Because cooling increases the risk of
acidosis, the infant should be kept warm so that his respiratory distress
isn't aggravated.
85. Answer: (A) 110 to 130 calories per kg.
Rationale: Calories per kg is the accepted way of determined appropriate
nutritional intake for a newborn. The recommended calorie requirement is
110 to 130 calories per kg of newborn body weight. This level will maintain
a consistent blood glucose level and provide enough calories for
continued growth and development.
86. Answer: (C) 30 to 32 weeks
Rationale: Individual twins usually grow at the same rate as singletons
until 30 to 32 weeks gestation, then twins dont gain weight as rapidly as
singletons of the same gestational age. The placenta can no longer keep
pace with the nutritional requirements of both fetuses after 32 weeks, so
theres some growth retardation in twins if they remain in utero at 38 to 40
weeks.
87. Answer: (A) conjoined twins
Rationale: The type of placenta that develops in monozygotic twins
depends on the time at which cleavage of the ovum occurs. Cleavage in
conjoined twins occurs more than 13 days after fertilization. Cleavage that
occurs less than 3 day after fertilization results in diamniotic dicchorionic
twins. Cleavage that occurs between days 3 and 8 results in diamniotic
monochorionic twins. Cleavage that occurs between days 8 to 13 result in
monoamniotic monochorionic twins.
88. Answer: (D) Ultrasound
Rationale: Once the mother and the fetus are stabilized, ultrasound
evaluation of the placenta should be done to determine the cause of the
bleeding. Amniocentesis is contraindicated in placenta previa. A digital or
speculum examination shouldnt be done as this may lead to severe
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bleeding or hemorrhage. External fetal monitoring wont detect a placenta
previa, although it will detect fetal distress, which may result from blood
loss or placenta separation.
89. Answer: (A) Increased tidal volume
Rationale: A pregnant client breathes deeper, which increases the tidal
volume of gas moved in and out of the respiratory tract with each breath.
The expiratory volume and residual volume decrease as the pregnancy
progresses. The inspiratory capacity increases during pregnancy. The
increased oxygen consumption in the pregnant client is 15% to 20%
greater than in the nonpregnant state.
90. Answer: (A) Diet
Rationale: Clients with gestational diabetes are usually managed by diet
alone to control their glucose intolerance. Oral hypoglycemic drugs are
contraindicated in pregnancy. Long-acting insulin usually isnt needed for
blood glucose control in the client with gestational diabetes.
91. Answer: (D) Seizure
Rationale: The anticonvulsant mechanism of magnesium is believes to
depress seizure foci in the brain and peripheral neuromuscular blockade.
Hypomagnesemia isnt a complication of preeclampsia. Antihypertensive
drug other than magnesium are preferred for sustained hypertension.
Magnesium doesnt help prevent hemorrhage in preeclamptic clients.
92. Answer: (C) I.V. fluids
Rationale: A sickle cell crisis during pregnancy is usually managed by
exchange transfusion oxygen, and L.V. Fluids. The client usually needs a
stronger analgesic than acetaminophen to control the pain of a crisis.
Antihypertensive drugs usually arent necessary. Diuretic wouldnt be used
unless fluid overload resulted.
93. Answer: (A) Calcium gluconate (Kalcinate)
Rationale: Calcium gluconate is the antidote for magnesium toxicity. Ten
milliliters of 10% calcium gluconate is given L.V. push over 3 to 5 minutes.
Hydralazine is given for sustained elevated blood pressure in preeclamptic
clients. Rho (D) immune globulin is given to women with Rh-negative
blood to prevent antibody formation from RH-positive conceptions.
Naloxone is used to correct narcotic toxicity.
94. Answer: (B) An indurated wheal over 10 mm in diameter appears in 48 to
72 hours.
Rationale: A positive PPD result would be an indurated wheal over 10
mm in diameter that appears in 48 to 72 hours. The area must be a raised
wheal, not a flat circumcised area to be considered positive.
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95. Answer: (C) Pyelonephritis
Rational: The symptoms indicate acute pyelonephritis, a serious condition
in a pregnant client. UTI symptoms include dysuria, urgency, frequency,
and suprapubic tenderness. Asymptomatic bacteriuria doesnt cause
symptoms. Bacterial vaginosis causes milky white vaginal discharge but
no systemic symptoms.
96. Answer: (B) Rh-positive fetal blood crosses into maternal blood,
stimulating maternal antibodies.
Rationale: Rh isoimmunization occurs when Rh-positive fetal blood cells
cross into the maternal circulation and stimulate maternal antibody
production. In subsequent pregnancies with Rh-positive fetuses, maternal
antibodies may cross back into the fetal circulation and destroy the fetal
blood cells.
97. Answer: (C) Supine position
Rationale: The supine position causes compression of the client's aorta
and inferior vena cava by the fetus. This, in turn, inhibits maternal
circulation, leading to maternal hypotension and, ultimately, fetal hypoxia.
The other positions promote comfort and aid labor progress. For instance,
the lateral, or side-lying, position improves maternal and fetal circulation,
enhances comfort, increases maternal relaxation, reduces muscle tension,
and eliminates pressure points. The squatting position promotes comfort
by taking advantage of gravity. The standing position also takes
advantage of gravity and aligns the fetus with the pelvic angle.
98. Answer: (B) Irritability and poor sucking.
Rationale: Neonates of heroin-addicted mothers are physically
dependent on the drug and experience withdrawal when the drug is no
longer supplied. Signs of heroin withdrawal include irritability, poor
sucking, and restlessness. Lethargy isn't associated with neonatal heroin
addiction. A flattened nose, small eyes, and thin lips are seen in infants
with fetal alcohol syndrome. Heroin use during pregnancy hasn't been
linked to specific congenital anomalies.
99. Answer: (A) 7th to 9th day postpartum
Rationale: The normal involutional process returns the uterus to the
pelvic cavity in 7 to 9 days. A significant involutional complication is the
failure of the uterus to return to the pelvic cavity within the prescribed time
period. This is known as subinvolution.
100. Answer: (B) Uterine atony
Rationale: Multiple fetuses, extended labor stimulation with oxytocin, and
traumatic delivery commonly are associated with uterine atony, which may
lead to postpartum hemorrhage. Uterine inversion may precede or follow
delivery and commonly results from apparent excessive traction on the
last for several days, the client is kept in flat in a supine position for
approximately 4 to 12 hours postoperatively. Headaches are believed to
be causes by the seepage of cerebral spinal fluid from the puncture site.
By keeping the client flat, cerebral spinal fluid pressures are equalized,
which avoids trauma to the neurons.
10. Answer: (C) The client is oriented when aroused from sleep, and goes
back to sleep immediately.
Rationale: This finding suggest that the level of consciousness is
decreasing.
11. Answer: (A) Altered mental status and dehydration
Rationale: Fever, chills, hemortysis, dyspnea, cough, and pleuritic chest
pain are the common symptoms of pneumonia, but elderly clients may first
appear with only an altered lentil status and dehydration due to a blunted
immune response.
12. Answer: (B) Chills, fever, night sweats, and hemoptysis
Rationale: Typical signs and symptoms are chills, fever, night sweats,
and hemoptysis. Chest pain may be present from coughing, but isnt
usual. Clients with TB typically have low-grade fevers, not higher than
102F (38.9C). Nausea, headache, and photophobia arent usual TB
symptoms.
13. Answer:(A) Acute asthma
Rationale: Based on the clients history and symptoms, acute asthma is
the most likely diagnosis. Hes unlikely to have bronchial pneumonia
without a productive cough and fever and hes too young to have
developed (COPD) and emphysema.
14. Answer: (B) Respiratory arrest
Rationale: Narcotics can cause respiratory arrest if given in large
quantities. Its unlikely the client will have asthma attack or a seizure or
wake up on his own.
15. Answer: (D) Decreased vital capacity
Rationale: Reduction in vital capacity is a normal physiologic changes
include decreased elastic recoil of the lungs, fewer functional capillaries in
the alveoli, and an increased in residual volume.
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16. Answer: (C) Presence of premature ventricular contractions (PVCs) on a
cardiac monitor.
Rationale: Lidocaine drips are commonly used to treat clients whose
arrhythmias havent been controlled with oral medication and who are
having PVCs that are visible on the cardiac monitor. SaO2, blood
pressure, and ICP are important factors but arent as significant as PVCs
in the situation.
17. Answer: (B) Avoid foods high in vitamin K
Rationale: The client should avoid consuming large amounts of vitamin K
because vitamin K can interfere with anticoagulation. The client may need
to report diarrhea, but isnt effect of taking an anticoagulant. An electric
razor-not a straight razor-should be used to prevent cuts that cause
with irregular edges. A mobile mass that is soft and easily delineated is
most often a fluid-filled benign cyst. Axillary lymph nodes may or may not
be palpable on initial detection of a cancerous mass. Nipple retraction
not eversion may be a sign of cancer.
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48. Answer: (C) Radiation
Rationale: The usual treatment for vaginal cancer is external or
intravaginal radiation therapy. Less often, surgery is performed.
Chemotherapy typically is prescribed only if vaginal cancer is diagnosed in
an early stage, which is rare. Immunotherapy isn't used to treat vaginal
cancer.
49. Answer: (B) Carcinoma in situ, no abnormal regional lymph nodes, and
no evidence of distant metastasis
Rationale: TIS, N0, M0 denotes carcinoma in situ, no abnormal regional
lymph nodes, and no evidence of distant metastasis. No evidence of
primary tumor, no abnormal regional lymph nodes, and no evidence of
distant metastasis is classified as T0, N0, M0. If the tumor and regional
lymph nodes can't be assessed and no evidence of metastasis exists, the
lesion is classified as TX, NX, M0. A progressive increase in tumor size,
no demonstrable metastasis of the regional lymph nodes, and ascending
degrees of distant metastasis is classified as T1, T2, T3, or T4; N0; and
M1, M2, or M3.
50. Answer: (D) "Keep the stoma moist."
Rationale: The nurse should instruct the client to keep the stoma moist,
such as by applying a thin layer of petroleum jelly around the edges,
because a dry stoma may become irritated. The nurse should recommend
placing a stoma bib over the stoma to filter and warm air before it enters
the stoma. The client should begin performing stoma care without
assistance as soon as possible to gain independence in self-care
activities.
51. Answer: (B) Lung cancer
Rationale: Lung cancer is the most deadly type of cancer in both women
and men. Breast cancer ranks second in women, followed (in descending
order) by colon and rectal cancer, pancreatic cancer, ovarian cancer,
uterine cancer, lymphoma, leukemia, liver cancer, brain cancer, stomach
cancer, and multiple myeloma.
52. Answer: (A) miosis, partial eyelid ptosis, and anhidrosis on the affected
side of the face.
Rationale: Horner's syndrome, which occurs when a lung tumor invades
the ribs and affects the sympathetic nerve ganglia, is characterized by
miosis, partial eyelid ptosis, and anhidrosis on the affected side of the
face. Chest pain, dyspnea, cough, weight loss, and fever are associated
with pleural tumors. Arm and shoulder pain and atrophy of the arm and
hand muscles on the affected side suggest Pancoast's tumor, a lung
tumor involving the first thoracic and eighth cervical nerves within the
brachial plexus. Hoarseness in a client with lung cancer suggests that the
loss has occurred. Bone densitometry can detect bone loss of 3% or less.
This test is sometimes recommended routinely for women over 35 who
are at risk. Strenuous exercise won't cause fractures.
60. Answer: (C) Joint flexion of less than 50%
Rationale: Arthroscopy is contraindicated in clients with joint flexion of
less than 50% because of technical problems in inserting the instrument
into the joint to see it clearly. Other contraindications for this procedure
include skin and wound infections. Joint pain may be an indication, not a
contraindication, for arthroscopy. Joint deformity and joint stiffness aren't
contraindications for this procedure.
61. Answer: (D) Gouty arthritis
Rationale: Gouty arthritis, a metabolic disease, is characterized by urate
deposits and pain in the joints, especially those in the feet and legs. Urate
deposits don't occur in septic or traumatic arthritis. Septic arthritis results
from bacterial invasion of a joint and leads to inflammation of the synovial
lining. Traumatic arthritis results from blunt trauma to a joint or ligament.
Intermittent arthritis is a rare, benign condition marked by regular,
recurrent joint effusions, especially in the knees.
62. Answer: (B) 30 ml/hou
Rationale: An infusion prepared with 25,000 units of heparin in 500 ml of
saline solution yields 50 units of heparin per milliliter of solution. The
equation is set up as 50 units times X (the unknown quantity) equals 1,500
units/hour, X equals 30 ml/hour.
63. Answer: (B) Loss of muscle contraction decreasing venous return
Rationale: In clients with hemiplegia or hemiparesis loss of muscle
contraction decreases venous return and may cause swelling of the
affected extremity. Contractures, or bony calcifications may occur with a
stroke, but dont appear with swelling. DVT may develop in clients with a
stroke but is more likely to occur in the lower extremities. A stroke isnt
linked to protein loss.
64. Answer: (B) It appears on the distal interphalangeal joint
Rationale: Heberdens nodes appear on the distal interphalageal joint on
both men and women. Bouchards node appears on the dorsolateral
aspect of the proximal interphalangeal joint.
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65. Answer: (B) Osteoarthritis is a localized disease rheumatoid arthritis is
systemic
Rationale: Osteoarthritis is a localized disease, rheumatoid arthritis is
systemic. Osteoarthritis isnt gender-specific, but rheumatoid arthritis is.
Clients have dislocations and subluxations in both disorders.
66. Answer: (C) The cane should be used on the unaffected side
Rationale: A cane should be used on the unaffected side. A client with
osteoarthritis should be encouraged to ambulate with a cane, walker, or
other assistive device as needed; their use takes weight and stress off
joints.
67. Answer: (A) a. 9 U regular insulin and 21 U neutral protamine Hagedorn
(NPH).
Rationale: A 70/30 insulin preparation is 70% NPH and 30% regular
insulin. Therefore, a correct substitution requires mixing 21 U of NPH and
9 U of regular insulin. The other choices are incorrect dosages for the
prescribed insulin.
68. Answer: (C) colchicines
Rationale: A disease characterized by joint inflammation (especially in
the great toe), gout is caused by urate crystal deposits in the joints. The
physician prescribes colchicine to reduce these deposits and thus ease
joint inflammation. Although aspirin is used to reduce joint inflammation
and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't
indicated for gout because it has no effect on urate crystal formation.
Furosemide, a diuretic, doesn't relieve gout. Calcium gluconate is used to
reverse a negative calcium balance and relieve muscle cramps, not to
treat gout.
69. Answer: (A) Adrenal cortex
Rationale: Excessive secretion of aldosterone in the adrenal cortex is
responsible for the client's hypertension. This hormone acts on the renal
tubule, where it promotes reabsorption of sodium and excretion of
potassium and hydrogen ions. The pancreas mainly secretes hormones
involved in fuel metabolism. The adrenal medulla secretes the
catecholamines epinephrine and norepinephrine. The parathyroids
secrete parathyroid hormone.
70. Answer: (C) They debride the wound and promote healing by secondary
intention
Rationale: For this client, wet-to-dry dressings are most appropriate
because they clean the foot ulcer by debriding exudate and necrotic
tissue, thus promoting healing by secondary intention. Moist, transparent
dressings contain exudate and provide a moist wound environment.
Hydrocolloid dressings prevent the entrance of microorganisms and
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minimize wound discomfort. Dry sterile dressings protect the wound from
mechanical trauma and promote healing.
71. Answer: (A) Hyperkalemia
Rationale: In adrenal insufficiency, the client has hyperkalemia due to
reduced aldosterone secretion. BUN increases as the glomerular filtration
rate is reduced. Hyponatremia is caused by reduced aldosterone
secretion. Reduced cortisol secretion leads to impaired glyconeogenesis
and a reduction of glycogen in the liver and muscle, causing
hypoglycemia.
72. Answer: (C) Restricting fluids
Rationale: To reduce water retention in a client with the SIADH, the
nurse should restrict fluids. Administering fluids by any route would further
increase the client's already heightened fluid load.
73. Answer: (D) glycosylated hemoglobin level.
Rationale: Because some of the glucose in the bloodstream attaches to
some of the hemoglobin and stays attached during the 120-day life span
of red blood cells, glycosylated hemoglobin levels provide information
about blood glucose levels during the previous 3 months. Fasting blood
glucose and urine glucose levels only give information about glucose
levels at the point in time when they were obtained. Serum fructosamine
levels provide information about blood glucose control over the past 2 to 3
weeks.
74. Answer: (C) 4:00 pm
Rationale: NPH is an intermediate-acting insulin that peaks 8 to 12 hours
after administration. Because the nurse administered NPH insulin at 7
a.m., the client is at greatest risk for hypoglycemia from 3 p.m. to 7 p.m.
75. Answer: (A) Glucocorticoids and androgens
Rationale: The adrenal glands have two divisions, the cortex and
medulla. The cortex produces three types of hormones: glucocorticoids,
mineralocorticoids, and androgens. The medulla produces catecholamines
epinephrine and norepinephrine.
76. Answer: (A) Hypocalcemia
Rationale: Hypocalcemia may follow thyroid surgery if the parathyroid
glands were removed accidentally. Signs and symptoms of hypocalcemia
may be delayed for up to 7 days after surgery. Thyroid surgery doesn't
directly cause serum sodium, potassium, or magnesium abnormalities.
Hyponatremia may occur if the client inadvertently received too much fluid;
however, this can happen to any surgical client receiving I.V. fluid therapy,
not just one recovering from thyroid surgery. Hyperkalemia and
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hypermagnesemia usually are associated with reduced renal excretion of
potassium and magnesium, not thyroid surgery.
77. Answer: (D) Carcinoembryonic antigen level
Rationale: In clients who smoke, the level of carcinoembryonic antigen is
elevated. Therefore, it can't be used as a general indicator of cancer.
However, it is helpful in monitoring cancer treatment because the level
usually falls to normal within 1 month if treatment is successful. An
elevated acid phosphatase level may indicate prostate cancer. An
elevated alkaline phosphatase level may reflect bone metastasis. An
elevated serum calcitonin level usually signals thyroid cancer.
78. Answer: (B) Dyspnea, tachycardia, and pallor
Rationale: Signs of iron-deficiency anemia include dyspnea, tachycardia,
and pallor as well as fatigue, listlessness, irritability, and headache. Night
sweats, weight loss, and diarrhea may signal acquired immunodeficiency
syndrome (AIDS). Nausea, vomiting, and anorexia may be signs of
hepatitis B. Itching, rash, and jaundice may result from an allergic or
hemolytic reaction.
79. Answer: (D) "I'll need to have a C-section if I become pregnant and have
a baby."
Rationale: The human immunodeficiency virus (HIV) is transmitted from
mother to child via the transplacental route, but a Cesarean section
delivery isn't necessary when the mother is HIV-positive. The use of birth
control will prevent the conception of a child who might have HIV. It's true
that a mother who's HIV positive can give birth to a baby who's HIV
negative.
80. Answer: (C) "Avoid sharing such articles as toothbrushes and razors."
Rationale: The human immunodeficiency virus (HIV), which causes
AIDS, is most concentrated in the blood. For this reason, the client
shouldn't share personal articles that may be blood-contaminated, such as
toothbrushes and razors, with other family members. HIV isn't transmitted
by bathing or by eating from plates, utensils, or serving dishes used by a
person with AIDS.
81. Answer: (B) Pallor, tachycardia, and a sore tongue
Rationale: Pallor, tachycardia, and a sore tongue are all characteristic
findings in pernicious anemia. Other clinical manifestations include
anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure;
palpitations; angina; weakness; fatigue; and paresthesia of the hands and
feet. Bradycardia, reduced pulse pressure, weight gain, and double vision
aren't characteristic findings in pernicious anemia.
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82. Answer: (B) Administer epinephrine, as prescribed, and prepare to
intubate the client if necessary.
Rationale: To reverse anaphylactic shock, the nurse first should
administer epinephrine, a potent bronchodilator as prescribed. The
physician is likely to order additional medications, such as antihistamines
and corticosteroids; if these medications don't relieve the respiratory
compromise associated with anaphylaxis, the nurse should prepare to
intubate the client. No antidote for penicillin exists; however, the nurse
should continue to monitor the client's vital signs. A client who remains
hypotensive may need fluid resuscitation and fluid intake and output
monitoring; however, administering epinephrine is the first priority.
83. Answer: (D) bilateral hearing loss.
Rationale: Prolonged use of aspirin and other salicylates sometimes
causes bilateral hearing loss of 30 to 40 decibels. Usually, this adverse
effect resolves within 2 weeks after the therapy is discontinued. Aspirin
doesn't lead to weight gain or fine motor tremors. Large or toxic salicylate
doses may cause respiratory alkalosis, not respiratory acidosis.
84. Answer: (D) Lymphocyte
Rationale: The lymphocyte provides adaptive immunity recognition of
a foreign antigen and formation of memory cells against the antigen.
Adaptive immunity is mediated by B and T lymphocytes and can be
acquired actively or passively. The neutrophil is crucial to phagocytosis.
The basophil plays an important role in the release of inflammatory
mediators. The monocyte functions in phagocytosis and monokine
production.
85. Answer: (A) moisture replacement.
Rationale: Sjogren's syndrome is an autoimmune disorder leading to
progressive loss of lubrication of the skin, GI tract, ears, nose, and vagina.
Moisture replacement is the mainstay of therapy. Though malnutrition and
electrolyte imbalance may occur as a result of Sjogren's syndrome's effect
on the GI tract, it isn't the predominant problem. Arrhythmias aren't a
problem associated with Sjogren's syndrome.
86. Answer: (C) stool for Clostridium difficile test.
Rationale: Immunosuppressed clients for example, clients receiving
chemotherapy, are at risk for infection with C. difficile, which causes
"horse barn" smelling diarrhea. Successful treatment begins with an
accurate diagnosis, which includes a stool test. The ELISA test is
diagnostic for human immunodeficiency virus (HIV) and isn't indicated in
this case. An electrolyte panel and hemogram may be useful in the overall
evaluation of a client but aren't diagnostic for specific causes of diarrhea.
A flat plate of the abdomen may provide useful information about bowel
function but isn't indicated in the case of "horse barn" smelling diarrhea.
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87. Answer: (D) Western blot test with ELISA.
Rationale: HIV infection is detected by analyzing blood for antibodies to
HIV, which form approximately 2 to 12 weeks after exposure to HIV and
denote infection. The Western blot test electrophoresis of antibody
proteins is more than 98% accurate in detecting HIV antibodies when
used in conjunction with the ELISA. It isn't specific when used alone. Erosette
immunofluorescence is used to detect viruses in general; it doesn't
confirm HIV infection. Quantification of T-lymphocytes is a useful
monitoring test but isn't diagnostic for HIV. The ELISA test detects HIV
antibody particles but may yield inaccurate results; a positive ELISA result
must be confirmed by the Western blot test.
88. Answer: (C) Abnormally low hematocrit (HCT) and hemoglobin (Hb)
levels
Rationale: Low preoperative HCT and Hb levels indicate the client may
require a blood transfusion before surgery. If the HCT and Hb levels
decrease during surgery because of blood loss, the potential need for a
transfusion increases. Possible renal failure is indicated by elevated BUN
or creatinine levels. Urine constituents aren't found in the blood.
Coagulation is determined by the presence of appropriate clotting factors,
not electrolytes.
89. Answer: (A) Platelet count, prothrombin time, and partial thromboplastin
time
Rationale: The diagnosis of DIC is based on the results of laboratory
studies of prothrombin time, platelet count, thrombin time, partial
thromboplastin time, and fibrinogen level as well as client history and other
assessment factors. Blood glucose levels, WBC count, calcium levels, and
potassium levels aren't used to confirm a diagnosis of DIC.
90. Answer: (D) Strawberries
Rationale: Common food allergens include berries, peanuts, Brazil nuts,
cashews, shellfish, and eggs. Bread, carrots, and oranges rarely cause
allergic reactions.
91. Answer: (B) A client with cast on the right leg who states, I have a funny
feeling in my right leg.
Rationale: It may indicate neurovascular compromise, requires immediate
assessment.
92. Answer: (D) A 62-year-old who had an abdominal-perineal resection three
days ago; client complaints of chills.
Rationale: The client is at risk for peritonitis; should be assessed for
further symptoms and infection.
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93. Answer: (C) The client spontaneously flexes his wrist when the blood
pressure is obtained.
Rationale: Carpal spasms indicate hypocalcemia.
94. Answer: (D) Use comfort measures and pillows to position the client.
Rationale: Using comfort measures and pillows to position the client is a
non-pharmacological methods of pain relief.
95. Answer: (B) Warm the dialysate solution.
Rationale: Cold dialysate increases discomfort. The solution should be
warmed to body temperature in warmer or heating pad; dont use
microwave oven.
96. Answer: (C) The client holds the cane with his left hand, moves the cane
forward followed by the right leg, and then moves the left leg.
Rationale: The cane acts as a support and aids in weight bearing for the
weaker right leg.
97. Answer: (A) Ask the womans family to provide personal items such as
photos or mementos.
Rationale: Photos and mementos provide visual stimulation to reduce
sensory deprivation.
98. Answer: (B) The client lifts the walker, moves it forward 10 inches, and
then takes several small steps forward.
Rationale: A walker needs to be picked up, placed down on all legs.
99. Answer: (C) Isolation from their families and familiar surroundings.
Rationale: Gradual loss of sight, hearing, and taste interferes with normal
functioning.
100. Answer: (A) Encourage the client to perform pursed lip breathing.
Rationale: Purse lip breathing prevents the collapse of lung unit and helps
client control rate and depth of breathing.
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TEST IV
Answers and Rationale Care of Clients with Physiologic and
Psychosocial Alterations
1. Answer: (C) Hypertension
Rationale: Hypertension, along with fever, and tenderness over the
grafted kidney, reflects acute rejection.
2. Answer: (A) Pain
Rationale: Sharp, severe pain (renal colic) radiating toward the genitalia
medulla insensitive to the CO2 stimulation for breathing. The hypoxic state
of the client then becomes the stimulus for breathing. Giving the client
oxygen in low concentrations will maintain the clients hypoxic drive.
14. Answer: (B) Facilitate ventilation of the left lung.
Rationale: Since only a partial pneumonectomy is done, there is a need
to promote expansion of this remaining Left lung by positioning the client
on the opposite unoperated side.
15. Answer: (A) Food and fluids will be withheld for at least 2 hours.
Rationale: Prior to bronchoscopy, the doctors sprays the back of the
throat with anesthetic to minimize the gag reflex and thus facilitate the
insertion of the bronchoscope. Giving the client food and drink after the
procedure without checking on the return of the gag reflex can cause the
client to aspirate. The gag reflex usually returns after two hours.
16. Answer: (C) hyperkalemia.
Rationale: Hyperkalemia is a common complication of acute renal failure.
It's life-threatening if immediate action isn't taken to reverse it. The
administration of glucose and regular insulin, with sodium bicarbonate if
necessary, can temporarily prevent cardiac arrest by moving potassium
into the cells and temporarily reducing serum potassium levels.
Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with
acute renal failure and aren't treated with glucose, insulin, or sodium
bicarbonate.
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17. Answer: (A) This condition puts her at a higher risk for cervical cancer;
therefore, she should have a Papanicolaou (Pap) smear annually.
Rationale: Women with condylomata acuminata are at risk for cancer of
the cervix and vulva. Yearly Pap smears are very important for early
detection. Because condylomata acuminata is a virus, there is no
permanent cure. Because condylomata acuminata can occur on the vulva,
a condom won't protect sexual partners. HPV can be transmitted to other
parts of the body, such as the mouth, oropharynx, and larynx.
18. Answer: (A) The left kidney usually is slightly higher than the right one.
Rationale: The left kidney usually is slightly higher than the right one. An
adrenal gland lies atop each kidney. The average kidney measures
approximately 11 cm (4-3/8") long, 5 to 5.8 cm (2" to 2.") wide, and 2.5
cm (1") thick. The kidneys are located retroperitoneally, in the posterior
aspect of the abdomen, on either side of the vertebral column. They lie
between the 12th thoracic and 3rd lumbar vertebrae.
19. Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine
6.5 mg/dl.
Rationale: The normal BUN level ranges 8 to 23 mg/dl; the normal serum
creatinine level ranges from 0.7 to 1.5 mg/dl. The test results in option C
are abnormally elevated, reflecting CRF and the kidneys' decreased ability
to remove nonprotein nitrogen waste from the blood. CRF causes
decreased pH and increased hydrogen ions not vice versa. CRF also
increases serum levels of potassium, magnesium, and phosphorous, and
decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls
within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also
falls with the normal range of 60% to 75%.
20. Answer: (D) Alteration in the size, shape, and organization of
differentiated cells
Rationale: Dysplasia refers to an alteration in the size, shape, and
organization of differentiated cells. The presence of completely
undifferentiated tumor cells that don't resemble cells of the tissues of their
origin is called anaplasia. An increase in the number of normal cells in a
normal arrangement in a tissue or an organ is called hyperplasia.
Replacement of one type of fully differentiated cell by another in tissues
where the second type normally isn't found is called metaplasia.
21. Answer: (D) Kaposi's sarcoma
Rationale: Kaposi's sarcoma is the most common cancer associated with
AIDS. Squamous cell carcinoma, multiple myeloma, and leukemia may
occur in anyone and aren't associated specifically with AIDS.
22. Answer: (C) To prevent cerebrospinal fluid (CSF) leakage
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Rationale: The client receiving a subarachnoid block requires special
positioning to prevent CSF leakage and headache and to ensure proper
anesthetic distribution. Proper positioning doesn't help prevent confusion,
seizures, or cardiac arrhythmias.
23. Answer: (A) Auscultate bowel sounds.
Rationale: If abdominal distention is accompanied by nausea, the nurse
must first auscultate bowel sounds. If bowel sounds are absent, the nurse
should suspect gastric or small intestine dilation and these findings must
be reported to the physician. Palpation should be avoided postoperatively
with abdominal distention. If peristalsis is absent, changing positions and
inserting a rectal tube won't relieve the client's discomfort.
24. Answer: (B) Lying on the left side with knees bent
Rationale: For a colonoscopy, the nurse initially should position the client
on the left side with knees bent. Placing the client on the right side with
legs straight, prone with the torso elevated, or bent over with hands
touching the floor wouldn't allow proper visualization of the large intestine.
25. Answer: (A) Blood supply to the stoma has been interrupted
Rationale: An ileostomy stoma forms as the ileum is brought through the
abdominal wall to the surface skin, creating an artificial opening for waste
elimination. The stoma should appear cherry red, indicating adequate
arterial perfusion. A dusky stoma suggests decreased perfusion, which
may result from interruption of the stoma's blood supply and may lead to
tissue damage or necrosis. A dusky stoma isn't a normal finding. Adjusting
the ostomy bag wouldn't affect stoma color, which depends on blood
supply to the area. An intestinal obstruction also wouldn't change stoma
color.
26. Answer: (A) Applying knee splints
Rationale: Applying knee splints prevents leg contractures by holding the
joints in a position of function. Elevating the foot of the bed can't prevent
contractures because this action doesn't hold the joints in a position of
function. Hyperextending a body part for an extended time is inappropriate
because it can cause contractures. Performing shoulder range-of-motion
exercises can prevent contractures in the shoulders, but not in the legs.
27. Answer: (B) Urine output of 20 ml/hour.
Rationale: A urine output of less than 40 ml/hour in a client with burns
indicates a fluid volume deficit. This client's PaO2 value falls within the
normal range (80 to 100 mm Hg). White pulmonary secretions also are
normal. The client's rectal temperature isn't significantly elevated and
probably results from the fluid volume deficit.
28. Answer: (A) Turn him frequently.
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Rationale: The most important intervention to prevent pressure ulcers is
frequent position changes, which relieve pressure on the skin and
underlying tissues. If pressure isn't relieved, capillaries become occluded,
reducing circulation and oxygenation of the tissues and resulting in cell
death and ulcer formation. During passive ROM exercises, the nurse
moves each joint through its range of movement, which improves joint
mobility and circulation to the affected area but doesn't prevent pressure
ulcers. Adequate hydration is necessary to maintain healthy skin and
ensure tissue repair. A footboard prevents plantar flexion and footdrop by
maintaining the foot in a dorsiflexed position.
29. Answer: (C) In long, even, outward, and downward strokes in the
direction of hair growth
Rationale: When applying a topical agent, the nurse should begin at the
midline and use long, even, outward, and downward strokes in the
direction of hair growth. This application pattern reduces the risk of follicle
irritation and skin inflammation.
30. Answer: (A) Beta -adrenergic blockers
Rationale: Beta-adrenergic blockers work by blocking beta receptors in
the myocardium, reducing the response to catecholamines and
sympathetic nerve stimulation. They protect the myocardium, helping to
reduce the risk of another infraction by decreasing myocardial oxygen
demand. Calcium channel blockers reduce the workload of the heart by
decreasing the heart rate. Narcotics reduce myocardial oxygen demand,
promote vasodilation, and decrease anxiety. Nitrates reduce myocardial
oxygen consumption bt decreasing left ventricular end diastolic pressure
(preload) and systemic vascular resistance (afterload).
31. Answer: (C) Raised 30 degrees
Rationale: Jugular venous pressure is measured with a centimeter ruler
to obtain the vertical distance between the sternal angle and the point of
highest pulsation with the head of the bed inclined between 15 to 30
degrees. Increased pressure cant be seen when the client is supine or
when the head of the bed is raised 10 degrees because the point that
marks the pressure level is above the jaw (therefore, not visible). In high
Fowlers position, the veins would be barely discernible above the clavicle.
32. Answer: (D) Inotropic agents
Rationale: Inotropic agents are administered to increase the force of the
hearts contractions, thereby increasing ventricular contractility and
ultimately increasing cardiac output. Beta-adrenergic blockers and calcium
channel blockers decrease the heart rate and ultimately decreased the
workload of the heart. Diuretics are administered to decrease the overall
vascular volume, also decreasing the workload of the heart.
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33. Answer: (B) Less than 30% of calories form fat
Rationale: A client with low serum HDL and high serum LDL levels should
get less than 30% of daily calories from fat. The other modifications are
appropriate for this client.
34. Answer: (C) The emergency department nurse calls up the latest
electrocardiogram results to check the clients progress
Rationale: The emergency department nurse is no longer directly
involved with the clients care and thus has no legal right to information
about his present condition. Anyone directly involved in his care (such as
the telemetry nurse and the on-call physician) has the right to information
about his condition. Because the client requested that the nurse update
his wife on his condition, doing so doesnt breach confidentiality.
35. Answer: (B) Check endotracheal tube placement.
Rationale: ET tube placement should be confirmed as soon as the client
arrives in the emergency department. Once the airways is secured,
oxygenation and ventilation should be confirmed using an end-tidal carbon
dioxide monitor and pulse oximetry. Next, the nurse should make sure
L.V. access is established. If the client experiences symptomatic
bradycardia, atropine is administered as ordered 0.5 to 1 mg every 3 to 5
minutes to a total of 3 mg. Then the nurse should try to find the cause of
the clients arrest by obtaining an ABG sample. Amiodarone is indicated
for ventricular tachycardia, ventricular fibrillation and atrial flutter not
symptomatic bradycardia.
36. Answer: (C) 95 mm Hg
Rationale: Use the following formula to calculate MAP
MAP = systolic + 2 (diastolic)
3
MAP=126 mm Hg + 2 (80 mm Hg)
3
MAP=286 mm HG
3
MAP=95 mm Hg
37. Answer: (C) Electrocardiogram, complete blood count, testing for occult
blood, comprehensive serum metabolic panel.
Rationale: An electrocardiogram evaluates the complaints of chest pain,
laboratory tests determines anemia, and the stool test for occult blood
determines blood in the stool. Cardiac monitoring, oxygen, and creatine
polydipsia, and polyphagia) and increasing fluid intake, the client may
prevent HHNS. Drinking a glass of nondiet soda would be appropriate for
hypoglycemia. A client whose diabetes is controlled with oral antidiabetic
agents usually doesn't need to monitor blood glucose levels. A highcarbohydrate
diet would exacerbate the client's condition, particularly if
fluid intake is low.
79. Answer: (D) Hyperparathyroidism
Rationale: Hyperparathyroidism is most common in older women and is
characterized by bone pain and weakness from excess parathyroid
hormone (PTH). Clients also exhibit hypercaliuria-causing polyuria. While
clients with diabetes mellitus and diabetes insipidus also have polyuria,
they don't have bone pain and increased sleeping. Hypoparathyroidism is
characterized by urinary frequency rather than polyuria.
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80. Answer: (C) "I'll take two-thirds of the dose when I wake up and one-third
in the late afternoon."
Rationale: Hydrocortisone, a glucocorticoid, should be administered
according to a schedule that closely reflects the body's own secretion of
this hormone; therefore, two-thirds of the dose of hydrocortisone should
be taken in the morning and one-third in the late afternoon. This dosage
schedule reduces adverse effects.
81. Answer: (C) High corticotropin and high cortisol levels
Rationale: A corticotropin-secreting pituitary tumor would cause high
corticotropin and high cortisol levels. A high corticotropin level with a low
cortisol level and a low corticotropin level with a low cortisol level would be
associated with hypocortisolism. Low corticotropin and high cortisol levels
would be seen if there was a primary defect in the adrenal glands.
82. Answer: (D) Performing capillary glucose testing every 4 hours
Rationale: The nurse should perform capillary glucose testing every 4
hours because excess cortisol may cause insulin resistance, placing the
client at risk for hyperglycemia. Urine ketone testing isn't indicated
because the client does secrete insulin and, therefore, isn't at risk for
ketosis. Urine specific gravity isn't indicated because although fluid
balance can be compromised, it usually isn't dangerously imbalanced.
Temperature regulation may be affected by excess cortisol and isn't an
accurate indicator of infection.
83. Answer: (C) onset to be at 2:30 p.m. and its peak to be at 4 p.m.
Rationale: Regular insulin, which is a short-acting insulin, has an onset of
15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the
insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m.
and the peak from 4 p.m. to 6 p.m.
84. Answer: (A) No increase in the thyroid-stimulating hormone (TSH) level
after 30 minutes during the TSH stimulation test
Rationale: In the TSH test, failure of the TSH level to rise after 30
minutes confirms hyperthyroidism. A decreased TSH level indicates a
pituitary deficiency of this hormone. Below-normal levels of T3 and T4, as
the morning.
Rationale: Promote venous return by applying external pressure on veins.
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TEST V
Answers and Rationale Care of Clients with Physiologic and
Psychosocial Alterations
1. Answer: (D) Focusing
Rationale: The nurse is using focusing by suggesting that the client
discuss a specific issue. The nurse didnt restate the question, make
observation, or ask further question (exploring).
2. Answer: (D) Remove all other clients from the dayroom.
Rationale: The nurses first priority is to consider the safety of the clients
in the therapeutic setting. The other actions are appropriate responses
after ensuring the safety of other clients.
3. Answer: (A) The client is disruptive.
Rationale: Group activity provides too much stimulation, which the client
will not be able to handle (harmful to self) and as a result will be disruptive
to others.
4. Answer: (C) Agree to talk with the mother and the father together.
Rationale: By agreeing to talk with both parents, the nurse can provide
emotional support and further assess and validate the familys needs.
5. Answer: (A) Perceptual disorders.
Rationale: Frightening visual hallucinations are especially common in
clients experiencing alcohol withdrawal.
6. Answer: (D) Suggest that it takes awhile before seeing the results.
Rationale: The client needs a specific response; that it takes 2 to 3 weeks
(a delayed effect) until the therapeutic blood level is reached.
7. Answer: (C) Superego
Rationale: This behavior shows a weak sense of moral consciousness.
According to Freudian theory, personality disorders stem from a weak
superego.
8. Answer: (C) Skeletal muscle paralysis.
Rationale: Anectine is a depolarizing muscle relaxant causing paralysis. It
is used to reduce the intensity of muscle contractions during the
convulsive stage, thereby reducing the risk of bone fractures or
dislocation.
9. Answer: (D) Increase calories, carbohydrates, and protein.
Rationale: This client increased protein for tissue building and increased
calories to replace what is burned up (usually via carbohydrates).
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10. Answer: (C) Acting overly solicitous toward the child.
Rationale: This behavior is an example of reaction formation, a coping
mechanism.
11. Answer: (A) By designating times during which the client can focus on the
behavior.
Rationale: The nurse should designate times during which the client can
execute an attempt.
39. Answer: (D) Disturbance in recalling recent events related to cerebral
hypoxia.
Rationale: Cell damage seems to interfere with registering input stimuli,
which affects the ability to register and recall recent events; vascular
dementia is related to multiple vascular lesions of the cerebral cortex and
subcortical structure.
40. Answer: (D) Encouraging the client to have blood levels checked as
ordered.
Rationale: Blood levels must be checked monthly or bimonthly when the
client is on maintenance therapy because there is only a small range
between therapeutic and toxic levels.
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41. Answer: (B) Fine hand tremors or slurred speech
Rationale: These are common side effects of lithium carbonate.
42. Answer: (D) Presence
Rationale: The constant presence of a nurse provides emotional support
because the client knows that someone is attentive and available in case
of an emergency.
43. Answer: (A) Clients perception of the presenting problem.
Rationale: The nurse can be most therapeutic by starting where the client
is, because it is the clients concept of the problem that serves as the
starting point of the relationship.
44. Answer: (B) Chocolate milk, aged cheese, and yogurt
Rationale: These high-tyramine foods, when ingested in the presence of
an MAO inhibitor, cause a severe hypertensive response.
45. Answer: (B) 4 to 6 weeks
Rationale: Crisis is self-limiting and lasts from 4 to 6 weeks.
46. Answer: (D) Males are more likely to use lethal methods than are females
Rationale: This finding is supported by research; females account for 90%
of suicide attempts but males are three times more successful because of
methods used.
47. Answer: (C) "Your cursing is interrupting the activity. Take time out in your
room for 10 minutes."
Rationale: The nurse should set limits on client behavior to ensure a
comfortable environment for all clients. The nurse should accept hostile or
quarrelsome client outbursts within limits without becoming personally
offended, as in option A. Option B is incorrect because it implies that the
client's actions reflect feelings toward the staff instead of the client's own
misery. Judgmental remarks, such as option D, may decrease the client's
self-esteem.
48. Answer: (C) lithium carbonate (Lithane)
Rationale: Lithium carbonate, an antimania drug, is used to treat clients
with cyclical schizoaffective disorder, a psychotic disorder once classified
under schizophrenia that causes affective symptoms, including maniclike
activity. Lithium helps control the affective component of this disorder.
Rationale: The best indicator that the behavior is controlled, if the client
exhibits no signs of aggression after partial release of restraints. Options
A, B, and D do not ensure that the client has controlled the behavior.
65. Answer: (A) increased attention span and concentration
Rationale: The medication has a paradoxic effect that decrease
hyperactivity and impulsivity among children with ADHD. B, C, D. Side
effects of Ritalin include anorexia, insomnia, diarrhea and irritability.
66. Answer: (C) Moderate
Rationale: The child with moderate mental retardation has an I.Q. of 3550 Profound Mental retardation has an I.Q. of below 20; Mild mental
retardation 50-70 and Severe mental retardation has an I.Q. of 20-35.
67. Answer: (D) Rearrange the environment to activate the child
Rationale: The child with autistic disorder does not want change.
Maintaining a consistent environment is therapeutic. A. Angry outburst can
be re-channeling through safe activities. B. Acceptance enhances a
trusting relationship. C. Ensure safety from self-destructive behaviors like
head banging and hair pulling.
68. Answer: (B) cocaine
Rationale: The manifestations indicate intoxication with cocaine, a CNS
stimulant. A. Intoxication with heroine is manifested by euphoria then
impairment in judgment, attention and the presence of papillary
constriction. C. Intoxication with hallucinogen like LSD is manifested by
grandiosity, hallucinations, synesthesia and increase in vital signs D.
Intoxication with Marijuana, a cannabinoid is manifested by sensation of
slowed time, conjunctival redness, social withdrawal, impaired judgment
and hallucinations.
69. Answer: (B) insidious onset
Rationale: Dementia has a gradual onset and progressive deterioration. It
causes pronounced memory and cognitive disturbances. A,C and D are all
characteristics of delirium.
70. Answer: (C) Claustrophobia
Rationale: Claustrophobia is fear of closed space. A. Agoraphobia is fear
of open space or being a situation where escape is difficult. B. Social
phobia is fear of performing in the presence of others in a way that will be
humiliating or embarrassing. D. Xenophobia is fear of strangers.
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71. Answer: (A) Revealing personal information to the client
Rationale: Counter-transference is an emotional reaction of the nurse on
the client based on her unconscious needs and conflicts. B and C. These
are therapeutic approaches. D. This is transference reaction where a
client has an emotional reaction towards the nurse based on her past.
72. Answer: (D) Hold the next dose and obtain an order for a stat serum
lithium level
Rationale: Diarrhea and vomiting are manifestations of Lithium toxicity.
The next dose of lithium should be withheld and test is done to validate
the observation. A. The manifestations are not due to drug interaction. B.
disorder is more commonly associated with small children rather than with
adolescents. Cognitive impairment is typically associated with delirium or
dementia. Labile mood is more characteristic of a client with cognitive
impairment or bipolar disorder.
86. Answer: (D) Its a mood disorder similar to major depression but of mild to
moderate severity
Rationale: Dysthymic disorder is a mood disorder similar to major
depression but it remains mild to moderate in severity. Cyclothymic
disorder is a mood disorder characterized by a mood range from moderate
depression to hypomania. Bipolar I disorder is characterized by a single
manic episode with no past major depressive episodes. Seasonalaffective
disorder is a form of depression occurring in the fall and winter.
87. Answer: (A) Vascular dementia has more abrupt onset
Rationale: Vascular dementia differs from Alzheimers disease in that it
has a more abrupt onset and runs a highly variable course. Personally
change is common in Alzheimers disease. The duration of delirium is
usually brief. The inability to carry out motor activities is common in
Alzheimers disease.
88. Answer: (C) Drug intoxication
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Rationale: This client was taking several medications that have a
propensity for producing delirium; digoxin (a digitalis glycoxide),
furosemide (a thiazide diuretic), and diazepam (a benzodiazepine).
Sufficient supporting data dont exist to suspect the other options as
causes.
89. Answer: (D) The client is experiencing visual hallucination
Rationale: The presence of a sensory stimulus correlates with the
definition of a hallucination, which is a false sensory perception. Aphasia
refers to a communication problem. Dysarthria is difficulty in speech
production. Flight of ideas is rapid shifting from one topic to another.
90. Answer: (D) The client looks at the shadow on a wall and tells the nurse
she sees frightening faces on the wall.
Rationale: Minor memory problems are distinguished from dementia by
their minor severity and their lack of significant interference with the
clients social or occupational lifestyle. Other options would be included in
the history data but dont directly correlate with the clients lifestyle.
91. Answer: (D) Loose association
Rationale: Loose associations are conversations that constantly shift in
topic. Concrete thinking implies highly definitive thought processes. Flight
of ideas is characterized by conversation thats disorganized from the
onset. Loose associations dont necessarily start in a cogently, then
becomes loose.
92. Answer: (C) Paranoid
Rationale: Because of their suspiciousness, paranoid personalities
ascribe malevolent activities to others and tent to be defensive, becoming
quarrelsome and argumentative. Clients with antisocial personality
PART III
PRACTICE TEST I
FOUNDATION OF NURSING
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FOUNDATION OF NURSING
1. Which element in the circular chain of infection can be eliminated by
preserving skin integrity?
a. Host
b. Reservoir
c. Mode of transmission
d. Portal of entry
2. Which of the following will probably result in a break in sterile technique for
respiratory isolation?
a. Opening the patients window to the outside environment
b. Turning on the patients room ventilator
c. Opening the door of the patients room leading into the hospital
corridor
d. Failing to wear gloves when administering a bed bath
3. Which of the following patients is at greater risk for contracting an
infection?
a. A patient with leukopenia
b. A patient receiving broad-spectrum antibiotics
c. A postoperative patient who has undergone orthopedic surgery
d. A newly diagnosed diabetic patient
41.In which step of the nursing process would the nurse ask a patient if the
medication she administered relieved his pain?
a. Assessmen t
b. Analysis
c. Planning
d. Evaluation
42.All of the following are good sources of vitamin A except:
a. White potatoes
b. Carrots
c. Apricots
d. Egg yolks
43.Which of the following is a primary nursing intervention necessary for all
patients with a Foley Catheter in place?
a. Maintain the drainage tubing and collection bag level with the
patients bladder
b. Irrigate the patient with 1% Neosporin solution three times a daily
c. Clamp the catheter for 1 hour every 4 hours to maintain the
bladders elasticity
d. Maintain the drainage tubing and collection bag below bladder level
to facilitate drainage by gravity
44.The ELISA test is used to:
a. Screen blood donors for antibodies to human immunodeficiency
virus (HIV)
b. Test blood to be used for transfusion for HIV antibodies
c. Aid in diagnosing a patient with AIDS
d. All of the above
45.The two blood vessels most commonly used for TPN infusion are the:
a. Subclavian and jugular veins
b. Brachial and subclavian veins
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c. Femoral and subclavian veins
d. Brachial and femoral veins
46.Effective skin disinfection before a surgical procedure includes which of
the following methods?
a. Shaving the site on the day before surgery
b. Applying a topical antiseptic to the skin on the evening before
surgery
c. Having the patient take a tub bath on the morning of surgery
d. Having the patient shower with an antiseptic soap on the evening
v=before and the morning of surgery
47.When transferring a patient from a bed to a chair, the nurse should use
which muscles to avoid back injury?
a. Abdominal muscles
b. Back muscles
c. Leg muscles
d. Upper arm muscles
operating room, the nurse and physician are required to wear sterile
gowns, gloves, masks, hair covers, and shoe covers for all invasive
procedures. Strict isolation requires the use of clean gloves, masks,
gowns and equipment to prevent the transmission of highly communicable
diseases by contact or by airborne routes. Terminal disinfection is the
disinfection of all contaminated supplies and equipment after a patient has
been discharged to prepare them for reuse by another patient. The
purpose of protective (reverse) isolation is to prevent a person with
seriously impaired resistance from coming into contact who potentially
pathogenic organisms.
8. C. The edges of a sterile field are considered contaminated. When sterile
items are allowed to come in contact with the edges of the field, the sterile
items also become contaminated.
9. B. Hair on or within body areas, such as the nose, traps and holds
particles that contain microorganisms. Yawning and hiccupping do not
prevent microorganisms from entering or leaving the body. Rapid eye
movement marks the stage of sleep during which dreaming occurs.
10. D. The inside of the glove is always considered to be clean, but not sterile.
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11. A. The back of the gown is considered clean, the front is contaminated.
So, after removing gloves and washing hands, the nurse should untie the
back of the gown; slowly move backward away from the gown, holding the
inside of the gown and keeping the edges off the floor; turn and fold the
gown inside out; discard it in a contaminated linen container; then wash
her hands again.
12. B. According to the Centers for Disease Control (CDC), blood-to-blood
contact occurs most commonly when a health care worker attempts to cap
a used needle. Therefore, used needles should never be recapped;
instead they should be inserted in a specially designed puncture resistant,
labeled container. Wearing gloves is not always necessary when
administering an I.M. injection. Enteric precautions prevent the transfer of
pathogens via feces.
13. A. Nurses and other health care professionals previously believed that
massaging a reddened area with lotion would promote venous return and
reduce edema to the area. However, research has shown that massage
only increases the likelihood of cellular ischemia and necrosis to the area.
14. B. Before a blood transfusion is performed, the blood of the donor and
recipient must be checked for compatibility. This is done by blood typing (a
test that determines a persons blood type) and cross-matching (a
procedure that determines the compatibility of the donors and recipients
blood after the blood types has been matched). If the blood specimens are
incompatible, hemolysis and antigen-antibody reactions will occur.
15. A. Platelets are disk-shaped cells that are essential for blood coagulation.
A platelet count determines the number of thrombocytes in blood available
for promoting hemostasis and assisting with blood coagulation after injury.
It also is used to evaluate the patients potential for bleeding; however, this
is not its primary purpose. The normal count ranges from 150,000 to
350,000/mm3. A count of 100,000/mm3 or less indicates a potential for
bleeding; count of less than 20,000/mm3 is associated with spontaneous
bleeding.
16. D. Leukocytosis is any transient increase in the number of white blood
cells (leukocytes) in the blood. Normal WBC counts range from 5,000 to
100,000/mm3. Thus, a count of 25,000/mm3 indicates leukocytosis.
17. A. Fatigue, muscle cramping, and muscle weaknesses are symptoms of
hypokalemia (an inadequate potassium level), which is a potential side
effect of diuretic therapy. The physician usually orders supplemental
potassium to prevent hypokalemia in patients receiving diuretics. Anorexia
is another symptom of hypokalemia. Dysphagia means difficulty
swallowing.
18. A. Pregnancy or suspected pregnancy is the only contraindication for a
chest X-ray. However, if a chest X-ray is necessary, the patient can wear
a lead apron to protect the pelvic region from radiation. Jewelry, metallic
objects, and buttons would interfere with the X-ray and thus should not be
worn above the waist. A signed consent is not required because a chest
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X-ray is not an invasive examination. Eating, drinking and medications are
allowed because the X-ray is of the chest, not the abdominal region.
19. A. Obtaining a sputum specimen early in this morning ensures an
adequate supply of bacteria for culturing and decreases the risk of
contamination from food or medication.
20. A. Initial sensitivity to penicillin is commonly manifested by a skin rash,
even in individuals who have not been allergic to it previously. Because of
the danger of anaphylactic shock, he nurse should withhold the drug and
notify the physician, who may choose to substitute another drug.
Administering an antihistamine is a dependent nursing intervention that
requires a written physicians order. Although applying corn starch to the
rash may relieve discomfort, it is not the nurses top priority in such a
potentially life-threatening situation.
21. D. The Z-track method is an I.M. injection technique in which the patients
skin is pulled in such a way that the needle track is sealed off after the
injection. This procedure seals medication deep into the muscle, thereby
minimizing skin staining and irritation. Rubbing the injection site is
contraindicated because it may cause the medication to extravasate into
the skin.
22. D. The vastus lateralis, a long, thick muscle that extends the full length of
the thigh, is viewed by many clinicians as the site of choice for I.M.
injections because it has relatively few major nerves and blood vessels.
The middle third of the muscle is recommended as the injection site. The
patient can be in a supine or sitting position for an injection into this site.
23. A. The mid-deltoid injection site can accommodate only 1 ml or less of
medication because of its size and location (on the deltoid muscle of the
arm, close to the brachial artery and radial nerve).
24. D. A 25G, 5/8 needle is the recommended size for insulin injection
because insulin is administered by the subcutaneous route. An 18G, 1 .
needle is usually used for I.M. injections in children, typically in the vastus
lateralis. A 22G, 1 . needle is usually used for adult I.M. injections, which
are typically administered in the vastus lateralis or ventrogluteal site.
25. D. Because an intradermal injection does not penetrate deeply into the
skin, a small-bore 25G needle is recommended. This type of injection is
used primarily to administer antigens to evaluate reactions for allergy or
sensitivity studies. A 20G needle is usually used for I.M. injections of oilbased
medications; a 22G needle for I.M. injections; and a 25G needle, for
I.M. injections; and a 25G needle, for subcutaneous insulin injections.
26. A. Parenteral penicillin can be administered I.M. or added to a solution
and given I.V. It cannot be administered subcutaneously or intradermally.
27. D. gr 10 x 60mg/gr 1 = 600 mg
28. C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute
29. A. Hemoglobinuria, the abnormal presence of hemoglobin in the urine,
indicates a hemolytic reaction (incompatibility of the donors and
recipients blood). In this reaction, antibodies in the recipients plasma
combine rapidly with donor RBCs; the cells are hemolyzed in either
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circulatory or reticuloendothelial system. Hemolysis occurs more rapidly in
ABO incompatibilities than in Rh incompatibilities. Chest pain and urticaria
may be symptoms of impending anaphylaxis. Distended neck veins are an
indication of hypervolemia.
30. C. In real failure, the kidney loses their ability to effectively eliminate
wastes and fluids. Because of this, limiting the patients intake of oral and
I.V. fluids may be necessary. Fever, chronic obstructive pulmonary
disease, and dehydration are conditions for which fluids should be
encouraged.
31. D. Phlebitis, the inflammation of a vein, can be caused by chemical
irritants (I.V. solutions or medications), mechanical irritants (the needle or
catheter used during venipuncture or cannulation), or a localized allergic
reaction to the needle or catheter. Signs and symptoms of phlebitis
include pain or discomfort, edema and heat at the I.V. insertion site, and a
red streak going up the arm or leg from the I.V. insertion site.
32. D. Return demonstration provides the most certain evidence for evaluating
the effectiveness of patient teaching.
33. D. Capsules, enteric-coated tablets, and most extended duration or
sustained release products should not be dissolved for use in a
gastrostomy tube. They are pharmaceutically manufactured in these forms
for valid reasons, and altering them destroys their purpose. The nurse
should seek an alternate physicians order when an ordered medication is
inappropriate for delivery by tube.
34. D. A drug-allergy is an adverse reaction resulting from an immunologic
response following a previous sensitizing exposure to the drug. The
reaction can range from a rash or hives to anaphylactic shock. Tolerance
PRACTICE TEST II
Maternal and Child Health
Nursing Crib Student Nurses Community 207
MATERNAL AND CHILD HEALTH
1. For the client who is using oral contraceptives, the nurse informs the client
about the need to take the pill at the same time each day to accomplish
which of the following?
a. Decrease the incidence of nausea
b. Maintain hormonal levels
c. Reduce side effects
d. Prevent drug interactions
2. When teaching a client about contraception. Which of the following would
the nurse include as the most effective method for preventing sexually
transmitted infections?
a. Spermicides
b. Diaphragm
c. Condoms
d. Vasectomy
3. When preparing a woman who is 2 days postpartum for discharge,
recommendations for which of the following contraceptive methods would
be avoided?
a. Diaphragm
b. Female condom
c. Oral contraceptives
d. Rhythm method
4. For which of the following clients would the nurse expect that an
intrauterine device would not be recommended?
a. Woman over age 35
b. Nulliparous woman
c. Promiscuous young adult
d. Postpartum client
5. A client in her third trimester tells the nurse, Im constipated all the time!
Which of the following should the nurse recommend?
a. Daily enemas
b. Laxatives
c. Increased fiber intake
d. Decreased fluid intake
6. Which of the following would the nurse use as the basis for the teaching
plan when caring for a pregnant teenager concerned about gaining too
much weight during pregnancy?
a. 10 pounds per trimester
b. 1 pound per week for 40 weeks
c. . pound per week for 40 weeks
d. A total gain of 25 to 30 pounds
7. The client tells the nurse that her last menstrual period started on January
14 and ended on January 20. Using Nageles rule, the nurse determines
her EDD to be which of the following?
a. September 27
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b. October 21
c. November 7
d. December 27
8. When taking an obstetrical history on a pregnant client who states, I had
a son born at 38 weeks gestation, a daughter born at 30 weeks gestation
and I lost a baby at about 8 weeks, the nurse should record her
obstetrical history as which of the following?
a. G2 T2 P0 A0 L2
b. G3 T1 P1 A0 L2
c. G3 T2 P0 A0 L2
d. G4 T1 P1 A1 L2
9. When preparing to listen to the fetal heart rate at 12 weeks gestation, the
nurse would use which of the following?
a. Stethoscope placed midline at the umbilicus
b. Doppler placed midline at the suprapubic region
c. Fetoscope placed midway between the umbilicus and the xiphoid
process
d. External electronic fetal monitor placed at the umbilicus
10.When developing a plan of care for a client newly diagnosed with
gestational diabetes, which of the following instructions would be the
priority?
a. Dietary intake
b. Medication
c. Exercise
d. Glucose monitoring
11.A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of
the following would be the priority when assessing the client?
a. Glucosuria
b. Depression
c. Hand/face edema
d. Dietary intake
12.A client 12 weeks pregnant come to the emergency department with
abdominal cramping and moderate vaginal bleeding. Speculum
examination reveals 2 to 3 cms cervical dilation. The nurse would
document these findings as which of the following?
a. Threatened abortion
b. Imminent abortion
c. Complete abortion
d. Missed abortion
13.Which of the following would be the priority nursing diagnosis for a client
with an ectopic pregnancy?
conception?
a. Chromosome
b. Blastocyst
c. Zygote
d. Trophoblast
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47.In the late 1950s, consumers and health care professionals began
challenging the routine use of analgesics and anesthetics during childbirth.
Which of the following was an outgrowth of this concept?
a. Labor, delivery, recovery, postpartum (LDRP)
b. Nurse-midwifery
c. Clinical nurse specialist
d. Prepared childbirth
48.A client has a midpelvic contracture from a previous pelvic injury due to a
motor vehicle accident as a teenager. The nurse is aware that this could
prevent a fetus from passing through or around which structure during
childbirth?
a. Symphysis pubis
b. Sacral promontory
c. Ischial spines
d. Pubic arch
49.When teaching a group of adolescents about variations in the length of the
menstrual cycle, the nurse understands that the underlying mechanism is
due to variations in which of the following phases?
a. Menstrual phase
b. Proliferative phase
c. Secretory phase
d. Ischemic phase
50.When teaching a group of adolescents about male hormone production,
which of the following would the nurse include as being produced by the
Leydig cells?
a. Follicle-stimulating hormone
b. Testosterone
c. Leuteinizing hormone
d. Gonadotropin releasing hormone
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ANSWERS AND RATIONALE MATERNAL AND CHILD HEALTH
1. B . Regular timely ingestion of oral contraceptives is necessary to maintain
hormonal levels of the drugs to suppress the action of the hypothalamus
and anterior pituitary leading to inappropriate secretion of FSH and LH.
Therefore, follicles do not mature, ovulation is inhibited, and pregnancy is
prevented. The estrogen content of the oral site contraceptive may cause
the nausea, regardless of when the pill is taken. Side effects and drug
interactions may occur with oral contraceptives regardless of the time the
pill is taken.
2. C . Condoms, when used correctly and consistently, are the most effective
evaporation during bathing. Placing the infant under the radiant warmer
after bathing will assist the infant to be rewarmed. Covering the scale with
a warmed blanket prior to weighing prevents heat loss through conduction.
A knit cap prevents heat loss from the head a large head, a large body
surface area of the newborns body.
21. B. A fractured clavicle would prevent the normal Moro response of
symmetrical sequential extension and abduction of the arms followed by
flexion and adduction. In talipes equinovarus (clubfoot) the foot is turned
medially, and in plantar flexion, with the heel elevated. The feet are not
involved with the Moro reflex. Hypothyroiddism has no effect on the
primitive reflexes. Absence of the Moror reflex is the most significant
single indicator of central nervous system status, but it is not a sign of
increased intracranial pressure.
22. B. Hemorrhage is a potential risk following any surgical procedure.
Although the infant has been given vitamin K to facilitate clotting, the
prophylactic dose is often not sufficient to prevent bleeding. Although
infection is a possibility, signs will not appear within 4 hours after the
surgical procedure. The primary discomfort of circumcision occurs during
the surgical procedure, not afterward. Although feedings are withheld prior
to the circumcision, the chances of dehydration are minimal.
23. B . The presence of excessive estrogen and progesterone in the maternalfetal
blood followed by prompt withdrawal at birth precipitates breast
engorgement, which will spontaneously resolve in 4 to 5 days after birth.
The trauma of the birth process does not cause inflammation of the
newborns breast tissue. Newborns do not have breast malignancy. This
reply by the nurse would cause the mother to have undue anxiety. Breast
tissue does not hypertrophy in the fetus or newborns.
24. D . The first 15 minutes to 1 hour after birth is the first period of reactivity
involving respiratory and circulatory adaptation to extrauterine life. The
data given reflect the normal changes during this time period. The infants
assessment data reflect normal adaptation. Thus, the physician does not
need to be notified and oxygen is not needed. The data do not indicate the
presence of choking, gagging or coughing, which are signs of excessive
secretions. Suctioning is not necessary.
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25. B. Application of 70% isopropyl alcohol to the cord minimizes
microorganisms (germicidal) and promotes drying. The cord should be
kept dry until it falls off and the stump has healed. Antibiotic ointment
should only be used to treat an infection, not as a prophylaxis. Infants
should not be submerged in a tub of water until the cord falls off and the
stump has completely healed.
26. B. To determine the amount of formula needed, do the following
mathematical calculation. 3 kg x 120 cal/kg per day = 360 calories/day
feeding q 4 hours = 6 feedings per day = 60 calories per feeding: 60
calories per feeding; 60 calories per feeding with formula 20 cal/oz = 3
ounces per feeding. Based on the calculation. 2, 4 or 6 ounces are
incorrect.
27. A. Intrauterine anoxia may cause relaxation of the anal sphincter and
emptying of meconium into the amniotic fluid. At birth some of the
meconium fluid may be aspirated, causing mechanical obstruction or
chemical pneumonitis. The infant is not at increased risk for
gastrointestinal problems. Even though the skin is stained with meconium,
it is noninfectious (sterile) and nonirritating. The postterm meconiumstained
infant is not at additional risk for bowel or urinary problems.
28. C . The nurse should use a nonelastic, flexible, paper measuring tape,
placing the zero point on the superior border of the symphysis pubis and
stretching the tape across the abdomen at the midline to the top of the
fundus. The xiphoid and umbilicus are not appropriate landmarks to use
when measuring the height of the fundus (McDonalds measurement).
29. B . Women hospitalized with severe preeclampsia need decreased CNS
stimulation to prevent a seizure. Seizure precautions provide
environmental safety should a seizure occur. Because of edema, daily
weight is important but not the priority. Preclampsia causes vasospasm
and therefore can reduce utero-placental perfusion. The client should be
placed on her left side to maximize blood flow, reduce blood pressure, and
promote diuresis. Interventions to reduce stress and anxiety are very
important to facilitate coping and a sense of control, but seizure
precautions are the priority.
30. C. Cessation of the lochial discharge signifies healing of the endometrium.
Risk of hemorrhage and infection are minimal 3 weeks after a normal
vaginal delivery. Telling the client anytime is inappropriate because this
response does not provide the client with the specific information she is
requesting. Choice of a contraceptive method is important, but not the
specific criteria for safe resumption of sexual activity. Culturally, the 6weeks examination has been used as the time frame for resuming sexual
activity, but it may be resumed earlier.
31. C . The middle third of the vastus lateralis is the preferred injection site for
vitamin K administration because it is free of blood vessels and nerves
and is large enough to absorb the medication. The deltoid muscle of a
newborn is not large enough for a newborn IM injection. Injections into this
muscle in a small child might cause damage to the radial nerve. The
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anterior femoris muscle is the next safest muscle to use in a newborn but
is not the safest. Because of the proximity of the sciatic nerve, the gluteus
maximus muscle should not be until the child has been walking 2 years.
32. D . Bartholins glands are the glands on either side of the vaginal orifice.
The clitoris is female erectile tissue found in the perineal area above the
urethra. The parotid glands are open into the mouth. Skenes glands open
into the posterior wall of the female urinary meatus.
33. D . The fetal gonad must secrete estrogen for the embryo to differentiate
as a female. An increase in maternal estrogen secretion does not effect
differentiation of the embryo, and maternal estrogen secretion occurs in
d. Anticonvulsants
2. Halfway through the administration of blood, the female client complains of
lumbar pain. After stopping the infusion Nurse Hazel should:
a. Increase the flow of normal saline
b. Assess the pain further
c. Notify the blood bank
d. Obtain vital signs.
3. Nurse Maureen knows that the positive diagnosis for HIV infection is made
based on which of the following:
a. A history of high risk sexual behaviors.
b. Positive ELISA and western blot tests
c. Identification of an associated opportunistic infection
d. Evidence of extreme weight loss and high fever
4. Nurse Maureen is aware that a client who has been diagnosed with chronic
renal failure recognizes an adequate amount of high-biologic-value protein
when the food the client selected from the menu was:
a. Raw carrots
b. Apple juice
c. Whole wheat bread
d. Cottage cheese
5. Kenneth who has diagnosed with uremic syndrome has the potential to
develop complications. Which among the following complications should the
nurse anticipates:
a. Flapping hand tremors
b. An elevated hematocrit level
c. Hypotension
d. Hypokalemia
6. A client is admitted to the hospital with benign prostatic hyperplasia, the nurse
most relevant assessment would be:
a. Flank pain radiating in the groin
b. Distention of the lower abdomen
c. Perineal edema
d. Urethral discharge
7. A client has undergone with penile implant. After 24 hrs of surgery, the clients
scrotum was edematous and painful. The nurse should:
a. Assist the client with sitz bath
b. Apply war soaks in the scrotum
c. Elevate the scrotum using a soft support
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d. Prepare for a possible incision and drainage.
8. Nurse hazel receives emergency laboratory results for a client with chest pain
and immediately informs the physician. An increased myoglobin level
suggests which of the following?
a. Liver disease
b. Myocardial damage
c. Hypertension
d. Cancer
9. Nurse Maureen would expect the a client with mitral stenosis would
demonstrate symptoms associated with congestion in the:
a. Right atrium
b. Superior vena cava
c. Aorta
d. Pulmonary
10. A client has been diagnosed with hypertension. The nurse priority nursing
diagnosis would be:
a. Ineffective health maintenance
b. Impaired skin integrity
c. Deficient fluid volume
d. Pain
11. Nurse Hazel teaches the client with angina about common expected side
effects of nitroglycerin including:
a. high blood pressure
b. stomach cramps
c. headache
d. shortness of breath
12. The following are lipid abnormalities. Which of the following is a risk factor for
the development of atherosclerosis and PVD?
a. High levels of low density lipid (LDL) cholesterol
b. High levels of high density lipid (HDL) cholesterol
c. Low concentration triglycerides
d. Low levels of LDL cholesterol.
13. Which of the following represents a significant risk immediately after surgery
for repair of aortic aneurysm?
a. Potential wound infection
b. Potential ineffective coping
c. Potential electrolyte balance
d. Potential alteration in renal perfusion
14. Nurse Josie should instruct the client to eat which of the following foods to
obtain the best supply of Vitamin B12?
a. dairy products
b. vegetables
c. Grains
d. Broccoli
15. Karen has been diagnosed with aplastic anemia. The nurse monitors for
changes in which of the following physiologic functions?
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a. Bowel function
b. Peripheral sensation
c. Bleeding tendencies
d. Intake and out put
16. Lydia is scheduled for elective splenectomy. Before the clients goes to
surgery, the nurse in charge final assessment would be:
a. signed consent
b. vital signs
c. name band
d. empty bladder
17. What is the peak age range in acquiring acute lymphocytic leukemia (ALL)?
a. 4 to 12 years.
b. 20 to 30 years
c. 40 to 50 years
d. 60 60 70 years
18. Marie with acute lymphocytic leukemia suffers from nausea and headache.
These clinical manifestations may indicate all of the following except
a. effects of radiation
b. chemotherapy side effects
c. meningeal irritation
d. gastric distension
19. A client has been diagnosed with Disseminated Intravascular Coagulation
(DIC). Which of the following is contraindicated with the client?
a. Administering Heparin
b. Administering Coumadin
c. Treating the underlying cause
d. Replacing depleted blood products
20. Which of the following findings is the best indication that fluid replacement for
the client with hypovolemic shock is adequate?
a. Urine output greater than 30ml/hr
b. Respiratory rate of 21 breaths/minute
c. Diastolic blood pressure greater than 90 mmhg
d. Systolic blood pressure greater than 110 mmhg
21. Which of the following signs and symptoms would Nurse Maureen include in
teaching plan as an early manifestation of laryngeal cancer?
a. Stomatitis
b. Airway obstruction
c. Hoarseness
d. Dysphagia
22. Karina a client with myasthenia gravis is to receive immunosuppressive
therapy. The nurse understands that this therapy is effective because it:
a. Promotes the removal of antibodies that impair the transmission of
impulses
b. Stimulates the production of acetylcholine at the neuromuscular
junction.
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c. Decreases the production of autoantibodies that attack the
acetylcholine receptors.
d. Inhibits the breakdown of acetylcholine at the neuromuscular junction.
23. A female client is receiving IV Mannitol. An assessment specific to safe
administration of the said drug is:
a. Vital signs q4h
b. Weighing daily
c. Urine output hourly
d. Level of consciousness q4h
24. Patricia a 20 year old college student with diabetes mellitus requests
additional information about the advantages of using a pen like insulin
delivery devices. The nurse explains that the advantages of these devices
over syringes includes:
a. Accurate dose delivery
b. Shorter injection time
c. Lower cost with reusable insulin cartridges
d. Use of smaller gauge needle.
25. A male clients left tibia is fractures in an automobile accident, and a cast is
applied. To assess for damage to major blood vessels from the fracture tibia,
the nurse in charge should monitor the client for:
a. Swelling of the left thigh
b. Increased skin temperature of the foot
c. Prolonged reperfusion of the toes after blanching
d. Increased blood pressure
26. After a long leg cast is removed, the male client should:
a. Cleanse the leg by scrubbing with a brisk motion
b. Put leg through full range of motion twice daily
c. Report any discomfort or stiffness to the physician
d. Elevate the leg when sitting for long periods of time.
27. While performing a physical assessment of a male client with gout of the
great toe, NurseVivian should assess for additional tophi (urate deposits) on
the:
a. Buttocks
b. Ears
c. Face
d. Abdomen
28. Nurse Katrina would recognize that the demonstration of crutch walking with
tripod gait was understood when the client places weight on the:
a. Palms of the hands and axillary regions
b. Palms of the hand
c. Axillary regions
d. Feet, which are set apart
29. Mang Jose with rheumatoid arthritis states, the only time I am without pain is
when I lie in bed perfectly still. During the convalescent stage, the nurse in
charge with Mang Jose should encourage:
a. Active joint flexion and extension
Nursing Crib Student Nurses Community 228
b. Continued immobility until pain subsides
c. Range of motion exercises twice daily
d. Flexion exercises three times daily
30. A male client has undergone spinal surgery, the nurse should:
a. Observe the clients bowel movement and voiding patterns
a. Normal
b. Atonic
c. Spastic
d. Uncontrolled
38. Which of the following stage the carcinogen is irreversible?
a. Progression stage
b. Initiation stage
c. Regression stage
d. Promotion stage
39. Among the following components thorough pain assessment, which is the
most significant?
a. Effect
b. Cause
c. Causing factors
d. Intensity
40. A 65 year old female is experiencing flare up of pruritus. Which of the clients
action could aggravate the cause of flare ups?
a. Sleeping in cool and humidified environment
b. Daily baths with fragrant soap
c. Using clothes made from 100% cotton
d. Increasing fluid intake
41. Atropine sulfate (Atropine) is contraindicated in all but one of the following
client?
a. A client with high blood
b. A client with bowel obstruction
c. A client with glaucoma
d. A client with U.T.I
42. Among the following clients, which among them is high risk for potential
hazards from the surgical experience?
a. 67-year-old client
b. 49-year-old client
c. 33-year-old client
d. 15-year-old client
43. Nurse Jon assesses vital signs on a client undergone epidural anesthesia.
Which of the following would the nurse assess next?
a. Headache
b. Bladder distension
c. Dizziness
d. Ability to move legs
44. Nurse Katrina should anticipate that all of the following drugs may be used in
the attempt to control the symptoms of Meniere's disease except:
a. Antiemetics
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b. Diuretics
c. Antihistamines
d. Glucocorticoids
neuromuscular junction
23. C . The osmotic diuretic mannitol is contraindicated in the presence of
inadequate renal function or heart failure because it increases the
intravascular volume that must be filtered and excreted by the kidney.
24. A . These devices are more accurate because they are easily to used and
have improved adherence in insulin regimens by young people because the
medication can be administered discreetly.
25. C . Damage to blood vessels may decrease the circulatory perfusion of the
toes, this would indicate the lack of blood supply to the extremity.
26. D . Elevation will help control the edema that usually occurs.
27. B . Uric acid has a low solubility, it tends to precipitate and form deposits at
various sites where blood flow is least active, including cartilaginous tissue
such as the ears.
28. B . The palms should bear the clients weight to avoid damage to the nerves in
the axilla.
29. A . Active exercises, alternating extension, flexion, abduction, and adduction,
mobilize exudates in the joints relieves stiffness and pain.
30. C . Alteration in sensation and circulation indicates damage to the spinal cord,
if these occurs notify physician immediately.
31. A . In the diuretic phase fluid retained during the oliguric phase is excreted
and may reach 3 to 5 liters daily, hypovolemia may occur and fluids should be
replaced.
32. C . The constituents of CSF are similar to those of blood plasma. An
examination for glucose content is done to determine whether a body fluid is
a mucus or a CSF. A CSF normally contains glucose.
33. B . Trauma is one of the primary cause of brain damage and seizure activity in
adults. Other common causes of seizure activity in adults include neoplasms,
withdrawal from drugs and alcohol, and vascular disease.
34. A . It is crucial to monitor the pupil size and papillary response to indicate
changes around the cranial nerves.
35. C . The nurse most positive approach is to encourage the client with multiple
sclerosis to stay active, use stress reduction techniques and avoid fatigue
because it is important to support the immune system while remaining active.
Nursing Crib Student Nurses Community 233
36. D . Restlessness is an early indicator of hypoxia. The nurse should suspect
hypoxia in unconscious client who suddenly becomes restless.
37. B . In spinal shock, the bladder becomes completely atonic and will continue
to fill unless the client is catheterized.
38. A . Progression stage is the change of tumor from the preneoplastic state or
low degree of malignancy to a fast growing tumor that cannot be reversed.
39. D . Intensity is the major indicative of severity of pain and it is important for the
evaluation of the treatment.
40. B . The use of fragrant soap is very drying to skin hence causing the pruritus.
41. C . Atropine sulfate is contraindicated with glaucoma patients because it
increases intraocular pressure.
42. A . A 67 year old client is greater risk because the older adult client is more
statement most likely would elicit which of the following client reaction?
a. Depensiveness
b. Embarrassment
c. Shame
d. Remorsefulness
20.Which of the following approaches would be most appropriate to use with
a client suffering from narcissistic personality disorder when discrepancies
exist between what the client states and what actually exist?
a. Rationalization
b. Supportive confrontation
c. Limit setting
d. Consistency
21.Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis and
hyperactivity. Blood pressure is 190/87 mmhg and pulse is 92 bpm. Which
of the medications would the nurse expect to administer?
a. Naloxone (Narcan)
b. Benzlropine (Cogentin)
c. Lorazepam (Ativan)
d. Haloperidol (Haldol)
22.Which of the following foods would the nurse Trish eliminate from the diet
of a client in alcohol withdrawal?
a. Milk
b. Orange Juice
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c. Soda
d. Regular Coffee
23.Which of the following would Nurse Hazel expect to assess for a client
who is exhibiting late signs of heroin withdrawal?
a. Yawning & diaphoresis
b. Restlessness & Irritability
c. Constipation & steatorrhea
d. Vomiting and Diarrhea
24.To establish open and trusting relationship with a female client who has
been hospitalized with severe anxiety, the nurse in charge should?
a. Encourage the staff to have frequent interaction with the client
b. Share an activity with the client
c. Give client feedback about behavior
d. Respect clients need for personal space
25. Nurse Monette recognizes that the focus of environmental (MILIEU)
therapy is to:
a. Manipulate the environment to bring about positive changes in
behavior
b. Allow the clients freedom to determine whether or not they will be
involved in activities
c. Role play life events to meet individual needs
d. Use natural remedies rather than drugs to control behavior
client. The Nurse should watch for clues, such as communicating suicidal
thoughts, and messages; hoarding medications and talking about death.
4. B . Establishing a consistent eating plan and monitoring clients weight are
important to this disorder.
5. C . Appropriate nursing interventions for an anxiety attack include using short
sentences, staying with the client, decreasing stimuli, remaining calm and
medicating as needed.
6. B . Delusion of grandeur is a false belief that one is highly famous and
important.
7. D . Individual with dependent personality disorder typically shows
indecisiveness submissiveness and clinging behavior so that others will
make decisions with them.
8. A . Clients with schizotypal personality disorder experience excessive social
anxiety that can lead to paranoid thoughts
9. B . Bulimia disorder generally is a maladaptive coping response to stress and
underlying issues. The client should identify anxiety causing situation that
stimulate the bulimic behavior and then learn new ways of coping with the
anxiety.
10. A . An adult age 31 to 45 generates new level of awareness.
11. A . Neuromuscular Blocker, such as SUCCINYLCHOLINE (Anectine)
produces respiratory depression because it inhibits contractions of respiratory
muscles.
12. C . With depression, there is little or no emotional involvement therefore little
alteration in affect.
13. D . These clients often hide food or force vomiting; therefore they must be
carefully monitored.
14. A . These clients have severely depleted levels of sodium and potassium
because of their starvation diet and energy expenditure, these electrolytes are
necessary for cardiac functioning.
15. B . Limiting unnecessary interaction will decrease stimulation and agitation.
16. C . Ritualistic behavior seen in this disorder is aimed at controlling guilt and
inadequacy by maintaining an absolute set pattern of behavior.
17. D . The nurse needs to set limits in the clients manipulative behavior to help
the client control dysfunctional behavior. A consistent approach by the staff is
necessary to decrease manipulation.
18. B . Any suicidal statement must be assessed by the nurse. The nurse should
discuss the clients statement with her to determine its meaning in terms of
suicide.
19. A . When the staff member ask the client if he wonders why others find him
repulsive, the client is likely to feel defensive because the question is
belittling. The natural tendency is to counterattack the threat to self image.
Nursing Crib Student Nurses Community 243
20. B . The nurse would specifically use supportive confrontation with the client to
point out discrepancies between what the client states and what actually
exists to increase responsibility for self.
21. C . The nurse would most likely administer benzodiazepine, such as lorazepan
43. B . Open ended questions and silence are strategies used to encourage
clients to discuss their problem in descriptive manner.
44. C . Clients who are withdrawn may be immobile and mute, and require
consistent, repeated interventions. Communication with withdrawn clients
requires much patience from the nurse. The nurse facilitates communication
with the client by sitting in silence, asking open-ended question and pausing
to provide opportunities for the client to respond.
45. D . When hallucination is present, the nurse should reinforce reality with the
client.
46. A . Personal characteristics of abuser include low self-esteem, immaturity,
dependence, insecurity and jealousy.
47. D . A short acting skeletal muscle relaxant such as succinylcholine (Anectine)
is administered during this procedure to prevent injuries during seizure.
48. C . Recognizing situations that produce anxiety allows the client to prepare to
cope with anxiety or avoid specific stimulus.
49. D . Electroconvulsive therapy is an effective treatment for depression that has
not responded to medication
50. B . In an emergency, lives saving facts are obtained first. The name and the
amount of medication ingested are of outmost important in treating this
potentially life threatening situation.
Nursing Crib Student Nurses Community 245
References
Maternal and Child Nursing by Adele Pilliterri
Wongs Nursing Care of Infants and Children 8th Edition
MS Manuals of Nursing Practice by Lippincot t
Psychiatric Mental Health Nursing 4th Edition by Fortinash
Management and Leadership for Nurse Administrators 5th Edition by Linda
Roussel
Essentials of Gerontological Nursing by Patricia Tablosk i
Fundamentals of Nursing 2nd Edition by Josie Quiambao-Udan RN, MAN
Nursing Practice in the Community 4th Edition by Araceli Maglaya
Community Health Nursing Services in the Philippines 9th Edition- DOH
Fundamentals of Nursing 7th Edition by Barbara Kozier Et al.
Modules for Basic Nursing Skills 6th Edition by Janice Rider Ellis
Kaplan NCLEX-RN 200 8-2009 Edition by Barbara Irwin
Saunders Q &A Review for the NCLEX-RN Examination 3rd Edition by Linda
Anne Silvestre
Sia's Nursing Questions and Answers 2005 Edition by Maria Loreto
Evangelista-Sia
NCLEX-RN Made Incredibly Easy by Lippincott and Williams
Lippincotts Review Series Pediatric Nursing 2nd Edition
Mosby's Review Questions for the NCLEX-RN Examination 5th Edition
Saunders NCLEX-RN Examination 3rd edition
Lippincotts Review for NCLEX-RN 8th edition
Davis NCLEX-RN Success 2nd edition
Lippincotts Review Series Maternal Newborn Nursing 2nd Edition