UPDATED VERSION FOR PROMETRIC EXAM2020

1. AFTER VAGINAL BIRTH OF A NEONATE,THE NURSE DETERMINES THAT THE

PLACENTA IS ABOUT TO SEPARATE WHEN WHICH OCCURS?
A. THE UTERUS BECOME OVAL SHAPED
B. THE UTERUS ENLARGES
C. A SUDDEN GUSH OF DARK BLOOD OCCURS
D. THE CLIENT EXPENDS EFFORTS PUSHING
ANS. C
2. A CLIENT AT 40+ WEEKS’ GESTATION VISITS THE EMERGENCY DEPARTMENT
BECAUSE SHE THINKS SHE IS IN LABOR . WHICH IS THE BEST INDICATION THAT THE
CLIENT IS IN TRUE LABOR?
A. FETAL DESCENT IN TO THE PELVIC INLET
B. CERVICAL DILATATION AND EFFACEMENT
C. PAINFUL CONTRACTIONS EVERY 3TO 5 MINUTES
D. LEAKING AMNIOTIC FLUID CLEAR IN COLOR
ANS. B
3. A CLIENT HAS A CERCLAGE PLACED AT 10WEEK’S GESTATION .SHE HAS HAD NO
CONTRACTIONS ,AND HER CERVIX IS DILATED 2CM.THE NURSE IS PREPARING THE
CLIENT FOR DISCHARGE .WHICH STATEMENT BY THE CLIENT SHOULD INDICATE TO
THE NURSE THAT THE CLIENT NEEDS FURTHER INSTRUCTION?
A. I WILL NEED MORE FREQUENT PRENATAL VISITS.
B. I SHOULD CALL IF IAM LEAKING FLUID OR HAVE BLEEDING OR CONTRACTIONS
C. I CAN HAVE SEX AGAIN IN ABOUT 2 WEEKS.
D. I CAN HAVE NOTHING IN MY VAGINA UNTIL IAM AT TERM
ANS. C
4. AT A OSTPARTUM CHECK UP 11DAYS AFTER CHILDBIRTH,THE NURSE ASKS THE
CLIENT ABOUT THE COLOR OF HER LOCHIA.WHICH COLOR IS EXPECTED?
A. DAR KRED
B. PINK
C. BROWN
D. WHITE
ANS. D
LOCHIA RUBRA –DARK RED TO RED-2-3 DAYS
LOCHIA SEROSA-PINK OR BROWN-3-11 DAYS
5. THE NURSE ASSESSES A CLIENT ,WHO DELIVERED VAGINALLY 6 DAYS AGO, DURING
A HOME VISIT,WHICH FINDING SHOULD THE NURSE REPORT IMMEDIATELY TO THE
HEALTHCARE PROVIDER( HCP)?SELECT ALL THAT APPLY.
A. FOUL-SMELLING LOCHIA
B. ENGORGED BREAST BILATERALLY
C. CLIENT WHO CRIES EASILY
D. SOAKING ONE PERIPAD EVERY 3-4 HOURS
E. TEMPERATURE OF 100.80F
ANS. A&E
6. A NURSE IS WALKING DOWN THE HALL IN THE MAIN CORRIDOR OF A HOSPITAL
WHEN THE INFANT SECURITY ALERT SYSTEM SOUNDS AND A CODE FOR AN INFANT
ABDUCTION IS ANNOUNCED.THE FIRST RESPONSIBILITY OF THE NURSE WHEN THIS
SITUATION OCCURS IS TO TAKE WHICH ACTION?
A. MOVE TO THE ENTRANCE OF THE HOSPITAL ,AND CHECK EACH PERSON LEAVING
B. GO TO THE OBSTETRICS UNIT TO DETERMINE IF THEY NEED HELP WITH THE
SITUATION
C. CALL THE NURSERY TO ASK WHICH BABY IS MISSING
D. OBSERVE INDIVIDUALS IN THE AREA FOR LARGE BAGS OR OVERSIZED COATS
ANS. D
7. DURING THE FIRST HOUR POSTPARTUM ,ASSESSMENT OF A MULTIPARAOUS
CLIENT WHO GIVE CESAREAN BIRTH TO A NEONATE WEIGHING 10 Ib,2oz REVEALS A
SOFT FUNDS WITH EXCESIVE LOCHIA RUBRA .THE NURSE SHOULD INCLUDE WHICH
INTERVENTIONS IN THE CLIENT’S PLAN OF CARE?
A. ADMINISTRATION OF INTRAVENOUS OXYTOCIN
B. PLACEMENT OF THE CLIENT IN A SIDE LYING POSITION
C. RIGOROUS FUNDAL MASSAGE EVERY 5 MINUTES
D. PREPARATION FOR AN EMERGENCY HYSTERECTOMY
ANS. A
8. A MULTIPARAOUS CLIENT VISITS THE URGENT CARE CENTER 5 DAYS AFTER A
VAGINAL BIRTH ,EXPERIENCING PERSISTANT LOCHIA RUBRA IN A MODERATE TO
HEAVY AMOUNT .THE CLIENT ASKS THE NURSE ,WHY AM I CONTINUING TO BLEED
LIKE THIS ?THE NURSE SHOULD INSTRUCT THE CLIENT THAT THIS TYPE OF
POSTPARTUM BLEEDING IS MOST LIKELY CAUSED BY WHICH PROBLEM?
A. UTERINE ATONY
B. CERVICAL LACERATIONS
C. VAGINAL LACERATIONS
D. RETAINED PLACENTAL FRAGMENTS
ANS.D
9. 36 HOURS AFTER A VAGINAL BIRTH,A MULTIPARAOUS CLIENT IS DIAGNOSED WITH
ENDOMETRITIS.WHEN ASSESSING THE CLIENT ,WHICH SYMPTOM WOULD THE
NURSE EXPECT TO FIND?
A. PROFUSE AMOUNTS OF LOCHIA
B. ABDOMINAL DISTENTION
C. NAUSEA AND VOMITING
D. FEVER GREATER THAN 100.40F
ANS. D
10. WHEN TEACHING A PRIMIPARAOUS CLIENT ABOUT THE GROWTH AND
DEVELOPMENT OF THE NEONATE ,THE NURSE SHOULD EXPLAIN THAT MOST BABIES
ARE ABLE TO DRINK INDEPENDENTLY FROM A SIPPY CUP AT WHAT AGE?
A. 5 TO 7 MONTHS
B. 8 TO 10 MONTHS
C. 12 TO 14 MONTHS
D. 15 TO 16 MONTHS
ANS. B
11. WHEN MEASURING THE FUNDAL HEIGHT OF A PRIMIGRAVID CLIENT AT 20 WEEK’S
GESTATION ,THE NURSE WILL LOCATE THE FUNDAL HEIGHT AT WHICH POINT?
A. HALFWAY BETWEEN THE CLIENT’S SYMPHYSIS PUBIS AND UMBILICUS
B. AT ABOUT THE LEVEL OF THE CLIENT’S UMBILICUS
C. BETWEEN THE CLIENT’S UMBILICUS AND XIPHOID PROCESS
D. NEAR THE CLIENT’S XIPHOID PROCESS AND COMPRESSING THE DIAPHRAGM
ANS. B
AT 12 WEEK’S-TYPICALLY OVER THE SYMPHYSIS PUBIS
D-36 WEEKS’ OR OLDER
C-BETWEEN20 AND 36 WEEKS’
12. THE NURSE INSTRUCTS A PRIMIGRAVID CLIENT ABOUT THE IMPORTANCE OF
SUFFICIENT VITAMIN A IN HER DIET.THE NURSE KNOWS THAT THE INSTRUCTIONS
HAVE BEEN EFFECTIVE WHE THE CLIENT INDICATES THAT SHE SHOULD INCLUDE
WHICH FOODS IN HER DIET?
A. BUTTERMILK AND CHEESE
B. STRAWBERRIES AND BROCCOLI
C. EGG YOLKS AND SQUASH
D. ORANGE JUICE AND TOMATOES
ANS.C
B-VIT-C
A-CALCIUM
D-VIT-C
13. A NEWLY DIAGNOSED PREGNANT CLIENT TELLS THE NURSE,IF IAM GOING TO HAVE
ALL OF THESE DISCOMFORTS ,I AM NOT SURE I WANT TO BE PREGNANT! THE NURSE
INTERPRETS THE CLIENT’S STATEMENT AS AN INDICATION OF WHICH PERCEPTION?
A. FEAR OF PREGANCY OUTCOME
B. REJECTION OF THE PREGNANCY
C. NORMAL AMBIVALENCE
D. INABILITY TO CARE FOR THE NEWBORN
ANS. C
14. AFTER INSTRUCTING PARTICIPANTS IN A BIRTH EDUCATION CLASS ABOUT METHODS
FOR COPING WITH DISCOMFORTS IN THE FIRST STAGE OF LABOR,THE NURSE
DETERMINES THAT ONE OF THE PREGNANT CLIENTS NEEDS FURTHER INSTRUCTION
WHEN SHE SAYS THAT SHE HAS BEEN PRACTICING WHICH TECHNIQUE?
A. BIOFEEDBACK
B. EFFLEURAGE
C. GUIDED IMAGERY
D. PELVIC TILT EXERCISES
ANS.D
A-A CONSCIOUS EFFORT TO CONTROLTHE RESPONSE TO PAIN
B-LIGHT UTERINE MASSAGE
C-FOCUSING ON A PLEASANT SCENE
15. WHICH DIAGNOSTIC TEST WOULD BE THE MOST IMPORTANT FOR A 40-YEAR OLD
PRIMIGRAVID CLIENT TO HAVE IN THE SECOND TRIMESTER OF HER PREGNANCY?
A. BETA STREP SCREENING
B. CHORIONIC VILLUS SAMPLING
C. ULTRASOUND TESTING
D. QUAD SCREEN
ANS. D(AFP,HCG,ESTRIOL,INHIBIN-A
16. A CLIENT IN THE TRIAGE AREA WHO IS AT 19 WEEKS’ GESTATION STATES THAT SHE
HAS NOT FELT HER BABY MOVE IN THE PAST WEEK ,AND NO FETAL HEART TONES
ARE FOUND .WHILE EVALUATING THIS CLIENT ,THE NURSE IDENTIFIES HER AS BEING
AT THE HIGHEST RISK FOR DEVELOPING WHICH PROBLEM?
A. ABRUPTIO PLACENTAE
B. HELLP SYNDROME
C. DISSEMINATED INTRAVASCULAR COAGULATION
D. THREATENED ABORTION
ANS. C
17. AFTER ADMINISTERING HYDRALAZINE 5MG INTRAVENOUSLY AS PRESCRIBED FOR A
PRIMIGRAVID CLIENT WITH SEVERE PREECLAMPSIA AT 39 WEEKS’ GESTATION ,THE
NURSE SHOULD ASSESS THE CLIENT FOR:
A. TACHYCARDIA
B. BRADYPNEA
C. POLYURIA
D. DYSPHAGIA
ANS. A
18. A 16 YEAR OLD UNMARRIED PRIMIGRAVID CLIENT AT 37 WEEKS’ GESTATION WITH
SEVERE PREECLAMPSIA IS IN EARLY ACTIVE LABOR.THE CLIENT’S BLOOD PRESSURE IS
164/110MMHG.WHICH FINDING WOULD ALERT THE NURSE THAT THE CLIENT MAY
BE ABOUT TO EXPERIENCE A SEIZURE?
A. DECREASED CONTRACTION INTENSITY
B. DECREASED TEMPERATURE
C. EPIGASTRIC PAIN
D. HYPOREFLEXIA
ANS.C
19. FOLLOWING AN ECLAMPTIC SEIZURE ,THE NURSE SHOULD ASSESS THE CLIENT FOR
WHICH COMPLICATION?
A. POLYURIA
B. FACIAL FLUSHING
C. HYPOTENSION
D. UTERINE CONTRACTIONS
ANS. D
20. A CLIENT AT 36 WEEKS’ GESTATION BEGINS TO EXHIBIT SIGNS OF LABOR AFTER AN
ECLAMPTIC SEIZURE.THE NURSE SHOULD ASSESS THE CLIENT FOR
A. ABRUPTIO PLACENTAE
B. TRANVERSE LIE
C. PLACENTA ACCRETA
D. UTERINE ATONY
ANS. A
21. THE PRIMARY HEALTH CARE PROVIDER (HCP)PRESCRIBES INTRAVENOUS
MAGNESIUM SULPHATE FOR A PRIMIGRAVID CLIENT AT 38 WEEKS’ GESTATION
DIAGNOSED WITH SEVERE PREECLAMPSIA.WHICH MEDICATION WOULD BE MOST
IMPORTANT FOR THE NURSE TO HAVE READILY AVAILABLE?
A. DIAZEPAM
B. HYDRALAZINE
C. CALCIUM GLUCONATE
D. PHENYTOIN
ANS. C
22. A PRIMIGRAVID CLIENT WITH SEVERE PREECLAMPSIA EXHIBITS HYPERACTIVE,VERY
BRISK PATELLAR REFLEXES WITH TWO BEATS OF ANKLE CLONUS PRESENT.HOW
DOES THE NURSE DOCUMENT THE PATELLAR REFLEXES?
A. 1+
B. 2+
C. 3+
D. 4+
ANS.D
23. WHEN DEVELOPING A SERIES OF PARENT CLASSES ON FETAL DEVELOPMENT ,THE
NURSE SHOULD INCLUDE WHICH FEATURE AS BEING DEVELOPED BY THE END OF
THE 3RD MONTH(9 TO 12 WEEKS’)?
A. EXTERNAL GENITALIA
B. MYELINIZATION OF NERVES
C. BROWN FAT STORES
D. AIR DUCTS AND ALVEOLI
ANS. A
B-20 WEEKS’
C-21 TO 24 WEEKS’
D-25 TO 28 WEEKS’
24. WHEN TEACHING A PRIMIGRAVID CLIENT HOW TO DO KEGEL EXERCISES,THE NURSE
EXPLAINS THAT THE EXPECTED OUTCOME OF THESE EXERCISES IS TO?
A. REDUCE RISK OF HEMORRHOIDS
B. ALLEVIATE LOWER BACK DISCOMFORT
C. STRENGTHEN THE PERINEAL MUSCLES
D. STRENGTHEN THE ABDOMIAL MUSCLES
ANS. C
25. A MULTIGRAVID CLIENT THOUGHT TO BE AT 14 WEEKS’ GESTATION REPORTS THAT
SHE IS EXPERIENCING SUCH SEVERE MORNING SICKNESS THAT SHE HAS NOT BEEN
ABLE TO KEEP ANYTHING DOWN FOR A WEEK.THE NURSE SHOULD ASSESS FOR
SIGNS AND SYMPTOMS OF WHICH CONDITION?
A. HYPERCALCEMIA
B. HYPOBILIRUBINEMIA
C. HYPOKALEMIA
D. HYPERGLYCEMIA
ANS. C
26. BEFORE PLACING THE FETAL MONITORING DEVICE ON A PRIMIGRAVID CLIENT’S
FUNDUS ,THE NURSE PERFORMS LEOPOLD’S MANEUVERS .THE NURSE EXPLAINS
THAT THIRD MANEUVER IS DONE FOR WHICH REASON?
A. TO DETERMINE WHETHER THE FETAL PRESENTING PART IS ENGAGED
B. TO LOCATE THE FETAL CEPHALIC PROMINENCE
C. TO DISTINGUISH BETWEEN A BREECH AND A CEPHALIC PRESENTATION
D. TO LOCATE THE POSITION OF THE FETAL ARMS AND LEGS
ANS. A
B-THE FOURTH MANEUVER
C-THE FIRST MANEUVER
D-THE SECOND MANEUVER
27. FOR THE PAST 8 HOURS ,A 20-YEAR OLD PRIMIGRAVID CLIENT IN ACTIVE LABOR
WITH INTACT MEMBRANES HAS BEEN EXPERIENCING REGULAR
CONTRACTIONS.THE FETAL HEART RATE IS 136 BPM WITH GOOD VARIABILITY.AFTER
DETERMINING THAT THE CLIENT IS STILL IN THE LATENT PHASE OF LABOR,THE
NURSE SHOULD OBSERVE THE CLIENT FOR:
A. EXHAUSTION
B. CHILLS AND FEVER
C. FLUID OVERLOAD
D. MECONEUM –STAINED FLUID
ANS. A
28. THE NURSE EXPLAINS TO A NEWLY ADMITTED PRIMIGRAVID CLIENT IN ACTIVE
LABOR THAT ,ACCORDING TO THE GATE –CONTROL THEORY OF PAIN ,A CLOSED
GATE MEANS THAT THE CLIENT SHOULD EXPERIENCE WHAT TYPE OF PAIN?
A. NO PAIN
B. SHARP PAIN
C. LIGHT PAIN
D. MODERATE PAIN

ANS. A

29. THE NURSE IS PERFORMING EFFLEURAGE FOR A PRIMIGRAVID CLIENT IN EARLY

LABOR.WHICH TECHNIQUE SHOULD THE NURSE USE?
A. DEEP KNEADING OF SUPERFICIAL MUSCLES
B. SECURE GRASPING OF MUSCULAR TISSUES
C. LIGHT STROCKING OF THE SKIN SURFACE
D. PROLONGED PRESSURE ON SPECIFIC SITES
ANS. C
30. A CLIENT AT 33 WEEKS’ GESTATION IS ADMITTED IN PRETERM LABOR .SHE IS GIVEN
BETAMETHASONE 12 MG IM EVERY 24 HOURS8 *2.WHAT IS THE EXPECTED
OUTCOME OF THIS DRUG THERAPY?
A. THE CONTRACTIONS WILL END WITHIN 24 HOURS
B. THE CLIENT WILL GIVE BIRTH TO A NEONATE WITHOUT INFECTION
C. THE CLIENT WILL GIVE BIRTH TO A FULL-TERM NEONATE
D. THE NEONATE WILL BE BORN WITH MATURE LUNGS
 ANS. D
31. A FULL TERM CLIENT IS ADMITTED FOR AN INDUCTION OF LABOR.THE HEALTH CARE
PROVIDER HAS ASSIGNED A BISHOP SCORE OF 10.WHICH DRUG WOULD THE NURSE
ANTICIPATE ADMINISTERING TO THIS CLIENT?
A. OXYTOCIN 30 UNITS IN 500ML D5WATER
B. PROSTAGLANDIN GEL 0.5MG
C. MISOPROSTOL 50MCQ
D. DINOPROSTONE 10MG
ANS. A
32. A FULL-TERM CLIENT IS ADMITTED FOR INDUCTION OF LABOR .WHEN ADMITTED
,HER CERVIX IS EFFACED 25%BUT HAS NOT DILATED .THE INITIAL GOAL IS CERVICAL
RIPENING PRIOR TO LABOR INDUCTION .WHICH DRUG WILL PREPARE HER CERVIX
FOR INDUCTION?
A. NALBUPHINE
B. OXYTOCIN
C. DINOPROSTONE
D. BETAMETHASONE
ANS. C
33. A CLIENT IS INDUCED WITH OXYTOCIN.THE FETAL HEART RATE IS SHOWING
ACCELERATIONS LASTING 15 SECCONDS AND EXCEEDING THE BASELINE WITH FETAL
MOVEMENT.WHAT ACTION ASSOCIATED WITH THIS FINDING SHOULD THE NURSE
TAKE?
A. TURN THE CLIENT TO HER LEFT SIDE
B. ADMINISTER OXYGEN VIA FACE MASK AT 10 TO 12L/MIN
C. NOTIFY THE HEALTH CARE PROVIDER(HCP) OF THE SITUATION
D. DOCUMENT FETAL WELL-BEING
ANS. D
34. A NURSE NOTICES REPETITIVE LATE DECELERATIONS ON THE FETAL HEART
MONITOR.THE BEST INITIAL ACTIONS BY THE NURSE INCLUDE
A. PREPARE FOR BIRTH ,REPOSITION THE CLIENT ,AND BEGIN PUSHING
B. PERFORM STERILE VAGINAL EXAM ,INCREASE IV FLUIDS, AND APPLY OXYGEN .
C. NOTIFY THE PROVIDER,EXPLAIN FINDINGS TO THE CLIENT,BEGAN PUSHING
D. REPOSITION THE CLIENT ,APPLY OXYGEN, AND INCREASE IV FLUIDS
ANS. D
35. A MULTIGRAVID CLIENT IN ACTIVE LABOR IS 7CM DILATED.THE FETAL HEART RATE
BASELINE IS 130 BPM WITH MODERATE VARIABILITY.THE CLIENT BEGINS TO HAVE
VARIABLE DECELERATIONS TO 100 TO 110 BPM.WHAT SHOULD THE NURSE DO
NEXT?
A. PERFORM A VAGINAL EXAMINATION
B. NOTIFY THE HEALTH CARE PROVIDER OF THE DECELERATIONS
C. REPOSITION THE CLIENT ,AND CONTINUE TO EVALUATE FETAL HEART RATE.
D. ADMINISTER OXYGEN VIA MASK AT 2L/MIN
ANS. C
36. THE NURSE IS PERFORMING A VAGINAL EXAMINATION ON A CLIENT IN LABOR.THE
NURSE FINDS THE FETAL PRESENTING PART1CM ABOVE THE ISCHIAL SPINES
.THE NURSE SHOULD CHART THE STATION AS:
A. -1 STATION
B. +1 STATION
C. ENGAGED
D. FLOATING
ANS. A
37. AT A POSTPARTUM CHECKUP 11DAYS AFTER CHILDBIRTH,THE NURSE ASKS THE
CLIENT ABOUT THE COLOR OF HER LOCHIA.WHICH COLOR IS EXPECTED?
A. DARK RED
B. PINK
C. BROWN
D. WHITE
ANS. D
38. A PRIMIPARAOUS WOMAN HAS RECENTLY GIVEN BIRTH TO A TERM INFANT
.PRIORITY TEACHING FOR THE CLIENT INCLUDES INFORMATION ON:
A. SUDDEN INFANT DEATH SYNDROME(SIDS)
B. BREAST-FEEDING
C. INFANT BATHING
D. INFANT SLEEP WAKE CYCLES
ANS. B
39. A NEONATE IS BORN BY CESAREAN SECTION AT 36 WEEK’S GESTATION .THE
TEMPERATURE IN THE BIRTHING ROOM IS 700F.TO PREVENT HEAT LOSS FROM
CONVECTION,WHICH ACTION SHOULD THE NURSE TAKE ?
A. DRY THE NEONATE QUICKLY AFTER BIRTH
B. KEEP THE NEONATE AWAY FROM AIR CONDITIONING VENTS
C. PLACE THE NEONATE AWAY FROM OUTSIDE WINDOWS.
D. PREWARM THE BED
ANS.B
40. THE NURSE IS PREPARING TO ADMINISTER A VITAMIN K INJECTION TO A MALE
NEONATE SHORTLY AFTER BIRTH .WHAT STATEMENT BY THE MOTHER INDICATES
THAT SHE UNDERSTANDS THE PURPOSE OF THE INJECTION?
A. MY BABY DOES NOT HAVE THE NORMAL BACTERIA IN HIS INTESTINES TO PRODUCE
THIS VITAMIN
B. MY BABY IS AT HIGH RISK FOR A PROBLEM INVOLVING HIS BLOOD’S ABILITY TO
CLOT
C. THE RED BLOOD CELLS MY BABY FORMED DURING PREGNANCY ARE DESTROYING
THE VITAMIN K
D. MY BABY’S LIVER IS NOT ABLE TO PRODUCE ENOUGH OF THIS VITAMIN SO SOON
AFTER BIRTH
ANS. A
41. WHEN PERFORMING AN INITIAL ASSESSMENT OF A POSTTERM MAE NEONATE
WEIGHING 4000GM(8Ib.13OZ)WHO WAS ADMITTED TO THE OBSERVATION
NURSERY AFTER A VAGINAL BIRTH WITH LOW FORCEPS ,THE NURSE DETECTS
OROLANI’S SIGN.WHICH ACTION SHOULD THE NURSE TAKE NEXT?
A. DETERMINE THE LENGTH OF THE MOTHER’S LABOR
B. NOTIFY THE HEALTH CARE PROVIDER(HCP) IMMEDIATELY
C. KEEP THE NEONATE UNDER THE RADIANT WARMER FOR 2 HOURS
D. OBTAIN A BLOOD SAMPLE TO CHECK FOR HYPOGLYCEMIA
ANS.B
42. WHILE ASSESSING A NEONATE WEIGHING 3.175G(7Ib) WHO WAS BORN AT 39
WEEK’S GESTATION TO A PRIMIPARAOUS CLIENT WHO ADMITS TO OPIATE USE
DURING PREGNANCY,WHICH FINDING WOULD ALERT THE NURSE TO POSSIBLE
OPIATE WITHDRAWL?
A. BRADYCARDIA
B. HIGH-PITCHED CRY
C. SLUGGISHNESS
D. HYPOCALCEMIA
ANS.B
43. A FEMALE NEONATE BORN VAGINALLY AT TERM WITH A CLEFT LIP AND CLEFT
PALATE IS ADMITTED TO THE REGULAR NURSERY.WHICH ACTION SHOULD THE
NURSE TAKE THE FIRST TIME THAT THE PARENTS VISIT THE NEONATE IN THE
NURSERY?
A. EXPLAIN THE SURGICAL INTERVENTIONS THAT WILL BE PERFORMED
B. STRESS THAT THIS DEFECT IS NOT LIFE THREATENING
C. EMPHASIZE THE NEONATE’S NORMAL CHARACTERISTICS
D. REASSURE THE PARENTS ABOUT THE SUCCESS RATE OF THE SURGERY
ANS. C
44. WHILE CARING FOR A MALE NEONATE DIAGNOSED WITH GASTROSCHISIS ,THE
NURSE OBSERVES THAT THE PARENTS SEEM HESISTANT TO TOUCH THE NEONATE
 BECAUSE OF HIS APPEARANCE.THE NURSE DETERMINES THAT THE PARENTS ARE
MOST LIKELY EXPERIENCING WHICH STAGE OF GRIEF?
A. DENIAL
B. SHOCK
C. BARGAINING
D. ANGER
ANS. B
45. WHICH INTERVENTION SHOULD THE NURSE EMPLOY TO REDUCE TRAUMA CAUSED
BY VACCINE ADMINISTRATION TO AN INFANT?
A. USE A 5/8-INCH (1.6)NEEDLE
B. SIMULTANEOUSLY ADMINISTER VACCINES AT SEPARATE SITES WITH A SECOND
NURSE
C. ASPIRATE TO VERIFY NEEDLE PLACEMENT
D. BREAST –FEED RIGHT BEFORE ADMINISTERING THE VACCINES
ANS. B
46. THE PARENTS OF A 9-MONTH-OLD BRING THE INFANT TO THE CLINIC FOR A
REGULAR CHECK UP.THE INFANT HAS RECEIVED NO IMMUNIZATIONS.WHICH
VACCINE IF PRESCRIBED WOULD THE NURSE QUESTION?
A. DIPHTHERIA,TETNUS,AND ACELLULAR PEERTUSSIS (DTaP)
B. HAEMOPHILUS INFLUENZAE TYPE B(HIB)
C. MEASLES,MUMPS,AND RUBELLA(MMR)
D. INACTVATED INFLUENZA(FLU)
ANS.C
47. A NURSE COMPARES A CHILD’S HEIGHT AND WEIGHT WITH STANDARD GROWTH
CHARTS AND FINDS THE CHILD TO BE IN THE 50TH PERCENTILE FOR HEIGHT AND IN
THE 25 TH PERCENTILE FOR WEIGHT.THE NURSE INTERPRETS THESE FINDINDS AS
INDICATING THAT THE CHILD IS:
A. TYPICAL HEIGHT AND WEIGHT
B. OVERWEIGHT FOR HEIGHT
C. UNDERWEIGHT FOR HEIGHT
D. ABNORMAL IN HEIGHT
ANS. A
48. TO INTERPRET THE RESULTS OF BLOOD PRESSURE SCREENINGS IN CHILDREN OVER 3
YEARS OF AGE ,THE NURSE COMPARES THE RESULTS TO PERCENTILES FOR SYSTOLIC
AND DIASTOLIC BLOO PRESSURE BASED ON WHAT FACTORS?SELECT ALL THAT
APPLY
A. AGE
B. BODY MASS INDEX
C. GENDER
D. HEIGHT
E. OCCIPITAL FRONTAL CIRCUMFERENCE(OFC)
ANS. A,C&D
49. AFTER TEACHING THE MULTIPARAOUS MOTHER ABOUT HEMOLYTIC DISEASE OF
THE NEWBORN AND RH SENITIZATION ,THE NURSE DETERMINES THAT THE CLIENT
UNDERSTANDS WHY SHE WAS NOT SENSITIZED DURING HER OTHER PREGNANCY
WHEN SHE MAKES WHICH STAEMENT?
A. MY OTHER BABY HAD A DIFFERENT FATHER
B. LIKE MOST WOMEN,I HAVE IMMUNITY AGAINST THE Rh FACTOR
C. ANTIBODIES ARE NOT USUALLY FORMED UNTIL AFTER EXPOSURE TO AN ATIGEN
D. MY BLOOD COULD NOT NEUTRALIZE ANTIBODIES FORMED FROM MY FIRST
PREGNANCY
ANS.C
50. A PRIGRAVID CLIENT IN A PREPARATION FOR PARENTING CLASS ASKS HOW MUCH
BLOOD IS LOST DURING AN UNCOMPLICATED VAGINAL BIRTH.THE NURSE SHOULD
TELL THE WOMAN
A. THE MAXIMUM BLOOD LOSS CONSIDERED WITHIN NORMAL LIMITS IS 500 ML
B. THE MINIMUM BLOOD LOSS CONSIDERED WITHIN NORMAL LIMIT IS 1000 ML
C. BLOOD LOSS DURING CHILDBIRTH IS RARELY ESTIMATED UNLESS THERE IS
HAEMORRHAGE
D. IT WOULD BE VERY UNUSUAL IF YOU LOST MORE THAN 100 ML OF BLOOD
DURING CHILDBIRTH
ANS. A
51. WHEN PERFORMING LEOPOLD’S MANEUVERS ON A PRIMIGRAVID CLIENT AT
22WEEKS’ GESTATION ,THE NURSE PERFORMS THE FIRST MANEUVER TO
ACCOMPLISH WHICH ACTION?
A. LOCATE THE FETAL BACK AND SPINE
B. DETERMINE WHAT IS IN THE FUNDUS
C. DETERMINE WHETHER THE FETAL HEAD IS AT THE PELVIC INLET
D. IDENTIFY THE DEGREE OF FETAL DESCENT AND FLEXION
ANS. B
52. A MULTIGRAVID CLIENT AT 32 WEEK’S GESTATION HAS EXPERIENCED HEMOLYTIC
DISEASE OF THE NEWBORN IN A PREVIOUS PREGNANCY .THJE NURSE SHOULD
PREPARE THE CLIENT FOR FREQUENT ANTIBODY TITER EVALUATIONS OBTAINED
FROM WHICH SOURCE?
A. PLACENTA BLOOD
B. AMNIOTIC FLUID
C. FETAL BLOOD
D. MATERNAL BLOOD
ANS. D
53. WHICH DIAGNOSTIC TEST WOULD BE THE MOST IMPORTANT FOR A 40 YEAR OLD
PRIMIGRAVID CLIENT TO HAVE IN THE SECOND TRIMESTER OF HER PREGNANCY?
A. BETA STREP SCREENING
B. CHORIONIC VILLUS SAMPLING
C. ULTRASOUND TESTING
D. QUAD SCREEN
ANS. D
54. A CLIENT WITH A PAST MEDICAL HISTORY OF VENTRICULAR SEPTAL DEFECT
REPAIRED IN INFANCY IS SEEN AT THE PRENATAL CLINIC.SHE HAS DYSPNEA WITH
EXERTION AND IS VERY TIRED.HER VITAL SIGNS ARE OXYGEN SATURATION 98,PULSE
80.RESPIRATIONS 20,BLOODPRESSURE 116/72MMHG .SHE HAS +2 PEDAL EDEMA
AND CLEAR BREATH SOUNDS .THE NURSE DETERMINES THE CLIENTS SYMPTOMS
INDICATIVE WHICH CARDIAC FUNCTIONAL CLASSIFICATION?
A. CLASS 1
B. CLASS11
C. CLASS 111
D. CLASS 1V
ANS. B
55. WHEN PROVIDING CARE TO THE CLIENT WHO HAS UNDERGONE A DILATATION
AND CURETTAGE (D&C)AFTER A SPOTANEOUS ABORTION ,THE NURSE ADMINISTERS
HYDROXYZINE AS PRESCRIBED .WHAT IS AN EXPECTED OUTCOME?
A. ABSENCE OF NAUSEA
B. MINIMIZED PAIN
C. DECREASE UTERINE CRAMPING
D. IMPROVED UTERINE CONTRACTILITY
ANS.A
56. AT 32 WEEKS’ GESTATION ,A 15 YEAR OLD PRIMIGRAVID CLIENT WHO IS 5 FEET ,2
INCHES HAS GAINED A TOTAL OF 20 IB ,WITH A 1 IB GAIN IN THE LAST 2 WEEKS
.URINALYSIS REVEALS NEGATIVE GLUCOSE AND A TRACE OF PROTEIN.THE NURSE
SHOULD ADVISE THE CLIENT THAT WHICH FACTOR INCREASES HER RISK FOR
PREECLAMPSIA?
A. TOTAL WEIGHT GAIN
B. SHORT STATURE
C. ADOLESCENT AGE GROUP
D. TRACE PROTEIN URIA
 ANS.C
57. WHEN PREPARING THE ROOM FOR ADMISSION OF A MULTIGRAVID CLIENT AT 36
WEEKS’ GESTATION DIAGNOSED WITH SEVERE PREECLAMPSIA ,WHICH ITEM IS
MOST IMPORTANT FOR THE NURSE TO OBTAIN?
A. OXYTOCIN INFUSION SOLUTION
B. DISPOSABLE TONGUE BLADES
C. PORTABLE ULTRASOUND MACHINE
D. PADDING FOR THE SIDE RAILS
ANS. D
58. WHEN PREPARING A MULTIGRAVID CLIENT AT 34 WEEKS’ GESTATION
EXPERIENCING PRETERM LABOUR FOR THE SHAKE TEST PERFORMED ON AMNIOTIC
FLUID ,THE NURSE WOULD INSTRUCT THE CLIENT THAT THIS TEST IS DONE TO
EVALUATE THE MATURITY OF WHICH FETAL SYSTEMS?
A. URINARY
B. GASTROINTESTINAL
C. CARDIOVASCULAR
D. PULMONARY
ANS.D
59. A PRIGRAVID CLIENT AT 30 WEEKS’GESTATION HAS BEEN ADMITTED TO THE
HOSPITAL WITH PREMATURE RUPTURE OF THE MEMBRANES WITHOUT
CONTRACTIONS .HER CERVIX IS 2CMDILATED AND 50% EFFACED.THE NURSE
SHOULD NEXT ASSESS THE CLIENT’S
A. RED BLOOD CELL COUNT
B. DEGREE OF DISCOMFORT
C. URINARY OUTPUT
D. TEMPERATURE
ANS.D
60. AFTER BIRTH ,A DIRECT COOMBS TEST IS PERFORMED ON THE UMBIICAL CORD
BLOOD OF A NEONATE WITH Rh-POSITIVE BLOOD BORN TO A MOTHER WITH Rh-
NEGATIVE BLOOD.THE NURSE EXPLAINS TO THE CLIENT THAT THIS TEST IS DONE TO
DETECT WHICH INFORMATION?
A. DEGREE OF ANEMIA IN THE NEONATE
B. INIIAL BILIRUBIN LEVEL
C. ANTIBODIES COATING THE NEONATE’S RED BLOOD CELLS
D. ANTIGENS COATING THE NEONATE’S RED BLOOD CELLS
ANS. C
61. THE NEONATE IN THE NURSE’S CARE HAS A PNEUMOTHORAX.THE NURSE KNOWS
THE SIGNS OF EARLY DECOMPENSATION AND TO OBSERVE CAREFULLY FOR
CHANGES IN WHICH ASSESSMENTS?SELECT ALL THAT APPLY
A. BLOOD PRESSURE
B. TEMPERATURE
C. URINARY OUTPUT
D. COLOR
E. HEART RATE
ANS.A,D&E
62. A NEONATE WITH HEART FAIURE IS BEING DISCHARGED HOME.IN TEACHING THE
PARENTS ABOUT THE NEONATE’S NUTRITIONAL NEEDS,THE NURSE SHOULD
EXPLAIN THAT:
A. FLUIDS MUST BE RESTRICTED
B. DECREASED ACTIVITY LEVEL SHOULD REDUCE THE NEED FOR ADDITIONAL CALORIES
C. THE FORMULA SHOULD BE LOW IN SODIUM
D. THE NEONATE MAY NEED A MORE CALORIE –DENSE FORMULA
ANS.D
63. A NURSE IS REVIEWING A CLIENT’S MATERNAL PRENATAL RECORD AND NOTES
THAT MOTHER USED NARCOTICS DURING HER PREGNANCY.A PRIMARY NURSING
INTERVENTION WHEN CARING FOR A DRUG –EXPOSED NEONATE IS TO
A. ASSESS VITAL SIGNS INCLUDING BLOOD PRESSURE EVERY HOUR
B. MINIMIZE ENVIRONMENTAL STIMULI
C. PLACE THE INFANT IN A WELL-LIGHTED AREA
D. INCREASE EYE CONTACT WITH CAREGIVER
ANS.B
64. TWO HOURS AGO,A NEONATE AT 38 WEEKS’ GESTATION AND WEIGHING 3.175G
WAS BORN TO A PRIMIPARAOUS CLIENT WHO TESTED POSITIVE FOR
BETAHEMOLYTIC STREPTOCOCUS .WHICH FINDING WOULD ALERT THE NURSE TO
NOTIFY THE HEALTHCARE PROVIDER?
A. ALKALOSIS
B. INCREASED MUSCLE TONE
C. TEMPERATURE INSTABILITY
D. POSITIVE BABINSKI’S REFLEX
ANS.C
65. WHICH ACTION SHOULD THE NURSE TAKE WHEN PERFORMING EXTERNAL CHEST
COMPRESSIONS ON A NEONATE BORN AT 28 WEEKS’ GESTATION?
A. MAINTAIN A COMPRESSION TO VENTIATION RATIO OF 3:1
B. COMPRESS THE STERNUM WITH THE PALM OF THE HAND
C. COMPRESS THE CHEST 70TO 80 TIMES /MIN
D. DISPLACE THE CHEST WALL HALF THE DEPTH OF THE ANTERIOR –POSTERIOR
DIAMETER OF THE CHEST
ANS.A
66. WHICH FINDING WOULD THE NURSE MOST EXPECT TO FIND IN A NEONATE BORN
AT 28 WEEKS’ GESTATION WHO IS DIAGNOSED WITH INTRAVENTRICULAR
HEMORRHAGE(IVH)
A. INCREASED MUSCLE TONE
B. HYPERBILIRUBINEMIA
C. BULGING FONTANELLES
D. HYPERACTIVITY
ANS. C
67. WHILE CARING FOR THE NEONATE OF A HUMAN IMMUNODEFICIENCY VIRUS –
POSITIVE MOTHER ,THE NURSE PREPARES TO ADMINISTER A PRESCRIBED VITAMIN K
INTRAMUSCULAR INJECTION AT 1 HOUR AFTER BIRTH.WHICH ACTION SHOULD THE
NURSE DO FIRST?
A. BATHE THE NEONATE
B. PLACE THE NEONATE UNDER A RADIANT WARMER
C. WASH THE INJECTION SITE WITH POVIDONE-IODINE SOLUTION
D. WAIT UNTIL THE FIRST DOSE OF ATIRETROVIRAL MEDICATION IS GIVEN
ANS.A
68. THE NURSE IS CARING FOR A TERM NEONATE WHO IS DIAGNOSED WITH PATENT
DUCTUS ARTERIOSUS.WHILE PERFORMING A PHYSICAL ASSESSMENT OF THE
NEONATE,THE NURSE ANTICIPATES THAT THE NEONATE WILL EXHIBIT WHICH
SIGNS?
A. DECREASED CARDIAC OUTPUT WITH FAINT PERIPHERAL PULSES
B. PROFOUND CYANOSIS OVER MOST OF THE BODY
C. LOUD CARDIAC ,MURMER THROUGH SYSTOLE AND DIASTOLE
D. HASRH SYSTOLIC MURMER WITH A PALPABLE THRILL
ANS.C
69. THE NURSE IS PERFORMING AN ADMISSION ASSESSMENT ON A NEONATE AND
FINDS THE FEMORAL PULSES TO BE WEAKER THAN THE BRACHIAL AND RADIAL
PULSES .THE NEXT NURSING ACTION SHOULD BE TO:
A. CALL FOR A CARDIAC CONSULT
B. NOTE AND TELL THE HEALTH CARE PROVIDER (HCP)WHEN ROUNDS ARE MADE
C. PLACE THE NEONATE IN REVERSE TREDELENBURG POSITION
D. TAKE THE NEONATE’S BLOOD PRESSURE IN ALL FOUR EXTREMITIES
ANS.D
70. A PRIMIGRAVID ADOLESCENT CLIENT AT APPROXIMATELY 15 WEEKS’ GESTATION IS
VISITING THE PRENATAL CLINIC TO UNDERGO MATERNAL QUAD SCREENING.WHAT
INFORMATION SHOULD THE NURSE INCLUDE IN THE TREACHING PLAN FOR THIS
CLIENT?
A. ULTRASONOGRAPHY USUALLY ACCOMPANIES MATERNAL QUAD SCREEN TESTING
B. RESULTS ARE USUALLY VERY ACCURATE UNTIL 20 WEEKS’ GESTATION
C. A CLEAN –CATCH MIDSTREAM URINE SPECIMEN IS NEEDED
D. INCREASED LEVELS OF ALPHA FETOPROTEIN ARE ASSOCIATED WITH NEURAL TUBE
DEFECTS
ANS. D
71. A PRIMIGRAVID CLIENT AT 36 WEEKS’ GESTATION TELLS THE NURSE THAT SHE HAS
BEEN EXPERIENCING INSOMNIA FOR THE PAST 2 WEEKS .WHICH SUGGESTION
WOULD BE MOST HELPFUL?
A. PRACTICE RELAXATION TECHNIQUES BEFORE BEDTIME
B. DRINK A CUP OF HOT CHOCOLATE BEFORE BEDTIME
C. DRINK A SMALL GLASS OF WINE WITH DINNER
D. EXERCISE FOR 30 MINUTES JUST BEFORE BEDTIME
ANS.A
72. A NEW ANTENATAL G6T4P0A1L4 CLIENT ATTENDS HER FIRST PRENATAL VISIT WITH
HER PARTNER.THE NURSE IS ASSESSING THIS COUPLE’S PSYCHOLOGICAL RESPONSE
TO THE PREGNANCY.WHICH FINDING REQUIRES THE MOST IMMEDIATE FOLLOW
UP?
A. THE COUPLE IS CONCERNED WITH FINANCIAL CHANGES THIS PREGNANCY CAUSES
B. THE COUPLE EXPRESSES AMBIVALENCE ABOUT THE CURRENT PREGNANCY
C. THE FATHER OF THE BABY STATES THAT THE PREGNANCY HAS CHANGED THE
MOTHER’S FOCUS.
D. THE FATHER OF THE BABY IS IRRITATED THAT THE MOTHER IS NOT LIKE SHE WAS
BEFORE PREGNANCY
ANS. D
73. AFTER A PREPARATION FOR PARENTING CLASS SESSION ,A PREGNANT CLIENT TELLS
THE NURSE THAT SHE HAS HAD SOME YELLOW –GREY FROTHY VAGINAL DISCHARGE
AND LOCAL ITCHING .WHAT IS THE BEST ADVICE FOR THE NURSE TO GIVE THE
CLIENT?
A. USE AN OVER-THE –COUNTER CREAM FOR YEAST INFECTIONS
B. SCHEDULE AN APPOINTMENT AT THE CLINIC FOR AN EXAMINATION
C. ADMINISTER A VINEGAR DOUCHE UNDER LOW PRESSURE
D. PREPARE FOR PRETERM LABOR AND BIRTH
ANS.B(SIGNS AND SYMPTOMS OF TRICHOMONAS VAGINALIS)
 74. DURING A PREPARATION FOR PARENTING CLASS,ONE OF THE PARTICIPANTS ASKS
THE NURSE ,HOW WILL I KNOW IF I AM REALLY IN LABOR?WHAT SHOULD THE
NURSE TELL THE PARTICIPANT ABOUT TRUE LABOR CONTRACTIONS?
A. WALKING AROUND HELPS TO DECREASE TRUE CONTRACTIONS
B. TRUE LABOR CONTRACTIONS MAY DISAPPEAR WITH AMBULATION ,REST,OR SLEEP
C. THE DURATION AND FREQUENCY OF TRUE LABOR CONTRACTIONS REMAIN THE
SAME
D. TRUE LABOR CONTRACTIONS ARE FELT FIRST IN THE LOWER BACK ,THEN THE
ABDOMEN
ANS.D
75. THE NURSE IS MANAGING CARE OF A PRIMIGRAVIDA AT FULL TERM WHO IS IN
ACTIVE LABOR.WHAT SHOULD BE INCLUDED IN DEVELOPING THE PLAN OF CARE
FOR THIS CLIENT?
A. OXYGEN SATURATION MONITORING EVERY HALF HOUR
B. SUPINE POSITIONING ON BACK.IF IT IS COMFORTABLE
C. ANESTHESIA /PAIN LEVEL ASSESSMENT EVERY 30 MINUTES
D. VAGINAL BLEEDING ,RUPTURE OF MEMBRANE ASSESSMENT EVERY SHIFT
ANS.A
76. WHICH CLIENT IS THE BEST CANDIDATE FOR A VAGINAL BIRTH AFTER A CAESAREAN
(VBAC)?
A. CLIENT WHO HAD AN EMERGENCY CAESAREAN SECTION BECAUSE OF FETALDISTRESS
DURING HER LAST DELIVERY AND HAS A CLASSIC INCISION?
B. CLIENT WHO HAD A BREECH PRESENTATION IN HER LAST PREGNANCY ,AND THIS
PREGNANCY IS A VERTEX PREGNANCY
C. CLIENT WHO DILATED 6CM IN HER LAST BIRTH AND FAILED TO PROGRESS BEYOND THIS
POINT DESPITE5 MORE HOURS OF LABOR
D. DIABETIC CLIENT WHOSE LAST INFANT WAS OVER 10Ib (4.5kg). THIS INFANT IS LARGER
,AS SEEN ON ULTRASOUND
ANS. B
77. A NEWLY POSTPARTUM CLIENT IS ASKING TO GO TO THE BATHROOM 45 MINUTES
AFTER CHILDBIRTH .SHE HAD AN EPIDURAL FOR LABOR AND BIRTH AND HAS AN IV
INFUSING ,AND EVERY 15 MINUTES ASSESSMENTS ARE IN PROGRESS.TO PROVIDE
THE SAFEST CARE FOR THIS CLIENT ,THE NURSE SHOULD
A. ASK HER TO REMAIN IN BED UNTIL THE 15 MINUTE ASSESSMENTS ARE COMPLETE.
B. ASSESS CLIENT’S ABILITY TO STAND AND BEAR WEIGHT BEFORE GOING TO THE
BATHROOM
C. ENCOURAGE THE CLIENT TO SIT AT THE SIDE OF THE BED BEFORE AMBULATING TO
THE BATHROOM
D. ASK THE CLIENT TO AMBULATE THE FIRST TIME WITH A STAFF MEMBER AT HER
ANS.B
78. DURING A SCHEDULED CESAREAN BIRTH OF A PRIMIGRAVID CLIENT WITH A FETUS
AT 39 WEEKS’ GESTATION IN A BREECH PRESENTATION ,A NEONATOLOGIST IS
PRESENT IN THE OPERATING ROOM.THE NURSE EXPLAINS TO THE CLIENT THAT THE
NEONATOLOGIST IS PRESENT BECAUSE NEONATES BORN BY CESAREAN BIRTH
TEND TO HAVE AN INCREASED INCIDENCE OF WHICH PROBLEM?
A. CONGENITAL ANOMALIES
B. PULMONARY HYPERTENSION
C. MECONEUM ASPIRATION SYNDROME
D. RESPIRATORY DISTRESS SYNDROME
ANS.D
79. A MULTIGRAVID CLIENT IN ACTIVE LABOR AT 39 WEEKS’ GESTATION HAS A HISTORY
OF SMOKING ONE OR TWO PACKS OF CIGARETTES DAILY.WHICH PROBLEM IS THE
NURSE MOST LIKELY TO FIND DURING THE INFANT’S ASSESSMENT?
1. SEDATION
2. HYPERBILIRUBINEMIA
3. LOW BIRTH WEIGHT
4. HYPOCALCEMIA
ANS. C
80. A CLIENT IS ADMITTED WITH A SUSPECTED ABRUPTIO PLACENTAE.THE NURSE
SHOULD ASSESS THE CLIENT FOR WHICH SIGNS AND SYMPTOMS?SELECT ALL THAT
APPLY
A. BLEEDING THAT IS CONCEALED OR APPARENT
B. ABDOMINAL RIGIDITY
C. PAINFUL ABDOMEN
D. PAINLESS BLEEDING
E. LARGE PLACENTA
F. BLEEDING THAT STOPS SPONTANEOUSLY
ANS. A,B&C
81. A MULTIGRAVID CLIENT IN LABOR AT 38 WEEKS’ GESTATION HAS BEEN DIAGNOSED
WITH Rh SENSITIZATION AND PROBABLE FETAL HYDROPS AND ANEMIA.WHICH
FETAL HEART RATE PATTERN WOULD THE NURSE FIND IS MOST CONCERNING?
A. EARLY DECELERATION PATTERN
B. SINUSOIDAL PATTERN
C. VARIABLE DECELERATION PATTERN
D. LATE DECELERATION PATTERN
 ANS. B(IT REFLECTS AN ABSENCE OF AUTONOMIC NERVOUS CONTROL OVER
THE FETAL HEART RATE RESULTING FROM SEVERE HYPOXIA)
A- HEAD COMPRESSION NORMAL
C. CORD COMPRESSION
D. POOR PLACENTAL PERFUSION

82. THE NURSE IN THE LABOR AND BIRTH AREA RECEIVES A TELEPHONE CALL FROM
THE EMERGENCY DEPARTMENT ANNOUNCING THAT A MULTIGRAVID CLIENT IN
ACTIVE LABOR IS BEING TRANSFERRED TO THE LABOR AREA.THE CLIENT HAS HAD NO
PRENATAL CARE.WHEN THE CLIENT ARRIVES BY STRETCHER,SHE SAYS ,I THINK THE BABY
IS COMING …HELP! THE FETAL SKULL IS CROWNING.THE NURSE SHOULD OBTAIN WHICH
INFORMATION FIRST?

A. ESTIMATED DATE OF BIRTH

B. AMNIOTIC FLUID STATUS

C. GRAVIDA AND PARITY

D. PRENATA HISTORY

ANS. A

82. THE NURSE IS CARING FOR A MULTIGRAVID CLIENT AND OBSERVES THE WOMAN
SQUATTING ON THE BED AND THE FETAL HEAD CROWING .AFTER CALLING FOR
ASSISTANCE AND HELPING THE CLIENT LIE DOWN ,WHICH ACTION SHOULD THE
NURSE DO NEXT?
A. TELL THE CLIENT TO PUSH BETWEEN CONTRACTIONS
B. PROVIDE GENTLE SUPPORT TO THE FETAL HEAD
C. APPLY GENTLE UPWARD TRACTION ON THE NEONATE’S ANTERIOR SHOULDER
D. MASSAGE THE PERINEUM TO STRETCH THE PERINEAL TISSUES
ANS. B
83. DURING THE FIRST HOUR AFTER A PRECIPITOUS BIRTH ,THE NURSE SHOULD
MONITOR A MULTIPARAOUS CLIENT FOR SIGNS AND SYMPTOMS OF WHICH
COMPLICATION?
A. POSTPARTUM BLUES
B. UTERINE ATONY
C. INTRAUTERINE INFECTION
D. URINARY TRACT INFECTION
ANS. B
84. A CLIENT, APPROXIMATELY 11 WEEKS PREGNANT ,AND HER HUSBAND ARE SEEN IN
THE ANTEPARTAL CLINIC .THE CLIENT’S HUSBAND TELLS THE NURSE THAT HE HAS
BEEN EXPERIENCING NAUSEA AND VOMITTING AND FATIGUE ALONG WITH HIS
WIFE.THE NURSE INTERPRETS THESE FINDINGS AS SUGGESTING THAT THE CLIENT’S
HUSBAND IS EXPERIENCING WHICH COMPLICATION?
A. PTYALISM
B. MITTELSCHMERZ
C. COUVADE SYNDROME
D. PICA
ANS.C
85. AFTER INSTRUCTING A FEMALE CLIENT ABOUT THE RADIOIMMUNOASSAY
PREGNANCY TEST,THE NURSE DETERMINES THAT THE CLIENT UNDERSTANDS THE
INSTRUCTIONS WHEN THE CLIENT STATES THAT WHICH HORMONE IS EVALUATED
BY THIS TEST?
A. PROLACTIN
B. FOLLICLE –STIMULATING HORMONE
C. LUTEINIZING HORMONE
D. HUMAN CHORIONIC GONADOTROPIN(HCG)
ANS. D
86. WHEN DEVELOPING A TEACHING PLAN FOR A CLIENT WHO IS 8 WEEKS PREGNANT
,WHAT FOODS WOULD THE NURSE SUGGEST TO MEET THE CLIENT’S NEED FOR
INCREASED FOLIC ACID?SELECT ALL THAT APPLY.
A. SPINACH
B. BANANAS
C. SEAFOOD
D. YOGURT
E. BEANS
ANS. A&E
87. WHICH INSTRUCTION SHOULD THE NURSE INCLUDE IN THE TEACHING PLAN FOR A
30 YEAR OLD MULTIPARAOUS CLIENT WHO WILL BE USING AN INTRAUTERINE
DEVICE (IUD) FOR FAMILY PLANNING?
A. AMENORRHEA IS A COMMON ADVERESE EFFECT OF IUDS
B. THE CLIENT NEEDS TO USE ADDITIONAL PROTECTION FOR CONCEPTION
C. IUDs ARE MORE COSTLY THAN OTHER FORMS OF CONTRACEPTION
D. SEVERE CRAMPING MAY OCCUR WHEN THE IUD IS INSERTED
ANS. D
 88. WHEN DEVELOPING A TEACHING PLAN FOR AN 18 YEAR OLD CLIENT WHO ASKS
ABOUT TREATMENTS FOR SEXUALLY TRANSMITTED INFECTIONS,THE NURSE
SHOULD EXPLAIN THAT
A. HERPES CAN BE USED TO CURE HERPES GENITALIS
B. CHLAMYDIA TRACOMATIS INFECTIONS ARE USUALLY TREATED WITH PENICILLIN
C. CEFRIAXONE MAY BE USED TO TREAT NEISSERIA GONORRHOEAE INFECTIONS
D. METRONIDAZOLE IS USED TO TREAT CONDYLOMATA ACUMINATA
ANS. C
89. A 20 YEAR OLD PRIMIGRAVID CLIENT TELLS THE NURSE THAT HER MOTHER HAD A
FRIEND WHO DIED FROM HEMORRHAGE ABOUT 10 YEARS AGO DURING A VAGINAL
BIRTH .WHICH RESPONSE WOULD BE MOST HELPFUL?
A. TODAY’S MODERN TECHNOLOGY HAS RESULTED IN A LOW MATERNAL MORTALITY
RATE
B. DO NOT CONCERN YOUSELF WITH THINGS THAT HAPPENED IN THE PAST
C. IN NORTH AMERICA ,MOTHERS SELDOM DIE IN CHILDBIRTH
D. WHAT IS IT THAT CONCERNS YOU ABOUT PREGNANCY, LABOR ,AND BIRTH?
ANS.D

90. THE NURSE IS PREPARING TO ADMINISTER EXOGENOUS SURFACTANT TO A PREMATURE

INFANT WHO HAS RESPIRATORY DISTRESS SYNDROME .THE NURSE PREPARES TO
ADMINISTER THE MEDICATION BY WHICH ROUTE?
A. INTRADERMAL
B. INTRATRACHEAL
C. SUBCUTANEOUS
D. INTRAMUSCULAR
ANS.B
91. A CLIENT IN PRETERM LABOR(31WEEKS) WHO IS DILATED TO 4 CM HAS BEEN STARTED
ON MAGNESIUM SULPHATE AND CONTRACTIONS HAVE STOPPED .IF THE CLIENT’S
LABOR CAN BE INHIBITED FOR THE NEXT 48 HOURS ,THE NURSE ANTICIPATES A
PRESCRIPTION FOR WHICH MEDICATION?
A. NALBUPHINE
B. BETAMETHASONE
C. Rh0(D)IMMUNE GLOBULINE
D. DINOPROSTONE VAGINAL INSERT
ANS.B
92. THE NURSE IS PLANNING CARE FOR A NEWBORN OF A MOTHER WITH DIABETES
MELLITUS.WHAT IS THE PRIORITY NURSING CONSIDERATION FOR THIS NEWBORN?
A. DEVELOPMENTAL DELAYS BECAUSE OF EXCESSIVE SIZE
B. MAINTAINING SAFETY BECAUSE OF LOW BLOOD GLUCOSE LEVELS
C. CHOKING BECAUSE OF IMPAIRED SUCK AND SWALLOW REFLEXES
D. ELEVATED BODY TEMPERATURE BECAUSE OF EXCESS FAT AND GLYCOGEN
ANS.B
93. THE NURSE ASSISTED WITH THE BIRTH OF A NEWBORN ,WHICH NURSING ACTION IS
MOST EFFECTIVE IN PREVENTING HEAT LOSS BY EVAPORATION?
A. WARMING THE CRIB PAD
B. CLOSING THE DOORS TO THE ROOM.
C. DRYING THE INFANT WITH A WARM BLANKET
D. TURNING ON THE OVERHEAD RADIANT WARMER
ANS. C
94. THE NURSE IS MONITORING A CLIENT WHO IS IN THE ACTIVE STAGE OF LABOR .THE
NURSE DOCUMENTS THAT THE CLIENT IS EXPERIENCING LABOR DYSTOCIA.THE
NURSE DETERMINES THAT WHICH RISK FACTORS IN THE CLIENT’S HISTORY PLACED
HER AT RISK FOR THIS COMPLICATION?SELECT ALL THAT APPLY?
A. AGE 54
B. BODY MASS INDEX OF 28
C. PREVIOUS DIFFICULTY WITH FERTILITY
D. ADMINISTRATION OF OXYTOCIN FOR INDUCTION
E. POTTASSIUM LEVEL OF 3.6MEQ/L
ANS AB&C
95. ASSESSMENT FINDINGS PF AN INFANT ADMITTED TO THE HOSPITAL REVEAL A
MACHINERY- LIKE MURMUR ON AUSCULTATION OF THE HEART AND SIGNS OF
HEART FAILURE. THE NURSE REVIEWS CONGENITAL CARDIAC ANOMALIES AND
IDENTIFIES THE INFANTS CONDITION AS WHICH DISORDER ?
A. AORTIC STENOSIS
B. ATRIAL SEPTAL DEFECT
C. PATENT DUCTUS ARTERIOSUS
D. VENTRICULAR SEPTAL DEFECT
ANS.C
96. THE NURSE IS MONITORING THE AMOUNT OF LOCHIA DRAINAGE IN A CLIENT WHO
IS 2 HOURS POSTPARTUM AND NOTES THAT THE CLIENT HAS SATURATED A
PERINEAL PAD IN 15 MTS .HOW SHOULD THE NURSE RESPOND TO THIS FINDING
INITIALLY?
A. DOCUMENT THE FINDING
B. ENCOURAGE THE CLIENT TO AMBULATE
C. ENCOURAGE THE CLIENT TO INCREASE FLUID INTAKE
 D. CONTACT THE HEALTH CARE PROVIDER (HCP)AND INFORM THE HCP OF THIS
FINDING
ANS. D
SCANT =LESS THAN 2.5CM ON MENSTRUAL PAD IN 1 HOUR
LIGHT =LESS THAN 10 CM ON MENSTRUAL PAD IN 1 HOUR
MODERATE =LESS THAN 15 CM ON MENSTRUAL PAD IN 1 HOUR
HEAVY =MENSTRUAL PAD SATURATED IN 1 HOUR
EXCESSIVE =MENSTRUAL PAD SATURATED IN 15 MTS
97. THE NURSE IS PERFORMING AN ASSESSMENT ON A CLIENT DIAGNOSED WITH
PLACENTA PREVIA.WHICH ASSESSMENT FINDINGS SHOULD THE NURSE EXPECT TO
NOTE?SELECT ALL THAT APPLY
A. UTERINE ATONY
B. UTERINE TENDERNESS
C. SEVERE ABDOMINAL PAIN
D. BRIGHT RED VAGINAL BLEEDING
E. SOFT,RELAXED NONTENDER UTERUS
F. FUNDAL HEIGHT MAY BE GREATER THAN EXPECTED FOR GESTATIONAL AGE
ANS. D E&F
98. THE NURSE HAS CREATED A PLAN OF CARE FOR A CLIENT EXPERIENCING DYSTOCIA
AND INCLUDES SEVERAL NURSING ACTIONS IN THE PLAN OF CARE.WHAT IS THE
PRIORITY NURSING ACTION?
A. PROVIDING COMFORT MEASURES
B. MONITORING THE FETAL HEART RATE
C. CHANGING THE CLIENT’S POSITION FREQUENTLY
D. KEEPING THE SIGNIFICANT OTHER INFORMED OF THE PROGRESS OF THE LABOR
ANS. B
99. THE NURSE IN THE POSTPARTUM UNIT IS CARING FOR A CLIENT WHO HAS JUST
DELIVERED A NEW BORN INFANT FOLLOWING A PREGNANCY WITH PLACENTA
PREVIA.THE NURSE REVIEWS THE PLAN OF CARE AND PREPARES TO MONITOR THE
CLIENT FOR WHICH RISK ASSOCIATED WITH PLACENTA PREVIA?
A. INFECTION
B. HEMORRHAGE
C. CHRONIC HYPERTENSION
D. DISSEMINATED INTRAVASCULAR COAGULATION
ANS. B
100. THE POSTPARTUM NURSE IS PROVIDING INSTRUCTIONS TO A CLIENT AFTER
BIRTH OF A HEALTHY NEWBORN.WHICH TIME FRAME SHOULD THE NURSE RELAY
TO THE CLIENT REGARDING THE RETURN OF BOWEL FUNCTION?
 A. 3 DAYS POSTPARTUM
B. 7 DAYS POSTPARTUM
C. ON THE DAY OF BIRTH
D. WITHIN TWO WEEKS POSTPARTUM
ANS. A
101. THE NURSE IS PLANING CARE FOR A POSTPARTUM CLIENT WHO HAD A VAGINAL
DELIVERY 2 HOURS AGO.THE CLIENT REQUIRED AN EPISIOTOMY AND HAS SEVERAL
HEMORRHOIDS.WHAT IS THE PRIORITY NURSING CONSIDERATION FOR THIS CLIENT?
A. CLIENT PAIN LEVEL
B. INADEQUATE URINARY OUTPUT
C. CLIENT PERCEPTION OF BODY IMAGE
D. POTENTIAL FOR IMBALANCED BODY FLUID VOLUME
ANS. A
102. THE NURSE IS MONITORING A CLIENT IN LABOR .THE NURSE SUSPECTS
UMBILICAL CORD COMPRESSION IF WHICH IS NOTED ON THE EXTERNAL MONITOR
TRACING DURING A CONTRACTION?
A. VARIABILITY
B. ACCELERATIONS
C. EARLY DECELERATIONS
D. VARIABLE DECELERATIONS
ANS. D
103. THE NURSE IS ADMITTING A PREGNANT CLIENT TO THE LABOR ROOM AND
ATTACHES AN EXTERNAL ELECTRONIC FETAL MONITOR TO THE CLIENT’S
ABDOMEN.AFTER ATTACHMENT OF THE ELECTRONIC FETAL MONITOR,WHAT IS THE
NEXT NURSING ACTION?
A. IDENTIFY THE TYPES OF ACCELERATIONS
B. ASSESS THE BASELINE FETAL HEART RATE
C. DETERMINE THE INTENSITY OF THE CONTRACTIONS
D. DETERMINE THE FREQUENCY OF THE CONTRACTIONS
ANS.B
104. THE NURSE IN THE LABOR ROOM IS CARING FOR A CLIENT IN THE ACTIVE STAGE
OF THE FIRST PHASE OF LABOR .THE NURSE IS ASSESSING THE FETAL PATTERNS AND
NOTES A LATE DECELERATION ON THE MONITOR STRIP.WHAT IS THE MOST
APPROPRIATE NURSING ACTION?
A. ADMINISTER OXYGEN VIA FACE MASK
B. PLACE THE MOTHER IN A SUPINE POSITION
C. INCREASE THE RATE OF THE OXYTOCIN INTRAVEOUS INFUSION
D. DOCUMENT THE FINDINGS AND CONTINUE TO MONITOR THE FETAL PATERNS
 ANS. A
105. A NURSE IS CARING FOR A CLIENT IN LABOR.THE NURSE DOCUMENTS THAT THE
CLIENT IS BEGINNING THE SECOND STAGE OF LABOR WHEN WHICH OF THE
FOLLOWING ASSESSMENTS IS NOTED?
A. THE CLIENT BEGINS TO EXPEL CLEAR VAGINAL FLUID
B. THE CONTRACTIONS ARE REGULAR
C. THE MEMBRANES HAVE RUPTURED
D. THE CERVIX IS COMPLETELY DILATED
ANS. D
106. A NURSE IN THE LABOR ROOM IS CARING FOR A CLIENT IN THE ACTIVE STAGE
OF LABOR .THE NURSE IS ASSESSING THE FETAL PATTERNS AND NOTES A LATE
DECELERATION ON THE MONITOR STRIP.THE MOST APPROPRIATE NURSING ACTION
IS TO
A. PLACE THE MOTHER IN A SUPINE POSITION
B. DOCUMENT THE FINDINGS AND CONTINUE TO MONITOR THE FETAL PATTERNS
C. ADMINISTER OXYGEN VIA FACE MASK
D. INCREASE THE RATE OF THE INTRAVENOUS(IV)OXYTOCIN (PITOCIN) INFUSION
ANS.C
107. A CLIENT IN LABOR IS TRANSPORTED TO THE DELIVERY ROOM AND IS PREPARED
FOR A CESAREAN DELIVERY.THE CLIENT IS TRANSFERRED TO THE DELIVERY ROOM
TABLE AND THE NURSE PLACEC THE CLIENT IN THE
A. TRENDELENBURG POSITION WITH THE LEGS IN STIRRUPS
B. SEMI-FOWLER’S POSITION WITH A PILLOW UNDER THE KNEES
C. PRONE POSITION WITH THE LEGS SEPERATED AND ELEVATED
D. SUPINE POSITION WITH A WEDGE UNDER THE RIGHT HIP
ANS. D
108. A NURSE IS CARING FOR A CLIENT IN LABOR WHO IS RECEIVING OXYTOIN BY
INTRAVENOUS INFUSION TO STIMULATE UTERINE CONTRACTIONS .WHICH
ASSESSMENT FINDING WOULD INDICATE TO THE NURSE THAT THE INFUSION NEEDS
TO BE DISCONTINUED?
A. THREE CONTRACTIONS OCCURING WITHIN A 10 MINUTE PERIOD
B. A FETAL HEART RATE OF 90 BEATS PER MINUTE
C. ADEQUATE RESTING TONE OF THE UTERUS PALPATED BETWEEN
CONTRACTIONS
D. INCREASED URINARY OUTPUT
ANS. B
109. A CLIENT ARRIVES AT A BIRTHING CENTER IN ACTIVE LABOR .HER MEMBRANES
ARE STILL INTACT .A NURSE –MIDWIFE PREPARES TO PERFORM AN AMNIOTOMY.A
 NURSE WHO IS ASSISTING THE NURSE –MIDWIFE EXPLAINS TO THE CLIENT THAT
AFTER THIS PROCEDURE ,SHE WILL MOST LIKELY HAVE
A. LESS PRESSURE ON HER CERVIX
B. INCREASED EFFICIENCY OF CONTRACTIONS
C. DECREASED NUMBER OF CONTRACTIONS
D. THE NEED FOR INCREASED MATERNAL BLOOD PRESSURE(BP) MONITORING
ANS. B
110. A NURSE EXPLAINS THE PURPOSE OF EFFLEURAGE TO A CLIENT IN EARLY
LABOR.THE NURSE TELLS THE CLIENT THAT EFFLEURAGE IS
A. A FORM OF BIOFEEDBACK TO ENHANCE BEARING DOWN EFFORTS DURING
DELIVERY
B. LIGHT STOKING OF THE ABDOMEN TO FACILITATE RELAXATION DURING LABOR
AND PROVIDE TACTILE STIMULATION OF THE FETUS
C. THE APPLICATION OF PRESSURE TO THE SACRUM TO RELIEVE A BACKACHE
D. PERFORMED TO STIMULATE UTERINE ACTIVITY BY CONTRACTING A SPECIFIC
MUSCLE GROUP WHILE OTHER PARTS OF THE BODY REST
ANS. B
111. A LOW –RISK CLIENT IS DILATED 10CM AND FEELING THE URGE TO PUSH WITH
CONTRACTIONS .AT THIS TIME DURING LABOR ,THE NURSE SHOULD PLAN TO
ASSESS AND DOCUMENT THE FETAL HEART RATE AT LEAST
A. BEFORE EACH CONTRACTION
B. EVERY 15 MINUTES
C. EVERY 30 MINUTES
D. HOURLY
ANS. B
112. A NURSE ASSISTS IN THE VAGINAL DELIVERY OF A NEWBORN INFANT .AFTER THE
DELIVERY ,THE NURSE OBSERVES THE UMBILICAL CORD LENGTHEN AND SPURT OF
BLOOD FROM THE VAGINA .THE NURSE DOCUMENTS THESE OBSERVATIONS AS
SIGNS OF
A. HEMATOMA
B. PLACENTA PREVIA
C. UTERINE ATONY
D. PLACENTAL SEPERATION
ANS. D
113. A NURSE IS MONITORING A CLIENT IN LABOR.THE NURSE SUSPECTS UMBILICAL
CORD COMPRESSION IF WHICH OF THE FOLLOWING IS NOTED ON THE EXTERNAL
MONITOR TRACING DURING A CONTRACTION?
A. EARLY DECELERATIONS
 B. VARIABLE DECELERATIONS
C. LATE DECELERATIONS
D. SHORT TERM VARIABILITY
ANS.B
114. A NURSE IS MONITORING A CLIENT WHO IS IN THE ACTIVE STAGE OF LABOR .THE
CLIENT HAS BEEN EXPERIENCING CONTRACTINS THAT ARE SHORT,IRREGULAR,AND
WEAK.THE NURSE DOCUMENTS THAT THE CLIENT IS EXPERIENCING WHICH TYPE OF
LABOR DYSTOCIA?
A. HYPOTONIC
B. PRECIPITUS
C. HYPERTONIC
D. PRETERM LABOR
ANS.A
115. A NURSE IN A POSTPARTUM UNIT IS INSTRUCTING A MOTHER REGARDING
LOCHIA AND THE AMOUNT OF EXPECTED LOCHIA DRAINAGE .THE NURSE INSTRUCTS
THE MOTHER THAT THE NORMAL AMOUNT OF LOCHIA MAY VARY BUT SHOULD
NEVER EXCEED THE NEED FOR
A. 1 PERIPAD A DAY
B. 2 PERIPADS A DAY
C. 3 PERIPADS A DAY
D. 8PERIPADS A DAY
ANS. D
116. WHEN PERFORMING A POSTPARTUM ASSESSMENT ON A CLIENT ,A NURSE
NOTES THE PRESENCE OF CLOTS IN THE LOCHIA.THE NURSE EXAMINES THE CLOTS
AND NOTES THAT THEY ARE LARGER THAN 1CM.WHICH OF THE FOLLOWING
NURSING ACTIONS IS MOST APPROPRIATE?
A. DOCUMENT THE FINDINGS
B. NOTIFY THE PHYSICIAN
C. REASSESS THE CLIENT IN2 HOURS
D. ENCOURAGE INCREASED ORAL INTAKE OF FLUIDS
ANS.B
117. A NURSE IS ASSESSING A CLIENT IN THE FOURTH STAGE OF LABOR AND NOTES
THAT THE FUNDUS IS FIRM BUT THAT BLEEDING IS EXCESSIVE.THE INITIAL NURSING
ACTION WOULD BE WHICH OF THE FOLLOWING?
A. MASSAGE THE FUNDUS
B. PLACE THE MOTHER IN THE TREDELENBURG POSITION
C. NOTIFY THE PHYSICIAN
D. RECORD THE FINDINGS
 ANS.C
118. A HOME CARE NURSE VISITS A CLIENT WHO DELIVERED A HEALTHY NEWBORN
INFANT VIA VAGINAL DELIVERY .AN EPISIOTOMY WAS PERFORMED ,AND THE
WOMAN HAS DEVELOPED A WOUND INFECTION AT THE EPISIOTOMY SITE.THE
NURSE PROVIDES INSTRUCTIONS TO THE MOTHER REGARDING CARE RELATED TO
THE INFECTION .WHICH OF THE FOLLOWING STATEMENTS IF MADE BY THE MOTHER
WOULD INDICATE A NEED FOR FURTHER INSTRUCTIONS?
A. I NEED TO TAKE THE ANTIBIOTICS AS PRECRIBED
B. I NEED TO APPLY WARM COMPRESSTO PROVIDE COMFORT
C. I NEED TO TAKE WARM BATHS TO PROMOTE HEALING
D. I NEED TO ISOLATE THE INFANT FOR 48 HOURS AFTER THE INITIATION OF THE
ANTIBIOTICS.
ANS. D
119. A NURSE IS CARING FOR A POSTPARTUM CLIENT WITH A DIAGNOSIS F DEEP VEIN
THROMBOSIS WHO IS RECEIVING A CONTINUOUS INTRAVENOUS INFUSION OF
HEPARIN SODIUM. WHICH OF THE FOLLOWING LABORATORY RESULTS WILL THE
NURSE SPECIFICALLY REVIEW TO DETERMINE IF AN EFFECTIVE AND APPROPRIATE
DOSE OF THE HEPARIN IS BEING DELIVERED?
A. PROTHROMBIN TIME
B. INTERNATIONAL NORMALIZED RATIO
C. ACTIVATED PARTIALTHROMBOPLASTIN TIME
D. PLATELET COUNT
ANS. C
120. A NURSE HAS ASSISTED IN PERFORMING A NONSTRESS TEST ON A PREGNANT
CLIENT AND IS REVIEWING THE DOCUMENTATION RELATED TO THE RESULTS OF TE
TEST.THE NURSE NOTES THAT THE PHYSICIAN HAS DOCUMENTED THE TEST
RESULTS AS REACTIVE.THE NURSE INTERPRETS THAT THIS RESULT INDICATES :
A. NORMAL FINDINGS
B. ABNORMAL FINDINGS
C. THE NEED FOR FURTHER EVALUATION
D. THAT THE FINDINGS ON THE MONITOR WERE DIFFICULT TO INTERPRET
ANS. A
THE NONSTRESS TEST TAKES ABOUT 20 TO 30MTS .THE TEST IS TERMED
NONSTRESS BECAUSE IT CONSISTS OF MONITORING ONLY; THE FETUS IS NOT
CHALLENGED OR STRESSED BY UTERINE CONTRACTIONS TO OBTAIN THE
NECESSARY DATA.IT IS A NONINVASIVE TEST,AND AN ULTRASOUND
TRANSDUCER THAT RECORDS FETAL HEART ACTIVITY IS SECURED OVER THE
MATERNAL ABDOMEN WHERE THE FETAL HEART IS HEARD MOST CLEARLY.A
 TOCOTRANSDUCER THAT DETECTS UTERINE ACTIVITY AND FETAL MOVEMENT IS
ALSO SECURED TO THE MATERNAL ADBOMEN.FETAL HEART ACTIVITY AND
MOVEMENTS ARE RECORDED.
121. A NONSTRESS TEST IS PERFORMED ON A CLIENT WHO IS PREGNANT,AND THE
RESULTS OF THE TEST INDICATE NONREACTIVE FINDINGS.THE PHYSICIAN
PRESCRIBED A CONTRACTION STRESS TEST.THE TEST IS PERFORMED ,AND THE
NURSE NOTES THAT THE PHYSICIAN HAS DOCUMENTED THE RESULTS AS NEGATIVE
.THE NURSE INTERPRETS THIS FINDING AS INDICATING
A. A HIGH RISK FOR FETAL DEMISE
B. A NORMAL TEST RESULT
C. THE NEED FOR A CESAREAN DELIVERY
D. AN ABNORMAL TEST RESULT
ANS. B
122. A NURSE IS REVIEWING THE RECORD OF A CLIENT WHO HAS JUST BEEN TOLD
THAT A PREGNANCY TEST IS POSITIVE.THE PHYSICIAN HAS DOCUMENTED THE
PRESENCE OF GOODELL’S SIGN.THE NURSE DETERMINES THAT THIS SIGN IS
INDICATIVE OF:
A. A SOFTENING OF THE CEVIX
B. A SOFT BLOWING SOUND THAT CORRESPONDS TO THE MATERNAL PULSE
DURING AUSCULTATION OF THE UTERUS
C. THE PRESENCE OF HUMAN CHORIONIC GONADOTROPHIN (HCG) IN THE URINE
D. THE PRESENCE OF FETAL MOVEMENT
ANS. A
123. A NURSE MIDWIFE IS PERFORMING AN ASSESSMENT OF A PREGNANT CLIENT
AND IS ASSESSING THE CLIENT FOR THE PRESENCE OF BALLOTTEMENT.WHICH OF
THE FOLLOWING WOULD THE NURSE IMPLEMENT TO TEST FOR THE PRESENCE OF
BALLOTTEMENT?
A. AUSCULTATING FOR FETAL HEART SOUNDS
B. PALPATING THE ABDOMEN FOR FETAL MOVEMENT
C. ASSESSING THE CERVIX FOR THINNING
D. INITIATING A GENTLE UPWARD TAP ON THE CERVIX
ANS. D
124. AN OPERATING ROOM NURSE IS POSITIONING A CLIENT ON THE OPERATING
ROOM TABLE SO AS TO PREVENT THE CLIENT’S EXTREMITIES FROM DANGLING OVER
THE SIDES OF THE TABLE.A NURSING STUDENT WHO IS OBSERVING FOR THE DAY
ASK THE NURSE WHY THIS IS SO IMPORTANT.THE NURSE RESPONDS THAT THIS IS
DONE PRIMARILY TO AVOID
A. A DROP IN BLOOD PRESSURE
 B. MUSCLE FATIGUE IN THE EXTREMITIES
C. AN INCREASE IN PULSE RATE
D. NERVE AND MUSCE DAMAGE
ANS. D
125. A 38 YEAR OLD CLIENT AT ABOUT 14 WEEKS’ GESTATION IS ADMITTED TO THE
HOSPITAL WITH DIAGNOSIS OF COMPLETE HYDATIDIFORM MOLE.SOON AFTER
ADMISSION ,THE NURSE WOULD ASSESS THE CLIENT FOR WHICH SIGNS AND
SYMPTOMS?
A. GESTATIONAL HYPERTENSION
B. GESTATIONAL DIABETES
C. HYPOTHYROIDISM
D. POLYCYTHEMIA
ANS. A
126. FOR THE PAST 8 HOURS , A 20 YEAR OLD PRIMIGRAVID CLIENT IN ACTIVE LABOR
WITH INTACT MEMBRANES HAS BEEN EXPERIENCING REGULAR CONTRACTIONS
.THE FETAL HEART RATE IS 136 BPM WITH GOOD VARIABILITY.AFTER DETERMINING
THAT THE CLIENT IS STILL IN THE LATENT PHASE OF LABOR ,THE NURSE SHOULD
OBSERVE THE CLIENT FOR?
A. EXHAUSTION
B. CHILLS AND FEVER
C. FLUID OVERLOAD
D. MECONEUM –STAINED FLUID
ANS. A
127. THE NURSE EXPLAINS TO A NEWLY ADMITTED PRIMIGRAVID CLIENT IN ACTIVE
LABOR THAT ,ACCORDING TO THE GATE CONTROL THEORY OF PAIN .A CLOSED
GATE MEANS THAT THE CLIENT SHOULD EXPERIENCE WHAT TYPE OF PAIN?
A. NO PAIN
B. SHARP PAIN
C. LIGHT PAIN
D. MODERATE PAIN
ANS. A
128. BEFORE PLACING THE FETAL MONITORING DEVICE ON A PRIMIGRAVID
CLIENT’S FUNDUS,THE NURSE PERFORMS LEOPOLD’S MANEUVERS.THE NURSE
EXPLAINS THAT THE THIRD MANEUVER IS DONE FOR WHICH REASON?
A. TO DETERMINE WHETHER THE FETAL PRESENTING PART IS ENGAGED
B. TO LOCATE THE FETAL CEPHALIC PROMINENCE
C. TO DISTINGUISH BETWEEN A BREECH AND A CEPHALIC PRESENTATION
D. TO LOCATE THE POSITION OF THE FETAL ARMS AND LEGS
 ANS. A
129. A 24 YEAR OLD PRIMIGRAVID CLIENT IN ACTIVE LABOR REQUESTS USE OF THE
JET HYDROTHERAPY TUB TO AID IN PAIN RELIEF .WHICH CONDITION WOULD THE
NURSE CONSIDER TO BE A CONTRAINDICATION FOR HYDROTHERAPY
A. RUPTURED MEMBRANES
B. MULTIFETAL GESTATION
C. DIABETES MELLITUS
D. HYPOTONIC LABOR PATTERNS
ANS. A
130. THE HEALTH CARE PROVIDER HAS PRESCRIBED PROSTAGLANDIN GEL TO BE
ADMINISTERED VAGINALLY TO A NEWLY ADMITTED PRIMIGRAVID CLIENT.WHICH
FINDING INDICATES THAT THE CLIENT HAS HAD A THERAPEUTIC RESPONSE TO THE
MEDICATION?
A. RESTING PERIOD OF 2 MINUTES BETWEEN CONTRACTIONS
B. NORMAL PATELLAR AND ELBOW REFLEXES FOR THE PAST 2 HOURS
C. SOFTENING OF THE VERVIX AND BEGINNING OF EFFACEMENT
D. LEAKING OF CLEAR AMNIOTIC FLUID IN SMALL AMOUNTS
ANS. C
131. THE HEALTHCARE PROVIDER (HCP)PRESCRIBES INTERMITTENT FETAL HEART
RATE MONITORING FOR A 20 YEAR OLD OBESE PRIMIGRAVID CLIENT AT 40 WEEKS’
GESTATION IN THE FIRST STAGE OF LABOR .THE NURSE SHOULD MONITOR THE
CLIENT’S FETAL HEART RATE PATTERN AT WHICH INTERVEL?
A. EVERY 15 MINUTES DURING THE LATENT PHASE
B. EVERY 30 MINUTES DURING THE ACTIVE PHASE
C. EVERY 60 MINUTES DURING THE PUSHING PHASE
D. EVERY 2 HOURS DURING THE TRANSITION PHASE
ANS. B
132. TWO HOURS AGO ,A MULTIGRAVID CLIENT WAS ADMITTED IN ACTIVE LABOR
WITH HER CERVIX DILATED AT 5CM AND COMPLETELY EFFACED AND THE FETUS AT
0 STATION .CURRENTLY ,THE CLIENT IS EXPERIENCING NAUSEA AND VOMITING ,A
SLIGHT CHILL WITH PERSPIRATION BEADS ON HER LIP ,AND EXTREME
IRRITABILITY.THE NURSE SHOULD FIRST;
A. WARM THE TEMPERATURE OF THE ROOM BY A FEW DEGREES
B. INCREASE THE RATE OF INTRAVENOUS FLUID ADMINISTRATION
C. OBTAIN A PRESCRIPTION FOR AN INTRAMUSCULAR ANTIEMETIC MEDICATION
D. ASSESS THE CLIENT’S CERVICAL DILATION AND STATION
ANS. D
133. THE NURSE IS MANAGING A PREGNANT CLIENT’S SECOND STAGE OF LABOR .THE
NURSE SHOULD INTERVENE WHEN OBSERVING WHICH ACTION?
A. CLOSED GLOTTIS PUSHING
B. OPEN GLOTTIS PUSHING
C. REST AND DESCENT
D. SQUATTINGWHILE PUSHING
ANS. A
134. AT A POSTPARTUM CHECK UP 11 DAYS AFTER CHILDBIRTH ,THE NURSE ASKS THE
CLIENT ABOUT THE COLOR OF HER LOCHIA.WHICH COLOR IS EXPECTED?
A. DARK RED
B. PINK
C. BROWN
D. WHITE
ANS. D
135. A PRIMIPARAOUS CLIENT ,48 HOURS AFTER A VAGINAL BIRTH ,IS TO BE
DISCHARGED WITH A PRESCRIPTION FOR VITAMINS WITH IRON BECAUSE SHE IS
ANEMIC .TO MAXIMIZE ABSORPTION OF THE IRON .THE NURSE INSTRUCTS THE
CLIENT TO TAKE THE MEDICATION WITH WHICH LIQUID?
A. ORANGE JUICE
B. HERBAL TEA
C. MILK
D. GRAPE JUICE
ANS. A
136. A BREAST FEEDING PRIMIPARAOUS CLIENT ASKS THE NURSE HOW BREAST MILK
DIFFERS FROM COW’S MILK .THE NURSE RESPONDS BY SAYING THAT BREAST MILK IS
HIGHER IN WHICH NUTRIENT?
A. FAT
B. IRON
C. SODIUM
D. CALCIUM
ANS. A
137. WHEN TEACHING A PRIMIPARAOUS CLIENT ABOUT THE GROWTH AND
DEVELOPMENT OF THE NEONATE ,THE NURSE SHOULD EXPLAIN THAT MOST BABIES
ARE ABLE TO DRINK INDEPENDENTLY FROM A SIPPY CUP AT WHAT AGE?
A. 5 TO 7 MONTHS
B. 8 TO 10 MONTHS
C. 12 TO 14 MONTHS
D. 15 TO 16 MONTHS
 ANS. B
138. WHILE CARING FOR A MALE NEONATE DIAGNOSED WITH GASTROSCHISIS,THE
NURSE OBSERVES THAT THE PARENTS SEEM HESISTANT TO TOUCH THE NEONATE
BECAUSE OF HIS APPEARANCE.THE NURSE DETERMINES THAT THE PARENTS ARE
MOST LIKELY EXPERIENCING WHICH STAGE OF GRIEF?
A. DENIAL
B. SHOCK
C. BARGAINING
D. ANGER
ANS. A
139. TO DETERMINE WHETHER A PRIMIGRAVID CLIENT IN LABOR WITH A FETUS IN
THE LEFT OCCIPITOANTERIOR (LOA)POSITION IS COMPLETELY DILATED,THE NURSE
PERFORMS A VAGINAL EXAMINATION.DURING THE EXAMINATION ,THE NURSE
SHOULD PALPATE WHICH CRANIAL SUTURES?
A. SAGITTAL
B. LAMBDOIDAL
C. CORONAL
D. FRONTAL
ANS. A
140. THE NURSE IS REVIEWING DISCHARGE INSTRUCTIONS WITH A POSTPARTUM
BREAST FEEDING CLIENT WHO IS GOING HOME.SHE HAS CHOSEN DEPOT
MEDROXYPROGESTERONE ACETATE(DMPA)AS BIRTH CONTROL. WHICH STATEMENT
BY THE CLIENT IDENTIFIES THAT SHE NEEDS FURTHER INSTRUCTION CONCERNING
BIRTH CONTROL?
A. I WILLWAIT FOR MY 6 WEEK CHECK UPTO GET MY FIRST DMPA INJECTION
B. DMPA INJECTIONS LAST FOR 90 DAYS
C. MY MILK SUPPLY SHOULD BE WELL ESTABLISHED BEFORE RECEIVING A BIRTH
CONTOL INJECTION
D. YOU WILL GIVE ME MY FIRST DMPA INJECTION BEFORE I LEAVE TODAY
ANS. D
141. THE NURSE IS PREPARING TO ADMINISTER A VITAMIN K INJECTION TO A MALE
NEONATE SHORTLY AFTER BIRTH.WHAT STATEMENT BY THE MOTHER INDICATES
THAT SHE UNDERSTANDS THE PURPOSE OF THE INJECTION?
A. MY BABY DOES NOT HAVE THE NORMAL BACTERIA IN HIS INTESTINES TO
PRODUCE THIS VITAMIN
B. MY BABY IS AT A HIGH RISK FOR A PROBLEM INVOLVING HIS BLOOD’S ABILITY
TO CLOT
 C. THE RED BLOOD CELLS MY BABY FORMED DURING PREGNANCY ARE
DESTROYING THE VITAMIN K.
D. MY BABY’S LIVER IS NOT ABLE TO PRODUCE ENOUGH OF THIS VITAMIN SO
SOON AFTER BIRTH.
ANS. A
142. AFTER TEACHING THE PARENTS OF A CHILD NEWLY DIGNOSED WITH LEUKEMIA
ABOUT THE DISEASE,WHICH DESCRIPTION IF GIVEN BY THE PARENT BEST INDICATES
UNDERSTANDING THE NATURE OF LEUKEMIA?
A. THE DISEASE IS AN INFECTION RESULTING IN INCREASED WHITE BLOOD CELL
PRODUCTION
B. THE DISEASE IS A TYPE OF CANCER CHARACTERIZED BY AN INCREASE IN
IMMATURE WHITE BLOOD CELLS.
C. THE DISEASE IS AN INFLAMMATION ASSOCIATED WITH ENLARGEMENT OF THE
LYMPH NODES
D. THE DISEASE IS AN ALLERGIC DISORDER INVOLVING INCREASED CIRCULATING
ANTIBODIES IN THE BLOOD
ANS. B
143. WHEN DEVELOPING THE PLAN OF CARE FOR A NEWLY ADMITTED 2 YEAR OLD
CHILD WITH THE DIAGNOSIS OF KAWASAKI DISEASE(KD),WHICH INTERVENTION
SHOULD BE THE PRIORITY?
A. TAKING VITAL SIGNS EVERY 6 HOURS
B. MONITORING INTAKE AND OUTPUT EVERY HOUR
C. MINIMIZING SKIN DISCOMFORT
D. PROVDING PASSIVE RANGE OF MOTION EXERCISES
ANS. B
144. THE NURSE IS TEACHING THE PARENTS OF A CHILD WITH SICKLE CELL DISEASE
.TO INSTRUCT THEM ON HOW TO PREVENT SICKLE CELL CRISIS ,THENURSE SHOULD
INCLUDE WHICH INSTRUCTIONS?
A. EXERCISE IN COOL TEMPERATURES
B. DRINK AT LEAST 2 QUARTS OF FLUID PER DAY
C. AVOID CONTACT SPORTS
D. TAKE ANTI INFLAMMATORY MEDICATIONS BEFORE EXERCISING
ANS.B
145. A TRANSFUSION OF PACKED RED BLOOD CELLS HAS BEEN PRESCRIBED FOR A 1
YEAR OLD WITH A SICKLE CELL ANEMIA.THE INFANT HAS A 25 GAUGE IV INFUSING
DEXTROSE WITH SODIUMAND POTASSIUM.USING THE SITUATION
,BACKGROUND,ASSESSMENT ,AND RECOMMENDATION(SBAR) METHOD OF
 COMMUNICATION ,THE NURSE CONTACTS THE HEALTHCARE PROVIDER(HCP)AND
RECOMMENDS
A. STARTING A SECOND IV WITH A 22GAUGE CATHETER TO INFUSE NORMAL
SALINE WITH THE BLOOD
B. USING THE EXISTING IV,BUT CHANGING THE FLUIDS TO NORMAL SALINE FOR
THE TRANSFUSION
C. REPLACING THE IV WITH A 22GAUGE CATHETER TO INFUSE THE PRESCRIBED
FLUIDS.
D. STARTING A SECOND IV WITH A 25 GAUGE CATHETER TO INFUSE NORMAL
SALINE WITH THE TRANSFUSION
ANS. B
146. WHEN BEING INTERVIEWED FOR A POSITION AS A REGISTERED PROFESSIONAL
NURSE, THE APPLICANT IS ASKED TO IDENTIFY AN EXAMPLE OF AN INTENTIONAL
TORT.WHAT IS THE APPROPRIATE RESPONSE?
A. NEGLIGENCE
B. MALPRACTICE
C. BREACH OF DUTY
D. FALSE IMPRISONMENT
ANS. D
147. A NURSE IS TEACHING A GROUP OF PARENTS ABOUT CHILD ABUSE.WHAT
DEFINITION OF ASSULT SHOULD THE NURSE INCLUDE IN THE TEACHING PLAN?
A. ASSULT IS A THREAT TO DO BODILY HARM TO ANOTHER PERSON
B. IT IS A LEGAL WRONG COMMITTED BY ONE PERSON AGAINST THE PROPERTY OF
ANOTHER
C. IT IS A LEGAL WRONG COMMITTED AGAINST THE PUBLIC THAT IS PUNISHABLE
BY STATELAW
D. ASSULT IS THE APPLICATION OF FORCE TO ANOTHER PERSON WITHOUT LAWFUL
JUSTIFICATION
ANS. A
148. A NURSE IS PERFORMING CARDIAC COMPRESSION ON AN ADULT CLIENT.HOW
FAR MUST THE NURSE DEPRESS THE LOWER STERNUM TO MAITAIN CIRCULATION
UNTIL A DEFIBRILLATOR IS AVAILABLE?
A. ¾ TO 1 INCH
B. ½ TO ¾ INCH
C. 1TO 1 1/2 INCHES
D. 2 TO 2 1/2INCHES
ANS.D
149. WHAT DIETARY CHOICES SHOULD THE NURSE INSTRUCT THE CLIENT TAKING
SPIRONOLACTONE(ALDATONE)TO AVOID?SELECT ALL THAT APPLY.
A. POTATOES
B. RED MEAT
C. CANTA LOUPE
D. WHEAT BREAD
E. FLAVORED YOGURT
ANS. A&C
150. AN EMERGENCY DEPARTMENT NURSE IS ADMITTING A CLIENT AFTER AN
AUTOMOBILE COLLISION .THE HEALTH CARE PROVIDER ESTIMATES THAT THE CLIENT
HAS LOST ABOUT 15%TO20?% OF BLOOD VOLUME .WHICH ASSESSMENTFINDING
SHOULD THE NURSE EXPECT THIS CLIENT TO EXHIBIT?
A. URINE OUTPUT OF 50ML/HOUR
B. BLOOD PRESSURE OF 150/90MMHG
C. APICAL HEART RATE OF 142 BEATS/MINUTES
D. RESPIRATORY RATE OF 16 BREATHS/MIN
ANS. C
151. A CLIENT WITH UPPER GASTROINTESTINAL (GI)BLEEDING DEVELOPS MILD
ANEMIA.WHAT SHOULD THE NURSE EXPECT TO BE PRESCRIBED FOR THIS CLIENT?
A. EPOGEN
B. DEXTRAN
C. IRON SALTS
D. VITAMIN B12
ANS. C
152. WHICH SIGNS CAUSE THE NURSE TO SUSPECT CARDIAC TAMPONADE AFTER A
CLIENT HAS CARDIAC SURGERY?SELECT ALL THAT APPLY
A. TACHY CARDIA
B. HYPERTENSION
C. INCREASED CVP
D. INCREASED URINE OUTPUT
E. JUGULAR VEIN DIATENSION
ANS. A,B&E
153. A NURSE IS CARING FOR A CLIENT WHO HAD A SPLENECTOMY.FOR WHICH
COMPLICATION SHOULD THE NURSE SPECIFICALLY ASSESS IN THE IMMEDIATE
POSTOPERATIVE PERIOD?
A. INFECTION
B. PERITONITIS
C. INTESTINAL OBSTRUCTION
 D. ABDOMINAL DISTENSION
ANS. D
154. A CLIENT IS SCHEDULED FOR A PULMONARY FUNCTION TEST.THE NURSE
EXPLAINS THAT DURING THE TEST ONE OF THE INSTRUCTIONS THE RESPIRATORY
THERAPIST WILL GIVE THE CLIENT IS TO BREATHE NORMALLY.WHAT SHOULD THE
NURSE TEACH IS BEING MEASURED WHEN THE CLIENT FOLLOWS THESE
DIRECTIONS?
A. TIDAL VOLUME
B. VITAL CAPACITY
C. EXPIRATORY RESERVE
D. INSPIRATORY RESERVE
ANS. A
155. A CLIENT WITH ASTHMA IS BEING TAUGHT HOW TO USE A PEAKFLOW METER TO
MONITOR HOW WELL THE ASTHMA IS BEING CONTROLLED.WHAT SHOULD THE
NURSE INSTRUCT THE CLIENT TO DO?
A. PERFORM THE PROCEDURE ONCE IN THE MORNING AND ONCE AT NIGHT
B. MOVE THE TRUNK TO AN UPRIGHT POSITION AND THEN EXHALE WHILE
BENDING OVER
C. INHALE COMPLETELY AND THEN BLOW OUT AS HARD AND AS FAST AS POSSIBLE
THROUGH THE MOUTH PIECE
D. PLACE THE MOUTH PIECE BETWEEN THE LIPS AND IN FRONT OF THE TEETH
BEFORE STARTING THE PROCEDURE
ANS. C
156. DURING A PHYSICAL IN THE PRENATAL CLINIC THE CLIENT’S VAGINAL MUCOSA
IS OBSERVED TO HAVE A PURPLISH DISCOLORATION .WHAT SIGN SHOULD THE
NURSE DOCUMENT IN THE CLIENT’S CLINICAL RECORD?
A. HEGAR
B. GOODELL
C. CHADWICK
D. BRAXTON HICKS
ANS. C
157. A 42 YEAR OLD CLIENT HAS AN AMNIOCENTESIS DURING THE 16 TH WEEK OF
GESTATION BECAUSE OF CONCERN ABOUT DOWN SYNDROME.WHAT ADDITIONAL
INFORMATION ABOUT THE FETUS WILL EXAMINATION OF THE AMNIOTIC FLUID
REVEAL AT THIS TIME?
A. LUNG MATURITY
B. TYPE 1 DIABETES
C. CARDIAC ANOMALY
 D. NEURAL TUBE DEFECT
ANS. D
158. WHEN A CLIENT’S LEGS ARE PLACED IN STIRRUPS FOR BIRTH ,THE NURSE
CONFIRMS THAT BOTH LEGS ARE POSITIONED SIMULTANEOUSLY TO PREVENT?
A. VENOUS STASIS IN THE LEGS
B. PRESSURE ON THE PERINEUM
C. EXCESSIVE PULL ON THE FASCIA
D. TRAUMA TO THE UTERINE LIGAMENTS
ANS. D
159. FOR WHAT COMPLICATION SHOULD A NURSE MONITOR A CLIENT WHEN AN
OXYTOCIN (PITOCIN)INFUSION IS USED TO INDUCE LABOR?
A. INTENSE PAIN
B. UTERINE TETANY
C. HYPOGLYCEMIA
D. UMBILICAL CORD PROLAPSE
ANS. B
160. A CLIENT AT 9 WEEKS’ GESTATION ASKS THE NURSE IN THE PRENATAL CLINIC IF
SHE CAN HAVE HER CHORIONIC VILLI SAMPLING(CVS) DONE AT THIS TIME.AT WHAT
WEEK GESTATION SHOULD THE NURSE RESPOND IS THE BEST TIME FOR THIS TEST?
A. 8 WEEKS AND LESS THAN 10 WEEKS
B. 10 WEEKS AND LESS THAN 12 WEEKS
C. 12 WEEKS AND LESS THAN 14 WEEKS
D. 14 WEEKS AND LESS THAN 16 WEEKS
ANS. B
161. TWO DAYS AFTER BEING DISCHARGED ANEW MOTHER CALLS THE CLINIC
STATING THAT SHE IS NOT SURE IF HER BABY IS RECEIVING ENOUGH BREAST MILK
.WHAT INFORMATION DOES THE NURSE NEED TO DETERMINE IF THE INFANT IS
BEING FED ADEQUATELY?
A. VOIDS 4 TIMES BEFORE 2PM
B. SLEEPS 31/2 TO 4 HOURS BETWEEEN FEEDINGS
C. HAS ATLEAST 2 OR MORE BOWEL MOVEMENTS A DAY
D. NURSES 5 MINUTES ON THE FIRST BREAST AND THEN 10 ON THE OTHER
ANS. A
162. A 2 DAY OLD INFANT WHO WEIGHS 6Ib IS FED FORMULA EVERY 4 HOURS
.NEWBORNS NEED ABOUT 73 ML OF FLUID PER POUND OF BODY WEIGHT EACH
DAY.BASED ON THIS INFORMATION APPROXIMATELY HOW MUCH FORMULA
SHOULD THE INFANT RECEIVE AT EACH FEEDING?
A. 1 TO 2 OZ
 B. 2TO 3 OZ
C. 3 TO 4 OZ
D. 4 TO 5 OZ
ANS. B
163. A 3 ½ YEAR OLD CHILD IS ADMITTED TO THE HOSPITAL FOR AN
APPENDECTOMY.WHAT SHOULD THE NURSE USE TO BEST PREPARE THE CHILD FOR
THE HOSPITAL EXPERIENCE?
A. A DIAGRAM
B. PUPPET PLAY
C. A STORY BOOK
D. THERAPEUTIC PLAY
ANS. D
164. A CLIENT WITH MULTIPLE SCLEROSIS IS IN REMISSION .WHICH DIVERSIONAL
ACTIVITY SHOULD THE NURSE ENCOURAGE THAT BEST MEETS THE CLIENT’S NEEDS
WHILE IN REMISSION?
A. HIKING
B. SWIMMING
C. COMPUTER CLASSES
D. WATCHING TELEVISION
ANS. B
165. A CLIENT IS ADMITTED TO THE HOSPITAL WITH A DIAGNOSIS OF MYASTHENIA
GRAVIS.FOR WHICH COMMON EARLY CLINICAL FINDING SHOULD THE NURSE ASSESS
THE CLIENT?
A. TEARING
B. BLURRING
C. DIPLOPIA
D. NYSTAGMUS
ANS. C
166. WHAT IS THE PRIORITY WHEN THE NURSE IS ESTABLISHING A THERAPEUTIC
ENVIRONMENT FOR A CLIENT?
A. PROVIDING FOR THE CLIENT’S SAFETY
B. ACCEPTING THE CLIENT’S INDIVIDUALITY
C. PROMOTING THE CLIENT’S INDEPENDENCE
D. EXPLAINING TO THE CLIENT WHAT IS BEING DONE
ANS. A
167. A 4 ½ YEAR OLD CHILD IS BROUGHT TO THE EMERGENCY DEPARTMENT WITH
A FRACTURED TIBIA.WHICH TYPE OF FRACTURE SHOULD THE NURSE ANTICIPATE
 WILL BE DIANOSED BECAUSE IT IS THE MOST FREQUENTLY ENCOUNTERED
FRACTURE IN CHILDREN OF THIS AGE?
A. GREENSTICK
B. TRANSVERSE
C. COMPOUND
D. COMMINUTED
ANS. A
168. A CLIENT RESCUED FROM A BURNING BUILDING HAS PARTIAL AND FULL
THICKNESS BURNS OVER 40% OF THE BODY.WHICH IS THE INITIAL PHYSIOLOGIC
CHANGE THAT THE NURSE CAN EXPECT?
A. AN INCREASE IN BLOOD VOLUME
B. AN INCREASE IN SERUM POTASSIUM
C. A DECREASE IN CAPILLARY PERMEABILITY
D. A DECREASE IN URINARY SPECIFIC GRAVITY
ANS. B
169. WHAT MUST THE NURSE DETERMINE BEFORE DISCONTINUING AIRBORNE
PRECAUTIONS FOR A CLIENT WITH PULMONARY TUBERCULOSIS?
A. CLIENT NO LONGER IS INFECTED
B. TUBERCULIN SKIN TEST IS NEGATIVE
C. SPUTUM IS FREE OF ACID FAST BACTERIA
D. CLIENT’S TEMPERATURE HAS RETURNED TO NORMAL
ANS. C
170. A NURSE IS TEACHING BREATHING EXERCISES TO A CLIENT WITH EMPHYSEMA
.WHAT IS THE REASON THE NURSE SHOULD INCLUDE IN THE TEACHING AS TO WHY
THESE EXERCISES ARE NECESSARY TO PROMOTE EFFECTIVE USE OF THE
DIAPHRAGM?
A. THE RESIDUAL CAPACITY OF THE LUNGS HAS BEEN INCREASED
B. INSPIRATION HAS BEEN MARKEDLY PROLONGED AND DIFFICULT
C. THE CLIENT HAS AN INCREASE IN THE VITAL CAPACITY OF THE LUNGS
D. ABDOMINAL BREATHING IS AN EFFECTIVE COMPENSATORY MECHANISM AND IS
SPONTANEOUSLY INITIATED
ANS. A
171. A NURSE TEACHES WOMEN IN THE FERTILITY CLINIC THAT AFTER OVULATION
HAS OCCURRED,THE OVUM IS THOUGHT TO REMAIN VIABLE FOR :
A. 1TO6 HOURS
B. 12 TO 18 HOURS
C. 24 TO 36 HOURS
D. 48 TO 72 HOURS
 ANS. C
172. A NURSE IS ASSESSING A CLIENT WHO IS BEING ADMITTED FOR SURGICAL
REPAIR OF A RECTOCELE.WHAT SIGNS OR SYMPTOMS DOES THE NURSE EXPECT THE
CLIENTTO REPORT?SELECT ALL THAT APPLY
A. PAINFUL INTERCOURSE
B. CRAMPY ABDOMINAL PAIN
C. BEARING DOWN SENSATION
D. URINARY STRESS INCONTINENCE
E. RECURRENT URINARY TRACT INFECTIONS
ANS. A&C
173. AT 6 WEEKS’ GESTATION A CLIENT IS DIAGNOSED WITH GONNORRHEA .WHAT
MEDICATION DOES A NURSE EXPECT THE HEALTH CARE PROVIDER TO PRESCRIBE?
A. CEFRIAXONE(ROCEPHIN)
B. LEVOFLOXACIN(LEVAQUIN)
C. SULFASALAZINE(AZULFIDINE)
D. TRIMETHOPRIM(BACTRIM)
ANS.A
174. WHEN DOES A NURSE CARING FOR A CLIENT WITH ECLAMPSIA DETERMINE THAT
THE RISK FOR ANOTHER SEIZURE HAS SUBSIDED?
A. AFTER BIRTH OCCURS
B. AFTER LABOR BEGINS
C. 48 HOURS POSTPARTUM
D. 24 HOURS POSTPARTUM
ANS. C
175. DURING AN EMERGENCY BIRTH THE FETAL HEAD IS CROWNING ON THE
PERINEUM.HOW SHOULD A NURSE SUPPORT THE HEAD AS IT IS BEING BORN?
A. APPLY SUPRAPUBIC PRESSURE
B. PLACE A HAND FIRMLY AGAINST THE PERINEUM
C. DISTRIBUTE THE FINGERS EVENLY AROUND THE HEAD
D. MAINTAIN PRESSURE AGAINST THE ANTERIOR FONTANEL
ANS. C
176. A NEWBORN HAS SMALL,WHITISH ,PINPOINT SPOTS OVER THE NOSE THAT ARE
CAUSED BY RETAINED SEBACEOUS SECRETIONS.WHEN DOCUMENTING THIS
OBSERVATION ,A NURSE IDENTIFIES THEM AS :
A. MILIA
B. LANUGO
C. WHITEHEADS
D. MONGOLIAN SPOTS
 ANS. A
177. A NURSE WHO IS ASSESSING A NEWBORN 1 MINUTE AFTER BIRTH DETERMINES
THAT THE CRY IS LUSTY ,THE HEART RATE IS 150 BEATS /MIN,AND THE
EXTREMITIES ARE FLEXED,BUT THE BOTTOMS OF THE FEET HAVE A MARKED BLUISH
TINGE.WHAT APGAR SCORE DOES THE NURSE ASSIGN TO THE NEONATE.?RECORD
YOUR ANSWER USING A WHOLE NUMBER.
ANS. 9
178. A NURSE OBSERVES A HEALTHY NEWBORN LYING IN THE SUPINE POSITION WITH
THE HEAD TURNED TO THE SIDE AND LEGS AND ARMS EXTENDED ON THE SAME
SIDE AND FLEXED ON THE OPPOSITE SIDE.WHICH REFLEX DOES THE NURSE
IDENTIFY?
A. MORO
B. BABINSKI
C. TONIC NECK
D. PALMAR GRASP
ANS. C
179. AN INFANT’S INTESTINES ARE STERILE AT BIRTH ,THUS LACKING THE BACTERIA
NECESSARY FOR THE SYNTHESIS OF
A. BILIRUBIN
B. BILE SALTS
C. PROTHROMBIN
D. INTRINSIC FACTOR
ANS. C
180. WHICH SHOULD THE NURSE EXPLAIN TO A NEW MOTHER WILL BE DELAYED
UNTIL HER NEWBORN IS 36 TO 48 HOURS OLD?
A. VITAMIN K INJECTION
B. TEST FOR BLOOD GLUCOSE LEVEL
C. TEST FOR NECROTIZING ENTEROCOLOTIS
D. SCREENING FOR PHENYLKETONURIA
ANS. D
181. A NURSE TEACHES A GROUP OF POSTPARTUM CLIENTS THAT ALL THEIR
NEWBORNS WILL BE SCREENED FOR PHENYLKETONURIA(PKU) TO:
A. ASSESS PROTEIN METABOLISM
B. REVEAL POTENTIAL RETARDATION
C. DETECT CHROMOSOMAL DAMAGE
D. IDENTIFY THYROID INSUFFICIENCY
ANS. A
182. WHAT SHOULD A NURSE USE TO FEED AN INFANT BORN WITH A UNILATERAL
CLEFT LIP AND PALATE?
A. PLASTIC SPOON
B. CROSS CUT NIPPLE
C. PARENTERAL INFUSION
D. RUBBER –TIPPED SYRINGE
ANS. D
183. A NURSE WHO IS CARING FOR AN INFANT WITH A CLEFT LIP IS CONCERNED
ABOUT PREVENTING AN INFECTION .WHY DOES THE CLEFT LIP PREDISPOSE THE
INFANT TO INFECTION?
A. WASTE PRODUCTS ACCUMULATE ALONG THE DEFECT
B. THERE IS INADEQUATE CIRCULATION IN THE DEFECTIVE AREA
C. NUTRITION IS INADEQUATE BECAUSE OF INEFFECTIVE FEEDING
D. MOUTH BREATHING DRIES THE OROPHARYNGEAL MUCOUS MEMBRANES
ANS. D
184. WHAT SHOULD NURSING CARE FOR AN INFANT AFTER THE SURGICAL REPAIR OF
A CLEFT LIP INCLUDE
A. PREVENTING CRYING
B. PLACING IN A SEMI-FOWLER POSITION
C. KEEPING NPO FOR 1 DAY AFTER SURGERY
D. FEEDING WITH A SPOON FOR 2 DAYS AFTER SURGERY
ANS. A
185. A NURSE IS CARING FOR AN INFANT WITH PHENYLKETONURIA(PKU),WHAT DIET
SHOULD THE NURSE ANTICIPATE WILL BE ORDERED BY THE HEALTH CARE
PROVIDER?
A. FAT –FREE
B. PROTEIN ENRICHED
C. PHENYLALANINE-FREE
D. LOW –PHENYLALANINE
ANS. D
186. AN INFANT HAD CORRECTIVE SURGERY FOR HYPERTROPHIC PYLORIC
STENOSIS(HPS).WHAT SHOULD THE NURSE TEACH A PARENT TO DO IMMEDIATELY
AFTER A FEEDING TO LIMIT VOMITING?
A. ROCK THE INFANT
B. PLACE THE INFANT FLAT ON THE RIGHT SIDE
C. PLACE THE INFANT IN AN INFANT SEAT
D. KEEP THE INFANT AWAKE WITH SENSORY STIMULATION
ANS. C
187. A NURSE IS CARING FOR A CLIENT WHO IS CACHCETIC.WHAT INFORMATION
ABOUT THE FUNCTION OF ADIPOSE TISSUE IN FAT METABOLISM IS NECESSARY TO
BETTER ADRESS THE NEEDS OF THIS CLIENT?
A. RELEASES GLUCOSE FOR ENERGY
B. REGULATES CHOLESTEROL PRODUCTION
C. USES LIPOPROTEINS FOR FAT TRANSPORT
D. STORES TRIGLYCERIDES FOR ENERGY RESERVES
ANS.D
188. A CLIENT IS TO HAVE GASTRIC GAVAGE.IN WHICH POSITION SHOULD THE
NURSE PLACE THE CLIENT WHEN THE NASOGASTRIC TUBE IS BEING INSERTED?
A. SUPINE
B. MID-FOWLER
C. HIGH-FOWLER
D. TRENDELENBURG
ANS. C
189. A HEALTH CARE PROVIDER ORDERS A SIGMOIDOSCOPY FOR ONE CLIENT AND A
BARIUM ENEMA FOR ANOTHER CLIENT .WHAT IS A NURSING RESPOSIBILITY
COMMON TO PREPARING BOTH OF THESE CLIENTS FOR THESE PROCEDURES?
A. WITHHOLDING FOOD FOR SEVERAL HOURS
B. GIVING CASTOR OIL THE AFTERNOON BEFORE
C. ADMINISTERING SOAPSUDS ENEMAS UNTIL CLEAR
D. ENSURING AN UNDERSTANDING OF THE PROCEDURE
ANS. D
190. A HIGH CLENSING ENEMA IS ORDERED FOR A CLIENT .WHAT IS THE MAXIMUM
HEIGHT AT WHICH THE CONTAINER OF FLUID SHOULD BE HELD BY THE NURSE
WHEN ADMINISTERING THIS ENEMA
A. 30CM(12INCHES)
B. 37CM(15INCHES)
C. 51CM(20INCHES)
D. 66CM(26 INCHES)
ANS.B
191. AN EXPLORATORY LAPROTOMY IS PERFORMED ON A CLIENT WITH
MELENA,AND GASTRIC CANCER IS DISCOVERED. A PARTIAL GASTRECTOMY IS
PERFORMED,AND A JEJUNOSTOMYTUBE IS SURGICALLY IMPLANTED.A
NASOGASTRIC TUBE TO SUCTION IS IN PLACE.WHAT WOULD THE NURSE EXPECT
REGARDING THE CLIENT’S NASOGASTRIC TUBE DRAINAGE DURING THE FIRST 24
HOURS AFTER SURGERY?
A. GREEN AND VISCID
 B. CONTAIN SOME BLOOD AND CLOTS
C. CONTAIN LARGE AMOUNT OF FRANK BLOOD
D. SIMILAR TO COFFEE GROUNDS IN COLOR AND CONSISTENCY
ANS. B
192. A CLIENT HAS A SUSPECTED PEPTIC ULCER IN THE DUODENUM.WHAT SHOULD
THE NURSE EXPECT THE CLIENT TO REPORT WHEN DESCRIBING THE PAIN
ASSOCIATED WITH THIS DISEASE?
A. AN ACHE RADIATING TO THE LEFT SIDE
B. AN INTERMITTENTCOLICKY FLANK PAIN
C. A GNAWING SENSATION RELIEVED BY FOOD
D. A GENERALIZED ADBOMINAL PAIN INTENSIFIED BY MOVING
ANS. C
193. A CLIENT WITH GASTROESOPHAGEAL REFLUX DISEASE IS TO RECEIVE
METOCLORPROMIDE(RAGLAN)15 MG ORALLY BEFORE MEALS.THE CONCENTRATED
SOLUTION CONTAINS 10MG/ML.HOW MUCH SOLUTION SHOULD THE NURSE
ADMINISTER?RECORD YOUR ANSWER USING ONE DECIMAL PLACE.
ANS. DESIRE 15MG = XML
HAVE 10MG 1ML
10X =15
X =15
10
X= 1.5ML
194. A NURSE IS EVALUATING A CLIENT’S RESPONSE TO RECEIVING AN INTERMITTENT
GRAVITY FLOW PERCUTANEOUS ENDOSCOPIC GASTROSTOMY(PEG) TUBE
FEEDING.WHICH CLINICAL FINDING INDICATES THAT THE CLIENT IS UNABLE TO
TOLERATE A CONTINUATION OF THE FEEDING?
A. PASSAGE OF FLATUS
B. RISE OF FORMULA IN THE TUBE
C. RAPID INFLOW OF THE FEEDING
D. TENDERNESS OF EPIGASTRIC AREA
ANS. B
195. A CLIENT IS SCHEDULED FOR LIGATION OF HEMORRHOIDS.WHICH DIET DOES
THE NURSE EXPECCT TO BE ORDERED IN PREPARATION FOR THIS SURGERY?
A. BLAND
B. CLEAR DLUID
C. HIGH-PROTEIN
D. LOW-RESIDUE
ANS. D
196. A HARISH FLUSH IS ORDERED TO REDUCE A CLIENT’S FLATUS AFTER ABDOMINAL
SURGERY.HOW MANY INCHES SHOULD THE NURSE INSERT THE RECTAL CATHETER?
A. 2
B. 4
C. 6
D. 8
ANS. B
197. A NURSE IS ASSESSING TWO CLIENT’S.ONE CLIENT HAS ULCERATIVE COLITIS AND
THE OTHER HAS CROHN DISEASE.WHICH IS MORE LIKELY TO BE IDENTIFIED IN THE
CLIENT WITH ULCERATIVE COLITIS THAN THE CLIENT WITH CROHN DISEASE?
A. INCLUSION OF TRANSMURAL INVOLVEMENT OF THE SMALL BOWEL WALL
B. CORRELATION WITH INCRESED MALIGNANCY BECAUSE OF MALABSORPTION
SYNDROME
C. PATHOLOGY BEGINNING PROXIMALLY WITH INTERMITTENT PLAQUES FOUND
ALONG THE COLON
D. INVOLVEMENT STARTING DISTALLY WITHRECTAL BLEEDING THAT SPREADS
CONTINUOUSLY UP THE COLON
ANS. D
198. AFTER A BRAIN ATTACK A CLIENT IS UNABLE TO DIFFERENTIATE BETWEEN HEAT
OR COLD AND SHARP OR DULL SENSORY STIMULATION. WHAT LOBE OF THE BRAIN
SHOULD THE NURSE CONCLUDE IS LIKELY AFFECTED?
A. FRONTAL
B. PARIETAL
C. OCCIPITAL
D. TEMPORAL
ANS. B A –ABSTRACT THINKING,MUSCULAR MVEMENTS,D-SOUND
199. WHEN COMPLETING A NEUROLOGICAL ASSESSMENT ,THE NURSE DETERMINES
THAT A CLIENT HAS A POSITIVE ROMBERG TEST.WHICH FINDING SUPPORTS THE
NURSE’S CONCLUSION?
A. INABILITY TO STAND WITH FEET TOGETHER WHEN EYES ARE CLOSED
B. FANNING OF TOES WHEN THE SOLE OF THE FOOT IS FIRMLY STROKED
C. DILATATION OF PUPILS WHEN FOCUSING ON AN OBJECT IN THE DISTANCE
D. MOVEMENT OF EYES TOWARD THE OPPOSITE SIDE WHEN HEAD IS TURNED
ANS.A
200. A NURSE ASSISTS THE HEALTH CARE PROVIDER TO PERFORM A LUMBAR
PUNCTURE.WHEN PRESSURE IS PLACED ON THE JUGULAR VEIN DURING A LUMBAR
PUNCTURE,THE SPINAL FLUID PRESSURE IS EXPECTED TO INCREASE.WHICH SIGN
SHOULD THE NURSE EXPECT THE HEALTH CARE PROVIDER TO DOCUMENT?
 A. HOMAN
B. ROMBERG
C. CHVOSTEK
D. QUECKENSTEDT
ANS. D
201. WHAT CLINICAL INDICATOR DOES THE NURSE EXPECT TO IDENTIFY WHEN
ASSESSING ACLIENT WITH A BRAIN TUMOR IN THE OCCIPITAL LOBE?
A. HEMIPARESIS
B. RECEPTIVE APHASIA
C. PERSONALITY CHANGES
D. VISUAL HALLUCINATIONS
ANS. D
202. A NURSE ADMINISTERS CARBIDOPA-LEVODOPA(SINEMET) TO A CLIENT WITH
PARKINSON DISEASE.WHICH THERAPEUTIC EFFECT DOES THE NURSE EXPECT THE
MEDICATION TO PRODUCE?
A. INCREASE IN ACETYLCHOLINE PRODUCTION
B. REGENERATION OF INJURED THALAMIC CELLS
C. IMPROVEMENT IN MYELINATION OF NEURONS
D. REPLACEMENT OF A NEUROTRANSMITTER IN THE BRAIN
ANS. D
203. A RECENTLY HOSPITALIZED CLIENT WITH MULTIPLE SCLEROSIS IS CONCERNED
ABOUT GENERALIZED WEAKNESS AND FLUCTUATING PHYSICAL STATUS.WHAT IS
THE PRIORITY NURSING INTERVENTION FOR THIS CLIENT?
A. ENCOURAGE BED REST
B. SPACE ACTIVITIES THROUGHOUT THE DAY
C. TEACH THE LIMITATIONS IMPOSED BY THE DISEASE
D. HEVE ONE OF THE CLIENT’S RELATIVES STAY AT THE BEDSIDE
ANS. B
204. WHEN HELPING A CLIENT WITHPARKINSON DISEASE TO AMBULATE,WHAT
INSTRUCTIONS SHOULD THE NURSE GIVE THE CLIENT?
A. AVOID LEANING FORWARD
B. HESITATE BETWEEN STEPS
C. REST WHEN TREMERS ARE EXPERIENCED
D. KEEP ARM CLOSE TO THE CENTER OF GRAVITY
ANS. A
205. A NURSE IS INTERVIEWING A CLIENT WITH A TENTATIVE DIAGNOSIS OF
PARKINSON DISEASE.WHAT SHOULD THE NURSE EXPECT THE CLIENT TO REPORT
ABOUT HOW THE ONSET OF SYMPTOMS OCCURRED?
 A. SUDDENLY
B. GRADUALLY
C. OVERNIGHT
D. IRREGULARLY
ANS. B
206. WHICH CRUTCH GAIT SHOULD THE NURSE TEACH THE CLIENT WEARING A
PROSTHESIS AFTER A SINGLE LEG AMPUTATION?
A. TRIPOD
B. FOUR-POINT
C. THREE-POINT
D. SWING-THROUGH
ANS. B
207. WHICH PRINCIPLE SHOULD THE NURSE CONSIDER WHEN ASSISTING A CLIENT
WITH CRUTCHES TO LEARN THE FOUR POINT GAIT?
A. ELBOWS SHOULD BE KEPT IN RIGID EXTENSION
B. MOST OF THE WEIGHT SHOULD BE SUPPORTED BY AXILLAE
C. THE CLIENT MUST BE ABLE TO BEAR WEIGHT ON BOTH LEGS
D. THE AFFECTED EXTREMITY SHOULD BE KEPTOFF THE GROUND
ANS. C(IN THE FOUR POINT GAIT THE CLIENT BRINGS THE LEFT CRUTCH
FORWARD FIRST,FOLLOWED BY THE RIGHT FOOT,THEN THE RIGHT CRETCH IS
BROUGHT FORWARD,FOLLOWED BY THE LEFT FOOT.
208. A CLIENT IS READY TO WALK WITH CRUTCHES AFTER KNEE SURGERY.WHICH
CRUTCH-WALKING TECHNIQUE WILL THE NURSE MOST LIKELY HAVE TO REINFORCE
AFTER THE CLIENT RETURNS FROM PHYSICAL THERAPY?
A. TWO-POINT
B. FOUR-POINT
C. THREE-POINT
D. SWING-THROUGH
ANS. C(THREE POINT GAIT,WHICH REGUIRS ARM STRENGTH, IS USED WHEN A
LIMB CANNOT BEAR WEIGHT .THE AFFECTED LEG AND CRUTCHES ARE
ADVANCED TOGETHER,AND THE STRONG LEG SWINGS THROUGH.
209. HOW DOES THE NURSE IDENTIFY TRUE LABOR AS OPPOSED TO FALSE LABOR?
A. CERVICAL DILATATION IS PROGRESSIVE
B. CONTRACTIONS STOP WHEN THE CLIENT WALKS AROUND
C. CLIENT’S CONTRACTIONS PROGRESS ONLY IN A SIDE –LYING POSITION
D. CONTRACTIONS OCCUR IMMEDIATELY AFTER THE MEMBRANES RUPTURE
ANS. A
210. A CLIENT IS ADMITTED TO THE BIRTHING SUITE IN EARLY ACTIVE LABOR.WHICH
NURSING ACTION TAKES PRIORITY DURING THE ADMISSION PROCESS?
A. AUSCULTATING THE FETAL HEART RATE
B. OBTAINING AN OBSTETRIC HISTORY
C. DETERMINING WHEN THE LAST MEAL WAS EATEN
D. ASCERTAINING WHETHER THE MEMBRANES HAVE RUPTURED
ANS. A
211. A CLIENT IS ADMITTED TO THE BIRTHING UNIT IN ACTIVE LABOR.WHAT SHOULD
THE NURSE EXPECT AFTER AN AMNIOTOMY IS PERFORMED
A. DIMINISHED BLOODY SHOW
B. INCREASED AND MORE VARIABLE FHR
C. LESS DISCMFORT WITH CONTRACTIONS
D. PROGRESSIVE DILATATION AND EFFACEMENT
ANS. D
212. A LABORING CLIENT IS TO HAVE A PUDENDAL BOCK.WHAT SHOULD A NURSE
TEACH THE CLIENT ABOUT THE EFFECTS OF THE PUDENTAL ?
A. BLADDER SENSATION MAY BE LOST
B. SHE WILL NOT FEEL AN EPISIOTOMY
C. SHE MAY LOOSE THE ABILITY TO PUSH
D. CONTRACTIONS WILL NO LONGER BE FELT
ANS. B
213. WHEN PLANNING DISCHARGE TEACHING FOR THE PARENTS OF A CHILD WITH
ASTHMA ,WHAT INFORMATION SHOULD THE NURSE INCLUDE?
A. AVOID FOODS HIGH IN FAT
B. STAY AT HOME FORBTWO WEEKS
C. INCREASE THE PROTEIN AND CALORIE INTAKE
D. MINIMIZE EXERTION AND EXPOSURE TO COLD
ANS. D
214. A HEALTH CARE PROVIDER LISTS ORDERS FOR A YOUNG CHILD WITH A
TENTATIVE DIAGNOSIS OF WILMS TUMOR.WHICH ORDER SHOULD THE NURSE
QUESTION?
A. MRI
B. CT SCAN
C. RENAL BIOPSY
D. ABDOMINAL ULTRASOUND
ANS. C
215. PARENTS OF A SICK INFANT TALK WITH A NURSE ABOUT THEIR BABY.ONE
PARENT SAYS ,I AM SO UPSET I DID NOT REALIZE OUR BABY WAS ILL.WHAT
 MAJOR INDICATION OF ILLNESS IN AN INFANT SHOULD THE NURSE EXPLAIN TO THE
PARENT?
A. GRUNTING RESPIRATIONS
B. EXCESSIVE PERSPIRATION
C. LONGER PERIODS OF SLEEP
D. CRYING IMMEDIATELY AFTER FEEDINGS
ANS. A
216. A NURSE IS ASSESSING THE ORAL CAVITY OF A 6 MONTH OLD INFANT .THE
PARENT ASKS WHICH TEETH WILL ERUPT FIRST.HOW SHOULD THE NURSE
RESPOND?
A. INCISORS
B. CANINES
C. UPPER MOLARS
D. LOWER MOLARS
ANS. A , B-IT APPEAR AT ABOUT 18 MONTHS,C&D APPEAR AT ABOUT 20
MONTHS
217. A 3 MONTH OLD INFANT HAS BEEN HOSPITALIZED WITH RESPIRATORY
SYNCYTIAL VIRUS(RSV).WHAT IS THE PRIORITY INTERVENTION?
A. ADMINISTERING AN ANTIVIRAL AGENT
B. CLUSTERING CARE TO CONSERVE ENERGY
C. OFFERING ORAL FLUIDS TO PROMOTE HYDRATION
D. PROVIDING AN ANTITUSSIVE AGENT WHENEVER NECESSARY
ANS. B
218. A NURSE AT WELL BABY CLINIC DETERMINES A 1 YEAR OLD INFANTS LENGTH TO
BE BELOW WHAT IS EXPECTED.THE CURRENT HEIGHT IS 28 INCHES,AND THE BIRTH
LENGTH WAS 20 INCHES .WHAT SHOULD THIS INFANTS CURRENT LENGTH
BE?RECORD YOUR ANSWER USING A WHOLE NUMBER?
ANS. 30 INCHES
AT 1 YEAR OF AGE AN INFANT SHOULD HAVE INCREASED THE BIRTH LENGTH BY
50% OF THE BIRTH LENGTH.THAT IS 20 +10=30
219. THE HEALTH CARE PROVIDER PRESCRIBES 375 MG AMPICILLINIV Q 6H FOR A 5
MONTH OLD WITH RECURRING RESPIRATORY INFECTIONS .THE DRUG IS SUPPLIED
AS 500MG OF POWDER IN A VIAL.THE DIRECTIONS STATE TO MIX THE POWDER
WITH 1.8 ML DILUENT, WHICH YIELDS 250MG/ML.HOW MANY MILLILITERS SHOULD
THE NURSE ADMINISTER?RECORD YOUR ANSWER USING ONE DECIMEL PLACE
ANS.DESIRED 375 =XML
AVAILABLE 250 1ML
250X= 375
 X=375÷250
X =1.5ML

220. CHILD IS ADMITTED TO THE HOSPITAL WITH PNEUMONIA.WHAT IS THE

PRIORITY NEED THAT MUST BE INCLUDED IN THE NURSING PLAN OF CARE FOR THIS
CHILD?
A. REST
B. EXERCISE
C. NUTRITION
D. ELIMINATION
ANS. A
221. A PARENT TELLS THE NURSE IN THE EMERGENCY DEPARTMENT ,MY 3 YEAR OLD
HAS HAD A FEVER FOR SEVERAL DAYS AND HAS BEEN VOMITING.AFTER
INSTITUTING ORDERED MEASURES TO REDUCE THE FEVER,WHAT NURSING ACTION
IS MOST IMPORTANT?
A. PREVENTING SHIVERING
B. RESTRICTING ORAL FLUIDS
C. MEASURING OUTPUT HOURLY
D. TAKING VITAL SIGNS HOURLY
ANS. A
222. AN INFANT WHO HAS HAD DIARRHEA FOR 3 DAYS IS ADMITTED IN A LETHARGIC
STATE AND IS BREATHING RAPIDLY.THE PARENT STATES THAT THE BABY HAS BEEN
INGESTING FORMULA ,ALTHOUGH NOT AS MUCH AS USUAL,AND CANNOT
UNDERSTAND THE SUDDEN CHANGE .WHAT EXPLANATION SHOULD THE NURSE
GIVE THE PARENT?
A. CELLULAR METABOLISM IS UNSTABLE IN YOUNG CHILDREN
B. THE PROPORTION OF WATER IN THE BODY IS LESS THAN IN ADULTS
C. RENAL FUNCTION IS IMMATURE IN CHILDREN UNTIL THEY REACH SCHOOL AGE
D. THE EXTRACELLULAR FLUID REQUIREMENT PER UNIT OF BODY WEIGHT IS
GREATER THAN IN ADULTS
ANS. D
FLUID’S PERCENTAGE OF TOTAL BODY WEIGHT ,80%AT BIRTH,63% AT 3
YEARS,APPROXIMATELY 60% AT 12YEARS
223. AN INFANT WHO HAD A REVISION OF A VENTRICULOPERITONEAL SHUNT IS
DIAGNOSED WITH MENINGITIS FROM AN INFECTED SHUNT.WHAT CLINICAL
MANIFESTATIONS SUPPORT THIS CONCLUSION?SELECT ALL THAT APPLY
A. FEVER
B. LETHARGY
 C. STIFF NECK
D. POOR FEEDING
E. DEPRESSED FONTANELS
ANS. A C&D
224. AN INFANT IS RECEIVING PARETERAL THERAPY .THE IV ORDERS ARE 400ML OF
D5 WATER 0.45% SODIUM CHLORIDE TO RUN OVER 8 HOURS .AT WHAT RATE
SHOULD THE NURSE MAINTAIN THE HOURLY RATE?RECORD YOUR ANSWER USING
A WHOLE NUMBER
ANS.400÷8=50ML
225. AN INFANT IS DIAGNOSED WITH COMMUNICATING HYDROCEPHALUS.THE
PARENTS ASK FOR CLARIFICATION OF THE HEALTH CARE PROVIDER’S EXPLANATION
OF THEIR BABY’S PROBLEM.HOW SHOULD THE NURSE RESPOND?
A. TOO MUCH SPINAL FLUID IS PRODUCED WITHIN THE SPACES(VENTRICLES)OF
THE BRAIN
B. THE FLOW OF SPINAL FLUID THROUGH THE BRAIN CELLS DOES NOT EMPTY
EFFECTIVELY IN TO THE SPINAL CORD
C. THE SPINAL FLUID IS PREVENTED FROM ADEQUATE ABSORPTION BY A
BLOCKAGE IN THE SPACES (VENTRICLES) OF THE BRAIN
D. THERE IS A PART OF THE BRAIN SURFACE THAT USUALLY ABSORBS SPINAL FLUID
AFTER ITS PRODUCTION THAT IS NOT FUNCTIONING ADEQUATELY
ANS. D
226. A 3 YEAR OLD CHILD IS SCHEDULED FOR A CARDIAC CATHETERIZATION.WHAT IS
THE PRIORITY NURSING CARE AFTER THIS PROCEDURE?
A. ENCOURAGING EARLY AMBULATION
B. MONITORING THE SITE FOR BLEEDING
C. RESTRICTING FLUIDS UNTIL THE BLOOD PRESSURE IS STABILIZED
D. COMPARING THE BLOOD PRESSURE OF BOTH LOWER EXTREMITIES
ANS. B
227. A HEALTH CARE PROVIDER PRESCRIBES AMOXICILLIN 145MG BY MOUTH THREE
TIMES DAILY FOR A 28-Ib TODDLER.IT IS SUPPLIED AS A SUSPENSION OF
250MG/5ML.THE SAFE DOSAGE IS 35MG/KG/24HOURS.HOW MANY MILLIGRAMS
WITHIN THE SAFE DOSAGE LIMIT IS THE DOSE?RECORD YOUR ANSWER USING ONE
DECIMAL PLACE.
ANS. 9.5MG.SINCE THERE ARE 2.2 POUNDS PER KILOGRAM ,THE CHILD’S
WEIGHT OF 28Ib IS EQUAL TO 12.7KG.THE SAFE DOSE IS DETERMINED BY
MULTIPLYING THE CHILD’S WEIGHT IN KILOGRAMS BY 35(12.7*35),WHICH IS
444.5MG/24HOURS.TO CALCULATE THE CHILD’S DOSE IN 24 HOURS,MULTIPLY
THE PRESCRIBED DOSE(145MG) BY3, WHICH EQUALS 435MG IN 24
 HOURS.SUBSTRACT 435 FROM 445.5,WHICH EQUALS 9.5MG.BECAUSE THE DAILY
DOSE IS 9.5MG LESS THAN THE MAXIMUM SAFE DAILY DOSE OF 444.5MG.
228. A PARENT AND 4NYEAR –OLD CHILD WHO RECENTLY EMIGRATED FROM
COLOMBIA ARRIVE AT THE PEDIATRIC CLINIC.THE CHILD HAS A TEMPERATURE OF
102OF IS IRRITABLE ,AND HAS A RUNNY NOSE.INSPECTION REVEALS A RASH AND
SEVERAL SMALL,RED ,IRREGULARLY SHAPED SPOTS WITH BLUE-WHITE CENTRES IN
THE MOUTH .WHAT ILLNESS DOES THE NURSE SUSPECT THE CHILD HAS?
A. MEASLES
B. CHICKENPOX
C. FIFTH DISEASE
D. SCARLET FEVER
ANS. A(CARDINAL SIGNS OF RUBEOLA OR MEASLES)KOPLIK SPOTS
SCARLET FEVER-STRAWBERRY TONGUE
229. ON THE THIRD DAY OF HOSPITALIZATION THE NURSE OBSERVES THAT A2YEAR
OLD TODDLER WHO HAD BEEN SCREAMING AND CRYING INCONSOLABLY BEGINS TO
REGRESS AND IS NOW LYING QUIETLY IN THE CRIB WITH A BLANKET.WHAT STAGES
OF SEPERATION ANXIETY HAS DEVELOPED?
A. DENIAL
B. DESPAIR
C. MISTRUST
D. REJECTION
ANS. B
230. HOW CAN A NURSE BEST ACCOMPLISH THERAPEUTIC COMMUNICATION WITH
AN ADOLESCENT ?
A. USING TEEN LANGUAGE
B. RELATING ON A PEER LEVEL
C. ESTABLISHING A RELATIONSHIP OVER TIME
D. INTERACTING BY USING CONCRETE CONCEPTS
ANS.C
231. WHAT MEDICATION DOES A NURSE EXPECT TO ADMINISTER TO CONTROL
BLEEDING IN A CHILD WITH HEMOPHILIA A?
A. ALBUMIN
B. FRESH FROZEN PLASMA
C. FACTOR VIII CONCENTRATE
D. FACTOR 11,VII,IX,X COMPLEX
ANS. C
232. A NURSE IS TEACHING A 12 YEAR OLD CHILD WITH TYPE 1 DIABETES ABOUT THE
EFECTS OF NOVOLIN N INSULIN.IF THE CHILD RECEIVES THE INSULIN AT 7.30 AM
,WHAT TIME OF THE DAY IN AN INSULIN REACTION LIKELY TO OCCUR?
A. 8.30PM
B. 2.30PM
C. 9.30PM
D. 1.30AM
ANS.B
233. A NURSE IS EXPLAINING HOW HEMOPHILIA IS INHERITED TO THE PARENTS OF A
RECENTLY DIAGNOSED CHILD .WHAT IS THE BEST EXPLANATION OF THE GENETIC
FACTOR THAT IS INVOLVED?
A. IT FOLLOWS THE MENDELIAN LAW OF INHERITED DISORDERS
B. THE MOTHER IS THE CARRIER OF THE DISORDER ,BUT IS NOT AFFECTED BY IT
C. IT IS AN AUTOSOMAL DOMINANT DISORDER IN WHICH THE WOMAN CARRIES
THE TRAIT
D. A CARRIER CAN BE MALE OR FEMALE ,BUT IT OCCURS IN THE SEX OPPOSITE
THAT OF THE CARRIER.
ANS. B
234. A 7 YEAR OLD CHILD IS ADMITTED FOR SURGERY.WHAT IS AN ESSENTIAL
PREOPERATIVE NURSING INTERVENTION?
A. ALLOW A FAVORITE TOY TO REMAIN WITH THE CHILD
B. DOCUENT THE CHILD’S ASO TITER AND C-REACTIVE PROTEIN LEVEL
C. INSPECT THE CHILD’S MOUTH FOR LOOSE TEETH AND REPORT THE FINDINGS
D. ENCOURAGE A PARENT TO STAY UNTIL THE CHILD LEAVES FOR THE OPERATING
ROOM
ANS. C
235. A 7 YEAR OLD CHILD DEVELOPS A URINARY TRACT INFECTION .A SULFONAMIDE
PREPARATION IS PRESCRIBED. WHAT IS A MAJOR NURSING RESPOSIBILITY WHEN
ADMINISTERING THIS DRUG?
A. WEIGH THE CHILD DAILY
B. GIVE THE MEDICATION WITH MILK
C. MONITOR THE CHILD’S TEMPERATURE FREQUENTLY
D. ADMINISTER THE DRUG AT THE PRESCRIBED TIMES
ANS. D
236. A 4 YEAR OLD CHILD IS DIAGNOSED WITH MUCOCUTANEOUS LYMPH NODE
SYNDROME(KAWASAKI DISEASE)THE CHILD IS ADMITTED TO THE PEDIATRIC UNIT
AND THE NURSE PERFORMS AN INITIAL ASSESSMENT.WHAT CLINICAL FINDING
SUPPORTS TIS DIAGNOSIS?
 A. STRAWBERRY TONGUE
B. COPIOUS DISCHARGES FROM THE EYES
C. INSIDIOUS ONSET OF LAW –GRADE FEVER
D. MACULOPAPULAR RASH ON THE EXTREMITIES
ANS. A
237. A 10 YEAR OLD CHILD IS DIAGNOSED WITH LYMPHOCYTIC
THYROIDITIS(HASHIMOTO DISEASE).WHAT SHOULD THE NURSE EXPLAIN TO THE
PARENTS AND CHILD ABOUT THIS CONDITION?
A. IT IS CHRONIC
B. TREATMENT IS DIFFICULT
C. IT IS AN INHERITED DISORDER
D. REGRESSION OCCURS SPONTANEOUSLY
ANS. D
238. PINWORMS CAUSE A NUMBER OF SYMPTOMS BESIDES ANAL ITCHING.A
COMPLICATION OF PINWORM INFESTATION ,ALTHOUGH RARE,THAT THE NURSE
SHOULD BE AWARE OF IS
A. HEPATITIS
B. STOMATITIS
C. PNEUMONITIS
D. APPENDICITIS
ANS. D
239. MEBENDAZOLE (VERMOX)IS PRESCRIBED FOR A CHILD WITH PINWORMS.FOR
WHOM SHOULD THIS MEDICATION ALSO BE PRESCRIBED?
A. THE CHILD’S INFANT BROTHER
B. PEOPLE USING THE SAME TOILET FACILITIES AS THE CHILD
C. MEMBERS OF THE CHILD’S FAMILY AFTER THEY TEST POSITIVE
D. THE CHILD’S IMMEDIATE FAMILY MEMBERS EVEN IF THEY ARE SYMPTOM FREE
ANS. D
240. A 7 YEAR OLD CHILD WITH CYSTIC FIBROSIS IS RECEIVING AN INTRAVENOUS
ANTIBIOTIC .THE MEDICATION IS SUPPLIED IN A 125ML BAG OF 0.45% SODIUM
CHLORIDE.IT IS TO BE INFUSED OVER 30 MINUTES.AT WHAT RATE SHOULD THE
INFUSION PUMP BE SET TO DELIVER THE MEDICATION IN THE PRESCRIBED
TIME?RECORD YOUR ANSWER USING A WHOLE NUMBER
ANS. 250ML/HOUR
241. THE PARENTS OF A CHILD NEWLY DIAGNOSED WITH CYSTIC FIBOSIS TELL A
NURSE THAT EVEN THOUGH THEY WERE TOLD IT IS AN INHERITED DISORDER THERE
IS NO HISTORY OF CYSTIC FIBROSIS IN THE FAMILY.HOW CAN THE NURSE CLARIFY
THE WAY IT WAS INHERITED?
 A. IT IS A MUTATED GENE
B. IT INVOLVES AN X-LINKED GENE
C. THE INHERITENCE IS AUTOSOMAL RECESSIVE
D. THE INHERITANCE IS AUTOSOMAL DOMINANT
ANS. C
242. THE PARENTS OF A CHILD NEWLY DIAGNOSED WITH CYSTIC FIBROSIS ASK A
NURSE WHAT CAUSES THE PROBLEMS RELATED TO THIS DISORDER.WHAT SHOULD
THE NURSE CONSIDER ABOUT THE PRIMARY PATHOLOGY BEFORE RESPONDING?
A. HYPERACTIVITY OF THE ECCRINE(SWEAT) GLANDS
B. HYPOACTIVITY OF THE AUTONOMIC NERVOUS SYSTEM
C. MECHANICAL OBSTRUCTION OF MUCUS SECRETING GLANDS
D. ATROPHIC CHANGES IN THE MUCOSAL LINING OF THE INTESTINES
ANS. C
243. A CHILD WITH β-THALASSEMIA (COOLEY ANEMIA)IS ADMITTED TO THE
AMBULATORY CARE UNIT FOR A TRANSFUSION.WHAT INSTRUCTIONS SHOULD THE
NURSE INCLUDE IN THE DISCHARGE PLAN?
A. ENCOURAGE FLUIDS
B. RESTRICT ACTIVITIES
C. PROTECT FROM INFECTIONS
D. OFFER SMALL MEALS FREQUENTLY
ANS. C
244. A NURSE IS CARING FOR A CHILD WITH SICKLE CELL ANEMIA.WHAT IS THE
PRIORITY NURSING INTERVENTION TO PREVENT THROMBUS FORMATION IN
CAPILLARIES AND THE STASIS AND CLOTTING OF BLOOD THAT OCCUR IN THE
SICKLING PROCESS?
A. ENCOURAGE FLUIDS
B. ENCOURAGE BED REST
C. ADMINISTER OXYGEN
D. ADMINISTER PRESCRIBED ANTICOAGULANTS
ANS. A
245. A NURSE IS CARING FOR A PRESCHOOLER ON THE PEDIATRIC UNIT.WHAT DOES
THE NURSE IDENTIFY AS THE CHILD’S GREATEST FEAR AT THIS AGE?
A. DEATH
B. MUTILATION
C. PAINFUL PROCEDURES
D. ISOLATION FROM PEERS
ANS. B
246. A CLIENT WHO WEIGHS 176 POUNDS IS BEING IMMUNOSUPPRESSED BY DAILY
MAINTENANCE DOSES OF CYCLOSPORINE (SANDIMMUNE)TO PREVENT ORGAN
TRANSPLANT REJECTION.THE DOSE PRESCRIBED IS 8MG/KG EACH DAY. HOW MANY
MILLIGRAMS SHOULD THE NURSE ADMINISTER EACH DAY?RECORD YOUR ANSWER
AS A WHOLE NUMBER
ANS. DESIRED 176 Ib =XKG
HAVE 2.2Ib 1KG
2.2X =176
X =176÷2.2
X =80KG

DESIRED 80KG × XMG

HAVE 1KG 8MG
1X =80×8
X =640MG
247. A HEALTH CARE PROVIDER PRESCRIBES SELEGILINE (ELDEPRYL)5MG TWICE A
DAY FOR A CLIENT WITH A DIAGNOSIS OF PARKINSON DISEASE.WHAT IS MOST
IMPORTANT FOR THE NURSE TO TEACH THE CLIENT?
A. EAT FOOD HIGH IN TYRAMINE
B. ENSURE THAT AN OPIOID IS NOT TAKEN CURRENTLY
C. TAKE THE MEDICATION IN THE MORNING AND EVENING
D. MONITOR FOR SIGNS OF HYPOGLYCEMIA AND HYPERGLYCEMIA
ANS. B
248. A NURSE IS DISCUSSING WEIGHT LOSS WITH AN OBESE INDIVIDUAL WITH
MENIERE’S DISEASE.WHICH SUGGESTION BY THE NURSE IS MOST IMPORTANT?
A. LIMIT INTAKE TO NINE HUNDRED CALORIES A DAY
B. ENROLL IN AN EXERCISE CLASS AT THE LOCAL HIGH SCHOOL
C. GET INVOLVED IN DIVERSIONARY ACTIVITIES WHEN THERE IS AN URGE TO EAT
D. KEEP A DIARY OF ALL FOODS EATEN EACH DAY,MAKING CERTAIN TO LIST
EVERYTHING
ANS. D
249. MEDICATION IS PRESCRIBED FOR A 7 YEAR OLD CHILD WITH ATTENTION DEFICIT
HYPERACTIVITY DISORSER (ADHD).WHAT INFORMATION SHOULD THE SCHOOL
NURSE EMPHASIZE WHEN DISCUSING THIS CHILD’S TREATMENT WITH THE
PARENTS?
A. TUTOR THEIR CHILD IN THE SUBJECTS THAT ARE TROUBLESOME
B. MONITOR THE EFFECTS OF THE DRUG ON THEIR CHILD’S BEHAVIOR
C. EXPLAIN TO THEIR CHILD THAT THE BEHAVIOR CAN BE CONTROLLED IF DESIRED
 D. AVOID IMPOSING TOO MANY RULES BECAUSE THESE WILL FRUSTRATE THE
CHILD
ANS. B
250. A NURSE IS SUPERVISING A RECENTLY HIRED NURSING ASSISTANT WHO IS
CARING FOR A DEBILITATED ,BEDBOUND CLIENT.WHAT INTERVENTION BEING
IMPLEMENTED NECESSITATES THE NURSE TO INTERVENE?
A. DRAINING THE CLIENT’S URINARY COLLECTTION BAG IN TO A MEASURING
CONTAINER
B. TAKING THE CLIENT’S BLOOD PRESSURE WITH AN ELECTRONIC
SPYGMOMANOMETER
C. REMOVING BOOTS THAT KEPT THE CLIENT’S FEET IN DORSIFLEXION BEFORE
GIVING A BATH
D. REPLACING A DRESSING ON THE CLIENT’S BUTTOCKS THAT WAS
CONTAMINATED WITH FECAL MATERIAL
ANS. D
251. WHEN ASSESSING THE ORALL CAVITY OF A NEWLY ADMITTED CLIENT WITH
ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS),THE NURSE IDENTIFIES AREAS
OF WHITE PLAQUE ON THE CLIENT’S TONGUE AND PALATE .WHAT IS THE NURSE’S
INITIAL RESPONSE?
A. SCRAPE AN AREA OF ONE OF THE LEIONS AND SEND THE SPECIMEN FOR A
BIOPSY
B. INSTRUCT THE CLIENT TO PERFORM METICULOUS ORAL HYGIENE AT LEAST
ONCE DAILY
C. DOCUMENT THE PRESENCE OF THE LESIONS ,DESCRIBING THEIR SIZE ,LOCATION
AND COLOR
D. CONSIDER THAT THESE LESIONS ARE UNIVERSALLY FOUND IN CLIENTS WITH
AIDS AND REQUIRE NO TREATMENT
ANS.C
252. THREE DAYS AFTER SURGERY FOR CANCER OF THE COLON ,A NURSE
INTRODUCES THE CLIENT TO COLOSTOMY CARE.WHICH SHOULD THE NURSE TEACH
THE CLIENT ABOUT SKIN CARE AROUND THE STOMA?
A. APPLY LIBERAL AMOUNTS OF AN OIL BASED OINTMENT AROUND THE STOMA
B. RINSE THE AREA WITH PEROXIDE BEFORE APPLYING FRESH GAUZE BANDAGES
C. POUR SALINE OVER THE STOMA AND RUB THE AREA TO REMOVE HARD FECAL
MATTER
D. WASH THE AREA WITH SOAP AND WATER AND THEN APPLY A PROTECTIVE
OINTMENT
ANS. D
253. A CLIENT IS ADMITTED TO THE HOSPITAL WITH A DIAGNOSIS OF MYASTHENIA
GRAVIS.FOR WHICH COMMON EARLY CLINICAL FINDING SHOULD THE NURSE ASSESS
THE CLIENT?
A. TEARING
B. BLURRING
C. DIPLOPIA
D. NYSTAGMUS
ANS. C
254. A CLIENT HAS SURGERY TO REPAIR A FRACTURED RIGHT HIP.WHERE SHOULD
THE NURSE STAND WHEN ASSISTING THE CLIENT TO AMBULATE?
A. BEHIND THE CLIENT
B. IN FRONT OF THE CLIENT
C. ON THE CLIENT’S LEFT SIDE
D. ON THE CLIENT’S RIGHT SIDE
ANS. C
255. A NEW BORN IS Rh POSITIVE ,AND THE MOTHER IS RH NEGATIVE .THE INFANT IS
TO RECEIVE AN EXCHANGE TRANSFUSION .THE NURSE EXPLAINS TO THE PARENTS
THAT THEIR BABY WILL RECEIVE Rh- NEGATIVE BLOOD BECAUSE?
A. IT IS THE SAME AS THE MOTHER’S BLOOD
B. IT IS NEUTRALAND WILL NOT REACT WITH THE BABY’S BLOOD
C. THE POSSIBILITY OF A TRANSFUSON REACTION IS ELIMINATED
D. THE RED BLOOD CELLS WILL NOT BE DESTROYED BY MATERNAL ANTI-Rh
ANTIBODIES
ANS. D
256. A NURSE IS CARING FOR A CLIENT WITH HEART FAILURE.THE HEALTH CARE
PROVIDER ORDERS A 2 GM SODIUM DIET.WHAT SHOULD THE NURSE INCLUDE
WHEN EXPLAINING HOW A LOW-SALT DIET HELPS ACHIEVE A THERAPEUTIC
OUTCOMES?
A. ALLOWS EXCESS TISSUE FLUID TO BE EXCRETED
B. HELPS TO CONTROL FOOD INTAKE AND THUS WEIGHT
C. AIDS THE WEAKENED HEART MUSCLE TO CONTRACT AND IMPROVES CARDIAC
OUTPUT
D. HELPS REDUCE POTASSIUM ACCUMULATION THAT OCCURS WHEN SODIUM
INTAKE IS HIGH
ANS. A
257. A 44 –YEAR-OLD CLIENT IS UNABLE TO FUNCTION SINCE HER HUSBAND ASKED
FOR A DIVORCE 2 WEEKS AGO.SHE IS BROUGHT TO THE CRISIS INTERVENTION
CENTER BY A FRIEND. WHAT TYPE OF CRISIS REFLECTS THIS SITUATION?
 A. SOCIAL
B. SITUATIONAL
C. MATURATIONAL
D. DEVELOPMENTAL
ANS. B
258. A CLIENT WITH DIABETES MELLITUS IS ABLE TO DISCUSS IN DETAIL THE DIABETIC
METABOLIC PROCESS WHILE EATING A PIECE OF CHOCOLATE CAKE.WHAT DEFENSE
MECHANISM DOES THE NURSE IDENTIFY WHEN EVALUATING THIS BEHAVIOR
A. PROJECTION
B. DISSOCIATION
C. DISPLACEMENT
D. INTELLECTUALIZATION
ANS. D(IT OCCURS WHEN A PAINFUL EMOTION IS AVOIDED BY MEANS OF A
RATIONAL EXPLANATION THAT REMOVES THE EVENT FROM ANY PERSONAL
SIGNIFICANCE
259. FAMOTIDINE(PEPCID)20MG IVPB IS PRESCRIBED FOR A CLIENT WITH A
DUODENAL ULCER.THE MEDICATION IS DILUTED IN 50 MLOF 5% DEXTROSE AND IS
TO INFUSE OVER 15 MTS.AT WHAT RATE SHOULD THE INFUSION CONTROL DEVICE
BE SET?RECORD YOUR ANSWER USING A WHOLE NUMBER
ANS. DESIRE 60MINUTES =XML
HAVE 15MINUTES 50ML
15X =60×50
15X = 3000
X =3000÷15
X =200ML/HOUR
260. A PHYSICALLY ILL CLIENT IS BEING VERBALLY AGGRESSIVE TO THE NURSING
STAFF.WHAT IS THE MOST APPROPRIATE INITIAL NURSING RESPONSE?
A. ACCEPT THE CLIENT’S BEHAVIOR
B. EXPLORE THE SITUATION WITH THE CLIENT
C. WITHDRAW FROM CONTACT WITH THE CLIENT
D. TELL THE CLIENT THE REASON FOR THE STAFF’S ACTIONS
ANS. A
261. A CLIENT HAD EXTENSIVE ,PROLONGED SURGERY .WHICH ELECTROLYTE LEVEL
SHOULD THE NURSE MOITOR MOST CLOSELY?
A. SODIUM
B. CALCIUM
C. CHLORIDE
D. POTASSIUM
 ANS. D(RELEASE OF ADRENOCORTICAL (CORTISOL) BY THE STRESS OF SURGERY
CAUSES RENAL RETENSION OF SODIUM AND EXCRETION OF POTASSIUM)
262. A NURSE ADMINISTERS AN INTRAVENOUS SOLUTION OF 0.45% SODIUM
CHLORIDE.IN WHAT CATEGARY OF FLUIDS DOES THIS SOLUTION BELONG?
A. ISOTONIC
B. ISOMETRIC
C. HYPOTONIC
D. HYPERTONIC
ANS. C(HYPOTONIC SOLUTONS ARE LESS CONCENTRATED THAT IS LESS THAN
0.85 G OF SODIUM CHLORIDE IN EACH 100ML THAN BODY FLUIDS
263. A NURSE ADDS 20mEq OF POTASSIUM CHLORIDE TO THE IV SOLUTION OF A
CLIENT WITH DIABETIC KETOACIDOSIS.WHAT IS THE PRIMARY PURPOSE FOR
ADMINISTERING THIS DRUG?
A. TREAT HYPERPNEA
B. PREVENT FLACCID PARALYSIS
C. REPLACE EXCESSIVE LOSSES
D. TREAT CARDIAC DYSRHYTHMIAS
ANS. C(ONCE TREATMENT WITH INSULIN FOR DKA IS BEGUN ,POTASSIUM
IONS REENTER THE CELL,CAUSING HYPOKALEMIA)
264. A NURSE IS WORKING IN A BUSY EMERGENCY DEPARTMENT ON A HOT SUMMER
DAY WHEN FOUR NEAR-DROWNING VICTIMS ARE ADMITTED .WHICH NEAR-
DROWNING VICTIM SHOULD THE NURSE ASSESS FOR SIGNS OF HYPOVOLEMIA?
A. 72 YEAR OLD RESCUED FROM A LAKE
B. 2 YEAR OLD RESCUED FROM A BATHTUB
C. 50 YEAR OLD RESCUED FROM THE OCEAN
D. 17 YEAR OLD RESCUED FROM A BACKYARD POOL
ANS. C(THE HIGH OSMOTIC PRESSURE OF THE SALT WATER DRAWS FLUID
FROM THE VASCULAR SPACE IN TO THE ALVEOLI)
265. A PLAN OF CARE FOR A CLIENT WITH TYPE 1 DIADETES INCLUDES TEACHING
HOW TO SELF –ADMINISTER INSULIN, ADJUST INSULIN DOSAGE ,SELECT
APPROPRIATE FOOD ON THE ORDERED DIET ,AND TEST THE SERUM FOR GLUCOSE.
THE CLIENT DEMONSTRATES ACHIEVEMENT OF THESE SKILLS AND IS DISCHARGED 5
DAYS FOLLOWING ADMISSION.WHAT IS THE LEGAL IMPLICATION IN THIS
SITUATION?
A. THE NURSE WAS FUNCTIONING AS A HEALTH TEACHER
B. A HOME HEALTH CARE NURSE SHOULD HAVE DONE THE HEALTH TEACHING IN
THE CLIENT’S HOME
 C. FAMILY MEMBERS ALSO SHOULD HAVE BEEN TAUGHT HOW TO ADMINISTER
INSULIN AND PERFORM OTHER ASPECTS OF CARE
D. HEALTH CARE PROVIDERS ARE RESPONSIBLE FOR THIS CARE,AND THE NURSE
SHOULD HAVE CLEARED THE TEACHING PLAN BEFORE ITS IMPLEMENTATION
ANS. A
266. IN WHAT POSITION SHOULD THE NURSE PLACE A CLIENT RECOVERING FROM
GENERAL ANESTHESIA?
A. SUPINE
B. SIDE –LYING
C. HIGH –FOWLER
D. TRENDELENBURG
ANS. B

267. WHAT IS THE PRIORITY NURSING INTERVENTION FOR A CLIENT DURING THE
IMMEDIATE POSTOPERATIVE PERIOD?
A. MONITORING VITAL SIGNS
B. OBSERVING FOR HEMORRHAGE
C. MAINTAINING A PATENT AIRWAY
D. RECORD THE INTAKE AND OUTPUT
ANS. C
268. A CLIENT REPORTS SEVERE PAIN 2 DAYS AFTER SURGERY.WHICH INITIAL ACTION
SHOULD THE NURSE TAKE AFTER ASSESSING THE CHARACTER OF THE PAIN?
A. ENCOURAGE REST
B. OBTAIN THE VITAL SIGNS
C. ADMINISTER THE PRN ANALGESIC
D. DOCUMENT THE CLIENT’S PAIN RESPONSE
ANS. B
269. A CLIENT WITH AN INFLAMED SCIATIC NERVE IS TO HAVE A CONVENTIONAL
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION(TENS) DEVICE APPLIED TO THE
PAINFUL NERVE PATHWAY.WHEN OPERATING THE TENS UNIT ,WHICH NURSING
ACTION IS APPROPRIATE?
A. MAINTAIN THE SETTINGS PROGRAMMED BY THE HEALTH CARE PROVIDER
B. TURN THE MACHINE ON SEVERAL TIMES A DAY FOR TEN TO TWENTY MINUTES
C. ADJUST THE DIAL ON THE UNIT UNTIL THE CLIENT STATES THE PAIN IS RELIEVED
D. APPLY THE COLOR-CODED ELECTODES ON THE CLIENT WHERE THEY ARE MOST
COMFORTABLE
ANS. C
270. NURSES ARE HELDRESPONSIBLE FOR THE COMMISSION OF A TORT.THE NURSE
UNDERSTANDS THAT A TORT IS:
A. THE APPLICATION OF FORCE TO THE BODY OF ANOTHER BY A REASONABLE
INDIVIDUAL
B. AN ILLEGALITY COMMITTED BY ONE PERSON AGAINST THE PROPERTY OR
PERSON OF ANOTHER
C. DOING SOMETHING THAT A REASONABLE PERSON UNDER ORDINARY
CIRCUMSTANCES WOULD NOT DO
D. AN ILLEGALITY COMMITTED AGAINST THE PUBLIC AND PUNISHABLE BY THE
LAW THROUGH THE COURTS
ANS. B
271. WHICH NURSING BEHAVIOR IS AN INTENTIONAL TORT?
A. MISCOUNTING GAUZE PADS DURING A CLIENT’S SURGERY
B. CAUSING A BURN WHEN APPLYING A WET DRESSING TO A CLIENT’S EXTREMITY
C. DIVULGING PRIVATE INFORMTION ABOUT A CLIENT’S HEALTH STATUS TO THE
MEDIA
D. FAILING TO MONITOR A CLIENT’S BLOOD PRESSURE BEFORE ADMINISTERING AN
ANTIHYPERTENSIVE
ANS. C
272. PLACE EACH STEP OF THE NURSING PROCESS IN THE ORDER THAT THEY SHOULD
BE USED
A. ---------IDENTIFY GOALS FOR CARE
B. ---------DEVELOP A PLAN OF CARE
C. ---------STATE CLIENT’S NURSING NEEDS
D. --------OBTAIN CLIENT’S NURSING HISTORY
E. --------IMPLEMENT NURSING INTERVENTIONS
ANS. D,C,A,B&E
273. A NURSE IS REVIEWING A CLIENT’S PLAN OF CARE.WHAT IS THE DETERMINING
FACTOR IN THE REVISION OF THE PLAN?
A. TIME AVAILABLE FOR CARE
B. VALIDITY OF THE PROBLEM
C. METHOD OF PROVIDING CARE
D. EFFECTIVENESS OF THE INTERVENTION
ANS. D
274. WHAT TYPE OF INTERVIEW IS MOST APPROPRIATE WHEN A NURSE ADMITS A
CLIENT TO A CLINIC?
A. DIRECTIVE
B. EXPLORATORY
 C. PROBLEM SOLVING
D. INFORMATION GIVING
ANS. A
275. THE NURSE MANAGER IS PLANNING TO ASSIGN A NURSING ASSISTANT (NA)TO
CARE FOR CLIENTS.WHAT CARE CAN BE DELEGATED ON A MEDICAL-SURGICAL UNIT
TO AN NA?SELECT ALL THAT APPLY.
A. PERFORMING A BED BATH FOR A CLIENT ON BED REST
B. EVALUATING THE EFFECTIVENESS OF ACETAMINOPHEN AND CODEINE(TYLENOL)
C. OBTAINING AN APICAL PULSE RATE BEFORE ORAL DIGOXIN(LANOXIN)IS
ADMINISTERED
D. ASSISTING A CLIENT WHO HAS PATIENT CONTROLLED ANALGESIA (PCA) TO THE
BATHROOM
E. ASSESSING THE WOUND INTEGRITY OF A CLIENT RECOVERING FROM AN
ABDOMINAL LAPAROTOMY
ANS. A&D
276. A CLIENT HAD SURGERY FOR A PERFORATED APPENDIX WITH LOCALIZED
PERITONITIS .IN WHICH POSITION SHOULD THE NURSE PLACE THIS CLIENT?
A. SIMS
B. SEMI-FOWLER
C. TREDELENBURG
D. DORSAL RECUMBENT
ANS. B
277. A CLIENT WITH CHRONIC HEPATIC FAILURE IS SOON TO BE DISCHARGED FROM
THE HOSPITAL .WHICH DIET SHOULD THE NURSE ENCOURAGE THE CLIENT TO
FOLLOW BASED ON THE HEALTH CARE PROVIDER’S ORDER?
A. HIGH-FAT
B. LOW –CALORIE
C. LOW-PROTEIN
D. HIGH-SODIUM
ANS. C
278. A NURSE INSTRUCTS A CLIENT WITH VIRAL HEPATITIS ABOUT THE TYPE OF DIET
THAT SHOULD BE INGESTED .WHICH LUNCH SELECTED BY THE CLIENT INDICATES
UNDERSTANDING ABOUT DIETARY PRINCIPLES ASSOCIATED WITH THIS DIAGNOSIS?
A. TURKEY SALAD,FRENCH FRIES,SHERBER
B. COTTAGE CHEESE,MIXED FRUIT SALAD,MILKSHAKE
C. SALAD,SLICED CHICKEN SANDWICH,GELATIN DESSERT
D. CHEESEBURGER,TORTILLA CHIPS ,CHOCOLATE PUDDING
ANS . C(HIGH CARBOHYDRATE MODERATE TO HIGH PROTEIN WITH LOW FAT
279. A NURSE IS REVIEWING THE LABORATORY RESULTS OF AND COLLECTING A
HEALTH HISTORY FROM A CLIENT WITH A DIAGNOSIS OF COLITIS WHICH COMMON
CLINICAL MANIFESTATION OF COLITIS SHOULD THE NURSE EXPECTS?
A. WEIGHT LOSS
B. HEMOPTYSIS
C. INCREASED RED BLOOD CELLS
D. DECREASED WHITE BLOOD CELLS
ANS. A
280. A NURSE IS TEACHING A CLIENT WITH AN ACUTE EXACERBATIONOF COLITIS
ABOUT THE MOST APPROPRIATE DIET.WHICH FOOD SELECTED BY THE CLIENT
INDICATES THAT THE DIETARY TEACHING IS EFFECTIVE?
A. ORANGE JUICE
B. SCRAMBLED EGGS
C. VANILLA MILKSHAKE
D. CREAMED POTATO SOUP
ANS. B
281. WHAT SHOULD THE NURSE DO WHEN COLLECTING A 24 –HOUR URINE
SPECIMEN?
A. CHECK TO VERIFY IF A PRESERVATIVE IS NEEDED
B. WEIGH THE CLIENT BEFORE STARTING THE COLLECTION
C. DISCARD THE LAST VOIDED SPECIMEN OF THE 24-HOUR PERIOD
D. ASSESS THE CLIENT’S INTAKE AND OUTPUT FOR THE PREVIOUS 24 HOUR PERIOD
ANS. A