A.
30 seconds
PNLE I for Foundation of
Nursing
1. Which element in the circular chain of infection
can be eliminated by preserving skin integrity?
A. Host
B. Reservoir
C. Mode of transmission
D. Portal of entry
Answer: D. In the circular chain of infection,
pathogens must be able to leave their reservoir
and be transmitted to a susceptible host through
a portal of entry, such as broken skin.
2. Which of the following will probably result in a
break in sterile technique for respiratory
isolation?
A. Opening the patient’s window to the
outside environment
B. Turning on the patient’s room ventilator
C. Opening the door of the patient’s
room leading into the hospital corridor
D. Failing to wear gloves when administering
a bed bath
Answer: C. Respiratory isolation, like strict
isolation, requires that the door to the door
patient’s room remain closed. However, the
patient’s room should be well ventilated, so
opening the window or turning on the ventricular
is desirable. The nurse does not need to wear
gloves for respiratory isolation, but good hand
washing is important for all types of isolation
3. Which of the following patients is at greater
risk for contracting an infection?
A. A patient with leukopenia
B. A patient receiving broad-spectrum
antibiotics
C. A postoperative patient who has
undergone orthopedic surgery
D. A newly diagnosed diabetic patient
Answer: A. Leukopenia is a decreased number of
leukocytes (white blood cells), which are
important in resisting infection. None of the
other situations would put the patient at risk for
contracting an infection; taking
broadspectrum antibiotics might actually reduce
the infection risk.
4. Effective hand washing requires the use of:
A. Soap or detergent to promote
emulsification
B. Hot water to destroy bacteria
C. A disinfectant to increase surface tension
D. All of the above
Answer: A. Soaps and detergents are used to
help remove bacteria because of their ability to
lower the surface tension of water and act as
emulsifying agents. Hot water may lead to skin
irritation or burns
5. After routine patient contact, hand washing
should last at least:
B. 1 minute
C. 2 minute
D. 3 minutes
Answer: A. Depending on the degree of
exposure to pathogens, hand washing may last
from 10 seconds to 4 minutes. After routine
patient contact, hand washing for 30 seconds
effectively minimizes the risk of
pathogen transmission.
6. Which of the following procedures always
requires surgical asepsis?
A. Vaginal instillation of conjugated estrogen
B. Urinary catheterization
C. Nasogastric tube insertion
D. Colostomy irrigation
Answer: B. The urinary system is normally free
of microorganisms except at the urinary meatus.
Any procedure that involves entering this system
must use surgically aseptic measures to
maintain a bacteria-free state
7. Sterile technique is used whenever:
A. Strict isolation is required
B. Terminal disinfection is performed
C. Invasive procedures are performed
D. Protective isolation is necessary
Answer: C. All invasive procedures, including
surgery, catheter insertion, and administration
of parenteral therapy, require sterile technique
to maintain a sterile environment. All equipment
must be sterile, and the nurse and the physician
must wear sterile gloves and maintain surgical
asepsis. In the operating room, the nurse and
physician are required to wear sterile gowns,
gloves, masks, hair covers, and shoe covers for
all invasive procedures. Strict isolation requires
the use of clean gloves, masks, gowns and
equipment to prevent the transmission of highly
communicable diseases by contact or by
airborne routes. Terminal disinfection is
the disinfection of all contaminated supplies and
equipment after a patient has been discharged
to prepare them for reuse by another patient.
The purpose of protective (reverse) isolation is
to prevent a person with seriously impaired
resistance from coming into contact who
potentially pathogenic organisms.
8. Which of the following constitutes a break in
sterile technique while preparing a sterile field for
a dressing change?
A. Using sterile forceps, rather than sterile
gloves, to handle a sterile item
B. Touching the outside wrapper of sterilized
material without sterile gloves
C. Placing a sterile object on the edge of
the sterile field
D. Pouring out a small amount of solution (15
to 30 ml) before pouring the solution into a
sterile container
Answer: C. The edges of a sterile field are
considered contaminated. When sterile items are
allowed to come in contact with the edges of the
field, the sterile items also become
contaminated

9. A natural body defense that plays an active
role in preventing infection is:
A. Yawning
B. Body hair
C. Hiccupping
D. Rapid eye movements
Answer: B. Hair on or within body areas, such as
the nose, traps and holds particles that contain
microorganisms. Yawning and hiccupping do
not prevent microorganisms from entering or
leaving the body. Rapid eye movement marks
the stage of sleep during which dreaming
occurs.
10. All of the following statement are true about
donning sterile gloves except:
A. The first glove should be picked up by
grasping the inside of the cuff.
B. The second glove should be picked up by
inserting the gloved fingers under the cuff
outside the glove.
C. The gloves should be adjusted by sliding
the gloved fingers under the sterile cuff and
pulling the glove over the wrist
D. The inside of the glove is considered
sterile
Answer: D. The inside of the glove is always
considered to be clean, but not sterile.
11.When removing a contaminated gown, the
nurse should be careful that the first thing she
touches is the:
A. Waist tie and neck tie at the back of
the gown
B. Waist tie in front of the gown
C. Cuffs of the gown
D. Inside of the gown
Answer: A. The back of the gown is considered
clean, the front is contaminated. So, after
removing gloves and washing hands, the nurse
should untie the back of the gown; slowly move
backward away from the gown, holding
the inside of the gown and keeping the edges off
the floor; turn and fold the gown inside out;
discard it in a contaminated linen container;
then wash her hands again.
12.Which of the following nursing interventions is
considered the most effective form or universal
precautions?
A. Cap all used needles before removing
them from their syringes
B. Discard all used uncapped needles
and syringes in an impenetrable
protective container
C. Wear gloves when administering IM
injections
D. Follow enteric precautions
Answer: B. According to the Centers for Disease
Control (CDC), blood-to-blood contact occurs
most commonly when a health care worker
attempts to cap a used needle. Therefore, used
needles should never be recapped; instead they
should be inserted in a specially designed
puncture resistant, labeled container. Wearing
gloves is not always necessary
when administering an I.M. injection. Enteric
precautions prevent the transfer of pathogens
via feces.
13.All of the following measures are
recommended to prevent pressure ulcers except:
A. Massaging the reddened are with
lotion
B. Using a water or air mattress
C. Adhering to a schedule for positioning and
turning
D. Providing meticulous skin care
Answer: A. Nurses and other health care
professionals previously believed that massaging
a reddened area with lotion would promote
venous return and reduce edema to the area.
However, research has shown that massage only
increases the likelihood of cellular ischemia and
necrosis to the area
14.Which of the following blood tests should be
performed before a blood transfusion?
A. Prothrombin and coagulation time
B. Blood typing and cross-matching
C. Bleeding and clotting time
D. Complete blood count (CBC) and
electrolyte levels.
Answer: B. Before a blood transfusion is
performed, the blood of the donor and recipient
must be checked for compatibility. This is done
by blood typing (a test that determines a
person’s blood type) and cross-matching
(a procedure that determines the compatibility
of the donor’s and recipient’s blood after the
blood types has been matched). If the blood
specimens are incompatible, hemolysis and
antigen-antibody reactions will occur
15.The primary purpose of a platelet count is to
evaluate the:
A. Potential for clot formation
B. Potential for bleeding
C. Presence of an antigen-antibody response
D. Presence of cardiac enzymes
Answer: A. Platelets are disk-shaped cells that
are essential for blood coagulation. A platelet
count determines the number of thrombocytes in
blood available for promoting hemostasis and
assisting with blood coagulation after injury. It
also is used to evaluate the patient’s potential for
bleeding; however, this is not its primary
purpose. The normal count ranges from 150,000
to 350,000/mm3. A count of 100,000/mm3 or less
indicates a potential for bleeding; count of less
than 20,000/mm3 is associated with
spontaneous bleeding.
16.Which of the following white blood cell (WBC)
counts clearly indicates leukocytosis?
A. 4,500/mm³
B. 7,000/mm³
C. 10,000/mm³
D. 25,000/mm³
Answer: D. Leukocytosis is any transient increase
in the number of white blood cells (leukocytes) in
the blood. Normal WBC counts range from 5,000
to 100,000/mm3. Thus, a count of 25,000/mm3
indicates leukocytosis

17. After 5 days of diuretic therapy with 20mg of
furosemide (Lasix) daily, a patient begins to
exhibit fatigue, muscle cramping and muscle
weakness. These symptoms probably indicate
that the patient is experiencing:
A. Hypokalemia
B. Hyperkalemia
C. Anorexia
D. Dysphagia
Answer: A. Fatigue, muscle cramping, and muscle
weaknesses are symptoms of hypokalemia (an
inadequate potassium level), which is a potential
side effect of diuretic therapy. The physician
usually orders supplemental potassium to
prevent hypokalemia in patients receiving
diuretics. Anorexia is another symptom of
hypokalemia. Dysphagia means
difficulty swallowing.
18.Which of the following statements about chest
X-ray is false?
A. No contradictions exist for this test
B. Before the procedure, the patient should
remove all jewelry, metallic objects, and
buttons above the waist
C. A signed consent is not required
D. Eating, drinking, and medications are
allowed before this test
Answer: A. Pregnancy or suspected pregnancy is
the only contraindication for a chest X-ray.
However, if a chest X-ray is necessary, the
patient can wear a lead apron to protect the
pelvic region from radiation. Jewelry,
metallic objects, and buttons would interfere with
the X-ray and thus should not be worn above the
waist. A signed consent is not required because a
chest X-ray is not an invasive examination.
Eating, drinking and medications are allowed
because the X-ray is of the chest, not the
abdominal region.
19.The most appropriate time for the nurse to
obtain a sputum specimen for culture is:
A. Early in the morning
B. After the patient eats a light breakfast
C. After aerosol therapy
D. After chest physiotherapy
Answer: A. Obtaining a sputum specimen early in
this morning ensures an adequate supply of
bacteria for culturing and decreases the risk
of contamination from food or medication.
20.A patient with no known allergies is to receive
penicillin every 6 hours. When administering the
medication, the nurse observes a fine rash on the
patient’s skin. The most appropriate nursing
action would be to:
A. Withhold the moderation and notify
the physician
B. Administer the medication and notify the
physician
C. Administer the medication with an
antihistamine
D. Apply corn starch soaks to the rash
Answer: A. Initial sensitivity to penicillin is
commonly manifested by a skin rash, even in
individuals who have not been allergic to it
previously. Because of the danger of anaphylactic
shock, he nurse should withhold the drug
and notify the physician, who may choose to
substitute another drug. Administering an
antihistamine is a dependent nursing intervention
that requires a written physician’s order. Although
applying corn starch to the rash may relieve
discomfort, it is not the nurse’s top priority in
such a potentially life-threatening situation.
21.All of the following nursing interventions are
correct when using the Ztrack method of drug
injection except:
A. Prepare the injection site with alcohol
B. Use a needle that’s a least 1” long
C. Aspirate for blood before injection
D. Rub the site vigorously after the
injection to promote absorption
Answer: D. The Z-track method is an I.M.
injection technique in which the patient’s skin is
pulled in such a way that the needle track is
sealed off after the injection. This procedure
seals medication deep into the muscle,
thereby minimizing skin staining and irritation.
Rubbing the injection site is contraindicated
because it may cause the medication to
extravasate into the skin
22.The correct method for determining the vastus
lateralis site for I.M. injection is to:
A. Locate the upper aspect of the upper
outer quadrant of the buttock about 5 to 8
cm below the iliac crest
B. Palpate the lower edge of the acromion
process and the midpoint lateral aspect of
the arm
C. Palpate a 1” circular area anterior to the
umbilicus
D. Divide the area between the greater
femoral trochanter and the lateral femoral
condyle into thirds, and select the middle
third on the anterior of the thigh
Answer: D. The vastus lateralis, a long, thick
muscle that extends the full length of the thigh, is
viewed by many clinicians as the site of choice
for I.M. injections because it has relatively few
major nerves and blood vessels. The middle third
of the muscle is recommended as the injection
site. The patient can be in a supine or sitting
position for an injection into this site.
23.The mid-deltoid injection site is seldom used
for I.M. injections because it:
A. Can accommodate only 1 ml or less of
medication
B. Bruises too easily
C. Can be used only when the patient is lying
down
D. Does not readily parenteral medication
Answer: A. The mid-deltoid injection site can
accommodate only 1 ml or less of medication
because of its size and location (on the deltoid
muscle of the arm, close to the brachial artery
and radial nerve
 29.Which of the following is a sign or symptom of
24.The appropriate needle size for insulin a hemolytic reaction to blood transfusion?
injection is:
A. Hemoglobinuria
A. 18G, 1 ½” long B. Chest pain
B. 22G, 1” long C. Urticaria
C. 22G, 1 ½” long D. Distended neck veins
D. 25G, 5/8” long
Answer: A. Hemoglobinuria, the abnormal
Answer: D. A 25G, 5/8” needle is the presence of hemoglobin in the urine, indicates a
recommended size for insulin injection because hemolytic reaction (incompatibility of the donor’s
insulin is administered by the subcutaneous and recipient’s blood). In this reaction, antibodies
route. An 18G, 1 ½” needle is usually used for in the recipient’s plasma combine rapidly with
I.M. injections in children, typically in the donor RBC’s; the cells are hemolyzed in
vastus lateralis. A 22G, 1 ½” needle is usually either circulatory or reticuloendothelial system.
used for adult I.M. injections, which are typically Hemolysis occurs more rapidly in ABO
administered in the vastus lateralis or incompatibilities than in Rh incompatibilities.
ventrogluteal site. Chest pain and urticaria may be symptoms of
impending anaphylaxis. Distended neck veins are
25.The appropriate needle gauge for intradermal an indication of hypervolemia.
injection is:
30.Which of the following conditions may require
A. 20G fluid restriction?
B. 22G
C. 25G A. Fever
D. 26G B. Chronic Obstructive Pulmonary Disease
C. Renal Failure
Answer: D. Because an intradermal injection does D. Dehydration
not penetrate deeply into the skin, a small-bore
25G needle is recommended. This type of Answer: C. In real failure, the kidney loses their
injection is used primarily to administer antigens ability to effectively eliminate wastes and fluids.
to evaluate reactions for allergy or sensitivity Because of this, limiting the patient’s intake of
studies. A 20G needle is usually used for I.M. oral and I.V. fluids may be necessary. Fever,
injections of oilbased medications; a 22G needle chronic obstructive pulmonary disease, and
for I.M. injections; and a 25G needle, for I.M. dehydration are conditions for which fluids should
injections; and a 25G needle, for subcutaneous be encouraged.
insulin injections.
31.All of the following are common signs and
26.Parenteral penicillin can be administered as symptoms of phlebitis except:
an:
A. Pain or discomfort at the IV insertion site
A. IM injection or an IV solution B. Edema and warmth at the IV insertion site
B. IV or an intradermal injection C. A red streak exiting the IV insertion site
C. Intradermal or subcutaneous injection D. Frank bleeding at the insertion site
D. IM or a subcutaneous injection
Answer: D. Phlebitis, the inflammation of a vein,
Answer: A. Parenteral penicillin can be can be caused by chemical irritants (I.V. solutions
administered I.M. or added to a solution and or medications), mechanical irritants (the needle
given I.V. It cannot be administered or catheter used during venipuncture or
subcutaneously or intradermally. cannulation), or a localized allergic reaction to the
needle or catheter. Signs and symptoms of
27.The physician orders gr 10 of aspirin for a phlebitis include pain or discomfort, edema and
patient. The equivalent dose in milligrams is: heat at the I.V. insertion site, and a red streak
going up the arm or leg from the I.V. insertion
A. 0.6 mg site.
B. 10 mg
C. 60 mg 32.The best way of determining whether a patient
D. 600 mg has learned to instill ear medication properly is
for the nurse to:
Answer: D. gr 10 x 60mg/gr 1 = 600 mg
A. Ask the patient if he/she has used ear
28.The physician orders an IV solution of dextrose drops before
5% in water at 100ml/hour. What would the flow B. Have the patient repeat the nurse’s
rate be if the drop factor is 15 gtt = 1 ml? instructions using her own words
C. Demonstrate the procedure to the patient
A. 5 gtt/minute and encourage to ask questions
B. 13 gtt/minute D. Ask the patient to demonstrate the
C. 25 gtt/minute procedure
D. 50 gtt/minute
Answer: D. Return demonstration provides the
Answer: C. 100ml/60 min X 15 gtt/ 1 ml = 25 most certain evidence for evaluating the
gtt/minute effectiveness of patient teaching.
33.Which of the following types of medications
can be administered via gastrostomy tube?
A. Any oral medications
B. Capsules whole contents are dissolve in
water
C. Enteric-coated tablets that are thoroughly
dissolved in water
D. Most tablets designed for oral use,
except for extended-
duration compounds
Answer: D. Capsules, enteric-coated tablets, and
most extended duration or sustained release
products should not be dissolved for use in
a gastrostomy tube. They are pharmaceutically
manufactured in these forms for valid reasons,
and altering them destroys their purpose. The
nurse should seek an alternate physician’s order
when an ordered medication is inappropriate for
delivery by tube.
34.A patient who develops hives after receiving
an antibiotic is exhibiting drug:
A. Tolerance
B. Idiosyncrasy
C. Synergism
D. Allergy
Answer: D. A drug-allergy is an adverse reaction
resulting from an immunologic response following
a previous sensitizing exposure to the drug.
The reaction can range from a rash or hives to
anaphylactic shock. Tolerance to a drug means
that the patient experiences a decreasing
physiologic response to repeated administration
of the drug in the same dosage. Idiosyncrasy is
an individual’s unique hypersensitivity to a drug,
food, or other substance; it appears to be
genetically determined. Synergism, is a drug
interaction in which the sum of the drug’s
combined effects is greater than that of their
separate effects.
35.A patient has returned to his room after
femoral arteriography. All of the following are
appropriate nursing interventions except:
A. Assess femoral, popliteal, and pedal
pulses every 15 minutes for 2 hours
B. Check the pressure dressing for
sanguineous drainage
C. Assess a vital signs every 15 minutes for 2
hours
D. Order a hemoglobin and hematocrit
count 1 hour after the arteriography
Answer: D. A hemoglobin and hematocrit count
would be ordered by the physician if bleeding
were suspected. The other answers are
appropriate nursing interventions for a patient
who has undergone femoral arteriography.
36.The nurse explains to a patient that a cough:
A. Is a protective response to clear the
respiratory tract of irritants
B. Is primarily a voluntary action
C. Is induced by the administration of an
antitussive drug
D. Can be inhibited by “splinting” the
abdomen
Answer: A. Coughing, a protective response that
clears the respiratory tract of irritants, usually is
involuntary; however it can be voluntary, as
when a patient is taught to perform coughing
exercises. An antitussive drug inhibits coughing.
Splinting the abdomen supports the abdominal
muscles when a patient coughs
37.An infected patient has chills and begins
shivering. The best nursing intervention is to:
A. Apply iced alcohol sponges
B. Provide increased cool liquids
C. Provide additional bedclothes
D. Provide increased ventilation
Answer: C. In an infected patient, shivering
results from the body’s attempt to increase heat
production and the production of neutrophils
and phagocytotic action through increased
skeletal muscle tension and contractions. Initial
vasoconstriction may cause skin to feel cold to
the touch. Applying additional bed clothes helps
to equalize the body temperature and stop the
chills. Attempts to cool the body result in
further shivering, increased metabloism, and thus
increased heat production.
38.A clinical nurse specialist is a nurse who has:
A. Been certified by the National League for
Nursing
B. Received credentials from the Philippine
Nurses’ Association
C. Graduated from an associate degree
program and is a registered professional
nurse
D. Completed a master’s degree in the
prescribed clinical area and is a
registered professional nurse.
Answer: D. A clinical nurse specialist must have
completed a master’s degree in a clinical
specialty and be a registered professional nurse.
The National League of Nursing accredits
educational programs in nursing and provides a
testing service to evaluate student nursing
competence but it does not certify nurses. The
American Nurses Association identifies
requirements for certification and offers
examinations for certification in many areas
of nursing., such as medical surgical nursing.
These certification (credentialing) demonstrates
that the nurse has the knowledge and the ability
to provide high quality nursing care in the area of
her certification. A graduate of an associate
degree program is not a clinical nurse
specialist: however, she is prepared to provide
bed side nursing with a high degree of knowledge
and skill. She must successfully complete the
licensing examination to become a registered
professional nurse.
39.The purpose of increasing urine acidity
through dietary means is to:
A. Decrease burning sensations
B. Change the urine’s color
C. Change the urine’s concentration
D. Inhibit the growth of microorganisms
Answer: D. Microorganisms usually do not grow in
an acidic environment.

40.Clay colored stools indicate:
A. Upper GI bleeding
B. Impending constipation
C. An effect of medication
D. Bile obstruction
Answer: D. Bile colors the stool brown. Any
inflammation or obstruction that impairs bile flow
will affect the stool pigment, yielding light, clay-
colored stool. Upper GI bleeding results in black
or tarry stool. Constipation is characterized by
small, hard masses. Many medications and foods
will discolor stool – for example, drugs containing
iron turn stool black.; beets turn stool red.
41.In which step of the nursing process would the
nurse ask a patient if the medication she
administered relieved his pain?
A. Assessment
B. Analysis
C. Planning
D. Evaluation
Answer: D. In the evaluation step of the nursing
process, the nurse must decide whether the
patient has achieved the expected outcome that
was identified in the planning phase.
42.All of the following are good sources of vitamin
A except:
A. White potatoes
B. Carrots
C. Apricots
D. Egg yolks
Answer: A. The main sources of vitamin A are
yellow and green vegetables (such as carrots,
sweet potatoes, squash, spinach, collard greens,
broccoli, and cabbage) and yellow fruits (such as
apricots, and cantaloupe). Animal sources include
liver, kidneys, cream, butter, and egg yolks.
43.Which of the following is a primary nursing
intervention necessary for all patients with a
Foley Catheter in place?
A. Maintain the drainage tubing and
collection bag level with the patient’s
bladder
B. Irrigate the patient with 1% Neosporin
solution three times a daily
C. Clamp the catheter for 1 hour every 4
hours to maintain the bladder’s elasticity
D. Maintain the drainage tubing and
collection bag below bladder level to
facilitate drainage by gravity
Answer: D. Maintaing the drainage tubing and
collection bag level with the patient’s bladder
could result in reflux of urine into the kidney.
Irrigating the bladder with Neosporin and
clamping the catheter for 1 hour every 4 hours
must be prescribed by a physician
44.The ELISA test is used to:
A. Screen blood donors for antibodies to
human immunodeficiency virus (HIV)
B. Test blood to be used for transfusion for
HIV antibodies
C. Aid in diagnosing a patient with AIDS
D. All of the above
Answer: D. The ELISA test of venous blood is
used to assess blood and potential blood donors
to human immunodeficiency virus (HIV). A
positive ELISA test combined with various signs
and symptoms helps to diagnose acquired
immunodeficiency syndrome (AIDS)
45.The two blood vessels most commonly used
for TPN infusion are the:
A. Subclavian and jugular veins
B. Brachial and subclavian veins
C. Femoral and subclavian veins
D. Brachial and femoral veins
Answer: D. Tachypnea (an abnormally rapid rate
of breathing) would indicate that the patient was
still hypoxic (deficient in oxygen).The partial
pressures of arterial oxygen and carbon dioxide
listed are within the normal range. Eupnea refers
to normal respiration.
46.Effective skin disinfection before a surgical
procedure includes which of the following
methods?
A. Shaving the site on the day before surgery
B. Applying a topical antiseptic to the skin on
the evening before surgery
C. Having the patient take a tub bath on the
morning of surgery
D. Having the patient shower with an
antiseptic soap on the
evening v=before and the morning of
surgery
Answer: D. Studies have shown that showering
with an antiseptic soap before surgery is the most
effective method of removing microorganisms
from the skin. Shaving the site of the intended
surgery might cause breaks in the skin, thereby
increasing the risk of infection; however, if
indicated, shaving, should be done immediately
before surgery, not the day before. A topical
antiseptic would not remove microorganisms and
would be beneficial only after proper cleaning and
rinsing. Tub bathing might transfer organisms to
another body site rather than rinse them away.
47.When transferring a patient from a bed to a
chair, the nurse should use which muscles to
avoid back injury?
A. Abdominal muscles
B. Back muscles
C. Leg muscles
D. Upper arm muscles
Answer: C. The leg muscles are the strongest
muscles in the body and should bear the greatest
stress when lifting. Muscles of the abdomen,
back, and upper arms may be easily injured.
48.Thrombophlebitis typically develops in
patients with which of the following conditions?
A. Increases partial thromboplastin time
B. Acute pulsus paradoxus
C. An impaired or traumatized blood
vessel wall
D. Chronic Obstructive Pulmonary Disease
(COPD)

Answer: C. The factors, known as Virchow’s triad,

collectively predispose a patient to
thromboplebitis; impaired venous return to the
heart, blood hypercoagulability, and injury to a
blood vessel wall. Increased
partial thromboplastin time indicates a prolonged
bleeding time during fibrin clot formation,
commonly the result of anticoagulant (heparin)
therapy. Arterial blood disorders (such as pulsus
paradoxus) and lung diseases (such as COPD) do
not necessarily impede venous return of injure
vessel walls.

49.In a recumbent, immobilized patient, lung

ventilation can become altered, leading to such
respiratory complications as:

A. Respiratory acidosis, ateclectasis, and

hypostatic pneumonia
B. Appneustic breathing, atypical pneumonia
and respiratory alkalosis
C. Cheyne-Strokes respirations and
spontaneous pneumothorax
D. Kussmail’s respirations and
hypoventilation

Answer: A. Because of restricted respiratory

movement, a recumbent, immobilize patient is
at particular risk for respiratory acidosis from
poor gas exchange; atelectasis from reduced
surfactant and accumulated mucus in the
bronchioles, and hypostatic pneumonia from
bacterial growth caused by stasis of mucus
secretions
50.Immobility impairs bladder elimination,
resulting in such disorders as
A. Increased urine acidity and relaxation of
the perineal muscles, causing incontinence
B. Urine retention, bladder distention,
and infection
C. Diuresis, natriuresis, and decreased urine
specific gravity
D. Decreased calcium and phosphate levels
in the urine
Answer: B. The immobilized patient commonly
suffers from urine retention caused by
decreased muscle tone in the perineum. This
leads to bladder distention and urine stagnation,
which provide an excellent medium for bacterial
growth leading to infection. Immobility also
results in more alkaline urine with excessive
amounts of calcium, sodium and phosphate, a
gradual decrease in urine production, and an
increased specific gravity.
PNLE II for Community Health
Nursing and Care of the
Mother and Child
1. May arrives at the health care clinic and tells the nurse that
her last menstrual period was 9 weeks ago. She also tells the
nurse that a home pregnancy test was positive but she began
to have mild cramps and is now having moderate vaginal
bleeding. During the physical examination of the client, the
nurse notes that May has a dilated cervix. The nurse
determines that May is experiencing which type of abortion?
A. Inevitable
B. Incomplete
C. Threatened
D. Septic
Answer: Answer: (A) Inevitable. An inevitable abortion is
termination of pregnancy that cannot be prevented.
Moderate to severe bleeding with mild cramping
and cervical dilation would be noted in this type of abortion
2. Nurse Reese is reviewing the record of a pregnant client for
her first prenatal visit. Which of the following data, if noted
on the client’s record, would alert the nurse that the client is
at risk for a spontaneous abortion?
A. Age 36 years
B. History of syphilis
C. History of genital herpes
D. History of diabetes mellitus

Answer: Answer: (B) History of syphilis. Maternal infections

such as syphilis, toxoplasmosis, and rubella are causes of
spontaneous abortion.

3. Nurse Hazel is preparing to care for a client who is newly

admitted to the hospital with a possible diagnosis of ectopic
pregnancy. Nurse Hazel develops a plan of care for the client
and determines that which of the following nursing actions is
the priority?
A. Monitoring weight
B. Assessing for edema
C. Monitoring apical pulse
 D. Monitoring temperature
Answer: Answer: (C) Monitoring apical pulse. Nursing care
for the client with a possible ectopic pregnancy is focused on
preventing or identifying hypovolemic shock and
controlling pain. An elevated pulse rate is an indicator of
shock
4. Nurse Oliver is teaching a diabetic pregnant client about
nutrition and insulin needs during pregnancy. The nurse
determines that the client understands dietary and insulin
needs if the client states that the second half of pregnancy
require:
A. Decreased caloric intake
B. Increased caloric intake
C. Decreased Insulin
D. Increase Insulin
Answer: (B) Increased caloric intake. Glucose crosses the
placenta, but insulin does not. High fetal demands for
glucose, combined with the insulin resistance caused
by hormonal changes in the last half of pregnancy can result
in elevation of maternal blood glucose levels. This increases
the mother’s demand for insulin and is referred to as the
diabetogenic effect of pregnancy.
5. Nurse Michelle is assessing a 24 year old client with a
diagnosis of hydatidiform mole. She is aware that one of the
following is unassociated with this condition?
A. Excessive fetal activity.
B. Larger than normal uterus for gestational age.
C. Vaginal bleeding
D. Elevated levels of human chorionic gonadotropin.
Answer: Answer: (A) Excessive fetal activity. The most
common signs and symptoms of hydatidiform mole includes
elevated levels of human chorionic gonadotropin,
vaginal bleeding, larger than normal uterus for gestational
age, failure to detect fetal heart activity even with sensitive
instruments, excessive nausea and vomiting, and early
development of pregnancy-induced hypertension. Fetal
activity would not be noted.
6. A pregnant client is receiving magnesium sulfate for severe
pregnancy induced hypertension (PIH). The clinical findings
that would warrant use of the antidote , calcium gluconate is:
A. Urinary output 90 cc in 2 hours.
B. Absent patellar reflexes.
C. Rapid respiratory rate above 40/min.
D. Rapid rise in blood pressure.
Answer: Answer: (B) Absent patellar reflexes. Absence of
patellar reflexes is an indicator of hypermagnesemia, which
requires administration of calcium gluconate
7. During vaginal examination of Janah who is in labor, the
presenting part is at station plus two. Nurse, correctly
interprets it as:
A. Presenting part is 2 cm above the plane of the ischial
spines.
B. Biparietal diameter is at the level of the ischial spines.
C. Presenting part in 2 cm below the plane of the ischial
spines.
D. Biparietal diameter is 2 cm above the ischial spines.
Answer: Answer: (C) Presenting part in 2 cm below the plane
of the ischial spines. Fetus at station plus two indicates that
the presenting part is 2 cm below the plane of the ischial
spines.
8. A pregnant client is receiving oxytocin (Pitocin) for
induction of labor. A condition that warrant the nurse in-
charge to discontinue I.V. infusion of Pitocin is:
A. Contractions every 1 ½ minutes lasting 70-80 seconds.
B. Maternal temperature 101.2
C. Early decelerations in the fetal heart rate.
D. Fetal heart rate baseline 140-160 bpm.
Answer: Answer: (A) Contractions every 1 ½ minutes lasting
70-80 seconds. Contractions every 1 ½ minutes lasting 70-80
seconds, is indicative of hyperstimulation of the uterus, which
could result in injury to the mother and the fetus if Pitocin is
not discontinued.
9. Calcium gluconate is being administered to a client with
pregnancy induced hypertension (PIH). A nursing action that
must be initiated as the plan of care throughout injection of
the drug is:
A. Ventilator assistance
B. CVP readings
C. EKG tracings
D. Continuous CPR
Answer: Answer: (C) EKG tracings. A potential side effect of
calcium gluconate administration is cardiac arrest. Continuous
monitoring of cardiac activity (EKG) throught administration
of calcium gluconate is an essential part of care.
10. A trial for vaginal delivery after an earlier caesareans,
would likely to be given to a gravida, who had:
A. First low transverse cesarean was for active herpes type
2 infections; vaginal culture at 39 weeks pregnancy was
positive.
B. First and second caesareans were for cephalopelvic
disproportion.
C. First caesarean through a classic incision as a result of
severe fetal distress.
D. First low transverse caesarean was for breech position.
Fetus in this pregnancy is in a vertex presentation.
Answer: Answer: (D) First low transverse caesarean was for
breech position. Fetus in this pregnancy is in a vertex
presentation. This type of client has no obstetrical indication
for a caesarean section as she did with her first caesarean
delivery.
11.Nurse Ryan is aware that the best initial approach when
trying to take a crying toddler’s temperature is:
A. Talk to the mother first and then to the toddler.
B. Bring extra help so it can be done quickly.
C. Encourage the mother to hold the child.
D. Ignore the crying and screaming.
Answer: Answer: (A) Talk to the mother first and then to the
toddler. When dealing with a crying toddler, the best
approach is to talk to the mother and ignore the toddler first.
This approach helps the toddler get used to the nurse before
she attempts any procedures. It also gives the toddler an
opportunity to see that the mother trusts the nurse.
12.Baby Tina a 3 month old infant just had a cleft lip and
palate repair. What should the nurse do to prevent trauma to
operative site?
A. Avoid touching the suture line, even when cleaning.
B. Place the baby in prone position.
C. Give the baby a pacifier.
D. Place the infant’s arms in soft elbow restraints.
Answer: Answer: (D) Place the infant’s arms in soft elbow
restraints. Soft restraints from the upper arm to the wrist
prevent the infant from touching her lip but allow him to hold
a favorite item such as a blanket. Because they could damage
the operative site, such as objects as pacifiers, suction
catheters, and small spoons shouldn’t be placed in a baby’s
mouth after cleft repair. A baby in a prone position may rub
her face on the sheets and traumatize the operative site. The
suture line should be cleaned gently to prevent infection,
which could interfere with healing and damage the cosmetic
appearance of the repair.
13. Which action should nurse Marian include in the care plan
for a 2 month old with heart failure?
A. Feed the infant when he cries.
B. Allow the infant to rest before feeding.
C. Bathe the infant and administer medications before
feeding.
D. Weigh and bathe the infant before feeding.
Answer: Answer: (B) Allow the infant to rest before
feeding. Because feeding requires so much energy, an infant
with heart failure should rest before feeding
14.Nurse Hazel is teaching a mother who plans to discontinue
breast feeding after 5 months. The nurse should advise her to
include which foods in her infant’s diet?
A. Skim milk and baby food.
B. Whole milk and baby food.
C. Iron-rich formula only.
D. Iron-rich formula and baby food.
Answer: Answer: (C) Iron-rich formula only. The infants at age
5 months should receive iron-rich formula and that they
shouldn’t receive solid food, even baby food until age 6
months.
15.Mommy Linda is playing with her infant, who is sitting
securely alone on the floor of the clinic. The mother hides a
toy behind her back and the infant looks for it. The nurse is
aware that estimated age of the infant would be:
A. 6 months
B. 4 months
C. 8 months
D. 10 months
Answer: Answer: (D) 10 months. A 10 month old infant can
sit alone and understands object permanence, so he would
look for the hidden toy. At age 4 to 6 months, infants can’t sit
securely alone. At age 8 months, infants can sit securely alone
but cannot understand the permanence of objects.
16.Which of the following is the most prominent feature of
public health nursing?
A. It involves providing home care to sick people who are
not confined in the hospital.
B. Services are provided free of charge to people within
the catchments area.
C. The public health nurse functions as part of a team
providing a public health nursing services.
D. Public health nursing focuses on preventive, not
curative, services.
Answer: Answer: (D) Public health nursing focuses on
preventive, not curative, services. The catchments area in
PHN consists of a residential community, many of whom are
well individuals who have greater need for preventive rather
than curative services.
17.When the nurse determines whether resources were
maximized in implementing Ligtas Tigdas, she is evaluating
A. Effectiveness
B. Efficiency
C. Adequacy
D. Appropriateness
Answer: Answer: (B) Efficiency. Efficiency is determining
whether the goals were attained at the least possible cost.
18.Vangie is a new B.S.N. graduate. She wants to become a
Public Health Nurse. Where should she apply?
A. Department of Health
B. Provincial Health Office
C. Regional Health Office
D. Rural Health Unit
Answer: Answer: (D) Rural Health Unit. R.A. 7160 devolved
basic health services to local government units (LGU’s ). The
public health nurse is an employee of the LGU.
19.Tony is aware the Chairman of the Municipal Health Board
is:
A. Mayor
B. Municipal Health Officer
C. Public Health Nurse
D. Any qualified physician
Answer: Answer: (A) Mayor. The local executive serves as the
chairman of the Municipal Health Board
20.Myra is the public health nurse in a municipality with a
total population of about 20,000. There are 3 rural health
midwives among the RHU personnel. How many more
midwife items will the RHU need?
A. 1
B. 2
C. 3
D. The RHU does not need any more midwife item.
Answer: Answer: (A) 1. Each rural health midwife is given a
population assignment of about 5,000.
21.According to Freeman and Heinrich, community health
nursing is a developmental service. Which of the following
best illustrates this statement?
A. The community health nurse continuously develops
himself personally and professionally.
B. Health education and community organizing are
necessary in providing community health services.
C. Community health nursing is intended primarily for
health promotion and prevention and treatment of
disease.
D. The goal of community health nursing is to provide
nursing services to people in their own places of
residence.
Answer: Answer: (B) Health education and community
organizing are necessary in providing community health
services. The community health nurse develops the health
capability of people through health education and
community organizing activities
22.Nurse Tina is aware that the disease declared through
Presidential Proclamation No. 4 as a target for eradication in
the Philippines is?
A. Poliomyelitis
B. Measles
C. Rabies
D. Neonatal tetanus
Answer: Answer: (B) Measles. Presidential Proclamation No.
4 is on the Ligtas Tigdas Program.
23.May knows that the step in community organizing that
involves training of potential leaders in the community is:
A. Integration
B. Community organization
C. Community study
D. Core group formation
Answer: Answer: (D) Core group formation. In core group
formation, the nurse is able to transfer the technology of
community organizing to the potential or informal community
leaders through a training program.
24.Beth a public health nurse takes an active role in
community participation. What is the primary goal of
community organizing?
A. To educate the people regarding community health
problems
B. To mobilize the people to resolve community health
problems
C. To maximize the community’s resources in dealing with
health problems.
D. To maximize the community’s resources in dealing with
health problems.
Answer: (D) To maximize the community’s resources in
dealing with health problems. Community organizing is a
developmental service, with the goal of developing the
people’s self-reliance in dealing with community health
problems. A, B and C are objectives of contributory
objectives to this goal.
25.Tertiary prevention is needed in which stage of the natural
history of disease?
A. Pre-pathogenesis
B. Pathogenesis
C. Prodromal
D. Terminal
Answeer: Answer: Answer: (D) Terminal. Tertiary prevention
involves rehabilitation, prevention of permanent disability
and disability limitation appropriate for convalescents, the
disabled, complicated cases and the terminally ill (those in
the terminal stage of a disease
26.The nurse is caring for a primigravid client in the labor and
delivery area. Which condition would place the client at risk
for disseminated intravascular coagulation (DIC)?
A. Intrauterine fetal death.
B. Placenta accreta.
C. Dysfunctional labor.
D. Premature rupture of the membranes.
Answer: Answer: (A) Intrauterine fetal death. Intrauterine
fetal death, abruptio placentae, septic shock, and amniotic
fluid embolism may trigger normal clotting mechanisms; if
clotting factors are depleted, DIC may occur. Placenta accreta,
dysfunctional labor, and premature rupture of the
membranes aren’t associated with DIC.
27.A fullterm client is in labor. Nurse Betty is aware that the
fetal heart rate would be:
A. 80 to 100 beats/minute
B. 100 to 120 beats/minute
C. 120 to 160 beats/minute
D. 160 to 180 beats/minute
Answer: Answer: (C) 120 to 160 beats/minute. A rate of 120
to 160 beats/minute in the fetal heart appropriate for filling
the heart with blood and pumping it out to the system.
28.The skin in the diaper area of a 7 month old infant is
excoriated and red. Nurse Hazel should instruct the mother
to:
A. Change the diaper more often.
B. Apply talc powder with diaper changes.
C. Wash the area vigorously with each diaper change.
D. Decrease the infant’s fluid intake to decrease saturating
diapers.
Answer: Answer: (A) Change the diaper more
often. Decreasing the amount of time the skin comes contact
with wet soiled diapers will help heal the irritation.
29.Nurse Carla knows that the common cardiac anomalies in
children with Down Syndrome (tri-somy 21) is:
A. Atrial septal defect
B. Pulmonic stenosis
C. Ventricular septal defect
D. Endocardial cushion defect
Answer: (D) Endocardial cushion defect. Endocardial cushion
defects are seen most in children with Down syndrome,
asplenia, or polysplenia
30.Malou was diagnosed with severe preeclampsia is now
receiving I.V. magnesium sulfate. The adverse effects
associated with magnesium sulfate is:
A. Anemia
B. Decreased urine output
C. Hyperreflexia
D. Increased respiratory rate
Answer: Answer: (B) Decreased urine output. Decreased urine
output may occur in clients receiving I.V. magnesium and
should be monitored closely to keep urine output at greater
than 30 ml/hour, because magnesium is excreted through the
kidneys and can easily accumulate to toxic levels.
31.A 23 year old client is having her menstrual period every 2
weeks that last for 1 week. This type of menstrual pattern is
bets defined by:
A. Menorrhagia
B. Metrorrhagia
C. Dyspareunia
D. Amenorrhea
Answer: Answer: (A) Menorrhagia. Menorrhagia is an
excessive menstrual period.
32. Jannah is admitted to the labor and delivery unit. The
critical laboratory result for this client would be:
A. Oxygen saturation
B. Iron binding capacity
C. Blood typing
D. Serum Calcium
Answer: Answer: (C) Blood typing. Blood type would be a
critical value to have because the risk of blood loss is always
a potential complication during the labor and delivery
process. Approximately 40% of a woman’s cardiac output is
delivered to the uterus, therefore, blood loss can occur quite
rapidly in the event of uncontrolled bleeding
33.Nurse Gina is aware that the most common condition
found during the second-trimester of pregnancy is:
A. Metabolic alkalosis
B. Respiratory acidosis
C. Mastitis
D. Physiologic anemia

Answer: Answer: (D) Physiologic anemia. Hemoglobin values
and hematocrit decrease during pregnancy as the increase in
plasma volume exceeds the increase in red blood cell
production.
34.Nurse Lynette is working in the triage area of an
emergency department. She sees that several pediatric clients
arrive simultaneously. The client who needs to be treated first
is:
A. A crying 5 year old child with a laceration on his scalp.
B. A 4 year old child with a barking coughs and flushed
appearance.
C. A 3 year old child with Down syndrome who is pale and
asleep in his mother’s arms.
D. A 2 year old infant with stridorous breath sounds,
sitting up in his mother’s arms and drooling.
Answer: Answer: (D) A 2 year old infant with stridorous
breath sounds, sitting up in his mother’s arms and
drooling. The infant with the airway emergency should be
treated first, because of the risk of epiglottitis.
35.Maureen in her third trimester arrives at the emergency
room with painless vaginal bleeding. Which of the following
conditions is suspected?
A. Placenta previa
B. Abruptio placentae
C. Premature labor
D. Sexually transmitted disease
Answer: Answer: (A) Placenta previa. Placenta previa with
painless vaginal bleeding.
36.A young child named Richard is suspected of having
pinworms. The community nurse collects a stool specimen to
confirm the diagnosis. The nurse should schedule the
collection of this specimen for:
A. Just before bedtime
B. After the child has been bathe
C. Any time during the day
D. Early in the morning
Answer: Answer: (D) Early in the morning. Based on the
nurse’s knowledge of microbiology, the specimen should be
collected early in the morning. The rationale for this timing is
that, because the female worm lays eggs at night around the
perineal area, the first bowel movement of the day will yield
the best results. The specific type of stool specimen used in
the diagnosis of pinworms is called the tape test
37.In doing a child’s admission assessment, Nurse Betty
should be alert to note which signs or symptoms of chronic
lead poisoning?
A. Irritability and seizures
B. Dehydration and diarrhea
C. Bradycardia and hypotension
D. Petechiae and hematuria
:Answer: (A) Irritability and seizures. Lead poisoning primarily
affects the CNS, causing increased intracranial pressure. This
condition results in irritability and changes in level of
consciousness, as well as seizure disorders, hyperactivity, and
learning disabilities.
38.To evaluate a woman’s understanding about the use of
diaphragm for family planning, Nurse Trish asks her to explain
how she will use the appliance. Which response indicates a
need for further health teaching?
A. “I should check the diaphragm carefully for holes every
time I use it”
B. “I may need a different size of diaphragm if I gain or lose
weight more than 20 pounds”
C. “The diaphragm must be left in place for atleast 6 hours
after intercourse”
D. “I really need to use the diaphragm and jelly most
during the middle of my menstrual cycle”.
Answer: (D) “I really need to use the diaphragm and jelly most
during the middle of my menstrual cycle”. The woman must
understand that, although the “fertile” period is
approximately mid-cycle, hormonal variations do occur and
can result in early or late ovulation. To be effective, the
diaphragm should be inserted before every intercourse.
39.Hypoxia is a common complication of
laryngotracheobronchitis. Nurse Oliver should frequently
assess a child with laryngotracheobronchitis for:
A. Drooling
B. Muffled voice
C. Restlessness
D. Low-grade fever
Answer: (C) Restlessness. In a child, restlessness is the earliest
sign of hypoxia. Late signs of hypoxia in a child are associated
with a change in color, such as pallor or cyanosis.
40.How should Nurse Michelle guide a child who is blind to
walk to the playroom?
A. Without touching the child, talk continuously as the
child walks down the hall.
B. Walk one step ahead, with the child’s hand on the
nurse’s elbow.
C. Walk slightly behind, gently guiding the child forward.
D. Walk next to the child, holding the child’s hand.
Answer: (B) Walk one step ahead, with the child’s hand on the
nurse’s elbow. This procedure is generally recommended to
follow in guiding a person who is blind.
41.When assessing a newborn diagnosed with ductus
arteriosus, Nurse Olivia should expect that the child most
likely would have an:
A. Loud, machinery-like murmur.
B. Bluish color to the lips.
C. Decreased BP reading in the upper extremities
D. Increased BP reading in the upper extremities.
Answer: (A) Loud, machinery-like murmur. A loud,
machinery-like murmur is a characteristic finding associated
with patent ductus arteriosus
42.The reason nurse May keeps the neonate in a neutral
thermal environment is that when a newborn becomes too
cool, the neonate requires:
A. Less oxygen, and the newborn’s metabolic rate
increases.
B. More oxygen, and the newborn’s metabolic rate
decreases.
C. More oxygen, and the newborn’s metabolic rate
increases.
D. Less oxygen, and the newborn’s metabolic rate
decreases.
Answer: (C) More oxygen, and the newborn’s metabolic rate
increases. When cold, the infant requires more oxygen and
there is an increase in metabolic rate. Non-shievering
thermogenesis is a complex process that increases the
metabolic rate and rate of oxygen consumption, therefore,
the newborn increase heat production.
43.Before adding potassium to an infant’s I.V. line, Nurse Ron
must be sure to assess whether this infant has:
A. Stable blood pressure
B. Patant fontanelles
C. Moro’s reflex
D. Voided
Answer: (D) Voided. Before administering potassium I.V. to
any client, the nurse must first check that the client’s kidneys
are functioning and that the client is voiding. If the client is
not voiding, the nurse should withhold the potassium and
notify the physician.
44.Nurse Carla should know that the most common causative
factor of dermatitis in infants and younger children is:
A. Baby oil
B. Baby lotion
C. Laundry detergent
D. Powder with cornstarch
Answer: Answer: (C) Laundry detergent. Eczema or
dermatitis is an allergic skin reaction caused by an offending
allergen. The topical allergen that is the most common
causative factor is laundry detergent
45.During tube feeding, how far above an infant’s stomach
should the nurse hold the syringe with formula?
A. 6 inches
B. 12 inches
C. 18 inches
D. 24 inches
Answer: (A) 6 inches. This distance allows for easy flow of
the formula by gravity, but the flow will be slow enough not
to overload the stomach too rapidly
46. In a mothers’ class, Nurse Lhynnete discussed childhood
diseases such as chicken pox. Which of the following
statements about chicken pox is correct?
A. The older one gets, the more susceptible he becomes
to the complications of chicken pox.
B. A single attack of chicken pox will prevent future
episodes, including conditions such as shingles.
C. To prevent an outbreak in the community, quarantine
may be imposed by health authorities.
D. Chicken pox vaccine is best given when there is an
impending outbreak in the community.
Answer: (A) The older one gets, the more susceptible he
becomes to the complications of chicken pox. Chicken pox is
usually more severe in adults than in children. Complications,
such as pneumonia, are higher in incidence in adults.
47.Barangay Pinoy had an outbreak of German measles. To
prevent congenital rubella, what is the BEST advice that you
can give to women in the first trimester of pregnancy in the
barangay Pinoy?
A. Advice them on the signs of German measles.
B. Avoid crowded places, such as markets and movie
houses.
C. Consult at the health center where rubella vaccine may
be given.
D. Consult a physician who may give them rubella
immunoglobulin.
Answer: (D) Consult a physician who may give them rubella
immunoglobulin. Rubella vaccine is made up of attenuated
German measles viruses. This is contraindicated in pregnancy.
Immune globulin, a specific prophylactic against German
measles, may be given to pregnant women.
48.Myrna a public health nurse knows that to determine
possible sources of sexually transmitted infections, the BEST
method that may be undertaken is:
A. Contact tracing
B. Community survey
C. Mass screening tests
D. Interview of suspects
Answer: (A) Contact tracing. Contact tracing is the most
practical and reliable method of finding possible sources of
person-to-person transmitted infections, such as sexually
transmitted diseases
49.A 33-year old female client came for consultation at the
health center with the chief complaint of fever for a week.
Accompanying symptoms were muscle pains and body
malaise. A week after the start of fever, the client noted
yellowish discoloration of his sclera. History showed that he
waded in flood waters about 2 weeks before the onset of
symptoms. Based on her history, which disease condition will
you suspect?
A. Hepatitis A
B. Hepatitis B
C. Tetanus
D. Leptospirosis
Answer: (D) Leptospirosis. Leptospirosis is transmitted
through contact with the skin or mucous membrane with
water or moist soil contaminated with urine of infected
animals, like rats
50.Mickey a 3-year old client was brought to the health center
with the chief complaint of severe diarrhea and the passage
of “rice water” stools. The client is most probably suffering
from which condition?
A. Giardiasis
B. Cholera
C. Amebiasis
D. Dysentery
Answer: (B) Cholera. Passage of profuse watery stools is the
major symptom of cholera. Both amebic and bacillary
dysentery are characterized by the presence of blood and/or
mucus in the stools. Giardiasis is characterized by fat
malabsorption and, therefore, steatorrhea.
51.The most prevalent form of meningitis among children
aged 2 months to 3 years is caused by which microorganism?
A. Hemophilus influenzae
B. Morbillivirus
C. Steptococcus pneumoniae
D. Neisseria meningitides
Answer: (A) Hemophilus influenzae. Hemophilus meningitis is
unusual over the age of 5 years. In developing countries, the
peak incidence is in children less than 6 months of age.
Morbillivirus is the etiology of measles. Streptococcus
pneumoniae and Neisseria meningitidis may cause meningitis,
but age distribution is not specific in young children.
52.The student nurse is aware that the pathognomonic sign of
measles is Koplik’s spot and you may see Koplik’s spot by
inspecting the:
A. Nasal mucosa
B. Buccal mucosa
C. Skin on the abdomen
D. Skin on neck
Answer: (B) Buccal mucosa. Koplik’s spot may be seen on the
mucosa of the mouth or the throat.
53.Angel was diagnosed as having Dengue fever. You will say
that there is slow capillary refill when the color of the nailbed
that you pressed does not return within how many seconds?
A. 3 seconds
B. 6 seconds
C. 9 seconds
D. 10 seconds
Answer: (A) 3 seconds. Adequate blood supply to the area
allows the return of the color of the nailbed within 3
seconds
54.In Integrated Management of Childhood Illness, the nurse
is aware that the severe conditions generally require urgent
referral to a hospital. Which of the following severe
conditions DOES NOT always require urgent referral to a
hospital?
A. Mastoiditis
B. Severe dehydration
C. Severe pneumonia
D. Severe febrile disease
Answer: (B) Severe dehydration. The order of priority in the
management of severe dehydration is as follows:
intravenous fluid therapy, referral to a facility where IV fluids
can be initiated within 30 minutes, Oresol or nasogastric
tube. When the foregoing measures are not possible or
effective, then urgent referral to the hospital is done.
55.Myrna a public health nurse will conduct outreach
immunization in a barangay Masay with a population of about
1500. The estimated number of infants in the barangay would
be:
A. 45 infants
B. 50 infants
C. 55 infants
D. 65 infants
Answer: (A) 45 infants. To estimate the number of infants,
multiply total population by 3%.
56.The community nurse is aware that the biological used in
Expanded Program on Immunization (EPI) should NOT be
stored in the freezer?
A. DPT
B. Oral polio vaccine
C. Measles vaccine
D. MMR
Answer: (A) DPT. DPT is sensitive to freezing. The appropriate
storage temperature of DPT is 2 to 8° C only. OPV and measles
vaccine are highly sensitive to heat and require freezing.
MMR is not an immunization in the Expanded Program on
Immunization.
57.It is the most effective way of controlling schistosomiasis in
an endemic area?
A. Use of molluscicides
B. Building of foot bridges
C. Proper use of sanitary toilets
D. Use of protective footwear, such as rubber boots
Answer: (C) Proper use of sanitary toilets. The ova of the
parasite get out of the human body together with feces.
Cutting the cycle at this stage is the most effective way of
preventing the spread of the disease to susceptible hosts.
58.Several clients is newly admitted and diagnosed with
leprosy. Which of the following clients should be classified as
a case of multibacillary leprosy?
A. 3 skin lesions, negative slit skin smear
B. 3 skin lesions, positive slit skin smear
C. 5 skin lesions, negative slit skin smear
D. 5 skin lesions, positive slit skin smear
Answer: (D) 5 skin lesions, positive slit skin smear. A
multibacillary leprosy case is one who has a positive slit skin
smear and at least 5 skin lesions.
59.Nurses are aware that diagnosis of leprosy is highly
dependent on recognition of symptoms. Which of the
following is an early sign of leprosy?
A. Macular lesions
B. Inability to close eyelids
C. Thickened painful nerves
D. Sinking of the nosebridge
Answer: Answer: (C) Thickened painful nerves. The lesion of
leprosy is not macular. It is characterized by a change in skin
color (either reddish or whitish) and loss of sensation,
sweating and hair growth over the lesion. Inability to close
the eyelids (lagophthalmos) and sinking of the nosebridge are
late symptoms.
60.Marie brought her 10 month old infant for consultation
because of fever, started 4 days prior to consultation. In
determining malaria risk, what will you do?
A. Perform a tourniquet test.
B. Ask where the family resides.
C. Get a specimen for blood smear.
D. Ask if the fever is present everyday.
Answer: (B) Ask where the family resides. Because malaria is
endemic, the first question to determine malaria risk is where
the client’s family resides. If the area of residence is not a
known endemic area, ask if the child had traveled within the
past 6 months, where she was brought and whether she
stayed overnight in that area.
61.Susie brought her 4 years old daughter to the RHU because
of cough and colds. Following the IMCI assessment guide,
which of the following is a danger sign that indicates the need
for urgent referral to a hospital?
A. Inability to drink
B. High grade fever
C. Signs of severe dehydration
D. Cough for more than 30 days
Answer: (A) Inability to drink. A sick child aged 2 months to 5
years must be referred urgently to a hospital if he/she has
one or more of the following signs: not able to feed or drink,
vomits everything, convulsions, abnormally sleepy or
difficult to awaken
62.Jimmy a 2-year old child revealed “baggy pants”. As a
nurse, using the IMCI guidelines, how will you manage
Jimmy?
A. Refer the child urgently to a hospital for confinement.
B. Coordinate with the social worker to enroll the child in a
feeding program.
C. Make a teaching plan for the mother, focusing on menu
planning for her child.
D. Assess and treat the child for health problems like
infections and intestinal parasitism.
Answer: (A) Refer the child urgently to a hospital for
confinement. “Baggy pants” is a sign of severe marasmus. The
best management is urgent referral to a hospital.
63.Gina is using Oresol in the management of diarrhea of her
3-year old child. She asked you what to do if her child vomits.
As a nurse you will tell her to:
A. Bring the child to the nearest hospital for further
assessment.
B. Bring the child to the health center for intravenous fluid
therapy.
C. Bring the child to the health center for assessment by
the physician.
D. Let the child rest for 10 minutes then continue giving
Oresol more slowly.
Answer: (D) Let the child rest for 10 minutes then continue
giving Oresol more slowly. If the child vomits persistently, that
is, he vomits everything that he takes in, he has to be referred
urgently to a hospital. Otherwise, vomiting is managed by
letting the child rest for 10 minutes and then continuing with
Oresol administration. Teach the mother to give Oresol more
slowly.
64.Nikki a 5-month old infant was brought by his mother to
the health center because of diarrhea for 4 to 5 times a day.
Her skin goes back slowly after a skin pinch and her eyes are
sunken. Using the IMCI guidelines, you will classify this infant
in which category?
A. No signs of dehydration
B. Some dehydration
C. Severe dehydration
D. The data is insufficient.
Answer: (B) Some dehydration. Using the assessment
guidelines of IMCI, a child (2 months to 5 years old) with
diarrhea is classified as having SOME DEHYDRATION if he
shows 2 or more of the following signs: restless or irritable,
sunken eyes, the skin goes back slow after a skin pinch.
65.Chris a 4-month old infant was brought by her mother to
the health center because of cough. His respiratory rate is
42/minute. Using the Integrated Management of Child Illness
(IMCI) guidelines of assessment, his breathing is considered
as:
A. Fast
B. Slow
C. Normal
D. Insignificant
Answer: (C) Normal. In IMCI, a respiratory rate of 50/minute
or more is fast breathing for an infant aged 2 to 12 months.
66.Maylene had just received her 4th dose of tetanus toxoid.
She is aware that her baby will have protection against
tetanus for
A. 1 year
B. 3 years
C. 5 years
D. Lifetime
Answer: (A) 1 year. The baby will have passive natural
immunity by placental transfer of antibodies. The mother will
have active artificial immunity lasting for about 10 years. 5
doses will give the mother lifetime protection.
67.Nurse Ron is aware that unused BCG should be discarded
after how many hours of reconstitution?
A. 2 hours
B. 4 hours
C. 8 hours
D. At the end of the day
Answer: (B) 4 hours. While the unused portion of other
biologicals in EPI may be given until the end of the day, only
BCG is discarded 4 hours after reconstitution. This is why BCG
immunization is scheduled only in the morning.
68.The nurse explains to a breastfeeding mother that breast
milk is sufficient for all of the baby’s nutrient needs only up
to:
A. 5 months
B. 6 months
C. 1 year
D. 2 years
Answer: (B) 6 months. After 6 months, the baby’s nutrient
needs, especially the baby’s iron requirement, can no longer
be provided by mother’s milk alone
69.Nurse Ron is aware that the gestational age of a conceptus
that is considered viable (able to live outside the womb) is:
A. 8 weeks
B. 12 weeks
C. 24 weeks
D. 32 weeks
Answer: (C) 24 weeks. At approximately 23 to 24 weeks’
gestation, the lungs are developed enough to sometimes
maintain extrauterine life. The lungs are the most immature
system during the gestation period. Medical care for
premature labor begins much earlier (aggressively at 21
weeks’ gestation
70.When teaching parents of a neonate the proper position
for the neonate’s sleep, the nurse Patricia stresses the
importance of placing the neonate on his back to reduce the
risk of which of the following?
A. Aspiration
B. Sudden infant death syndrome (SIDS)
C. Suffocation
D. Gastroesophageal reflux (GER)
Answer: (B) Sudden infant death syndrome (SIDS). Supine
positioning is recommended to reduce the risk of SIDS in
infancy. The risk of aspiration is slightly increased with the
supine position. Suffocation would be less likely with an infant
supine than prone and the position for GER requires the head
of the bed to be elevated.
71.Which finding might be seen in baby James a neonate
suspected of having an infection?
A. Flushed cheeks
B. Increased temperature
C. Decreased temperature
D. Increased activity level
Answer: (C) Decreased temperature. Temperature instability,
especially when it results in a low temperature in the
neonate, may be a sign of infection. The neonate’s color often
changes with an infection process but generally becomes
ashen or mottled. The neonate with an infection will usually
show a decrease in activity level or lethargy.
72.Baby Jenny who is small-for-gestation is at increased risk
during the transitional period for which complication?
A. Anemia probably due to chronic fetal hyposia
B. Hyperthermia due to decreased glycogen stores
C. Hyperglycemia due to decreased glycogen stores
D. Polycythemia probably due to chronic fetal hypoxia

Answer: (D) Polycythemia probably due to chronic fetal
hypoxia. The small-for-gestation neonate is at risk for
developing polycythemia during the transitional period in an
attempt to decreasehypoxia. The neonates are also at
increased risk for developing hypoglycemia and hypothermia
due to decreased glycogen stores.
73.Marjorie has just given birth at 42 weeks’ gestation. When
the nurse assessing the neonate, which physical finding is
expected?
A. A sleepy, lethargic baby
B. Lanugo covering the body
C. Desquamation of the epidermis
D. Vernix caseosa covering the body
Answer: (C) Desquamation of the epidermis. Postdate fetuses
lose the vernix caseosa, and the epidermis may become
desquamated. These neonates are usually very alert. Lanugo
is missing in the postdate neonate.
74.After reviewing the Myrna’s maternal history of
magnesium sulfate during labor, which condition would nurse
Richard anticipate as a potential problem in the neonate?
A. Hypoglycemia
B. Jitteriness
C. Respiratory depression
D. Tachycardia
Answer: (C) Respiratory depression. Magnesium sulfate
crosses the placenta and adverse neonatal effects are
respiratory depression, hypotonia, and bradycardia. The
serum blood sugar isn’t affected by magnesium sulfate. The
neonate would be floppy, not jittery.
75.Which symptom would indicate the Baby Alexandra was
adapting appropriately to extra-uterine life without difficulty?
A. Nasal flaring
B. Light audible grunting
C. Respiratory rate 40 to 60 breaths/minute
D. Respiratory rate 60 to 80 breaths/minute
Answer: (C) Respiratory rate 40 to 60 breaths/minute. A
respiratory rate 40 to 60 breaths/minute is normal for a
neonate during the transitional period. Nasal flaring,
respiratory rate more than 60 breaths/minute, and audible
grunting are signs of respiratory distress.
76. When teaching umbilical cord care for Jennifer a new
mother, the nurse Jenny would include which information?
A. Apply peroxide to the cord with each diaper change
B. Cover the cord with petroleum jelly after bathing
C. Keep the cord dry and open to air
D. Wash the cord with soap and water each day during a
tub bath.
Answer: (C) Keep the cord dry and open to air. Keeping the
cord dry and open to air helps reduce infection and hastens
drying. Infants aren’t given tub bath but are sponged off until
the cord falls off. Petroleum jelly prevents the cord from
drying and encourages infection. Peroxide could be painful
and isn’t recommended.
77.Nurse John is performing an assessment on a neonate.
Which of the following findings is considered common in the
healthy neonate?
A. Simian crease
B. Conjunctival hemorrhage
C. Cystic hygroma
D. Bulging fontanelle
Answer: (B) Conjunctival hemorrhage. Conjunctival
hemorrhages are commonly seen in neonates secondary to
the cranial pressure applied during the birth process. Bulging
fontanelles are a sign of intracranial pressure. Simian creases
are present in 40% of the neonates with trisomy 21. Cystic
hygroma is a neck mass that can affect the airway.
78.Dr. Esteves decides to artificially rupture the membranes
of a mother who is on labor. Following this procedure, the
nurse Hazel checks the fetal heart tones for which the
following reasons?
A. To determine fetal well-being.
B. To assess for prolapsed cord
C. To assess fetal position
D. To prepare for an imminent delivery.
Answer: (B) To assess for prolapsed cord. After a client has an
amniotomy, the nurse should assure that the cord isn’t
prolapsed and that the baby tolerated the procedure well.
The most effective way to do this is to check the fetal heart
rate. Fetal well-being is assessed via a nonstress test. Fetal
position is determined by vaginal examination. Artificial
rupture of membranes doesn’t indicate an imminent delivery
79.Which of the following would be least likely to indicate
anticipated bonding behaviors by new parents?
A. The parents’ willingness to touch and hold the new
born.
B. The parent’s expression of interest about the size of the
new born.
C. The parents’ indication that they want to see the
newborn.
D. The parents’ interactions with each other.
Answer: (D) The parents’ interactions with each
other. Parental interaction will provide the nurse with a good
assessment of the stability of the family’s home life but it has
no indication for parental bonding. Willingness to touch and
hold the newborn, expressing interest about the newborn’s
size, and indicating a desire to see the newborn are behaviors
indicating parental bonding.
80.Following a precipitous delivery, examination of the
client’s vagina reveals
a fourth-degree laceration. Which of the following would be
contraindicated when caring for this client?
A. Applying cold to limit edema during the first 12 to 24
hours.
B. Instructing the client to use two or more peripads to
cushion the area.
C. Instructing the client on the use of sitz baths if ordered.
D. Instructing the client about the importance of perineal
(kegel) exercises.
Answer: (B) Instructing the client to use two or more peripads
to cushion the area. Using two or more peripads would do
little to reduce the pain or promote perineal healing. Cold
applications, sitz baths, and Kegel exercises are important
measures when the client has a fourth-degree laceration.
81. A pregnant woman accompanied by her husband, seeks
admission to the labor and delivery area. She states that she’s
in labor and says she attended the facility clinic for prenatal
care. Which question should the nurse Oliver ask her first?
A. “Do you have any chronic illnesses?”
B. “Do you have any allergies?”
C. “What is your expected due date?”
D. “Who will be with you during labor?”
Answer: (C) “What is your expected due date?” When
obtaining the history of a client who may be in labor, the
nurse’s highest priority is to determine her current status,
particularly her due date, gravidity, and parity. Gravidity and
parity affect the duration of labor and the potential for labor
complications. Later, the nurse should ask about chronic
illnesses, allergies, and support persons.
82.A neonate begins to gag and turns a dusky color. What
should the nurse do first?
A. Calm the neonate.
B. Notify the physician.
C. Provide oxygen via face mask as ordered
D. Aspirate the neonate’s nose and mouth with a bulb
syringe.
Answer: (D) Aspirate the neonate’s nose and mouth with a
bulb syringe. The nurse’s first action should be to clear the
neonate’s airway with a bulb syringe. After the airway is clear
and the neonate’s color improves, the nurse should comfort
and calm the neonate. If the problem recurs or the neonate’s
color doesn’t improve readily, the nurse should notify the
physician. Administering oxygen when the airway isn’t clear
would be ineffective.
83. When a client states that her “water broke,” which of the
following actions would be inappropriate for the nurse to do?
A. Observing the pooling of straw-colored fluid.
B. Checking vaginal discharge with nitrazine paper.
C. Conducting a bedside ultrasound for an amniotic fluid
index.
D. Observing for flakes of vernix in the vaginal discharge.
Answer: (C) Conducting a bedside ultrasound for an amniotic
fluid index. It isn’t within a nurse’s scope of practice to
perform and interpret a bedside ultrasound under these
conditions and without specialized training. Observing for
pooling of straw-colored fluid, checking vaginal discharge with
nitrazine paper, and observing for flakes of vernix are
appropriate assessments for determining whether a client has
ruptured membranes.
84. A baby girl is born 8 weeks premature. At birth, she has no
spontaneous respirations but is successfully resuscitated.
Within several hours she develops respiratory grunting,
cyanosis, tachypnea, nasal flaring, and retractions. She’s
diagnosed with respiratory distress syndrome, intubated, and
placed on a ventilator. Which nursing action should be
included in the baby’s plan of care to prevent retinopathy of
prematurity?
A. Cover his eyes while receiving oxygen.
B. Keep her body temperature low.
C. Monitor partial pressure of oxygen (Pao2) levels.
D. Humidify the oxygen.
Answer: (C) Monitor partial pressure of oxygen (Pao2)
levels. Monitoring PaO2 levels and reducing the oxygen
concentration to keep PaO2 within normal limits reduces the
risk of retinopathy of prematurity in a premature infant
receiving oxygen. Covering the infant’s eyes and humidifying
the oxygen don’t reduce the risk of retinopathy of
prematurity. Because cooling increases the risk of acidosis,
the infant should be kept warm so that his respiratory
distress isn’t aggravated.
85. Which of the following is normal newborn calorie intake?
A. 110 to 130 calories per kg.
B. 30 to 40 calories per lb of body weight.
C. At least 2 ml per feeding
D. 90 to 100 calories per kg
Answer: (A) 110 to 130 calories per kg. Calories per kg is the
accepted way of determined appropriate nutritional intake for
a newborn. The recommended calorie requirement is 110 to
130 calories per kg of newborn body weight. This level will
maintain a consistent blood glucose level and provide enough
calories for continued growth and development.
86. Nurse John is knowledgeable that usually individual twins
will grow appropriately and at the same rate as singletons
until how many weeks?
A. 16 to 18 weeks
B. 18 to 22 weeks
C. 30 to 32 weeks
D. 38 to 40 weeks
Answer: (C) 30 to 32 weeks. Individual twins usually grow at
the same rate as singletons until 30 to 32 weeks’ gestation,
then twins don’t’ gain weight as rapidly as singletons of the
same gestational age. The placenta can no longer keep pace
with the nutritional requirements of both fetuses after 32
weeks, so there’s some growth retardation in twins if they
remain in utero at 38 to 40 weeks.
87. Which of the following classifications applies to
monozygotic twins for whom the cleavage of the fertilized
ovum occurs more than 13 days after fertilization?
A. conjoined twins
B. diamniotic dichorionic twins
C. diamniotic monochorionic twin
D. monoamniotic monochorionic twins
Answer: (A) conjoined twins. The type of placenta that
develops in monozygotic twins depends on the time at which
cleavage of the ovum occurs. Cleavage in conjoined twins
occurs more than 13 days after fertilization. Cleavage that
occurs less than 3 day after fertilization results in diamniotic
dicchorionic twins. Cleavage that occurs between days 3 and
8 results in diamniotic monochorionic twins. Cleavage that
occurs between days 8 to 13 result in monoamniotic
monochorionic twins.
88. Tyra experienced painless vaginal bleeding has just been
diagnosed as having a placenta previa. Which of the following
procedures is usually performed to diagnose placenta previa?
A. Amniocentesis
B. Digital or speculum examination
C. External fetal monitoring
D. Ultrasound
Answer: (D) Ultrasound. Once the mother and the fetus are
stabilized, ultrasound evaluation of the placenta should be
done to determine the cause of the bleeding. Amniocentesis
is contraindicated in placenta previa. A digital or speculum
examination shouldn’t be done as this may lead to severe
bleeding or hemorrhage. External fetal monitoring won’t
detect a placenta previa, although it will detect fetal distress,
which may result from blood loss or placenta separation.
89. Nurse Arnold knows that the following changes in
respiratory functioning during pregnancy is considered
normal:
A. Increased tidal volume
B. Increased expiratory volume
C. Decreased inspiratory capacity
D. Decreased oxygen consumption
Answer: (A) Increased tidal volume. A pregnant client
breathes deeper, which increases the tidal volume of gas
moved in and out of the respiratory tract with each breath.
The expiratory volume and residual volume decrease as the
pregnancy progresses. The inspiratory capacity increases
during pregnancy. The increased oxygen consumption in the
pregnant client is 15% to 20% greater than in the
nonpregnant state.
90. Emily has gestational diabetes and it is usually managed
by which of the following therapy?
A. Diet
B. Long-acting insulin
C. Oral hypoglycemic
D. Oral hypoglycemic drug and insulin
Answer: (A) Diet. Clients with gestational diabetes are
usually managed by diet alone to control their glucose
intolerance. Oral hypoglycemic drugs are contraindicated in
pregnancy. Long-acting insulin usually isn’t needed for blood
glucose control in the client with gestational diabetes
91. Magnesium sulfate is given to Jemma with preeclampsia
to prevent which of the following condition?
A. Hemorrhage
B. Hypertension
C. Hypomagnesemia
D. Seizure
1. Answer: (D) Seizure. The anticonvulsant mechanism
of magnesium is believes to depress seizure foci in the
brain and peripheral neuromuscular blockade.
Hypomagnesemia isn’t a complication of preeclampsia.
Antihypertensive drug other than magnesium are
preferred for sustained hypertension. Magnesium
doesn’t help prevent hemorrhage in preeclamptic
clients.
92. Cammile with sickle cell anemia has an increased risk for
having a sickle cell crisis during pregnancy. Aggressive
management of a sickle cell crisis includes which of the
following measures?
A. Antihypertensive agents
B. Diuretic agents
C. I.V. fluids
D. Acetaminophen (Tylenol) for pain
Answer: (C) I.V. fluids. A sickle cell crisis during pregnancy is
usually managed by exchange transfusion oxygen, and L.V.
Fluids. The client usually needs a stronger analgesic than
acetaminophen to control the pain of a crisis.
Antihypertensive drugs usually aren’t necessary. Diuretic
wouldn’t be used unless fluid overload resulted.
93. Which of the following drugs is the antidote for
magnesium toxicity?
A. Calcium gluconate (Kalcinate)
B. Hydralazine (Apresoline)
C. Naloxone (Narcan)
D. Rho (D) immune globulin (RhoGAM)
Answer: (A) Calcium gluconate (Kalcinate). Calcium gluconate
is the antidote for magnesium toxicity. Ten milliliters of 10%
calcium gluconate is given L.V. push over 3 to 5 minutes.
Hydralazine is given for sustained elevated blood pressure in
preeclamptic clients. Rho (D) immune globulin is given to
women with Rh-negative blood to prevent antibody
formation from RH-positive conceptions. Naloxone is used to
correct narcotic toxicity.
94. Marlyn is screened for tuberculosis during her first
prenatal visit. An intradermal injection of purified protein
derivative (PPD) of the tuberculin bacilli is given. She is
considered to have a positive test for which of the following
results?
A. An indurated wheal under 10 mm in diameter appears
in 6 to 12 hours.
B. An indurated wheal over 10 mm in diameter appears in
48 to 72 hours.
C. A flat circumcised area under 10 mm in diameter
appears in 6 to 12 hours.
D. A flat circumcised area over 10 mm in diameter appears
in 48 to 72 hours.
Answer: (B) An indurated wheal over 10 mm in diameter
appears in 48 to 72 hours. A positive PPD result would be an
indurated wheal over 10 mm in diameter that appears in 48
to 72 hours. The area must be a raised wheal, not a flat
circumcised area to be considered positive.
95. Dianne, 24 year-old is 27 weeks’ pregnant arrives at her
physician’s office with complaints of fever, nausea, vomiting,
malaise, unilateral flank pain, and costovertebral angle
tenderness. Which of the following diagnoses is most likely?
A. Asymptomatic bacteriuria
B. Bacterial vaginosis
C. Pyelonephritis
D. Urinary tract infection (UTI)
Answer: (C) Pyelonephritis. The symptoms indicate acute
pyelonephritis, a serious condition in a pregnant client. UTI
symptoms include dysuria, urgency, frequency, and
suprapubic tenderness. Asymptomatic bacteriuria doesn’t
cause symptoms. Bacterial vaginosis causes milky white
vaginal discharge but no systemic symptoms
96. Rh isoimmunization in a pregnant client develops during
which of the following conditions?
A. Rh-positive maternal blood crosses into fetal blood,
stimulating fetal antibodies.
B. Rh-positive fetal blood crosses into maternal blood,
stimulating maternal antibodies.
C. Rh-negative fetal blood crosses into maternal blood,
stimulating maternal antibodies.
D. Rh-negative maternal blood crosses into fetal blood,
stimulating fetal antibodies.
Answer: (B) Rh-positive fetal blood crosses into maternal
blood, stimulating maternal antibodies. Rh isoimmunization
occurs when Rh-positive fetal blood cells cross into the
maternal circulation and stimulate maternal
antibody production. In subsequent pregnancies with Rh-
positive fetuses, maternal antibodies may cross back into the
fetal circulation and destroy the fetal blood cells
97. To promote comfort during labor, the nurse John advises a
client to assume certain positions and avoid others. Which
position may cause maternal hypotension and fetal hypoxia?
A. Lateral position
B. Squatting position
C. Supine position
D. Standing position
Answer: (C) Supine position. The supine position causes
compression of the client’s aorta and inferior vena cava by the
fetus. This, in turn, inhibits maternal circulation, leading to
maternal hypotension and, ultimately, fetal hypoxia. The
other positions promote comfort and aid labor progress. For
instance, the lateral, or side-lying, position improves maternal
and fetal circulation, enhances comfort, increases maternal
relaxation, reduces muscle tension, and eliminates pressure
points. The squatting position promotes comfort by taking
advantage of gravity. The standing position also takes
advantage of gravity and aligns the fetus with the pelvic
angle.
98. Celeste who used heroin during her pregnancy delivers a
neonate. When assessing the neonate, the nurse Lhynnette
expects to find:
A. Lethargy 2 days after birth.
B. Irritability and poor sucking.
C. A flattened nose, small eyes, and thin lips.
D. Congenital defects such as limb anomalies.
Answer: (B) Irritability and poor sucking. Neonates of heroin-
addicted mothers are physically dependent on the drug and
experience withdrawal when the drug is no longer supplied.
Signs of heroin withdrawal include irritability, poor sucking,
and restlessness. Lethargy isn’t associated with neonatal
heroin addiction. A flattened nose, small eyes, and thin lips
are seen in infants with fetal alcohol syndrome. Heroin use
during pregnancy hasn’t been linked to specific congenital
anomalies.
99. The uterus returns to the pelvic cavity in which of the
following time frames?
A. 7th to 9th day postpartum.
B. 2 weeks postpartum.
C. End of 6th week postpartum.
D. When the lochia changes to alba.
Answer: (A) 7th to 9th day postpartum. The normal
involutional process returns the uterus to the pelvic cavity in
7 to 9 days. A significant involutional complication is the
failure of the uterus to return to the pelvic cavity within the
prescribed time period. This is known as subinvolution
100. Maureen, a primigravida client, age 20, has just
completed a difficult, forceps-assisted delivery of twins. Her
labor was unusually long and required oxytocin (Pitocin)
augmentation. The nurse who’s caring for her should stay
alert for:
A. Uterine inversion
B. Uterine atony
C. Uterine involution
D. Uterine discomfort
Answer: (B) Uterine atony. Multiple fetuses, extended labor
stimulation with oxytocin, and traumatic delivery commonly
are associated with uterine atony, which may lead to
postpartum hemorrhage. Uterine inversion may precede or
follow delivery and commonly results from apparent
excessive traction on the umbilical cord and attempts to
deliver the placenta manually. Uterine involution and some
uterine discomfort are normal after delivery.
PNLE III for Care of Clients with
Physiologic and Psychosocial
Alterations (Part 1)
1. Nurse Michelle should know that the drainage is normal 4
days after a sigmoid colostomy when the stool is:
A. Green liquid
B. Solid formed
C. Loose, bloody
D. Semiformed
Answer: (C) Loose, bloody. Normal bowel function and soft-
formed stool usually do not occur until around the seventh
day following surgery. The stool consistency is related to how
much water is being absorbed
2. Where would nurse Kristine place the call light for a male
client with a right-sided brain attack and left homonymous
hemianopsia?
A. On the client’s right side
B. On the client’s left side
C. Directly in front of the client
D. Where the client like
Answer: (A) On the client’s right side. The client has left
visual field blindness. The client will see only from the right
side
3. A male client is admitted to the emergency department
following an accident. What are the first nursing actions of
the nurse?
A. Check respiration, circulation, neurological response.
B. Align the spine, check pupils, and check for hemorrhage.
C. Check respirations, stabilize spine, and check
circulation.
D. Assess level of consciousness and circulation.
Answer: (C) Check respirations, stabilize spine, and check
circulation. Checking the airway would be priority, and a
neck injury should be suspected
4. In evaluating the effect of nitroglycerin, Nurse Arthur
should know that it reduces preload and relieves angina by:
A. Increasing contractility and slowing heart rate.
B. Increasing AV conduction and heart rate.
C. Decreasing contractility and oxygen consumption.
D. Decreasing venous return through vasodilation.
Answer: (D) Decreasing venous return through
vasodilation. The significant effect of nitroglycerin is
vasodilation and decreased venous return, so the heart does
not have to work hard.
5. Nurse Patricia finds a female client who is post-myocardial
infarction (MI) slumped on the side rails of the bed and
unresponsive to shaking or shouting. Which is the nurse next
action?
A. Call for help and note the time.
B. Clear the airway
C. Give two sharp thumps to the precordium, and check
the pulse.
D. Administer two quick blows.
Answer: (A) Call for help and note the time. Having
established, by stimulating the client, that the client
is unconscious rather than sleep, the nurse should
immediately call for help. This may be done by dialing the
operator from the client’s phone and giving the hospital
code for cardiac arrest and the client’s room number to the
operator, of if the phone is not available, by pulling the
emergency call button. Noting the time is important baseline
information for cardiac arrest procedure
6. Nurse Monett is caring for a client recovering from gastro-
intestinal bleeding. The nurse should:
 A. Plan care so the client can receive 8 hours of
uninterrupted sleep each night.
B. Monitor vital signs every 2 hours.
C. Make sure that the client takes food and medications
at prescribed intervals.
D. Provide milk every 2 to 3 hours.
Answer: (C) Make sure that the client takes food and
medications at prescribed intervals. Food and drug therapy
will prevent the accumulation of hydrochloric acid, or will
neutralize and buffer the acid that does accumulate.
7. A male client was on warfarin (Coumadin) before
admission, and has been receiving heparin I.V. for 2 days. The
partial thromboplastin time (PTT) is 68 seconds. What should
Nurse Carla do?
A. Stop the I.V. infusion of heparin and notify the physician.
B. Continue treatment as ordered.
C. Expect the warfarin to increase the PTT.
D. Increase the dosage, because the level is lower than
normal.
Answer: (B) Continue treatment as ordered. The effects of
heparin are monitored by the PTT is normally 30 to 45
seconds; the therapeutic level is 1.5 to 2 times the normal
level.
8. A client undergone ileostomy, when should the drainage
appliance be applied to the stoma?
A. 24 hours later, when edema has subsided.
B. In the operating room.
C. After the ileostomy begin to function.
D. When the client is able to begin self-care procedures.
Answer: (B) In the operating room. The stoma drainage bag is
applied in the operating room. Drainage from the ileostomy
contains secretions that are rich in digestive enzymes and
highly irritating to the skin. Protection of the skin from
the effects of these enzymes is begun at once. Skin exposed
to these enzymes even for a short time becomes reddened,
painful, and excoriated.
9. A client undergone spinal anesthetic, it will be important
that the nurse immediately position the client in:
A. On the side, to prevent obstruction of airway by tongue.
B. Flat on back.
C. On the back, with knees flexed 15 degrees.
D. Flat on the stomach, with the head turned to the side.
Answer: (B) Flat on back. To avoid the complication of a
painful spinal headache that can last for several days, the
client is kept in flat in a supine position for approximately 4 to
12 hours postoperatively. Headaches are believed to be
causes by the seepage of cerebral spinal fluid from the
puncture site. By keeping the client flat, cerebral spinal fluid
pressures are equalized, which avoids trauma to the neurons.
10.While monitoring a male client several hours after a motor
vehicle accident, which assessment data suggest increasing
intracranial pressure?
A. Blood pressure is decreased from 160/90 to 110/70.
B. Pulse is increased from 87 to 95, with an occasional
skipped beat.
C. The client is oriented when aroused from sleep, and
goes back to sleep immediately.
D. The client refuses dinner because of anorexia.
Answer: (C) The client is oriented when aroused from sleep,
and goes back to sleep immediately. This finding suggest that
the level of consciousness is decreasing.
11.Mrs. Cruz, 80 years old is diagnosed with pneumonia.
Which of the following symptoms may appear first?
A. Altered mental status and dehydration
B. Fever and chills
C. Hemoptysis and Dyspnea
D. Pleuritic chest pain and cough
Answer: (A) Altered mental status and dehydration. Fever,
chills, hemortysis, dyspnea, cough, and pleuritic chest pain
are the common symptoms of pneumonia, but elderly clients
may first appear with only an altered lentil status and
dehydration due to a blunted immune response.
12. A male client has active tuberculosis (TB). Which of the
following symptoms will be exhibit?
A. Chest and lower back pain
B. Chills, fever, night sweats, and hemoptysis
C. Fever of more than 104°F (40°C) and nausea
D. Headache and photophobia
Answer: (B) Chills, fever, night sweats, and
hemoptysis. Typical signs and symptoms are chills, fever,
night sweats, and hemoptysis. Chest pain may be present
from coughing, but isn’t usual. Clients with TB typically have
low-grade fevers, not higher than 102°F (38.9°C). Nausea,
headache, and photophobia aren’t usual TB symptoms.
13. Mark, a 7-year-old client is brought to the emergency
department. He’s tachypneic and afebrile and has a
respiratory rate of 36 breaths/minute and has a
nonproductive cough. He recently had a cold. Form this
history; the client may have which of the following
conditions?
A. Acute asthma
B. Bronchial pneumonia
C. Chronic obstructive pulmonary disease (COPD)
D. Emphysema
Answer:(A) Acute asthma. Based on the client’s history and
symptoms, acute asthma is the most likely diagnosis. He’s
unlikely to have bronchial pneumonia without a productive
cough and fever and he’s too young to have developed
(COPD) and emphysema.
14. Marichu was given morphine sulfate for pain. She is
sleeping and her respiratory rate is 4 breaths/minute. If action
isn’t taken quickly, she might have which of the following
reactions?
A. Asthma attack
B. Respiratory arrest
C. Seizure
D. Wake up on his own
Answer: (B) Respiratory arrest. Narcotics can cause
respiratory arrest if given in large quantities. It’s unlikely the
client will have asthma attack or a seizure or wake up on his
own.
15. A 77-year-old male client is admitted for elective knee
surgery. Physical examination reveals shallow respirations but
no sign of respiratory distress. Which of the following is a
normal physiologic change related to aging?
 A. Increased elastic recoil of the lungs
B. Increased number of functional capillaries in the alveoli
C. Decreased residual volume
D. Decreased vital capacity
Answer: (D) Decreased vital capacity. Reduction in vital
capacity is a normal physiologic changes include decreased
elastic recoil of the lungs, fewer functional capillaries in the
alveoli, and an increased in residual volume.
16. Nurse John is caring for a male client receiving lidocaine
I.V. Which factor is the most relevant to administration of this
medication?
A. Decrease in arterial oxygen saturation (SaO2) when
measured with a pulse oximeter.
B. Increase in systemic blood pressure.
C. Presence of premature ventricular contractions (PVCs)
on a cardiac monitor.
D. Increase in intracranial pressure (ICP).
Answer: (C) Presence of premature ventricular contractions
(PVCs) on a cardiac monitor. Lidocaine drips are commonly
used to treat clients whose arrhythmias haven’t been
controlled with oral medication and who are having PVCs that
are visible on the cardiac monitor. SaO2, blood pressure, and
ICP are important factors but aren’t as significant as PVCs in
the situation.
17. Nurse Ron is caring for a male client taking an
anticoagulant. The nurse should teach the client to:
A. Report incidents of diarrhea.
B. Avoid foods high in vitamin K
C. Use a straight razor when shaving.
D. Take aspirin to pain relief.
Answer: (B) Avoid foods high in vitamin K. The client should
avoid consuming large amounts of vitamin K because vitamin
K can interfere with anticoagulation. The client may need to
report diarrhea, but isn’t effect of taking an anticoagulant. An
electric razor-not a straight razor-should be used to prevent
cuts that cause bleeding. Aspirin may increase the risk of
bleeding; acetaminophen should be used to pain relief.
18. Nurse Lhynnette is preparing a site for the insertion of an
I.V. catheter. The nurse should treat excess hair at the site by:
A. Leaving the hair intact
B. Shaving the area
C. Clipping the hair in the area
D. Removing the hair with a depilatory.
Answer: (C) Clipping the hair in the area. Hair can be a source
of infection and should be removed by clipping. Shaving the
area can cause skin abrasions and depilatories can irritate the
skin.
19. Nurse Michelle is caring for an elderly female with
osteoporosis. When teaching the client, the nurse should
include information about which major complication:
A. Bone fracture
B. Loss of estrogen
C. Negative calcium balance
D. Dowager’s hump
Answer: (A) Bone fracture. Bone fracture is a major
complication of osteoporosis that results when loss of calcium
and phosphate increased the fragility of bones. Estrogen
deficiencies result from menopause-not
osteoporosis. Calcium and vitamin D supplements may be
used to support normal bone metabolism, But a negative
calcium balance isn’t a complication of osteoporosis.
Dowager’s hump results from bone fractures. It
develops when repeated vertebral fractures increase spinal
curvature.
20. Nurse Len is teaching a group of women to perform BSE.
The nurse should explain that the purpose of performing the
examination is to discover:
A. Cancerous lumps
B. Areas of thickness or fullness
C. Changes from previous examinations.
D. Fibrocystic masses
Answer: (C) Changes from previous examinations. Women are
instructed to examine themselves to discover changes that
have occurred in the breast. Only a physician can
diagnose lumps that are cancerous, areas of thickness or
fullness that signal the presence of a malignancy, or masses
that are fibrocystic as opposed to malignant.
21. When caring for a female client who is being treated for
hyperthyroidism, it is important to:
A. Provide extra blankets and clothing to keep the client
warm.
B. Monitor the client for signs of restlessness, sweating,
and excessive weight loss during thyroid replacement
therapy.
C. Balance the client’s periods of activity and rest.
D. Encourage the client to be active to prevent constipation
Answer: (C) Balance the client’s periods of activity and
rest. A client with hyperthyroidism needs to be encouraged
to balance periods of activity and rest. Many clients with
hyperthyroidism are hyperactive and complain of feeling
very warm
.
22. Nurse Kris is teaching a client with history of
atherosclerosis. To decrease the risk of atherosclerosis, the
nurse should encourage the client to:
A. Avoid focusing on his weight.
B. Increase his activity level.
C. Follow a regular diet.
D. Continue leading a high-stress lifestyle.
Answer: (B) Increase his activity level. The client should be
encouraged to increase his activity level. Maintaining an ideal
weight; following a low-cholesterol, low sodium diet; and
avoiding stress are all important factors in decreasing the risk
of atherosclerosis.
23. Nurse Greta is working on a surgical floor. Nurse Greta
must logroll a client following a:
A. Laminectomy
B. Thoracotomy
C. Hemorrhoidectomy
D. Cystectomy.
Answer: (A) Laminectomy. The client who has had spinal
surgery, such as laminectomy, must be log rolled to keep the
spinal column straight when turning. Thoracotomy and
cystectomy may turn themselves or may be assisted into a
comfortable position. Under normal
circumstances, hemorrhoidectomy is an outpatient
procedure, and the client may resume normal activities
immediately after surgery.

24. A 55-year old client underwent cataract removal with
intraocular lens implant. Nurse Oliver is giving the client
discharge instructions. These instructions should include
which of the following?
A. Avoid lifting objects weighing more than 5 lb (2.25 kg).
B. Lie on your abdomen when in bed
C. Keep rooms brightly lit.
D. Avoiding straining during bowel movement or bending
at the waist.
Answer: (D) Avoiding straining during bowel movement or
bending at the waist. The client should avoid straining, lifting
heavy objects, and coughing harshly because these activities
increase intraocular pressure. Typically, the client is
instructed to avoid lifting objects weighing more than 15 lb
(7kg) – not 5lb. instruct the client when lying in bed to lie on
either the side or back. The client should avoid bright light
by wearing sunglasses.
25. George should be taught about testicular examinations
during:
A. when sexual activity starts
B. After age 69
C. After age 40
D. Before age 20.
Answer: (D) Before age 20. Testicular cancer commonly
occurs in men between ages 20 and 30. A male client should
be taught how to perform testicular selfexamination before
age 20, preferably when he enters his teens.
26. A male client undergone a colon resection. While turning
him, wound dehiscence with evisceration occurs. Nurse Trish
first response is to:
A. Call the physician
B. Place a saline-soaked sterile dressing on the wound.
C. Take a blood pressure and pulse.
D. Pull the dehiscence closed.
Answer: (B) Place a saline-soaked sterile dressing on the
wound. The nurse should first place saline-soaked sterile
dressings on the open wound to prevent tissue drying and
possible infection. Then the nurse should call the physician
and take the client’s vital signs. The dehiscence needs to be
surgically closed, so the nurse should never try to close it.
27. Nurse Audrey is caring for a client who has suffered a
severe cerebrovascular accident. During routine assessment,
the nurse notices Cheyne- Strokes respirations. Cheyne-
strokes respirations are:
A. A progressively deeper breaths followed by shallower
breaths with apneic periods.
B. Rapid, deep breathing with abrupt pauses between
each breath.
C. Rapid, deep breathing and irregular breathing without
pauses.
D. Shallow breathing with an increased respiratory rate.
Answer: (A) A progressively deeper breaths followed by
shallower breaths with apneic periods. Cheyne-Strokes
respirations are breaths that become progressively deeper
fallowed by shallower respirations with apneas periods. Biot’s
respirations are rapid, deep breathing with abrupt
pauses between each breath, and equal depth between each
breath. Kussmaul’s respirations are rapid, deep breathing
without pauses. Tachypnea is shallow breathing with
increased respiratory rate
28. Nurse Bea is assessing a male client with heart failure. The
breath sounds commonly auscultated in clients with heart
failure are:
A. Tracheal
B. Fine crackles
C. Coarse crackles
D. Friction rubs
Answer: (B) Fine crackles. Fine crackles are caused by fluid in
the alveoli and commonly occur in clients with heart failure.
Tracheal breath sounds are auscultated over the trachea.
Coarse crackles are caused by secretion accumulation in the
airways. Friction rubs occur with pleural inflammation.
29. The nurse is caring for Kenneth experiencing an acute
asthma attack. The client stops wheezing and breath sounds
aren’t audible. The reason for this change is that:
A. The attack is over.
B. The airways are so swollen that no air cannot get
through.
C. The swelling has decreased.
D. Crackles have replaced wheezes.
Answer: (B) The airways are so swollen that no air cannot get
through. During an acute attack, wheezing may stop and
breath sounds become inaudible because the airways are so
swollen that air can’t get through. If the attack is over and
swelling has decreased, there would be no more wheezing
and less emergent concern. Crackles do not replace wheezes
during an acute asthma attack.
30. Mike with epilepsy is having a seizure. During the active
seizure phase, the nurse should:
A. Place the client on his back remove dangerous objects,
and insert a bite block.
B. Place the client on his side, remove dangerous objects,
and insert a bite block.
C. Place the client o his back, remove dangerous objects,
and hold down his arms.
D. Place the client on his side, remove dangerous objects,
and protect his head.
Answer: (D) Place the client on his side, remove dangerous
objects, and protect his head. During the active seizure
phase, initiate precautions by placing the client on his side,
removing dangerous objects, and protecting his head from
injury. A bite block should never be inserted during the
active seizure phase. Insertion can break the teeth and lead
to aspiration
31. After insertion of a cheat tube for a pneumothorax, a
client becomes hypotensive with neck vein distention,
tracheal shift, absent breath sounds, and diaphoresis. Nurse
Amanda suspects a tension pneumothorax has
occurred. What cause of tension pneumothorax should the
nurse check for?
A. Infection of the lung.
B. Kinked or obstructed chest tube
C. Excessive water in the water-seal chamber
D. Excessive chest tube drainage
Answer: (B) Kinked or obstructed chest tube. Kinking and
blockage of the chest tube is a common cause of a tension
pneumothorax. Infection and excessive drainage won’t cause
a tension pneumothorax. Excessive water won’t affect the
chest tube drainage.
32. Nurse Maureen is talking to a male client, the client
begins choking on his lunch. He’s coughing forcefully. The
nurse should:
A. Stand him up and perform the abdominal thrust
maneuver from behind.
B. Lay him down, straddle him, and perform the abdominal
thrust maneuver.
C. Leave him to get assistance
D. Stay with him but not intervene at this time.
Answer: (D) Stay with him but not intervene at this time. If
the client is coughing, he should be able to dislodge
the object or cause a complete obstruction. If complete
obstruction occurs, the nurse should perform the abdominal
thrust maneuver with the client standing. If the client is
unconscious, she should lay him down. A nurse should never
leave a choking client alone.
33. Nurse Ron is taking a health history of an 84 year old
client. Which information will be most useful to the nurse for
planning care?
A. General health for the last 10 years.
B. Current health promotion activities.
C. Family history of diseases.
D. Marital status.
Answer: (B) Current health promotion activities. Recognizing
an individual’s positive health measures is very useful.
General health in the previous 10 years is important,
however, the current activities of an 84 year old client are
most significant in planning care. Family history of disease for
a client in later years is of minor significance. Marital status
information may be important for discharge planning but is
not as significant for addressing the immediate
medical problem.
34. When performing oral care on a comatose client, Nurse
Krina should:
A. Apply lemon glycerin to the client’s lips at least every 2
hours.
B. Brush the teeth with client lying supine.
C. Place the client in a side lying position, with the head
of the bed lowered.
D. Clean the client’s mouth with hydrogen peroxide.
Answer: (C) Place the client in a side lying position, with the
head of the bed lowered. The client should be positioned in a
side-lying position with the head of the bed lowered to
prevent aspiration. A small amount of toothpaste should be
used and the mouth swabbed or suctioned to remove pooled
secretions. Lemon glycerin can be drying if used for extended
periods. Brushing the teeth with the client lying supine may
lead to aspiration. Hydrogen peroxide is caustic to tissues and
should not be used.
35. A 77-year-old male client is admitted with a diagnosis of
dehydration and change in mental status. He’s being hydrated
with L.V. fluids. When the nurse takes his vital signs, she notes
he has a fever of 103°F (39.4°C) a cough producing yellow
sputum and pleuritic chest pain. The nurse suspects this client
may have which of the following conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Myocardial infarction (MI)
C. Pneumonia
D. Tuberculosis
Answer: (C) Pneumonia. Fever productive cough and pleuritic
chest pain are common signs and symptoms of pneumonia.
The client with ARDS has dyspnea and hypoxia with
worsening hypoxia over time, if not treated
aggressively. Pleuritic chest pain varies with respiration, unlike
the constant chest pain during an MI; so this client most likely
isn’t having an MI. the client with TB typically has a cough
producing blood-tinged sputum. A sputum culture should be
obtained to confirm the nurse’s suspicions.
36. Nurse Oliver is working in a out patient clinic. He has been
alerted that there is an outbreak of tuberculosis (TB). Which
of the following clients entering the clinic today most likely to
have TB?
A. A 16-year-old female high school student
B. A 33-year-old day-care worker
C. A 43-yesr-old homeless man with a history of
alcoholism
D. A 54-year-old businessman
Answer: (C) A 43-yesr-old homeless man with a history of
alcoholism. Clients who are economically disadvantaged,
malnourished, and have reduced immunity, such as a client
with a history of alcoholism, are at extremely high risk for
developing TB. A high school student, daycare worker, and
businessman probably have a much low risk of contracting TB.
37. Virgie with a positive Mantoux test result will be sent for a
chest X-ray. The nurse is aware that which of the following
reasons this is done?
A. To confirm the diagnosis
B. To determine if a repeat skin test is needed
C. To determine the extent of lesions
D. To determine if this is a primary or secondary infection
Answer: (C ) To determine the extent of lesions. If the lesions
are large enough, the chest X-ray will show their presence in
the lungs. Sputum culture confirms the diagnosis. There
can be false-positive and false-negative skin test results. A
chest X-ray can’t determine if this is a primary or secondary
infection.
38. Kennedy with acute asthma showing inspiratory and
expiratory wheezes and a decreased forced expiratory volume
should be treated with which of the following classes of
medication right away?
A. Beta-adrenergic blockers
B. Bronchodilators
C. Inhaled steroids
D. Oral steroids
Answer: (B) Bronchodilators. Bronchodilators are the first line
of treatment for asthma because broncho-constriction is the
cause of reduced airflow. Beta adrenergic blockers aren’t used
to treat asthma and can cause bronchoconstriction. Inhaled
oral steroids may be given to reduce the inflammation but
aren’t used for emergency relief.
39. Mr. Vasquez 56-year-old client with a 40-year history of
smoking one to two packs of cigarettes per day has a chronic
cough producing thick sputum, peripheral edema and
cyanotic nail beds. Based on this information, he most likely
has which of the following conditions?
A. Adult respiratory distress syndrome (ARDS)
 B. Asthma
C. Chronic obstructive bronchitis
D. Emphysema
Answer: (C) Chronic obstructive bronchitis. Because of this
extensive smoking history and symptoms the client most
likely has chronic obstructive bronchitis. Client with
ARDS have acute symptoms of hypoxia and typically need
large amounts of oxygen. Clients with asthma and
emphysema tend not to have chronic cough or peripheral
edema
Situation: Francis, age 46 is admitted to the hospital with
diagnosis of Chronic Lymphocytic Leukemia.
40. The treatment for patients with leukemia is bone marrow
transplantation. Which statement about bone marrow
transplantation is not correct?
A. The patient is under local anesthesia during the
procedure
B. The aspirated bone marrow is mixed with heparin.
C. The aspiration site is the posterior or anterior iliac crest.
D. The recipient receives cyclophosphamide (Cytoxan) for 4
consecutive days before the procedure.
Answer: (A) The patient is under local anesthesia during the
procedure. Before the procedure, the patient is administered
with drugs that would help to prevent infection and rejection
of the transplanted cells such as antibiotics, cytotoxic, and
corticosteroids. During the transplant, the patient is placed
under general anesthesia.
41. After several days of admission, Francis becomes
disoriented and complains of frequent headaches. The nurse
in-charge first action would be:
A. Call the physician
B. Document the patient’s status in his charts.
C. Prepare oxygen treatment
D. Raise the side rails
Answer: (D) Raise the side rails. A patient who is disoriented
is at risk of falling out of bed. The initial action of the nurse
should be raising the side rails to ensure patients safety
42. During routine care, Francis asks the nurse, “How can I be
anemic if this disease causes increased my white blood cell
production?” The nurse in-charge best response would be
that the increased number of white blood cells (WBC) is:
A. Crowd red blood cells
B. Are not responsible for the anemia.
C. Uses nutrients from other cells
D. Have an abnormally short life span of cells.
Answer: (A) Crowd red blood cells. The excessive production
of white blood cells crowd out red blood cells production
which causes anemia to occur.
43. Diagnostic assessment of Francis would probably not
reveal:
A. Predominance of lymhoblasts
B. Leukocytosis
C. Abnormal blast cells in the bone marrow
D. Elevated thrombocyte counts
Answer: (B) Leukocytosis. Chronic Lymphocytic leukemia (CLL)
is characterized by increased production of leukocytes and
lymphocytes resulting in leukocytosis, and proliferation of
these cells within the bone marrow, spleen and liver.
44. Robert, a 57-year-old client with acute arterial occlusion
of the left leg undergoes an emergency embolectomy. Six
hours later, the nurse isn’t able to obtain pulses in his left foot
using Doppler ultrasound. The nurse immediately notifies the
physician, and asks her to prepare the client for surgery. As
the nurse enters the client’s room to prepare him, he states
that he won’t have any more surgery. Which of the following
is the best initial response by the nurse?
A. Explain the risks of not having the surgery
B. Notifying the physician immediately
C. Notifying the nursing supervisor
D. Recording the client’s refusal in the nurses’ notes
Answer: (A) Explain the risks of not having the surgery. The
best initial response is to explain the risks of not having the
surgery. If the client understands the risks but still refuses the
nurse should notify the physician and the nurse supervisor
and then record the client’s refusal in the nurses’ notes.
45. During the endorsement, which of the following clients
should the on-duty nurse assess first?
A. The 58-year-old client who was admitted 2 days ago
with heart failure, blood pressure of 126/76 mm Hg, and
a respiratory rate of 22 breaths/minute.
B. The 89-year-old client with end-stage right-sided heart
failure, blood pressure of 78/50 mm Hg, and a “do not
resuscitate” order
C. The 62-year-old client who was admitted 1 day ago
with thrombophlebitis and is receiving L.V. heparin
D. The 75-year-old client who was admitted 1 hour ago
with new-onset atrial fibrillation and is receiving L.V.
dilitiazem (Cardizem)
Answer: (D) The 75-year-old client who was admitted 1 hour
ago with new-onset atrial fibrillation and is receiving L.V.
dilitiazem (Cardizem). The client with atrial fibrillation has the
greatest potential to become unstable and is on L.V.
medication that requires close monitoring. After assessing
this client, the nurse should assess the client
with thrombophlebitis who is receiving a heparin infusion,
and then the 58- year-old client admitted 2 days ago with
heart failure (his signs and symptoms are resolving and don’t
require immediate attention). The lowest priority is the 89-
year-old with end stage right-sided heart failure, who requires
time-consuming supportive measures.
46. Honey, a 23-year old client complains of substernal chest
pain and states that her heart feels like “it’s racing out of the
chest”. She reports no history of cardiac disorders. The nurse
attaches her to a cardiac monitor and notes sinus tachycardia
with a rate of 136beats/minutes. Breath sounds are clear and
the respiratory rate is 26 breaths/minutes. Which of the
following drugs should the nurse question the client about
using?
A. Barbiturates
B. Opioids
C. Cocaine
D. Benzodiazepines
Answer: (C) Cocaine. Because of the client’s age and
negative medical history, the nurse should question her
about cocaine use. Cocaine increases myocardial oxygen
consumption and can cause coronary artery spasm, leading
to tachycardia, ventricular fibrillation, myocardial ischemia,
 and myocardial infarction. Barbiturate overdose may trigger
respiratory depression and slow pulse. Opioids can cause
marked respiratory depression, while benzodiazepines can
cause drowsiness and confusion
47. A 51-year-old female client tells the nurse in-charge that
she has found a painless lump in her right breast during her
monthly self-examination. Which assessment finding would
strongly suggest that this client’s lump is cancerous?
A. Eversion of the right nipple and mobile mass
B. Nonmobile mass with irregular edges
C. Mobile mass that is soft and easily delineated
D. Nonpalpable right axillary lymph nodes
Answer: (B) Nonmobile mass with irregular edges. Breast
cancer tumors are fixed, hard, and poorly delineated with
irregular edges. A mobile mass that is soft and easily
delineated is most often a fluid-filled benign cyst. Axillary
lymph nodes may or may not be palpable on initial detection
of a cancerous mass. Nipple retraction — not eversion —
may be a sign of cancer
48. A 35-year-old client with vaginal cancer asks the nurse,
“What is the usual treatment for this type of cancer?” Which
treatment should the nurse name?
A. Surgery
B. Chemotherapy
C. Radiation
D. Immunotherapy
Answer: (C) Radiation. The usual treatment for vaginal
cancer is external or intravaginal radiation therapy. Less
often, surgery is performed. Chemotherapy typically is
prescribed only if vaginal cancer is diagnosed in an early
stage, which is rare. Immunotherapy isn’t used to treat
vaginal cancer.
49. Cristina undergoes a biopsy of a suspicious lesion. The
biopsy report classifies the lesion according to the TNM
staging system as follows: TIS, N0, M0. What does this
classification mean?
A. No evidence of primary tumor, no abnormal regional
lymph nodes, and no evidence of distant metastasis
B. Carcinoma in situ, no abnormal regional lymph nodes,
and no evidence of distant metastasis
C. Can’t assess tumor or regional lymph nodes and no
evidence of metastasis
D. Carcinoma in situ, no demonstrable metastasis of the
regional lymph nodes, and ascending degrees of distant
metastasis
Answer: (B) Carcinoma in situ, no abnormal regional lymph
nodes, and no evidence of distant metastasis. TIS, N0, M0
denotes carcinoma in situ, no abnormal regional lymph
nodes, and no evidence of distant metastasis. No evidence
of primary tumor, no abnormal regional lymph nodes, and no
evidence of distant metastasis is classified as T0, N0, M0. If
the tumor and regional lymph nodes can’t be assessed and no
evidence of metastasis exists, the lesion is classified as TX, NX,
M0. A progressive increase in tumor size, no demonstrable
metastasis of the regional lymph nodes, and
ascending degrees of distant metastasis is classified as T1, T2,
T3, or T4; N0; and M1, M2, or M3.
50. Lydia undergoes a laryngectomy to treat laryngeal cancer.
When teaching the client how to care for the neck stoma, the
nurse should include which instruction?
A. “Keep the stoma uncovered.”
B. “Keep the stoma dry.”
C. “Have a family member perform stoma care initially
until you get used to the procedure.”
D. “Keep the stoma moist.”
Answer: (D) “Keep the stoma moist.” The nurse should
instruct the client to keep the stoma moist, such as by
applying a thin layer of petroleum jelly around the
edges, because a dry stoma may become irritated. The nurse
should recommend placing a stoma bib over the stoma to
filter and warm air before it enters the stoma. The client
should begin performing stoma care without assistance as
soon as possible to gain independence in self-care activities.
51. A 37-year-old client with uterine cancer asks the nurse,
“Which is the most common type of cancer in women?” The
nurse replies that it’s breast cancer. Which type of cancer
causes the most deaths in women?
A. Breast cancer
B. Lung cancer
C. Brain cancer
D. Colon and rectal cancer
Answer: (B) Lung cancer. Lung cancer is the most deadly type
of cancer in both women and men. Breast cancer ranks
second in women, followed (in descending order) by colon
and rectal cancer, pancreatic cancer, ovarian cancer, uterine
cancer, lymphoma, leukemia, liver cancer, brain cancer,
stomach cancer, and multiple myeloma.
52. Antonio with lung cancer develops Horner’s syndrome
when the tumor invades the ribs and affects the sympathetic
nerve ganglia. When assessing for signs and symptoms of this
syndrome, the nurse should note:
A. miosis, partial eyelid ptosis, and anhidrosis on the
affected side of the face.
B. chest pain, dyspnea, cough, weight loss, and fever.
C. arm and shoulder pain and atrophy of arm and hand
muscles, both on the affected side.
D. hoarseness and dysphagia.
Answer: (A) miosis, partial eyelid ptosis, and anhidrosis on the
affected side of the face. Horner’s syndrome, which occurs
when a lung tumor invades the ribs and affects the
sympathetic nerve ganglia, is characterized by miosis, partial
eyelid ptosis, and anhidrosis on the affected side of the face.
Chest pain, dyspnea, cough, weight loss, and fever are
associated with pleural tumors. Arm and shoulder pain and
atrophy of the arm and hand muscles on the affected side
suggest Pancoast’s tumor, a lung tumor involving the first
thoracic and eighth cervical nerves within the brachial plexus.
Hoarseness in a client with lung cancer suggests that
the tumor has extended to the recurrent laryngeal nerve;
dysphagia suggests that the lung tumor is compressing the
esophagus.
53. Vic asks the nurse what PSA is. The nurse should reply
that it stands for:
A. prostate-specific antigen, which is used to screen for
prostate cancer.
B. protein serum antigen, which is used to determine
protein levels.
C. pneumococcal strep antigen, which is a bacteria that
causes pneumonia.
D. Papanicolaou-specific antigen, which is used to screen
for cervical cancer.
 Answer: (A) prostate-specific antigen, which is used to
screen for prostate cancer. PSA stands for prostate-specific
antigen, which is used to screen for prostate cancer. The
other answers are incorrect
54. What is the most important postoperative instruction that
nurse Kate must give a client who has just returned from the
operating room after receiving a subarachnoid block?
A. “Avoid drinking liquids until the gag reflex returns.”
B. “Avoid eating milk products for 24 hours.”
C. “Notify a nurse if you experience blood in your urine.”
D. “Remain supine for the time specified by the
physician.”
Answer: (D) “Remain supine for the time specified by the
physician.” The nurse should instruct the client to remain
supine for the time specified by the physician. Local
anesthetics used in a subarachnoid block don’t alter the gag
reflex. No interactions between local anesthetics and food
occur. Local anesthetics don’t cause hematuria.
55. A male client suspected of having colorectal cancer will
require which diagnostic study to confirm the diagnosis?
A. Stool Hematest
B. Carcinoembryonic antigen (CEA)
C. Sigmoidoscopy
D. Abdominal computed tomography (CT) scan
Answer: (C) Sigmoidoscopy. Used to visualize the lower GI
tract, sigmoidoscopy and proctoscopy aid in the detection of
two-thirds of all colorectal cancers. Stool Hematest detects
blood, which is a sign of colorectal cancer; however, the test
doesn’t confirm the diagnosis. CEA may be elevated
in colorectal cancer but isn’t considered a confirming test.
An abdominal CT scan is used to stage the presence of
colorectal cancer.
56. During a breast examination, which finding most strongly
suggests that the Luz has breast cancer?
A. Slight asymmetry of the breasts.
B. A fixed nodular mass with dimpling of the overlying
skin
C. Bloody discharge from the nipple
D. Multiple firm, round, freely movable masses that
change with the menstrual cycle
Answer: (B) A fixed nodular mass with dimpling of the
overlying skin. A fixed nodular mass with dimpling of the
overlying skin is common during late stages of breast cancer.
Many women have slightly asymmetrical breasts. Bloody
nipple discharge is a sign of intraductal papilloma, a benign
condition. Multiple firm, round, freely movable masses that
change with the menstrual cycle indicate fibrocystic breasts, a
benign condition.
57. A female client with cancer is being evaluated for possible
metastasis. Which of the following is one of the most
common metastasis sites for cancer cells?
A. Liver
B. Colon
C. Reproductive tract
D. White blood cells (WBCs)
Answer: (A) Liver. The liver is one of the five most common
cancer metastasis sites. The others are the lymph nodes, lung,
bone, and brain. The colon, reproductive tract, and WBCs are
occasional metastasis sites.
58. Nurse Mandy is preparing a client for magnetic resonance
imaging (MRI) to confirm or rule out a spinal cord lesion.
During the MRI scan, which of the following would pose a
threat to the client?
A. The client lies still.
B. The client asks questions.
C. The client hears thumping sounds.
D. The client wears a watch and wedding band.
Answer: (D) The client wears a watch and wedding
band. During an MRI, the client should wear no metal
objects, such as jewelry, because the strong magnetic field
can pull on them, causing injury to the client and (if they fly
off) to others. The client must lie still during the MRI but can
talk to those performing the test by way of the microphone
inside the scanner tunnel. The client should hear
thumping sounds, which are caused by the sound waves
thumping on the magnetic field
59. Nurse Cecile is teaching a female client about preventing
osteoporosis. Which of the following teaching points is
correct?
A. Obtaining an X-ray of the bones every 3 years is
recommended to detect bone loss.
B. To avoid fractures, the client should avoid strenuous
exercise.
C. The recommended daily allowance of calcium may be
found in a wide variety of foods.
D. Obtaining the recommended daily allowance of calcium
requires taking a calcium supplement
Answer: (C) The recommended daily allowance of calcium
may be found in a wide variety of foods. Premenopausal
women require 1,000 mg of calcium per day. Postmenopausal
women require 1,500 mg per day. It’s often, though
not always, possible to get the recommended daily
requirement in the foods we eat. Supplements are available
but not always necessary. Osteoporosis doesn’t show up on
ordinary X-rays until 30% of the bone loss has occurred. Bone
densitometry can detect bone loss of 3% or less. This test is
sometimes recommended routinely for women over 35
who are at risk. Strenuous exercise won’t cause fractures.
.
60. Before Jacob undergoes arthroscopy, the nurse reviews
the assessment findings for contraindications for this
procedure. Which finding is a contraindication?
A. Joint pain
B. Joint deformity
C. Joint flexion of less than 50%
D. Joint stiffness
Answer: (C) Joint flexion of less than 50%. Arthroscopy is
contraindicated in clients with joint flexion of less than 50%
because of technical problems in inserting the instrument into
the joint to see it clearly. Other contraindications for this
procedure include skin and wound infections. Joint pain may
be an indication, not a contraindication, for arthroscopy. Joint
deformity and joint stiffness aren’t contraindications for this
procedure.
61. Mr. Rodriguez is admitted with severe pain in the knees.
Which form of arthritis is characterized by urate deposits and
joint pain, usually in the feet and legs, and occurs primarily in
men over age 30?
A. Septic arthritis
B. Traumatic arthritis
 C. Intermittent arthritis
D. Gouty arthritis
Answer: (D) Gouty arthritis. Gouty arthritis, a metabolic
disease, is characterized by urate deposits and pain in the
joints, especially those in the feet and legs. Urate deposits
don’t occur in septic or traumatic arthritis. Septic arthritis
results from bacterial invasion of a joint and leads to
inflammation of the synovial lining. Traumatic arthritis results
from blunt trauma to a joint or ligament. Intermittent arthritis
is a rare, benign condition marked by regular, recurrent joint
effusions, especially in the knees.
62. A heparin infusion at 1,500 unit/hour is ordered for a 64-
year-old client with stroke in evolution. The infusion contains
25,000 units of heparin in 500 ml of saline solution. How
many milliliters per hour should be given?
A. 15 ml/hour
B. 30 ml/hour
C. 45 ml/hour
D. 50 ml/hour
Answer: (B) 30 ml/hour. An infusion prepared with 25,000
units of heparin in 500 ml of saline solution yields 50 units of
heparin per milliliter of solution. The equation is set up as 50
units times X (the unknown quantity) equals 1,500 units/hour,
X equals 30 ml/hour.
63. A 76-year-old male client had a thromboembolic right
stroke; his left arm is swollen. Which of the following
conditions may cause swelling after a stroke?
A. Elbow contracture secondary to spasticity
B. Loss of muscle contraction decreasing venous return
C. Deep vein thrombosis (DVT) due to immobility of the
ipsilateral side
D. Hypoalbuminemia due to protein escaping from an
inflamed glomerulus
Answer: (B) Loss of muscle contraction decreasing venous
return. In clients with hemiplegia or hemiparesis loss of
muscle contraction decreases venous return and may cause
swelling of the affected extremity. Contractures, or bony
calcifications may occur with a stroke, but don’t appear with
swelling. DVT may develop in clients with a stroke but is
more likely to occur in the lower extremities. A stroke
isn’t linked to protein loss
64. Heberden’s nodes are a common sign of osteoarthritis.
Which of the following statement is correct about this
deformity?
A. It appears only in men
B. It appears on the distal interphalangeal joint
C. It appears on the proximal interphalangeal joint
D. It appears on the dorsolateral aspect of the
interphalangeal joint.
Answer: (B) It appears on the distal interphalangeal
joint. Heberden’s nodes appear on the distal interphalageal
joint on both men and women. Bouchard’s node appears on
the dorsolateral aspect of the proximal interphalangeal joint.
65. Which of the following statements explains the main
difference between rheumatoid arthritis and osteoarthritis?
A. Osteoarthritis is gender-specific, rheumatoid arthritis
isn’t
B. Osteoarthritis is a localized disease rheumatoid
arthritis is systemic
C. Osteoarthritis is a systemic disease, rheumatoid arthritis
is localized
D. Osteoarthritis has dislocations and subluxations,
rheumatoid arthritis doesn’t
Answer: (B) Osteoarthritis is a localized disease rheumatoid
arthritis is systemic. Osteoarthritis is a localized disease,
rheumatoid arthritis is systemic. Osteoarthritis isn’t gender-
specific, but rheumatoid arthritis is. Clients have dislocations
and subluxations in both disorders.
66. Mrs. Cruz uses a cane for assistance in walking. Which of
the following statements is true about a cane or other
assistive devices?
A. A walker is a better choice than a cane.
B. The cane should be used on the affected side
C. The cane should be used on the unaffected side
D. A client with osteoarthritis should be encouraged to
ambulate without the cane
Answer: (C) The cane should be used on the unaffected
side. A cane should be used on the unaffected side. A client
with osteoarthritis should be encouraged to ambulate with a
cane, walker, or other assistive device as needed; their use
takes weight and stress off joints.
67. A male client with type 1 diabetes is scheduled to receive
30 U of 70/30 insulin. There is no 70/30 insulin available. As a
substitution, the nurse may give the client:
A. 9 U regular insulin and 21 U neutral protamine
Hagedorn (NPH).
B. 21 U regular insulin and 9 U NPH.
C. 10 U regular insulin and 20 U NPH.
D. 20 U regular insulin and 10 U NPH.
Answer: (A) 9 U regular insulin and 21 U neutral protamine
Hagedorn (NPH). A 70/30 insulin preparation is 70% NPH
and 30% regular insulin. Therefore, a correct substitution
requires mixing 21 U of NPH and 9 U of regular insulin. The
other choices are incorrect dosages for the prescribed
insulin
68. Nurse Len should expect to administer which medication
to a client with gout?
A. aspirin
B. furosemide (Lasix)
C. colchicines
D. calcium gluconate (Kalcinate)
Answer: (C) colchicines. A disease characterized by joint
inflammation (especially in the great toe), gout is
caused by urate crystal deposits in the joints.
The physician prescribes colchicine to reduce these
deposits and thus ease joint inflammation. Although
aspirin is used to reduce joint inflammation and pain in
clients with osteoarthritis and rheumatoid arthritis, it
isn’t indicated for gout because it has no effect on urate
crystal formation. Furosemide, a diuretic, doesn’t relieve
gout. Calcium gluconate is used to reverse a negative
calcium balance and relieve muscle cramps, not to treat
gout.
69. Mr. Domingo with a history of hypertension is diagnosed
with primary hyperaldosteronism. This diagnosis indicates
that the client’s hypertension is caused by excessive hormone
secretion from which of the following glands?
A. Adrenal cortex
 B. Pancreas
C. Adrenal medulla
D. Parathyroid
Answer: (A) Adrenal cortex. Excessive secretion of
aldosterone in the adrenal cortex is responsible for the
client’s hypertension. This hormone acts on the renal tubule,
where it promotes reabsorption of sodium and excretion
of potassium and hydrogen ions. The pancreas mainly
secretes hormones involved in fuel metabolism. The adrenal
medulla secretes the catecholamines — epinephrine and
norepinephrine. The parathyroids secrete parathyroid
hormone.
70. For a diabetic male client with a foot ulcer, the doctor
orders bed rest, a wetto- dry dressing change every shift, and
blood glucose monitoring before meals and bedtime. Why are
wet-to-dry dressings used for this client?
A. They contain exudate and provide a moist wound
environment.
B. They protect the wound from mechanical trauma and
promote healing.
C. They debride the wound and promote healing by
secondary intention.
D. They prevent the entrance of microorganisms and
minimize wound discomfort.
Answer: (C) They debride the wound and promote healing
by secondary intention. For this client, wet-to-dry dressings
are most appropriate because they clean the foot ulcer by
debriding exudate and necrotic tissue, thus promoting
healing by secondary intention. Moist, transparent dressings
contain exudate and provide a moist wound
environment. Hydrocolloid dressings prevent the entrance of
microorganisms and minimize wound discomfort. Dry sterile
dressings protect the wound from mechanical trauma and
promote healing.
71. Nurse Zeny is caring for a client in acute addisonian crisis.
Which laboratory data would the nurse expect to find?
A. Hyperkalemia
B. Reduced blood urea nitrogen (BUN)
C. Hypernatremia
D. Hyperglycemia
Answer: (A) Hyperkalemia. In adrenal insufficiency, the client
has hyperkalemia due to reduced aldosterone secretion. BUN
increases as the glomerular filtration rate is reduced.
Hyponatremia is caused by reduced aldosterone secretion.
Reduced cortisol secretion leads to impaired
glyconeogenesis and a reduction of glycogen in the liver and
muscle, causing hypoglycemia.
72. A client is admitted for treatment of the syndrome of
inappropriate antidiuretic hormone (SIADH). Which nursing
intervention is appropriate?
A. Infusing I.V. fluids rapidly as ordered
B. Encouraging increased oral intake
C. Restricting fluids
D. Administering glucose-containing I.V. fluids as ordered
Answer: (C) Restricting fluids. To reduce water retention in a
client with the SIADH, the nurse should restrict fluids.
Administering fluids by any route would further increase the
client’s already heightened fluid load.
73. A female client tells nurse Nikki that she has been working
hard for the last 3 months to control her type 2 diabetes
mellitus with diet and exercise. To determine the
effectiveness of the client’s efforts, the nurse should check:
A. urine glucose level.
B. fasting blood glucose level.
C. serum fructosamine level.
D. glycosylated hemoglobin level.
Answer: (D) glycosylated hemoglobin level. Because some of
the glucose in the bloodstream attaches to some of the
hemoglobin and stays attached during the 120-day life span of
red blood cells, glycosylated hemoglobin levels provide
information about blood glucose levels during the previous 3
months. Fasting blood glucose and urine glucose levels only
give information about glucose levels at the point in time
when they were obtained. Serum fructosamine levels provide
information about blood glucose control over the past 2 to
3 weeks.
74. Nurse Trinity administered neutral protamine Hagedorn
(NPH) insulin to a diabetic client at 7 a.m. At what time would
the nurse expect the client to be most at risk for a
hypoglycemic reaction?
A. 10:00 am
B. Noon
C. 4:00 pm
D. 10:00 pm
Answer: (C) 4:00 pm. NPH is an intermediate-acting insulin
that peaks 8 to 12 hours after administration. Because the
nurse administered NPH insulin at 7 a.m., the client is at
greatest risk for hypoglycemia from 3 p.m. to 7 p.m.
75. The adrenal cortex is responsible for producing which
substances?
A. Glucocorticoids and androgens
B. Catecholamines and epinephrine
C. Mineralocorticoids and catecholamines
D. Norepinephrine and epinephrine
Answer: (A) Glucocorticoids and androgens. The adrenal
glands have two divisions, the cortex and medulla. The
cortex produces three types of hormones:
glucocorticoids, mineralocorticoids, and androgens. The
medulla produces catecholamines — epinephrine and
norepinephrine
76. On the third day after a partial thyroidectomy, Proserfina
exhibits muscle twitching and hyperirritability of the nervous
system. When questioned, the client reports numbness and
tingling of the mouth and fingertips. Suspecting a
lifethreatening electrolyte disturbance, the nurse notifies the
surgeon immediately. Which electrolyte disturbance most
commonly follows thyroid surgery?
A. Hypocalcemia
B. Hyponatremia
C. Hyperkalemia
D. Hypermagnesemia
Answer: (A) Hypocalcemia. Hypocalcemia may follow thyroid
surgery if the parathyroid glands were removed accidentally.
Signs and symptoms of hypocalcemia may be delayed for up
to 7 days after surgery. Thyroid surgery doesn’t directly cause
serum sodium, potassium, or magnesium
abnormalities. Hyponatremia may occur if the client
inadvertently received too much fluid; however, this can
happen to any surgical client receiving I.V. fluid therapy, not
just one recovering from thyroid surgery. Hyperkalemia
and hypermagnesemia usually are associated with reduced
renal excretion of potassium and magnesium, not thyroid
surgery.
77. Which laboratory test value is elevated in clients who
smoke and can’t be used as a general indicator of cancer?
A. Acid phosphatase level
B. Serum calcitonin level
C. Alkaline phosphatase level
D. Carcinoembryonic antigen level
Answer: (D) Carcinoembryonic antigen level. In clients who
smoke, the level of carcinoembryonic antigen is elevated.
Therefore, it can’t be used as a general indicator of
cancer. However, it is helpful in monitoring cancer treatment
because the level usually falls to normal within 1 month if
treatment is successful. An elevated acid phosphatase level
may indicate prostate cancer. An elevated alkaline
phosphatase level may reflect bone metastasis. An elevated
serum calcitonin level usually signals thyroid cancer
78. Francis with anemia has been admitted to the medical-
surgical unit. Which assessment findings are characteristic of
iron-deficiency anemia?
A. Nights sweats, weight loss, and diarrhea
B. Dyspnea, tachycardia, and pallor
C. Nausea, vomiting, and anorexia
D. Itching, rash, and jaundice
Answer: (B) Dyspnea, tachycardia, and pallor. Signs of iron-
deficiency anemia include dyspnea, tachycardia, and pallor as
well as fatigue, listlessness, irritability, and headache.
Night sweats, weight loss, and diarrhea may signal acquired
immunodeficiency syndrome (AIDS). Nausea, vomiting, and
anorexia may be signs of hepatitis B. Itching, rash, and
jaundice may result from an allergic or hemolytic reaction.
79. In teaching a female client who is HIV-positive about
pregnancy, the nurse would know more teaching is necessary
when the client says:
A. The baby can get the virus from my placenta.”
B. “I’m planning on starting on birth control pills.”
C. “Not everyone who has the virus gives birth to a baby
who has the virus.”
D. “I’ll need to have a C-section if I become pregnant and
have a baby.”
Ans wer: (D) “I’ll need to have a C-section if I become
pregnant and have a baby.” The human immunodeficiency
virus (HIV) is transmitted from mother to child via the
transplacental route, but a Cesarean section delivery isn’t
necessary when the mother is HIV-positive. The use of
birth control will prevent the conception of a child who might
have HIV. It’s true that a mother who’s HIV positive can give
birth to a baby who’s HIV negative.
80. When preparing Judy with acquired immunodeficiency
syndrome (AIDS) for discharge to the home, the nurse should
be sure to include which instruction?
A. “Put on disposable gloves before bathing.”
B. “Sterilize all plates and utensils in boiling water.”
C. “Avoid sharing such articles as toothbrushes and
razors.”
D. “Avoid eating foods from serving dishes shared by other
family members.”
Answer: (C) “Avoid sharing such articles as toothbrushes and
razors.” The human immunodeficiency virus (HIV), which
causes AIDS, is most concentrated in the blood. For this
reason, the client shouldn’t share personal articles that may
be blood-contaminated, such as toothbrushes and razors,
with other family members. HIV isn’t transmitted by bathing
or by eating from plates, utensils, or serving dishes used by
a person with AIDS.
81. Nurse Marie is caring for a 32-year-old client admitted
with pernicious anemia. Which set of findings should the
nurse expect when assessing the
client?
A. Pallor, bradycardia, and reduced pulse pressure
B. Pallor, tachycardia, and a sore tongue
C. Sore tongue, dyspnea, and weight gain
D. Angina, double vision, and anorexia
Answer: (B) Pallor, tachycardia, and a sore tongue. Pallor,
tachycardia, and a sore tongue are all characteristic findings in
pernicious anemia. Other clinical manifestations
include anorexia; weight loss; a smooth, beefy red tongue; a
wide pulse pressure; palpitations; angina; weakness; fatigue;
and paresthesia of the hands and feet. Bradycardia, reduced
pulse pressure, weight gain, and double vision aren’t
characteristic findings in pernicious anemia.
82. After receiving a dose of penicillin, a client develops
dyspnea and hypotension. Nurse Celestina suspects the client
is experiencing anaphylactic shock. What should the nurse do
first?
A. Page an anesthesiologist immediately and prepare to
intubate the client.
B. Administer epinephrine, as prescribed, and prepare to
intubate the client if necessary.
C. Administer the antidote for penicillin, as prescribed, and
continue to monitor the client’s vital signs.
D. Insert an indwelling urinary catheter and begin to infuse
I.V. fluids as ordered.
Answer: (B) Administer epinephrine, as prescribed, and
prepare to intubate the client if necessary. To reverse
anaphylactic shock, the nurse first should administer
epinephrine, a potent bronchodilator as prescribed.
The physician is likely to order additional medications, such
as antihistamines and corticosteroids; if these medications
don’t relieve the respiratory compromise associated with
anaphylaxis, the nurse should prepare to intubate the client.
No antidote for penicillin exists; however, the nurse should
continue to monitor the client’s vital signs. A client who
remains hypotensive may need fluid resuscitation and fluid
intake and output monitoring; however, administering
epinephrine is the first priority.
83. Mr. Marquez with rheumatoid arthritis is about to begin
aspirin therapy to reduce inflammation. When teaching the
client about aspirin, the nurse discusses adverse reactions to
prolonged aspirin therapy. These include:
A. weight gain.
B. fine motor tremors.
C. respiratory acidosis.
D. bilateral hearing loss.
Answer: (D) bilateral hearing loss. Prolonged use of aspirin
and other salicylates sometimes causes bilateral hearing loss
of 30 to 40 decibels. Usually, this adverse effect resolves
within 2 weeks after the therapy is discontinued.
Aspirin doesn’t lead to weight gain or fine motor tremors.
Large or toxic salicylate doses may cause respiratory alkalosis,
not respiratory acidosis.
84. A 23-year-old client is diagnosed with human
immunodeficiency virus (HIV). After recovering from the
initial shock of the diagnosis, the client expresses a desire to
learn as much as possible about HIV and acquired
immunodeficiency syndrome (AIDS). When teaching the client
about the immune system, the nurse states that adaptive
immunity is provided by which type of white blood cell?
A. Neutrophil
B. Basophil
C. Monocyte
D. Lymphocyte
Answer: (D) Lymphocyte. The lymphocyte provides adaptive
immunity — recognition of a foreign antigen and formation of
memory cells against the antigen. Adaptive immunity is
mediated by B and T lymphocytes and can be acquired
actively or passively. The neutrophil is crucial to
phagocytosis. The basophil plays an important role in the
release of inflammatory mediators. The monocyte functions
in phagocytosis and monokine production.
85. In an individual with Sjögren’s syndrome, nursing care
should focus on:
A. moisture replacement.
B. electrolyte balance.
C. nutritional supplementation.
D. arrhythmia management.
Answer: (A) moisture replacement. Sjogren’s syndrome is an
autoimmune disorder leading to progressive loss of
lubrication of the skin, GI tract, ears, nose, and
vagina. Moisture replacement is the mainstay of therapy.
Though malnutrition and electrolyte imbalance may occur as
a result of Sjogren’s syndrome’s effect on the GI tract, it isn’t
the predominant problem. Arrhythmias aren’t a problem
associated with Sjogren’s syndrome.
86. During chemotherapy for lymphocytic leukemia, Mathew
develops abdominal pain, fever, and “horse barn” smelling
diarrhea. It would be most important for the nurse to advise
the physician to order:
A. enzyme-linked immunosuppressant assay (ELISA) test.
B. electrolyte panel and hemogram.
C. stool for Clostridium difficile test.
D. flat plate X-ray of the abdomen.
Answer: (C) stool for Clostridium difficile
test. Immunosuppressed clients — for example, clients
receiving chemotherapy, — are at risk for infection with C.
difficile, which causes “horse barn” smelling diarrhea.
Successful treatment begins with an accurate diagnosis,
which includes a stool test. The ELISA test is diagnostic for
human immunodeficiency virus (HIV) and isn’t indicated
in this case. An electrolyte panel and hemogram may be
useful in the overall evaluation of a client but aren’t
diagnostic for specific causes of diarrhea. A flat plate of the
abdomen may provide useful information about
bowel function but isn’t indicated in the case of “horse barn”
smelling diarrhea
87. A male client seeks medical evaluation for fatigue, night
sweats, and a 20-lb weight loss in 6 weeks. To confirm that
the client has been infected with the human
immunodeficiency virus (HIV), the nurse expects the physician
to order:
A. E-rosette immunofluorescence.
B. quantification of T-lymphocytes.
C. enzyme-linked immunosorbent assay (ELISA).
D. Western blot test with ELISA.
Answer: (D) Western blot test with ELISA. HIV infection is
detected by analyzing blood for antibodies to HIV, which form
approximately 2 to 12 weeks after exposure to HIV
and denote infection. The Western blot test —
electrophoresis of antibody proteins — is more than 98%
accurate in detecting HIV antibodies when used in
conjunction with the ELISA. It isn’t specific when used alone.
Erosette immunofluorescence is used to detect viruses in
general; it doesn’t confirm HIV infection. Quantification of T-
lymphocytes is a useful monitoring test but isn’t diagnostic for
HIV. The ELISA test detects HIV antibody particles but may
yield inaccurate results; a positive ELISA result must be
confirmed by the Western blot test.
88. A complete blood count is commonly performed before a
Joe goes into surgery. What does this test seek to identify?
A. Potential hepatic dysfunction indicated by decreased
blood urea nitrogen (BUN) and creatinine levels
B. Low levels of urine constituents normally excreted in the
urine
C. Abnormally low hematocrit (HCT) and hemoglobin (Hb)
levels
D. Electrolyte imbalance that could affect the blood’s
ability to coagulate properly
Answer: (C) Abnormally low hematocrit (HCT) and
hemoglobin (Hb) levels. Low preoperative HCT and Hb levels
indicate the client may require a blood transfusion before
surgery. If the HCT and Hb levels decrease during surgery
because of blood loss, the potential need for a transfusion
increases. Possible renal failure is indicated by elevated
BUN or creatinine levels. Urine constituents aren’t found in
the blood. Coagulation is determined by the presence of
appropriate clotting factors, not electrolytes.
89. While monitoring a client for the development of
disseminated intravascular coagulation (DIC), the nurse
should take note of what assessment parameters?
A. Platelet count, prothrombin time, and partial
thromboplastin time
B. Platelet count, blood glucose levels, and white blood cell
(WBC) count
C. Thrombin time, calcium levels, and potassium levels
D. Fibrinogen level, WBC, and platelet count
Answer: (A) Platelet count, prothrombin time, and partial
thromboplastin time. The diagnosis of DIC is based on the
results of laboratory studies of prothrombin time, platelet
count, thrombin time, partial thromboplastin time, and
fibrinogen level as well as client history and
other assessment factors. Blood glucose levels, WBC count,
calcium levels, and potassium levels aren’t used to confirm a
diagnosis of DIC
90. When taking a dietary history from a newly admitted
female client, Nurse Len should remember that which of the
following foods is a common allergen?
A. Bread
B. Carrots
C. Orange
 D. Strawberries
Answer: (D) Strawberries. Common food allergens include
berries, peanuts, Brazil nuts, cashews, shellfish, and eggs.
Bread, carrots, and oranges rarely cause allergic reactions.
91. Nurse John is caring for clients in the outpatient clinic.
Which of the following phone calls should the nurse return
first?
A. A client with hepatitis A who states, “My arms and legs
are itching.”
B. A client with cast on the right leg who states, “I have a
funny feeling in my right leg.”
C. A client with osteomyelitis of the spine who states, “I
am so nauseous that I can’t eat.”
D. A client with rheumatoid arthritis who states, “I am
having trouble sleeping.”
Answer: (B) A client with cast on the right leg who states, “I
have a funny feeling in my right leg.” It may indicate
neurovascular compromise, requires immediate assessment
92. Nurse Sarah is caring for clients on the surgical floor and
has just received report from the previous shift. Which of the
following clients should the nurse see first?
A. A 35-year-old admitted three hours ago with a gunshot
wound; 1.5 cm area of dark drainage noted on the
dressing.
B. A 43-year-old who had a mastectomy two days ago; 23
ml of serosanguinous fluid noted in the Jackson-Pratt
drain.
C. A 59-year-old with a collapsed lung due to an accident;
no drainage noted in the previous eight hours.
D. A 62-year-old who had an abdominal-perineal resection
three days ago; client complaints of chills.
Answer: (D) A 62-year-old who had an abdominal-perineal
resection three days ago; client complaints of chills. The client
is at risk for peritonitis; should be assessed for further
symptoms and infection.
93. Nurse Eve is caring for a client who had a thyroidectomy
12 hours ago for treatment of Grave’s disease. The nurse
would be most concerned if which of the following was
observed?
A. Blood pressure 138/82, respirations 16, oral
temperature 99 degrees Fahrenheit.
B. The client supports his head and neck when turning his
head to the right.
C. The client spontaneously flexes his wrist when the
blood pressure is obtained.
D. The client is drowsy and complains of sore throat.
Answer: (C) The client spontaneously flexes his wrist when
the blood pressure is obtained. Carpal spasms indicate
hypocalcemia.
94. Julius is admitted with complaints of severe pain in the
lower right quadrant of the abdomen. To assist with pain
relief, the nurse should take which of the following actions?
A. Encourage the client to change positions frequently in
bed.
B. Administer Demerol 50 mg IM q 4 hours and PRN.
C. Apply warmth to the abdomen with a heating pad.
D. Use comfort measures and pillows to position the
client.
Answer: (D) Use comfort measures and pillows to position
the client.Using comfort measures and pillows to position
the client is a non-pharmacological methods of pain relief
95. Nurse Tina prepares a client for peritoneal dialysis. Which
of the following actions should the nurse take first?
A. Assess for a bruit and a thrill.
B. Warm the dialysate solution.
C. Position the client on the left side.
D. Insert a Foley catheter
Answer: (B) Warm the dialysate solution. Cold dialysate
increases discomfort. The solution should be warmed to body
temperature in warmer or heating pad; don’t use microwave
oven.
96. Nurse Jannah teaches an elderly client with right-sided
weakness how to use cane. Which of the following behaviors,
if demonstrated by the client to the nurse, indicates that the
teaching was effective?
A. The client holds the cane with his right hand, moves the
can forward followed by the right leg, and then moves
the left leg.
B. The client holds the cane with his right hand, moves the
cane forward followed by his left leg, and then moves
the right leg.
C. The client holds the cane with his left hand, moves the
cane forward followed by the right leg, and then
moves the left leg.
D. The client holds the cane with his left hand, moves the
cane forward followed by his left leg, and then moves
the right leg.
Answer: (C) The client holds the cane with his left hand,
moves the cane forward followed by the right leg, and then
moves the left leg. The cane acts as a support and aids in
weight bearing for the weaker right leg.
97. An elderly client is admitted to the nursing home setting.
The client is occasionally confused and her gait is often
unsteady. Which of the following actions, if taken by the
nurse, is most appropriate?
A. Ask the woman’s family to provide personal items such
as photos or mementos.
B. Select a room with a bed by the door so the woman can
look down the hall.
C. Suggest the woman eat her meals in the room with her
roommate.
D. Encourage the woman to ambulate in the halls twice a
day.
Answer: (A) Ask the woman’s family to provide personal items
such as photos or mementos.Photos and mementos provide
visual stimulation to reduce sensory deprivation.
98. Nurse Evangeline teaches an elderly client how to use a
standard aluminum walker. Which of the following behaviors,
if demonstrated by the client, indicates that the nurse’s
teaching was effective?
A. The client slowly pushes the walker forward 12 inches,
then takes small steps forward while leaning on the
walker.
B. The client lifts the walker, moves it forward 10 inches,
and then takes several small steps forward.
C. The client supports his weight on the walker while
advancing it forward, then takes small steps while
balancing on the walker.
 D. The client slides the walker 18 inches forward, then
takes small steps while holding onto the walker for
balance.
Answer: (B) The client lifts the walker, moves it forward 10
inches, and then takes several small steps forward. A walker
needs to be picked up, placed down on all legs.
99. Nurse Deric is supervising a group of elderly clients in a
residential home setting. The nurse knows that the elderly are
at greater risk of developing sensory deprivation for what
reason?
A. Increased sensitivity to the side effects of medications.
B. Decreased visual, auditory, and gustatory abilities.
C. Isolation from their families and familiar surroundings.
D. Decrease musculoskeletal function and mobility.
Answer: (C) Isolation from their families and familiar
surroundings. Gradual loss of sight, hearing, and taste
interferes with normal functioning.
100. A male client with emphysema becomes restless and
confused. What step should nurse Jasmine take next?
A. Encourage the client to perform pursed lip breathing.
B. Check the client’s temperature.
C. Assess the client’s potassium level.
D. Increase the client’s oxygen flow rate.
Answer: (A) Encourage the client to perform pursed lip
breathing. Purse lip breathing prevents the collapse of lung
unit and helps client control rate and depth of breathing.
PNLE IV for Care of
Clients with Physiologic
and Psychosocial
Alterations (Part 2)
1. Randy has undergone kidney transplant, what assessment
would prompt Nurse Katrina to suspect organ rejection?
A. Sudden weight loss
B. Polyuria
C. Hypertension
D. Shock
Answer: (C) Hypertension. Hypertension, along with fever,
and tenderness over the grafted kidney, reflects acute
rejection.
2. The immediate objective of nursing care for an overweight,
mildly hypertensive male client with ureteral colic and
hematuria is to decrease:
A. Pain
B. Weight
C. Hematuria
D. Hypertension
Answer: (A) Pain. Sharp, severe pain (renal colic) radiating
toward the genitalia and thigh is caused by uretheral
distention and smooth muscle spasm; relief form pain is the
priority.
3. Matilda, with hyperthyroidism is to receive Lugol’s iodine
solution before a subtotal thyroidectomy is performed. The
nurse is aware that this medication is given to:
A. Decrease the total basal metabolic rate.
B. Maintain the function of the parathyroid glands.
C. Block the formation of thyroxine by the thyroid gland.
D. Decrease the size and vascularity of the thyroid gland.
Answer: (D) Decrease the size and vascularity of the thyroid
gland. Lugol’s solution provides iodine, which aids in
decreasing the vascularity of the thyroid gland, which limits
the risk of hemorrhage when surgery is performed.
4. Ricardo, was diagnosed with type I diabetes. The nurse is
aware that acute hypoglycemia also can develop in the client
who is diagnosed with:
A. Liver disease
B. HypertensionX
C. Type 2 diabetes
D. Hyperthyroidism
Answer: (A) Liver Disease. The client with liver disease has a
decreased ability to metabolize carbohydrates because of a
decreased ability to form glycogen (glycogenesis) and to form
glucose from glycogen.
5. Tracy is receiving combination chemotherapy for treatment
of metastatic carcinoma. Nurse Ruby should monitor the
client for the systemic side effect of:
A. Ascites
B. Nystagmus
C. Leukopenia
D.
E.
F. Polycythemia
Answer: (C) Leukopenia. Leukopenia, a reduction in WBCs, is
a systemic effect of chemotherapy as a result of
myelosuppression
6. Norma, with recent colostomy expresses concern about the
inability to control the passage of gas. Nurse Oliver should
suggest that the client plan to:
A. Eliminate foods high in cellulose.
B. Decrease fluid intake at meal times.
C. Avoid foods that in the past caused flatus.
D. Adhere to a bland diet prior to social events.
Answer: (C) Avoid foods that in the past caused flatus. Foods
that bothered a person preoperatively will continue to do so
after a colostomy.
7. Nurse Ron begins to teach a male client how to perform
colostomy irrigations. The nurse would evaluate that the
instructions were understood when the client states, “I
should:
A. Lie on my left side while instilling the irrigating solution.”
B. Keep the irrigating container less than 18 inches above
the stoma.”
C. Instill a minimum of 1200 ml of irrigating solution to
stimulate evacuation of the bowel.”
D. Insert the irrigating catheter deeper into the stoma if
cramping occurs during the procedure.”
Answer: (B) Keep the irrigating container less than 18 inches
above the stoma.” This height permits the solution to flow
slowly with little force so that excessive peristalsis is not
immediately precipitated
8. Patrick is in the oliguric phase of acute tubular necrosis and
is experiencing fluid and electrolyte imbalances. The client is
somewhat confused and complains of nausea and muscle
weakness. As part of the prescribed therapy to correct this
electrolyte imbalance, the nurse would expect to:
A. Administer Kayexalate
B. Restrict foods high in protein
C. Increase oral intake of cheese and milk.
D. Administer large amounts of normal saline via I.V.
Answer: (A) Administer Kayexalate. Kayexalate,a potassium
exchange resin, permits sodium to be exchanged for
potassium in the intestine, reducing the serum
potassium level.
9. Mario has burn injury. After Forty48 hours, the physician
orders for Mario 2 liters of IV fluid to be administered q12 h.
The drop factor of the tubing is 10 gtt/ml. The nurse should
set the flow to provide:
A. X18 gtt/min
B. 28 gtt/min
C. 32 gtt/min
D. 36 gtt/min
Answer:(B) 28 gtt/min. This is the correct flow rate; multiply
the amount to be infused (2000 ml) by the drop factor (10)
and divide the result by the amount of time in minutes (12
hours x 60 minutes
10.Terence suffered form burn injury. Using the rule of nines,
which has the largest percent of burns?
A. Face and neck
B. Right upper arm and penis
C. Right thigh and penis
D. Upper trunk
Answer: (D) Upper trunk. The percentage designated for
each burned part of the body using the rule of nines: Head
and neck 9%; Right upper extremity 9%; Left upper extremity
9%; Anterior trunk 18%; Posterior trunk 18%; Right
lower extremity 18%; Left lower extremity 18%; Perineum
1%.
11. Herbert, a 45 year old construction engineer is brought to
the hospital unconscious after falling from a 2-story building.
When assessing the client, the nurse would be most
concerned if the assessment revealed:
A. Reactive pupils
B. A depressed fontanel
C. Bleeding from ears
D. An elevated temperature
Answer: (C) Bleeding from ears. The nurse needs to perform
a thorough assessment that could indicate alterations in
cerebral function, increased intracranial pressures, fractures
and bleeding. Bleeding from the ears occurs only with basal
skull fractures that can easily contribute to increased
intracranial pressure and brain herniation
12. Nurse Sherry is teaching male client regarding his
permanent artificial pacemaker. Which information given by
the nurse shows her knowledge deficit about the artificial
cardiac pacemaker?
A. take the pulse rate once a day, in the morning upon
awakening
B. May be allowed to use electrical appliances
C. Have regular follow up care
D. May engage in contact sports
Answer: (D) may engage in contact sports. The client should
be advised by the nurse to avoid contact sports. This will
prevent trauma to the area of the pacemaker generator.
13.The nurse is ware that the most relevant knowledge about
oxygen administration to a male client with COPD is
A. Oxygen at 1-2L/min is given to maintain the hypoxic
stimulus for breathing.
B. Hypoxia stimulates the central chemoreceptors in the
medulla that makes the client breath.
C. Oxygen is administered best using a non-rebreathing
mask
D. Blood gases are monitored using a pulse oximeter.
Answer: (A) Oxygen at 1-2L/min is given to maintain the
hypoxic stimulus for breathing. COPD causes a chronic CO2
retention that renders the medulla insensitive to the CO2
stimulation for breathing. The hypoxic state of the client then
becomes the stimulus for breathing. Giving the client oxygen
in low concentrations will maintain the client’s hypoxic drive.
14.Tonny has undergoes a left thoracotomy and a partial
pneumonectomy. Chest tubes are inserted, and one-bottle
water-seal drainage is instituted in the operating room. In the
postanesthesia care unit Tonny is placed in Fowler’s position
on either his right side or on his back. The nurse is aware that
this position:
A. Reduce incisional pain.
B. Facilitate ventilation of the left lung.
C. Equalize pressure in the pleural space.
D. Increase venous return
Answer: (B) Facilitate ventilation of the left lung. Since only a
partial pneumonectomy is done, there is a need to promote
expansion of this remaining Left lung by positioning the
client on the opposite unoperated side.
15.Kristine is scheduled for a bronchoscopy. When teaching
Kristine what to expect afterward, the nurse’s highest priority
of information would be:
A. Food and fluids will be withheld for at least 2 hours.
B. Warm saline gargles will be done q 2h.
C. Coughing and deep-breathing exercises will be done
q2h.
D. Only ice chips and cold liquids will be allowed initially.
Answer: (A) Food and fluids will be withheld for at least 2
hours. Prior to bronchoscopy, the doctors sprays the back of
the throat with anesthetic to minimize the gag reflex and
thus facilitate the insertion of the bronchoscope. Giving the
client food and drink after the procedure without checking
on the return of the gag reflex can cause the client to
aspirate. The gag reflex usually returns after two hours
16.Nurse Tristan is caring for a male client in acute renal
failure. The nurse should expect hypertonic glucose, insulin
infusions, and sodium bicarbonate to be used to treat:
A. hypernatremia.
B. hypokalemia.
C. hyperkalemia.
D. hypercalcemia.
Answer: (C) hyperkalemia. Hyperkalemia is a common
complication of acute renal failure. It’s life-threatening if
immediate action isn’t taken to reverse it.
The administration of glucose and regular insulin, with
sodium bicarbonate if necessary, can temporarily prevent
cardiac arrest by moving potassium into the cells and
temporarily reducing serum potassium
levels. Hypernatremia, hypokalemia, and hypercalcemia
 don’t usually occur with acute renal failure and aren’t
treated with glucose, insulin, or sodium bicarbonate
17.Ms. X has just been diagnosed with condylomata
acuminata (genital warts). What information is appropriate to
tell this client?
A. This condition puts her at a higher risk for cervical
cancer; therefore, she should have a Papanicolaou
(Pap) smear annually.
B. The most common treatment is metronidazole (Flagyl),
which should eradicate the problem within 7 to 10 days.
C. The potential for transmission to her sexual partner will
be eliminated if condoms are used every time they have
sexual intercourse.
D. The human papillomavirus (HPV), which causes
condylomata acuminata, can’t be transmitted during
oral sex.
Answer: (A) This condition puts her at a higher risk for
cervical cancer; therefore, she should have a Papanicolaou
(Pap) smear annually. Women with condylomata acuminata
are at risk for cancer of the cervix and vulva. Yearly Pap
smears are very important for early detection. Because
condylomata acuminata is a virus, there is no permanent
cure. Because condylomata acuminata can occur on the
vulva, a condom won’t protect sexual partners. HPV can be
transmitted to other parts of the body, such as the mouth,
oropharynx, and larynx.
18.Maritess was recently diagnosed with a genitourinary
problem and is being examined in the emergency
department. When palpating the her kidneys, the nurse
should keep which anatomical fact in mind?
A. The left kidney usually is slightly higher than the right
one.
B. The kidneys are situated just above the adrenal glands.
C. The average kidney is approximately 5 cm (2″) long and
2 to 3 cm (¾” to 1-1/8″) wide.
D. The kidneys lie between the 10th and 12th thoracic
vertebrae.
Answer: (A) The left kidney usually is slightly higher than the
right one. The left kidney usually is slightly higher than the
right one. An adrenal gland lies atop each kidney. The average
kidney measures approximately 11 cm (4-3/8″) long, 5 to 5.8
cm (2″ to 2¼”) wide, and 2.5 cm (1″) thick. The kidneys are
located retroperitoneally, in the posterior aspect of the
abdomen, on either side of the vertebral column. They
lie between the 12th thoracic and 3rd lumbar vertebrae.
19.Jestoni with chronic renal failure (CRF) is admitted to the
urology unit. The nurse is aware that the diagnostic test are
consistent with CRF if the result is:
A. Increased pH with decreased hydrogen ions.
B. Increased serum levels of potassium, magnesium, and
calcium.
C. Blood urea nitrogen (BUN) 100 mg/dl and serum
creatinine 6.5 mg/ dl.
D. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein
(PSP) excretion 75%.
Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and serum
creatinine 6.5 mg/dl. The normal BUN level ranges 8 to 23
mg/dl; the normal serum creatinine level ranges from 0.7 to
1.5 mg/dl. The test results in option C are abnormally
elevated, reflecting CRF and the kidneys’ decreased ability to
remove nonprotein nitrogen waste from the blood. CRF
causes decreased pH and increased hydrogen ions — not vice
versa. CRF also increases serum levels of potassium,
magnesium, and phosphorous, and decreases serum levels of
calcium. A uric acid analysis of 3.5 mg/dl falls within the
normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75%
also falls with the normal range of 60% to 75%.
20. Katrina has an abnormal result on a Papanicolaou test.
After admitting that she read her chart while the nurse was
out of the room, Katrina asks what dysplasia means. Which
definition should the nurse provide?
A. Presence of completely undifferentiated tumor cells that
don’t resemble cells of the tissues of their origin.
B. Increase in the number of normal cells in a normal
arrangement in a tissue or an organ.
C. Replacement of one type of fully differentiated cell by
another in tissues where the second type normally isn’t
found.
D. Alteration in the size, shape, and organization of
differentiated cells.
Answer: (D) Alteration in the size, shape, and organization
of differentiated cells. Dysplasia refers to an alteration in the
size, shape, and organization of differentiated cells. The
presence of completely undifferentiated tumor cells that
don’t resemble cells of the tissues of their origin is called
anaplasia. An increase in the number of normal cells in
a normal arrangement in a tissue or an organ is called
hyperplasia. Replacement of one type of fully differentiated
cell by another in tissues where the second type normally
isn’t found is called metaplasia.
21. During a routine checkup, Nurse Mariane assesses a male
client with acquired immunodeficiency syndrome (AIDS) for
signs and symptoms of cancer. What is the most common
AIDS-related cancer?
A. Squamous cell carcinoma
B. Multiple myeloma
C. Leukemia
D. Kaposi’s sarcoma
Answer: (D) Kaposi’s sarcoma. Kaposi’s sarcoma is the most
common cancer associated with AIDS. Squamous cell
carcinoma, multiple myeloma, and leukemia may occur in
anyone and aren’t associated specifically with AIDS.
22.Ricardo is scheduled for a prostatectomy, and the
anesthesiologist plans to use a spinal (subarachnoid) block
during surgery. In the operating room, the nurse positions the
client according to the anesthesiologist’s instructions. Why
does the client require special positioning for this type of
anesthesia?
A. To prevent confusion
B. To prevent seizures
C. To prevent cerebrospinal fluid (CSF) leakage
D. To prevent cardiac arrhythmias
Answer: (C) To prevent cerebrospinal fluid (CSF) leakage. The
client receiving a subarachnoid block requires
special positioning to prevent CSF leakage and headache and
to ensure proper anesthetic distribution. Proper positioning
doesn’t help prevent confusion, seizures, or cardiac
arrhythmias.
23.A male client had a nephrectomy 2 days ago and is now
complaining of abdominal pressure and nausea. The first
nursing action should be to:
A. Auscultate bowel sounds.
B. Palpate the abdomen.
C. Change the client’s position.
D. Insert a rectal tube.
Answer: (A) Auscultate bowel sounds. If abdominal distention
is accompanied by nausea, the nurse must first auscultate
bowel sounds. If bowel sounds are absent, the nurse should
suspect gastric or small intestine dilation and these findings
must be reported to the physician. Palpation should be
avoided postoperatively with abdominal distention. If
peristalsis is absent, changing positions and inserting a rectal
tube won’t relieve the client’s discomfort.
24.Wilfredo with a recent history of rectal bleeding is being
prepared for a colonoscopy. How should the nurse Patricia
position the client for this test initially?
A. Lying on the right side with legs straight
B. Lying on the left side with knees bent
C. Prone with the torso elevated
D. Bent over with hands touching the floor
Answer: (B) Lying on the left side with knees bent. For a
colonoscopy, the nurse initially should position the client on
the left side with knees bent. Placing the client on the right
side with legs straight, prone with the torso elevated, or bent
over with hands touching the floor wouldn’t allow proper
visualization of the large intestine.
25.A male client with inflammatory bowel disease undergoes
an ileostomy. On the first day after surgery, Nurse Oliver notes
that the client’s stoma appears dusky. How should the nurse
interpret this finding?
A. Blood supply to the stoma has been interrupted.
B. This is a normal finding 1 day after surgery.
C. The ostomy bag should be adjusted.
D. An intestinal obstruction has occurred.
Answer: (A) Blood supply to the stoma has been
interrupted. An ileostomy stoma forms as the ileum is
brought through the abdominal wall to the surface skin,
creating an artificial opening for waste elimination. The stoma
should appear cherry red, indicating adequate arterial
perfusion. A dusky stoma suggests decreased perfusion,
which may result from interruption of the stoma’s blood
supply and may lead to tissue damage or necrosis. A dusky
stoma isn’t a normal finding. Adjusting the ostomy bag
wouldn’t affect stoma color, which depends on blood supply
to the area. An intestinal obstruction also wouldn’t change
stoma color.
26.Anthony suffers burns on the legs, which nursing
intervention helps prevent contractures?
A. Applying knee splints
B. Elevating the foot of the bed
C. Hyperextending the client’s palms
D. Performing shoulder range-of-motion exercises
Answer: (A) Applying knee splints. Applying knee splints
prevents leg contractures by holding the joints in a position of
function. Elevating the foot of the bed can’t
prevent contractures because this action doesn’t hold the
joints in a position of function. Hyperextending a body part
for an extended time is inappropriate because it can cause
contractures. Performing shoulder range-of-motion exercises
can prevent contractures in the shoulders, but not in the legs.
27.Nurse Ron is assessing a client admitted with second- and
third-degree burns on the face, arms, and chest. Which
finding indicates a potential problem?
A. Partial pressure of arterial oxygen (PaO2) value of 80
mm Hg.
B. Urine output of 20 ml/hour.
C. White pulmonary secretions.
D. Rectal temperature of 100.6° F (38° C).
Answer: (B) Urine output of 20 ml/hour. A urine output of less
than 40 ml/hour in a client with burns indicates a fluid volume
deficit. This client’s PaO2 value falls within the normal range
(80 to 100 mm Hg). White pulmonary secretions also
are normal. The client’s rectal temperature isn’t significantly
elevated and probably results from the fluid volume deficit.
28. Mr. Mendoza who has suffered a cerebrovascular accident
(CVA) is too weak to move on his own. To help the client avoid
pressure ulcers, Nurse Celia should:
A. Turn him frequently.
B. Perform passive range-of-motion (ROM) exercises.
C. Reduce the client’s fluid intake.
D. Encourage the client to use a footboard.
Answer: (A) Turn him frequently. The most important
intervention to prevent pressure ulcers is frequent position
changes, which relieve pressure on the skin and underlying
tissues. If pressure isn’t relieved, capillaries become
occluded, reducing circulation and oxygenation of the tissues
and resulting in cell death and ulcer formation. During passive
ROM exercises, the nurse moves each joint through its range
of movement, which improves joint mobility and circulation
to the affected area but doesn’t prevent pressure ulcers.
Adequate hydration is necessary to maintain healthy skin
and ensure tissue repair. A footboard prevents plantar flexion
and footdrop by maintaining the foot in a dorsiflexed position.
29.Nurse Maria plans to administer dexamethasone cream to
a female client who has dermatitis over the anterior chest.
How should the nurse apply this topical agent?
A. With a circular motion, to enhance absorption.
B. With an upward motion, to increase blood supply to the
affected area
C. In long, even, outward, and downward strokes in the
direction of hair growth
D. In long, even, outward, and upward strokes in the
direction opposite hair growth
Answer: (C) In long, even, outward, and downward strokes in
the direction of hair growth. When applying a topical agent,
the nurse should begin at the midline and use long, even,
outward, and downward strokes in the direction of hair
growth. This application pattern reduces the risk of
follicle irritation and skin inflammation.
30.Nurse Kate is aware that one of the following classes of
medication protect the ischemic myocardium by blocking
catecholamines and sympathetic nerve stimulation is:
A. Beta -adrenergic blockers
B. Calcium channel blocker
C. Narcotics
D. Nitrates
Answer: (A) Beta -adrenergic blockers. Beta-adrenergic
blockers work by blocking beta receptors in the myocardium,
reducing the response to catecholamines and sympathetic
nerve stimulation. They protect the myocardium, helping
to reduce the risk of another infraction by decreasing
myocardial oxygen demand. Calcium channel blockers reduce
the workload of the heart by decreasing the heart rate.
Narcotics reduce myocardial oxygen demand, promote
vasodilation, and decrease anxiety. Nitrates reduce
myocardial oxygen consumption bt decreasing left ventricular
end diastolic pressure (preload) and systemic vascular
resistance (afterload).
31.A male client has jugular distention. On what position
should the nurse place the head of the bed to obtain the most
accurate reading of jugular vein distention?
A. High Fowler’s
B. Raised 10 degrees
C. Raised 30 degrees
D. Supine position
Answer: (C) Raised 30 degrees. Jugular venous pressure is
measured with a centimeter ruler to obtain the vertical
distance between the sternal angle and the point of highest
pulsation with the head of the bed inclined between 15 to
30 degrees. Increased pressure can’t be seen when the client
is supine or when the head of the bed is raised 10 degrees
because the point that marks the pressure level is above the
jaw (therefore, not visible). In high Fowler’s position, the
veins would be barely discernible above the clavicle.
32.The nurse is aware that one of the following classes of
medications maximizes cardiac performance in clients with
heart failure by increasing ventricular contractility?
A. Beta-adrenergic blockers
B. Calcium channel blocker
C. Diuretics
D. Inotropic agents
Answer: (D) Inotropic agents. Inotropic agents are
administered to increase the force of the heart’s contractions,
thereby increasing ventricular contractility and ultimately
increasing cardiac output. Beta-adrenergic blockers and
calcium channel blockers decrease the heart rate and
ultimately decreased the workload of the heart. Diuretics are
administered to decrease the overall vascular volume, also
decreasing the workload of the heart.
33.A male client has a reduced serum high-density lipoprotein
(HDL) level and an elevated low-density lipoprotein (LDL)
level. Which of the following dietary modifications is not
appropriate for this client?
A. Fiber intake of 25 to 30 g daily
B. Less than 30% of calories form fat
C. Cholesterol intake of less than 300 mg daily
D. Less than 10% of calories from saturated fat
Answer: (B) Less than 30% of calories form fat. A client with
low serum HDL and high serum LDL levels should get less than
30% of daily calories from fat. The other modifications
are appropriate for this client.
34. A 37-year-old male client was admitted to the coronary
care unit (CCU) 2 days ago with an acute myocardial
infarction. Which of the following actions would breach the
client confidentiality?
A. The CCU nurse gives a verbal report to the nurse on the
telemetry unit before transferring the client to that unit
B. The CCU nurse notifies the on-call physician about a
change in the client’s condition
C. The emergency department nurse calls up the latest
electrocardiogram results to check the client’s
progress.
D. At the client’s request, the CCU nurse updates the
client’s wife on his condition
Answer: (C) The emergency department nurse calls up the
latest electrocardiogram results to check the client’s
progress. The emergency department nurse is no longer
directly involved with the client’s care and thus has no legal
right to information about his present condition. Anyone
directly involved in his care (such as the telemetry nurse and
the on-call physician) has the right to information about his
condition. Because the client requested that the nurse
update his wife on his condition, doing so doesn’t breach
confidentiality
35. A male client arriving in the emergency department is
receiving cardiopulmonary resuscitation from paramedics
who are giving ventilations through an endotracheal (ET) tube
that they placed in the client’s home. During a pause in
compressions, the cardiac monitor shows narrow QRS
complexes and a heart rate of beats/minute with a palpable
pulse. Which of the following actions
should the nurse take first?
A. Start an L.V. line and administer amiodarone
(Cardarone), 300 mg L.V. over 10 minutes.
B. Check endotracheal tube placement.
C. Obtain an arterial blood gas (ABG) sample.
D. Administer atropine, 1 mg L.V.
Answer: (B) Check endotracheal tube placement. ET tube
placement should be confirmed as soon as the client arrives
in the emergency department. Once the airways is
secured, oxygenation and ventilation should be confirmed
using an end-tidal carbon dioxide monitor and pulse oximetry.
Next, the nurse should make sure L.V. access is established. If
the client experiences symptomatic bradycardia, atropine is
administered as ordered 0.5 to 1 mg every 3 to 5 minutes to a
total of 3 mg. Then the nurse should try to find the cause
of the client’s arrest by obtaining an ABG sample. Amiodarone
is indicated for ventricular tachycardia, ventricular fibrillation
and atrial flutter – not symptomatic bradycardia.
36. After cardiac surgery, a client’s blood pressure measures
126/80 mm Hg. Nurse Katrina determines that mean arterial
pressure (MAP) is which of the following?
A. 46 mm Hg
B. 80 mm Hg
C. 95 mm Hg
D. 90 mm Hg
Answer: (C) 95 mm Hg. Use the following formula to calculate
MAP
 MAP = systolic + 2 (diastolic) /3
 MAP=[126 mm Hg + 2 (80 mm Hg) ]/3
 MAP=286 mm HG/ 3
 MAP=95 mm Hg
37. A female client arrives at the emergency department with
chest and stomach pain and a report of black tarry stool for
several months. Which of the following order should the
nurse Oliver anticipate?
A. Cardiac monitor, oxygen, creatine kinase and lactate
dehydrogenase levels
B. Prothrombin time, partial thromboplastin time,
fibrinogen and fibrin split product values.
C. Electrocardiogram, complete blood count, testing for
occult blood, comprehensive serum metabolic panel.
D. Electroencephalogram, alkaline phosphatase and
aspartate aminotransferase levels, basic serum
metabolic panel
Answer: (C) Electrocardiogram, complete blood count, testing
for occult blood, comprehensive serum metabolic panel. An
electrocardiogram evaluates the complaints of chest
pain, laboratory tests determines anemia, and the stool test
for occult blood determines blood in the stool. Cardiac
monitoring, oxygen, and creatine kinase and lactate
dehydrogenase levels are appropriate for a cardiac primary
problem. A basic metabolic panel and alkaline phosphatase
and aspartate aminotransferase levels assess liver function.
Prothrombin time, partial thromboplastin time, fibrinogen
and fibrin split products are measured to verify bleeding
dyscrasias, An electroencephalogram evaluates brain
electrical activity.
38. Macario had coronary artery bypass graft (CABG) surgery
3 days ago. Which of the following conditions is suspected by
the nurse when a decrease in platelet count from 230,000 ul
to 5,000 ul is noted?
A. Pancytopenia
B. Idiopathic thrombocytopemic purpura (ITP)
C. Disseminated intravascular coagulation (DIC)
D. Heparin-associated thrombosis and thrombocytopenia
(HATT)
Answer: (D) Heparin-associated thrombosis and
thrombocytopenia (HATT). HATT may occur after CABG
surgery due to heparin use during surgery. Although DIC and
ITP cause platelet aggregation and bleeding, neither is
common in a client after revascularization
surgery. Pancytopenia is a reduction in all blood cells.
39. Which of the following drugs would be ordered by the
physician to improve the platelet count in a male client with
idiopathic thrombocytopenic purpura (ITP)?
A. Acetylsalicylic acid (ASA)
B. Corticosteroids
C. Methotrezate
D. Vitamin K
Answer: (B) Corticosteroids. Corticosteroid therapy can
decrease antibody production and phagocytosis of the
antibody-coated platelets, retaining more
functioning platelets. Methotrexate can cause
thrombocytopenia. Vitamin K is used to treat an excessive
anticoagulate state from warfarin overload, and
ASA decreases platelet aggregation.
40. A female client is scheduled to receive a heart valve
replacement with a porcine valve. Which of the following
types of transplant is this?
A. Allogeneic
B. Autologous
C. Syngeneic
D. Xenogeneic
Answer: (D) Xenogeneic. An xenogeneic transplant is between
is between human and another species. A syngeneic
transplant is between identical twins, allogeneic transplant is
between two humans, and autologous is a transplant from
the same individual.
41. Marco falls off his bicycle and injuries his ankle. Which of
the following actions shows the initial response to the injury
in the extrinsic pathway?
A. Release of Calcium
B. Release of tissue thromboplastin
C. Conversion of factors XII to factor XIIa
D. Conversion of factor VIII to factor VIIIa
Answer: (B). Tissue thromboplastin is released when
damaged tissue comes in contact with clotting factors.
Calcium is released to assist the conversion of factors X to
Xa. Conversion of factors XII to XIIa and VIII to VIII a are part
of the intrinsic pathway
42. Instructions for a client with systemic lupus
erythematosus (SLE) would include information about which
of the following blood dyscrasias?
A. Dressler’s syndrome
B. Polycythemia
C. Essential thrombocytopenia
D. Von Willebrand’s disease
Answer: (C) Essential thrombocytopenia. Essential
thrombocytopenia is linked to immunologic disorders, such as
SLE and human immunodeficiency vitus. The disorder known
as von Willebrand’s disease is a type of hemophilia and isn’t
linked to SLE. Moderate to severe anemia is associated with
SLE, not polycythermia. Dressler’s syndrome is pericarditis
that occurs after a myocardial infarction and isn’t linked to
SLE.
43. The nurse is aware that the following symptoms is most
commonly an early indication of stage 1 Hodgkin’s disease?
A. Pericarditis
B. Night sweat
C. Splenomegaly
D. Persistent hypothermia
Answer: (B) Night sweat. In stage 1, symptoms include a single
enlarged lymph node (usually), unexplained fever, night
sweats, malaise, and generalized pruritis. Although
splenomegaly may be present in some clients, night sweats
are generally more prevalent. Pericarditis isn’t associated
with Hodgkin’s disease, nor is hypothermia. Moreover,
splenomegaly and pericarditis aren’t symptoms. Persistent
hypothermia is associated with Hodgkin’s but isn’t an early
sign of the disease.
44. Francis with leukemia has neutropenia. Which of the
following functions must frequently assessed?
A. Blood pressure
B. Bowel sounds
C. Heart sounds
D. Breath sounds
Answer: (D) Breath sounds. Pneumonia, both viral and
fungal, is a common cause of death in clients with
neutropenia, so frequent assessment of respiratory rate
and breath sounds is required. Although assessing blood
pressure, bowel sounds, and heart sounds is important, it
won’t help detect pneumonia
45. The nurse knows that neurologic complications of
multiple myeloma (MM) usually involve which of the
following body system?
A. Brain
B. Muscle spasm
C. Renal dysfunction
D. Myocardial irritability
Answer: (B) Muscle spasm. Back pain or paresthesia in the
lower extremities may indicate impending spinal cord
compression from a spinal tumor. This should be recognized
and treated promptly as progression of the tumor may result
in paraplegia. The other options, which reflect parts of the
nervous system, aren’t usually affected by MM.
46. Nurse Patricia is aware that the average length of time
from human immunodeficiency virus (HIV) infection to the
development of acquired immunodeficiency syndrome
(AIDS)?
A. Less than 5 years
B. 5 to 7 years
C. 10 years
D. More than 10 years
Answer: (C)10 years. Epidermiologic studies show the
average time from initial contact with HIV to the
development of AIDS is 10 years

47. An 18-year-old male client admitted with heat stroke
begins to show signs of disseminated intravascular
coagulation (DIC). Which of the following laboratory findings
is most consistent with DIC?
A. Low platelet count
B. Elevated fibrinogen levels
C. Low levels of fibrin degradation products
D. Reduced prothrombin time
Answer: (A) Low platelet count. In DIC, platelets and clotting
factors are consumed, resulting in microthrombi and
excessive bleeding. As clots form, fibrinogen levels decrease
and the prothrombin time increases. Fibrin
degeneration products increase as fibrinolysis takes places.
48. Mario comes to the clinic complaining of fever, drenching
night sweats, and unexplained weight loss over the past 3
months. Physical examination reveals a single enlarged
supraclavicular lymph node. Which of the following is the
most probable diagnosis?
A. Influenza
B. Sickle cell anemia
C. Leukemia
D. Hodgkin’s disease
Answer: (D) Hodgkin’s disease. Hodgkin’s disease typically
causes fever night sweats, weight loss, and lymph mode
enlargement. Influenza doesn’t last for months. Clients with
sickle cell anemia manifest signs and symptoms of
chronic anemia with pallor of the mucous membrane,
fatigue, and decreased tolerance for exercise; they don’t
show fever, night sweats, weight loss or lymph node
enlargement. Leukemia doesn’t cause lymph
node enlargement
49. A male client with a gunshot wound requires an
emergency blood transfusion. His blood type is AB negative.
Which blood type would be the safest for him to receive?
A. AB Rh-Xpositive
B. A Rh-positive
C. A Rh-negative
D. O Rh-positive
Answer: (C) A Rh-negative. Human blood can sometimes
contain an inherited D antigen. Persons with the D antigen
have Rh-positive blood type; those lacking the antigen have
Rh-negative blood. It’s important that a person with
Rhnegative blood receives Rh-negative blood. If Rh-positive
blood is administered to an Rh-negative person, the
recipient develops anti-Rh agglutinins, and sub sequent
transfusions with Rh-positive blood may cause serious
reactions with clumping and hemolysis of red blood cells
Situation: Stacy is diagnosed with acute lymphoid leukemia
(ALL) and beginning chemotherapy.
50. Stacy is discharged from the hospital following her
chemotherapy treatments. Which statement of Stacy’s
mother indicated that she understands when she will contact
the physician?
A. “I should contact the physician if Stacy has difficulty in
sleeping”.
B. “I will call my doctor if Stacy has persistent vomiting
and diarrhea”.
C. “My physician should be called if Stacy is irritable and
unhappy”.
D. “Should Stacy have continued hair loss, I need to call the
doctor”.
Answer: (B) “I will call my doctor if Stacy has persistent
vomiting and diarrhea”. Persistent (more than 24 hours)
vomiting, anorexia, and diarrhea are signs of toxicity and the
patient should stop the medication and notify the health
care provider. The other manifestations are expected side
effects of chemotherapy
51. Stacy’s mother states to the nurse that it is hard to see
Stacy with no hair. The best response for the nurse is:
A. “Stacy looks very nice wearing a hat”.
B. “You should not worry about her hair, just be glad that
she is alive”.
C. “Yes it is upsetting. But try to cover up your feelings
when you are with her or else she may be upset”.
D. “This is only temporary; Stacy will re-grow new hair in
3-6 months, but may be different in texture”.
Answer: (D) “This is only temporary; Stacy will re-grow new
hair in 3-6 months, but may be different in texture”. This is the
appropriate response. The nurse should help the mother how
to cope with her own feelings regarding the child’s disease
so as not to affect the child negatively. When the hair grows
back, it is still of the same color and texture.
52. Stacy has beginning stomatitis. To promote oral hygiene
and comfort, the nurse in-charge should:
A. Provide frequent mouthwash with normal saline.
B. Apply viscous Lidocaine to oral ulcers as needed.
C. Use lemon glycerine swabs every 2 hours.
D. Rinse mouth with Hydrogen Peroxide.
Answer: (B) Apply viscous Lidocaine to oral ulcers as
needed. Stomatitis can cause pain and this can be relieved by
applying topical anesthetics such as lidocaine before mouth
care. When the patient is already comfortable, the nurse can
proceed with providing the patient with oral rinses of saline
solution mixed with equal part of water or hydrogen peroxide
mixed water in 1:3 concentrations to promote oral hygiene.
Every 2-4 hours.
53. During the administration of chemotherapy agents, Nurse
Oliver observed that the IV site is red and swollen, when the
IV is touched Stacy shouts in pain. The first nursing action to
take is:
A. Notify the physician
B. Flush the IV line with saline solution
C. Immediately discontinue the infusion
D. Apply an ice pack to the site, followed by warm
compress.
Answer: (C) Immediately discontinue the infusion. Edema or
swelling at the IV site is a sign that the needle has been
dislodged and the IV solution is leaking into the tissues
causing the edema. The patient feels pain as the nerves are
irritated by pressure and the IV solution. The first action of
the nurse would be to discontinue the infusion right away to
prevent further edema and other complication
54. The term “blue bloater” refers to a male client which of
the following conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Asthma
C. Chronic obstructive bronchitis
D. Emphysema
Answer: (C) Chronic obstructive bronchitis. Clients with
chronic obstructive bronchitis appear bloated; they have large
barrel chest and peripheral edema, cyanotic nail beds, and
at times, circumoral cyanosis. Clients with ARDS are acutely
short of breath and frequently need intubation for
mechanical ventilation and large amount of oxygen. Clients
with asthma don’t exhibit characteristics of chronic disease,
and clients with emphysema appear pink and cachectic.
55. The term “pink puffer” refers to the female client with
which of the following conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Asthma
C. Chronic obstructive bronchitis
D. Emphysema
Answer: (D) Emphysema. Because of the large amount of
energy it takes to breathe, clients with emphysema are
usually cachectic. They’re pink and usually breathe through
pursed lips, hence the term “puffer.” Clients with ARDS are
usually acutely short of breath. Clients with asthma don’t
have any particular characteristics, and clients with chronic
obstructive bronchitis are bloated and cyanotic in
appearance.
56. Jose is in danger of respiratory arrest following the
administration of a narcotic analgesic. An arterial blood gas
value is obtained. Nurse Oliver would expect the paco2 to be
which of the following values?
A. 15 mm Hg
B. 30 mm Hg
C. 40 mm Hg
D. 80 mm Hg
Answer: D 80 mm Hg. A client about to go into respiratory
arrest will have inefficient ventilation and will be retaining
carbon dioxide. The value expected would be around 80 mm
Hg. All other values are lower than expected.
57. Timothy’s arterial blood gas (ABG) results are as follows;
pH 7.16; Paco2 80 mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L;
Sao2 81%. This ABG result represents which of the following
conditions?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respirator y alkalosis
Answer: (C) Respiratory acidosis. Because Paco2 is high at 80
mm Hg and the metabolic measure, HCO3- is normal, the
client has respiratory acidosis. The pH is less than 7.35,
academic, which eliminates metabolic and
respiratory alkalosis as possibilities. If the HCO3- was below
22 mEq/L the client would have metabolic acidosis.
58. Norma has started a new drug for hypertension. Thirty
minutes after she takes the drug, she develops chest tightness
and becomes short of breath and tachypneic. She has a
decreased level of consciousness. These signs indicate which
of the following conditions?
A. Asthma attack
B. Pulmonary embolism
C. Respiratory failure
D. Rheumatoid arthritis
Answer: (C) Respiratory failure. The client was reacting to the
drug with respiratory signs of impending anaphylaxis, which
could lead to eventually respiratory failure. Although the signs
are also related to an asthma attack or a
pulmonary embolism, consider the new drug first.
Rheumatoid arthritis doesn’t manifest these signs.
Situation: Mr. Gonzales was admitted to the hospital with
ascites and jaundice. To rule out cirrhosis of the liver:
59. Which laboratory test indicates liver cirrhosis?
A. Decreased red blood cell count
B. Decreased serum acid phosphate level
C. Elevated white blood cell count
D. Elevated serum aminotransferase
Answer: (D) Elevated serum aminotransferase. Hepatic cell
death causes release of liver enzymes
alanine aminotransferase (ALT), aspartate aminotransferase
(AST) and lactate dehydrogenase (LDH) into the circulation.
Liver cirrhosis is a chronic and irreversible disease of the liver
characterized by generalized inflammation and fibrosis of the
liver tissues.
60.The biopsy of Mr. Gonzales confirms the diagnosis of
cirrhosis. Mr. Gonzales is at increased risk for excessive
bleeding primarily because of:
A. Impaired clotting mechanism
B. Varix formation
C. Inadequate nutrition
D. Trauma of invasive procedure
Answer: (A) Impaired clotting mechanism. Cirrhosis of the
liver results in decreased Vitamin K absorption and formation
of clotting factors resulting in impaired clotting mechanism.
61. Mr. Gonzales develops hepatic encephalopathy. Which
clinical manifestation is most common with this condition?
A. Increased urine output
B. Altered level of consciousness
C. Decreased tendon reflex
D. Hypotension
Answer: (B) Altered level of consciousness. Changes in
behavior and level of consciousness are the first sins of
hepatic encephalopathy. Hepatic encephalopathy is caused by
liver failure and develops when the liver is unable to convert
protein metabolic product ammonia to urea. This results in
accumulation of ammonia and other toxic in the blood that
damages the cells.
62. When Mr. Gonzales regained consciousness, the physician
orders 50 ml of Lactose p.o. every 2 hours. Mr. Gozales
develops diarrhea. The nurse best action would be:
A. “I’ll see if your physician is in the hospital”.
B. “Maybe your reacting to the drug; I will withhold the
next dose”.
C. “I’ll lower the dosage as ordered so the drug causes
only 2 to 4 stools a day”.
D. “Frequently, bowel movements are needed to reduce
sodium level”.
Answer: (C) “I’ll lower the dosage as ordered so the drug
causes only 2 to 4 stools a day”. Lactulose is given to a
patients with hepatic encephalopathy to reduce absorption of
ammonia in the intestines by binding with ammonia and
promoting more frequent bowel movements. If the patient
experience diarrhea, it indicates over dosage and the nurse
must reduce the amount of medication given to the patient.
The stool will be mashy or soft. Lactulose is also very sweet
and may cause cramping and bloating.
63. Which of the following groups of symptoms indicates a
ruptured abdominal aortic aneurysm?
A. Lower back pain, increased blood pressure, decreased
re blood cell (RBC) count, increased white blood (WBC)
count.
B. Severe lower back pain, decreased blood pressure,
decreased RBC count, increased WBC count.
C. Severe lower back pain, decreased blood pressure,
decreased RBC count, decreased RBC count, decreased
WBC count.
 D. Intermitted lower back pain, decreased blood pressure,
decreased RBC count, increased WBC count.
Answer: (B) Severe lower back pain, decreased blood
pressure, decreased RBC count, increased WBC count.Severe
lower back pain indicates an aneurysm rupture, secondary to
pressure being applied within the abdominal cavity.
When ruptured occurs, the pain is constant because it can’t
be alleviated until the aneurysm is repaired. Blood pressure
decreases due to the loss of blood. After the aneurysm
ruptures, the vasculature is interrupted and blood volume is
lost, so blood pressure wouldn’t increase. For the
same reason, the RBC count is decreased – not increased. The
WBC count increases as cell migrate to the site of injury.
64. After undergoing a cardiac catheterization, Tracy has a
large puddle of blood under his buttocks. Which of the
following steps should the nurse take first?
A. Call for help.
B. Obtain vital signs
C. Ask the client to “lift up”
D. Apply gloves and assess the groin site
Answer: (D) Apply gloves and assess the groin site. Observing
standard precautions is the first priority when dealing with
any blood fluid. Assessment of the groin site is the
second priority. This establishes where the blood is coming
from and determineshow much blood has been lost. The goal
in this situation is to stop the bleeding. The nurse would call
for help if it were warranted after the assessment of the
situation. After determining the extent of the bleeding, vital
signs assessment is important. The nurse should never move
the client, in case a clot has formed. Moving can disturb the
clot and cause rebleeding.
65. Which of the following treatment is a suitable surgical
intervention for a client with unstable angina?
A. Cardiac catheterization
B. Echocardiogram
C. Nitroglycerin
D. Percutaneous transluminal coronary angioplasty
(PTCA)
Answer: (D) Percutaneous transluminal coronary angioplasty
(PTCA). PTCA can alleviate the blockage and restore blood
flow and oxygenation. An echocardiogram is a noninvasive
diagnosis test. Nitroglycerin is an oral sublingual medication.
Cardiac catheterization is a diagnostic tool – not a treatment
66. The nurse is aware that the following terms used to
describe reduced cardiac output and perfusion impairment
due to ineffective pumping of the heart is:
A. Anaphylactic shock
B. Cardiogenic shock
C. Distributive shock
D. Myocardial infarction (MI)
Answer: (B) Cardiogenic shock. Cardiogenic shock is shock
related to ineffective pumping of the heart. Anaphylactic
shock results from an allergic reaction. Distributive shock
results from changes in the intravascular volume distribution
and is usually associated with increased cardiac output. MI
isn’t a shock state, though a severe MI can lead to shock.
67. A client with hypertension ask the nurse which factors can
cause blood pressure to drop to normal levels?
A. Kidneys’ excretion to sodium only.
B. Kidneys’ retention of sodium and water
C. Kidneys’ excretion of sodium and water
D. Kidneys’ retention of sodium and excretion of water
Answer: (C) Kidneys’ excretion of sodium and water. The
kidneys respond to rise in blood pressure by excreting sodium
and excess water. This response ultimately affects sysmolic
blood pressure by regulating blood volume. Sodium or water
retention would only further increase blood pressure. Sodium
and water travel together across the membrane in the
kidneys; one can’t travel without the other.
68. Nurse Rose is aware that the statement that best explains
why furosemide (Lasix) is administered to treat hypertension
is:
A. It dilates peripheral blood vessels.
B. It decreases sympathetic cardioacceleration.
C. It inhibits the angiotensin-coverting enzymes
D. It inhibits reabsorption of sodium and water in the
loop of Henle
Answer: (D) It inhibits reabsorption of sodium and water in
the loop of Henle. Furosemide is a loop diuretic that inhibits
sodium and water reabsorption in the loop Henle, thereby
causing a decrease in blood pressure. Vasodilators cause
dilation of peripheral blood vessels, directly relaxing vascular
smooth muscle and decreasing blood pressure. Adrenergic
blockers decrease sympathetic cardioacceleration
and decrease blood pressure. Angiotensin-converting enzyme
inhibitors decrease blood pressure due to their action on
angiotensin.
.
69. Nurse Nikki knows that laboratory results supports the
diagnosis of systemic lupus erythematosus (SLE) is:
A. Elavated serum complement level
B. Thrombocytosis, elevated sedimentation rate
C. Pancytopenia, elevated antinuclear antibody (ANA)
titer
D. Leukocysis, elevated blood urea nitrogen (BUN) and
creatinine levels
Answer: (C) Pancytopenia, elevated antinuclear antibody
(ANA) titer. Laboratory findings for clients with SLE usually
show pancytopenia, elevated ANA titer, and decreased
serum complement levels. Clients may have elevated BUN
and creatinine levels from nephritis, but the increase does
not indicate SLE
70. Arnold, a 19-year-old client with a mild concussion is
discharged from the emergency department. Before
discharge, he complains of a headache. When offered
acetaminophen, his mother tells the nurse the headache is
severe and she would like her son to have something stronger.
Which of the following responses by the nurse is appropriate?
A. “Your son had a mild concussion, acetaminophen is
strong enough.”
B. “Aspirin is avoided because of the danger of Reye’s
syndrome in children or young adults.”
C. “Narcotics are avoided after a head injury because they
may hide a worsening condition.”
D. Stronger medications may lead to vomiting, which
increases the intracarnial pressure (ICP).”
Answer: (C) Narcotics are avoided after a head injury because
they may hide a worsening condition. Narcotics may mask
changes in the level of consciousness that indicate increased
ICP and shouldn’t acetaminophen is strong enough ignores
the mother’s question and therefore isn’t appropriate. Aspirin
is contraindicated in conditions that may have bleeding, such
as trauma, and for children or young adults with viral illnesses
due to the danger of Reye’s syndrome. Stronger medications
may not necessarily lead to vomiting but will sedate the
client, thereby masking changes in his level of consciousness.
71. When evaluating an arterial blood gas from a male client
with a subdural hematoma, the nurse notes the Paco2 is 30
mm Hg. Which of the following responses best describes the
result?
A. Appropriate; lowering carbon dioxide (CO2) reduces
intracranial pressure (ICP)
B. Emergent; the client is poorly oxygenated
C. Normal
D. Significant; the client has alveolar hypoventilation
Answer: (A) Appropriate; lowering carbon dioxide (CO2)
reduces intracranial pressure (ICP). A normal Paco2 value is 35
to 45 mm Hg CO2 has vasodilating properties; therefore,
lowering Paco2 through hyperventilation will lower ICP
caused by dilated cerebral vessels. Oxygenation is evaluated
through Pao2 and oxygen saturation. Alveolar
hypoventilation would be reflected in an increased Paco2.
72. When prioritizing care, which of the following clients
should the nurse Olivia assess first?
A. A 17-year-old clients 24-hours postappendectomy
B. A 33-year-old client with a recent diagnosis of Guillain-
Barre syndrome
C. A 50-year-old client 3 days postmyocardial infarction
D. A 50-year-old client with diverticulitis
Answer: (B) A 33-year-old client with a recent diagnosis of
Guillain-Barre syndrome . Guillain-Barre syndrome is
characterized by ascending paralysis and potential respiratory
failure. The order of client assessment should follow client
priorities, with disorder of airways, breathing, and
then circulation. There’s no information to suggest the
postmyocardial infarction client has an arrhythmia or other
complication. There’s no evidence to suggest hemorrhage or
perforation for the remaining clients as a priority of care.
73. JP has been diagnosed with gout and wants to know why
colchicine is used in the treatment of gout. Which of the
following actions of colchicines explains why it’s effective for
gout?
A. Replaces estrogen
B. Decreases infection
C. Decreases inflammation
D. Decreases bone demineralization
Answer: (C) Decreases inflammation. Then action of
colchicines is to decrease inflammation by reducing the
migration of leukocytes to synovial fluid. Colchicine
doesn’t replace estrogen, decrease infection, or decrease
bone demineralization.
74. Norma asks for information about osteoarthritis. Which of
the following statements about osteoarthritis is correct?
A. Osteoarthritis is rarely debilitating
B. Osteoarthritis is a rare form of arthritis
C. Osteoarthritis is the most common form of arthritis
D. Osteoarthritis afflicts people over 60
Answer: (C) Osteoarthritis is the most common form of
arthritis. Osteoarthritis is the most common form of arthritis
and can be extremely debilitating. It can afflict people of any
age, although most are elderly
75. Ruby is receiving thyroid replacement therapy develops
the flu and forgets to take her thyroid replacement medicine.
The nurse understands that skipping this medication will put
the client at risk for developing which of the following
lifethreatening complications?
A. Exophthalmos
B. Thyroid storm
C. Myxedema coma
D. Tibial myxedema
Answer: (C) Myxedema coma. Myxedema coma, severe
hypothyroidism, is a life-threatening condition that may
develop if thyroid replacement medication isn’t
taken. Exophthalmos, protrusion of the eyeballs, is seen with
hyperthyroidism. Thyroid storm is life-threatening but is
caused by severe hyperthyroidism. Tibial myxedema,
peripheral mucinous edema involving the lower leg,
is associated with hypothyroidism but isn’t life-threatening
76. Nurse Sugar is assessing a client with Cushing’s syndrome.
Which observation should the nurse report to the physician
immediately?
A. Pitting edema of the legs
B. An irregular apical pulse
C. Dry mucous membranes
D. Frequent urination
Answer: (B) An irregular apical pulse. Because Cushing’s
syndrome causes aldosterone overproduction, which
increases urinary potassium loss, the disorder may lead to
hypokalemia. Therefore, the nurse should immediately report
signs and symptoms of hypokalemia, such as an irregular
apical pulse, to the physician. Edema is an expected finding
because aldosterone overproduction causes sodium and fluid
retention. Dry mucous membranes and frequent urination
signal dehydration, which isn’t associated with Cushing’s
syndrome.
77. Cyrill with severe head trauma sustained in a car accident
is admitted to the intensive care unit. Thirty-six hours later,
the client’s urine output suddenly rises above 200 ml/hour,
leading the nurse to suspect diabetes insipidus. Which
laboratory findings support the nurse’s suspicion of diabetes
insipidus?
A. Above-normal urine and serum osmolality levels
B. Below-normal urine and serum osmolality levels
C. Above-normal urine osmolality level, below-normal
serum osmolality level
D. Below-normal urine osmolality level, above-normal
serum osmolality level
Answer: (D) Below-normal urine osmolality level, above-
normal serum osmolality level. In diabetes insipidus,
excessive polyuria causes dilute urine, resulting in a below-
normal urine osmolality level. At the same time, polyuria
depletes the body of water, causing dehydration that leads to
an above-normal serum osmolality level. For the same
reasons, diabetes insipidus doesn’t cause above-normal urine
osmolality or below-normal serum osmolality levels.
78. Jomari is diagnosed with hyperosmolar hyperglycemic
nonketotic syndrome (HHNS) is stabilized and prepared for
discharge. When preparing the client for discharge and home
management, which of the following statements indicates
that the client understands her condition and how to control
it?
A. “I can avoid getting sick by not becoming dehydrated
and by paying attention to my need to urinate, drink,
or eat more than usual.”
B. “If I experience trembling, weakness, and headache, I
should drink a glass of soda that contains sugar.”
C. “I will have to monitor my blood glucose level closely
and notify the physician if it’s constantly elevated.”
D. “If I begin to feel especially hungry and thirsty, I’ll eat a
snack high in carbohydrates.”
Answer: (A) “I can avoid getting sick by not becoming
dehydrated and by paying attention to my need to urinate,
drink, or eat more than usual.” Inadequate fluid intake during
hyperglycemic episodes often leads to HHNS. By recognizing
the signs of hyperglycemia (polyuria, polydipsia, and
polyphagia) and increasing fluid intake, the client may prevent
HHNS. Drinking a glass of nondiet soda would be appropriate
for hypoglycemia. A client whose diabetes is controlled with
oral antidiabetic agents usually doesn’t need to monitor
blood glucose levels. A highcarbohydrate diet would
exacerbate the client’s condition, particularly if fluid intake is
low.
79. A 66-year-old client has been complaining of sleeping
more, increased urination, anorexia, weakness, irritability,
depression, and bone pain that interferes with her going
outdoors. Based on these assessment findings, the nurse
would suspect which of the following disorders?
A. Diabetes mellitus
B. Diabetes insipidus
C. Hypoparathyroidism
D. Hyperparathyroidism
Answer: (D) Hyperparathyroidism. Hyperparathyroidism is
most common in older women and is characterized by bone
pain and weakness from excess parathyroid hormone (PTH).
Clients also exhibit hypercaliuria-causing polyuria.
While clients with diabetes mellitus and diabetes insipidus
also have polyuria, they don’t have bone pain and increased
sleeping. Hypoparathyroidism is characterized by urinary
frequency rather than polyuria.
80. Nurse Lourdes is teaching a client recovering from
addisonian crisis about the need to take fludrocortisone
acetate and hydrocortisone at home. Which statement by the
client indicates an understanding of the instructions?
A. “I’ll take my hydrocortisone in the late afternoon, before
dinner.”
B. “I’ll take all of my hydrocortisone in the morning, right
after I wake up.”
C. “I’ll take two-thirds of the dose when I wake up and
one-third in the late afternoon.”
D. “I’ll take the entire dose at bedtime.”
Answer: (C) “I’ll take two-thirds of the dose when I wake up
and one-third in the late afternoon.” Hydrocortisone, a
glucocorticoid, should be administered according to a
schedule that closely reflects the body’s own secretion of this
hormone; therefore, two-thirds of the dose of hydrocortisone
should be taken in the morning and one-third in the late
afternoon. This dosage schedule reduces adverse effects.
81. Which of the following laboratory test results would
suggest to the nurse Len that a client has a corticotropin-
secreting pituitary adenoma?
A. High corticotropin and low cortisol levels
B. Low corticotropin and high cortisol levels
C. High corticotropin and high cortisol levels
D. Low corticotropin and low cortisol levels
Answer: (C) High corticotropin and high cortisol levels. A
corticotropin-secreting pituitary tumor would cause
high corticotropin and high cortisol levels. A high
corticotropin level with a low cortisol level and a low
corticotropin level with a low cortisol level would
be associated with hypocortisolism. Low corticotropin and
high cortisol levels would be seen if there was a primary
defect in the adrenal glands
82. A male client is scheduled for a transsphenoidal
hypophysectomy to remove a pituitary tumor. Preoperatively,
the nurse should assess for potential complications by doing
which of the following?
A. Testing for ketones in the urine
B. Testing urine specific gravity
C. Checking temperature every 4 hours
D. Performing capillary glucose testing every 4 hours
Answer: (D) Performing capillary glucose testing every 4
hours. The nurse should perform capillary glucose testing
every 4 hours because excess cortisol may cause insulin
resistance, placing the client at risk for hyperglycemia. Urine
ketone testing isn’t indicated because the client does secrete
insulin and, therefore, isn’t at risk for ketosis. Urine specific
gravity isn’t indicated because although fluid balance can be
compromised, it usually isn’t dangerously
imbalanced. Temperature regulation may be affected by
excess cortisol and isn’t an accurate indicator of infection.
83. Capillary glucose monitoring is being performed every 4
hours for a client diagnosed with diabetic ketoacidosis. Insulin
is administered using a scale of regular insulin according to
glucose results. At 2 p.m., the client has a capillary glucose
level of 250 mg/dl for which he receives 8 U of regular insulin.
Nurse Mariner should expect the dose’s:
A. onset to be at 2 p.m. and its peak to be at 3 p.m.
B. onset to be at 2:15 p.m. and its peak to be at 3 p.m.
C. onset to be at 2:30 p.m. and its peak to be at 4 p.m.
D. onset to be at 4 p.m. and its peak to be at 6 p.m.
Answer: (C) onset to be at 2:30 p.m. and its peak to be at 4
p.m.. Regular insulin, which is a short-acting insulin, has an
onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because
the nurse gave the insulin at 2 p.m., the expected onset
would be from 2:15 p.m. to 2:30 p.m. and the peak from 4
p.m. to 6 p.m.
84. The physician orders laboratory tests to confirm
hyperthyroidism in a female client with classic signs and
symptoms of this disorder. Which test result would confirm
the diagnosis?
A. No increase in the thyroid-stimulating hormone (TSH)
level after 30 minutes during the TSH stimulation test
B. A decreased TSH level
C. An increase in the TSH level after 30 minutes during the
TSH stimulation test
D. Below-normal levels of serum triiodothyronine (T3) and
serum thyroxine (T4) as detected by radioimmunoassay
Answer: (A) No increase in the thyroid-stimulating hormone
(TSH) level after 30 minutes during the TSH stimulation
test. In the TSH test, failure of the TSH level to rise after
30 minutes confirms hyperthyroidism. A decreased TSH level
indicates a pituitary deficiency of this hormone. Below-
normal levels of T3 and T4, as detected by radioimmunoassay,
signal hypothyroidism. A below-normal T4 level also occurs in
malnutrition and liver disease and may result
from administration of phenytoin and certain other drugs.
85. Rico with diabetes mellitus must learn how to self-
administer insulin. The physician has prescribed 10 U of U-100
regular insulin and 35 U of U-100 isophane insulin suspension
(NPH) to be taken before breakfast. When teaching the client
how to select and rotate insulin injection sites, the nurse
should provide which instruction?
A. “Inject insulin into healthy tissue with large blood
vessels and nerves.”
B. “Rotate injection sites within the same anatomic
region, not among different regions.”
 C. “Administer insulin into areas of scar tissue or
hypotrophy whenever possible.”
D. “Administer insulin into sites above muscles that you
plan to exercise heavily later that day.”
Answer: (B) “Rotate injection sites within the same anatomic
region, not among different regions.” The nurse should
instruct the client to rotate injection sites within the same
anatomic region. Rotating sites among different regions may
cause excessive day-to-day variations in the blood glucose
level; also, insulin absorption differs from one region to the
next. Insulin should be injected only into healthy tissue
lacking large blood vessels, nerves, or scar tissue or other
deviations. Injecting insulin into areas of hypertrophy may
delay absorption. The client shouldn’t inject insulin into areas
of lipodystrophy (such as hypertrophy or atrophy); to prevent
lipodystrophy, the client should rotate injection sites
systematically. Exercise speeds drug absorption, so the client
shouldn’t inject insulin into sites above muscles that will be
exercised heavily.
86. Nurse Sarah expects to note an elevated serum glucose
level in a client with hyperosmolar hyperglycemic nonketotic
syndrome (HHNS). Which other laboratory finding should the
nurse anticipate?
A. Elevated serum acetone level
B. Serum ketone bodies
C. Serum alkalosis
D. Below-normal serum potassium level
Answer: (D) Below-normal serum potassium level. A client
with HHNS has an overall body deficit of potassium resulting
from diuresis, which occurs secondary to the
hyperosmolar, hyperglycemic state caused by the relative
insulin deficiency. An elevated serum acetone level and serum
ketone bodies are characteristic of diabetic ketoacidosis.
Metabolic acidosis, not serum alkalosis, may occur in HHNS.
87. For a client with Graves’ disease, which nursing
intervention promotes comfort?
A. Restricting intake of oral fluids
B. Placing extra blankets on the client’s bed
C. Limiting intake of high-carbohydrate foods
D. Maintaining room temperature in the low-normal range
Answer: (D) Maintaining room temperature in the low-normal
range. Graves’ disease causes signs and symptoms
of hypermetabolism, such as heat intolerance, diaphoresis,
excessive thirst and appetite, and weight loss. To reduce heat
intolerance and diaphoresis, the nurse should keep the
client’s room temperature in the low-normal range. To
replace fluids lost via diaphoresis, the nurse
should encourage, not restrict, intake of oral fluids. Placing
extra blankets on the bed of a client with heat intolerance
would cause discomfort. To provide needed energy and
calories, the nurse should encourage the client to eat high-
carbohydrate foods.
88. Patrick is treated in the emergency department for a
Colles’ fracture sustained during a fall. What is a Colles’
fracture?
A. Fracture of the distal radius
B. Fracture of the olecranon
C. Fracture of the humerus
D. Fracture of the carpal scaphoid
Answer: (A) Fracture of the distal radius. Colles’ fracture is a
fracture of the distal radius, such as from a fall on an
outstretched hand. It’s most common in women.
Colles’ fracture doesn’t refer to a fracture of the olecranon,
humerus, or carpal scaphoid
89. Cleo is diagnosed with osteoporosis. Which electrolytes
are involved in the development of this disorder?
A. Calcium and sodium
B. Calcium and phosphorous
C. Phosphorous and potassium
D. Potassium and sodium
Answer: (B) Calcium and phosphorous. In osteoporosis, bones
lose calcium and phosphate salts, becoming porous, brittle,
and abnormally vulnerable to fracture. Sodium and potassium
aren’t involved in the development of osteoporosis.
90. Johnny a firefighter was involved in extinguishing a house
fire and is being treated to smoke inhalation. He develops
severe hypoxia 48 hours after the incident, requiring
intubation and mechanical ventilation. He most likely has
developed which of the following conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Atelectasis
C. Bronchitis
D. Pneumonia
Answer: (A) Adult respiratory distress syndrome
(ARDS). Severe hypoxia after smoke inhalation is typically
related to ARDS. The other conditions listed aren’t typically
associated with smoke inhalation and severe hypoxia.
91. A 67-year-old client develops acute shortness of breath
and progressive hypoxia requiring right femur. The hypoxia
was probably caused by which of the following conditions?
A. Asthma attack
B. Atelectasis
C. Bronchitis
D. Fat embolism
Answer: (D) Fat embolism. Long bone fractures are correlated
with fat emboli, whichcause shortness of breath and hypoxia.
It’s unlikely the client has developed asthma or bronchitis
without a previous history. He could develop atelectasis but it
typically doesn’t produce progressive hypoxia.
92. A client with shortness of breath has decreased to absent
breath sounds on the right side, from the apex to the base.
Which of the following conditions would best explain this?
A. Acute asthma
B. Chronic bronchitis
C. Pneumonia
D. Spontaneous pneumothorax
Answer: (D) Spontaneous pneumothorax. A spontaneous
pneumothorax occurs when the client’s lung collapses,
causing an acute decreased in the amount of functional
lung used in oxygenation. The sudden collapse was the cause
of his chest pain and shortness of breath. An asthma attack
would show wheezing breath sounds, and bronchitis would
have rhonchi. Pneumonia would have bronchial breath
sounds over the area of consolidation
93. A 62-year-old male client was in a motor vehicle accident
as an unrestrained driver. He’s now in the emergency
department complaining of difficulty of breathing and chest
pain. On auscultation of his lung field, no breath sounds are
present in the upper lobe. This client may have which of the
following conditions?
A. Bronchitis
B. Pneumonia
C. Pneumothorax
 D. Tuberculosis (TB)
Answer: (C) Pneumothorax. From the trauma the client
experienced, it’s unlikely he has bronchitis, pneumonia, or
TB; rhonchi with bronchitis, bronchial breath sounds with TB
would be heard.
94. If a client requires a pneumonectomy, what fills the area
of the thoracic cavity?
A. The space remains filled with air only
B. The surgeon fills the space with a gel
C. Serous fluids fills the space and consolidates the region
D. The tissue from the other lung grows over to the other
side
Answer: (C) Serous fluids fills the space and consolidates the
region. Serous fluid fills the space and eventually
consolidates, preventing extensive mediastinal shift of the
heart and remaining lung. Air can’t be left in the space.
There’s no gel that can be placed in the pleural space. The
tissue from the other lung can’t cross the
mediastinum, although a temporary mediastinal shift exits
until the space is filled.
95. Hemoptysis may be present in the client with a pulmonary
embolism because of which of the following reasons?
A. Alveolar damage in the infracted area
B. Involvement of major blood vessels in the occluded area
C. Loss of lung parenchyma
D. Loss of lung tissue
Answer: (A) Alveolar damage in the infracted area. The
infracted area produces alveolar damage that can lead to the
production of bloody sputum, sometimes in massive
amounts. Clot formation usually occurs in the legs. There’s a
loss of lung parenchyma and subsequent scar tissue
formation
96. Aldo with a massive pulmonary embolism will have an
arterial blood gas analysis performed to determine the extent
of hypoxia. The acid-base disorder that may be present is?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Answer: (D) Respiratory alkalosis. A client with massive
pulmonary embolism will have a large region and blow off
large amount of carbon dioxide, which crosses the unaffected
alveolar-capillary membrane more readily than does
oxygen and results in respiratory alkalosis.
97. After a motor vehicle accident, Armand an 22-year-old
client is admitted with a pneumothorax. The surgeon inserts a
chest tube and attaches it to a chest drainage system.
Bubbling soon appears in the water seal chamber. Which of
the following is the most likely cause of the bubbling?
A. Air leak
B. Adequate suction
C. Inadequate suction
D. Kinked chest tube
Answer: (A) Air leak. Bubbling in the water seal chamber of a
chest drainage system stems from an air leak. In
pneumothorax an air leak can occur as air is pulled from the
pleural space. Bubbling doesn’t normally occur with
either adequate or inadequate suction or any preexisting
bubbling in the water seal chamber.
98. Nurse Michelle calculates the IV flow rate for a
postoperative client. The client receives 3,000 ml of Ringer’s
lactate solution IV to run over 24 hours. The IV infusion set
has a drop factor of 10 drops per milliliter. The nurse should
regulate the client’s IV to deliver how many drops per
minute?
A. 18
B. 21
C. 35
D. 40
Answer: (B) 21. 3000 x 10 divided by 24 x 60
99. Mickey, a 6-year-old child with a congenital heart disorder
is admitted with congestive heart failure. Digoxin (lanoxin)
0.12 mg is ordered for the child. The bottle of Lanoxin
contains .05 mg of Lanoxin in 1 ml of solution. What amount
should the nurse administer to the child?
A. 1.2 ml
B. 2.4 ml
C. 3.5 ml
D. 4.2 ml
Answer: (B) 2.4 ml. .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x =
2.4 ml.
100. Nurse Alexandra teaches a client about elastic stockings.
Which of the following statements, if made by the client,
indicates to the nurse that the teaching was successful?
A. “I will wear the stockings until the physician tells me to
remove them.”
B. “I should wear the stockings even when I am sleep.”
C. “Every four hours I should remove the stockings for a
half hour.”
D. “I should put on the stockings before getting out of bed
in the morning.”
Answer: (D) “I should put on the stockings before getting out
of bed in the morning. Promote venous return by applying
external pressure on veins.
PNLE V for Care of Clients with
Physiologic and Psychosocial
Alterations (Part 3)
1. Mr. Marquez reports of losing his job, not being able to
sleep at night, and feeling upset with his wife. Nurse John
responds to the client, “You may want to talk about your
employment situation in group today.” The Nurse is using
which therapeutic technique?
A. Observations
B. Restating
C. Exploring
D. Focusing\
Answer: (D) Focusing. The nurse is using focusing by
suggesting that the client discuss a specific issue. The nurse
didn’t restate the question, make observation, or ask further
question (exploring).
2. Tony refuses his evening dose of Haloperidol (Haldol), then
becomes extremely agitated in the dayroom while other
clients are watching television. He begins cursing and
throwing furniture. Nurse Oliver first action is to:
A. Check the client’s medical record for an order for an as-
needed I.M. dose of medication for agitation.
B. Place the client in full leather restraints.
 C. Call the attending physician and report the behavior.
D. Remove all other clients from the dayroom.
Answer: (D) Remove all other clients from the dayroom. The
nurse’s first priority is to consider the safety of the clients in
the therapeutic setting. The other actions are appropriate
responses after ensuring the safety of other clients.
3. Tina who is manic, but not yet on medication, comes to the
drug treatment center. The nurse would not let this client join
the group session because:
A. The client is disruptive.
B. The client is harmful to self.
C. The client is harmful to others.
D. The client needs to be on medication first.
Answer: (A) The client is disruptive. Group activity provides
too much stimulation, which the client will not be able to
handle (harmful to self) and as a result will be disruptive to
others.
4. Dervid, an adolescent boy was admitted for substance
abuse and hallucinations. The client’s mother asks Nurse
Armando to talk with his husband when he arrives at the
hospital. The mother says that she is afraid of what the father
might say to the boy. The most appropriate nursing
intervention would be to:
A. Inform the mother that she and the father can work
through this problem themselves.
B. Refer the mother to the hospital social worker.
C. Agree to talk with the mother and the father together.
D. Suggest that the father and son work things out.
Answer: (C) Agree to talk with the mother and the father
together. By agreeing to talk with both parents, the nurse can
provide emotional support and further assess and validate
the family’s needs.
5. What is Nurse John likely to note in a male client being
admitted for alcohol withdrawal?
A. Perceptual disorders.
B. Impending coma.
C. Recent alcohol intake.
D. Depression with mutism.
Answer: (A) Perceptual disorders. Frightening visual
hallucinations are especially common in clients experiencing
alcohol withdrawal.
6. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now
complains that it “doesn’t help” and refuses to take it. What
should the nurse say or do?
A. Withhold the drug.
B. Record the client’s response.
C. Encourage the client to tell the doctor.
D. Suggest that it takes awhile before seeing the results.
Answer: (D) Suggest that it takes awhile before seeing the
results. The client needs a specific response; that it takes 2
to 3 weeks (a delayed effect) until the therapeutic blood
level is reached
7. Dervid, an adolescent has a history of truancy from school,
running away from home and “barrowing” other people’s
things without their permission. The adolescent denies
stealing, rationalizing instead that as long as no one was using
the items, it was all right to borrow them. It is important for
the nurse to understand the psychodynamically, this behavior
may be largely attributed to a developmental defect related
to the:
A. Id
B. Ego
C. Superego
D. Oedipal complex
Answer: (C) Superego. This behavior shows a weak sense of
moral consciousness. According to Freudian theory,
personality disorders stem from a weak superego.
8. In preparing a female client for electroconvulsive therapy
(ECT), Nurse Michelle knows that succinylcoline (Anectine)
will be administered for which therapeutic effect?
A. Short-acting anesthesia
B. Decreased oral and respiratory secretions.
C. Skeletal muscle paralysis.
D. Analgesia.
Answer: (C) Skeletal muscle paralysis. Anectine is a
depolarizing muscle relaxant causing paralysis. It is used to
reduce the intensity of muscle contractions during
the convulsive stage, thereby reducing the risk of bone
fractures or dislocation
9. Nurse Gina is aware that the dietary implications for a
client in manic phase of bipolar disorder is:
A. Serve the client a bowl of soup, buttered French bread,
and apple slices.
B. Increase calories, decrease fat, and decrease protein.
C. Give the client pieces of cut-up steak, carrots, and an
apple.
D. Increase calories, carbohydrates, and protein.
Answer: (D) Increase calories, carbohydrates, and protein.This
client increased protein for tissue building and
increased calories to replace what is burned up (usually via
carbohydrates).
10.What parental behavior toward a child during an admission
procedure should cause Nurse Ron to suspect child abuse?
A. Flat affect
B. Expressing guilt
C. Acting overly solicitous toward the child.
D. Ignoring the child.
Answer: (C) Acting overly solicitous toward the child. This
behavior is an example of reaction formation, a
coping mechanism.
11.Nurse Lynnette notices that a female client with obsessive-
compulsive disorder washes her hands for long periods each
day. How should the nurse respond to this compulsive
behavior?
A. By designating times during which the client can focus
on the behavior.
B. By urging the client to reduce the frequency of the
behavior as rapidly as possible.
C. By calling attention to or attempting to prevent the
behavior.
D. By discouraging the client from verbalizing anxieties.

Answer: (A) By designating times during which the client can
focus on the behavior. The nurse should designate times
during which the client can focus on the compulsive behavior
or obsessive thoughts. The nurse should urge the client to
reduce the frequency of the compulsive behavior gradually,
not rapidly. She shouldn’t call attention to or try to prevent
the behavior. Trying to prevent the behavior may cause pain
and terror in the client. The nurse should encourage the client
to verbalize anxieties to help distract attention from the
compulsive behavior.
12.After seeking help at an outpatient mental health clinic,
Ruby who was raped while walking her dog is diagnosed with
posttraumatic stress disorder (PTSD). Three months later,
Ruby returns to the clinic, complaining of fear, loss of control,
and helpless feelings. Which nursing intervention is most
appropriate for Ruby?
A. Recommending a high-protein, low-fat diet.
B. Giving sleep medication, as prescribed, to restore a
normal sleepwake cycle.
C. Allowing the client time to heal.
D. Exploring the meaning of the traumatic event with the
client.
Answer: (D) Exploring the meaning of the traumatic event
with the client. The client with PTSD needs encouragement to
examine and understand the meaning of the traumatic event
and consequent losses. Otherwise, symptoms may worsen
and the client may become depressed or engage in self-
destructive behavior such as substance abuse. The client must
explore the meaning of the event and won’t heal without
this, no matter how much time passes. Behavioral techniques,
such as relaxation therapy, may help decrease the client’s
anxiety and induce sleep. The physician may prescribe
antianxiety agents or antidepressants cautiously to avoid
dependence; sleep medication is rarely appropriate. A special
diet isn’t indicated unless the client also has an eating
disorder or a nutritional problem.
13.Meryl, age 19, is highly dependent on her parents and
fears leaving home to go away to college. Shortly before the
semester starts, she complains that her legs are paralyzed and
is rushed to the emergency department. When physical
examination rules out a physical cause for her paralysis, the
physician admits her to the psychiatric unit where she is
diagnosed with conversion disorder. Meryl asks the nurse,
“Why has this happened to me?” What is the nurse’s best
response?
A. “You’ve developed this paralysis so you can stay with
your parents. You must deal with this conflict if you
want to walk again.”
B. “It must be awful not to be able to move your legs. You
may feel better if you realize the problem is
psychological, not physical.”
C. “Your problem is real but there is no physical basis for
it. We’ll work on what is going on in your life to find
out why it’s happened.”
D. “It isn’t uncommon for someone with your personality
to develop a conversion disorder during times of stress.”
Answer: (C) “Your problem is real but there is no physical
basis for it. We’ll work on what is going on in your life to find
out why it’s happened.” The nurse must be honest with the
client by telling her that the paralysis has no physiologic cause
while also conveying empathy and acknowledging that her
symptoms are real. The client will benefit from psychiatric
treatment, which will help her understand the underlying
cause of her symptoms. After the psychological conflict is
resolved, her symptoms will disappear. Saying that it must be
awful not to be able to move her legs wouldn’t answer the
client’s question; knowing that the cause is psychological
wouldn’t necessarily make her feel better. Telling her that she
has developed paralysis to avoid leaving her parents or
that her personality caused her disorder wouldn’t help her
understand and resolve the underlying conflict.
14.Nurse Krina knows that the following drugs have been
known to be effective in treating obsessive-compulsive
disorder (OCD):
A. benztropine (Cogentin) and diphenhydramine
(Benadryl).
B. chlordiazepoxide (Librium) and diazepam (Valium)
C. fluvoxamine (Luvox) and clomipramine (Anafranil)
D. divalproex (Depakote) and lithium (Lithobid)
Answer: (C) fluvoxamine (Luvox) and clomipramine
(Anafranil). The antidepressants fluvoxamine and
clomipramine have been effective in the treatment of OCD.
Librium and Valium may be helpful in treating anxiety related
to OCD but aren’t drugs of choice to treat the illness. The
other medications mentioned aren’t effective in the
treatment of OCD.
15.Alfred was newly diagnosed with anxiety disorder. The
physician prescribed buspirone (BuSpar). The nurse is aware
that the teaching instructions for newly prescribed buspirone
should include which of the following?
A. A warning about the drugs delayed therapeutic effect,
which is from 14 to 30 days.
B. A warning about the incidence of neuroleptic malignant
syndrome (NMS).
C. A reminder of the need to schedule blood work in 1
week to check blood levels of the drug.
D. A warning that immediate sedation can occur with a
resultant drop in pulse.
Answer: (A) A warning about the drugs delayed therapeutic
effect, which is from 14 to 30 days. The client should be
informed that the drug’s therapeutic effect might not be
reached for 14 to 30 days. The client must be instructed
to continue taking the drug as directed. Blood level checks
aren’t necessary. NMS hasn’t been reported with this drug,
but tachycardia is frequently reported
16.Richard with agoraphobia has been symptom-free for 4
months. Classic signs and symptoms of phobias include:
A. Insomnia and an inability to concentrate.
B. Severe anxiety and fear.
C. Depression and weight loss.
D. Withdrawal and failure to distinguish reality from
fantasy.
Answer: (B) Severe anxiety and fear. Phobias cause severe
anxiety (such as a panic attack) that is out of proportion to
the threat of the feared object or situation. Physical signs and
symptoms of phobias include profuse sweating, poor
motor control, tachycardia, and elevated blood pressure.
Insomnia, an inability to concentrate, and weight loss are
common in depression. Withdrawal and failure to distinguish
reality from fantasy occur in schizophrenia.
17.Which medications have been found to help reduce or
eliminate panic attacks?
 A. Antidepressants
B. Anticholinergics
C. Antipsychotics
D. Mood stabilizers
Answer: (A) Antidepressants. Tricyclic and monoamine
oxidase (MAO) inhibitor antidepressants have been found to
be effective in treating clients with panic attacks. Why these
drugs help control panic attacks isn’t clearly understood.
Anticholinergic agents, which are smooth-muscle
relaxants, relieve physical symptoms of anxiety but don’t
relieve the anxiety itself. Antipsychotic drugs are
inappropriate because clients who experience panic attacks
aren’t psychotic. Mood stabilizers aren’t indicated
because panic attacks are rarely associated with mood
changes.
18.A client seeks care because she feels depressed and has
gained weight. To treat her atypical depression, the physician
prescribes tranylcypromine sulfate (Parnate), 10 mg by mouth
twice per day. When this drug is used to treat atypical
depression, what is its onset of action?
A. 1 to 2 days
B. 3 to 5 days
C. 6 to 8 days
D. 10 to 14 days
Answer: (B) 3 to 5 days. Monoamine oxidase inhibitors, such
as tranylcypromine, have an onset of action of
approximately 3 to 5 days. A full clinical response may be
delayed for 3 to 4 weeks. The therapeutic effects may
continue for 1 to 2 weeks after discontinuation
19. A 65 years old client is in the first stage of Alzheimer’s
disease. Nurse Patricia should plan to focus this client’s care
on:
A. Offering nourishing finger foods to help maintain the
client’s nutritional status.
B. Providing emotional support and individual counseling.
C. Monitoring the client to prevent minor illnesses from
turning into major problems.
D. Suggesting new activities for the client and family to do
together.
Answer: (B) Providing emotional support and individual
counseling. Clients in the first stage of Alzheimer’s disease are
aware that something is happening to them and may become
overwhelmed and frightened. Therefore, nursing care
typically focuses on providing emotional support and
individual counseling. The other options are appropriate
during the second stage of Alzheimer’s disease, when
the client needs continuous monitoring to prevent minor
illnesses from progressing into major problems and when
maintaining adequate nutrition may become a challenge.
During this stage, offering nourishing finger foods helps
clients to feed themselves and maintain adequate nutrition.
20.The nurse is assessing a client who has just been admitted
to the emergency department. Which signs would suggest an
overdose of an antianxiety agent?
A. Combativeness, sweating, and confusion
B. Agitation, hyperactivity, and grandiose ideation
C. Emotional lability, euphoria, and impaired memory
D. Suspiciousness, dilated pupils, and increased blood
pressure
Answer: (C) Emotional lability, euphoria, and impaired
memory. Signs of antianxiety agent overdose include
emotional lability, euphoria, and impaired memory.
Phencyclidine overdose can cause combativeness, sweating,
and confusion. Amphetamine overdose can result in agitation,
hyperactivity, and grandiose ideation. Hallucinogen overdose
can produce suspiciousness, dilated pupils, and increased
blood pressure.
21.The nurse is caring for a client diagnosed with antisocial
personality disorder. The client has a history of fighting,
cruelty to animals, and stealing. Which of the following traits
would the nurse be most likely to uncover during assessment?
A. History of gainful employment
B. Frequent expression of guilt regarding antisocial
behavior
C. Demonstrated ability to maintain close, stable
relationships
D. d. A low tolerance for frustration
Answer: (D) A low tolerance for frustration. Clients with an
antisocial personality disorder exhibit a low tolerance for
frustration, emotional immaturity, and a lack of
impulse control. They commonly have a history of
unemployment, miss work repeatedly, and quit work without
other plans for employment. They don’t feel guilt about their
behavior and commonly perceive themselves as victims. They
also display a lack of responsibility for the outcome of
their actions. Because of a lack of trust in others, clients with
antisocial personality disorder commonly have difficulty
developing stable, close relationships.
22.Nurse Amy is providing care for a male client undergoing
opiate withdrawal. Opiate withdrawal causes severe physical
discomfort and can be life-threatening. To minimize these
effects, opiate users are commonly detoxified with:
A. Barbiturates
B. Amphetamines
C. Methadone
D. Benzodiazepines
Answer: (C) Methadone. Methadone is used to detoxify
opiate users because it binds with opioid receptors at many
sites in the central nervous system but doesn’t have the same
deterious effects as other opiates, such as cocaine, heroin,
and morphine. Barbiturates, amphetamines,
and benzodiazepines are highly addictive and would require
detoxification treatment.
23.Nurse Cristina is caring for a client who experiences false
sensory perceptions with no basis in reality. These
perceptions are known as:
A. Delusions
B. Hallucinations
C. Loose associations
D. Neologisms
Answer: (B) Hallucinations. Hallucinations are visual, auditory,
gustatory, tactile, or olfactory perceptions that have no basis
in reality. Delusions are false beliefs, rather than perceptions,
that the client accepts as real. Loose associations are rapid
shifts among unrelated ideas. Neologisms are bizarre words
that have meaning only to the client.
24. Nurse Marco is developing a plan of care for a client with
anorexia nervosa. Which action should the nurse include in
the plan?
 A. Restricts visits with the family and friends until the
client begins to eat.
B. Provide privacy during meals.
C. Set up a strict eating plan for the client.
D. Encourage the client to exercise, which will reduce her
anxiety.
Answer: (C) Set up a strict eating plan for the
client. Establishing a consistent eating plan and monitoring
the client’s weight are very important in this disorder. The
family and friends should be included in the client’s care. The
client should be monitored during meals-not given privacy.
Exercise must be limited and supervised.
25.Tim is admitted with a diagnosis of delusions of grandeur.
The nurse is aware that this diagnosis reflects a belief that
one is:
A. Highly important or famous.
B. Being persecuted
C. Connected to events unrelated to oneself
D. Responsible for the evil in the world.
Answer: (A) Highly important or famous. A delusion of
grandeur is a false belief that one is highly important or
famous. A delusion of persecution is a false belief that one
is being persecuted. A delusion of reference is a false belief
that one is connected to events unrelated to oneself or a
belief that one is responsible for the evil in the world
26.Nurse Jen is caring for a male client with manic depression.
The plan of care for a client in a manic state would include:
A. Offering a high-calorie meals and strongly encouraging
the client to finish all food.
B. Insisting that the client remain active through the day so
that he’ll sleep at night.
C. Allowing the client to exhibit hyperactive, demanding,
manipulative behavior without setting limits.
D. Listening attentively with a neutral attitude and
avoiding power struggles.
Answer: (D) Listening attentively with a neutral attitude and
avoiding power struggles. The nurse should listen to the
client’s requests, express willingness to seriously consider the
request, and respond later. The nurse should encourage the
client to take short daytime naps because he expends so
much energy. The nurse shouldn’t try to restrain the
client when he feels the need to move around as long as his
activity isn’t harmful. High calorie finger foods should be
offered to supplement the client’s diet, if he can’t remain
seated long enough to eat a complete meal. The nurse
shouldn’t be forced to stay seated at the table to finish
a meal. The nurse should set limits in a calm, clear, and self-
confident tone of voice.
27.Ramon is admitted for detoxification after a cocaine
overdose. The client tells the nurse that he frequently uses
cocaine but that he can control his use if he chooses. Which
coping mechanism is he using?
A. Withdrawal
B. Logical thinking
C. Repression
D. Denial
Answer: (D) Denial. Denial is unconscious defense mechanism
in which emotional conflict and anxiety is avoided by refusing
to acknowledge feelings, desires, impulses, or external facts
that are consciously intolerable. Withdrawal is a common
response to stress, characterized by apathy. Logical thinking is
the ability to think rationally and make responsible decisions,
which would lead the client admitting the problem and
seeking help. Repression is suppressing past events from the
consciousness because of guilty association.
28.Richard is admitted with a diagnosis of schizotypal
personality disorder. Which signs would this client exhibit
during social situations?
A. Aggressive behavior
B. Paranoid thoughts
C. Emotional affect
D. Independence needs
Answer: (B) Paranoid thoughts. Clients with schizotypal
personality disorder experience excessive social anxiety that
can lead to paranoid thoughts. Aggressive behavior is
uncommon, although these clients may experience
agitation with anxiety. Their behavior is emotionally cold with
a flattened affect, regardless of the situation. These clients
demonstrate a reduced capacity for close or dependent
relationships.
29. Nurse Mickey is caring for a client diagnosed with bulimia.
The most appropriate initial goal for a client diagnosed with
bulimia is to:
A. Avoid shopping for large amounts of food.
B. Control eating impulses.
C. Identify anxiety-causing situations
D. Eat only three meals per day.
Answer: (C) Identify anxiety-causing situations. Bulimic
behavior is generally a maladaptive coping response to stress
and underlying issues. The client must identify anxiety-
causing situations that stimulate the bulimic behavior and
then learn new ways of coping with the anxiety.
30.Rudolf is admitted for an overdose of amphetamines.
When assessing the client, the nurse should expect to see:
A. Tension and irritability
B. Slow pulse
C. Hypotension
D. Constipation
Answer: (A) Tension and irritability. An amphetamine is a
nervous system stimulant that is subject to abuse because of
its ability to produce wakefulness and euphoria. An overdose
increases tension and irritability. Options B and C are
incorrect because amphetamines stimulate norepinephrine,
which increase the heart rate and blood flow. Diarrhea is a
common adverse effect so option D in is incorrect
31.Nicolas is experiencing hallucinations tells the nurse, “The
voices are telling me I’m no good.” The client asks if the nurse
hears the voices. The most appropriate response by the nurse
would be:
A. “It is the voice of your conscience, which only you can
control.”
B. “No, I do not hear your voices, but I believe you can
hear them”.
C. “The voices are coming from within you and only you
can hear them.”
D. “Oh, the voices are a symptom of your illness; don’t pay
any attention to them.”
 Answer: (B) “No, I do not hear your voices, but I believe you
can hear them”. The nurse, demonstrating knowledge and
understanding, accepts the client’s perceptions even though
they are hallucinatory
32.The nurse is aware that the side effect of electroconvulsive
therapy that a client may experience:
Answer: (D) Moderate-level anxiety. A moderately anxious
person can ignore peripheral events and focuses on central
concerns
37.When assessing a premorbid personality characteristics of
a client with a major depression, it would be unusual for the
nurse to find that this client demonstrated:

A. Loss of appetite A. Rigidity

B. Postural hypotension B. Stubbornness
C. Confusion for a time after treatment C. Diverse interest
D. Complete loss of memory for a time D. Over meticulousness

Answer: (C) Confusion for a time after treatment. The Answer: (C) Diverse interest. Before onset of depression,
electrical energy passing through the cerebral cortex during these clients usually have very narrow, limited interest.
ECT results in a temporary state of confusion after treatment.
38.Nurse Krina recognizes that the suicidal risk for depressed
33.A dying male client gradually moves toward resolution of client is greatest:
feelings regarding impending death. Basing care on the theory
of Kubler-Ross, Nurse Trish plans to use nonverbal A. As their depression begins to improve
interventions when assessment reveals that the client is in B. When their depression is most severe
the: C. Before nay type of treatment is started
D. As they lose interest in the environment
A. Anger stage
B. Denial stage Answer: (A) As their depression begins to improve. At this
C. Bargaining stage point the client may have enough energy to plan
D. Acceptance stage and execute an attempt

Answer: (D) Acceptance stage. Communication and
intervention during this stage are mainly nonverbal, as when
the client gestures to hold the nurse’s hand
34.The outcome that is unrelated to a crisis state is:
A. Learning more constructive coping skills
B. Decompensation to a lower level of functioning.
C. Adaptation and a return to a prior level of functioning.
D. A higher level of anxiety continuing for more than 3
months.
Answer: (D) A higher level of anxiety continuing for more than
3 months. This is not an expected outcome of a crisis because
by definition a crisis would be resolved in 6 weeks.
35.Miranda a psychiatric client is to be discharged with orders
for haloperidol (haldol) therapy. When developing a teaching
plan for discharge, the nurse should include cautioning the
client against:
39.Nurse Kate would expect that a client with vascular
dementis would experience:
A. Loss of remote memory related to anoxia
B. Loss of abstract thinking related to emotional state
C. Inability to concentrate related to decreased stimuli
D. Disturbance in recalling recent events related to
cerebral hypoxia.
Answer: (D) Disturbance in recalling recent events related to
cerebral hypoxia. Cell damage seems to interfere with
registering input stimuli, which affects the ability to register
and recall recent events; vascular dementia is related to
multiple vascular lesions of the cerebral cortex
and subcortical structure.
40.Josefina is to be discharged on a regimen of lithium
carbonate. In the teaching plan for discharge the nurse should
include:

A. Driving at night A. Advising the client to watch the diet carefully

B. Staying in the sun B. Suggesting that the client take the pills with milk
C. Ingesting wines and cheeses C. Reminding the client that a CBC must be done once a
D. Taking medications containing aspirin month.
D. Encouraging the client to have blood levels checked as
Answer: (B) Staying in the sun. Haldol causes ordered.
photosensitivity. Severe sunburn can occur on exposure to
the sun Answer: (D) Encouraging the client to have blood levels
checked as ordered. Blood levels must be checked monthly
36.Jen a nursing student is anxious about the upcoming board or bimonthly when the client is on maintenance therapy
examination but is able to study intently and does not because there is only a small range between therapeutic and
become distracted by a roommate’s talking and loud music. toxic levels.
The student’s ability to ignore distractions and to focus on
studying demonstrates: 41.The psychiatrist orders lithium carbonate 600 mg p.o t.i.d
for a female client. Nurse Katrina would be aware that the
A. Mild-level anxiety teaching about the side effects of this drug were understood
B. Panic-level anxiety when the client state, “I will call my doctor immediately if I
C. Severe-level anxiety notice any:
D. Moderate-level anxiety
A. Sensitivity to bright light or sun
B. Fine hand tremors or slurred speech
 C. Sexual dysfunction or breast enlargement
D. d. Inability to urinate or difficulty when urinating
Answer: (B) Fine hand tremors or slurred speech. These are
common side effects of lithium carbonate.
42.Nurse Mylene recognizes that the most important factor
necessary for the establishment of trust in a critical care area
is:
A. Privacy
B. Respect
C. Empathy
D. Presence
Answer: (D) Presence. The constant presence of a nurse
provides emotional support because the client knows that
someone is attentive and available in case of an emergency
43.When establishing an initial nurse-client relationship,
Nurse Hazel should explore with the client the:
A. Client’s perception of the presenting problem.
B. Occurrence of fantasies the client may experience.
C. Details of any ritualistic acts carried out by the client
D. Client’s feelings when external; controls are instituted.
Answer: (A) Client’s perception of the presenting
problem. The nurse can be most therapeutic by starting
where the client is, because it is the client’s concept of the
problem that serves as the starting point of the relationship.
44.Tranylcypromine sulfate (Parnate) is prescribed for a
depressed client who has not responded to the tricyclic
antidepressants. After teaching the client about the
medication, Nurse Marian evaluates that learning has
occurred when the client states, “I will avoid:
A. Citrus fruit, tuna, and yellow vegetables.”
B. Chocolate milk, aged cheese, and yogurt’”
C. Green leafy vegetables, chicken, and milk.”
D. Whole grains, red meats, and carbonated soda.”
Answer: (B) Chocolate milk, aged cheese, and yogurt’. These
high-tyramine foods, when ingested in the presence of an
MAO inhibitor, cause a severe hypertensive response.
45.Nurse John is a aware that most crisis situations should
resolve in about:
A. 1 to 2 weeks
B. 4 to 6 weeks
C. 4 to 6 months
D. 6 to 12 months
Answer: (B) 4 to 6 weeks. Crisis is self-limiting and lasts from 4
to 6 weeks.
46. Nurse Judy knows that statistics show that in adolescent
suicide behavior:
A. Females use more dramatic methods than males
B. Males account for more attempts than do females
C. Females talk more about suicide before attempting it
D. Males are more likely to use lethal methods than are
females
Answer: (D) Males are more likely to use lethal methods than
are females. This finding is supported by research; females
account for 90% of suicide attempts but males are three times
more successful because of methods used.
47. Dervid with paranoid schizophrenia repeatedly uses
profanity during an activity therapy session. Which response
by the nurse would be most appropriate?
A. “Your behavior won’t be tolerated. Go to your room
immediately.”
B. “You’re just doing this to get back at me for making you
come to therapy.”
C. “Your cursing is interrupting the activity. Take time out
in your room for 10 minutes.”
D. “I’m disappointed in you. You can’t control yourself even
for a few minutes.”
Answer: (C) “Your cursing is interrupting the activity. Take
time out in your room for 10 minutes.” The nurse should set
limits on client behavior to ensure a comfortable
environment for all clients. The nurse should accept hostile
or quarrelsome client outbursts within limits without
becoming personally offended, as in option A. Option B is
incorrect because it implies that the client’s actions reflect
feelings toward the staff instead of the client’s own misery.
Judgmental remarks, such as option D, may decrease the
client’s self-esteem
48.Nurse Maureen knows that the nonantipsychotic
medication used to treat some clients with schizoaffective
disorder is:
A. phenelzine (Nardil)
B. chlordiazepoxide (Librium)
C. lithium carbonate (Lithane)
D. imipramine (Tofranil)
Answer: (C) lithium carbonate (Lithane). Lithium carbonate,
an antimania drug, is used to treat clients with cyclical
schizoaffective disorder, a psychotic disorder once
classified under schizophrenia that causes affective
symptoms, including maniclike activity. Lithium helps control
the affective component of this disorder. Phenelzine is a
monoamine oxidase inhibitor prescribed for clients
who don’t respond to other antidepressant drugs such as
imipramine. Chlordiazepoxide, an antianxiety agent,
generally is contraindicated in psychotic clients. Imipramine,
primarily considered an antidepressant agent, is also used to
treat clients with agoraphobia and that undergoing cocaine
detoxification
49.Which information is most important for the nurse Trinity
to include in a teaching plan for a male schizophrenic client
taking clozapine (Clozaril)?
A. Monthly blood tests will be necessary.
B. Report a sore throat or fever to the physician
immediately.
C. Blood pressure must be monitored for hypertension.
D. Stop the medication when symptoms subside.
Answer: (B) Report a sore throat or fever to the physician
immediately. A sore throat and fever are indications of an
infection caused by agranulocytosis, a potentially life-
threatening complication of clozapine. Because of the risk of
agranulocytosis, white blood cell (WBC) counts are necessary
weekly, not monthly. If the WBC count drops below
3,000/μl, the medication must be stopped. Hypotension may
occur in clients taking this medication. Warn the client to
stand up slowly to avoid dizziness from orthostatic
hypotension. The medication should be continued, even
when symptoms have been controlled. If the medication must
be stopped, it should be slowly tapered over 1 to 2 weeks and
only under the supervision of a physician.
50.Ricky with chronic schizophrenia takes neuroleptic
medication is admitted to the psychiatric unit. Nursing
assessment reveals rigidity, fever, hypertension, and
diaphoresis. These findings suggest which
lifethreatening reaction:
A. Tardive dyskinesia.
B. Dystonia.
C. Neuroleptic malignant syndrome.
D. Akathisia.
Answer: (C) Neuroleptic malignant syndrome. The client’s
signs and symptoms suggest neuroleptic malignant syndrome,
a life-threatening reaction to neuroleptic medication that
requires immediate treatment. Tardive dyskinesia causes
involuntary movements of the tongue, mouth, facial muscles,
and arm and leg muscles. Dystonia is characterized by cramps
and rigidity of the tongue, face, neck, and back muscles.
Akathisia causes restlessness, anxiety, and jitteriness.
51.Which nursing intervention would be most appropriate if a
male client develop orthostatic hypotension while taking
amitriptyline (Elavil)?
A. Consulting with the physician about substituting a
different type of antidepressant.
B. Advising the client to sit up for 1 minute before getting
out of bed.
C. Instructing the client to double the dosage until the
problem resolves.
D. Informing the client that this adverse reaction should
disappear within 1 week.
Answer: (B) Advising the client to sit up for 1 minute before
getting out of bed. To minimize the effects of amitriptyline-
induced orthostatic hypotension, the nurse should advise the
client to sit up for 1 minute before getting out of bed.
Orthostatic hypotension commonly occurs with tricyclic
antidepressant therapy. In these cases, the dosage may
be reduced or the physician may prescribe nortriptyline,
another tricyclic antidepressant. Orthostatic hypotension
disappears only when the drug is discontinued.
52.Mr. Cruz visits the physician’s office to seek treatment for
depression, feelings of hopelessness, poor appetite, insomnia,
fatigue, low selfesteem, poor concentration, and difficulty
making decisions. The client states that these symptoms
began at least 2 years ago. Based on this report, the nurse
Tyfany suspects:
A. Cyclothymic disorder.
B. Atypical affective disorder.
C. Major depression.
D. Dysthymic disorder.
Answer: (D) Dysthymic disorder. Dysthymic disorder is marked
by feelings of depression lasting at least 2 years, accompanied
by at least two of the following symptoms: sleep disturbance,
appetite disturbance, low energy or fatigue, low
selfesteem, poor concentration, difficulty making decisions,
and hopelessness. These symptoms may be relatively
continuous or separated by intervening periods of normal
mood that last a few days to a few weeks. Cyclothymic
disorder is a chronic mood disturbance of at least 2 years’
duration marked by numerous periods of depression
and hypomania. Atypical affective disorder is characterized by
manic signs and symptoms. Major depression is a recurring,
persistent sadness or loss of interest or pleasure in almost all
activities, with signs and symptoms recurring for at least 2
weeks.
53. After taking an overdose of phenobarbital (Barbita), Mario
is admitted to the emergency department. Dr. Trinidad
prescribes activated charcoal (Charcocaps) to be administered
by mouth immediately. Before administering the dose, the
nurse verifies the dosage ordered. What is the usual
minimum dose of activated charcoal?
A. 5 g mixed in 250 ml of water
B. 15 g mixed in 500 ml of water
C. 30 g mixed in 250 ml of water
D. 60 g mixed in 500 ml of water
Answer: (C) 30 g mixed in 250 ml of water. The usual adult
dosage of activated charcoal is 5 to 10 times the estimated
weight of the drug or chemical ingested, or a minimum
dose of 30 g, mixed in 250 ml of water. Doses less than this
will be ineffective; doses greater than this can increase the
risk of adverse reactions, although toxicity doesn’t occur with
activated charcoal, even at the maximum dose.
54.What herbal medication for depression, widely used in
Europe, is now being prescribed in the United States?
A. Ginkgo biloba
B. Echinacea
C. St. John’s wort
D. Ephedra
Answer: (C) St. John’s wort. St. John’s wort has been found to
have serotonin-elevating properties, similar to prescription
antidepressants. Ginkgo biloba is prescribed to enhance
mental acuity. Echinacea has immune-stimulating properties.
Ephedra is a naturally occurring stimulant that is similar
to ephedrine.
55.Cely with manic episodes is taking lithium. Which
electrolyte level should the nurse check before administering
this medication?
A. Calcium
B. Sodium
C. Chloride
D. Potassium
Answer: (B) Sodium. Lithium is chemically similar to sodium. If
sodium levels are reduced, such as from sweating or diuresis,
lithium will be reabsorbed by the kidneys, increasing the risk
of toxicity. Clients taking lithium shouldn’t restrict their intake
of sodium and should drink adequate amounts of fluid each
day. The other electrolytes are important for normal body
functions but sodium is most important to the absorption of
lithium.
56.Nurse Josefina is caring for a client who has been
diagnosed with delirium. Which statement about delirium is
true?
A. It’s characterized by an acute onset and lasts about 1
month.
B. It’s characterized by a slowly evolving onset and lasts
about 1 week.
C. It’s characterized by a slowly evolving onset and lasts
about 1 month.
 D. It’s characterized by an acute onset and lasts hours to a
number of days.
Answer: (D) It’s characterized by an acute onset and lasts
hours to a number of days. Delirium has an acute onset and
typically can last from several hours to several days.
57.Edward, a 66 year old client with slight memory
impairment and poor concentration is diagnosed with
primary degenerative dementia of the Alzheimer’s type. Early
signs of this dementia include subtle personality changes and
withdrawal from social interactions. To assess for progression
to the middle stage of Alzheimer’s disease, the nurse
should observe the client for:
A. Occasional irritable outbursts.
B. Impaired communication.
C. Lack of spontaneity.
D. Inability to perform self-care activities.
Answer: (B) Impaired communication. Initially, memory
impairment may be the only cognitive deficit in a client with
Alzheimer’s disease. During the early stage of this
disease, subtle personality changes may also be present.
However, other than occasional irritable outbursts and lack
of spontaneity, the client is usually cooperative and exhibits
socially appropriate behavior. Signs of advancement to the
middle stage of Alzheimer’s disease include exacerbated
cognitive impairment with obvious personality changes
and impaired communication, such as inappropriate
conversation, actions, and responses. During the late stage,
the client can’t perform self-care activities and may become
mute
58.Isabel with a diagnosis of depression is started on
imipramine (Tofranil), 75 mg by mouth at bedtime. The nurse
should tell the client that:
A. This medication may be habit forming and will be
discontinued as soon as the client feels better.
B. This medication has no serious adverse effects.
C. The client should avoid eating such foods as aged
cheeses, yogurt, and chicken livers while taking the
medication.
D. This medication may initially cause tiredness, which
should become less bothersome over time.
Answer: (D) This medication may initially cause tiredness,
which should become less bothersome over time. Sedation is
a common early adverse effect of imipramine, a tricyclic
antidepressant, and usually decreases as tolerance
develops. Antidepressants aren’t habit forming and don’t
cause physical or psychological dependence. However, after a
long course of high-dose therapy, the dosage should be
decreased gradually to avoid mild withdrawal symptoms.
Serious adverse effects, although rare, include myocardial
infarction, heart failure, and tachycardia. Dietary
restrictions, such as avoiding aged cheeses, yogurt, and
chicken livers, are necessary for a client taking a monoamine
oxidase inhibitor, not a tricyclic antidepressant.
59.Kathleen is admitted to the psychiatric clinic for treatment
of anorexia nervosa. To promote the client’s physical health,
the nurse should plan to:
A. Severely restrict the client’s physical activities.
B. Weigh the client daily, after the evening meal.
C. Monitor vital signs, serum electrolyte levels, and acid-
base balance.
D. Instruct the client to keep an accurate record of food
and fluid intake.
Answer: (C) Monitor vital signs, serum electrolyte levels, and
acid-base balance. An anorexic client who requires
hospitalization is in poor physical condition from starvation
and may die as a result of arrhythmias, hypothermia,
malnutrition, infection, or cardiac abnormalities secondary
to electrolyte imbalances. Therefore, monitoring the client’s
vital signs, serum electrolyte level, and acid base balance is
crucial. Option A may worsen anxiety. Option B is incorrect
because a weight obtained after breakfast is more accurate
than one obtained after the evening meal. Option D
would reward the client with attention for not eating and
reinforce the control issues that are central to the underlying
psychological problem; also, the client may record food and
fluid intake inaccurately.
60.Celia with a history of polysubstance abuse is admitted to
the facility. She complains of nausea and vomiting 24 hours
after admission. The nurse assesses the client and notes
piloerection, pupillary dilation, and lacrimation. The nurse
suspects that the client is going through which of the
following withdrawals?
A. Alcohol withdrawal
B. Cannibis withdrawal
C. Cocaine withdrawal
D. Opioid withdrawal
Answer: (D) Opioid withdrawal. The symptoms listed are
specific to opioid withdrawal. Alcohol withdrawal would show
elevated vital signs. There is no real withdrawal from cannibis.
Symptoms of cocaine withdrawal include depression, anxiety,
and agitation.
61.Mr. Garcia, an attorney who throws books and furniture
around the office after losing a case is referred to the
psychiatric nurse in the law firm’s employee assistance
program. Nurse Beatriz knows that the client’s behavior most
likely represents the use of which defense mechanism?
A. Regression
B. Projection
C. Reaction-formation
D. Intellectualization
Answer: (A) Regression. An adult who throws temper
tantrums, such as this one, is displaying regressive behavior,
or behavior that is appropriate at a younger age. In
projection, the client blames someone or something
other than the source. In reaction formation, the client acts in
opposition to his feelings. In intellectualization, the client
overuses rational explanations orabstract thinking to decrease
the significance of a feeling or event.
62.Nurse Anne is caring for a client who has been treated long
term with antipsychotic medication. During the assessment,
Nurse Anne checks the client for tardive dyskinesia. If tardive
dyskinesia is present, Nurse Anne would most likely observe:
A. Abnormal movements and involuntary movements of
the mouth, tongue, and face.
B. Abnormal breathing through the nostrils accompanied
by a “thrill.”
C. Severe headache, flushing, tremors, and ataxia.
D. Severe hypertension, migraine headache,
Answer: (A) Abnormal movements and involuntary
movements of the mouth, tongue, and face. Tardive
dyskinesia is a severe reaction associated with long term use
of antipsychotic medication. The clinical manifestations
include abnormal movements (dyskinesia) and involuntary
movements of the mouth, tongue (fly catcher tongue), and
face.
63.Dennis has a lithium level of 2.4 mEq/L. The nurse
immediately would assess the client for which of the
following signs or symptoms?
A. Weakness
B. Diarrhea
C. Blurred vision
D. Fecal incontinence
Answer: (C) Blurred vision. At lithium levels of 2 to 2.5 mEq/L
the client will experienced blurred vision, muscle twitching,
severe hypotension, and persistent nausea and vomiting.
With levels between 1.5 and 2 mEq/L the client experiencing
vomiting, diarrhea, muscle weakness, ataxia,
dizziness, slurred speech, and confusion. At lithium levels of
2.5 to 3 mEq/L or higher, urinary and fecal incontinence
occurs, as well as seizures, cardiac dysrythmias, peripheral
vascular collapse, and death.
64.Nurse Jannah is monitoring a male client who has been
placed inrestraints because of violent behavior. Nurse
determines that it will be safe to remove the restraints when:
A. The client verbalizes the reasons for the violent
behavior.
B. The client apologizes and tells the nurse that it will
never happen again.
C. No acts of aggression have been observed within 1
hour after the release of two of the extremity
restraints.
D. The administered medication has taken effect.
Answer: (C) No acts of aggression have been observed
within 1 hour after the release of two of the extremity
restraints. The best indicator that the behavior is controlled,
if the client exhibits no signs of aggression after partial
release of restraints. Options A, B, and D do not ensure that
the client has controlled the behavior.
65.Nurse Irish is aware that Ritalin is the drug of choice for a
child with ADHD. The side effects of the following may be
noted by the nurse:
A. Increased attention span and concentration
B. Increase in appetite
C. Sleepiness and lethargy
D. Bradycardia and diarrhea
Answer: (A) increased attention span and concentration. The
medication has a paradoxic effect that decrease hyperactivity
and impulsivity among children with ADHD. B, C, D.
Side effects of Ritalin include anorexia, insomnia, diarrhea
and irritability.
66.Kitty, a 9 year old child has very limited vocabulary and
interaction skills. She has an I.Q. of 45. She is diagnosed to
have Mental retardation of this classification:
A. Profound
B. Mild
C. Moderate
D. Severe
Answer: (C) Moderate. The child with moderate mental
retardation has an I.Q. of 35- 50 Profound Mental retardation
has an I.Q. of below 20; Mild mental retardation 50-70 and
Severe mental retardation has an I.Q. of 20-35.
67.The therapeutic approach in the care of Armand an autistic
child include the following EXCEPT:
A. Engage in diversionary activities when acting -out
B. Provide an atmosphere of acceptance
C. Provide safety measures
D. Rearrange the environment to activate the child
Answer: (D) Rearrange the environment to activate the
child. The child with autistic disorder does not want
change. Maintaining a consistent environment is
therapeutic. A. Angry outburst can be re-channeling through
safe activities. B. Acceptance enhances a trusting
relationship. C. Ensure safety from self-destructive behaviors
like head banging and hair pulling
68.Jeremy is brought to the emergency room by friends who
state that he took something an hour ago. He is actively
hallucinating, agitated, with irritated nasal septum.
A. Heroin
B. Cocaine
C. LSD
D. Marijuana
Answer: (B) cocaine. The manifestations indicate intoxication
with cocaine, a CNS stimulant. A. Intoxication with heroine is
manifested by euphoria then impairment in judgment,
attention and the presence of papillary constriction. C.
Intoxication with hallucinogen like LSD is manifested
by grandiosity, hallucinations, synesthesia and increase in vital
signs D. Intoxication with Marijuana, a cannabinoid is
manifested by sensation of slowed time, conjunctival redness,
social withdrawal, impaired judgment and hallucinations.
69.Nurse Pauline is aware that Dementia unlike delirium is
characterized by:
A. Slurred speech
B. Insidious onset
C. Clouding of consciousness
D. Sensory perceptual change
Answer: (B) insidious onset. Dementia has a gradual onset
and progressive deterioration. It causes pronounced memory
and cognitive disturbances. A,C and D are all characteristics of
delirium.
70.A 35 year old female has intense fear of riding an elevator.
She claims “ As if I will die inside.” The client is suffering from:
A. Agoraphobia
B. Social phobia
C. Claustrophobia
D. Xenophobia
Answer: (C) Claustrophobia. Claustrophobia is fear of closed
space. A. Agoraphobia is fear of open space or being a
situation where escape is difficult. B. Social phobia is fear of
performing in the presence of others in a way that will
be humiliating or embarrassing. D. Xenophobia is fear of
strangers.
71.Nurse Myrna develops a counter-transference reaction.
This is evidenced by:
 A. Revealing personal information to the client
B. Focusing on the feelings of the client.
C. Confronting the client about discrepancies in verbal or
non-verbal behavior
D. The client feels angry towards the nurse who resembles
his mother.
Answer: (A) Revealing personal information to the
client. Counter-transference is an emotional reaction of the
nurse on the client based on her unconscious needs and
conflicts. B and C. These are therapeutic approaches. D. This is
transference reaction where a client has an emotional
reaction towards the nurse based on her past.
72.Tristan is on Lithium has suffered from diarrhea and
vomiting. What should the nurse in-charge do first:
A. Recognize this as a drug interaction
B. Give the client Cogentin
C. Reassure the client that these are common side effects
of lithium therapy
D. Hold the next dose and obtain an order for a stat
serum lithium level
Answer: (D) Hold the next dose and obtain an order for a stat
serum lithium level. Diarrhea and vomiting are manifestations
of Lithium toxicity. The next dose of lithium should be
withheld and test is done to validate the observation. A. The
manifestations are not due to drug interaction. B. Cogentin is
used to manage the extra pyramidal symptom side effects
of antipsychotics. C. The common side effects of Lithium are
fine hand tremors, nausea, polyuria and polydipsia.
73.Nurse Sarah ensures a therapeutic environment for all the
client. Which of the following best describes a therapeutic
milieu?
A. A therapy that rewards adaptive behavior
B. A cognitive approach to change behavior
C. A living, learning or working environment.
D. A permissive and congenial environment
Answer: (C) A living, learning or working environment. A
therapeutic milieu refers to a broad conceptual approach
in which all aspects of the environment are channeled to
provide a therapeutic environment for the client. The six
environmental elements include structure, safety, norms;
limit setting, balance and unit modification. A. Behavioral
approach in psychiatric care is based on the premise that
behavior can be learned or unlearned through the use
of reward and punishment. B. Cognitive approach to change
behavior is done by correcting distorted perceptions and
irrational beliefs to correct maladaptive behaviors. D. This is
not congruent with therapeutic milieu.
74.Anthony is very hostile toward one of the staff for no
apparent reason. He is manifesting:
A. Splitting
B. Transference
C. Countertransference
D. Resistance
Answer: (B) Transference. Transference is a positive or
negative feeling associated with a significant person in the
client’s past that are unconsciously assigned to another A.
Splitting is a defense mechanism commonly seen in a
client with personality disorder in which the world is
perceived as all good or all bad C. Countert-transference is a
phenomenon where the nurse shifts feelings assigned to
someone in her past to the patient D. Resistance is the client’s
refusal to submit himself to the care of the nurse
75.Marielle, 17 years old was sexually attacked while on her
way home from school. She is brought to the hospital by her
mother. Rape is an example of which type of crisis:
A. Situational
B. Adventitious
C. Developmental
D. Internal
Answer: (B) Adventitious. Adventitious crisis is a crisis
involving a traumatic event. It is not part of everyday life. A.
Situational crisis is from an external source that upset ones
psychological equilibrium C and D. Are the same. They are
transitional or developmental periods in life
76. Nurse Greta is aware that the following is classified as an
Axis I disorder by the Diagnosis and Statistical Manual of
Mental Disorders, Text Revision (DSM-IV-TR) is:
A. Obesity
B. Borderline personality disorder
C. Major depression
D. Hypertension
Answer: (C) Major depression. The DSM-IV-TR classifies major
depression as an Axis I disorder. Borderline personality
disorder as an Axis II; obesity and hypertension, Axis III.
77.Katrina, a newly admitted is extremely hostile toward a
staff member she has just met, without apparent reason.
According to Freudian theory, the nurse should suspect that
the client is experiencing which of the following phenomena?
A. Intellectualization
B. Transference
C. Triangulation
D. Splitting
Answer: (B) Transference. Transference is the unconscious
assignment of negative or positive feelings evoked by a
significant person in the client’s past to another person.
Intellectualization is a defense mechanism in which the client
avoids dealing with emotions by focusing on facts.
Triangulation refers to conflicts involving three family
members. Splitting is a defense mechanism commonly seen in
clients with personality disorder in which the world is
perceived as all good or all bad.
78.An 83year-old male client is in extended care facility is
anxious most of the time and frequently complains of a
number of vague symptoms that interfere with his ability to
eat. These symptoms indicate which of the following
disorders?
A. Conversion disorder
B. Hypochondriasis
C. Severe anxiety
D. Sublimation
Answer: (B) Hypochondriasis. Complains of vague physical
symptoms that have no apparent medical causes are
characteristic of clients with hypochondriasis. In many cases,
the GI system is affected. Conversion disorders are
characterized by one or more neurologic symptoms. The
client’s symptoms don’t suggest severe anxiety. A client
experiencing sublimation channels maladaptive feelings or
impulses into socially acceptable behavior
79. Charina, a college student who frequently visited the
health center during the past year with multiple vague
complaints of GI symptoms before course examinations.
Although physical causes have been eliminated, the
student continues to express her belief that she has a serious
illness. These symptoms are typically of which of the following
disorders?
A. Conversion disorder
B. Depersonalization
C. Hypochondriasis
D. Somatization disorder
Answer: (C) Hypochondriasis. Hypochodriasis in this case is
shown by the client’s belief that she has a serious illness,
although pathologic causes have been eliminated. The
disturbance usually lasts at lease 6 with identifiable
life stressor such as, in this case, course examinations.
Conversion disorders are characterized by one or more
neurologic symptoms. Depersonalization refers to persistent
recurrent episodes of feeling detached from one’s self or
body. Somatoform disorders generally have a chronic course
with few remissions
80. Nurse Daisy is aware that the following pharmacologic
agents are sedative hypnotic medication is used to induce
sleep for a client experiencing a sleep disorder is:
A. Triazolam (Halcion)
B. Paroxetine (Paxil)\
C. Fluoxetine (Prozac)
D. Risperidone (Risperdal)
Answer: (A) Triazolam (Halcion). Triazolam is one of a group of
sedative hypnotic medication that can be used for a limited
time because of the risk of dependence. Paroxetine is a
scrotonin-specific reutake inhibitor used for treatment
of depression panic disorder, and obsessive-compulsive
disorder. Fluoxetine is a scrotonin-specific reuptake inhibitor
used for depressive disorders and obsessive-compulsive
disorders. Risperidome is indicated for psychotic disorders.
81. Aldo, with a somatoform pain disorder may obtain
secondary gain. Which of the following statement refers to a
secondary gain?
A. It brings some stability to the family
B. It decreases the preoccupation with the physical illness
C. It enables the client to avoid some unpleasant activity
D. It promotes emotional support or attention for the
client
Answer: (D) It promotes emotional support or attention for
the client. Secondary gain refers to the benefits of the illness
that allow the client to receive emotional support or
attention. Primary gain enables the client to avoid some
unpleasant activity. A dysfunctional family may disregard the
real issue, although some conflict is relieved.
Somatoform pain disorder is a preoccupation with pain in the
absence of physical disease.
82. Dervid is diagnosed with panic disorder with agoraphobia
is talking with the nurse in-charge about the progress made in
treatment. Which of the following statements indicates a
positive client response?
A. “I went to the mall with my friends last Saturday”
B. “I’m hyperventilating only when I have a panic attack”
C. “Today I decided that I can stop taking my medication”
D. “Last night I decided to eat more than a bowl of cereal”
Answer: (A) “I went to the mall with my friends last
Saturday”. Clients with panic disorder tent to be socially
withdrawn. Going to the mall is a sign of working on
avoidance behaviors. Hyperventilating is a key symptom of
panic disorder. Teaching breathing control is a
major intervention for clients with panic disorder. The client
taking medications for panic disorder; such as tricylic
antidepressants and benzodiazepines, must be weaned off
these drugs. Most clients with panic disorder
with agoraphobia don’t have nutritional problems.
83. The effectiveness of monoamine oxidase (MAO) inhibitor
drug therapy in client with posttraumatic stress disorder can
be demonstrated by which of the following client self –
reports?
A. “I’m sleeping better and don’t have nightmares”
B. “I’m not losing my temper as much”
C. “I’ve lost my craving for alcohol”
D. “I’ve lost my phobia for water”
Answer: (A) “I’m sleeping better and don’t have
nightmares” MAO inhibitors are used to treat sleep problems,
nightmares, and intrusive daytime thoughts in individual with
posttraumatic stress disorder. MAO inhibitors aren’t used to
help control flashbacks or phobias or to decrease the craving
for alcohol.
84. Mark, with a diagnosis of generalized anxiety disorder
wants to stop taking his lorazepam (Ativan). Which of the
following important facts should nurse Betty discuss with the
client about discontinuing the medication?
A. Stopping the drug may cause depression
B. Stopping the drug increases cognitive abilities
C. Stopping the drug decreases sleeping difficulties
D. Stopping the drug can cause withdrawal symptoms
Answer: (D) Stopping the drug can cause withdrawal
symptoms. Stopping antianxiety drugs such as
benzodiazepines can cause the client to have withdrawal
symptoms. Stopping a benzodiazepine doesn’t tend to cause
depression, increase cognitive abilities, or decrease sleeping
difficulties.
85. Jennifer, an adolescent who is depressed and reported by
his parents as having difficulty in school is brought to the
community mental health center to be evaluated. Which of
the following other health problems would the
nurse suspect?
A. Anxiety disorder
B. Behavioral difficulties
C. Cognitive impairment
D. Labile moods
Answer: (B) Behavioral difficulties. Adolescents tend to
demonstrate severe irritability and behavioral problems
rather than simply a depressed mood. Anxiety disorder is
more commonly associated with small children rather than
with adolescents. Cognitive impairment is typically
associated with delirium or dementia. Labile mood is more
characteristic of a client with cognitive impairment or
bipolar disorder
86. Ricardo, an outpatient in psychiatric facility is diagnosed
with dysthymic disorder. Which of the following statement
about dysthymic disorder is true?
A. It involves a mood range from moderate depression to
hypomania
B. It involves a single manic depression
C. It’s a form of depression that occurs in the fall and
winter
D. It’s a mood disorder similar to major depression but of
mild to moderate severity
Answer: (D) It’s a mood disorder similar to major depression
but of mild to moderate severity. Dysthymic disorder is a
mood disorder similar to major depression but it remains mild
to moderate in severity. Cyclothymic disorder is a mood
disorder characterized by a mood range from
moderate depression to hypomania. Bipolar I disorder is
characterized by a single manic episode with no past major
depressive episodes. Seasonalaffective disorder is a form of
depression occurring in the fall and winter.
87. The nurse is aware that the following ways in vascular
dementia different from Alzheimer’s disease is:
A. Vascular dementia has more abrupt onset
B. The duration of vascular dementia is usually brief
C. Personality change is common in vascular dementia
D. The inability to perform motor activities occurs in
vascular dementia
Answer: (A) Vascular dementia has more abrupt
onset. Vascular dementia differs from Alzheimer’s disease in
that it has a more abrupt onset and runs a highly variable
course. Personally change is common in Alzheimer’s disease.
The duration of delirium is usually brief. The inability to carry
out motor activities is common in Alzheimer’s disease
88. Loretta, a newly admitted client was diagnosed with
delirium and has history of hypertension and anxiety. She had
been taking digoxin, furosemide (Lasix), and diazepam
(Valium) for anxiety. This client’s impairment may be related
to which of the following conditions?
A. Infection
B. Metabolic acidosis
C. Drug intoxication
D. Hepatic encephalopathy
Answer: (C) Drug intoxication. This client was taking several
medications that have a propensity for producing delirium;
digoxin (a digitalis glycoxide), furosemide (a thiazide diuretic),
and diazepam (a benzodiazepine). Sufficient supporting data
don’t exist to suspect the other options as causes.
89. Nurse Ron enters a client’s room, the client says, “They’re
crawling on my sheets! Get them off my bed!” Which of the
following assessment is the most accurate?
A. The client is experiencing aphasia
B. The client is experiencing dysarthria
C. The client is experiencing a flight of ideas
D. The client is experiencing visual hallucination
Answer: (D) The client is experiencing visual hallucination. The
presence of a sensory stimulus correlates with the definition
of a hallucination, which is a false sensory perception.
Aphasia refers to a communication problem. Dysarthria is
difficulty in speech production. Flight of ideas is rapid shifting
from one topic to another
90. Which of the following descriptions of a client’s
experience and behavior can be assessed as an illusion?
A. The client tries to hit the nurse when vital signs must be
taken
B. The client says, “I keep hearing a voice telling me to run
away”
C. The client becomes anxious whenever the nurse leaves
the bedside
D. The client looks at the shadow on a wall and tells the
nurse she sees frightening faces on the wall.
Answer: (D) The client looks at the shadow on a wall and tells
the nurse she sees frightening faces on the wall. Minor
memory problems are distinguished from dementia by their
minor severity and their lack of significant interference with
the client’s social or occupational lifestyle. Other options
would be included in the history data but don’t directly
correlate with the client’s lifestyle.
91. During conversation of Nurse John with a client, he
observes that the client shift from one topic to the next on a
regular basis. Which of the following terms describes this
disorder?
A. Flight of ideas
B. Concrete thinking
C. Ideas of reference
D. Loose association
Answer: (D) Loose association. Loose associations are
conversations that constantly shift in topic. Concrete
thinking implies highly definitive thought processes. Flight of
ideas is characterized by conversation that’s disorganized
from the onset. Loose associations don’t necessarily start in
a cogently, then becomes loose
92. Francis tells the nurse that her coworkers are sabotaging
the computer. When the nurse asks questions, the client
becomes argumentative. This behavior shows personality
traits associated with which of the following personality
disorder?
A. Antisocial
B. Histrionic
C. Paranoid
D. Schizotypal
Answer: (C) Paranoid. Because of their suspiciousness,
paranoid personalities ascribe malevolent activities to others
and tent to be defensive, becoming quarrelsome and
argumentative. Clients with antisocial personality disorder
can also be antagonistic and argumentative but are
less suspicious than paranoid personalities. Clients with
histrionic personality disorder are dramatic, not suspicious
and argumentative. Clients with schizoid personality disorder
are usually detached from other and tend to have eccentric
behavior.
93. Which of the following interventions is important for a
Cely experiencing with paranoid personality disorder taking
olanzapine (Zyprexa)?
A. Explain effects of serotonin syndrome
B. Teach the client to watch for extrapyramidal adverse
reaction
 C. Explain that the drug is less affective if the client
smokes
D. Discuss the need to report paradoxical effects such as
euphoria
Answer: (C) Explain that the drug is less affective if the client
smokes. Olanzapine (Zyprexa) is less effective for clients who
smoke cigarettes. Serotonin syndrome occurs with clients who
take a combination of antidepressant medications.
Olanzapine doesn’t cause euphoria, and extrapyramidal
adverse reactions aren’t a problem. However, the client
should be aware of adverse effects such as tardive dyskinesia.
94. Nurse Alexandra notices other clients on the unit avoiding
a client diagnosed with antisocial personality disorder. When
discussing appropriate behavior in group therapy, which of
the following comments is expected about this client by his
peers?
A. Lack of honesty
B. Belief in superstition
C. Show of temper tantrums
D. Constant need for attention
Answer: (A) Lack of honesty. Clients with antisocial
personality disorder tent to engage in acts of dishonesty,
shown by lying. Clients with schizotypal personality disorder
tend to be superstitious. Clients with histrionic
personality disorders tend to overreact to frustrations and
disappointments, have temper tantrums, and seek attention.
95. Tommy, with dependent personality disorder is working to
increase his selfesteem. Which of the following statements by
the Tommy shows teaching was successful?
A. “I’m not going to look just at the negative things about
myself”
B. “I’m most concerned about my level of competence and
progress”
C. “I’m not as envious of the things other people have as I
used to be”
D. “I find I can’t stop myself from taking over things other
should be doing”
Answer: (A) “I’m not going to look just at the negative things
about myself”. As the clients makes progress on improving
self-esteem, selfblame and negative self evaluation will
decrease. Clients with dependent personality disorder tend to
feel fragile and inadequate and would be extremely unlikely
to discuss their level of competence and progress. These
clients focus on self and aren’t envious or jealous. Individuals
with dependent personality disorders don’t take over
situations because they see themselves as inept and
inadequate.
96. Norma, a 42-year-old client with a diagnosis of chronic
undifferentiated schizophrenia lives in a rooming house that
has a weekly nursing clinic. She scratches while she tells the
nurse she feels creatures eating away at her skin. Which of
the following interventions should be done first?
A. Talk about his hallucinations and fears
B. Refer him for anticholinergic adverse reactions
C. Assess for possible physical problems such as rash
D. Call his physician to get his medication increased to
control his psychosis
Answer: (C) Assess for possible physical problems such as
rash. Clients with schizophrenia generally have poor
visceral recognition because they live so fully in their fantasy
world. They need to have as in-depth assessment of physical
complaints that may spill over into their delusional symptoms.
Talking with the client won’t provide as assessment of his
itching, and itching isn’t as adverse reaction of antipsychotic
drugs, calling the physician to get the client’s
medication increased doesn’t address his physical complaints.
97. Ivy, who is on the psychiatric unit is copying and imitating
the movements of her primary nurse. During recovery, she
says, “I thought the nurse was my mirror. I felt connected only
when I saw my nurse.” This behavior is known by which of the
following terms?
A. Modeling
B. Echopraxia
C. Ego-syntonicity
D. Ritualism
Answer: (B) Echopraxia. Echopraxia is the copying of
another’s behaviors and is the result of the loss of ego
boundaries. Modeling is the conscious copying of someone’s
behaviors. Ego-syntonicity refers to behaviors that
correspond with the individual’s sense of self. Ritualism
behaviors are repetitive and compulsive
98. Jun approaches the nurse and tells that he hears a voice
telling him that he’s evil and deserves to die. Which of the
following terms describes the client’s perception?
A. Delusion
B. Disorganized speech
C. Hallucination
D. Idea of reference
Answer: (C) Hallucination. Hallucinations are sensory
experiences that are misrepresentations of reality or have no
basis in reality. Delusions are beliefs not based in reality.
Disorganized speech is characterized by jumping from one
topic to the next or using unrelated words. An idea
of reference is a belief that an unrelated situation holds
special meaning for the client.
99. Mike is admitted to a psychiatric unit with a diagnosis of
undifferentiated schizophrenia. Which of the following
defense mechanisms is probably used by mike?
A. Projection
B. Rationalization
C. Regression
D. Repression
Answer: (C) Regression. Regression, a return to earlier
behavior to reduce anxiety, is the basic defense mechanism
in schizophrenia. Projection is a defense mechanism in which
one blames others and attempts to justify actions; it’s used
primarily by people with paranoid schizophrenia and
delusional disorder. Rationalization is a defense mechanism
used to justify one’s action. Repression is the basic defense
mechanism in the neuroses; it’s an involuntary exclusion of
painful thoughts, feelings, or experiences from awareness
100. Rocky has started taking haloperidol (Haldol). Which of
the following instructions is most appropriate for Ricky before
taking haloperidol?
A. Should report feelings of restlessness or agitation at
once
B. Use a sunscreen outdoors on a year-round basis
C. Be aware you’ll feel increased energy taking this drug
 D. This drug will indirectly control essential hypertension
Answer: (A) Should report feelings of restlessness or agitation
at once. Agitation and restlessness are adverse effect of
haloperidol and can be treated with antocholinergic drugs.
Haloperidol isn’t likely to cause photosensitivity or control
essential hypertension. Although the client may experience
increased concentration and activity, these effects are due to
a decreased in symptoms, not the drug itself.
SET 2
PNLE I Nursing Practice
Scope of this Nursing Test I is parallel to the NP1
NLE Coverage:
 Foundation of Nursing
 Nursing Research
 Professional Adjustment
 Leadership and Management
1. The registered nurse is planning to delegate
tasks to unlicensed assistive personnel (UAP).
Which of the following task could the registered
nurse safely assigned to a UAP?
A. Monitor the I&O of a comatose toddler client
with salicylate poisoning
B. Perform a complete bed bath on a 2-year-old
with multiple injuries from a serious fall
C. Check the IV of a preschooler with Kawasaki
disease
D. Give an outmeal bath to an infant with
eczema
Answer: D. Bathing an infant with eczema can be
safely delegated to an aide; this task is basic
and can competently performed by an aid.
2. A nurse manager assigned a registered nurse
from telemetry unit to the pediatrics unit. There
were three patients assigned to the RN. Which of
the following patients should not be assigned to
the floated nurse?
A. A 9-year-old child diagnosed with rheumatic
fever
B. A young infant after pyloromyotomy
C. A 4-year-old with VSD following cardiac
catheterization
D. A 5-month-old with Kawasaki disease
Answer: B. The RN floated from the telemetry
unit would be least prepared to care for a young
infant who has just had GI surgery and requires
a specific feeding regimen.
3. A nurse in charge in the pediatric unit is
absent. The nurse manager decided to assign the
nurse in the obstetrics unit to the pediatrics unit.
Which of the following patients could the nurse
manager safely assign to the float nurse?
A. A child who had multiple injuries from a
serious vehicle accident
B. A child diagnosed with Kawasaki disease and
with cardiac complications
C. A child who has had a nephrectomy for
Wilm’s tumor
D. A child receiving an IV chelating therapy for
lead poisoning
Answer: C. RN floated from the obstetrics unit
should be able to care for a client with major
abdominal surgery, because this nurse has
experienced caring for clients with cesarean
births.
4. The registered nurse is planning to delegate
task to a certified nursing assistant. Which of the
following clients should not be assigned to a
CAN?
A. A client diagnosed with diabetes and
who has an infected toe
B. A client who had a CVA in the past two
months
C. A client with Chronic renal failure
D. A client with chronic venous insufficiency
Answer: A. The patient is experiencing a
potentially serious complication related to
diabetes and needs ongoing assessment by an
RN
5. The nurse in the medication unit passes the
medications for all the clients on the nursing unit.
The head nurse is making rounds with the
physician and coordinates clients’ activities with
other departments. The nurse assistant changes
the bed lines and answers call lights. A second
nurse is assigned for changing wound dressings;
a licensed practitioner nurse takes vital signs and
bathes theclients. This illustrates of what method
of nursing care?
A. Case management method
B. Primary nursing method
C. Team method
D. Functional method
Answer: D. It describes functional nursing. Staff
is assigned to specific task rather than specific
clients.
6. A registered nurse has been assigned to six
clients on the 12-hour shift. The RN is responsible
for every aspect of care such as formulating the
care of plan, intervention and evaluating the care
during her shift. At the end of her shift, the RN
will pass this same task to the next RN in charge.
This nursing care illustrates of what kind of
method?
A. primary nursing method
B. case method
C. team method
D. functional method
Answer: B. Case management. The nurse
assumes total responsibility for meeting the
needs of the client during her entire duty.
7. A newly hired nurse on an adult medicine unit
with 3 months experience was asked to float to
pediatrics. The nurse hesitates to perform
pediatric skills and receive an interesting
assignment that feels overwhelming. The nurse
should:
A. resign on the spot from the nursing position
and apply for a position that does not require
floating
B. Inform the nursing supervisor and the
charge nurse on the pediatric floor
about the nurse’s lack of skill and
feelings of hesitations and request
assistance
C. Ask several other nurses how they feel about
pediatrics and find someone else who is
willing to accept the assignment
D. Refuse the assignment and leave the unit
requesting a vacation a day
Answer: B. The nurse is ethically obligated to
inform the person responsible for the
assignment and the person responsible for the
unit about the nurse’s skill level. The nurse
therefore avoids a situation of abandoningclients
and exposing them to greater risks
8. An experienced nurse who voluntarily trained a
less experienced nurse with the intention of
enhancing the skills and knowledge and
promoting professional advancement to the nurse
is called a:
A. mentor
B. team leader
C. case manager
D. change agent
Answer: A. This describes a mentor
9. The pediatrics unit is understaffed and the
nurse manager informs the nurses in the
obstetrics unit that she is going to assign one
nurse to float in the pediatric units. Which
statement by the designated float nurse may put
her job at risk?
A. “I do not get along with one of the nurses on
the pediatrics unit”
B. “I have a vacation day coming and
would like to take that now”
C. “I do not feel competent to go and work on
that area”
D. “ I am afraid I will get the most serious
clients in the unit”
Answer:B. This action demonstrates a lack of
responsibility and the nurse should attempt
negotiation with the nurse manager
10. The newly hired staff nurse has been working
on a medical unit for 3 weeks. The nurse
manager has posted the team leader
assignments for the following week. The new staff
knows that a major responsibility of the team
leader is to:
A. Provide care to the most acutely ill client on
the team
B. Know the condition and needs of all the
patients on the team
C. Document the assessments completed by
the team members
D. Supervise direct care by nursing assistants
Answer: B. The team leader is responsible for the
overall management of all clients and staff on
the team, and this information is essential in
order to accomplish this
11. A 15-year-old girl just gave birth to a baby
boy who needs emergency surgery. The nurse
prepared the consent form and it should be
signed by:
A. The Physician
B. The Registered Nurse caring for the client
C. The 15-year-old mother of the baby boy
D. The mother of the girl
Answer: C. Even though the mother is a minor,
she is legally able to sign consent for her own
child.
12. A nurse caring to a client with Alzheimer’s
disease overheard a family member say to the
client, “if you pee one more time, I won’t give you
any more food and drinks”. What initial action is
best for the nurse to take?
A. Take no action because it is the family
member saying that to the client
B. Talk to the family member and explain
that what she/he has said is not
appropriate for the client
C. Give the family member the number for an
Elder Abuse Hot line
D. Document what the family member has said
Answer: B. This response is the most direct and
immediate. This is a case of potential need for
advocacy and patient’s rights.
13. Which is true about informed consent?
A. A nurse may accept responsibility signing a
consent form if the client is unable
B. Obtaining consent is not the responsibility of
the physician
C. A physician will not subject himself to liability
if he withholds any facts that are necessary
to form the basis of an intelligent consent
D. If the nurse witnesses a consent for
surgery, the nurse is, in effect,
indicating that the signature is that of
the purported person and that the
person’s condition is as indicated at the
time of signing
Answer: D. The nurse who witness a consent for
treatment or surgery is witnessing only that the
client signed the form and that the client’s
condition is as indicated at the time of signing.
The nurse is not witnessing that the client is
“informed”.
14. A mother in labor told the nurse that she was
expecting that her baby has no chance to survive
and expects that the baby will be born dead. The
mother accepts the fate of the baby and informs
the nurse that when the baby is born and requires
resuscitation, the mother refuses any treatment
to her baby and expresses hostility toward the
nurse while the pediatric team is taking care of
the baby. The nurse is legally obligated to:
A. Notify the pediatric team that the mother has
refused resuscitation and any treatment for
the baby and take the baby to the mother
B. Get a court order making the baby a ward of
the court
C. Record the statement of the mother,
notify the pediatric team, and observe
carefully for signs of impaired bonding
 and neglect as a reasonable suspicion
of child abuse
D. Do nothing except record the mother’s
statement in the medical record
Answer: C. Although the statements by the
mother may not create a suspicion of neglect,
when they are coupled with observations about
impaired bonding and maternal attachment,
they may impose the obligation to report child
neglect. The nurse is further obligated to notify
caregivers of refusal to consent to treatment
15. The hospitalized client with a chronic cough is
scheduled for bronchoscopy. The nurse is tasks to
bring the informed consent document into the
client’s room for a signature. The client asks the
nurse for details of the procedure and demands
an explanation why the process of informed
consent is necessary. The nurse responds that
informed consent means:
A. The patient releases the physician from all
responsibility for the procedure.
B. The immediate family may make decision
against the patient’s will.
C. The physician must give the client or
surrogates enough information to make
health care judgments consistent with
their values and goals.
D. The patient agrees to a procedure ordered by
the physician even if the client does not
understand what the outcome will be.
1. Answer: C. It best explains what informed
consent is and provides for legal rights of the
patient
16. A hospitalized client with severe necrotizing
ulcer of the lower leg is schedule for an
amputation. The client tells the nurse that he will
not sign the consent form and he does not want
any surgery or treatment because of religious
beliefs about reincarnation. What is the role of
the RN?
A. call a family meeting
B. discuss the religious beliefs with the
physician
C. encourage the client to have the surgery
D. inform the client of other options
Answer: B. The physician may not be aware of
the role that religious beliefs play in making a
decision about surgery.
17. While in the hospital lobby, the RN overhears
the three staff discussing the health condition of
her client. What would be the appropriate nursing
action for the RN to take?
A. Tell them it is not appropriate to discuss
the condition of the client
B. Ignore them, because it is their right to
discuss anything they want to
C. Join in the conversation, giving them
supportive input about the case of the client
D. Report this incident to the nursing supervisor
Answer: A. The behavior should be stopped. The
first step is to remind the staff that
confidentiality may be violated
18. A staff nurse has had a serious issue with her
colleague. In this situation, it is best to:
A. Discuss this with the supervisor
B. Not discuss the issue with anyone. It will
probably resolve itself
C. Try to discuss with the colleague about
the issue and resolve it when both are
calmer
D. Tell other members of the network what the
team member did
Answer: C. Waiting for emotions to dissipate and
sitting down with the colleague is the first rule of
conflict resolution.
19. The nurse is caring to a client who just gave
birth to a healthy baby boy. The nurse may not
disclose confidential information when:
A. The nurse discusses the condition of the
client in a clinical conference with other
nurses
B. The client asks the nurse to discuss the her
condition with the family
C. The father of a woman who just
delivered a baby is on the phone to find
out the sex of the baby
D. A researcher from an institutionally approved
research study reviews the medical record of
a patient
Answer: C. The nurse has no idea who the
person is on the phone and therefore may not
share the information even if the patient gives
permission
20. A 17-year-old married client is scheduled for
surgery. The nurse taking care of the client
realizes that consent has not been signed after
preoperative medications were given. What
should the nurse do?
A. Call the surgeon
B. Ask the spouse to sign the consent
C. Obtain a consent from the client as soon as
possible
D. Get a verbal consent from the parents of the
client
Answer: A. The priority is to let the surgeon
know, who in turn may ask the husband to sign
the consent
21. A 12-year-old client is admitted to the
hospital. The physician ordered Dilantin to the
client. In administering IV phenytoin (Dilantin) to
a child, the nurse would be most correct in mixing
it with:
A. Normal Saline
B. Heparinized normal saline
C. 5% dextrose in water
D. Lactated Ringer’s solution
Answer: A. Phenytoin (Dilantin) can cause
venous irritation due to its alkalinity, therefore it
should be mixed with normal saline.
22. The nurse is caring to a client who is
hypotensive. Following a large hematemesis, how
should the nurse position the client?
A. Feet and legs elevated 20 degrees,
trunk horizontal, head on small pillow
B. Low Fowler’s with knees gatched at 30
degrees
C. Supine with the head turned to the left
D. Bed sloped at a 45 degree angle with the
head lowest and the legs highest
Answer: A. This position increases venous return,
improves cardiac volume, and promotes
adequate ventilation and cerebral perfusion
23. The client is brought to the emergency
department after a serious accident. What would
be the initial nursing action of the nurse to the
client?
A. assess the level of consciousness and
circulation
B. check respirations, circulation, neurological
response
C. align the spine, check pupils, check for
hemorrhage
D. check respiration, stabilize spine, check
circulation
Answer: D. Checking the airway would be a
priority, and a neck injury should be suspected
24. A nurse is assigned to care to a client with
Parkinson’s disease. What interventions are
important if the nurse wants to improve nutrition
and promote effective swallowing of the client?
A. Eat solid food
B. Give liquids with meals
C. Feed the client
D. Sit in an upright position to eat
Answer: D. Client with Parkinson’s disease are at
a high risk for aspiration and undernutrition.
Sitting upright promotes more effective
swallowing.
25. During tracheal suctioning, the nurse should
implement safety measures. Which of the
following should the nurse implements?
A. limit suction pressure to 150-180 mmHg
B. suction for 15-20 seconds
C. wear eye goggles
D. remove the inner cannula
Answer: C. It is important to protect the RN’s
eyes from the possible contamination of
coughed-up secretions
26. The nurse is conducting a discharge
instructions to a client diagnosed with diabetes.
What sign of hypoglycemia should be taught to a
client?
A. warm, flushed skin
B. hunger and thirst
C. increase urinary output
D. palpitation and weakness
Answer: D. There has been too little food or too
much insulin. Glucose levels can be markedly
decreased (less than 50 mg/dl). Severe
hypoglycemia may be fatal if not detected
27. A client admitted to the hospital and
diagnosed with Addison’s disease. What would be
the appropriate nursing action to the client?
A. administering insulin-replacement therapy
B. providing a low-sodium diet
C. restricting fluids to 1500 ml/day
D. reducing physical and emotional stress
Answer: D. Because the client’s ability to react
to stress is decreased, maintaining a quiet
environment becomes a nursing priority.
Dehydration is a common problem in Addison’s
disease, so close observation of the client’s
hydration level is crucial.
28. The nurse is to perform tracheal suctioning.
During tracheal suctioning, which nursing action
is essential to prevent hypoxemia?
A. aucultating the lungs to determine the
baseline data to assess the effectiveness of
suctioning
B. removing oral and nasal secretions
C. encouraging the patient to deep breathe and
cough to facilitate removal of upper-airway
secretions
D. administering 100% oxygen to reduce
the effects of airway obstruction during
suctioning.
Answer: D. Presuctioning and postsuctioning
ventilation with 100% oxygen is important in
reducing hypoxemia which occurs when the flow
of gases in the airway is obstructed by the
suctioning catheter.
29. An infant is admitted and diagnosed with
pneumonia and suspicious-looking red marks on
the swollen face resembling a handprint. The
nurse does further assessment to the client. How
would the nurse document the finding?
A. Facial edema with ecchymosis and handprint
mark: crackles and wheezes
B. Facial edema, with red marks; crackles
in the lung
C. Facial edema with ecchymosis that looks like
a handprint
D. Red bruise mark and ecchymosis on face
Answer: B. This is an example of objective data
of both pulmonary status and direct observation
on the skin by the nurse.
30. On the evening shift, the triage nurse
evaluates several clients who were brought to the
emergency department. Which in the following
clients should receive highest priority?
A. an elderly woman complaining of a loss of
appetite and fatigue for the past week
B. A football player limping and complaining of
pain and swelling in the right ankle
C. A 50-year-old man, diaphoretic and
complaining of severe chest pain
radiating to his jaw
D. A mother with a 5-year-old boy who says her
son has been complaining of nausea and
vomited once since noon
Answer: C. These are likely signs of an acute
myocardial infarction (MI). An acute MI is a
cardiovascular emergency requiring immediate
attention. Acute MI is potentially fatal if not
treated immediately.
31. A 80-year-old female client is brought to the
emergency department by her caregiver, on the
nurse’s assessment; the following are the
manifestations of the client: anorexia, cachexia
and multiple bruises. What would be the best
nursing intervention?
A. check the laboratory data for serum albumin,
hematocrit, and hemoglobin
B. talk to the client about the caregiver and
support system
C. complete a police report on elder abuse
D. complete a gastrointestinal and
neurological assessment
Answer: D. Assessment and more data collection
are needed. The client may have gastrointestinal
or neurological problems that account for the
symptoms. The anorexia could result from
medications, poor dentition, or indigestion, and
the bruises may be attributed to ataxia, frequent
falls, vertigo or medication.
32. The night shift nurse is making rounds. When
the nurse enters a client’s room, the client is on
the floor next to the bed. What would be the
initial action of the nurse?
A. chart that the patient fell
B. call the physician
C. chart that the client was found on the floor
next to the bed
D. fill out an incident report
Answer: B. This is closest to suggesting action-
assessment, rather than paperwork- and is
therefore the best of the four.
33. The nurse on the night shift is about to
administer medication to a preschooler client and
notes that the child has no ID bracelet. The best
way for the nurse to identify the client is to ask:
A. The adult visiting, “The child’s name is
____________________?”
B. The child, “Is your name____________?”
C. Another staff nurse to identify this child
D. The other children in the room what the
child’s name is
Answer: C. The only acceptable way to identify a
preschooler client is to have a parent or another
staff member identify the client.
34. The nurse caring to a client has completed
the assessment. Which of the following will be
considered to be the most accurate charting of a
lump felt in the right breast?
A. “abnormally felt area in the right breast,
drainage noted”
B. “hard nodular mass in right breast nipple”
C. “firm mass at five ‘ clock, outer
quadrant, 1cm from right nipple’
D. “mass in the right breast 4cmx1cm
Answer: C. It describes the mass in the greatest
detail.
35. The physician instructed the nurse that
intravenous pyelogram will be done to the client.
The client asks the nurse what is the purpose of
the procedure. The appropriate nursing response
is to:
A. outline the kidney vasculature
B. determine the size, shape, and placement of
the kidneys
C. test renal tubular function and the
patency of the urinary tract
D. measure renal blood flow
Answer: C. Intravenous pyelogram tests both the
function and patency of the kidneys. After the
intravenous injection of a radiopaque contrast
medium, the size, location, and patency of the
kidneys can be observed by roentgenogram, as
well as the patency of the urethra and bladder
as the kidneys function to excrete the contrast
medium.
36. A client visits the clinic for screening of
scoliosis. The nurse should ask the client to:
A. bend all the way over and touch the toes
B. stand up as straight and tall as possible
C. bend over at a 90-degree angle from
the waist
D. bend over at a 45-degree angle from the
waist
Answer: C. This is the recommended position for
screening for scoliosis. It allows the nurse to
inspect the alignment of the spine, as well as to
compare both shoulders and both hips.
37. A client with tuberculosis is admitted in the
hospital for 2 weeks. When a client’s family
members come to visit, they would be adhering
to respiratory isolation precautions when they:
A. wash their hands when leaving
B. put on gowns, gloves and masks
C. avoid contact with the client’s roommate
D. keep the client’s room door open
Answer: A. Handwashing is the best method for
reducing cross-contamination. Gowns and gloves
are not always required when entering a client’s
room.
38. An infant is brought to the emergency
department and diagnosed with pyloric stenosis.
The parents of the client ask the nurse, “Why
does my baby continue to vomit?” Which of the
following would be the best nursing response of
the nurse?
A. “Your baby eats too rapidly and overfills the
stomach, which causes vomiting
B. “Your baby can’t empty the formula that
is in the stomach into the bowel”
C. “The vomiting is due to the nausea that
accompanies pyloric stenosis”
D. “Your baby needs to be burped more
thoroughly after feeding”
Answer: B. Pyloric stenosis is an anomaly of the
upper gastrointestinal tract. The condition
involves a thickening, or hypertrophy, of the
pyloric sphincter located at the distal end of the
stomach. This causes a mechanical intestinal
obstruction, which leads to vomiting after
feeding the infant. The vomiting associated with
pyloric stenosis is described as being projectile
in nature. This is due to the increasing amounts
of formula the infant begins to consume coupled
with the increasing thickening of the pyloric
sphincter.
39. A 70-year-old client with suspected
tuberculosis is brought to the geriatric care
facilities. An intradermal tuberculosis test is
schedule to be done. The client asks the nurse
what is the purpose of the test. Which of the
following would be the best rationale for this?
A. reactivation of an old tuberculosis infection
B. increased incidence of new cases of
tuberculosis in persons over 65 years
old
C. greater exposure to diverse health care
workers
D. respiratory problems are characteristic in this
population
Answer: B. Increased incidence of TB has been
seen in the general population with a high
incidence reported in hospitalized elderly clients.
Immunosuppression and lack of classic
manifestations because of the aging process are
just two of the contributing factors of
tuberculosis in the elderly.
40. The nurse is making a health teaching to the
parents of the client. In teaching parents how to
measure the area of induration in response to a
PPD test, the nurse would be most accurate in
advising the parents to measure:
A. both the areas that look red and feel raised
B. The entire area that feels itchy to the child
C. Only the area that looks reddened
D. Only the area that feels raised
Answer: D. Parents should be taught to feel the
area that is raised and measure only that
41. A community health nurse is schedule to do
home visit. She visits to an elderly person living
alone. Which of the following observation would
be a concern?
A. Picture windows
B. Unwashed dishes in the sink
C. Clear and shiny floors
D. Brightly lit rooms
Answer: C. It is a safety hazard to have shiny
floors because they can cause falls.
42. After a birth, the physician cut the cord of the
baby, and before the baby is given to the mother,
what would be the initial nursing action of the
nurse?
A. examine the infant for any observable
abnormalities
B. confirm identification of the infant and apply
bracelet to mother and infant
C. instill prophylactic medication in the infant’s
eyes
D. wrap the infant in a prewarmed blanket
and cover the head
Answer:D. The first priority, beside maintaining a
newborn’s patent airway, is body temperature.
43. A 2-year-old client is admitted to the hospital
with severe eczema lesions on the scalp, face,
neck and arms. The client is scratching the
affected areas. What would be the best nursing
intervention to prevent the client from scratching
the affected areas?
A. elbow restraints to the arms
B. Mittens to the hands
C. Clove-hitch restraints to the hands
D. A posey jacket to the torso
Answer: B. The purpose of restraints for this
child is to keep the child from scratching the
affected areas. Mittens restraint would prevent
scratching, while allowing the most movement
permissible.
44. The parents of the hospitalized client ask the
nurse how their baby might have gotten pyloric
stenosis. The appropriate nursing response would
be:
A. There is no way to determine this
preoperatively
B. Their baby was born with this condition
C. Their baby developed this condition
during the first few weeks of life
D. Their baby acquired it due to a formula
allergy
Answer: C. Pyloric stenosis is not a congenital
anatomical defect, but the precise etiology is
unknown. It develops during the first few weeks
of life.
45. A male client comes to the clinic for check-up.
In doing a physical assessment, the nurse should
report to the physician the most common
symptom of gonorrhea, which is:
A. pruritus
B. pus in the urine
C. WBC in the urine
D. Dysuria
Answer: B. Pus is usually the first symptom,
because the bacteria reproduce in the bladder.
46. Which of the following would be the most
important goal in the nursing care of an infant
client with eczema?
A. preventing infection
B. maintaining the comfort level
C. providing for adequate nutrition
D. decreasing the itching
Answer:A. Preventing infection in the infant with
eczema is the nurse’s most important goal. The
infant with eczema is at high risk for infection
due to numerous breaks in the skin’s integrity.
Intact skin is always the infant’s first line of
defense against infection.
47. The nurse is making a discharge instruction to
a client receiving chemotherapy. The client is at
risk for bone marrow depression. The nurse gives
instructions to the client about how to prevent
infection at home. Which of the following health
teaching would be included?
A. “Get a weekly WBC count”
B. “Do not share a bathroom with children or
pregnant woman”
C. “Avoid contact with others while receiving
chemotherapy”
D. “Do frequent hand washing and
maintain good hygiene”
Answer: D. Frequent hand washing and good
hygiene are the best means of preventing
infection.
48. The nurse is assigned to care the client with
infectious disease. The best antimicrobial agent
for the nurse to use in handwashing is:
A. Isopropyl alcohol
B. Hexachlorophene (Phisohex)
C. Soap and water
D. Chlorhexidine gluconate (CHG)
(Hibiclens)
Answer: D. CHG is a highly effective
antimicrobial ingredient, especially when it is
used consistently over time.
49. The mother of the client tells the nurse, “ I’m
not going to have my baby get any
immunization”. What would be the best nursing
response to the mother?
A. “You and I need to review your
rationale for this decision”
B. “Your baby will not be able to attend day
care without immunizations”
C. “Your decision can be viewed as a form of
child abuse and neglect”
D. “You are needlessly placing other people at
risk for communicable diseases”
Answer: A. The mother may have many reasons
for such a decision. It is the nurse’s
responsibility to review this decision with the
mother and clarify any misconceptions regarding
immunizations that may exist.
50. The nurse is teaching the client about breast
self-examination. Which observation should the
client be taught to recognize when doing the
examination for detection of breast cancer?
A. tender, movable lump
B. pain on breast self-examination
C. round, well-defined lump
D. dimpling of the breast tissue
Answer: D. The tumor infiltrates nearby tissue, it
can cause retraction of the overlying skin and
create a dimpling appearance.
PNLE II Nursing Practice
The scope of this Nursing Test II is parallel to the NP2 NLE
Coverage:
 Maternal and Child Health
 Community Health Nursing
 Communicable Diseases
 Integrated Management of Childhood Illness
1. The student nurse is assigned to take the vital signs of the
clients in the pediatric ward. The student nurse reports to the
staff nurse that the parent of a toddler who is 2 days
postoperative after a cleft palate repair has given the toddler
a pacifier. What would be the best immediate action of the
nurse?
A. Notify the pediatrician of this finding
B. Reassure the student that this is an acceptable action on
the parent’s part
C. Discuss this action with the parents
D. Ask the student nurse to remove the pacifier from the
toddler’s mouth
Answer: C. Nothing must be placed in the mouth of a toddler
who just undergone a cleft palate repair until the suture line
has completely healed. It is the nurse’s responsibility to
inform the parent of the client. Spoon, forks, straws, and
tongue blades are other unacceptable items to place in the
mouth of a toddler who just undergone cleft palate repair.
The general principle of care is that nothing should enter the
mouth until the suture line has completely healed.
2. The nurse is providing a health teaching to the mother of
an 8-year-old child with cystic fibrosis. Which of the following
statement if made by the mother would indicate to the nurse
the need for further teaching about the medication regimen
of the child?
A. “My child might need an extra capsule if the meal is
high in fat”
B. “I’ll give the enzyme capsule before every snack”
C. “I’ll give the enzyme capsule before every meal”
D. “My child hates to take pills, so I’ll mix the capsule into
a cup of hot chocolate
Answer: D. The pancreatic capsules contain pancreatic
enzyme that should be administered in a cold, not a hot,
medium (example: chilled applesauce versus hot chocolate)
to maintain the medication’s integrity.
3. The mother brought her child to the clinic for follow-up
check up. The mother tells the nurse that 14 days after
starting an oral iron supplement, her child’s stools are black.
Which of the following is the best nursing response to the
mother?
A. “I will notify the physician, who will probably decrease
the dosage slightly”
B. “This is a normal side effect and means the medication
is working”
C. “You sound quite concerned. Would you like to talk
about this further?”
D. “I will need a specimen to check the stool for possible
bleeding”
Answer: B. When oral iron preparations are given correctly,
the stools normally turn dark green or black. Parents of
children receiving this medication should be advised that
this side effect indicates the medication is being absorbed
and is working well.
4. An 8-year-old boy with asthma is brought to the clinic for
check up. The mother asks the nurse if the treatment given to
her son is effective. What would be the appropriate response
of the nurse?
 A. I will review first the child’s height on a growth chart to
know if the treatment is working
B. I will review first the child’s weight on a growth chart to
know if the treatment is working
C. I will review first the number of prescriptions refills the
child has required over the last 6 months to give you
an accurate answer
D. I will review first the number of times the child has seen
the pediatrician during the last 6 months to give you an
accurate answer
Answer: C. Reviewing the number of prescription refills the
child has required over the last 6 months would be the best
indicator of how well controlled and thus how effective the
child’s asthma treatment is. Breakthrough wheezing,
shortness of breath, and upper respiratory infections would
require that the child take additional medication. This would
be reflected in the number of prescription refills.
5. The nurse is caring to a child client who is receiving
tetracycline. The nurse is aware that in taking this medication,
it is very important to:
A. Administer the drug between meals
B. Monitor the child’s hearing
C. Give the drug through a straw
D. Keep the child out of the sunlight
Answer: D. Tetracycline may cause a phototoxic reaction.
6. A 14 day-old infant with a cyanotic heart defects and mild
congestive heart failure is brought to the emergency
department. During assessment, the nurse checks the apical
pulse rate of the infant. The apical pulse rate is 130 beats per
minute. Which of the following is the appropriate nursing
action?
A. Retake the apical pulse in 15 minutes
B. Retake the apical pulse in 30 minutes
C. Notify the pediatrician immediately
D. Administer the medication as scheduled
Answer: D. The normal heart rate of an infant is 120-160
beats per minute
7. The physician prescribed gentamicin (Garamycin) to a child
who is also receiving chemotherapy. Before administering the
drug, the nurse should check the results of the child’s:
A. CBC and platelet count
B. Auditory tests
C. Renal Function tests
D. Abdominal and chest x-rays
Answer: C. Both gentamicin and chemotherapeutic agents
can cause renal impairment and acute renal failure; thus
baseline renal function must be evaluated before initiating
either medication.
8. Which of the following is the suited size of the needle
would the nurse select to administer the IM injection to a
preschool child?
A. 18 G, 1-1/2 inch
B. 25 G, 5/8 inch
C. 21 G, 1 inch
D. 18 G, 1inch
Answer: C. In selecting the correct needle to administer an
IM injection to a preschooler, the nurse should always look
at the child and use judgment in evaluating muscle mass and
amount of subcutaneous fat. In this case, in the absence of
further data, the nurse would be most correct in selecting a
needle gauge and length appropriate for the “average’
preschool child. A medium-gauge needle (21G) that is 1 inch
long would be most appropriate.
9. A 9-year-old boy is admitted to the hospital. The boy is
being treated with salicylates for the migratory polyarthritis
accompanying the diagnosis of rheumatic fever. Which of the
following activities performed by the child would give a best
sign that the medication is effective?
A. Listening to story of his mother
B. Listening to the music in the radio
C. Playing mini piano
D. Watching movie in the dvd mini player
Answer: C. The purpose of the salicylate therapy is to relieve
the pain associated with the migratory polyarthritis
accompanying the rheumatic fever. Playing mini piano would
require movement of the child’s joints and would provide
the nurse with a means of evaluating the child’s level of pain.
10. The physician decided to schedule the 4-year-old client for
repair of left undescended testicle. The Injection of a
hormone, HCG finds it less successful for treatment. To
administer a pentobarbital sodium (Nembutal) suppository
preoperatively to this client, in which position should the
nurse place him?
A. Supine with foot of bed elevated
B. Prone with legs abducted
C. Sitting with foot of bed elevated
D. Side-lying with upper leg flexed
Answer: D. The recommended position to administer rectal
medications to children is side-lying with the upper leg
flexed. This position allows the nurse to safely and effectively
administer the medication while promoting comfort for the
child.
11. The nurse is caring to a 24-month-old child diagnosed
with congenital heart defect. The physician prescribed digoxin
(Lanoxin) to the client. Before the administration of the drug,
the nurse checks the apical pulse rate to be 110 beats per
minute and regular. What would be the next nursing action?
A. Check the other vital signs and level of consciousness
B. Withhold the digoxin and notify the physician
C. Give the digoxin as prescribed
D. Check the apical and radial simultaneously, and if they
are the same, give the digoxin.
Answer:C. For a 12month-old child, 110 apical pulse rate is
normal and therefore it is safe to give the digoxin. A
toddler’s normal pulse rate is slightly lower than an infant’s
(120).
12. An 8-year-old client with cystic fibrosis is admitted to the
hospital and will undergo a chest physiotherapy treatment.
The therapy should be properly coordinated by the nurse with
the respiratory therapy department so that treatments occur
during:
A. After meals
B. Between meals
 C. After medication
D. Around the child’s play schedule
Answer: B. Chest physiotherapy treatments are scheduled
between meals to prevent aspiration of stomach contents,
because the child is placed in a variety of positions during
the treatment process.
13. The nurse is providing health teaching about the
breastfeeding and family planning to the client who gave birth
to a healthy baby girl. Which of the following statement
would alert the nurse that the client needs further teaching?
A. “I understand that the hormones for breastfeeding may
affect when my periods come”
B. “Breastfeeding causes my womb to tighten and bleed
less after birth”
C. “I may not have periods while I am breastfeeding, so I
don’t need family planning”
D. “I can get pregnant as early as one month after my baby
was born”
Answer: C. It is common misconception that breastfeeding
may prevent pregnancy.
14. A toddler is brought to the hospital because of severe
diarrhea and vomiting. The nurse assigned to the client enters
the client’s room and finds out that the client is using a soiled
blanket brought in from home. The nurse attempts to remove
the blanket and replace it with a new and clean blanket. The
toddler refuses to give the soiled blanket. The nurse realizes
that the best explanation for the toddler’s behavior is:
A. The toddler did not bond well with the maternal figure
B. The blanket is an important transitional object
C. The toddler is anxious about the hospital experience
D. The toddler is resistive to nursing interventions
Answer: B. The “security blanket” is an important transitional
object for the toddler. It provides a feeling of comfort and
safety when the maternal figure is not present or when in a
new situation for which the toddler was not prepared.
Virtually any object (stuffed animal, doll, book etc) can
become a security blanket for the toddler
15. The nurse has knowledge about the developmental task
of the child. In caring a 3-year-old-client, the nurse knows that
the suited developmental task of this child is to:
A. Learn to play with other children
B. Able to trust others
C. Express all needs through speaking
D. Explore and manipulate the environment
Answer: D. Toddlers need to meet the developmental
milestone of autonomy versus shame and doubt. In order to
accomplish this, the toddler must be able to explore and
manipulate the environment.
16. A mother who gave birth to her second daughter is so
concerned about her 2-year old daughter. She tells the nurse,
“I am afraid that my 2-year-old daughter may not accept her
newly born sister”. It is appropriate to the nurse to response
that:
A. The older daughter be given more responsibility and
assure her “that she is a big girl now, and doesn’t need
Mommy as much”
B. The older daughter not have interaction with the baby
at the hospital, because she may harm her new sibling
C. The older daughter stay with her grandmother for a few
days until the parents and new baby are settled at home
D. The mother spend time alone with her older daughter
when the baby is sleeping
Answer: D. The introduction of a baby into a family with one
or more children challenges parent to promote acceptance
of the baby by siblings. The parent’s attitudes toward the
arrival of the baby can set the stage for the other children’s
reaction. Spending time with the older siblings alone will
also reassure them of their place in the family, even though
the older children will have to eventually assume new
positions within the family hierarchy.
17. A 2-year-old client with cystic fibrosis is confined to bed
and is not allowed to go to the playroom. Which of the
following is an appropriate toy would the nurse select for the
child:
A. Puzzle
B. Musical automobile
C. Arranging stickers in the album
D. Pounding board and hammer
Answer: D. The autonomous toddler would be frustrated by
being confined to be. The pounding board and hammer is
developmentally appropriate and an excellent way for the
toddler to release frustration.
18. Which of the following clients is at high risk for
developmental problem?
A. A toddler with acute Glomerulonephritis on
antihypertensive and antibiotics
B. A 5-year-old with asthma on cromolyn sodium
C. A preschooler with tonsillitis
D. A 2 1/2 –year old boy with cystic fibrosis
Answer: D. It is the developmental task of an 18-month-old
toddler to explore and learn about the environment. The
respiratory complications associated with cystic fibrosis
(which are present in almost all children with cystic fibrosis)
could prevent this development task from occurring.
19. Which of the following would be the best divesionary
activity for the nurse to select for a 2 weeks hospitalized 3-
year-old girl?
A. Crayons and coloring books
B. doll
C. xylophone toy
D. Puzzles
Answer: C. The best diversion for a hospitalized child aged 2-
3 years old would be anything that makes noise or makes a
mess; xylophone which certainly makes noise or music
would be the best choice.
20. A nurse is providing safety instructions to the parents of
the 11-month-old child. Which of the following will the nurse
includes in the instructions?
A. Plugging all electrical outlets in the house
B. Installing a gate at the top and bottom of any stairs in
the home
C. Purchasing an infant car seat as soon as possible
 D. Begin to teach the child not to place small objects in the
mouth
Answer: B. An 11-month-old child stands alone and can walk
holding onto people or objects. Therefore the installation of a
gate at the top and bottom of any stairs in the house is crucial
for the child’s safety
21. An 8-year-old girl is in second grade and the parents
decided to enroll her to a new school. While the child is
focusing on adjusting to new environment and peers, her
grades suffer. The child’s father severely punishes the child
and forces her daughter to study after school. The father does
not allow also her daughter to play with other children. These
data indicate to the nurse that this child is deprived of
forming which normal phase of development?
A. Heterosexual relationships
B. A love relationship with the father
C. A dependency relationship with the father
D. Close relationship with peers
Answer: D. In second grade a child needs to form a close
relationships with peers.
22. A 5-year-old boy client is scheduled for hernia surgery. The
nurse is preparing to do preoperative teaching with the child.
The nurse should knows that the 5-year-old would:
A. Expect a simple yet logical explanation regarding the
surgery
B. Asks many questions regarding the condition and the
procedure
C. Worry over the impending surgery
D. Be uninterested in the upcoming surgery
Answer: B. A 5-year-old is highly concerned with body
integrity. The preschool-age child normally asks many
questions and in a situation such as this, could be expected to
ask even more
23. The nine-year-old client is admitted in the hospital for
almost 1 week and is on bed rest. The child complains of
being bored and it seems tiresome to stay on bed and doing
nothing. What activity selected by the nurse would the child
most likely find stimulating?
A. Watching a video
B. Putting together a puzzle
C. Assembling handouts with the nurse for an upcoming
staff development meeting
D. Listening to a compact disc
Answer: C. A 9-year-old enjoys working and feeling a sense
of accomplishment. The school-age child also enjoys
“showing off,” and doing something with the nurse on the
pediatric unit would allow this. This activity also provides the
school-age child a needed opportunity to interact with
others in the absence of school and personal friends.
24. The parent of a 16-year-old boy tells the nurse that his son
is driving a motorbike very fast and with one hand. “It is
making me crazy!” What would be the best explanation of the
nurse to the behavior of the boy?
A. The adolescent might have an unconscious death wish
B. The adolescent feels indestructible
C. The adolescent lacks life experience to realize how
dangerous the behavior is
D. The adolescent has found a way to act out hostility
toward the parent
Answer: B. Adolescents do feel indestructible, and this is
reflected in many risk-taking behaviors.
25. An 8-month-old infant is admitted to the hospital due to
diarrhea. The nurse caring for the client tells the mother to
stay beside the infant while making assessment. Which of the
following developmental milestones the infant has reached?
A. Has a three-word vocabulary
B. Interacts with other infants
C. Stands alone
D. Recognizes but is fearful of strangers
Answer: D. An 8-month-old infant both recognizes and is
fearful of strangers. This developmental milestone is known
as “stranger anxiety”.
26. The community nurse is conducting a health teaching in
the group of married women. When teaching a woman about
fertility awareness, the nurse should emphasize that the basal
body temperature:
A. Should be recorded each morning before any activity
B. Is the average temperature taken each morning
C. Can be done with a mercury thermometer but not a
digital one
D. Has a lower degree of accuracy in predicting ovulation
than the cervical mucus test
Answer: A. The basal body temperature (BBT) is the lowest
body temperature of a healthy person that is taken
immediately after waking and before getting out of bed. The
BBT usually varies from 36.2 – 36.3 degree Celsius during
menses and for about 5-7 days afterward. About the time of
ovulation, a slight drop approximately 0.05 degree Celsius in
temperature may be seen; after ovulation, in concert with
the increasing progesterone levels of the early luteal phase,
the BBT rises 0.2-0.4 degree Celsius. This elevation remains
until 2-3 days before menstruation, or if pregnancy has
occurred.
27. The community nurse is providing an instruction to the
clients in the health center about the use of diaphragm for
family planning. To evaluate the understanding of the woman,
the nurse asks her to demonstrate the use of the diaphragm.
Which of following statement indicates a need for further
health teaching?
A. “I should check the diaphragm carefully for holes every
time I use it.”
B. “The diaphragm must be left in place for at least 6 hours
after intercourse.”
C. “I really need to use the diaphragm and jelly most
during the middle of my menstrual cycle
D. “I may need a different size diaphragm if I gain or lose
more than 20 pounds”
Answer: C. The woman must understand that, although the
“fertile” period is approximately midcycle, hormonal
variations do occur and can result in early or late ovulations.
To be effective, the diaphragm should be inserted before
every intercourse.
28. The client visits the clinic for prenatal check-up. While
waiting for the physician, the nurse decided to conduct health
teaching to the client. The nurse informed the client that
primigravida mother should go to the hospital when which
patter is evident?
A. Contractions are 2-3 minutes apart, lasting 90 seconds,
and membranes have ruptured
B. Contractions are 5-10 minutes apart, lasting 30 seconds,
and are felt as strong menstrual cramps
C. Contractions are 3-5 minutes apart, accompanied by
rectal pressure and bloody show
D. Contractions are 5 minutes apart, lasting 60 seconds,
and increasing in intensity
Answer: D. Although instructions vary among birth centers,
primigravidas should seek care when regular contractions
are felt about 5 minutes apart, becoming longer and
stronger.
29. A nurse is planning a home visit program to a new mother
who is 2 weeks postpartum and breastfeeding, the nurse
includes in her health teaching about the resumption of
fertility, contraception and sexual activity. Which of the
following statement indicates that the mother has understood
the teaching?
A. “Because breastfeeding speeds the healing process after
birth, I can have sex right away and not worry about
infection”
B. “Because I am breastfeeding and my hormones are
decreased, I may need to use a vaginal lubricant when I
have sex”
C. “After birth, you have to have a period before you can
get pregnant again’
D. “Breastfeeding protects me from pregnancy because it
keeps my hormones down, so I don’t need any
contraception until I stop breastfeeding”
Answer: B. Prolactin suppresses estrogen, which is needed
to stimulate vaginal lubrication during arousal.
30. A community nurse enters the home of the client for
follow-up visit. Which of the following is the most appropriate
area to place the nursing bag of the nurse when conducting a
home visit?
A. cushioned footstool
B. bedside wood table
C. kitchen countertop
D. living room sofa
Answer: B. A wood surface provides the least chance for
organisms to be present.
31. The nurse in the health center is making an assessment to
the infant client. The nurse notes some rashes and small fluid-
filled bumps in the skin. The nurse suspects that the infant
has eczema. Which of the following is the most important
nursing goal:
A. Preventing infection
B. Providing for adequate nutrition
C. Decreasing the itching
D. Maintaining the comfort level
Answer: A. Preventing infection in the infant with eczema is
the nurse’s most important goal. The infant with eczema is at
high risk for infection due to numerous breaks in the skin’s
integrity. Intact skin is always the infant’s first line of defense
against infection.
32. The nurse in the health center is providing immunization
to the children. The nurse is carefully assessing the condition
of the children before giving the vaccines. Which of the
following would the nurse note to withhold the infant’s
scheduled immunizations?
A. a dry cough
B. a skin rash
C. a low-grade fever
D. a runny nose
Answer: B. A skin rash could indicate a concurrent infectious
disease process in the infant. The scheduled immunizations
should be withheld until the status of the infant’s health can
be determined. Fevers above 38.5 degrees Celsius, alteration
in skin integrity, and infectious-appearing secretions are
indications to withhold immunizations.
33. A mother brought her child in the health center for
hepatitis B vaccination in a series. The mother informs the
nurse that the child missed an appointment last month to
have the third hepatitis B vaccination. Which of the following
statements is the appropriate nursing response to the
mother?
A. “I will examine the child for symptoms of hepatitis B”
B. “Your child will start the series again”
C. “Your child will get the next dose as soon as possible”
D. “Your child will have a hepatitis titer done to determine
if immunization has taken place.”
Answer: C. Continuity is essential to promote active
immunity and give hepatitis B lifelong prophylaxis. Optimally,
the third vaccination is given 6 months after the first.
34. The community health nurse implemented a new program
about effective breast cancer screening technique for the
female personnel of the health department of Valenzuela.
Which of the following technique should the nurse consider
to be of the lowest priority?
A. Yearly breast exam by a trained professional
B. Detailed health history to identify women at risk
C. Screening mammogram every year for women over age
50
D. Screening mammogram every 1-2 years for women over
age of 40.
Answer: B. Because of the high incidence of breast cancer, all
women are considered to be at risk regardless of health
history.
35. Which of the following technique is considered an aseptic
practice during the home visit of the community health
nurse?
A. Wrapping used dressing in a plastic bag before placing
them in the nursing bag
B. Washing hands before removing equipment from the
nursing bag
C. Using the client’s soap and cloth towel for hand washing
D. Placing the contaminated needles and syringes in a
labeled container inside the nursing bag
Answer: B. Handwashing is the best way to prevent the
spread of infection.
36. The nurse is planning to conduct a home visit in a small
community. Which of the following is the most important
factor when planning the best time for a home care visit?
A. Purpose of the home visit
B. Preference of the patient’s family
C. Location of the patient’s home
D. Length of time of the visit will take
Answer: A. The purpose of the visit takes priority.
37. The nurse assigned in the health center is counseling a 30-
year-old client requesting oral contraceptives. The client tells
the nurse that she has an active yeast infection that has
recurred several times in the past year. Which statement by
the nurse is inaccurate concerning health promotion actions
to prevent recurring yeast infection?
A. “During treatment for yeast, avoid vaginal intercourse
for one week”
B. “Wear loose-fitting cotton underwear”
C. “Avoid eating large amounts of sugar or sugar-bingeing”
D. “Douche once a day with a mild vinegar and water
solution”
Answer: D. Frequent douching interferes with the natural
protective barriers in the vagina that resist yeast infection
and should be avoided.
38. During immunization week in the health center, the
parent of a 6-month-old infant asks the health nurse, “Why is
our baby going to receive so many immunizations over a long
time period?” The best nursing response would be:
A. “The number of immunizations your baby will receive
shows how many pediatric communicable and
infectious diseases can now be prevented.”
B. “You need to ask the physician”
C. “The number of immunizations your baby will receive is
determined by your baby’s health history and age”
D. “It is easier on your baby to receive several
immunizations rather than one at a time”
Answer: A. Completion for the recommended schedule of
infant immunizations does not require a large number of
immunizations, but it also provides protection against
multiple pediatric communicable and infectious diseases.
39. The community health nurse is conducting a health
teaching about nutrition to a group of pregnant women who
are anemic and are lactose intolerant. Which of the following
foods should the nurse especially encourage during the third
trimester?
A. Cheese, yogurt, and fish for protein and calcium needs
plus prenatal vitamins and iron supplements
B. Prenatal iron and calcium supplements plus a regular
adult diet
C. Red beans, green leafy vegetables, and fish for iron
and calcium needs plus prenatal vitamins and iron
supplements
D. Red meat, milk and eggs for iron and calcium needs plus
prenatal vitamins and iron supplements
Answer: C. This is appropriate foods that are high in iron and
calcium but would not affect lactose intolerance.
40. A woman with active tuberculosis (TB) and has visited the
health center for regular therapy for five months wants to
become pregnant. The nurse knows that further information
is necessary when the woman states:
A. “Spontaneous abortion may occur in one out of five
women who are infected”
B. “Pulmonary TB may jeopardize my pregnancy”
C. “I know that I may not be able to have close contact
with my baby until contagious is no longer a problem
D. “I can get pregnant after I have been free of TB for 6
months”
Answer: D. Intervention is needed when the woman thinks
that she needs to wait only 6 months after being free of TB
before she can get pregnant. She needs to wait 1.5-2years
after she is declared to be free of TB before she should
attempt pregnancy.
41. The Department of Health is alarmed that almost 33
million people suffer from food poisoning every year.
Salmonella enteritis is responsible for almost 4 million cases
of food poisoning. One of the major goals is to promote
proper food preparation. The community health nurse is tasks
to conduct health teaching about the prevention of food
poisoning to a group of mother everyday. The nurse can help
identify signs and symptoms of specific organisms to help
patients get appropriate treatment. Typical symptoms of
salmonella include:
A. Nausea, vomiting and paralysis
B. Bloody diarrhea
C. Diarrhea and abdominal cramps
D. Nausea, vomiting and headache
Answer: C. Salmonella organisms cause lower GI symptoms
42. A community health nurse makes a home visit to an
elderly person living alone in a small house. Which of the
following observation would be a great concern?
A. Big mirror in a wall
B. Scattered and unwashed dishes in the sink
C. Shiny floors with scattered rugs
D. Brightly lit rooms
Answer: C. It is a safety hazard to have shiny floors and
scattered rugs because they can cause falls and rugs should
be removed.
43. The health nurse is conducting health teaching about
“safe” sex to a group of high school students. Which of the
following statement about the use of condoms should the
nurse avoid making?
A. “Condoms should be used because they can prevent
infection and because they may prevent pregnancy”
B. “Condoms should be used even if you have recently
tested negative for HIV”
C. “Condoms should be used every time you have sex
because condoms prevent all forms of sexually
transmitted diseases”
D. “Condoms should be used every time you have sex even
if you are taking the pill because condoms can prevent
the spread of HIV and gonorrhea”
Answer: C. Condoms do not prevent ALL forms of sexually
transmitted diseases
44. The department of health is promoting the breastfeeding
program to all newly mothers. The nurse is formulating a plan
of care to a woman who gave birth to a baby girl. The nursing
care plan for a breast-feeding mother takes into account that
breast-feeding is contraindicated when the woman:
A. Is pregnant
B. Has genital herpes infection
C. Develops mastitis
D. Has inverted nipples
Answer: A. Pregnancy is one contraindication to breast-
feeding. Milk secretion is inhibited and the baby’s sucking
may stimulate uterine contractions.
45. The City health department conducted a medical mission
in Barangay Marulas. Majority of the children in the Barangay
Marulas were diagnosed with pinworms. The community
health nurse should anticipate that the children’s chief
complaint would be:
A. Lack of appetite
B. Severe itching of the scalp
C. Perianal itching
D. Severe abdominal pain
Answer: C. Perianal itching is the child’s chief complaint
associated with the diagnosis of pinworms. The itching, in this
instance, is often described as being “intense” in nature.
Pinworms infestation usually occurs because the child is in the
anus-to-mouth stage of development (child uses the toilet,
does not wash hands, places hands and pinworm eggs in
mouth). Teaching the child hand washing before eating and
after using the toilet can assist in breaking the cycle
46. The mother brought her daughter to the health center.
The child has head lice. The nurse anticipates that the nursing
diagnosis most closely correlated with this is:
A. Fluid volume deficit related to vomiting
B. Altered body image related to alopecia
C. Altered comfort related to itching
D. Diversional activity deficit related to hospitalization
Answer: C. Severe itching of the scalp is the classic sign and
symptom of head lice in a child. In turn, this would lead to
the nursing diagnosis of “altered comfort”.
47. The mother brings a child to the health care clinic because
of severe headache and vomiting. During the assessment of
the health care nurse, the temperature of the child is 40
degree Celsius, and the nurse notes the presence of nuchal
rigidity. The nurse is suspecting that the child might be
suffering from bacterial meningitis. The nurse continues to
assess the child for the presence of Kernig’s sign. Which
finding would indicate the presence of this sign?
A. Flexion of the hips when the neck is flexed from a lying
position
B. Calf pain when the foot is dorsiflexed
C. Inability of the child to extend the legs fully when lying
supine
D. Pain when the chin is pulled down to the chest
Answer: C. Kernig’s sign is the inability of the child to extend
the legs fully when lying supine. This sign is frequently
present in bacterial meningitis. Nuchal rigidity is also present
in bacterial meningitis and occurs when pain prevents the
child from touching the chin to the chest.
48. A community health nurse makes a home visit to a child
with an infectious and communicable disease. In planning
care for the child, the nurse must determine that the primary
goal is that the:
A. Child will experience mild discomfort
B. Child will experience only minor complications
C. Child will not spread the infection to others
D. Public health department will be notified
Answer: C. The primary goal is to prevent the spread of the
disease to others. The child should experience no
complication. Although the health department may need to
be notified at some point, it is no the primary goal. It is also
important to prevent discomfort as much as possible
49. The mother brings her daughter to the health care clinic.
The child was diagnosed with conjunctivitis. The nurse
provides health teaching to the mother about the proper care
of her daughter while at home. Which statement by the
mother indicates a need for additional information?
A. “I do not need to be concerned about the spreading of
this infection to others in my family”
B. “I should apply warm compresses before instilling
antibiotic drops if purulent discharge is present in my
daughter’s eye”
C. “I can use an ophthalmic analgesic ointment at
nighttime if I have eye discomfort”
D. “I should perform a saline eye irrigation before instilling,
the antibiotic drops into my daughter’s eye if purulent
discharge is present”
Answer: A. Conjunctivitis is highly contagious. Antibiotic
drops are usually administered four times a day. When
purulent discharge is present, saline eye irrigations or eye
applications of warm compresses may be necessary before
instilling the medication. Ophthalmic analgesic ointment or
drops may be instilled, especially at bedtime, because
discomfort becomes more noticeable when the eyelids are
closed.
50. A community health nurse is caring for a group of flood
victims in Marikina area. In planning for the potential needs
of this group, which is the most immediate concern?
A. Finding affordable housing for the group
B. Peer support through structured groups
C. Setting up a 24-hour crisis center and hotline
D. Meeting the basic needs to ensure that adequate food,
shelter and clothing are available
Answer: D. The question asks about the immediate concern.
The ABCs of community health care are always attending to
people’s basic needs of food, shelter, and clothing
PNLE III Nursing Practice
The scope of this Nursing Test III is parallel to the NP3 NLE
Coverage:
 Medical Surgical Nursing
1. The nurse is going to replace the Pleur-O-Vac attached to
the client with a small, persistent left upper lobe
pneumothorax with a Heimlich Flutter Valve. Which of the
following is the best rationale for this?
A. Promote air and pleural drainage
B. Prevent kinking of the tube
 C. Eliminate the need for a dressing
D. Eliminate the need for a water-seal drainage
Answer: D. The Heimlich flutter valve has a one-way valve
that allows air and fluid to drain. Underwater seal drainage is
not necessary. This can be connected to a drainage bag for
the patient’s mobility. The absence of a long drainage tubing
and the presence of a one-way valve promote effective
therapy
2. The client with acute pancreatitis and fluid volume deficit is
transferred from the ward to the ICU. Which of the following
will alert the nurse?
A. Decreased pain in the fetal position
B. Urine output of 35mL/hr
C. CVP of 12 mmHg
D. Cardiac output of 5L/min
Answer: C. C = the normal CVP is 0-8 mmHg. This value
reflects hypervolemia. The right ventricular function of this
client reflects fluid volume overload, and the physician
should be notified.
3. The nurse in the morning shift is making rounds in the
ward. The nurse enters the client’s room and found the client
in discomfort condition. The client complains of stiffness in
the joints. To reduce the early morning stiffness of the joints
of the client,the nurse can encourage the client to:
A. Sleep with a hot pad
B. Take to aspirins before arising, and wait 15 minutes
before attempting locomotion
C. Take a hot tub bath or shower in the morning
D. Put joints through passive ROM before trying to move
them actively
Answer: C. A hot tub bath or shower in the morning helps
many patients limber up and reduces the symptoms of early
morning stiffness. Cold and ice packs are used to a lesser
degree, though some clients state that cold decreases
localized pain, particularly during acute attacks.
4. The nurse is planning of care to a client with peptic ulcer
disease. To avoid the worsening condition of the client, the
nurse should carefully plan the diet of the client. Which of the
following will be included in the diet regime of the client?
A. Eating mainly bland food and milk or dairy products
B. Reducing intake of high-fiber foods
C. Eating small, frequent meals and a bedtime snack
D. Eliminating intake of alcohol and coffee
Answer: D. These substances stimulate the production of
hydrochloric acid, which is detrimental in peptic ulcer
disease.
5. The physician has given instruction to the nurse that the
client can be ambulated on crutches, with no weight bearing
on the affected limb. The nurse is aware that the appropriate
crutch gait for the nurse to teach the client would be:
A. Tripod gait
B. Two-point gait
C. Four-point gait
D. Three-point gait
Answer: D. The three-point gait is appropriate when weight
bearing is not allowed on the affected limb. The swing-to
and swing-through crutch gaits may also be used when only
one leg can be used for weight bearing
6. The client is transferred to the nursing care unit from the
operating room after a transurethral resection of the prostate.
The client is complaining of pain in the abdomen area. The
nurse suspects of bladder spasms, which of the following is
the best nursing action to minimize the pain felt by the client?
A. Advising the client not to urinate around catheter
B. Intermittent catheter irrigation with saline
C. Giving prescribed narcotics every 4 hour
D. Repositioning catheter to relieve pressure
Answer: A. The client needs to be told before surgery that
the catheter causes the urge to void. Attempts to void
around the catheter cause the bladder muscles to contract
and result in painful spasms.
7. A client is diagnosed with peptic ulcer. The nurse caring for
the client expects the physician to order which diet?
A. NPO
B. Small feedings of bland food
C. A regular diet given frequently in small amounts
D. Frequent feedings of clear liquids
Answer; B. Bland feedings should be given in small amounts
on a frequent basis to neutralize the hydrochloric acid and to
prevent overload
8. The nurse is going to insert a Miller-Abbott tube to the
client. Before insertion of the tube, the balloon is tested for
patency and capacity and then deflated. Which of the
following nursing measure will ease the insertion to the tube?
A. Positioning the client in Semi-Fowler’s position
B. Administering a sedative to reduce anxiety
C. Chilling the tube before insertion
D. Warming the tube before insertion
Answer: C. Chilling the tube before insertion assists in
relieving some of the nasal discomfort. Water-soluble
lubricants along with viscous lidocaine (Xylocaine) may also
be used. It is usually only lightly lubricated before insertion
9. The physician ordered a low-sodium diet to the client.
Which of the following food will the nurse avoid to give to the
client?
A. Orange juice.
B. Whole milk.
C. Ginger ale.
D. Black coffee.
Answer: B. Whole milk should be avoided to include in the
client’s diet because it has 120 mg of sodium in 8 0z of milk
10. Mr. Bean, a 70-year-old client is admitted in the hospital
for almost one month. The nurse understands that prolonged
immobilization could lead to decubitus ulcers. Which of the
following would be the least appropriate nursing intervention
in the prevention of decubitus?
A. Giving backrubs with alcohol
B. Use of a bed cradle
C. Frequent assessment of the skin
D. Encouraging a high-protein diet
 Answer: A. Alcohol is extremely drying and contributes to
skin break down. An emollient lotion should be used.
11. The physician prescribed digoxin 0.125 mg PO qd to a
client and instructed the nurse that the client is on high-
potassium diet. High potassium foods are recommended in
the diet of a client taking digitalis preparations because a low
serum potassium has which of the following effects?
A. Potentiates the action of digoxin
B. Promotes calcium retention
C. Promotes sodium excretion
D. Puts the client at risk for digitalis toxicity
Answer: D. Potassium influences the excitability of nerves
and muscles. When potassium is low and the client is on
digoxin, the risk of digoxin toxicity is increased.
12. The nurse is caring for a client who is transferred from the
operating room for pneumonectomy. The nurse knows that
immediately following pneumonectomy; the client should be
in what position?
A. Supine on the unaffected side
B. Low-Fowler’s on the back
C. Semi-Fowler’s on the affected side
D. Semi-Fowler’s on the unaffected side
Answer: C. This position allows maximum expansion,
ventilation, and perfusion of the remaining lung.
13. A client is placed on digoxin, high potassium foods are
recommended in the diet of the client. Which of the following
foods willthe nurse give to the client?
A. Whole grain cereal, orange juice, and apricots
B. Turkey, green bean, and Italian bread
C. Cottage cheese, cooked broccoli, and roast beef
D. Fish, green beans and cherry pie
Answer: C. This position allows maximum expansion,
ventilation, and perfusion of the remaining lung.
14. The nurse is assigned to care to a client who undergone
thyroidectomy. What nursing intervention is important during
the immediate postoperative period following a
thyroidectomy?
A. Assess extremities for weakness and flaccidity
B. Support the head and neck during position changes
C. Position the client in high Fowler’s
D. Medicate for restlessness and anxiety
Answer: B. Stress on the suture line should be avoided.
Prevent flexion or hyperextension of the neck, and provide a
small pillow under thehead and neck. Neck muscles have
been affected during a thyroidectomy, support essential for
comfort and incisional support.
15. What would be the recommended diet the nurse will
implement to a client with burns of the head, face, neck and
anterior chest?
A. Serve a high-protein, high-carbohydrate diet
B. Encourage full liquid diet
C. Serve a high-fat diet, high-fiber diet
D. Monitor intake to prevent weight gain
Answer: A. A positive nitrogen balance is important for
meeting metabolic needs, tissue repair, and resistance to
infection. Caloric goals may be as high as 5000 calories per
day.
16. A client with multiple fractures of both lower extremities
is admitted for 3 days ago and is on skeletal traction. The
client is complaining of having difficulty in bowel movement.
Which of the following would be the most appropriate
nursing intervention?
A. Administer an enema
B. Perform range-of-motion exercise to all extremities
C. Ensure maximum fluid intake (3000ml/day)
D. Put the client on the bedpan every 2 hours
Answer: C. The best early intervention would be to increase
fluid intake, because constipation is common when activity is
decreased or usual routines have been interrupted.
17. John is diagnosed with Addison’s disease and admitted in
the hospital. What would be the appropriate nursing care for
John?
A. Reducing physical and emotional stress
B. Providing a low-sodium diet
C. Restricting fluids to 1500ml/day
D. Administering insulin-replacement therapy
Answer: A. Because the client’s ability is to react to stress is
decreased, maintaining a quiet environment becomes A
nursing priority. Dehydration is a common problem in
Addison’s disease, so close observation of the client’s
hydration level is crucial. To promote optimal hydration and
sodium intake, fluid intake is increased, particularly fluid
containing electrolytes, such as broths, carbonated
beverages, and juices.
18. Mr. Smith is scheduled for an above-the-knee amputation.
After the surgery he was transferred to the nursing care unit.
The nurse assigned to him knows that 72 hours after the
procedure the client should be positioned properly to prevent
contractures. Which of the following is the best position to
the client?
A. Side-lying, alternating left and right sides
B. Sitting in a reclining chair twice a day
C. Lying on abdomen several times daily
D. Supine with stump elevated at least 30 degrees
Answer: C. At about 48-72 hours, the client must be turned
onto the abdomen to prevent flexion contractures.
19. A client is scheduled to have an inguinal herniorraphy in
the outpatient surgical department. The nurse is providing
health teaching about post surgical care to the client. Which
of the following statement if made by the client would reflect
the need for more teaching?
A. “I should call the physician if I have a cough or cold
before surgery”
B. “I will be able to drive soon after surgery”
C. “I will not be able to do any heavy lifting for 3-6 weeks
after surgery”
D. “I should support my incision if I have to cough or turn”
Answer:B. The client should not drive for 2 weeks after
surgery to avoid stress on the incision. This reflects a need
for additional teaching.
 regarding expectoration of thick sputum. Which nursing
20. Ms Jones is brought to the emergency room and is action is most effective?
complaining of muscle spasms, numbness, tremors and
weakness in the arms and legs. The client was diagnosed with A. Place the client in a lateral position every 2 hour
multiple sclerosis. The nurse assigned to Ms. Jones is aware B. Splint the patient’s chest with pillows when coughing
that she has to prevent fatigue to the client to alleviate the C. Use humified oxygen
discomfort. Which of the following teaching is necessary to D. Offer fluids at regular intervals
prevent fatigue?
Answer: D. Fluids liquefy secretions and therefore make it
A. Avoid extremes in temperature easier to expectorate
B. Install safety devices in the home
C. Attend support group meetings 25. The nurse is going to assess the bowel sound of the client.
D. Avoid physical exercise For accurate assessment of the bowel sound, the nurse
should listen for at least:
Answer: A. Extremes in heat and cold will exacerbate
symptoms. Heat delays transmission of impulses and A. 5 minutes
increases fatigue. B. 60 seconds
C. 30 seconds
D. 2 minutes
21. Mr. Stewart is in sickle cell crisis and complaining pain in
the joints and difficulty of breathing. On the assessment of Answer: D. Physical assessment guidelines recommend
the nurse, his temperature is 38.1 ºC. The physician ordered listening for atleast 2 minutes in each quadrant (and up to 5
Morphine sulfate via patient-controlled analgesia (PCA), and minutes, not at least 5 minutes).
oxygen at 4L/min. A priority nursing diagnosis to Mr. Stewart
is risk for infection. A nursing intervention to assist in 26. The nurse encourages the client to wear compression
preventing infection is: stockings. What is the rationale behind in using compression
stockings?
A. Using standard precautions and medical asepsis
B. Enforcing a “no visitors” rule A. Compression stockings promote venous return
C. Using moist heat on painful joints B. Compression stockings divert blood to major vessels
D. Monitoring a vital signs every 2 hour C. Compression stockings decreases workload on the heart
D. Compression stockings improve arterial circulation
Answer: A. Vigilant implementation of standard precautions
and medical asepsis is an effective means of preventing Answer: A. Compression stockings promote venous return
infection and prevent peripheral pooling.

22. Mrs. Maupin is a professor in a prestigious university for 27. Mr. Whitman is a stroke client and is having difficulty in
30 years. After lecture, she experience blurring of vision and swallowing. Which is the best nursing intervention is most
tiredness. Mrs. Maupin is brought to the emergency likely to assist the client?
department. On assessment, the nurse notes that the blood
pressure of the client is 139/90. Mrs. Maupin has been
A. Placing food in the unaffected side of the mouth
diagnosed with essential hypertension and placed on
B. Increasing fiber in the diet
medication to control her BP. Which potential nursing
C. Asking the patient to speak slowly
diagnosis will be a priority for discharge teaching?
D. Increasing fluid intake

A. Sleep Pattern disturbance Answer: A. Placing food in the unaffected side of the mouth
B. Impaired physical mobility assists in the swallowing process because the client has
C. Noncompliance sensation on that side and will have more control over the
D. Fluid volume excess swallowing process.

Answer: C. Noncompliance is a major problem in the
management of chronic disease. In hypertension, the client
often does not feel ill and thus does not see a need to follow
a treatment regimen.
23. Following a needle biopsy of the kidney, which
assessment is an indication that the client is bleeding?
A. Slow, irregular pulse
B. Dull, abdominal discomfort
C. Urinary frequency
D. Throbbing headache
Answer: B. An accumulation of blood from the kidney into
the abdomen would manifest itself with these symptoms
24. A client with acute bronchitis is admitted in the hospital.
The nurse assigned to the client is making a plan of care
28. Following nephrectomy, the nurse closely monitors the
urinary output of the client. Which assessment finding is an
early indicator of fluid retention in the postoperative period?
A. Periorbital edema
B. Increased specific gravity of urine
C. A urinary output of 50mL/hr
D. Daily weight gain of 2 lb or more
Answer: D. Daily weights are taken following nephrectomy.
Daily increases of 2 lb or more are indicative of fluid
retention and should be reported to the physician. Intake
and output records may also reflect this imbalance.
29. A nurse is completing an assessment to a client with
cirrhosis. Which of the following nursing assessment is
important to notify the physician?
A. Expanding ecchymosis
 B. Ascites and serum albumin of 3.2 g/dl
C. Slurred speech
D. Hematocrit of 37% and hemoglobin of 12g/dl
Answer: A. Clients with cirrhosis have already coagulation
due to thrombocytopenia and vitamin K deficiency. This
could be a sign of bleeding
30. Mr. Park is 32-year-old, a badminton player and has a type
1 diabetes mellitus. After the game, the client complains of
becoming diaphoretic and light-headedness. The client asks
the nurse how to avoid this reaction. The nurse will
recommend to:
A. Allow plenty of time after the insulin injection and
before beginning the match
B. Eat a carbohydrate snack before and during the
badminton match
C. Drink plenty of fluids before, during, and after bed time
D. Take insulin just before starting the badminton match
Answer: B. Exercise enhances glucose uptake, and the client
is at risk for an insulin reaction. Snacks with carbohydrates
will help.
31. A client is rushed to the emergency room due to serious
vehicle accident. The nurse is suspecting of head injury.
Which of the following assessment findings would the nurse
report to the physician?
A. CVP of 5mmHa
B. Glasgow Coma Scale score of 13
C. Polyuria and dilute urinary output
D. Insomnia
Answer: C. These are symptoms of diabetes insipidus. The
patient can become hypovolemic and vasopressin may
reverse the Polyuria.
32. Mrs. Moore, 62-year-old, with diabetes is in the
emergency department. She stepped on a sharp sea shells
while walking barefoot along the beach. Mrs. Moore did not
notice that the object pierced the skin until later that evening.
What problem does the client most probably have?
A. Nephropathy
B. Macroangiopathy
C. Carpal tunnel syndrome
D. Peripheral neuropathy
Answer: D. Peripheral neuropathy refers to nerve damage of
the hands and feet. The client did not notice that the object
pierced the skin.
33. A client with gangrenous foot has undergone a below-
knee amputation. The nurse in the nursing care unit knows
that the priority nursing intervention in the immediate post
operative care of this client is:
A. Elevate the stump on a pillow for the first 24 hours
B. Encourage use of trapeze
C. Position the client prone periodically
D. Apply a cone-shaped dressing
Answer: A. The elevation of the stump on a pillow for the
first 24 hours decreases edema and increases venous return.
34. A client with a diagnosis of gastric ulcer is complaining of
syncope and vertigo. What would be the initial nursing
intervention by the nurse?
A. Monitor the client’s vital signs
B. Keep the client on bed rest
C. Keep the patient on bed rest
D. Give a stat dose of Sucralfate (Carafate)
Answer: B. The priority is to maintain client’s safety. With
syncope and vertigo, the client is at high risk for falling.
35. After a right lower lobectomy on a 55-year-old client,
which action should the nurse initiate when the client is
transferred from the post anesthesia care unit?
A. Notify the family to report the client’s condition
B. Immediately administer the narcotic as ordered
C. Keep client on right side supported by pillows
D. Encourage coughing and deep breathing every 2 hours
Answer: D. Coughing and deep breathing are essential for re-
expansion of the lung
36. The nurse is providing a discharge instruction about the
prevention of urinary stasis to a client with frequent bladder
infection. Which of the following will the nurse include in the
instruction?
A. Drink 3-4 quarts of fluid every day
B. Empty the bladder every 2-4 hours while awake
C. Encourage the use of coffee, tea, and colas for their
diuretic effect
D. Teach Kegel exercises to control bladder flow
Answer:B. Avoiding stasis of urine by emptying the bladder
every 2-4 hours will prevent overdistention of the bladder
and future urinary tract infections.
37. A male client visits the clinic for check-up. The client tells
the nurse that there is a yellow discharge from his penis. He
also experiences a burning sensation when urinating. The
nurse is suspecting of gonorrhea. What teaching is necessary
for this client?
A. Sex partner of 3 months ago must be treated
B. Women with gonorrhea are symptomatic
C. Use a condom for sexual activity
D. Sex partner needs to be evaluated
Answer: D. If infected, the sex partner must be evaluated
and treated
38. A client with AIDS is admitted in the hospital. He is
receiving intravenous therapy. While the nurse is assessing
the IV site, the client becomes confused and restless and the
intravenous catheter becomes disconnected and minimal
amount of the client’s blood spills onto the floor. Which
action will the nurse take to remove the blood spill?
A. Promptly clean with a 1:10 solution of household
bleach and water
B. Promptly clean up the blood spill with full-strength
antimicrobial cleaning solution
C. Immediately mop the floor with boiling water
D. Allow the blood to dry before cleaning to decrease the
possibility of cross-contamination
 Answer: A. A 1:10 solution of household bleach and water is
recommended by the Centers for Disease Control and
Prevention to kill the human immunodeficiency virus (HIV).
39. Before surgery, the physician ordered pentobarbital
sodium (Nembutal) for the client to sleep. The night before
the scheduled surgery, the nurse gave the pre-medication.
One hour later the client is still unable to sleep. The nurse
review the client’s chart and note the physician’s prescription
with an order to repeat. What should the nurse do next?
A. Rub the client’s back until relaxed
B. Prepare a glass of warm milk
C. Give the second dose of pentobarbital sodium
D. Explore the client’s feelings about surgery
Answer: D. Given the data, presurgical anxiety is suspected.
The client needs an opportunity to talk about concerns
related to surgery before further actions (which may mask
the anxiety).
40. The nurse on the night shift is making rounds in the
nursing care unit. The nurse is about to enter to the client’s
room when a ventilator alarm sounds, what is the first action
the nurse should do?
A. Assess the lung sounds
B. Suction the client right away
C. Look at the client
D. Turn and position the client
Answer: C. A quick look at the client can help identify the
type and cause of the ventilator alarm. Disconnection of the
tube from the ventilator, bronchospasm, and anxiety are
some of the obvious reasons that could trigger an alarm.
41. What effective precautions should the nurse use to
control the transmission of methicillin-resistant
Staphylococcus aureus (MRSA)?
A. Use gloves and handwashing before and after client
contact
B. Do nasal cultures on healthcare providers
C. Place the client on total isolation
D. Use mask and gown during care of the MRSA client
Answer: A. Contact isolation has been advised by the
Centers for Disease Control and Prevention (CDC) to control
transmission of MRSA, which includes gloves and
handwashing.
42. The postoperative gastrectomy client is scheduled for
discharge. The client asks the nurse, “When I will be allowed
to eat three meals a day like the rest of my family?”. The
appropriate nursing response is:
A. “You will probably have to eat six meals a day for the
rest of your life.”
B. “Eating six meals a day can be a bother, can’t it?”
C. “Some clients can tolerate three meals a day by the time
they leave the hospital. Maybe it will be a little longer
for you.”
D. “ It varies from client to client, but generally in 6-12
months most clients can return to their previous meal
patterns”
Answer:D. In response to the question of the client, the nurse
needs to provide brief, accurate information. Some clients
who have had gastrectomies are able to tolerate three meals
a day before discharge from the hospital. However, for the
majority of clients, it takes 6-12 months before their surgically
reduced stomach has stretched enough to accommodate a
larger meal
43. A male client with cirrhosis is complaining of belly pain,
itchiness and his breasts are getting larger and also the
abdomen. The client is so upset because of the discomfort
and asks the nurse why his breast and abdomen are getting
larger. Which of the following is the appropriate nursing
response?
A. “How much of a difference have you noticed”
B. “It’s part of the swelling your body is experiencing”
C. “It’s probably because you have been less physically
active”
D. “Your liver is not destroying estrogen hormones that all
men produce”
Answer: A. This allows the client to elaborate his concern
and provides the nurse a baseline of assessment
44. A client is diagnosed with detached retina and scheduled
for surgery. Preoperative teaching of the nurse to the client
includes:
A. No eye pain is expected postoperatively
B. Semi-fowler’s position will be used to reduce pressure in
the eye.
C. Eye patches may be used postoperatively
D. Return of normal vision is expected following surgery
Answer: C. Use of eye patches may be continued
postoperatively, depending on surgeon preference. This is
done to achieve >90% success rate of the surgery.
45. A 70-year-old client is brought to the emergency
department with a caregiver. The client has manifestations of
anorexia, wasting of muscles and multiple bruises. What
nursing interventions would the nurse implement?
A. Talk to the client about the caregiver and support
system
B. Complete a gastrointestinal and neurological
assessment
C. Check the lab data for serum albumin, hematocrit and
hemoglobin
D. Complete a police report on elder abuse
Answer: B. Assessment and more data collection are
needed. The client may have gastrointestinal or neurological
problems that account for the symptoms. The anorexia could
result from medications, poor dentition, or indigestion, the
bruises may be attributed to ataxia, frequent falls, vertigo, or
medication.
46. A nurse is providing a discharge instruction to the client
about the self-catheterization at home. Which of the
following instructions would the nurse include?
A. Wash the catheter with soap and water after each use
B. Lubricate the catheter with Vaseline
C. Perform the Valsalva maneuver to promote insertion
D. Replace the catheter with a new one every 24 hour
Answer: A. The catheter should be washed with soap and
water after withdrawal and placed in a clean container. It can
be reused until it is too hard or too soft for insertion. Self-
 care, prevention of complications, and cost-effectiveness are
important in home management.
47. The nurse in the nursing care unit is assigned to care to a
client who is Immunocompromised. The client tells the nurse
that his chest is painful and the blisters are itchy. What would
be the nursing intervention to this client?
A. Call the physician
B. Give a prn pain medication
C. Clarify if the client is on a new medication
D. Use gown and gloves while assessing the lesions
Answer: D. The client may have herpes zoster (shingles), a
viral infection. The nurse should use standard precautions in
assessing the lesions. Immunocompromised clients are at
risk for infection.
48. A client is admitted and has been diagnosed with bacterial
(meningococcal) meningitis. The infection control registered
nurse visits the staff nurse caring to the client. What
statement made by the nurse reflects an understanding of the
management of this client?
A. speech pattern may be altered
B. Respiratory isolation is necessary for 24 hours after
antibiotics are started
C. Perform skin culture on the macular popular rash
D. Expect abnormal general muscle contractions
Answer: B. After a minimum of 24 hours of IV antibiotics, the
client is no longer considered communicable. Evaluation of
the nurse’s knowledge is needed for safe care and continuity
of care
 Medical Surgical Nursing
1. Following spinal injury, the nurse should encourage the
client to drink fluids to avoid:
A. Urinary tract infection.
B. Fluid and electrolyte imbalance.
C. Dehydration.
D. Skin breakdown.
Answer: A. Clients in the early stage of spinal cord damage
experience an atonic bladder, which is characterized by the
absence of muscle tone, an enlarged capacity, no feeling of
discomfort with distention, and overflow with a large
residual. This leads to urinary stasis and infection. High fluid
intake limits urinary stasis and infection by diluting the urine
and increasing urinary output.
2. The client is transferred from the operating room to
recovery room after an open-heart surgery. The nurse
assigned is taking the vital signs of the client. The nurse
notified the physician when the temperature of the client
rises to 38.8 ºC or 102 ºF because elevated temperatures:
A. May be a forerunner of hemorrhage.
B. Are related to diaphoresis and possible chilling.
C. May indicate cerebral edema.
D. Increase the cardiac output.
Answer: D. The temperature of 102 ºF (38.8ºC) or greater
lead to an increased metabolism and cardiac workload.
3. After radiation therapy for cancer of the prostate, the client
experienced irritation in the bladder. Which of the following
sign of bladder irritability is correct?

49. A 18-year-old male client had sustained a head injury from A. Hematuria
a motorbike accident. It is uncertain whether the client may B. Dysuria
have minimal but permanent disability. The family is C. Polyuria
concerned regarding the client’s difficulty accepting the D. Dribbling
possibility of long term effects. Which nursing diagnosis is
best for this situation? ANSWER: B. Dysuria, nocturia, and urgency are all signs an
irritable bladder after radiation therapy.
A. Nutrition, less than body requirements
B. Injury, potential for sensory-perceptual alterations 4. A client is diagnosed with a brain tumor in the occipital
C. Impaired mobility, related to muscle weakness lobe. Which of the following will the client most likely
D. Anticipatory grieving, due to the loss of independence experience?

Answer: D. Stem of the question supports this choice by A. Visual hallucinations.

stating that the client has difficulty accepting the potential B. Receptive aphasia.
disability. C. Hemiparesis.
D. Personality changes.
50. A client with AIDS is scheduled for discharge. The client
tells the nurse that one of his hobbies at home is gardening. ANSWER: A. The occipital lobe is involve with visual
What will be the discharge instruction of the nurse to the interpretation.
client knowing that the client is prone to toxoplasmosis?
5. A client with Addison’s disease has a blood pressure of
A. Wash all vegetables before cooking 65/60. The nurse understands that decreased blood pressure
B. Wear gloves when gardening of the client with Addison’s disease involves a disturbance in
C. Wear a mask when travelling to foreign countries the production of:
D. Avoid contact with cats and birds
A. Androgens
Answer: B. Toxoplasmosis is an opportunistic infection and a B. Glucocorticoids
parasite of birds and mammals. The oocysts remain infectious C. Mineralocorticoids
in moist soil for about 1 year D. Estrogen

PNLE IV Nursing Practice ANSWER: C. Mineralocorticoids such as aldosterone cause

the kidneys to retain sodium ions. With sodium, water is also
The scope of this Nursing Test IV is parallel to the NP4 NLE retained, elevating blood pressure. Absence of this hormone
Coverage: thus causes hypotension.

6. The nurse is planning to teach the client about a
spontaneous pneumothorax. The nurse would base the
teaching on the understanding that:
A. Inspired air will move from the lung into the pleural
space.
B. There is greater negative pressure within the chest
cavity.
C. The heart and great vessels shift to the affected side.
D. The other lung will collapse if not treated immediately.
ANSWER: B. As a person with a tear in the lung inhales, air
moves through that opening into the intrapleural and causes
partial or complete collapse of the lungs.
7. During an assessment, the nurse recognizes that the client
has an increased risk for developing cancer of the tongue.
Which of the following health history will be a concern?
A. Heavy consumption of alcohol.
B. Frequent gum chewing.
C. Nail biting.
D. Poor dental habits.
ANSWER: A. Heavy alcohol ingestion predisposes an
individual to the development of oral cancer.
8. The client in the orthopedic unit asks the nurse the reason
behind why compact bone is stronger than cancellous bone.
Which of the following is the correct response of the nurse?
A. Compact bone is stronger than cancellous bone because
of its greater size.
B. Compact bone is stronger than cancellous bone because
of its greater weight.
C. Compact bone is stronger than cancellous bone because
of its greater volume.
D. Compact bone is stronger than cancellous bone
because of its greater density.
ANSWER: D. The greater the density of compact bone makes
it stronger than the cancellous bone. Compact bone forms
from cancellous bone by the addition of concentric rings of
bones substances to the marrow spaces of cancellous bone.
The large marrow spaces are reduced to haversian canals.
9. The nurse is reviewing the laboratory results of the client.
In reviewing the results of the RBC count, the nurse
understands that the higher the red blood cell count, the :
A. Greater the blood viscosity.
B. Higher the blood pH.
C. Less it contributes to immunity.
D. Lower the hematocrit.
ANSWER: A. Viscosity, a measure of a fluid’s internal
resistance to flow, is increased as the number of red cells
suspended in plasma.
10. The physician advised the client with Hemiparesis to use a
cane. The client asks the nurse why cane will be needed. The
nurse explains to the client that cane is advised specifically to:
A. Aid in controlling involuntary muscle movements.
B. Relieve pressure on weight-bearing joints.
C. Maintain balance and improve stability.
D. Prevent further injury to weakened muscles.
ANSWER: C. Hemiparesis creates instability. Using a cane
provides a wider base of support and, therefore greater
stability.
11. The nurse is conducting a discharge teaching regarding
the prevention of further problems to a client who undergone
surgery for carpal tunnel syndrome of the right hand. Which
of the following instruction will the nurse includes?
A. Learn to type using your left hand only.
B. Avoid typing in a long period of time.
C. Avoid carrying heavy things using the right hand.
D. Do manual stretching exercise during breaks.
ANSWER: D. Manual stretching exercises will assist in
keeping the muscles and tendons supple and pliable,
reducing the traumatic consequences of repetitive activity.
12. A female client is admitted because of recurrent urinary
tract infections. The client asks the nurse why she is prone to
this disease. The nurse states that the client is most
susceptible because of:
A. Continuity of the mucous membrane.
B. Inadequate fluid intake.
C. The length of the urethra.
D. Poor hygienic practices.
ANSWER: C. The length of the urethra is shorter in females
than in males; therefore microorganisms have a shorter
distance to travel to reach the bladder. The proximity of the
meatus to the anus in females also increases this incidence.
13. A 55-year-old client is admitted with chest pain that
radiates to the neck, jaw and shoulders that occurs at rest,
with high body temperature, weak with generalized sweating
and with decreased blood pressure. A myocardial infarction is
diagnosed. The nurse knows that the most accurate
explanation for one of these presenting adaptations is:
A. Catecholamines released at the site of the infarction
causes intermittent localized pain.
B. Parasympathetic reflexes from the infarcted
myocardium causes diaphoresis.
C. Constriction of central and peripheral blood vessels
causes a decrease in blood pressure.
D. Inflammation in the myocardium causes a rise in the
systemic body temperature.
ANSWER: D. Temperature may increase within the first 24
hours and persist as long as a week.
14. Following an amputation of a lower limb to a male client,
the nurse provides an instruction on how to prevent a hip
flexion contracture. The nurse should instruct the client to:.
A. Perform quadriceps muscle setting exercises twice a day.
B. Sit in a chair for 30 minutes three times a day.
C. Lie on the abdomen 30 minutes every four hours.
D. Turn from side to side every 2 hours.
ANSWER: C. The hips are in extension when the client is
prone; this keeps the hips from flexing.
15. The physician scheduled the client with rheumatoid
arthritis for the injection of hydrocortisone into the knee
joint. The client asks the nurse why there is a need for this
injection. The nurse explains that the most important reason
for doing this is to:
 A. Lubricate the joint.
B. Prevent ankylosis of the joint.
C. Reduce inflammation.
D. Provide physiotherapy.
ANSWER: C. Steroids have an anti-inflammatory effect that
can reduce arthritic pannus formation.
16. The nurse is assigned to care for a 57-year-old female
client who had a cataract surgery an hour ago. The nurse
should:
A. Advise the client to refrain from vigorous brushing of
teeth and hair.
B. Instruct the client to avoid driving for 2 weeks.
C. Encourage eye exercises to strengthen the ocular
musculature.
D. Teach the client coughing and deep-breathing
techniques.
ANSWER: A. Activities such as rigorous brushing of hair and
teeth cause increased intraocular pressure and may lead to
hemorrhage in the anterior chamber.
17. A client with AIDS develops bacterial pneumonia is
admitted in the emergency department. The client’s arterial
blood gases is drawn and the result is PaO2 80mmHg. then
arterial blood gases are drawn again and the level is reduced
from 80 mmHg to 65 mmHg. The nurse should;
A. Have arterial blood gases performed again to check for
accuracy.
B. Increase the oxygen flow rate.
C. Notify the physician.
D. Decrease the tension of oxygen in the plasma.
ANSWER: C. This decrease in PaO2 indicates respiratory
failure; it warrants immediate medical evaluation.
18. An 18-year-old college student is brought to the
emergency department due to serious motor vehicle
accident. Right above-knee-amputation is done. Upon
awakening from surgery the client tells the nurse, “What
happened to me? I cannot remember anything?” Which of
the following would be the appropriate initial nursing
response?
A. “You sound concerned; You’ll probably remember more
as you wake up.”
B. “Tell me what you think happened.”
C. “You were in a car accident this morning.”
D. “An amputation of your right leg was necessary because
of an accident.”
ANSWER: C. This is truthful and provides basic information
that may prompt recollection of what happened; it is a
starting point.
19. A 38-year-old client with severe hypertension is
hospitalized. The physician prescribed a Captopril (Capoten)
and Alprazolam (Xanax) for treatment. The client tells the
nurse that there is something wrong with the medication and
nursing care. The nurse recognizes this behavior is probably a
manifestation of the client’s:
A. Reaction to hypertensive medications.
B. Denial of illness.
C. Response to cerebral anoxia.
D. Fear of the health problem.
ANSWER: D. Clients adapting to illness frequently feel afraid
and helpless and strike out at health team members as a
way of maintaining control or denying their fear.
20. Before discharge, the nurse scheduled the client who had
a colostomy for colorectal cancer for discharge instruction
about resuming activities. The nurse should plan to help the
client understands that:
A. After surgery, changes in activities must be made to
accommodate for the physiologic changes caused by the
operation.
B. Most sports activities, except for swimming, can be
resumed based on the client’s overall physical condition.
C. With counseling and medical guidance, a near normal
lifestyle, including complete sexual function is possible.
D. Activities of daily living should be resumed as quickly as
possible to avoid depression and further dependency.
ANSWER: C. There are few physical restraints on activity
postoperatively, but the client may have emotional problems
resulting from the body image changes.
21. A client is scheduled for bariatric surgery. Preoperative
teaching is done. Which of the following statement would
alert the nurse that further teaching to the client is
necessary?
A. “I will be limiting my intake to 600 to 800 calories a day
once I start eating again.”
B. “I’m going to have a figure like a model in about a
year.”
C. “I need to eat more high-protein foods.”
D. “I will be going to be out of bed and sitting in a chair the
first day after surgery.”.
ANSWER: B. Clients need to be prepared emotionally for the
body image changes that occur after bariatric surgery.
Clients generally experience excessive abdominal skin folds
after weight stabilizes, which may require a panniculectomy.
Body image disturbance often occurs in response to
incorrectly estimating one’s size; it is not uncommon for the
client to still feel fat no matter how much weight is lost.
22. The client who had transverse colostomy asks the nurse
about the possible effect of the surgery on future sexual
relationship. What would be the best nursing response?
A. The surgery will temporarily decrease the client’s sexual
impulses.
B. Sexual relationships must be curtailed for several weeks.
C. The partner should be told about the surgery before any
sexual activity.
D. The client will be able to resume normal sexual
relationships.
ANSWER: D. Surgery on the bowel has no direct anatomic or
physiologic effect on sexual performance. However, the
nurse should encourage verbalization.
23. A 75-year-old male client tells the nurse that his wife has
osteoporosis and asks what chances he had of getting also
osteoporosis like his wife. Which of the following is the
correct response of the nurse?
A. “This is only a problem for women.”
B. “You are not at risk because of your small frame.”
C. “You might think about having a bone density test,”
 D. “Exercise is a good way to prevent this problem.”
ANSWER: C. Osteoporosis is not restricted to women; it is a
potential major health problem of all older adults; estimates
indicate that half of all women have at least one osteoporitic
fracture and the risk in men is estimated between 13% and
25%; a bone mineral density measurement assesses the
mass of bone per unit volume or how tightly the bone is
packed.
24. An older adult client with acute pain is admitted in the
hospital. The nurse understands that in managing acute pain
of the client during the first 24 hours, the nurse should ensure
that:
A. Ordered PRN analgesics are administered on a
scheduled basis.
B. Patient controlled analgesia is avoided in this
population.
C. Pain medication is ordered via the intramuscular route.
D. An order for meperidine (Demerol) is secured for pain
relief.
ANSWER: A. Around-the-clock administration of analgesics is
recommended for acute pain in the older adult population;
this help to maintain a therapeutic blood level of pain
medication.
25. A nurse is caring to an older adult with presbycusis. In
formulating nursing care plan for this client, the nurse should
expect that hearing loss of the client that is caused by aging
to have:
A. Overgrowth of the epithelial auditory lining.
B. Copious, moist cerumen.
C. Difficulty hearing women’s voices.
D. Tears in the tympanic membrane.
ANSWER: C. Generally, female voices have a higher pitch
than male voices; older adults with presbycusis (hearing loss
caused by the aging process) have more difficulty hearing
higher-pitched sounds.
26. The nurse is reviewing the client’s chart about the ordered
medication. The nurse must observe for signs of hyperkalemia
when administering:
A. Furosemide (Lasix)
B. Hydrochlorothiazide (HydroDIURIL)
C. Metolazone (Zaroxolyn)
D. Spironolactone (Aldactone)
ANSWER: D. Aldactone is a potassium-sparing diuretic;
hyperkalemia is an adverse effect.
27. The physician prescribed Albuterol (Proventil) to the client
with severe asthma. After the administration of the
medication the nurse should monitor the client for:
A. Palpitation
B. Visual disturbance
C. Decreased pulse rate
D. Lethargy
ANSWER: A. Albuterol’s sympathomimetic effect causes
cardiac stimulation that may cause tachycardia and
palpitation.
28. A client is receiving diltiazem (Cardizem). What should the
nurse include in a teaching plan aimed at reducing the side
effects of this medication?
A. Take the drug with an antacid.
B. Lie down after meals.
C. Avoid dairy products in diet.
D. Change positions slowly.
ANSWER: D. Changing positions slowly will help prevent the
side effect of orthostatic hypotension.
29. A client is receiving simvastatin (Zocor). The nurse is
aware that this medication is effective when there is decrease
in:
A. The triglycerides
B. The INR
C. Chest pain
D. Blood pressure
ANSWER: A. Therapeutic effects of simvastatin include
decreased serum triglyceries, LDL and cholesterol.
30. A client is taking nitroglycerine tablets, the nurse should
teach the client the importance of:
A. Increasing the number of tablets if dizziness or
hypertension occurs.
B. Limiting the number of tablets to 4 per day.
C. Making certain the medication is stored in a dark
container.
D. Discontinuing the medication if a headache develops.
ANSWER: C. Nitroglycerine is sensitive to light and moisture
ad must be stored in a dark, airtight container.
31. The physician prescribes Ibuprofen (Motrin) and
hydroxychloroquine sulfate (Plaquenil) for a 58-year-old male
client with arthritis. The nurse provides information about
toxicity of the hydroxychloroquine. The nurse can determine
if the information is clearly understood if the client states:
A. “I will contact the physician immediately if I develop
blurred vision.”
B. “I will contact the physician immediately if I develop
urinary retention.”
C. “I will contact the physician immediately if I develop
swallowing difficulty.”
D. “I will contact the physician immediately if I develop
feelings of irritability.”
ANSWER: A. Visual disturbance are a sign of toxicity because
retinopathy can occur with this drug.
32. The client with an acute myocardial infarction is
hospitalized for almost one week. The client experiences
nausea and loss of appetite. The nurse caring for the client
recognizes that these symptoms may indicate the:
A. Adverse effects of spironolactone (Aldactone)
B. Adverse effects of digoxin (Lanoxin)
C. Therapeutic effects of propranolol (Indiral)
D. Therapeutic effects of furosemide (Lasix)
ANSWER: B. Toxic levels of Lanoxin stimulate the medullary
chemoreceptor trigger zone, resulting in nausea and
subsequent anorexia.
33. A client with a partial occlusion of the left common
carotid artery is scheduled for discharge. The client is still
receiving Coumadin. The nurse provided a discharge
instruction to the client regarding adverse effects of
Coumadin. The nurse should tell the client to consult with the
physician if:
A. Swelling of the ankles increases.
B. Blood appears in the urine.
C. Increased transient Ischemic attacks occur.
D. The ability to concentrate diminishes.
Answer: B. Warfarin derivatives cause an increase in the
prothrombin time and INR, leading to an increased risk for
bleeding. Any abnormal or excessive bleeding must be
reported, because it may indicate toxic levels of the drug.
34. Levodopa is ordered for a client with Parkinson’s disease.
Before starting the medication, the nurse should know that:
A. Levodopa is inadequately absorbed if given with meals.
B. Levodopa may cause the side effects of orthostatic
hypotension.
C. Levodopa must be monitored by weekly laboratory
tests.
D. Levodopa causes an initial euphoria followed by
depression.
Answer: B. Levodopa is the metabolic precursor of
dopamine. It reduces sympathetic outflow by limiting
vasoconstriction, which may result in orthostatic
hypotension.
35. In making a diagnosis of myasthenia gravis Edrophonium
HCI (Tensilon) is used. The nurse knows that this drug will
cause a temporary increase in:
A. Muscle strength
B. Symptoms
C. Blood pressure
D. Consciousness
Answer: A. Tensilon, an anticholinesterase drug, causes
temporary relief of symptoms of myasthenia gravis in client
who have the disease and is therefore an effective diagnostic
aid.
36. The nurse can determine the effectiveness of
carbamazepine (Tegretol) in the management of trigeminal
neuralgia by monitoring the client’s:
A. Seizure activity
B. Liver function
C. Cardiac output
D. Pain relief
Answer: D. Carbamazepine ( Tegretol) is administered to
control pain by reducing the transmission of nerve impulses
in clients with trigeminal neuralgia.
37. Administration of potassium iodide solution is ordered to
the client who will undergo a subtotal thyroidectomy. The
nurse understands that this medication is given to:
A. Ablate the cells of the thyroid gland that produce T4.
B. Decrease the total basal metabolic rate.
C. Decrease the size and vascularity of the thyroid.
D. Maintain function of the parathyroid gland.
Answer: C. Potassium iodide, which aids in decreasing the
vascularity of the thyroid gland, decreases the risk for
hemorrhage.
38. A client with Addison’s disease is scheduled for discharge.
Before the discharge, the physician prescribes hydrocortisone
and fludrocortisone. The nurse expects the hydrocortisone to:
A. Increase amounts of angiotensin II to raise the client’s
blood pressure.
B. Control excessive loss of potassium salts.
C. Prevent hypoglycemia and permit the client to respond
to stress.
D. Decrease cardiac dysrhythmias and dyspnea.
Answer: C. Hydrocortisone is a glucocorticoid that has anti-
inflammatory action and aids in metabolism of
carbohydrate, fat, and protein, causing elevation of blood
glucose. Thus it enables the body to adapt to stress.
39. A client with diabetes insipidus is taking Desmopressin
acetate (DDAVP). To determine if the drug is effective, the
nurse should monitor the client’s:
A. Arterial blood pH
B. Pulse rate
C. Serum glucose
D. Intake and output
Answer: D. DDAVP replaces the ADH, facilitating
reabsorption of water and consequent return of normal
urine output and thirst.
40. A client with recurrent urinary tract infections is to be
discharged. The client will be taking nitrofurantoin (Macrobid)
50 mg po every evening at home. The nurse provides
discharge instructions to the client. Which of the following
instructions will be correct?
A. Strain urine for crystals and stones
B. Increase fluid intake.
C. Stop the drug if the urinary output increases
D. Maintain the exact time schedule for drug taking.
Answer: B. To prevent crystal formation, the client should
have sufficient intake to produce 1000 to 1500 mL of urine
daily while taking this drug.
41. A client with cancer of the lung is receiving chemotherapy.
The physician orders antibiotic therapy for the client. The
nurse understands that chemotherapy destroys rapidly
growing leukocytes in the:
A. Bone marrow
B. Liver
C. Lymph nodes
D. Blood
Answer: A. Prolonged chemotherapy may slow the
production of leukocytes in bone marrow, thus suppressing
the activity of the immune system. Antibiotics may be
required to help counter infections that the body can no
longer handle easily.
42. The physician reduced the client’s Dexamethasone
(Decadron) dosage gradually and to continue a lower
maintenance dosage. The client asks the nurse about the
change of dosage. The nurse explains to the client that the
purpose of gradual dosage reduction is to allow:
 A. Return of cortisone production by the adrenal glands. Answer: A. Once treatment with insulin for diabetic
B. Production of antibodies by the immune system ketoacidosis is begun, potassium ions reenter the cell,
C. Building of glycogen and protein stores in liver and causing hypokalemia; therefore potassium, along with the
muscle replacement fluid, is generally supplied.
D. Time to observe for return of increases intracranial
pressure 48. A female client is brought to the emergency unit. The
client is complaining of abdominal cramps. On assessment,
Answer: A. Any hormone normally produced by the body client is experiencing anorexia and weight is reduced. The
must be withdrawn slowly to allow the appropriate organ to physician’s diagnosis is colitis. Which of the following
adjust and resume production. symptoms of fluid and electrolyte imbalance should the nurse
report immediately?
43. The nurse is assigned to care for a client with diarrhea.
Excessive fluid loss is expected. The nurse is aware that fluid A. Skin rash, diarrhea, and diplopia
deficit can most accurately be assessed by: B. Development of tetaniy with muscles spasms
C. Extreme muscle weakness and tachycardia
A. The presence of dry skin D. Nausea, vomiting, and leg and stomach cramps.
B. A change in body weight
C. An altered general appearance Answer: C. Potassium, the major intracellular cation,
D. A decrease in blood pressure functions with sodium and calcium to regulate
neuromuscular activity and contraction of muscle fibers,
Answer: B. Dehydration is most readily and accurately particularly the heart muscle. In hypokalemia these
measured by serial assessment of body weight; 1 L of fluid symptoms develop.
weighs 2.2 pounds.
49. The client is to receive an IV piggyback medication. When
44. Which of the following is the most important electrolyte preparing the medication the nurse should be aware that it is
of intracellular fluid? very important to:

A. Potassium A. Use strict sterile technique

B. Sodium B. Use exactly 100mL of fluid to mix the medication
C. Chloride C. Change the needle just before adding the medication
D. Calcium D. Rotate the bag after adding the medication

Answer: A. The concentration of potassium is greater inside Answer: A. Because IV solutions enter the body’s internal
the cell and is important in establishing a membrane environment, all solutions and medications utilizing this
potential, a critical factor in the cell’s ability to function. route must be sterile to prevent the introduction of
microbes.
45. Which of the following client has a high risk for developing
hyperkalemia? 50. The nurse is reviewing the laboratory result of the client.
An arterial blood gas report indicates the client’s pH is 7.20,
A. Crohn’s disease PCO2 35 mmHg and HCO3 is 19 mEq/L. The results are
B. End-Stage renal disease consistent with:
C. Cushing’s syndrome
D. Chronic heart failure A. Metabolic acidosis
B. Metabolic alkalosis
Answer: B. The kidneys normally eliminate potassium from C. Respiratory acidosis
the body; hyperkalemia may necessitate dialysis. D. Respiratory alkalosis

46. The nurse is reviewing the laboratory result of the client. Answer: A. A low pH and bicarbonate level are consistent
The client’s serum potassium level is 5.8 mEq/L. Which of the with metabolic acidosis.
following is the initial nursing action?

A. Call the cardiac arrest team to alert them PNLE V Nursing Practice
B. Call the laboratory and repeat the test The scope of this Nursing Test V is parallel
C. Take the client’s vital signs and notify the physician to the NP5 NLE Coverage:
D. Obtain an ECG strip and have lidocaine available  Psychiatric Nursing
1. A 17-year-old client has a record of being
Answer: C. Vital signs monitor cardiorespiratory status; absent in the class without permission, and
hyperkalemia causes serious cardiac dysrhythmias. “borrowing” other people’s things without asking
permission. The client denies stealing;
47. Potassium chloride, 20 mEq, is ordered and to be added in rationalizing instead that as long as no one was
the IV solution of a client in a diabetic ketoacidosis. The using the items, there is no problem to use it by
primary reason for administering this drug is: other people. It is important for the nurse to
understand that psychodynamically, the behavior
of the client may be largely attributed to a
A. Replacement of excessive losses
development defect related to the:
B. Treatment of hyperpnea
C. Prevention of flaccid paralysis
D. Treatment of cardiac dysrhythmias A. Oedipal complex
B. Superego
C. Id
D. Ego
 Answer: B. This shows a weak sense of moral
consciousness. According to Freudian theory,
personality disorders stem from a weak
superego.
2. A client tells the nurse, “Yesterday, I was
planning to kill myself.” What is the best nursing
response to this cient?
A. “What are you going to do this time?”
B. Say nothing. Wait for the client’s next
comment
C. “You seem upset. I am going to be here
with you; perhaps you will want to talk
about it”
D. “Have you felt this way before?”
Answer: C. The client needs to have his or her
feelings acknowledged, with encouragement to
discuss feelings, and be reassured about the
nurse’s presence.
3. In crisis intervention therapy, which of the
following principle that the nurse will use to plan
her/his goals?
A. Crises are related to deep, underlying
problems
B. Crises seldom occur in normal people’s lives
C. Crises may go on indefinitely.
D. Crises usually resolved in 4-6 weeks.
Answer: D. Part of the definition of a crisis is a
time span of 4-6 weeks.
4. The nurse enters the room of the male client
and found out that the client urinates on the floor.
The client hides when the nurse is about to talk to
him. Which of the following is the best nursing
intervention?
A. Place restriction on the client’s activities
when his behavior occurs.
B. Ask the client to clean the soiled floor.
C. Take the client to the bathroom at
regular intervals.
D. Limit fluid intake.
Answer; C. The client is most likely confused,
rather than exhibiting acting-out, hostile
behavior. Frequent toileting will allow urination in
an appropriate place.
5. A young lady with a diagnosis of schizophrenic
reaction is admitted to the psychiatric unit. In the
past two months, the client has poor appetite,
experienced difficulty in sleeping, was mute for
long periods of time, just stayed in her room,
grinning and pointing at things. What would be
the initial nursing action on admitting the client
to the unit?
A. Assure the client that “ You will be well cared
for.”
B. Introduce the client to some of the other
clients.
C. Ask “Do you know where you are?”
D. Take the client to the assigned room.
Answer: D. The client needs basic, simple
orientation that directly relates to the here-and-
now, and does not require verbal interaction.
6. A 16-year-old girl was diagnosed with anorexia.
What would be the first assessment of the nurse?
A. What food she likes.
B. Her desired weight.
C. Her body image.
D. What causes her behavior.
Answer: A. Although all options may appear
correct. A is the best because it focuses on a
range of possible positive reinforcers, a basis for
an effective behavior modification program. It
can lead to concrete, specific nursing
interventions right away and provides a
therapeutic use of “control” for the 16-year-old.
7. On an adolescent unit, a nurse caring to a
client was informed that her client’s closest
roommate dies at night. What would be the most
appropriate nursing action?
A. Do not bring it up unless the client
asks.
B. Tell the client that her roommate went home.
C. Tell the client, if asked, “You should ask the
doctor.”
D. Tell the client that her closest roommate
died.
Answer: A. The nurse needs to wait and see: do
not “jump the gun”; do not assume that the
client wants to know now.
8. A woman gave birth to an unhealthy infant,
and with some body defects. The nurse should
expect the woman’s initial reactions to include:
A. Depression
B. Withdrawal
C. Apathy
D. Anger
Answer: D. The woman is experiencing an actual
loss and will probably exhibit many of the same
symptoms as a person who has lost someone to
death.
9. A client in the psychiatric unit is shouting out
loud and tells the nurse, “Please, help me. They
are coming to get me.” What would be the
appropriate nursing response?
A. “ I won’t let anyone get you.”
B. “Who are they?”
C. “I don’t see anyone coming.”
D. “You look frightened.”
Answer: C. This option is an example of pointing
out reality- the nurse’s perception.
10. A client who is severely obese tells the nurse,
“My therapist told me that I eat a lot because I
didn’t get any attention and love from my
mother. What does the therapist mean?” What is
the best nursing response?
A. “What do you think is the connection
between your not getting enough love and
overeating?”
B. “Tell me what you think the therapist
means.”
C. “You need to ask your therapist.”
D. “ We are here to deal with your diet, not with
your psychological problems.”
Answer: B. This response asks information that
the nurse can use. If the client understands the
statement, the nurse can support the therapist
when focusing on connection between food,
love, and mother. If the client does not
understand thestatement, the nurse can help
get clarification from the therapist.
11. After the discussion about the procedure the
physician scheduled the client for mastectomy.
The client tells the nurse, “If my breasts will be
removed, I’m afraid my husband will not love me
anymore and maybe he will never touch me.”
What should the nurse’s response?
A. “I doubt that he feels that way.”
B. “What makes you feel that way?”
C. “Have you discussed your feelings with
your husband?”
D. Ask the husband, in front of the wife, how he
feels about this.
Answer: C. This option redirects the client to talk
to her husband.
12. The child is brought to the hospital by the
parents. During assessment of the nurse, what
parental behavior toward a child should alert the
nurse to suspect child abuse?
A. Ignoring the child.
B. Flat affect.
C. Expressions of guilt.
D. Acting overly solicitous toward the child
Answer: D. This is an example of reaction
formation, a coping mechanism.
13. A nurse is caring to a client with manic
disorder in the psychiatric ward. On the morning
shift, the nurse is talking with the client who is
now exhibiting a manic episode with flight of
ideas. The nurse primarily needs to:
A. Focus on the feelings conveyed rather
than the thoughts expressed.
B. Speak loudly and rapidly to keep the client’s
attention, because the client is easily
distracted.
C. Allow the client to talk freely.
D. Encourage the client to complete one
thought at a time.
Answer: A. Often the verbalized ideas are
jumbled, but the underlying feelings are
discernible and must be acknowledged.
14. The nurse is caring to an autistic child. Which
of the following play behavior would the nurse
expect to see in a child?
A. competitive play
B. nonverbal play
C. cooperative play
D. solitary play
Answer: D. Autistic children do best with solitary
play because they typically do not interact with
others in a socially comprehensible and
acceptable way.
15. The client is telling the nurse in the
psychiatric ward, “I hate them.” Which of the
following is the most appropriate nursing
response to the client?
A. “Tell me about your hate.”
B. “I will stay with you as long as you feel this
way.”
C. “For whom do you have these feelings?”
D. “I understand how you can feel this way.”
Answer: A. The nurse is asking the client to
clarify and further discuss feelings.
16. The mother visits her son with major
depression in the psychiatric unit. After the
conversation of the client and the mother, the
nurse asks the mother how it is talking to her son.
The mother tells the nurse that it was a stressful
time. During an interview with the client, the
client says, “we had a marvelous visit.” Which of
the following coping mechanism can be described
to thestatement of the client?
A. Identification.
B. Rationalization.
C. Denial.
D. Compensation.
Answer: C. Denial is the act of avoiding
disagreeable realities by ignoring them.
17. A male client is quiet when the physician told
him that he has stage IV cancer and has 4
months to live. The nurse determines that this
reaction may be an example of:
A. Indifference
B. Denial
C. Resignation
D. Anger
Answer: B. Reactions when told of a life-
threatening illness stem from Kübler-Ross’ ideas
on death and dying. Denial is a typical grief
response, and usually is a first reaction.
18. A nurse is caring to a female client with five
young children. The family member told the client
that her ex-husband has died 2 days ago. The
reaction of the client is stunned silence, followed
by anger that the ex-husband left no insurance
money for their young children. The nurse should
understand that:
A. The children and the injustice done to them
by their father’s death are the woman’s main
concern.
B. To explain the woman’s reaction, the nurse
needs more information about the
relationship and breakup.
C. The woman is not reacting normally to the
news.
D. The woman is experiencing a normal
bereavement reaction.
Answer: D. Shock and anger are commonly the
primary initial reactions.
19. A client who is manic comes to the outpatient
department. The nurse is assigning an activity for
the client. What activity is best for the nurse to
encourage for a client in a manic phase?
A. Solitary activity, such as walking with
the nurse, to decrease stimulation.
B. Competitive activity, such as bingo, to
increase the client’s self-esteem.
C. Group activity, such as basketball, to
decrease isolation.
D. Intellectual activity, such as scrabble, to
increase concentration.
Answer: A. This option avoids external stimuli,
yet channels the excess motor activity that is
often part of the manic phase.
20. The nurse is about to administer Imipramine
HCI (Tofranil) to the client, the client says, “Why
should I take this?” The doctor started me on this
10days ago; it didn’t help me at all.” Which of the
following is the best nursing response:
A. “What were you expecting to happen?”
B. “It usually takes 2-3 weeks to be
effective.”
C. “Do you want to refuse this medication? You
have the right.”
D. “That’s a long time wait when you feel so
depressed.”
Answer: B. The patient needs a brief, factual
answer.
21. Which of the following drugs the nurse should
choose to administer to a client to prevent
pseudoparkinsonism?
A. Isocarboxazid (Marplan)
B. Chlorpromazine HCI (Thorazine)
C. Trihexyphenidyl HCI (Artane)
D. Trifluoperazine HCI (Stelazine)
Answer: C. Trihexyphenidyl HCI (Artane) is often
used to counteract side effect of
pseudoparkinsonism, which often accompanies
the use of phenothiazine, such as
chlorpromazine HCI (Thorazine or Trifluoperazine
HCI (Stelazine).
22. The nurse is caring to an 80-year-old client
with dementia? What is the most important
psychosocial need for this client?
A. Focus on the there-and-then rather the here-
and-now.
B. Limit in the number of visitors, to minimize
confusion.
C. Variety in their daily life, to decrease
depression.
D. A structured environment, to minimize
regressive behaviors.
Answer: D. Persons with dementia needs
sameness, consistency, structure, routine, and
predictability.
23. A client tells the nurse, “I don’t want to eat
any meals offered in this hospital because the
food is poisoned.” The nurse is aware that the
client is expressing an example of:
A. Delusion.
B. Hallucination.
C. Negativism.
D. Illusion.
Answer: A. This is a false belief developed in
response to an emotional need.
24. A client is admitted in the hospital. On
assessment, the nurse found out that the client
had several suicidal attempts. Which of the
following is the most important nursing action?
A. Ignore the client as long as he or she is
talking about suicide, because suicide
attempt is unlikely.
B. Administer medication.
C. Relax vigilance when the client seems to be
recovering from depression.
D. Maintain constant awareness of the
client’s whereabouts.
Answer:D. The client must be constantly
observed.
25. The nurse suspects that the client is suffering
from depression. During assessment, what are
the most characteristic signs and symptoms of
depression the nurse would note?
A. Constipation, increased appetite.
B. Anorexia, insomnia.
C. Diarrhea, anger.
D. Verbosity, increased social interaction
Answer: B. The appetite is diminished and
sleeping is affected to a client with depression.
.
26. The client in the psychiatric unit states that,
“The goodas are coming! I must be ready.” In
response to this neologism, the nurse’s initial
response is to:
A. Acknowledge that the word has some
special meaning for the client.
B. Try to interpret what the client means.
C. Divert the client’s attention to an aspect of
reality.
D. State that what the client is saying has not
been understood and then divert attention to
something that is really bound.
Answer: A. It is important to acknowledge a
statement, even if it is not understood.
27. A male client diagnosed with depression tells
the nurse, “I don’t want to look weak and I don’t
even cry because my wife and my kids can’t bear
it.” The nurse understands that this is an example
of:
A. Repression.
B. Suppression.
C. Undoing.
D. Rationalization.
Answer: D. Rationalization is the process of
constructing plausible reasons for one’s
responses
28. A female client tells the nurse that she is
afraid to go out from her room because she
thinks that the other client might kill her. The
nurse is aware that this behavior is related to:
A. Hallucination.
B. Ideas of reference.
C. Delusion of persecution.
D. Illusion.
Answer: C. The client has ideas that someone is
out to kill her.
29. A female client is taking Imipramine HCI
(Tofranil) for almost 1 week and shows less
awareness of the physical body. What problem
would the nurse be most concerned?
A. Nausea.
B. Gait disturbances.
C. Bowel movements.
D. Voiding.
Answer: D. A serious side effect of Imipramine
HCI (Tofranil) is urinary retention (voiding
problems)
30. A 6-year-old client dies in the nursing unit.
The parents want to see the child. What is the
most appropriate nursing action?
A. Give the parents time alone with the
body.
B. Ask the physician for permission.
C. Complete the postmortem care and quietly
accompany the family to the child’s room.
D. Suggest the parents to wait until the funeral
service to say “good-bye.”
Answer: A. This allows the parents/family to
grieve over the loss of the child, by going
through the steps of leave taking.
31. A 20-year-old female client is diagnosed with
anxiety disorder. The physician prescribed
Flouxetine (Prozac). What is the most important
side effects should a nurse be concerned?
A. Tremor, drowsiness.
B. Seizures, suicidal tendencies.
C. Visual disturbance, headache.
D. Excessive diaphoresis, diarrhea.
Answer: B. Assess for suicidal tendencies,
especially during early therapy. There is an
increased risk of seizures in debilitated client
and those with a history of seizures.
32. A nurse is assigned to activate a client who is
withdrawn, hears voices and negativistic. What
would be the best nursing approach?
A. Mention that the “voices” would want the
client to participate.
B. Demand that the client must join a group
activity.
C. Give the client a long explanation of the
benefits of activity.
D. Tell the client that the nurse needs a
partner for an activity.
Answer: D. The nurse helps to activate by doing
something with the client.
33. A nurse is going to give a rectal suppository
as a preoperative medication to a 4-year-old boy.
The boy is very anxious and frightened. Which of
the following statement by the nurse would be
most appropriate to gain the child’s cooperation?
A. “Be a big kid! Everyone’s waiting for you.”
B. “Lie still now and I’ll let you have one of your
presents before you even have your
operation.”
C. “Take a nice, big, deep breath and then
let me hear you count to five.”
D. “You look so scared. Want to know a secret?
This won’t hurt a bit!”
Answer: C. Preschool children commonly
experience fears and fantasies regarding
invasive procedures. The nurse should attempts
to momentarily distract the child with a simple
task that can be easily accomplished while the
child remains in the side-lying position. The
suppository can be slipped into place while the
child is counting, and then the nurse can praise
the child for cooperating, while holding the
buttocks together to prevent expulsion of the
suppository.
34. A depressed client is on an MAO inhibitor?
What should the nurse watch out for?
A. Hypertensive crisis.
B. Diet restrictions.
C. Taking medication with meals.
D. Exposure to sunlight.
Answer: A. This is the more inclusive answer,
although diet restrictions (answer1) are
important, their purpose is to prevent
hypertensive crisis (answer 2).
35. A 16-year-old girl is admitted for treatment of
a fracture. The client shares to the nurse caring
to her that her step-father has made sexual
advances to her. She got the chance to tell it to
her mother but refuses to believe. What is the
most therapeutic action of the nurse would be:
A. Tell the client to work it out with her father.
B. Tell the client to discuss it with her mother.
C. Ask the father about it.
D. Ask the mother what she thinks.
Answer: D. This comes closest to beginning to
focus on family-centered approach to intervene
in the “conspiracy of silence”. This is therefore
the best among the options.
36. A client with a diagnosis of paranoid disorder
is admitted in the psychiatric hospital. The client
tells the nurse, “the FBI is following me. These
people are plotting against me.” With this
statement the nurse will need to:
A. Acknowledge that this is the client’s
belief but not the nurse’s belief.
B. Ask how that makes the client feel.
C. Show the client that no one is behind.
D. Use logic to help the client doubt this belief.
Answer: A. The nurse should neither challenge
nor use logic to dispel an irrational belief.
37. A nurse is completing the routine physical
examination to a healthy 16-year-old male client.
The client shares to the nurse that he feels like
killing his girlfriend because he found out that her
girlfriend had another boyfriend. He then laughs,
and asks the nurse to keep this a secret just
between the two of them. The nurse reviews his
chart and notes that there is no previously history
of violence or psychiatric illness. Which of the
following would be the best action of the nurse to
take at this time?
A. Suggest the teen meet with a counselor to
discuss his feelings about his girlfriend.
B. Tell the teen that his feelings are normal, and
recommend that he find another girlfriend to
take his mind off the problem.
C. Recall the teenage boys often say things
they really do not mean and ignore the
comment.
D. Regard the comment seriously and
notify the teen’s primary health care
provider and parents
Answer: D. Any threat to the safety of oneself or
other should always be taken seriously and
never disregarded by the nurse.
38. Which of the following person will be at
highest risk for suicide?
A. A student at exam time
B. A married woman, age 40, with 6 children.
C. A person who is an alcoholic.
D. A person who made a previous suicide
attempt.
Answer: C. The likelihood of multiple contributing
factors may make this person at higher risk for
suicide. Some factors that may exist are physical
illness related to alcoholism, emotional factors
( anxiety, guilt, remorse), social isolation due to
impaired relationships and economic problems
related to employment.
39. A male client is repetitively doing the
handwashing every time he touches things. It is
important for a nurse to understand that the
client’s behavior is probably an attempt to:
A. Seek attention from the staff.
B. Control unacceptable impulses or
feelings.
C. Do what the voices the patient hears tell him
or her to do.
D. Punish himself or herself for guilt feeling.
Answer: B. A ritual, such as compulsive
handwashing, is an attempt to allay anxiety
caused by unconscious impulses that are
frightening.
40. In a mental health settings, the basic goal of
nursing is to:
A. Advance the science of psychiatry by
initiating research and gathering data for
current statistics on emotional illness.
B. Plan activity programs for clients.
C. Understand various types of family therapy
and psychological tests and how to interpret
them.
D. Maintain a therapeutic environment.
Answer: D. This is the most neutral answer by
process of elimination.
41. A 3-year-old boy is brought to the emergency
department. After an hour, the boy dies of
respiratory failure. The mother of the boy
becomes upset, shouting and abusive, saying to
the nurse, “If it had been your son, they would
have done more to save it. “What should the
nurse say or do?
A. Touch her and tell her exactly what was done
for her baby.
B. Allow the mother to continue her
present behavior while sitting quietly
with her.
C. “No, all clients are given the same good
care.”
D. “Yes, you’re probably right. Your son did not
get better care.”
Answer: B. This option allows a normal grief
response (anger).
42. The nurse is interacting to a client with an
antisocial personality disorder. What would be the
most therapeutic approach of the nurse to an
antisocial behavior?
A. Gratify the client’s inner needs.
B. Give the client opportunities to test reality.
C. Provide external controls.
D. Reinforce the client’s self-concept.
Answer: C. Personality disorders stem from a
weak superego, implying a lack of adequate
controls.
43. A 55-year-old male client tells the nurse that
he needs his glasses and hearing aid with him in
the recovery room after the surgery, or he will be
upset for not granting his request. What is the
appropriate nursing response?
A. “Do you get upset and confused often?”
B. “You won’t need your glasses or hearing aid.
The nurses will take care of you.”
C. “I understand. You will be able to
cooperate best if you know what is
going on, so I will find out how I can
arrange to have your glasses and
hearing aid available to you in the
recovery room.”
D. I understand you might be more cooperative
if you have your aid and glasses, but that is
just not possible. Rules, you know.”
Answer: C. The client will be easier to care for if
he has his hearing aid and glasses.
44. The male client had fight with his roommates
in the psychiatric unit. The client agitated client is
placed in isolation for seclusion. The nurse knows
it is essential that:
A. A staff member has frequent contacts
with the client.
B. Restraints are applied.
C. The client is allowed to come out after 4
hours.
D. All the furniture is removed form the isolation
room.
Answer: A. Frequent contacts at times of stress
are important, especially when a client is
isolated.
45. A medical representative comes to the
hospital unit for the promotion of a new product.
A female client, admitted for hysterical behavior,
is found embracing him. What should the nurse
say?
A. “Have you considered birth control?”
B. “This isn’t the purpose of either of you
being here.”
C. “I see you’ve made a new friend.”
D. “Think about what you are doing.”
Answer: B. This response is aimed at redirecting
the inappropriate behavior.
46. A client with dementia is for discharge. The
nurse is providing a discharge instruction to the
family member regarding safety measures at
home. What suggestion can the nurse make to
the family members?
A. Avoid stairs without banisters.
B. Use restraints while the client is in bed to
keep him or her from wandering off during
the night.
C. Use restraints while the client is sitting in a
chair to keep him or her from wandering off
during the day.
D. Provide a night-light and a big clock.
Answer: D. This option is best to decrease
confusion and disorientation to place and time
47. A 30-year-old married woman comes to the
hospital for treatment of fractures. The woman
tells the nurse that she was physically abused by
her husband. The woman receives a call from her
husband telling her to get home and things will
be different. He felt sorry of what he did. What
can the nurse advise her?
A. “Do you think so?”
B. “It’s not likely.”
C. “What will be different?”
D. “I hope so, for your sake.”
Answer: C. This option helps the woman to think
through and elaborate on her own thoughts and
prognosis.
48. A female client was diagnosed with breast
cancer. It is found to be stage IV, and a modified
mastectomy is performed. After the procedure,
what behaviors could the nurse expects the client
to display?
A. Denial of the possibility of carcinoma.
B. Signs of grief reaction.
C. Relief that the operation is over.
D. Signs of deep depression.
Answer:B. It is mostly likely that grief would be
expressed because of object loss.
49. A client is withdrawn and does not want to
interact to anybody even to the nurse. What is
the best initial nursing approach to encourage
communication with this client?
A. Use simple questions that call for a response.
B. Encourage discussion of feelings.
C. Look through a photo album together.
D. Bring up neutral topics.
Answer: D. Neutral, nonthreatening topics are
best in attempting to encourage a response.
50. Which of the following nursing approach is
most important in a client with depression?
A. Deemphasizing preoccupation with
elimination, nourishment, and sleep.
B. Protecting against harm to others.
C. Providing motor outlets for aggressive,
hostile feelings.
D. Reducing interpersonal contacts.
Answer: C. It is important to externalize the
anger away from self.
SET 3
PNLE I for Foundation of
Nursing
1. Which element in the circular chain of infection
can be eliminated by preserving skin integrity?
A. Host
B. Reservoir
C. Mode of transmission
D. Portal of entry
Answer: D. In the circular chain of infection,
pathogens must be able to leave their reservoir
and be transmitted to a susceptible host through
a portal of entry, such as broken skin.
2. Which of the following will probably result in a
break in sterile technique for respiratory
isolation?
A. Opening the patient’s window to the outside
environment
B. Turning on the patient’s room ventilator
C. Opening the door of the patient’s room
leading into the hospital corridor
D. Failing to wear gloves when administering a
bed bath
Answer: C. Respiratory isolation, like strict
isolation, requires that the door to the door
patient’s room remain closed. However, the
patient’s room should be well ventilated, so
opening the window or turning on the ventricular
is desirable. The nurse does not need to wear
gloves for respiratory isolation, but good hand
washing is important for all types of isolation.
3. Which of the following patients is at greater
risk for contracting an infection?
A. A patient with leukopenia
B. A patient receiving broad-spectrum
antibiotics
C. A postoperative patient who has undergone
orthopedic surgery
D. A newly diagnosed diabetic patient

Answer: A. Leukopenia is a decreased number of
leukocytes (white blood cells), which are
important in resisting infection. None of the
other situations would put the patient at risk for
contracting an infection; taking
broadspectrum antibiotics might actually reduce
the infection risk.
4. Effective hand washing requires the use of:
A. Soap or detergent to promote
emulsification
B. Hot water to destroy bacteria
C. A disinfectant to increase surface tension
D. All of the above
Answer: A. Soaps and detergents are used to
help remove bacteria because of their ability to
lower the surface tension of water and act as
emulsifying agents. Hot water may lead to skin
irritation or burns.
5. After routine patient contact, hand washing
should last at least:
A. 30 seconds
B. 1 minute
C. 2 minute
D. 3 minutes
Answer: A. Depending on the degree of
exposure to pathogens, hand washing may last
from 10 seconds to 4 minutes. After routine
patient contact, hand washing for 30 seconds
effectively minimizes the risk of
pathogen transmission.
6. Which of the following procedures always
requires surgical asepsis?
A. Vaginal instillation of conjugated estrogen
B. Urinary catheterization
C. Nasogastric tube insertion
D. Colostomy irrigation
Answer: B. The urinary system is normally free
of microorganisms except at the urinary meatus.
Any procedure that involves entering this system
must use surgically aseptic measures to
maintain a bacteria-free state.
7. Sterile technique is used whenever:
A. Strict isolation is required
B. Terminal disinfection is performed
C. Invasive procedures are performed
D. Protective isolation is necessary
Answer: C. All invasive procedures, including
surgery, catheter insertion, and administration
of parenteral therapy, require sterile technique
to maintain a sterile environment. All equipment
must be sterile, and the nurse and the physician
must wear sterile gloves and maintain surgical
asepsis. In the operating room, the nurse and
physician are required to wear sterile gowns,
gloves, masks, hair covers, and shoe covers for
all invasive procedures. Strict isolation requires
the use of clean gloves, masks, gowns and
equipment to prevent the transmission of highly
communicable diseases by contact or by
airborne routes. Terminal disinfection is
the disinfection of all contaminated supplies and
equipment after a patient has been discharged
to prepare them for reuse by another patient.
The purpose of protective (reverse) isolation is
to prevent a person with seriously impaired
resistance from coming into contact who
potentially pathogenic organisms.
8. Which of the following constitutes a break in
sterile technique while preparing a sterile field for
a dressing change?
A. Using sterile forceps, rather than sterile
gloves, to handle a sterile item
B. Touching the outside wrapper of sterilized
material without sterile gloves
C. Placing a sterile object on the edge of
the sterile field
D. Pouring out a small amount of solution (15 to
30 ml) before pouring the solution into a
sterile container
Answer: C. The edges of a sterile field are
considered contaminated. When sterile items are
allowed to come in contact with the edges of the
field, the sterile items also become
contaminated.
9. A natural body defense that plays an active
role in preventing infection is:
A. Yawning
B. Body hair
C. Hiccupping
D. Rapid eye movements
Answer: B. Hair on or within body areas, such as
the nose, traps and holds particles that contain
microorganisms. Yawning and hiccupping do
not prevent microorganisms from entering or
leaving the body. Rapid eye movement marks
the stage of sleep during which dreaming
occurs.
10. All of the following statement are true about
donning sterile gloves except:
A. The first glove should be picked up by
grasping the inside of the cuff.
B. The second glove should be picked up by
inserting the gloved fingers under the cuff
outside the glove.
C. The gloves should be adjusted by sliding the
gloved fingers under the sterile cuff and
pulling the glove over the wrist
D. The inside of the glove is considered
sterile
Answer: D. The inside of the glove is always
considered to be clean, but not sterile.
11.When removing a contaminated gown, the
nurse should be careful that the first thing she
touches is the:
A. Waist tie and neck tie at the back of the
gown
B. Waist tie in front of the gown
C. Cuffs of the gown
D. Inside of the gown
Answer: A. The back of the gown is considered
clean, the front is contaminated. So, after
removing gloves and washing hands, the nurse
should untie the back of the gown; slowly move
backward away from the gown, holding
the inside of the gown and keeping the edges off
the floor; turn and fold the gown inside out;
discard it in a contaminated linen container;
then wash her hands again.
12.Which of the following nursing interventions is
considered the most effective form or universal
precautions?
A. Cap all used needles before removing them
from their syringes
B. Discard all used uncapped needles and
syringes in an impenetrable protective
container
C. Wear gloves when administering IM
injections
D. Follow enteric precautions
Answer: B. According to the Centers for Disease
Control (CDC), blood-to-blood contact occurs
most commonly when a health care worker
attempts to cap a used needle. Therefore, used
needles should never be recapped; instead they
should be inserted in a specially designed
puncture resistant, labeled container. Wearing
gloves is not always necessary
when administering an I.M. injection. Enteric
precautions prevent the transfer of pathogens
via feces.
13.All of the following measures are
recommended to prevent pressure ulcers except:
A. Massaging the reddened are with lotion
B. Using a water or air mattress
C. Adhering to a schedule for positioning and
turning
D. Providing meticulous skin care
Answer: A. Nurses and other health care
professionals previously believed that massaging
a reddened area with lotion would promote
venous return and reduce edema to the area.
However, research has shown that massage only
increases the likelihood of cellular ischemia and
necrosis to the area.
14.Which of the following blood tests should be
performed before a blood transfusion?
A. Prothrombin and coagulation time
B. Blood typing and cross-matching
C. Bleeding and clotting time
D. Complete blood count (CBC) and electrolyte
levels.
Answer: B. Before a blood transfusion is
performed, the blood of the donor and recipient
must be checked for compatibility. This is done
by blood typing (a test that determines a
person’s blood type) and cross-matching
(a procedure that determines the compatibility
of the donor’s and recipient’s blood after the
blood types has been matched). If the blood
specimens are incompatible, hemolysis and
antigen-antibody reactions will occur.
15.The primary purpose of a platelet count is to
evaluate the:
A. Potential for clot formation
B. Potential for bleeding
C. Presence of an antigen-antibody response
D. Presence of cardiac enzymes
Answer: A. Platelets are disk-shaped cells that
are essential for blood coagulation. A platelet
count determines the number of thrombocytes
in blood available for promoting hemostasis and
assisting with blood coagulation after injury. It
also is used to evaluate the patient’s potential
for bleeding; however, this is not its primary
purpose. The normal count ranges from 150,000
to 350,000/mm3. A count of 100,000/mm3 or
less indicates a potential for bleeding; count of
less than 20,000/mm3 is associated with
spontaneous bleeding.
16.Which of the following white blood cell (WBC)
counts clearly indicates leukocytosis?
A. 4,500/mm³
B. 7,000/mm³
C. 10,000/mm³
D. 25,000/mm³
Answer: D. Leukocytosis is any transient
increase in the number of white blood cells
(leukocytes) in the blood. Normal WBC counts
range from 5,000 to 100,000/mm3. Thus, a
count of 25,000/mm3 indicates leukocytosis.
17. After 5 days of diuretic therapy with 20mg of
furosemide (Lasix) daily, a patient begins to
exhibit fatigue, muscle cramping and muscle
weakness. These symptoms probably indicate
that the patient is experiencing:
A. Hypokalemia
B. Hyperkalemia
C. Anorexia
D. Dysphagia
Answer: A. Fatigue, muscle cramping, and
muscle weaknesses are symptoms
of hypokalemia (an inadequate potassium level),
which is a potential side effect of diuretic
therapy. The physician usually orders
supplemental potassium to prevent hypokalemia
in patients receiving diuretics. Anorexia is
another symptom of hypokalemia. Dysphagia
means difficulty swallowing.
18.Which of the following statements about chest
X-ray is false?
A. No contradictions exist for this test
B. Before the procedure, the patient should
remove all jewelry, metallic objects, and
buttons above the waist
C. A signed consent is not required
D. Eating, drinking, and medications are
allowed before this test
Answer: A. Pregnancy or suspected pregnancy is
the only contraindication for a chest X-ray.
However, if a chest X-ray is necessary, the
patient can wear a lead apron to protect the
pelvic region from radiation. Jewelry,
metallic objects, and buttons would interfere
with the X-ray and thus should not be worn
above the waist. A signed consent is not
required because a chest X-ray is not an invasive
examination. Eating, drinking and medications
are allowed because the X-ray is of the chest,
not the abdominal region.
19.The most appropriate time for the nurse to
obtain a sputum specimen for culture is:
A. Early in the morning
B. After the patient eats a light breakfast
C. After aerosol therapy
D. After chest physiotherapy
Answer: A. Obtaining a sputum specimen early
in this morning ensures an adequate supply of
bacteria for culturing and decreases the risk
of contamination from food or medication.
20.A patient with no known allergies is to receive
penicillin every 6 hours. When administering the
medication, the nurse observes a fine rash on the
patient’s skin. The most appropriate nursing
action would be to:
A. Withhold the moderation and notify the
physician
B. Administer the medication and notify the
physician
C. Administer the medication with an
antihistamine
D. Apply corn starch soaks to the rash
Answer: A. Initial sensitivity to penicillin is
commonly manifested by a skin rash, even in
individuals who have not been allergic to it
previously. Because of the danger of
anaphylactic shock, he nurse should withhold
the drug and notify the physician, who may
choose to substitute another drug. Administering
an antihistamine is a dependent nursing
intervention that requires a written physician’s
order. Although applying corn starch to the rash
may relieve discomfort, it is not the nurse’s top
priority in such a potentially life-threatening
situation.
21.All of the following nursing interventions are
correct when using the Ztrack method of drug
injection except:
A. Prepare the injection site with alcohol
B. Use a needle that’s a least 1” long
C. Aspirate for blood before injection
D. Rub the site vigorously after the
injection to promote absorption
Answer: D. The Z-track method is an I.M.
injection technique in which the patient’s skin is
pulled in such a way that the needle track is
sealed off after the injection. This procedure
seals medication deep into the muscle,
thereby minimizing skin staining and irritation.
Rubbing the injection site is contraindicated
because it may cause the medication to
extravasate into the skin.
22.The correct method for determining the vastus
lateralis site for I.M. injection is to:
A. Locate the upper aspect of the upper outer
quadrant of the buttock about 5 to 8 cm
below the iliac crest
B. Palpate the lower edge of the acromion
process and the midpoint lateral aspect of
the arm
C. Palpate a 1” circular area anterior to the
umbilicus
D. Divide the area between the greater
femoral trochanter and the lateral
femoral condyle into thirds, and select
the middle third on the anterior of the
thigh
Answer: D. The vastus lateralis, a long, thick
muscle that extends the full length of the thigh,
is viewed by many clinicians as the site of choice
for I.M. injections because it has relatively few
major nerves and blood vessels. The middle
third of the muscle is recommended as the
injection site. The patient can be in a supine or
sitting position for an injection into this site.
23.The mid-deltoid injection site is seldom used
for I.M. injections because it:
A. Can accommodate only 1 ml or less of
medication
B. Bruises too easily
C. Can be used only when the patient is lying
down
D. Does not readily parenteral medication
Answer: A. The mid-deltoid injection site can
accommodate only 1 ml or less of medication
because of its size and location (on the deltoid
muscle of the arm, close to the brachial artery
and radial nerve).
24.The appropriate needle size for insulin
injection is:
A. 18G, 1 ½” long
B. 22G, 1” long
C. 22G, 1 ½” long
D. 25G, 5/8” long
Answer: D. A 25G, 5/8” needle is the
recommended size for insulin injection because
insulin is administered by the subcutaneous
route. An 18G, 1 ½” needle is usually used for
I.M. injections in children, typically in the
vastus lateralis. A 22G, 1 ½” needle is usually
used for adult I.M. injections, which are typically
administered in the vastus lateralis or
ventrogluteal site.
25.The appropriate needle gauge for intradermal
injection is:
A. 20G
B. 22G
C. 25G
D. 26G
Answer:D. Because an intradermal injection
does not penetrate deeply into the skin, a small-
bore 25G needle is recommended. This type of
injection is used primarily to administer antigens
to evaluate reactions for allergy or sensitivity
studies. A 20G needle is usually used for I.M.
injections of oilbased medications; a 22G needle
for I.M. injections; and a 25G needle, for I.M.
injections; and a 25G needle, for subcutaneous
insulin injections.
26.Parenteral penicillin can be administered as
an:
A. IM injection or an IV solution
B. IV or an intradermal injection
C. Intradermal or subcutaneous injection
D. IM or a subcutaneous injection
Answer: A. Parenteral penicillin can be
administered I.M. or added to a solution and
given I.V. It cannot be administered
subcutaneously or intradermally.
27.The physician orders gr 10 of aspirin for a
patient. The equivalent dose in milligrams is:
A. 0.6 mg
B. 10 mg
C. 60 mg
D. 600 mg
Answer:D. gr 10 x 60mg/gr 1 = 600 mg
28.The physician orders an IV solution of dextrose
5% in water at 100ml/hour. What would the flow
rate be if the drop factor is 15 gtt = 1 ml?
A. 5 gtt/minute
B. 13 gtt/minute
C. 25 gtt/minute
D. 50 gtt/minute
Answer: C. 100ml/60 min X 15 gtt/ 1 ml = 25
gtt/minute
29.Which of the following is a sign or symptom of
a hemolytic reaction to blood transfusion?
A. Hemoglobinuria
B. Chest pain
C. Urticaria
D. Distended neck veins
Answer: A. Hemoglobinuria, the abnormal
presence of hemoglobin in the urine, indicates a
hemolytic reaction (incompatibility of the
donor’s and recipient’s blood). In this reaction,
antibodies in the recipient’s plasma combine
rapidly with donor RBC’s; the cells are
hemolyzed in either circulatory or
reticuloendothelial system. Hemolysis occurs
more rapidly in ABO incompatibilities than in Rh
incompatibilities. Chest pain and urticaria may
be symptoms of impending anaphylaxis.
Distended neck veins are an indication of
hypervolemia.
30.Which of the following conditions may require
fluid restriction?
A. Fever
B. Chronic Obstructive Pulmonary Disease
C. Renal Failure
D. Dehydration
Answer: C. In real failure, the kidney loses their
ability to effectively eliminate wastes and fluids.
Because of this, limiting the patient’s intake of
oral and I.V. fluids may be necessary. Fever,
chronic obstructive pulmonary disease, and
dehydration are conditions for which fluids
should be encouraged.
31.All of the following are common signs and
symptoms of phlebitis except:
A. Pain or discomfort at the IV insertion site
B. Edema and warmth at the IV insertion site
C. A red streak exiting the IV insertion site
D. Frank bleeding at the insertion site
Answer: D. Phlebitis, the inflammation of a vein,
can be caused by chemical irritants (I.V.
solutions or medications), mechanical irritants
(the needle or catheter used during
venipuncture or cannulation), or a localized
allergic reaction to the needle or catheter. Signs
and symptoms of phlebitis include pain or
discomfort, edema and heat at the I.V. insertion
site, and a red streak going up the arm or leg
from the I.V. insertion site.
32.The best way of determining whether a patient
has learned to instill ear medication properly is
for the nurse to:
A. Ask the patient if he/she has used ear drops
before
B. Have the patient repeat the nurse’s
instructions using her own words
C. Demonstrate the procedure to the patient
and encourage to ask questions
D. Ask the patient to demonstrate the
procedure
Answer: D. Return demonstration provides the
most certain evidence for evaluating the
effectiveness of patient teaching.
33.Which of the following types of medications
can be administered via gastrostomy tube?
A. Any oral medications
B. Capsules whole contents are dissolve in
water
C. Enteric-coated tablets that are thoroughly
dissolved in water
D. Most tablets designed for oral use,
except for extended-
duration compounds
Answer: D. Capsules, enteric-coated tablets, and
most extended duration or sustained release
products should not be dissolved for use in
a gastrostomy tube. They are pharmaceutically
manufactured in these forms for valid reasons,
and altering them destroys their purpose. The
nurse should seek an alternate physician’s order
when an ordered medication is inappropriate for
delivery by tube.
34.A patient who develops hives after receiving
an antibiotic is exhibiting drug:
A. Tolerance
B. Idiosyncrasy
C. Synergism
D. Allergy
Answer: D. A drug-allergy is an adverse reaction
resulting from an immunologic response
following a previous sensitizing exposure to the
drug. The reaction can range from a rash or
hives to anaphylactic shock. Tolerance to a drug
means that the patient experiences a decreasing
physiologic response to repeated administration
of the drug in the same dosage. Idiosyncrasy is
an individual’s unique hypersensitivity to a drug,
food, or other substance; it appears to be
genetically determined. Synergism, is a drug
interaction in which the sum of the drug’s
combined effects is greater than that of their
separate effects.
35.A patient has returned to his room after
femoral arteriography. All of the following are
appropriate nursing interventions except:
A. Assess femoral, popliteal, and pedal pulses
every 15 minutes for 2 hours
B. Check the pressure dressing for sanguineous
drainage
C. Assess a vital signs every 15 minutes for 2
hours
D. Order a hemoglobin and hematocrit
count 1 hour after the arteriography
Answer: D. A hemoglobin and hematocrit count
would be ordered by the physician if bleeding
were suspected. The other answers are
appropriate nursing interventions for a patient
who has undergone femoral arteriography.
36.The nurse explains to a patient that a cough:
A. Is a protective response to clear the
respiratory tract of irritants
B. Is primarily a voluntary action
C. Is induced by the administration of an
antitussive drug
D. Can be inhibited by “splinting” the abdomen
Answer: A. Coughing, a protective response that
clears the respiratory tract of irritants, usually is
involuntary; however it can be voluntary, as
when a patient is taught to perform coughing
exercises. An antitussive drug inhibits coughing.
Splinting the abdomen supports the abdominal
muscles when a patient coughs.
37.An infected patient has chills and begins
shivering. The best nursing intervention is to:
A. Apply iced alcohol sponges
B. Provide increased cool liquids
C. Provide additional bedclothes
D. Provide increased ventilation
Answer: C. In an infected patient, shivering
results from the body’s attempt to increase heat
production and the production of neutrophils
and phagocytotic action through increased
skeletal muscle tension and contractions. Initial
vasoconstriction may cause skin to feel cold to
the touch. Applying additional bed clothes helps
to equalize the body temperature and stop the
chills. Attempts to cool the body result in
further shivering, increased metabloism, and
thus increased heat production.
38.A clinical nurse specialist is a nurse who has:
A. Been certified by the National League for
Nursing
B. Received credentials from the Philippine
Nurses’ Association
C. Graduated from an associate degree
program and is a registered professional
nurse
D. Completed a master’s degree in the
prescribed clinical area and is a
registered professional nurse
Answer: .D. A clinical nurse specialist must have
completed a master’s degree in a clinical
specialty and be a registered professional nurse.
The National League of Nursing accredits
educational programs in nursing and provides a
testing service to evaluate student nursing
competence but it does not certify nurses. The
American Nurses Association identifies
requirements for certification and offers
examinations for certification in many areas
of nursing., such as medical surgical nursing.
These certification (credentialing) demonstrates
that the nurse has the knowledge and the ability
to provide high quality nursing care in the area
of her certification. A graduate of an associate
degree program is not a clinical nurse
specialist: however, she is prepared to provide
bed side nursing with a high degree of
knowledge and skill. She must successfully
complete the licensing examination to become a
registered professional nurse.
39.The purpose of increasing urine acidity
through dietary means is to:
A. Decrease burning sensations
B. Change the urine’s color
C. Change the urine’s concentration
D. Inhibit the growth of microorganisms
Answer: D. Microorganisms usually do not grow
in an acidic environment.
40.Clay colored stools indicate:
A. Upper GI bleeding
B. Impending constipation
C. An effect of medication
D. Bile obstruction
Answer: D. Bile colors the stool brown. Any
inflammation or obstruction that impairs bile
flow will affect the stool pigment, yielding light,
clay-colored stool. Upper GI bleeding results in
black or tarry stool. Constipation is characterized
by small, hard masses. Many medications and
foods will discolor stool – for example, drugs
containing iron turn stool black.; beets turn stool
red.
41.In which step of the nursing process would the
nurse ask a patient if the medication she
administered relieved his pain?
A. Assessment
B. Analysis
C. Planning
D. Evaluation
Answer: D. In the evaluation step of the nursing
process, the nurse must decide whether the
patient has achieved the expected outcome that
was identified in the planning phase.
42.All of the following are good sources of vitamin
A except:
A. White potatoes
B. Carrots
C. Apricots
D. Egg yolks
Answer: A. The main sources of vitamin A are
yellow and green vegetables (such as carrots,
sweet potatoes, squash, spinach, collard greens,
broccoli, and cabbage) and yellow fruits (such as
apricots, and cantaloupe). Animal sources
include liver, kidneys, cream, butter, and egg
yolks.

43.Which of the following is a primary nursing
intervention necessary for all patients with a
Foley Catheter in place?
A. Maintain the drainage tubing and collection
bag level with the patient’s bladder
B. Irrigate the patient with 1% Neosporin
solution three times a daily
C. Clamp the catheter for 1 hour every 4 hours
to maintain the bladder’s elasticity
D. Maintain the drainage tubing and
collection bag below bladder level to
facilitate drainage by gravity
Answer: D. Maintaing the drainage tubing and
collection bag level with the patient’s bladder
could result in reflux of urine into the kidney.
Irrigating the bladder with Neosporin and
clamping the catheter for 1 hour every 4 hours
must be prescribed by a physician.
44.The ELISA test is used to:
A. Screen blood donors for antibodies to human
immunodeficiency virus (HIV)
B. Test blood to be used for transfusion for HIV
antibodies
C. Aid in diagnosing a patient with AIDS
D. All of the above
Answer: D. The ELISA test of venous blood is
used to assess blood and potential blood donors
to human immunodeficiency virus (HIV). A
positive ELISA test combined with various signs
and symptoms helps to diagnose acquired
immunodeficiency syndrome (AIDS)
45.The two blood vessels most commonly used
for TPN infusion are the:
A. Subclavian and jugular veins
B. Brachial and subclavian veins
C. Femoral and subclavian veins
D. Brachial and femoral veins
: D. Tachypnea (an abnormally rapid rate of
breathing) would indicate that the patient was
still hypoxic (deficient in oxygen).The partial
pressures of arterial oxygen and carbon dioxide
listed are within the normal range. Eupnea refers
to normal respiration.
46.Effective skin disinfection before a surgical
procedure includes which of the following
methods?
A. Shaving the site on the day before surgery
B. Applying a topical antiseptic to the skin on
the evening before surgery
C. Having the patient take a tub bath on the
morning of surgery
D. Having the patient shower with an
antiseptic soap on the
evening v=before and the morning of
surgery
Answer: D. Studies have shown that showering
with an antiseptic soap before surgery is the
most effective method of removing
microorganisms from the skin. Shaving the site
of the intended surgery might cause breaks in
the skin, thereby increasing the risk of infection;
however, if indicated, shaving, should be done
immediately before surgery, not the day
before. A topical antiseptic would not remove
microorganisms and would be beneficial only
after proper cleaning and rinsing. Tub bathing
might transfer organisms to another body site
rather than rinse them away.
47.When transferring a patient from a bed to a
chair, the nurse should use which muscles to
avoid back injury?
A. Abdominal muscles
B. Back muscles
C. Leg muscles
D. Upper arm muscles
Answer: C. The leg muscles are the strongest
muscles in the body and should bear the greatest
stress when lifting. Muscles of the abdomen,
back, and upper arms may be easily injured
48.Thrombophlebitis typically develops in
patients with which of the following conditions?
A. Increases partial thromboplastin time
B. Acute pulsus paradoxus
C. An impaired or traumatized blood vessel wall
D. Chronic Obstructive Pulmonary Disease
(COPD)
Answer: C. The factors, known as Virchow’s
triad, collectively predispose a patient to
thromboplebitis; impaired venous return to the
heart, blood hypercoagulability, and injury to a
blood vessel wall. Increased
partial thromboplastin time indicates a
prolonged bleeding time during fibrin
clot formation, commonly the result of
anticoagulant (heparin) therapy. Arterial blood
disorders (such as pulsus paradoxus) and lung
diseases (such as COPD) do not necessarily
impede venous return of injure vessel walls.
49.In a recumbent, immobilized patient, lung
ventilation can become altered, leading to such
respiratory complications as:
A. Respiratory acidosis, ateclectasis, and
hypostatic pneumonia
B. Appneustic breathing, atypical pneumonia
and respiratory alkalosis
C. Cheyne-Strokes respirations and
spontaneous pneumothorax
D. Kussmail’s respirations and hypoventilation
Answer: A. Because of restricted respiratory
movement, a recumbent, immobilize patient is
at particular risk for respiratory acidosis from
poor gas exchange; atelectasis from reduced
surfactant and accumulated mucus in the
bronchioles, and hypostatic pneumonia from
bacterial growth caused by stasis of mucus
secretions.
50.Immobility impairs bladder elimination,
resulting in such disorders as
A. Increased urine acidity and relaxation of the
perineal muscles, causing incontinence
B. Urine retention, bladder distention, and
infection
C. Diuresis, natriuresis, and decreased urine
specific gravity
D. Decreased calcium and phosphate levels in
the urine
Answer: B. The immobilized patient commonly
suffers from urine retention caused by decreased
muscle tone in the perineum. This leads to
bladder distention and urine stagnation, which
provide an excellent medium for bacterial growth
leading to infection. Immobility also results in
more alkaline urine with excessive amounts of
calcium, sodium and phosphate, a gradual
decrease in urine production, and an increased
specific gravity.
PNLE II for
Maternal and
Child Health
1. For the client who is using oral
contraceptives, the nurse informs
the client about the need to take the
pill at the same time each day to
accomplish which of the following?
A. Decrease the incidence of
nausea
B. Maintain hormonal levels
C. Reduce side effects
D. Prevent drug interactions
Answer: B . Regular timely ingestion
of oral contraceptives is necessary
to maintain hormonal levels of the
drugs to suppress the action of the
hypothalamus and anterior pituitary
leading to inappropriate secretion of
FSH and LH. Therefore, follicles do
not mature, ovulation is inhibited,
and pregnancy is prevented. The
estrogen content of the oral site
contraceptive may cause the
nausea, regardless of when the pill
is taken. Side effects and
drug interactions may occur with
oral contraceptives regardless of
the time the pill is taken.
2. When teaching a client about
contraception. Which of the
following would the nurse include as
the most effective method for
preventing sexually transmitted
infections?
A. Spermicides
B. Diaphragm
C. Condoms
D. Vasectomy
1. Answer:C . Condoms, when used
correctly and consistently, are
the most effective contraceptive
method or barrier against
bacterial and viral
sexually transmitted infections.
Although spermicides kill sperm,
they do not provide reliable
protection against the spread of
sexually transmitted infections,
especially intracellular organisms
such as HIV. Insertion
and removal of the diaphragm
along with the use of the
spermicides may cause vaginal
irritations, which could place the
client at risk for
infection transmission. Male
sterilization eliminates
spermatozoa from the
ejaculate, but it does not
eliminate bacterial and/or viral
microorganisms that can cause
sexually transmitted infections.
3. When preparing a woman who is 2
days postpartum for
discharge, recommendations for
which of the following contraceptive
methods would be avoided?
A. Diaphragm
B. Female condom
C. Oral contraceptives
D. Rhythm method
Answer: A . The diaphragm must be
fitted individually to ensure
effectiveness. Because of the
changes to the reproductive
structures during pregnancy and
following delivery, the diaphragm
must be refitted, usually at the
6 weeks’ examination following
childbirth or after a weight loss of 15
lbs or more. In addition, for
maximum effectiveness, spermicidal
jelly should be placed in the dome
and around the rim. However,
spermicidal jelly should not be
inserted into the vagina until
involution is completed
at approximately 6 weeks. Use of a
female condom protects the
reproductive system from the
introduction of semen or
spermicides into the vagina and may
be used after childbirth. Oral
contraceptives may be started
within the first postpartum week to
ensure suppression of ovulation. For
the couple who has determined the
female’s fertile period, using the
rhythm method, avoidance of
intercourse during this period, is
safe and effective
4. For which of the following clients
would the nurse expect that
an intrauterine device would not be
recommended?
A. Woman over age 35
B. Nulliparous woman
C. Promiscuous young adult
D. Postpartum client
Answer: C . An IUD may increase
the risk of pelvic inflammatory
disease, especially in women with
more than one sexual partner,
because of the increased risk of
sexually transmitted infections. An
UID should not be used if
the woman has an active or chronic
pelvic infection, postpartum
infection, endometrial hyperplasia
or carcinoma, or uterine
abnormalities. Age is not a factor in
determining the risks associated
with IUD use. Most IUD users are
over the age of 30. Although there
is a slightly higher risk for
infertility in women who have never
been pregnant, the IUD is an
acceptable option as long as the
risk-benefit ratio is discussed. IUDs
may be inserted immediately after
delivery, but this is not
recommended because of
the increased risk and rate of
expulsion at this time.
5. A client in her third trimester tells
the nurse, “I’m constipated all the
time!” Which of the following should
the nurse recommend?
A. Daily enemas
B. Laxatives
C. Increased fiber intake
D. Decreased fluid intake
Answer: C . During the third
trimester, the enlarging uterus
places pressure on the intestines.
This coupled with the effect of
hormones on smooth
muscle relaxation causes decreased
intestinal motility (peristalsis).
Increasing fiber in the diet will help
fecal matter pass more quickly
through the intestinal tract, thus
decreasing the amount of water
that is absorbed. As a result, stool is
softer and easier to pass. Enemas
could precipitate preterm labor
and/or electrolyte loss and should
be avoided. Laxatives may
cause preterm labor by stimulating
peristalsis and may interfere with
the absorption of nutrients. Use for
more than 1 week can also lead to
laxative dependency. Liquid in the
diet helps provide a semisolid, soft
consistency to the stool. Eight to
ten glasses of fluid per day are
essential to maintain hydration and
promote stool evacuation.
6. Which of the following would the
nurse use as the basis for the
teaching plan when caring for a
pregnant teenager concerned about
gaining too much weight during
pregnancy?
A. 10 pounds per trimester
B. 1 pound per week for 40 weeks
C. ½ pound per week for 40 weeks
D. A total gain of 25 to 30
pounds
Answer: D . To ensure adequate
fetal growth and development
during the 40 weeks of a
pregnancy, a total weight gain 25 to
30 pounds is recommended:
1.5 pounds in the first 10 weeks; 9
pounds by 30 weeks; and 27.5
pounds by 40 weeks. The pregnant
woman should gain less weight in
the first and second trimester than
in the third. During the first
trimester, the client should only
gain 1.5 pounds in the first 10
weeks, not 1 pound per week.
A weight gain of ½ pound per week
would be 20 pounds for the
total pregnancy, less than the
recommended amount.
7. The client tells the nurse that her
last menstrual period started on
January 14 and ended on January 20.
Using Nagele’s rule, the nurse
determines her EDD to be which of
the following?
A. September 27
B. October 21
C. November 7
D. December 27
Answer: B . To calculate the EDD by
Nagele’s rule, add 7 days to the first
day of the last menstrual period and
count back 3 months, changing the
year appropriately. To obtain a date
of September 27, 7 days have been
added to the last day of the LMP
(rather than the first day of the
LMP), plus 4 months (instead of 3
months) were counted back. To
obtain the date of November 7, 7
days have been subtracted (instead
of added) from the first day of LMP
plus November indicates counting
back 2 months (instead of 3
months) from January. To obtain the
date of December 27, 7 days were
added to the last day of the LMP
(rather than the first day of
the LMP) and December indicates
counting back only 1 month
(instead of 3 months) from January.
8. When taking an obstetrical history
on a pregnant client who states, “I
had a son born at 38 weeks
gestation, a daughter born at 30
weeks gestation and I lost a baby at
about 8 weeks,” the nurse should
record her obstetrical history as
which of the following?
A. G2 T2 P0 A0 L2
B. G3 T1 P1 A0 L2
C. G3 T2 P0 A0 L2
D. G4 T1 P1 A1 L2
Answer: D. The client has been
pregnant four times, including
current pregnancy (G). Birth at 38
weeks’ gestation is considered full
term (T), while birth form 20 weeks
to 38 weeks is considered preterm
(P). A spontaneous abortion
occurred at 8 weeks (A). She has
two living children (L).
9. When preparing to listen to the
fetal heart rate at 12 weeks’
gestation, the nurse would use
which of the following?
A. Stethoscope placed midline at
the umbilicus
B. Doppler placed midline at the
suprapubic region
C. Fetoscope placed midway
between the umbilicus and the
xiphoid process
D. External electronic fetal monitor
placed at the umbilicus
Answer: B. At 12 weeks gestation,
the uterus rises out of the pelvis
and is palpable above the
symphysis pubis. The Doppler
intensifies the sound of the
fetal pulse rate so it is audible. The
uterus has merely risen out of the
pelvis into the abdominal cavity and
is not at the level of the umbilicus.
The fetal heart rate at this age is
not audible with a stethoscope. The
uterus at 12 weeks is just above the
symphysis pubis in the abdominal
cavity, not midway between the
umbilicus and the xiphoid process.
At 12 weeks the FHR would be
difficult to auscultate with a
fetoscope. Although the external
electronic fetal monitor would
project the FHR, the uterus has
not risen to the umbilicus at 12
weeks.

10.When developing a plan of care
for a client newly diagnosed
with gestational diabetes, which of
the following instructions would be
the priority?
A. Dietary intake
B. Medication
C. Exercise
D. Glucose monitoring
Answer: A . Although all of the
choices are important in the
management of diabetes, diet
therapy is the mainstay of the
treatment plan and should always
be the priority. Women diagnosed
with gestational diabetes generally
need only diet therapy without
medication to control their
blood sugar levels. Exercise, is
important for all pregnant women
and especially for diabetic women,
because it burns up glucose, thus
decreasing blood sugar. However,
dietary intake, not exercise, is the
priority. All pregnant women with
diabetes should have periodic
monitoring of serum
glucose. However, those with
gestational diabetes generally do
not need daily glucose monitoring.
The standard of care recommends a
fasting and 2- hour postprandial
blood sugar level every 2 weeks.
11.A client at 24 weeks gestation
has gained 6 pounds in 4 weeks.
Which of the following would be the
priority when assessing the client?
A. Glucosuria
B. Depression
C. Hand/face edema
D. Dietary intake
Answer: C. After 20 weeks’
gestation, when there is a rapid
weight gain, preeclampsia should
be suspected, which may be caused
by fluid retention manifested by
edema, especially of the hands and
face. The three classic signs of
preeclampsia are hypertension,
edema, and proteinuria. Although
urine is checked for glucose at each
clinic visit, this is not the priority.
Depression may cause either
anorexia or excessive food intake,
leading to excessive weight gain or
loss. This is not, however, the
priority consideration at this time.
Weight gain thought to be caused
by excessive food intake would
require a 24-hour diet recall.
However, excessive intake would
not be the primary consideration for
this client at this time.
12. A client 12 weeks’ pregnant
come to the emergency department
with abdominal cramping and
moderate vaginal bleeding.
Speculum examination reveals 2 to 3
cms cervical dilation. The nurse
would document these findings as
which of the following?
A. Threatened abortion
B. Imminent abortion
C. Complete abortion
D. Missed abortion
Answer:B. Cramping and vaginal
bleeding coupled with cervical
dilation signifies that termination of
the pregnancy is inevitable and
cannot be prevented. Thus, the
nurse would document an imminent
abortion. In a threatened abortion,
cramping and vaginal bleeding are
present, but there is no cervical
dilation. The symptoms may subside
or progress to abortion. In
a complete abortion all the products
of conception are expelled. A
missed abortion is early fetal
intrauterine death without expulsion
of the products of conception.
13.Which of the following would be
the priority nursing diagnosis for a
client with an ectopic pregnancy?
A. Risk for infection
B. Pain
C. Knowledge Deficit
D. Anticipatory Grieving
Answer:B . For the client with an
ectopic pregnancy, lower abdominal
pain, usually unilateral, is the
primary symptom. Thus, pain is the
priority. Although the potential for
infection is always present, the risk
is low in ectopic pregnancy because
pathogenic microorganisms have
not been introduced from external
sources. The client may have a
limited knowledge of the pathology
and treatment of the condition and
will most likely experience grieving,
but this is not the priority at this
time.
14.Before assessing the postpartum
client’s uterus for firmness and
position in relation to the umbilicus
and midline, which of the following
should the nurse do first?
A. Assess the vital signs
B. Administer analgesia
C. Ambulate her in the hall
D. Assist her to urinate
Answer: D. Before uterine
assessment is performed, it is
essential that the woman empty her
bladder. A full bladder will interfere
with the accuracy of
the assessment by elevating the
uterus and displacing to the side of
the midline. Vital sign assessment is
not necessary unless an
abnormality in uterine assessment
is identified. Uterine assessment
should not cause acute pain that
requires administration of
analgesia. Ambulating the client is
an essential component of
postpartum care, but is not
necessary prior to assessment of
the uterus.
15.Which of the following should the
nurse do when a primipara who
is lactating tells the nurse that she
has sore nipples?
A. Tell her to breast feed more
frequently
B. Administer a narcotic before
breast feeding
C. Encourage her to wear a nursing
brassiere
D. Use soap and water to clean the
nipples
Answer:A. Feeding more frequently,
about every 2 hours, will decrease
the infant’s frantic, vigorous sucking
from hunger and will decrease
breast engorgement, soften the
breast, and promote ease of correct
latching-on for feeding. Narcotics
administered prior to breast feeding
are passed through the breast milk
to the infant, causing excessive
sleepiness. Nipple soreness is not
severe enough to warrant narcotic
analgesia. All postpartum clients,
especially lactating mothers, should
wear a supportive brassiere with
wide cotton straps. This does not,
however, prevent or reduce nipple
soreness. Soaps are drying to the
skin of the nipples and should not
be used on the breasts of lactating
mothers. Dry nipple
skin predisposes to cracks and
fissures, which can become sore
and painful.
16.The nurse assesses the vital
signs of a client, 4 hours’
postpartum that are as follows: BP
90/60; temperature 100.4ºF; pulse
100 weak, thready; R 20 per minute.
Which of the following should the
nurse do first?
A. Report the temperature to the
physician
B. Recheck the blood pressure with
another cuff
C. Assess the uterus for firmness
and position
D. Determine the amount of
lochia
Answer: D. A weak, thready pulse
elevated to 100 BPM may indicate
impending hemorrhagic shock. An
increased pulse is a compensatory
mechanism of the body in response
to decreased fluid volume. Thus,
the nurse should check the amount
of lochia present. Temperatures up
to 100.48F in the first 24 hours after
birth are related to the dehydrating
effects of labor and are considered
normal. Although rechecking the
blood pressure may be a correct
choice of action, it is not the first
action that should be implemented
in light of the other data. The data
indicate a potential impending
hemorrhage. Assessing the uterus
for firmness and position in relation
to the umbilicus and midline is
important, but the nurse
should check the extent of vaginal
bleeding first. Then it would be
appropriate to check the uterus,
which may be a possible cause of
the hemorrhage.
17.The nurse assesses the
postpartum vaginal discharge
(lochia) on four clients. Which of the
following assessments would
warrant notification of the physician?
A. A dark red discharge on a 2-day
postpartum client
B. A pink to brownish discharge on a
client who is 5 days postpartum
C. Almost colorless to creamy
discharge on a client 2 weeks
after delivery
D. A bright red discharge 5 days
after delivery
Answer: D. Any bright red vaginal
discharge would be considered
abnormal, but especially 5 days
after delivery, when the lochia is
typically pink to brownish. Lochia
rubra, a dark red discharge, is
present for 2 to 3 days after
delivery. Bright red vaginal bleeding
at this time suggests
late postpartum hemorrhage, which
occurs after the first 24 hours
following delivery and is generally
caused by retained placental
fragments or bleeding disorders.
Lochia rubra is the normal dark red
discharge occurring in the first 2 to
3 days after delivery, containing
epithelial cells, erythrocyes,
leukocytes and decidua. Lochia
serosa is a pink to
brownish serosanguineous
discharge occurring from 3 to 10
days after delivery that contains
decidua, erythrocytes, leukocytes,
cervical mucus,
and microorganisms. Lochia alba is
an almost colorless to yellowish
discharge occurring from 10 days to
3 weeks after delivery and
containing leukocytes, decidua,
epithelial cells, fat, cervical mucus,
cholesterol crystals, and bacteria.
18.A postpartum client has a
temperature of 101.4ºF, with a
uterus that is tender when palpated,
remains unusually large, and not
descending as normally expected.
Which of the following should the
nurse assess next?
A. Lochia
B. Breasts
C. Incision
D. Urine
Answer: A. The data suggests an
infection of the endometrial lining of
the uterus. The lochia may be
decreased or copious, dark brown in
appearance, and foul smelling,
providing further evidence of a
possible infection. All the client’s
data indicate a uterine problem, not
a breast problem.
Typically, transient fever, usually
101ºF, may be present with breast
engorgement. Symptoms of mastitis
include influenza-like
manifestations. Localized infection
of an episiotomy or C-section
incision rarely causes
systemic symptoms, and uterine
involution would not be affected.
The client data do not include
dysuria, frequency, or urgency,
symptoms of urinary
tract infections, which would
necessitate assessing the client’s
urine.
19.Which of the following is the
priority focus of nursing practice
with the current early postpartum
discharge?
A. Promoting comfort and
restoration of health
B. Exploring the emotional status of
the family
C. Facilitating safe and effective
self-and newborn care
D. Teaching about the importance of
family planning
Answer: C. Because of early
postpartum discharge and limited
time for teaching, the nurse’s
priority is to facilitate the safe and
effective care of the client and
newborn. Although promoting
comfort and restoration of
health, exploring the family’s
emotional status, and teaching
about family planning are important
in postpartum/newborn nursing
care, they are not the priority focus
in the limited time presented by
early post-partum discharge.
20. Which of the following actions
would be least effective in
maintaining a neutral thermal
environment for the newborn?
A. Placing infant under radiant
warmer after bathing
B. Covering the scale with a
warmed blanket prior to weighing
C. Placing crib close to nursery
window for family viewing
D. Covering the infant’s head with a
knit stockinette
Answer: C. Heat loss by radiation
occurs when the infant’s crib is
placed too near cold walls or
windows. Thus placing the
newborn’s crib close to the viewing
window would be least effective.
Body heat is lost
through evaporation during bathing.
Placing the infant under the radiant
warmer after bathing will assist the
infant to be rewarmed. Covering the
scale with a warmed blanket prior
to weighing prevents heat loss
through conduction. A knit cap
prevents heat loss from the head a
large head, a large body surface
area of the newborn’s body.
21.A newborn who has an
asymmetrical Moro reflex response
should be further assessed for which
of the following?
A. Talipes equinovarus
B. Fractured clavicle
C. Congenital hypothyroidism
D. Increased intracranial pressure
Answer: B. A fractured clavicle
would prevent the normal Moro
response of symmetrical sequential
extension and abduction of the
arms followed by flexion and
adduction. In talipes equinovarus
(clubfoot) the foot is
turned medially, and in plantar
flexion, with the heel elevated. The
feet are not involved with the Moro
reflex. Hypothyroiddism has no
effect on the primitive reflexes.
Absence of the Moror reflex is the
most significant single indicator of
central nervous system status, but
it is not a sign of increased
intracranial pressure.
22.During the first 4 hours after a
male circumcision, assessing for
which of the following is the priority?
A. Infection
B. Hemorrhage
C. Discomfort
D. Dehydration
Answer:B. Hemorrhage is a
potential risk following any surgical
procedure. Although the infant has
been given vitamin K to facilitate
clotting, the prophylactic dose is
often not sufficient to prevent
bleeding. Although infection is a
possibility, signs will not appear
within 4 hours after the surgical
procedure. The primary discomfort
of circumcision occurs during the
surgical procedure, not afterward.
Although feedings are withheld
prior to the circumcision, the
chances of dehydration are
minimal.
23.The mother asks the nurse.
“What’s wrong with my son’s
breasts? Why are they so enlarged?”
Whish of the following would be the
best response by the nurse?
A. “The breast tissue is inflamed
from the trauma experienced
with birth”
B. “A decrease in material
hormones present before
birth causes enlargement,”
C. “You should discuss this with
your doctor. It could be a
malignancy”
D. “The tissue has hypertrophied
while the baby was in the uterus”
Answer: B . The presence of
excessive estrogen and
progesterone in the maternal
fetal blood followed by prompt
withdrawal at birth precipitates
breast engorgement, which will
spontaneously resolve in 4 to 5
days after birth. The trauma of the
birth process does not cause
inflammation of the newborn’s
breast tissue. Newborns do not
have breast malignancy. This reply
by the nurse would cause the
mother to have undue anxiety.
Breast tissue does not hypertrophy
in the fetus or newborns.
24. Immediately after birth the nurse
notes the following on a male
newborn: respirations 78; apical
hearth rate 160 BPM, nostril flaring;
mild intercostal
retractions; and grunting at the end
of expiration. Which of the
following should the nurse do?
A. Call the assessment data to the
physician’s attention
B. Start oxygen per nasal cannula at
2 L/min.
C. Suction the infant’s mouth and
nares
D. Recognize this as normal first
period of reactivity
Answer: D . The first 15 minutes to
1 hour after birth is the first period
of reactivity involving respiratory
and circulatory adaptation to
extrauterine life. The data given
reflect the normal changes during
this time period. The
infant’s assessment data reflect
normal adaptation. Thus, the
physician does not need to be
notified and oxygen is not needed.
The data do not indicate
the presence of choking, gagging or
coughing, which are signs of
excessive secretions. Suctioning is
not necessary.
25.The nurse hears a mother telling
a friend on the telephone about
umbilical cord care. Which of the
following statements by the mother
indicates effective teaching?
A. “Daily soap and water cleansing
is best”
B. ‘Alcohol helps it dry and kills
germs”
C. “An antibiotic ointment applied
daily prevents infection”
D. “He can have a tub bath each
day”
Answer: B. Application of 70%
isopropyl alcohol to the cord
minimizes microorganisms
(germicidal) and promotes drying.
The cord should be kept dry until it
falls off and the stump has healed.
Antibiotic ointment should only be
used to treat an infection, not as a
prophylaxis. Infants should not be
submerged in a tub of water until
the cord falls off and the stump has
completely healed.
26.A newborn weighing 3000 grams
and feeding every 4 hours needs
120 calories/kg of body weight every
24 hours for proper growth
and development. How many ounces
of 20 cal/oz formula should this
newborn receive at each feeding to
meet nutritional needs?
A. 2 ounces
B. 3 ounces
C. 4 ounces
D. 6 ounces
Answer:B. To determine the amount
of formula needed, do the
following mathematical calculation.
3 kg x 120 cal/kg per day = 360
calories/day feeding q 4 hours = 6
feedings per day = 60 calories per
feeding: 60 calories per feeding; 60
calories per feeding with formula 20
cal/oz = 3 ounces per feeding.
Based on the calculation. 2, 4 or 6
ounces are incorrect.
27.The postterm neonate with
meconium-stained amniotic fluid
needs care designed to especially
monitor for which of the following?
A. Respiratory problems
B. Gastrointestinal problems
C. Integumentary problems
D. Elimination problems
Answer: A. Intrauterine anoxia may
cause relaxation of the anal
sphincter and emptying of
meconium into the amniotic fluid. At
birth some of the meconium fluid
may be aspirated, causing
mechanical obstruction or chemical
pneumonitis. The infant is not at
increased risk for gastrointestinal
problems. Even though the skin is
stained with meconium, it is
noninfectious (sterile) and
nonirritating. The postterm
meconiumstained infant is not at
additional risk for bowel or urinary
problems.
28.When measuring a client’s fundal
height, which of the following
techniques denotes the correct
method of measurement used by the
nurse?
A. From the xiphoid process to the
umbilicus
B. From the symphysis pubis to the
xiphoid process
C. From the symphysis pubis to
the fundus
D. From the fundus to the umbilicus
Answer: C . The nurse should use a
nonelastic, flexible, paper
measuring tape, placing the zero
point on the superior border of the
symphysis pubis and stretching the
tape across the abdomen at the
midline to the top of the fundus.
The xiphoid and umbilicus are not
appropriate landmarks to use when
measuring the height of the fundus
(McDonald’s measurement).
29.A client with severe preeclampsia
is admitted with of BP
160/110, proteinuria, and severe
pitting edema. Which of the
following would be most important
to include in the client’s plan of
care?
A. Daily weights
B. Seizure precautions
C. Right lateral positioning
D. Stress reduction
Answer: B . Women hospitalized
with severe preeclampsia need
decreased CNS stimulation to
prevent a seizure. Seizure
precautions provide environmental
safety should a seizure occur.
Because of edema, daily weight is
important but not the priority.
Preclampsia causes vasospasm and
therefore can reduce utero-
placental perfusion. The client
should be placed on her left side to
maximize blood flow, reduce blood
pressure, and promote diuresis.
Interventions to reduce stress and
anxiety are very important to
facilitate coping and a sense of
control, but seizure precautions are
the priority.
30. A postpartum primipara asks the
nurse, “When can we have
sexual intercourse again?” Which of
the following would be the nurse’s
best response?
A. “Anytime you both want to.”
B. “As soon as choose a
contraceptive method.”
C. “When the discharge has
stopped and the incision is
healed.”
D. “After your 6 weeks
examination.”
Answer: C. Cessation of the lochial
discharge signifies healing of the
endometrium. Risk of hemorrhage
and infection are minimal 3 weeks
after a normal vaginal delivery.
Telling the client anytime is
inappropriate because this response
does not provide the client with the
specific information she
is requesting. Choice of a
contraceptive method is important,
but not the specific criteria for safe
resumption of sexual activity.
Culturally, the 6- weeks’
examination has been used as the
time frame for resuming
sexual activity, but it may be
resumed earlier.
31.When preparing to administer the
vitamin K injection to a neonate,
the nurse would select which of the
following sites as appropriate for
the injection?
A. Deltoid muscle
B. Anterior femoris muscle
C. Vastus lateralis muscle
D. Gluteus maximus muscle
Answer: C . The middle third of the
vastus lateralis is the preferred
injection site for vitamin K
administration because it is free of
blood vessels and nerves and is
large enough to absorb the
medication. The deltoid muscle of
a newborn is not large enough for a
newborn IM injection. Injections into
this muscle in a small child might
cause damage to the radial nerve.
The anterior femoris muscle is the
next safest muscle to use in a
newborn but is not the safest.
Because of the proximity of the
sciatic nerve, the gluteus maximus
muscle should not be until the child
has been walking 2 years.
32.When performing a pelvic
examination, the nurse observes a
red swollen area on the right side of
the vaginal orifice. The nurse would
document this as enlargement of
which of the following?
A. Clitoris
B. Parotid gland
C. Skene’s gland
D. Bartholin’s gland
Answer: D . Bartholin’s glands are
the glands on either side of the
vaginal orifice. The clitoris is female
erectile tissue found in the perineal
area above the urethra. The parotid
glands are open into the mouth.
Skene’s glands open into the
posterior wall of the female urinary
meatus.
33.To differentiate as a female, the
hormonal stimulation of the embryo
that must occur involves which of
the following?
A. Increase in maternal estrogen
secretion
B. Decrease in maternal androgen
secretion
C. Secretion of androgen by the
fetal gonad
D. Secretion of estrogen by the
fetal gonad
Answer: D . The fetal gonad must
secrete estrogen for the embryo to
differentiate as a female. An
increase in maternal estrogen
secretion does not
effect differentiation of the embryo,
and maternal estrogen secretion
occurs in every pregnancy. Maternal
androgen secretion remains the
same as before pregnancy and does
not effect differentiation. Secretion
of androgen by the fetal gonad
would produce a male fetus.

34.A client at 8 weeks’ gestation
calls complaining of slight nausea in
the morning hours. Which of the
following client interventions should
the nurse question?
A. Taking 1 teaspoon of
bicarbonate of soda in an 8-
ounce glass of water
B. Eating a few low-sodium crackers
before getting out of bed
C. Avoiding the intake of liquids in
the morning hours
D. Eating six small meals a day
instead of thee large meals
Answer: A . Using bicarbonate
would increase the amount of
sodium ingested, which can cause
complications. Eating low-sodium
crackers would be appropriate.
Since liquids can increase nausea
avoiding them in the morning hours
when nausea is usually the
strongest is appropriate. Eating six
small meals a day would keep the
stomach full, which often
decrease nausea.
35.The nurse documents positive
ballottement in the client’s prenatal
record. The nurse understands that
this indicates which of the following?
A. Palpable contractions on the
abdomen
B. Passive movement of the
unengaged fetus
C. Fetal kicking felt by the client
D. Enlargement and softening of the
uterus
Answer: B . Ballottement indicates
passive movement of the
unengaged fetus. Ballottement is
not a contraction. Fetal kicking felt
by the client represents quickening.
Enlargement and softening of the
uterus is known as Piskacek’s sign.
36.During a pelvic exam the nurse
notes a purple-blue tinge of the
cervix. The nurse documents this as
which of the following?
A. Braxton-Hicks sign
B. Chadwick’s sign
C. Goodell’s sign
D. McDonald’s sign
Answer: B . Chadwick’s sign refers
to the purple-blue tinge of the
cervix. Braxton Hicks contractions
are painless contractions beginning
around the 4th month. Goodell’s
sign indicates softening of the
cervix. Flexibility of the uterus
against the cervix is known as
McDonald’s sign.
37.During a prenatal class, the nurse
explains the rationale for
breathing techniques during
preparation for labor based on the
understanding that breathing
techniques are most important in
achieving which of the following?
A. Eliminate pain and give the
expectant parents something to
do
B. Reduce the risk of fetal distress
by increasing
uteroplacental perfusion
C. Facilitate relaxation, possibly
reducing the perception of
pain
D. Eliminate pain so that less
analgesia and anesthesia are
needed
Answer: C . Breathing techniques
can raise the pain threshold and
reduce the perception of pain. They
also promote relaxation. Breathing
techniques do not eliminate pain,
but they can reduce it. Positioning,
not breathing, increases
uteroplacental perfusion.
38.After 4 hours of active labor, the
nurse notes that the contractions of
a primigravida client are not strong
enough to dilate the cervix. Which of
the
following would the nurse anticipate
doing?
A. Obtaining an order to begin
IV oxytocin infusion
B. Administering a light sedative to
allow the patient to rest for
several hour
C. Preparing for a cesarean section
for failure to progress
D. Increasing the encouragement to
the patient when pushing begins
Answer:A . The client’s labor is
hypotonic. The nurse should call the
physical and obtain an order for an
infusion of oxytocin, which will
assist the uterus to contact more
forcefully in an attempt to dilate the
cervix. Administering light sedative
would be done for hypertonic
uterine contractions. Preparing for
cesarean section is unnecessary at
this time. Oxytocin would
increase the uterine contractions
and hopefully progress labor before
a cesarean would be necessary. It is
too early to anticipate client
pushing with contractions.
39.A multigravida at 38 weeks’
gestation is admitted with painless,
bright red bleeding and mild
contractions every 7 to 10 minutes.
Which of the following assessments
should be avoided?
A. Maternal vital sign
B. Fetal heart rate
C. Contraction monitoring
D. Cervical dilation
Answer: D . The signs indicate
placenta previa and vaginal exam
to determine cervical dilation would
not be done because it could cause
hemorrhage. Assessing maternal
vital signs can help determine
maternal physiologic status. Fetal
heart rate is important to assess
fetal well-being and should be done.
Monitoring the contractions will help
evaluate the progress of labor.
40.Which of the following would be
the nurse’s most appropriate
response to a client who asks why
she must have a cesarean delivery if
she has a complete placenta previa?
A. “You will have to ask your
physician when he returns.”
B. “You need a cesarean to prevent
hemorrhage.”
C. “The placenta is covering most of
your cervix.”
D. “The placenta is covering the
opening of the uterus and
blocking your baby.”
Answer: D . A complete placenta
previa occurs when the placenta
covers the opening of the uterus,
thus blocking the passageway for
the baby. This response explains
what a complete previa is and the
reason the baby cannot come out
except by cesarean delivery. Telling
the client to ask the physician is a
poor response and would increase
the patient’s anxiety. Although a
cesarean would help to prevent
hemorrhage, the statement does
not explain why the hemorrhage
could occur. With a complete previa,
the placenta is covering all the
cervix, not just most of it.
41.The nurse understands that the
fetal head is in which of the
following positions with a face
presentation?
A. Completely flexed
B. Completely extended
C. Partially extended
D. Partially flexed
Answer: B . With a face
presentation, the head is
completely extended. With a vertex
presentation, the head is
completely or partially flexed. With
a brow (forehead) presentation, the
head would be partially extended.
42.With a fetus in the left-anterior
breech presentation, the nurse
would expect the fetal heart rate
would be most audible in which of
the following areas?
A. Above the maternal umbilicus
and to the right of midline
B. In the lower-left maternal
abdominal quadrant
C. In the lower-right maternal
abdominal quadrant
D. Above the maternal umbilicus
and to the left of midline
Answer: D . With this presentation,
the fetal upper torso and back face
the left upper maternal abdominal
wall. The fetal heart rate would be
most audible above the maternal
umbilicus and to the left of the
middle.A The other positions would
be incorrect.
43.The amniotic fluid of a client has
a greenish tint. The nurse interprets
this to be the result of which of the
following?
A. Lanugo
B. Hydramnio
C. Meconium
D. Vernix
Answer: C. The greenish tint is due
to the presence of meconium.
Lanugo is the soft, downy hair on
the shoulders and back of the fetus.
Hydramnios represents excessive
amniotic fluid. Vernix is the white,
cheesy substance covering the
fetus.
44.A patient is in labor and has just
been told she has a breech
presentation. The nurse should be
particularly alert for which of the
following?
A. Quickening
B. Ophthalmia neonatorum
C. Pica
D. Prolapsed umbilical cord
Answer: D . In a breech position,
because of the space between the
presenting part and the cervix,
prolapse of the umbilical cord is
common. Quickening is the
woman’s first perception of fetal
movement. Ophthalmia
neonatorum usually results from
maternal gonorrhea and is
conjunctivitis. Pica refers to the oral
intake of nonfood substances.
45.When describing dizygotic twins
to a couple, on which of the
following would the nurse base the
explanation?
A. Two ova fertilized by
separate sperm
B. Sharing of a common placenta
C. Each ova with the same
genotype
D. Sharing of a common chorion
Answer: A . Dizygotic (fraternal)
twins involve two ova fertilized by
separate sperm. Monozygotic
(identical) twins involve a common
placenta, same genotype, and
common chorion.
46.Which of the following refers to
the single cell that reproduces itself
after conception?
A. Chromosome
B. Blastocyst
C. Zygote
D. Trophoblast
Answer: C . The zygote is the single
cell that reproduces itself after
conception. The chromosome is the
material that makes up the cell and
is gained from each parent.
Blastocyst and trophoblast are later
terms for the embryo after zygote.
47.In the late 1950s, consumers and
health care professionals
began challenging the routine use of
analgesics and anesthetics during
childbirth. Which of the following
was an outgrowth of this concept?
A. Labor, delivery, recovery,
postpartum (LDRP)
B. Nurse-midwifery
C. Clinical nurse specialist
D. Prepared childbirth
Answer: D . Prepared childbirth was
the direct result of the 1950’s
challenging of the routine use of
analgesic and anesthetics during
childbirth. The LDRP was a much
later concept and was not a direct
result of the challenging of routine
use of analgesics and anesthetics
during childbirth. Roles for nurse
midwives and clinical nurse
specialists did not develop from
this challenge.
48.A client has a midpelvic
contracture from a previous pelvic
injury due to a motor vehicle
accident as a teenager. The nurse is
aware that this could
prevent a fetus from passing
through or around which structure
during childbirth?
A. Symphysis pubis
B. Sacral promontory
C. Ischial spines
D. Pubic arch
Answer: C . The ischial spines are
located in the mid-pelvic region and
could be narrowed due to the
previous pelvic injury. The
symphysis pubis,
sacral promontory, and pubic arch
are not part of the mid-pelvis.
49.When teaching a group of
adolescents about variations in the
length of the menstrual cycle, the
nurse understands that the
underlying mechanism is
due to variations in which of the
following phases?
A. Menstrual phase
B. Proliferative phase
C. Secretory phase
D. Ischemic phase
Answer: B . Variations in the length
of the menstrual cycle are due to
variations in the proliferative phase.
The menstrual, secretory and
ischemic phases do not contribute
to this variation.
50.When teaching a group of
adolescents about male hormone
production, which of the following
would the nurse include as being
produced by the Leydig cells?
A. Follicle-stimulating hormone
B. Testosterone
C. Leuteinizing hormone
D. Gonadotropin releasing hormone
Answer: B . Testosterone is
produced by the Leyding cells in the
seminiferous tubules. Follicle-
stimulating hormone and
leuteinzing hormone are released
by the anterior pituitary gland. The
hypothalamus is responsible for
releasing gonadotropin-releasing
hormone.
PNLE III for
Medical Surgical
Nursing
1. Marco who was diagnosed
with brain tumor was scheduled for
craniotomy. In preventing the
development of cerebral edema
after surgery, the nurse should
expect the use of:
A. Diuretics
B. Antihypertensive
C. Steroids
D. Anticonvulsants
Answer: C . Glucocorticoids
(steroids) are used for their anti-
inflammatory action,
which decreases the development
of edema.
2. Halfway through the
administration of blood, the female
client complains of lumbar pain.
After stopping the infusion Nurse
Hazel should:
A. Increase the flow of normal
saline
B. Assess the pain further
C. Notify the blood bank
D. Obtain vital signs.
Answer: A . The blood must be
stopped at once, and then normal
saline should be infused to keep the
line patent and maintain blood
volume.
3. Nurse Maureen knows that the
positive diagnosis for HIV infection is
made based on which of the
following:
A. A history of high risk sexual
behaviors.
B. Positive ELISA and western
blot tests
C. Identification of an associated
opportunistic infection
D. Evidence of extreme weight loss
and high fever
Answer:B . These tests confirm the
presence of HIV antibodies that
occur in response to the presence of
the human immunodeficiency virus
(HIV).
4. Nurse Maureen is aware that a
client who has been diagnosed with
chronic renal failure recognizes an
adequate amount of high-biologic-
value protein when the food the
client selected from the menu was:
A. Raw carrots
B. Apple juice
C. Whole wheat bread
D. Cottage cheese
Answer: D . One cup of cottage
cheese contains approximately 225
calories, 27 g of protein, 9 g of fat,
30 mg cholesterol, and 6 g of
carbohydrate. Proteins of high
biologic value (HBV) contain optimal
levels of amino acids essential
for life.
5. Kenneth who has diagnosed with
uremic syndrome has the potential
to develop complications. Which
among the following complications
should the nurse anticipates:
A. Flapping hand tremors
B. An elevated hematocrit level
C. Hypotension
D. Hypokalemia
Answer: A . Elevation of uremic
waste products causes irritation of
the nerves, resulting in flapping
hand tremors.
6. A client is admitted to the hospital
with benign prostatic hyperplasia,
the nurse most relevant assessment
would be:
A. Flank pain radiating in the groin
B. Distention of the lower
abdomen
C. Perineal edema
D. Urethral discharge
Answer: B . This indicates that the
bladder is distended with urine,
therefore palpable.
7. A client has undergone with penile
implant. After 24 hrs of surgery, the
client’s scrotum was edematous and
painful. The nurse should:
A. Assist the client with sitz bath
B. Apply war soaks in the scrotum
C. Elevate the scrotum using a
soft support
D. Prepare for a possible incision
and drainage.
Answer: C . Elevation increases
lymphatic drainage, reducing
edema and pain.
8. Nurse hazel receives emergency
laboratory results for a client with
chest pain and immediately informs
the physician. An increased
myoglobin level suggests which of
the following?
A. Liver disease
B. Myocardial damage
C. Hypertension
D. Cancer
Answer: B . Detection of myoglobin
is a diagnostic tool to determine
whether myocardial damage has
occurred.
9. Nurse Maureen would expect the
a client with mitral stenosis would
demonstrate symptoms associated
with congestion in the:
A. Right atrium
B. Superior vena cava
C. Aorta
D. Pulmonary
Answer: D . When mitral stenosis is
present, the left atrium has
difficulty emptying its contents into
the left ventricle because there is
no valve to prevent back ward flow
into the pulmonary vein, the
pulmonary circulation is under
pressure.
10. A client has been diagnosed with
hypertension. The nurse priority
nursing diagnosis would be:
A. Ineffective health
maintenance
B. Impaired skin integrity
C. Deficient fluid volume
D. Pain
Answer: A . Managing hypertension
is the priority for the client with
hypertension. Clients with
hypertension frequently do not
experience pain, deficient
volume, or impaired skin integrity. It
is the asymptomatic nature of
hypertension that makes it so
difficult to treat.
11. Nurse Hazel teaches the client
with angina about common
expected side effects of nitroglycerin
including:
A. high blood pressure
B. stomach cramps
C. headache
D. shortness of breath
Answer: C . Because of its
widespread vasodilating effects,
nitroglycerin often produces side
effects such as headache,
hypotension and dizziness.
12. The following are lipid
abnormalities. Which of the following
is a risk factor for the development
of atherosclerosis and PVD?
A. High levels of low density
lipid (LDL) cholesterol
B. High levels of high density lipid
(HDL) cholesterol
C. Low concentration triglycerides
D. Low levels of LDL cholesterol.
Answer: A. An increased in LDL
cholesterol concentration has been
documented at risk factor for the
development of atherosclerosis. LDL
cholesterol is not broken down into
the liver but is deposited into the
wall of the blood vessels.
13. Which of the following
represents a significant risk
immediately after surgery for repair
of aortic aneurysm?
A. Potential wound infection
B. Potential ineffective coping
C. Potential electrolyte balance
D. Potential alteration in renal
perfusion
Answer: D . There is a potential
alteration in renal perfusion
manifested by decreased urine
output. The altered renal perfusion
may be related to renal
artery embolism, prolonged
hypotension, or prolonged aortic
cross-clamping during the surgery.
14. Nurse Josie should instruct the
client to eat which of the following
foods to obtain the best supply of
Vitamin B12?
A. dairy products
B. vegetables
C. Grains
D. Broccoli
Answer: A . Good source of vitamin
B12 are dairy products and meats.
15. Karen has been diagnosed with
aplastic anemia. The nurse monitors
for changes in which of the following
physiologic functions?
A. Bowel function
B. Peripheral sensation
C. Bleeding tendencies
D. Intake and out put
Answer: C . Aplastic anemia
decreases the bone marrow
production of RBC’s, white blood
cells, and platelets. The client is at
risk for bruising and
bleeding tendencies.
16. Lydia is scheduled for elective
splenectomy. Before the clients goes
to surgery, the nurse in charge final
assessment would be:
A. signed consent
B. vital signs
C. name band
D. empty bladder
Answer: B . An elective procedure is
scheduled in advance so that all
preparations can be completed
ahead of time. The vital signs are
the final check that must
be completed before the client
leaves the room so that continuity
of care and assessment is provided
for.
17. What is the peak age range in
acquiring acute lymphocytic
leukemia (ALL)?
A. 4 to 12 years.
B. 20 to 30 years
C. 40 to 50 years
D. 60 60 70 years
Answer: A . The peak incidence of
Acute Lymphocytic Leukemia (ALL)
is 4 years of age. It is uncommon
after 15 years of age.
18. Marie with acute lymphocytic
leukemia suffers from nausea and
headache. These clinical
manifestations may indicate all of
the following except
A. effects of radiation
B. chemotherapy side effects
C. meningeal irritation
D. gastric distension
Answer: D . Acute Lymphocytic
Leukemia (ALL) does not cause
gastric distention. It does invade
the central nervous system, and
clients experience headaches and
vomiting from meningeal irritation.
19. A client has been diagnosed with
Disseminated Intravascular
Coagulation (DIC). Which of the
following is contraindicated with the
client?
A. Administering Heparin
B. Administering Coumadin
C. Treating the underlying cause
D. Replacing depleted blood
products
Answer: B . Disseminated
Intravascular Coagulation (DIC) has
not been found to respond to oral
anticoagulants such as Coumadin.
20. Which of the following findings is
the best indication that fluid
replacement for the client with
hypovolemic shock is adequate?
A. Urine output greater than
30ml/hr
B. Respiratory rate of 21
breaths/minute
C. Diastolic blood pressure greater
than 90 mmhg
D. Systolic blood pressure greater
than 110 mmhg
Answer: A . Urine output provides
the most sensitive indication of the
client’s response to therapy for
hypovolemic shock. Urine output
should be consistently greater than
30 to 35 mL/hr.
21. Which of the following signs and
symptoms would Nurse Maureen
include in teaching plan as an early
manifestation of laryngeal cancer?
A. Stomatitis
B. Airway obstruction
C. Hoarseness
D. Dysphagia
Answer: C . Early warning signs of
laryngeal cancer can vary
depending on tumor location.
Hoarseness lasting 2 weeks should
be evaluated because it is one of
the most common warning signs.
22. Karina a client with myasthenia
gravis is to receive
immunosuppressive therapy. The
nurse understands that this therapy
is effective because it:
A. Promotes the removal of
antibodies that impair the
transmission of impulses
B. Stimulates the production of
acetylcholine at the
neuromuscular junction.
C. Decreases the production of
autoantibodies that attack
the acetylcholine receptors.
D. Inhibits the breakdown of
acetylcholine at the
neuromuscular junction.
Answer: C . Steroids decrease the
body’s immune response thus
decreasing the production of
antibodies that attack the
acetylcholine receptors at
the neuromuscular junction
23. A female client is receiving IV
Mannitol. An assessment specific to
safe administration of the said drug
is:
A. Vital signs q4h
B. Weighing daily
C. Urine output hourly
D. Level of consciousness q4h
Answer: C . The osmotic diuretic
mannitol is contraindicated in the
presence of inadequate renal
function or heart failure because it
increases the intravascular volume
that must be filtered and excreted
by the kidney.
24. Patricia a 20 year old college
student with diabetes mellitus
requests additional information
about the advantages of using a pen
like insulin
delivery devices. The nurse explains
that the advantages of these
devices over syringes includes:
A. Accurate dose delivery
B. Shorter injection time
C. Lower cost with reusable insulin
cartridges
D. Use of smaller gauge needle.
Answer: A . These devices are more
accurate because they are easily to
used and have improved adherence
in insulin regimens by young people
because the medication can be
administered discreetly.
25. A male client’s left tibia is
fractures in an automobile accident,
and a cast is applied. To assess for
damage to major blood vessels from
the fracture tibia, the nurse in
charge should monitor the client for:
A. Swelling of the left thigh
B. Increased skin temperature of
the foot
C. Prolonged reperfusion of the
toes after blanching
D. Increased blood pressure
Answer: C . Damage to blood
vessels may decrease the
circulatory perfusion of the toes,
this would indicate the lack of blood
supply to the extremity.
26. After a long leg cast is removed,
the male client should:
A. Cleanse the leg by scrubbing
with a brisk motion
B. Put leg through full range of
motion twice daily
C. Report any discomfort or stiffness
to the physician
D. Elevate the leg when sitting
for long periods of time.
Answer: D . Elevation will help
control the edema that usually
occurs.
27. While performing a physical
assessment of a male client with
gout of the great toe, NurseVivian
should assess for additional tophi
(urate deposits) on the:
A. Buttocks
B. Ears
C. Face
D. Abdomen
Answer: B . Uric acid has a low
solubility, it tends to precipitate and
form deposits at various sites where
blood flow is least active, including
cartilaginous tissue such as the
ears.
28. Nurse Katrina would recognize
that the demonstration of crutch
walking with tripod gait was
understood when the client places
weight on the:
A. Palms of the hands and axillary
regions
B. Palms of the hand
C. Axillary regions
D. Feet, which are set apart
Answer: B . The palms should bear
the client’s weight to avoid damage
to the nerves in the axilla.
29. Mang Jose with rheumatoid
arthritis states, “the only time I am
without pain is when I lie in bed
perfectly still”. During the
convalescent stage, the nurse in
charge with Mang Jose should
encourage:
A. Active joint flexion and
extension
B. Continued immobility until pain
subsides
C. Range of motion exercises twice
daily
D. Flexion exercises three times
daily
Answer: A . Active exercises,
alternating extension, flexion,
abduction, and adduction, mobilize
exudates in the joints relieves
stiffness and pain.
30. A male client has undergone
spinal surgery, the nurse should:
A. Observe the client’s bowel
movement and voiding patterns
B. Log-roll the client to prone
position
C. Assess the client’s feet for
sensation and circulation
D. Encourage client to drink plenty
of fluids
Answer: C . Alteration in sensation
and circulation indicates damage to
the spinal cord, if these occurs
notify physician immediately.
31. Marina with acute renal failure
moves into the diuretic phase after
one week of therapy. During this
phase the client must be assessed
for signs of developing:
A. Hypovolemia
B. renal failure
C. metabolic acidosis
D. Hyperkalemia
Answer: A . In the diuretic phase
fluid retained during the oliguric
phase is excreted and may reach 3
to 5 liters daily, hypovolemia may
occur and fluids should be replaced.
32. Nurse Judith obtains a specimen
of clear nasal drainage from a client
with a head injury. Which of the
following tests differentiates mucus
from cerebrospinal fluid (CSF)?
A. Protein
B. Specific gravity
C. Glucose
D. Microorganism
Answer: C . The constituents of CSF
are similar to those of blood
plasma. An examination for glucose
content is done to determine
whether a body fluid is a mucus or a
CSF. A CSF normally contains
glucose.
33. A 22 year old client suffered
from his first tonic-clonic seizure.
Upon awakening the client asks the
nurse, “What caused me to have a
seizure? Which of the following
would the nurse include in the
primary cause of tonic clonic
seizures in adults more the 20
years?
A. Electrolyte imbalance
B. Head trauma
C. Epilepsy
D. Congenital defect
Answer: B . Trauma is one of the
primary cause of brain damage and
seizure activity in adults. Other
common causes of seizure activity
in adults include
neoplasms, withdrawal from drugs
and alcohol, and vascular disease.
34. What is the priority nursing
assessment in the first 24 hours
after admission of the client with
thrombotic CVA?
A. Pupil size and papillary
response
B. cholesterol level
C. Echocardiogram
D. Bowel sounds
Answer: A . It is crucial to monitor
the pupil size and papillary
response to indicate changes
around the cranial nerves.
35. Nurse Linda is preparing a client
with multiple sclerosis for discharge
from the hospital to home. Which of
the following instruction is most
appropriate?
A. “Practice using the mechanical
aids that you will need when
future disabilities arise”.
B. “Follow good health habits to
change the course of the
disease”.
C. “Keep active, use stress
reduction strategies, and
avoid fatigue.
D. “You will need to accept the
necessity for a quiet and inactive
lifestyle”.
Answer: C . The nurse most positive
approach is to encourage the client
with multiple sclerosis to stay
active, use stress reduction
techniques and avoid
fatigue because it is important to
support the immune system while
remaining active.
36. The nurse is aware the early
indicator of hypoxia in the
unconscious client is:
A. Cyanosis
B. Increased respirations
C. Hypertension
D. Restlessness
Answer: D . Restlessness is an early
indicator of hypoxia. The nurse
should suspect hypoxia in
unconscious client who suddenly
becomes restless.
37. A client is experiencing spinal
shock. Nurse Myrna should expect
the function of the bladder to be
which of the following?
A. Normal
B. Atonic
C. Spastic
D. Uncontrolled
Answer: B . In spinal shock, the
bladder becomes completely atonic
and will continue to fill unless the
client is catheterized.
38. Which of the following stage the
carcinogen is irreversible?
A. Progression stage
B. Initiation stage
C. Regression stage
D. Promotion stage
Answer: A . Progression stage is the
change of tumor from the
preneoplastic state or low degree of
malignancy to a fast growing tumor
that cannot be reversed.
39. Among the following
components thorough pain
assessment, which is the most
significant?
A. Effect
B. Cause
C. Causing factors
D. Intensity
Answer: D . Intensity is the major
indicative of severity of pain and it
is important for the evaluation of
the treatment.
40. A 65 year old female is
experiencing flare up of pruritus.
Which of the client’s action could
aggravate the cause of flare ups?
A. Sleeping in cool and humidified
environment
B. Daily baths with fragrant
soap
C. Using clothes made from 100%
cotton
D. Increasing fluid intake
Answer: B . The use of fragrant
soap is very drying to skin hence
causing the pruritus.
41. Atropine sulfate (Atropine) is
contraindicated in all but one of the
following client?
A. A client with high blood
B. A client with bowel obstruction
C. A client with glaucoma
D. A client with U.T.I
Answer: C . Atropine sulfate is
contraindicated with glaucoma
patients because it increases
intraocular pressure.
42. Among the following clients,
which among them is high risk for
potential hazards from the surgical
experience?
A. 67-year-old client
B. 49-year-old client
C. 33-year-old client
D. 15-year-old client
Answer: A . A 67 year old client is
greater risk because the older adult
client is more likely to have a less-
effective immune system.
43. Nurse Jon assesses vital signs on
a client undergone epidural
anesthesia.
Which of the following would the
nurse assess next?
A. Headache
B. Bladder distension
C. Dizziness
D. Ability to move legs
Answer: B . The last area to return
sensation is in the perineal area,
and the nurse in charge should
monitor the client for distended
bladder.
44. Nurse Katrina should anticipate
that all of the following drugs may
be used in the attempt to control the
symptoms of Meniere’s disease
except:
A. Antiemetics
B. Diuretics
C. Antihistamines
D. Glucocorticoids
Answer: D . Glucocorticoids play no
significant role in disease
treatment.
45. Which of the following
complications associated with
tracheostomy tube?
A. Increased cardiac output
B. Acute respiratory distress
syndrome (ARDS)
C. Increased blood pressure
D. Damage to laryngeal nerves
Answer: D . Tracheostomy tube has
several potential complications
including bleeding, infection and
laryngeal nerve damage.
46. Nurse Faith should recognize
that fluid shift in an client with burn
injury results from increase in the:
A. Total volume of circulating whole
blood
B. Total volume of intravascular
plasma
C. Permeability of capillary
walls
D. Permeability of kidney tubules
Answer: C . In burn, the capillaries
and small vessels dilate, and cell
damage cause the release of a
histamine-like substance. The
substance causes the capillary walls
to become more permeable and
significant quantities of fluid are
lost.
47. An 83-year-old woman has
several ecchymotic areas on her
right arm. The bruises are probably
caused by:
A. increased capillary fragility
and permeability
B. increased blood supply to the
skin
C. self inflicted injury
D. elder abuse
Answer: A . Aging process involves
increased capillary fragility and
permeability. Older adults have a
decreased amount of subcutaneous
fat and cause an
increased incidence of bruise like
lesions caused by collection of
extravascular blood inloosely
structured dermis.
48. Nurse Anna is aware that early
adaptation of client with renal
carcinoma is:
A. Nausea and vomiting
B. flank pain
C. weight gain
D. intermittent hematuria
Answer: D . Intermittent pain is the
classic sign of renal carcinoma. It is
primarily due to capillary erosion by
the cancerous growth.
49. A male client with tuberculosis
asks Nurse Brian how long the
chemotherapy must be continued.
Nurse Brian’s accurate reply would
be:
A. 1 to 3 weeks
B. 6 to 12 months
C. 3 to 5 months
D. 3 years and more
Answer: B . Tubercle bacillus is a
drug resistant organism and takes a
long time to be eradicated. Usually
a combination of three drugs is
used for minimum of 6 months and
at least six months beyond culture
conversion.
50. A client has undergone
laryngectomy. The immediate
nursing priority would be:
A. Keep trachea free of
secretions
B. Monitor for signs of infection
C. Provide emotional support
D. Promote means of
communication
Answer: A . Patent airway is the
most priority; therefore removal of
secretions is necessary.
PNLE IV for
Psychiatric
Nursing
 Answer: B . Establishing a consistent
eating plan and monitoring client’s
1. Marco approached Nurse Trish asking
weight are important to this disorder.
for advice on how to deal with his alcohol
addiction. Nurse Trish should tell the
5. A client is experiencing anxiety attack.
client that the only effective treatment
The most appropriate
for alcoholism is:
nursing intervention should include?
A. Psychotherapy
A. Turning on the television
B. Alcoholics anonymous (A.A.)
B. Leaving the client alone
C. Total abstinence
C. Staying with the client and
D. Aversion Therapy
speaking in short sentences
D. Ask the client to play with other
Answer: C . Total abstinence is the only
clients
effective treatment for alcoholism
Answer: C . Appropriate nursing
2. Nurse Hazel is caring for a male client
interventions for an anxiety attack
who experience false
include using short sentences, staying
sensory perceptions with no basis in
with the client, decreasing stimuli,
reality. This perception is known as:
remaining calm and medicating as
needed.
A. Hallucinations
B. Delusions 6. A female client is admitted with a
C. Loose associations diagnosis of delusions of GRANDEUR. This
D. Neologisms diagnosis reflects a belief that one is:
Answer: A . Hallucinations are visual,
A. Being Killed
auditory, gustatory, tactile or
B. Highly famous and important
olfactory perceptions that have no basis
C. Responsible for evil world
in reality.
D. Connected to client unrelated to
oneself
3. Nurse Monet is caring for a female
client who has suicidal tendency. When
Answer: B . Delusion of grandeur is a
accompanying the client to the restroom,
false belief that one is highly famous
Nurse Monet should…
and important.
A. Give her privacy 7. A 20 year old client was diagnosed
B. Allow her to urinate with dependent personality
C. Open the window and allow her to disorder. Which behavior is not likely to
get some fresh air be evidence of ineffective individual
D. Observe her coping?
Answer: D . The Nurse has a
A. Recurrent self-destructive behavior
responsibility to observe continuously
B. Avoiding relationship
the acutely suicidal client. The Nurse
C. Showing interest in solitary activities
should watch for clues, such as
D. Inability to make choices and
communicating suicidal thoughts, and
decision without advise
messages; hoarding medications and
talking about death.
Answer: D . Individual with dependent
personality disorder typically
4. Nurse Maureen is developing a plan of
shows indecisiveness submissiveness
care for a female client with anorexia
and clinging behavior so that others
nervosa. Which action should the nurse
will make decisions with them.
include in the plan?
8. A male client is diagnosed with
A. Provide privacy during meals schizotypal personality disorder.
B. Set-up a strict eating plan for the Which signs would this client exhibit
client during social situation?
C. Encourage client to exercise to
reduce anxiety
A. Paranoid thoughts
D. Restrict visits with the family
B. Emotional affect
C. Independence need
D. Aggressive behavior
Answer: A . Clients with schizotypal
personality disorder experience
excessive social anxiety that can lead to
paranoid thoughts
9. Nurse Claire is caring for a client
diagnosed with bulimia. The
most appropriate initial goal for a client
diagnosed with bulimia is?
A. Encourage to avoid foods
B. Identify anxiety causing
situations
C. Eat only three meals a day
D. Avoid shopping plenty of groceries
Answer: B . Bulimia disorder generally is
a maladaptive coping response to stress
and underlying issues. The client should
identify anxiety causing situation
that stimulate the bulimic behavior and
then learn new ways of coping with
the anxiety.
10. Nurse Tony was caring for a 41 year
old female client. Which behavior by the
client indicates adult cognitive
development?
A. Generates new levels of
awareness
B. Assumes responsibility for her actions
C. Has maximum ability to solve
problems and learn new skills
D. Her perception are based on reality
Answer: A . An adult age 31 to 45
generates new level of awareness.
11.A neuromuscular blocking agent is
administered to a client before
ECT therapy. The Nurse should carefully
observe the client for?
A. Respiratory difficulties
B. Nausea and vomiting
C. Dizziness
D. Seizures
Answer: A . Neuromuscular Blocker,
such as SUCCINYLCHOLINE
(Anectine) produces respiratory
depression because it inhibits
contractions of respiratory muscles.
12.A 75 year old client is admitted to the
hospital with the diagnosis of dementia
of the Alzheimer’s type and depression.
The symptom that is unrelated to
depression would be?
A. Apathetic response to the
environment
B. “I don’t know” answer to questions
C. Shallow of labile effect
D. Neglect of personal hygiene
Answer: C . With depression, there is
little or no emotional involvement
therefore little alteration in affect.
13.Nurse Trish is working in a mental
health facility; the nurse priority
nursing intervention for a newly admitted
client with bulimia nervosa would be to?
A. Teach client to measure I & O
B. Involve client in planning daily meal
C. Observe client during meals
D. Monitor client continuously
Answer: D . These clients often hide food
or force vomiting; therefore they must
be carefully monitored.
14.Nurse Patricia is aware that the major
health complication associated
with intractable anorexia nervosa would
be?
A. Cardiac dysrhythmias resulting
to cardiac arrest
B. Glucose intolerance resulting in
protracted hypoglycemia
C. Endocrine imbalance causing cold
amenorrhea
D. Decreased metabolism causing cold
intolerance
Answer: A . These clients have severely
depleted levels of sodium and
potassium because of their starvation
diet and energy expenditure, these
electrolytes are necessary for cardiac
functioning.
15.Nurse Anna can minimize agitation in
a disturbed client by?
A. Increasing stimulation
B. limiting unnecessary interaction
C. increasing appropriate sensory
perception
D. ensuring constant client and staff
contact
Anaswer: B . Limiting unnecessary
interaction will decrease stimulation and
agitation.

16.A 39 year old mother with obsessive-
compulsive disorder has
become immobilized by her elaborate
hand washing and walking rituals.
Nurse Trish recognizes that the basis of
O.C. disorder is often:
A. Problems with being too
conscientious
B. Problems with anger and remorse
C. Feelings of guilt and inadequacy
D. Feeling of unworthiness and
hopelessness
Answer: C . Ritualistic behavior seen in
this disorder is aimed at controlling guilt
and inadequacy by maintaining an
absolute set pattern of behavior.
17.Mario is complaining to other clients
about not being allowed by staff to keep
food in his room. Which of the following
interventions would be most appropriate?
A. Allowing a snack to be kept in his
room
B. Reprimanding the client
C. Ignoring the clients behavior
D. Setting limits on the behavior
Answer: D . The nurse needs to set
limits in the client’s manipulative
behavior to help the client control
dysfunctional behavior. A consistent
approach by the staff is necessary to
decrease manipulation.
18.Conney with borderline personality
disorder who is to be discharge
soon threatens to “do something” to
herself if discharged. Which of the
following actions by the nurse would be
most important?
A. Ask a family member to stay with the
client at home temporarily
B. Discuss the meaning of the
client’s statement with her
C. Request an immediate extension for
the client
D. Ignore the clients statement because
it’s a sign of manipulation
Answer: B . Any suicidal statement must
be assessed by the nurse. The nurse
should discuss the client’s statement
with her to determine its meaning in
terms of suicide
19.Joey a client with antisocial
personality disorder belches loudly. A
staff member asks Joey, “Do you know
why people find you repulsive?”
this statement most likely would elicit
which of the following client reaction?
A. Depensiveness
B. Embarrassment
C. Shame
D. Remorsefulness
A . When the staff member ask the
client if he wonders why others find
him repulsive, the client is likely to feel
defensive because the question
is belittling. The natural tendency is to
counterattack the threat to self image.
20.Which of the following approaches
would be most appropriate to use with a
client suffering from narcissistic
personality disorder when
discrepancies exist between what the
client states and what actually exist?
A. Rationalization
B. Supportive confrontation
C. Limit setting
D. Consistency
Answer: B . The nurse would specifically
use supportive confrontation with the
client to point out discrepancies
between what the client states and what
actually exists to increase responsibility
for self.
21.Cely is experiencing alcohol
withdrawal exhibits tremors, diaphoresis
and hyperactivity. Blood pressure is
190/87 mmhg and pulse is 92 bpm.
Which of the medications would the
nurse expect to administer?
A. Naloxone (Narcan)
B. Benzlropine (Cogentin)
C. Lorazepam (Ativan)
D. Haloperidol (Haldol)
Answer: C . The nurse would most likely
administer benzodiazepine, such as
lorazepan (ativan) to the client who is
experiencing symptom: The client’s
experiences symptoms of withdrawal
because of the rebound phenomenon
when the sedation of the CNS from
alcohol begins to decrease.
22.Which of the following foods would
the nurse Trish eliminate from the diet of
a client in alcohol withdrawal?
A. Milk
B. Orange Juice
C. Soda
D. Regular Coffee
Answer: D . Regular coffee contains
caffeine which acts as psychomotor
stimulants and leads to feelings of
anxiety and agitation. Serving coffee top
the client may add to tremors or
wakefulness.
23.Which of the following would Nurse
Hazel expect to assess for a client who is
exhibiting late signs of heroin
withdrawal?
A. Yawning & diaphoresis
B. Restlessness & Irritability
C. Constipation & steatorrhea
D. Vomiting and Diarrhea
Answer: D . Vomiting and diarrhea are
usually the late signs of heroin
withdrawal, along with muscle spasm,
fever, nausea, repetitive, abdominal
cramps and backache.
24.To establish open and trusting
relationship with a female client who
has been hospitalized with severe
anxiety, the nurse in charge should?
A. Encourage the staff to have frequent
interaction with the client
B. Share an activity with the client
C. Give client feedback about behavior
D. Respect client’s need for
personal space
Answer: D . Moving to a client’s personal
space increases the feeling of threat,
which increases anxiety.
25. Nurse Monette recognizes that the
focus of environmental (MILIEU) therapy
is to:
A. Manipulate the environment to
bring about positive changes
in behavior
B. Allow the client’s freedom to
determine whether or not they will
be involved in activities
C. Role play life events to meet
individual needs
D. Use natural remedies rather than
drugs to control behavior
Answer: A . Environmental (MILIEU)
therapy aims at having everything in the
client’s surrounding area toward helping
the client.
26.Nurse Trish would expect a child with
a diagnosis of reactive
attachment disorder to:
A. Have more positive relation with the
father than the mother
B. Cling to mother & cry on separation
C. Be able to develop only
superficial relation with the
others
D. Have been physically abuse
Answer: C . Children who have
experienced attachment difficulties with
primary caregiver are not able to trust
others and therefore relate superficially
27.When teaching parents about
childhood depression Nurse Trina
should say?
A. It may appear acting out
behavior
B. Does not respond to conventional
treatment
C. Is short in duration & resolves easily
D. Looks almost identical to adult
depression
Answer: A . Children have difficulty
verbally expressing their feelings, acting
out behavior, such as temper tantrums,
may indicate underlying depression.
28.Nurse Perry is aware that language
development in autistic child resembles:
A. Scanning speech
B. Speech lag
C. Shuttering
D. Echolalia
Answer: D . The autistic child repeat
sounds or words spoken by others.
29.A 60 year old female client who lives
alone tells the nurse at the community
health center “I really don’t need anyone
to talk to”. The TV is my best friend. The
nurse recognizes that the client is using
the defense mechanism known as?
A. Displacement
B. Projection
C. Sublimation
D. Denial
Answer: D . The client statement is an
example of the use of denial, a defense
that blocks problem by unconscious
refusing to admit they exist
30.When working with a male client
suffering phobia about black cats,
Nurse Trish should anticipate that a
problem for this client would be?
A. Anxiety when discussing phobia
B. Anger toward the feared object
C. Denying that the phobia exist
D. Distortion of reality when completing
daily routines
Answer: A . Discussion of the feared
object triggers an emotional response to
the object.
31.Linda is pacing the floor and appears
extremely anxious. The duty
nurse approaches in an attempt to
alleviate Linda’s anxiety. The
most therapeutic question by the nurse
would be?
A. Would you like to watch TV?
B. Would you like me to talk with
you?
C. Are you feeling upset now?
D. Ignore the client
Answer: B . The nurse presence may
provide the client with support & feeling
of control.
32.Nurse Penny is aware that the
symptoms that distinguish post
traumatic stress disorder from other
anxiety disorder would be:
A. Avoidance of situation & certain
activities that resemble the stress
B. Depression and a blunted affect when
discussing the traumatic situation
C. Lack of interest in family & others
D. Re-experiencing the trauma in
dreams or flashback
Answer: D . Experiencing the actual
trauma in dreams or flashback is the
major symptom that distinguishes post
traumatic stress disorder from other
anxiety disorder.
33.Nurse Benjie is communicating with a
male client with substance-
induced persisting dementia; the client
cannot remember facts and fills in the
gaps with imaginary information. Nurse
Benjie is aware that this is typical of?
A. Flight of ideas
B. Associative looseness
C. Confabulation
D. Concretism
Answer: C . Confabulation or the filling in
of memory gaps with imaginary facts is
a defense mechanism used by people
experiencing memory deficits.
34.Nurse Joey is aware that the signs &
symptoms that would be most specific
for diagnosis anorexia are?
A. Excessive weight loss,
amenorrhea & abdominal
distension
B. Slow pulse, 10% weight loss &
alopecia
C. Compulsive behavior, excessive fears
& nausea
D. Excessive activity, memory lapses &
an increased pulse
Answer: A . These are the major signs of
anorexia nervosa. Weight loss is
excessive (15% of expected weight)
35.A characteristic that would suggest to
Nurse Anne that an adolescent may have
bulimia would be:
A. Frequent regurgitation & re-
swallowing of food
B. Previous history of gastritis
C. Badly stained teeth
D. Positive body image
Answer: C . Dental enamel erosion
occurs from repeated self-induced
vomiting.
36.Nurse Monette is aware that
extremely depressed clients seem to do
best in settings where they have:
A. Multiple stimuli
B. Routine Activities
C. Minimal decision making
D. Varied Activities
Answer: B . Depression usually is both
emotional & physical. A simple daily
routine is the best, least stressful and
least anxiety producing.
37.To further assess a client’s suicidal
potential. Nurse Katrina should
be especially alert to the client
expression of:
A. Frustration & fear of death
B. Anger & resentment
C. Anxiety & loneliness
D. Helplessness & hopelessness
Answer: D . The expression of these
feeling may indicate that this client is
unable to continue the struggle of life.
38.A nursing care plan for a male client
with bipolar I disorder should include:
A. Providing a structured
environment
B. Designing activities that will require
the client to maintain contact with
reality
C. Engaging the client in conversing
about current affairs
D. Touching the client provide assurance
Answer: A . Structure tends to decrease
agitation and anxiety and to increase
the client’s feeling of security.
39.When planning care for a female
client using ritualistic behavior,
Nurse Gina must recognize that the
ritual:
A. Helps the client focus on the inability
to deal with reality
B. Helps the client control the
anxiety
C. Is under the client’s conscious control
D. Is used by the client primarily for
secondary gains
Answer: B . The rituals used by a client
with obsessive compulsive disorder
help control the anxiety level by
maintaining a set pattern of action.
40.A 32 year old male graduate student,
who has become increasingly withdrawn
and neglectful of his work and personal
hygiene, is brought to the psychiatric
hospital by his parents. After detailed
assessment, a diagnosis of schizophrenia
is made. It is unlikely that the client
will demonstrate:
A. Low self esteem
B. Concrete thinking
C. Effective self boundaries
D. Weak ego
Answer:C . A person with this disorder
would not have adequate self-
boundaries
41.A 23 year old client has been
admitted with a diagnosis of
schizophrenia says to the nurse “Yes, its
march, March is little woman”. That’s
literal you know”. These statement
illustrate:
A. Neologisms
B. Echolalia
C. Flight of ideas
D. Loosening of association
Answer: D . Loose associations are
thoughts that are presented without the
logical connections usually necessary for
the listening to interpret the message.
42.A long term goal for a paranoid male
client who has unjustifiably accused his
wife of having many extramarital affairs
would be to help the client develop:
A. Insight into his behavior
B. Better self control
C. Feeling of self worth
D. Faith in his wife
Answer: C . Helping the client to develop
feeling of self worth would reduce the
client’s need to use pathologic defenses.
43.A male client who is experiencing
disordered thinking about food
being poisoned is admitted to the mental
health unit. The nurse uses
which communication technique to
encourage the client to eat dinner?
A. Focusing on self-disclosure of own
food preference
B. Using open ended question and
silence
C. Offering opinion about the need to
eat
D. Verbalizing reasons that the client
may not choose to eat
Answer: B . Open ended questions and
silence are strategies used to
encourage clients to discuss their
problem in descriptive manner.
44.Nurse Nina is assigned to care for a
client diagnosed with Catatonic Stupor.
When Nurse Nina enters the client’s
room, the client is found lying on the bed
with a body pulled into a fetal position.
Nurse Nina should?
A. Ask the client direct questions to
encourage talking
B. Rake the client into the dayroom to
be with other clients
C. Sit beside the client in silence
and occasionally ask open-
ended question
D. Leave the client alone and continue
with providing care to the
other clients
Answer: C . Clients who are withdrawn
may be immobile and mute, and
require consistent, repeated
interventions. Communication with
withdrawn clients requires much
patience from the nurse. The nurse
facilitates communication with the client
by sitting in silence, asking open-ended
question and pausing to provide
opportunities for the client to respond.
45.Nurse Tina is caring for a client with
delirium and states that “look at
the spiders on the wall”. What should the
nurse respond to the client?
A. “You’re having hallucination, there
are no spiders in this room at all”
B. “I can see the spiders on the wall, but
they are not going to hurt you”
C. “Would you like me to kill the
spiders”
D. “I know you are frightened, but I
do not see spiders on the wall”
Answer: D . When hallucination is
present, the nurse should reinforce
reality with the client.
46.Nurse Jonel is providing information to
a community group about violence in the
family. Which statement by a group
member would indicate a need to provide
additional information?
A. “Abuse occurs more in low-
income families”
B. “Abuser Are often jealous or self-
centered”
C. “Abuser use fear and intimidation”
D. “Abuser usually have poor self-
esteem”
Answer: A . Personal characteristics of
abuser include low self-esteem,
immaturity, dependence, insecurity and
jealousy
47.During electroconvulsive therapy
(ECT) the client receives oxygen by mask
via positive pressure ventilation. The
nurse assisting with this procedure knows
that positive pressure ventilation is
necessary because?
A. Anesthesia is administered during the
procedure
B. Decrease oxygen to the brain
increases confusion
and disorientation
C. Grand mal seizure activity depresses
respirations
D. Muscle relaxations given to
prevent injury during seizure
activity depress respirations.
Answer: D . A short acting skeletal
muscle relaxant such as succinylcholine
(Anectine) is administered during this
procedure to prevent injuries during
seizure.
48.When planning the discharge of a
client with chronic anxiety, Nurse
Chris evaluates achievement of the
discharge maintenance goals. Which
goal would be most appropriately having
been included in the plan of
care requiring evaluation?
A. The client eliminates all anxiety from
daily situations
B. The client ignores feelings of anxiety
C. The client identifies anxiety
producing situations
D. The client maintains contact with a
crisis counselor
Answer: C . Recognizing situations that
produce anxiety allows the client to
prepare to cope with anxiety or avoid
specific stimulus.
49.Nurse Tina is caring for a client with
depression who has not responded
to antidepressant medication. The nurse
anticipates that what
treatment procedure may be prescribed.
A. Neuroleptic medication
B. Short term seclusion
C. Psychosurgery
D. Electroconvulsive therapy
Answer: D . Electroconvulsive therapy is
an effective treatment for depression
that has not responded to medication
50.Mario is admitted to the emergency
room with drug-included anxiety related
to over ingestion of prescribed
antipsychotic medication. The
most important piece of information the
nurse in charge should obtain initially
is the:
A. Length of time on the med.
B. Name of the ingested medication
& the amount ingested
C. Reason for the suicide attempt
D. Name of the nearest relative & their
phone number
Answer: B . In an emergency, lives
saving facts are obtained first. The
name and the amount of medication
ingested are of outmost important in
treating this potentially life threatening
situation.
FOUNDATION OF NURSING
PNLE: FON
Practice Exam for
History ,
Concepts and
Theories
1. The four major concepts in
nursing theory are the
A. Person, Environment, Nurse,
Health
B. Nurse, Person, Environment, Cure
C. Promotive, Preventive, Curative,
Rehabilitative
D. Person, Environment,
Nursing, Health
Answer: D. Person, Environment,
Nursing, Health. This is an actual
board exam question and is a
common board question. Theorist
always describes The nursing
profession by first defining what is
NURSING, followed by the PERSON,
ENVIRONMENT and HEALTH
CONCEPT. The most popular theory
was perhaps Nightingale’s. She
defined nursing as the utilization of
the persons environment to assist
him towards recovery. She defined
the person as somebody who has a
reparative capabilities mediated
and enhanced by factors in his
environment. She describes the
environment as something that
would facilitate the person’s
reparative process and identified
different factors like sanitation,
noise, etc. that affects a person’s
reparative state.
2. The act of utilizing the
environment of the patient to assist
him in his recovery is theorized by
A. Nightingale
B. Benner
C. Swanson
D. King
Answer: A. Nightingale. Florence
nightingale do not believe in the
germ theory, and perhaps this was
her biggest mistake. Yet, her theory
was the first in nursing. She
believed that manipulation of
environment that includes
appropriate noise, nutrition,
hygiene, light, comfort, sanitation
etc. could provide the client’s body
the nurturance it needs for repair
and recovery.
3. For her, Nursing is a theoretical
system of knowledge that prescribes
a process of analysis and action
related to care of the ill person
A. King
B. Henderson
C. Roy
D. Leininger
Answer: C. Roy. Remember the
word “ THEOROYTICAL “ For Callista
Roy, Nursing is a theoretical body of
knowledge that prescribes analysis
and action to care for an ill person.
She introduced the ADAPTATION
MODEL and viewed person as a
BIOSPSYCHOSOCIAL BEING. She
believed that by adaptation, Man
can maintain homeostasis.
4. According to her, Nursing is a
helping or assistive profession to
persons who are wholly or partly
dependent or when those who are
supposedly caring for them are no
longer able to give care.
A. Henderson
B. Orem
C. Swanson
D. Neuman
Answer: B. Orem. In self care deficit
theory, Nursing is defined as A
helping or assistive profession to
person who are wholly or partly
dependent or when people who are
to give care to them are no longer
available. Self care, are the
activities that a person do for
himself to maintain health, life and
well being.
5. Nursing is a unique profession,
Concerned with all the variables
affecting an individual’s response to
stressors, which are intra, inter and
extra personal in nature.
A. Neuman
B. Johnson
C. Watson
D. Parse
Answer: A. Neuman. Neuman
divided stressors as either intra,
inter and extra personal in nature.
She said that NURSING is concerned
with eliminating these stressors to
obtain a maximum level of
wellness. The nurse helps the client
through PRIMARY, SECONDARY AND
TERTIARY prevention modes. Please
do not confuse this with LEAVELL
and CLARK’S level of prevention.
6. The unique function of the nurse
is to assist the individual, sick or
well, in the performance of those
activities contributing to health that
he would perform unaided if he has
the necessary strength, will and
knowledge, and do this in such a
way as to help him gain
independence as rapidly as possible.
A. Henderson
B. Abdellah
C. Levin
D. Peplau
Answer: A. Henderson. This was an
actual board question. Remember
this definition and associate it with
Virginia Henderson. Henderson also
describes the NATURE OF NURSING
theory. She identified 14 basic
needs of the client. She describes
nursing roles as SUBSTITUTIVE :
Doing everything for the client,
SUPPLEMENTARY : Helping the client
and COMPLEMENTARY : Working
with the client. Breathing normally,
Eliminating waste, Eating and
drinking adquately, Worship and
Play are some of the basic needs
according to her.
7. Caring is the essence and central
unifying, a dominant domain that
distinguishes nursing from other
health disciplines. Care is an
essential human need.
A. Benner
B. Watson
C. Leininger
D. Swanson
Answer:C. Leininger. There are
many theorist that describes
nursing as CARE. The most popular
was JEAN WATSON’S Human Caring
Model. But this question pertains to
Leininger’s definition of caring. CUD
I LIE IN GER? [ Could I Lie In There ]
Is the Mnemonics I am using not to
get confused. C stands for CENTRAL
, U stands for UNIFYING, D stands
for DOMINANT DOMAIN. I
emphasize on this matter due to
feedback on the last June 2006
batch about a question about
CARING.
8. Caring involves 5 processes,
KNOWING, BEING WITH, DOING FOR,
ENABLING and MAINTAINING BELIEF.
A. Benner
B. Watson
C. Leininger
D. Swanson
Answer:D. Swanson . Caring
according to Swanson involves 5
processes. Knowing means
understanding the client. Being with
emphasizes the Physical presence
of the nurse for the patient. Doing
for means doing things for the
patient when he is incapable of
doing it for himself. Enabling means
helping client transcend
maturational and developmental
stressors in life while Maintaining
belief is the ability of the Nurse to
inculcate meaning to these events.
9. Caring is healing, it is
communicated through the
consciousness of the nurse to the
individual being cared for. It allows
access to higher human spirit.
A. Benner
B. Watson
C. Leininger
D. Swanson
Answer: B. Watson. The deepest
and spiritual definition of Caring
came from Jean watson. For her,
Caring expands the limits of
openess and allows access to
higher human spirit.
10. Caring means that person,
events, projects and things matter to
people. It reveals stress and coping
options. Caring creates
responsibility. It is an inherent
feature of nursing practice. It helps
the nurse assist clients to recover in
the face of the illness.
A. Benner
B. Watson
C. Leininger
D. Swanson
Answer: A. Benner. I think of CARE
BEAR to facilitate retainment of
BENNER. As in, Care Benner. For
her, Caring means being
CONNECTED or making things
matter to people. Caring according
to Benner give meaning to illness
and re establish connection.
11. Which of the following is NOT
TRUE about profession according to
Marie Jahoda?
A. A profession is an organization of
an occupational group based on
the application of special
knowledge
B. It serves specific interest of a
group
C. It is altruistic
D. Quality of work is of greater
importance than the rewards
Answer: B. It serves specific interest
of a group.Believe it or not, you
should know the definition of
profession according to Jahoda
because it is asked in the Local
boards. A profession should serve
the WHOLE COMMUNITY and not
just a specific intrest of a group.
Everything else, are correct.
12. Which of the following is NOT an
attribute of a professional?
A. Concerned with quantity
B. Self directed
C. Committed to spirit of inquiry
D. Independent
Answer: A. Concerned with
quantity. A professional is
concerned with QUALITY and not
QUANTITY. In nursing, We have
methods of quality assurance and
control to evaluate the
effectiveness of nursing care.
Nurses, are never concerned with
QUANTITY of care provided.
13. The most unique characteristic
of nursing as a profession is
A. Education
B. Theory
C. Caring
D. Autonomy
Answer: C. Caring. Caring and
caring alone, is the most unique
quality of the Nursing Profession. It
is the one the delineate Nursing
from other professions.
14. This is the distinctive individual
qualities that differentiate a person
to another
A. Philosophy
B. Personality
C. Charm
D. Character
Answer: B. Personality. Personality
are qualities that make us different
from each other. These are
impressions that we made, or the
footprints that we leave behind.
This is the result of the integration
of one’s talents, behavior,
appearance, mood, character,
morals and impulses into one
harmonious whole. Philosophy is the
basic truth that fuel our soul and
give our life a purpose, it shapes
the facets of a person’s character.
Charm is to attract other people to
be a change agent. Character is our
moral values and belief that guides
our actions in life.
15. Refers to the moral values and
beliefs that are used as guides to
personal behavior and actions
A. Philosophy
B. Personality
C. Charm
D. Character
Answer:D. Character.Rationale: Refe
r to number 14
16. As a nurse manager, which of
the following best describes this
function?
A. Initiate modification on client’s
lifestyle
B. Protect client’s right
C. Coordinates the activities of
other members of the health
team in managing patient care
D. Provide in service education
programs, Use accurate
nursing audit, formulate
philosophy and vision of the
institution
Answer:Provide in service education
programs, Use accurate nursing
audit, formulate philosophy and
vision of the institution
17. What best describes nurses as a
care provider?
A. Determine client’s need
B. Provide direct nursing care
C. Help client recognize and cope
with stressful psychological
situation
D. Works in combined effort with all
those involved in patient’s care
Answer: A. Determine client’s
need.You can never provide nursing
care if you don’t know what are the
needs of the client. How can you
provide an effective postural
drainage if you do not know where
is the bulk of the client’s secretion.
Therefore, the best description of a
care provider is the accurate and
prompt determination of the client’s
need to be able to render an
appropriate nursing care.
18. The nurse questions a doctors
order of Morphine sulfate 50 mg, IM
for a client with pancreatitis. Which
role best fit that statement?
A. Change agent
B. Client advocate
C. Case manager
D. Collaborator
Answer: B. Client advocate. As a
client’s advocate, Nurses are to
protect the client’s right and
promotes what is best for the client.
Knowing that Morphine causes
spasm of the sphincter of Oddi and
will lead to further increase in the
client’s pain, The nurse knew that
the best treatment option for the
client was not provided and
intervene to provide the best
possible care.
19. These are nursing intervention
that requires knowledge, skills and
expertise of multiple health
professionals.
A. Dependent
B. Independent
C. Interdependent
D. Intradependent
Answer:
C. Interdependent. Interdependent
functions are those that needs
expertise and skills of multiple
health professionals. Example is
when A child was diagnosed with
nephrotic syndrome and the doctor
ordered a high protein diet, Budek
then work together with the
dietician about the age appropriate
high protein foods that can be given
to the child, Including the
preparation to entice the child into
eating the food. NOTE : It is still
debated if the diet in NS is low,
moderate or high protein, In the
U.S, Protein is never restricted and
can be taken in moderate amount.
As far as the local examination is
concerned, answer LOW PROTEIN
HIGH CALORIC DIET.
20. What type of patient care model
is the most common for student
nurses and private duty nurses?
A. Total patient care
B. Team nursing
C. Primary Nursing
D. Case management
Answer: A. Total patient care. This is
also known as case nursing. It is a
method of nursing care wherein,
one nurse is assigned to one patient
for the delivery of total care. These
are the method use by Nursing
students, Private duty nurses and
those in critical or isolation units.
21. This is the best patient care
model when there are many nurses
but few patients.
A. Functional nursing
B. Team nursing
C. Primary nursing
D. Total patient care
Answer: D. Total patient care .Total
patient care works best if there are
many nurses but few patients.
22. This patient care model works
best when there are plenty of
patient but few nurses
A. Functional nursing
B. Team nursing
C. Primary nursing
D. Total patient care
ANSWER:A. Functional
nursing. Functional nursing is task
oriented, One nurse is assigned on
a particular task leading to task
expertise and efficiency. The nurse
will work fast because the
procedures are repetitive leading to
task mastery. This care is not
recommended as this leads
fragmented nursing care.
23. RN assumes 24 hour
responsibility for the client to
maintain continuity of care across
shifts, days or visits.
A. Functional nursing
B. Team nursing
C. Primary nursing
D. Total patient care
Answer: C. Primary nursing. Your
keyword in Primary nursing is the
24 hours. This does not necessarily
means the nurse is awake for 24
hours, She can have a SECONDARY
NURSES that will take care of the
patient in shifts where she is not
arround.

24. Who developed the first theory
of nursing?
A. Hammurabi
B. Alexander
C. Fabiola
D. Nightingale
Answer: D. Nightingale . Refer to
question # 2. Hammurabi is the
king of babylon that introduces the
LEX TALIONES law, If you kill me,
you should be killed… If you rob
me, You should be robbed, An eye
for an eye and a tooth for a tooth.
Alexander the great was the son of
King Philip II and is from macedonia
but he ruled Greece including Persia
and Egypt. He is known to use a
hammer to pierce a dying soldier’s
medulla towards speedy death
when he thinks that the soldier will
die anyway, just to relieve their
suffering. Fabiola was a beautiful
roman matron who converted her
house into a hospital.
25. She introduces the NATURE OF
NURSING MODEL.
A. Henderson
B. Nightingale
C. Parse
D. Orlando
Answer: A. Henderson. Refer to
question # 6.
26. She described the four
conservation principle.
A. Levin
B. Leininger
C. Orlando
D. Parse
Answer: A. Levin. Myra Levin
described the 4 Conservation
principles which are concerned with
the Unity and Integrity of an
individual. These are ENERGY : Our
output to facilitate meeting of our
needs. STRUCTURAL INTEGRITY : We
mus maintain the integrity of our
organs, tissues and systems to be
able to function and prevent harmful
agents entering our body. PERSONAL
INTEGRITY : These refers to our self
esteem, self worth, self concept,
identify and personality. SOCIAL
INTEGRITY : Reflects our societal
roles to our society, community,
family, friends and fellow individuals
27. Proposed the HEALTH CARE
SYSTEM MODEL.
A. Henderson
B. Orem
C. Parse
D. Neuman
Answer: D. Neuman . Betty Neuman
asserted that nursing is a unique
profession and is concerned with all
the variables affecting the
individual’s response to stressors.
These are INTRA or within
ourselves, EXTRA or outside the
individual, INTER means between
two or more people. She proposed
the HEALTH CARE SYSTEM MODEL
which states that by PRIMARY,
SECONDARY and TERTIARY
prevention, The nurse can help the
client maintain stability against
these stressors.
28. Conceptualized the BEHAVIORAL
SYSTEM MODEL
A. Orem
B. Johnson
C. Henderson
D. Parse
Answer: B. Johnson. According to
Dorothy Johnson, Each person is a
behavioral system that is composed
of 7 subsystems. Man adjust or
adapt to stressors by a using a
LEARNED PATTERN OF RESPONSE.
Man uses his behavior to meet the
demands of the environment, and is
able to modified his behavior to
support these demands
29. Developed the CLINICAL
NURSING – A HELPING ART MODEL
A. Swanson
B. Hall
C. Weidenbach
D. Zderad
Asnwer: C. Weidenbach.Just
remember ERNESTINE
WEIDENBACHLINICAL.
30. Developed the ROLE MODELING
and MODELING theory
A. Erickson,Tomlin,Swain
B. Neuman
C. Newman
D. Benner and Wrubel
Answer: A. Erickson,Tomlin,Swain
31. Proposed the GRAND THEORY OF
NURSING AS CARING
A. Erickson, Tomlin, Swain
B. Peterson,Zderad
C. Bnner,Wrubel
D. Boykin,Schoenhofer
Answer:
D. Boykin,Schoenhofer . This theory
was called GRAND THEORY because
boykin and schoenofer thinks that
ALL MAN ARE CARING, And that
nursing is a response to this unique
call. According to them, CARING IS
A MORAL IMPERATIVE, meaning, ALL
PEOPLE will tend to help a man who
fell down the stairs even if he is not
trained to do so.
32. Postulated the INTERPERSONAL
ASPECT OF NURSING
A. Travelbee
B. Swanson
C. Zderad
D. Peplau
Answer: A. Travelbee. Travelbee’s
theory was referred to as
INTERPERSONAL theory because
she postulated that NURSING is to
assist the individual and all people
that affects this individual to cope
with illness, recover and FIND
MEANING to this experience. For
her, Nursing is a HUMAN TO HUMAN
relationship that is formed during
illness. To her, an individual is a
UNIQUE and irreplaceable being in
continuous process of becoming,
evolving and changing. PLEASE do
remember, that it is PARSE who
postulated the theory of HUMAN
BECOMING and not TRAVELBEE, for I
read books that say it was
TRAVELBEE and not PARSE.
33. He proposed the theory of
morality that is based on MUTUAL
TRUST
A. Freud
B. Erikson
C. Kohlberg
D. Peters
Answer: C. Kohlberg. Kohlber states
that relationships are based on
mutual trust. He postulated the
levels of morality development. At
the first stage called the PREMORAL
or preconventional, A child do things
and label them as BAD or GOOD
depending on the PUNISHMENT or
REWARD they get. They have no
concept of justice, fairness and
equity, for them, If I punch this kid
and mom gets mad, thats WRONG.
But if I dance and sing, mama smiles
and give me a new toy, then I am
doing something good. In the
Conventional level, The individual
actuates his act based on the
response of the people around him.
He will follow the rules, regulations,
laws and morality the society
upholds. If the law states that I
should not resuscitate this man with
a DNR order, then I would not.
However, in the Post conventional
level or the AUTONOMOUS level, the
individual still follows the rules but
can make a rule or bend part of
these rules according to his own
MORALITY. He can change the rules if
he thinks that it is needed to be
changed. Example is that, A nurse
still continue resuscitating the client
even if the client has a DNR order
because he believes that the client
can still recover and his mission is to
save lives, not watch patients die
34. He proposed the theory of
morality based on PRINCIPLES
A. Freud
B. Erikson
C. Kohlberg
D. Peters
Answer: D. Peters . Remember
PETERS for PRINCIPLES. P is to P. He
believes that morality has 3
components : EMOTION or how one
feels, JUDGEMENT or how one
reason and BEHAVIOR or how one
actuates his EMOTION and
JUDGEMENT. He believes that
MORALITY evolves with the
development of PRINCPLES or the
person’s vitrue and traits. He also
believes in AUTOMATICITY of virtues
or he calls HABIT, like kindness,
charity, honesty, sincerity and thirft
which are innate to a person and
therfore, will be performed
automatically.
35. Freud postulated that child
adopts parental standards and traits
through
A. Imitation
B. Introjection
C. Identification
D. Regression
Answer:C. Identification. A child,
according to Freud adopts parental
standards, traits, habits and norms
through identication. A good
example is the corned beef
commercial ” WALK LIKE A MAN,
TALK LIKE A MAN ” Where the child
identifies with his father by wearing
the same clothes and doing the
same thing.
36. According to them, Morality is
measured of how people treat
human being and that a moral child
strives to be kind and just
A. Zderad and Peterson
B. Benner and Wrubel
C. Fowler and Westerhoff
D. Schulman and Mekler
Answer: D. Schulman and
Mekler . According to Schulman and
Mekler, there are 2 components
that makes an action MORAL : The
intention should be good and the
Act must be just. A good example is
ROBIN HOOD, His intention is GOOD
but the act is UNJUST, which makes
his action IMMORAL.
37. Postulated that FAITH is the way
of behaving. He developed four
theories of faith and development
based on his experience.
A. Giligan
B. Westerhoff
C. Fowler
D. Freud
Answer: B. Westerhoff. There are
only 2 theorist of FAITH that might
be asked in the board examinations.
Fowler and Westerhoff. What differs
them is that, FAITH of fowler is
defined abstractly, Fowler defines
faith as a FORCE that gives a
meaning to a person’s life while
Westerhoff defines faith as a
behavior that continuously develops
through time.
38. He described the development of
faith. He suggested that faith is a
spiritual dimension that gives
meaning to a persons life. Faith
according to him, is a relational
phenomenon.
A. Giligan
B. Westerhoff
C. Fowler
D. Freud
Answer:C. Fowler. Rationale: Refer
to # 37
39. Established in 1906 by the
Baptist foreign mission society of
America. Miss rose nicolet, was it’s
first superintendent.
A. St. Paul Hospital School of
nursing
B. Iloilo Mission Hospital School
of nursing
C. Philippine General Hospital
School of nursing
D. St. Luke’s Hospital School of
nursing
Answer:B. Iloilo Mission Hospital
School of nursing
40. Anastacia Giron-Tupas was the
first Filipino nurse to occupy the
position of chief nurse in this
hospital.
A. St. Paul Hospital
B. Iloilo Mission Hospital
C. Philippine General Hospital
D. St. Luke’s Hospital
Answer:C. Philippine General
Hospital
41. She was the daughter of
Hungarian kings, who feed 300-900
people everyday in their gate, builds
hospitals, and care of the poor and
sick herself.
A. Elizabeth
B. Catherine
C. Nightingale
D. Sairey Gamp
Answer:A. Elizabeth.Saint Elizabeth
of Hungary was a daughter of a
King and is the patron saint of
nurses. She build hospitals and feed
hungry people everyday using the
kingdom’s money. She is a princess,
but devoted her life in feeding the
hungry and serving the sick.
42. She dies of yellow fever in her
search for truth to prove that yellow
fever is carried by a mosquitoes.
A. Clara louise Maas
B. Pearl Tucker
C. Isabel Hampton Robb
D. Caroline Hampton Robb
Answer:A. Clara louise Maas. Clara
Louise Maas sacrificed her life in
research of YELLOW FEVER. People
during her time do not believe that
yellow fever was brought by
mosquitoes. To prove that they are
wrong, She allowed herself to be
bitten by the vector and after days,
She died.
43. He was called the father of
sanitation.
A. Abraham
B. Hippocrates
C. Moses
D. Willam Halstead
Answer: C. Moses
44. The country where SHUSHURUTU
originated
A. China
B. Egypt
C. India
D. Babylonia
Answer: india
45. They put girls clothes on male
infants to drive evil forces away
A. Chinese
B. Egyptian
C. Indian
D. Babylonian
Answer: A. Chinese. Chinese
believes that male newborns are
demon magnets. To fool those
demons, they put female clothes to
their male newborn.
46. In what period of nursing does
people believe in TREPHINING to
drive evil forces away?
A. Dark period
B. Intuitive period
C. Contemporary period
D. Educative period
Answer: B. Intuitive
period.Egyptians believe that a sick
person is someone with an evil
force or demon that is inside their
heads. To release these evil spirits,
They would tend to drill holes on
the patient’s skull and it is called
TREPHINING.
47. This period ended when Pastor
Fliedner, build Kaiserwerth institute
for the training of Deaconesses
A. Apprentice period
B. Dark period
C. Contemporary period
D. Educative period
Answer: A. Apprentice period.What
dilineates apprentice period among
others is that, it ENDED when
formal schools were established.
During the apprentice period, There
is no formal educational institution
for nurses. Most of them receive
training inside the convent or
church. Some of them are trained
just for the purpose of nursing the
wounded soldiers. But almost all of
them are influenced by the christian
faith to serve and nurse the sick.
When Fliedner build the first formal
school for nurses, It marked the end
of the APPRENTICESHIP period.
48. Period of nursing where religious
Christian orders emerged to take
care of the sick
A. Apprentice period
B. Dark period
C. Contemporary period
D. Educative period
Answer: A. Apprentice
period. Apprentice period is marked
by the emergence of religious
orders the are devoted to religious
life and the practice of nursing.
49. Founded the second order of St.
Francis of Assisi
A. St. Catherine
B. St. Anne
C. St. Clare
D. St. Elizabeth
Answer:C. St. Clare. The poor clares,
is the second order of St. Francis of
assisi. The first order was founded
by St. Francis himself. St. Catherine
of Siena was the first lady with the
lamp. St. Anne is the mother of
mama mary. St. Elizabeth is the
patron saint of Nursing.
50. This period marked the religious
upheaval of Luther, Who questions
the Christian faith.
A. Apprentice period
B. Dark period
C. Contemporary period
D. Educative period
Answer:B. Dark
period. Protestantism emerged with
Martin Luther questions the Pope
and Christianity. This started the
Dark period of nursing when the
christian faith was smeared by
controversies. These leads to
closure of some hospital and
schools run by the church. Nursing
became the work of prostitutes,
slaves, mother and least desirable
of women.
51. According to the Biopsychosocial
and spiritual theory of Sister Callista
Roy, Man, As a SOCIAL being is
A. Like all other men
B. Like some other men
C. Like no other men
D. Like men
Answer:B. Like some other
men.According to ROY, Man as a
social being is like some other man.
As a spiritual being and Biologic
being, Man are all alike. As a
psychologic being, No man thinks
alike. This basically summarized her
BIOPSYHOSOCIAL theory which is
included in our licensure exam
coverage.
52. She conceptualized that man, as
an Open system is in constant
interaction and transaction with a
changing environment.
A. Roy
B. Levin
C. Neuman
D. Newman
Answer:A. Roy. OPEN system theory
is ROY. As an open system, man
continuously allows input from the
environment. Example is when you
tell me Im good looking, I will be
happy the entire day, Because I am
an open system and continuously
interact and transact with my
environment. A close system is best
exemplified by a CANDLE. When
you cover the candle with a glass, it
will die because it will eventually
use all the oxygen it needs inside
the glass for combustion. A closed
system do not allow inputs and
output in its environment.
53. In a CLOSED system, which of
the following is true?
A. Affected by matter
B. A sole island in vast ocean
C. Allows input
D. Constantly affected by matter,
energy, information
Answer: B. A sole island in vast
ocean
54. Who postulated the WHOLISTIC
concept that the totality is greater
than sum of its parts?
A. Roy
B. Rogers
C. Henderson
D. Johnson
Answer: B. Rogers. The wholistic
theory by Martha Rogers states that
MAN is greater than the sum of all
its parts and that his dignity and
worth will not be lessen even if one
of this part is missing. A good
example is ANNE BOLEYN, The
mother of Queen Elizabeth and the
wife of King Henry VIII. She was
beheaded because Henry wants to
mary another wife and that his
divorce was not approved by the
pope. Outraged, He insisted on the
separation of the Church and State
and divorce Anne himself by making
everyone believe that Anne is
having an affair to another man.
Anne was beheaded while her lips is
still saying a prayer. Even without
her head, People still gave respect
to her diseased body and a
separate head. She was still
remembered as Anne boleyn,
Mother of Elizabeth who lead
england to their GOLDEN AGE.
55. She theorized that man is
composed of sub and supra systems.
Subsystems are cells, tissues,
organs and systems while the
suprasystems are family, society
and community.
A. Roy
B. Rogers
C. Henderson
D. Johnson
Answer: B. Rogers. According to
Martha Rogers, Man is composed of
2 systems : SUB which includes
cells, tissues, organs and system
and SUPRA which includes our
famly, community and society. She
stated that when any of these
systems are affected, it will affect
the entire individual.
56. Which of the following is not true
about the human needs?
A. Certain needs are common to all
people
B. Needs should be followed
exactly in accordance with
their hierarchy
C. Needs are stimulated by internal
factors
D. Needs are stimulated by external
factors
Answer: B. Needs should be
followed exactly in accordance with
their hierarchy.Needs can be
deferred. I can urinate later as not
to miss the part of the movie’s
climax. I can save my money that
are supposedly for my lunch to
watch my idols in concert. The
physiologic needs can be meet later
for some other needs and need not
be strictly followed according to
their hierarchy.
57. Which of the following is TRUE
about the human needs?
Answer: A. Makes decision contrary
to public opinion. Refer to question
# 58.
60. This is the essence of mental
health
A. Self awareness
B. Self actualization
C. Self esteem
D. Self worth
Answer: B. Self actualization. The
peak of maslow’s hierarchy is the
essence of mental health

A. May not be deferred 61. Florence nightingale is born in

B. Are not interrelated
C. Met in exact and rigid way A. Germany
D. Priorities are alterable B. Britain
C. France
Answer: D. Priorities are D. Italy
alterable. Refer to question # 56.
Answer: D. Italy. Florence
58. According to Maslow, which of Nightingale was born in Florence,
Italy, May 12, 1820. Studied in
the following is NOT TRUE about a
Germany and Practiced in England.
self actualized person?
A. Understands poetry, music, 62. Which is unlikely of Florence
philosophy, science etc. Nightingale?
B. Desires privacy, autonomous
A. Born May 12, 1840
C. Follows the decision of the
B. Built St. Thomas school of
majority, uphold justice and
nursing when she was 40 years
truth
old
D. Problem centered
C. Notes in nursing
D. Notes in hospital
Answer: C. Follows the decision of
the majority, uphold justice and
1. Answer: A. Born May 12, 1840
truth. A,B and D are all qualities of a
self actualized person. A self
63. What country did Florence
actualized person do not follow the
decision of majority but is self Nightingale train in nursing?
directed and can make decisions A. Belgium
contrary to a popular opinion. B. US
C. Germany
59. According to Maslow, which of D. England
the following is TRUE about a self
actualized person? Answer: germany
A. Makes decision contrary to 64. Which of the following is
public opinion
recognized for developing the
B. Do not predict events
C. Self centered concept of HIGH LEVEL WELLNESS?
D. Maximum degree of self conflict A. Erikson
B. Madaw
C. Peplau
D. Dunn
Answer:D. Dunn. According to Dunn,
High level wellness is the ability of
an individual to maximize his full
potential with the limitations
imposed by his environment.
According to him, An individual can
be healthy or ill in both favorable
and unfavorable environment.
65. One of the expectations is for
nurses to join professional
association primarily because of
A. Promotes advancement and
professional growth among
its members
B. Works for raising funds for
nurse’s benefit
C. Facilitate and establishes
acquaintances
D. Assist them and securing jobs
abroad
Answer: A. Promotes advancement
and professional growth among its
members
66. Founder of the PNA
A. Julita Sotejo
B. Anastacia Giron Tupas
C. Eufemia Octaviano
D. Anesia Dionisio
Answer: Anastacia Giron Tupas
67. Which of the following provides
that nurses must be a member of a
national nurse organization?
A. R.A 877
B. 1981 Code of ethics approved by
the house of delegates and the
PNA
C. Board resolution No. 1955
Promulgated by the BON
D. RA 7164
Answer: C. Board resolution No.
1955 Promulgated by the BON. This
is an old board resolution. The new
Board resolution is No. 220 series of
2004 also known as the Nursing
Code Of ethics which states that
[ SECTION 17, A ] A nurse should be
a member of an accredited
professional organization which is
the PNA.
68. Which of the following best
describes the action of a nurse who
documents her nursing diagnosis?
A. She documents it and charts it
whenever necessary
B. She can be accused of
malpractice
C. She does it regularly as an
important responsibility
D. She charts it only when the
patient is acutely ill
Answer: C. She does it regularly as
an important responsibility
69. Which of the following does not
govern nursing practice?
A. RA 7164
B. RA 9173
C. BON Res. Code Of Ethics
D. BON Res. Scope of Nursing
Practice
Answer: A. RA 7164. 7164 is an old
law. This is the 1991 Nursing Law
which was repealed by the newer
9173.
70. A nurse who is maintaining a
private clinic in the community
renders service on maternal and
child health among the
neighborhood for a fee is:
A. Primary care nurse
B. Independent nurse
practitioner
C. Nurse-Midwife
D. Nurse specialist
Answer: B. Independent nurse
practitioner
71. When was the PNA founded?
A. September 22, 1922
B. September 02, 1920
C. October 21, 1922
D. September 02, 1922
Answer: D. September 02,
1922. According to the official PNA
website, they are founded
September 02, 1922.
72. Who was the first president of
the PNA ?
A. Anastacia Giron-Tupas
B. Loreto Tupas
C. Rosario Montenegro
D. Ricarda Mendoza
Answer: C. Rosario
Montenegro. Anastacia Giron Tupas
founded the FNA, the former name
of the PNA but the first President
was Rosario Montenegro.
73. Defines health as the ability to
maintain internal milieu. Illness
according to him/her/them is the
failure to maintain internal
environment.
A. Cannon
B. Bernard
C. Leddy and Pepper
D. Roy
Answer: B. Bernard. According to
Bernard, Health is the ability to
maintain and Internal Milieu and
Illness is the failure to maintain the
internal environment.
74. Postulated that health is a state
and process of being and becoming
an integrated and whole person.
A. Cannon
B. Bernard
C. Dunn
D. Roy
Answer: D. Roy. According to ROY,
Health is a state and process of
becoming a WHOLE AND
INTEGRATED Person.
75. What regulates HOMEOSTASIS
according to the theory of Walter
Cannon?
A. Positive feedback
B. Negative feedback
C. Buffer system
D. Various mechanisms
Answer: B. Negative feedback. The
theory of Health as the ability to
maintain homeostasis was
postulated by Walter Cannon.
According to him, There are certain
FEEDBACK Mechanism that
regulates our Homeostasis. A good
example is that when we overuse
our arm, it will produce pain. PAIN is
a negative feedback that signals us
that our arm needs a rest.
76. Stated that health is WELLNESS.
A termed define by the culture or an
individual.
A. Roy
B. Henderson
C. Rogers
D. King
Answer: C. Rogers. Martha Rogers
states that HEALTH is synonymous
with WELLNESS and that HEALTH
and WELLNESS is subjective
depending on the definition of one’s
culture.
77. Defined health as a dynamic
state in the life cycle, and Illness as
interference in the life cycle.
A. Roy
B. Henderson
C. Rogers
D. King
Answer: D. King .Emogene King
states that health is a state in the
life cycle and Illness is any
interference on this cycle. I enjoyed
the Movie LION KING and like what
Mufasa said that they are all part of
the CIRCLE OF LIFE, or the Life
cycle.
78. She defined health as the
soundness and wholness of
developed human structure and
bodily mental functioning.
A. Orem
B. Henderson
C. Neuman
D. Clark
Answer: A. Orem. Orem defined
health as the SOUNDNESS and
WHOLENESS of developed human
structure and of bodily and mental
functioning.
79. According to her, Wellness is a
condition in which all parts and
subparts of an individual are in
harmony with the whole system.
A. Orem
B. Henderson
C. Neuman
D. Johnson
Answer: C. Neuman. Neuman
believe that man is composed of
subparts and when this subparts
are in harmony with the whole
system, Wellness results. Please do
not confuse this with the SUB and
SUPRA systems of martha rogers.
80. Postulated that health is
reflected by the organization,
interaction, interdependence and
integration of the subsystem of the
behavioral system.
A. Orem
B. Henderson
C. Neuman
D. Johnson
Answer: D. Johnson . Once you see
the phrase BEHAVIORAL SYSTEM,
answer Dorothy Johnson.
81. According to them, Well being is
a subjective perception of BALANCE,
HARMONY and VITALITY
A. Leavell and Clark
B. Peterson and Zderad
C. Benner and Wruber
D. Leddy and Pepper
Answer: D. Leddy and
Pepper .According to Leddy and
Pepper, Wellness is subjective and
depends on an individuals
perception of balance, harmony and
vitality. Leavell and Clark postulared
the ecologic model of health and
illness or the AGENT-HOST-
ENVIRONMENT model. Peterson and
Zderad developed the HUMANISTIC
NURSING PRACTICE theory while
Benner and Wruber postulate the
PRIMACY OF CARING MODEL.
82. He describes the WELLNESS-
ILLNESS Continuum as interaction of
the environment with well being and
illness.
A. Cannon
B. Bernard
C. Dunn
D. Clark
Answer: Dunn
83. An integrated method of
functioning that is oriented towards
maximizing one’s potential within
the limitation of the environment.
A. Well being
B. Health
C. Low level Wellness
D. High level Wellness
Answer: High level Wellness
84. What kind of illness precursor,
according to DUNN is cigarette
smoking?
A. Heredity
B. Social
C. Behavioral
D. Environmental
Answer: C. Behavioral. Behavioral
precursors includes smoking,
alcoholism, high fat intake and
other lifestyle choices.
Environmental factors involved poor
sanitation and over crowding.
Heridity includes congenital and
diseases acquired through the
genes. There are no social
precursors according to DUNN.
85. According to DUNN,
Overcrowding is what type of illness
precursor?
A. Heredity
B. Social
C. Behavioral
D. Environmental
Answer: Environmental
86. Health belief model was
formulated in 1975 by who?
A. Becker
B. Smith
C. Dunn
D. Leavell and Clark
Answer:A. Becker. According to
Becker, The belief of an individual
greatly affects his behavior. If a
man believes that he is susceptible
to an illness, He will alter his
behavior in order to prevent its
occurence. For example, If a man
thinks that diabetes is acquired
through high intake of sugar and
simple carbohydrates, then he will
limit the intake of foods rich in
these components.
87. In health belief model, Individual
perception matters. Which of the
following is highly UNLIKELY to
influence preventive behavior?
A. Perceived susceptibility to an
illness
B. Perceived seriousness of an
illness
C. Perceived threat of an illness
D. Perceived curability of an
illness
Answer: D. Perceived curability of an
illness . If a man think he is
susceptibe to a certain disease,
thinks that the disease is serious
and it is a threat to his life and
functions, he will use preventive
behaviors to avoid the occurence of
this threat.
88. Which of the following is not a
PERCEIVED BARRIER in preventive
action?
A. Difficulty adhering to the
lifestyle
B. Economic factors
C. Accessibility of health care
facilities
D. Increase adherence to medical
therapies
Answer:A. Difficulty adhering to the
lifestyle and B. Economic
factors. Perceived barriers are those
factors that affects the individual’s
health preventive actions. Both A
and B can affect the individual’s
ability to prevent the occurence of
diseases. C and D are called
Preventive Health Behaviors which
enhances the individual’s
preventive capabilities.
89. Conceptualizes that health is a
condition of actualization or
realization of person’s potential.
Avers that the highest aspiration of
people is fulfillment and complete
development actualization.
A. Clinical Model
B. Role performance Model
C. Adaptive Model
D. Eudaemonistic Model
Answer: D. Eudaemonistic
Model . Smith formulated 5 models
of health. Clinical model simply
states that when people experience
sign and symptoms, they would
think that they are unhealthy
therefore, Health is the absence of
clinical sign and symptoms of a
disease. Role performance model
states that when a person does his
role and activities without deficits,
he is healthy and the inability to
perform usual roles means that the
person is ill. Adaptive Model states
that if a person adapts well with his
environment, he is healthy and
maladaptation equates illness.
Eudaemonistic Model of health
according to smith is the
actualization of a person’s fullest
potential. If a person functions
optimally and develop self
actualization, then, no doubt that
person is healthy.
90. Views people as physiologic
system and Absence of sign and
symptoms equates health.
A. Clinical Model
B. Role performance Model
C. Adaptive Model
D. Eudaemonistic Model
Answer:A. Clinical
Model. Rationale: Refer to question
# 89.
91. Knowledge about the disease
and prior contact with it is what type
of VARIABLE according to the health
belief model?
A. Demographic
B. Sociopsychologic
C. Structural
D. Cues to action
Answer: C. Structural. Modifying
variables in Becker’s health belief
model includes DEMOGRAPHIC : Age,
sex, race etc. SOCIOPSYCHOLOGIC :
Social and Peer influence.
STRUCTURAL : Knowledge about the
disease and prior contact with it and
CUES TO ACTION : Which are the
sign and symptoms of the disease or
advice from friends, mass media and
others that forces or makes the
individual seek help
92. It includes internal and external
factors that leads the individual to
seek help
A. Demographic
B. Sociopsychologic
C. Structural
D. Cues to action
Answer: D. Cues to action . Refer to
question # 91.
93. Influence from peers and social
pressure is included in what variable
of HBM?
A. Demographic
B. Sociopsychologic
C. Structural
D. Cues to action
Answer: B. Sociopsychologic. Refer
to question # 91.
94. Age, Sex, Race etc. is included in
what variable of HBM?
A. Demographic
B. Sociopsychologic
C. Structural
D. Cues to action
Answer: A. Demographic. Refer to
question # 91.
95. According to Leavell and Clark’s
ecologic model, All of this are factors
that affects health and illness except
A. Reservoir
B. Agent
C. Environment
D. Host
Answer: A. Reservoir. According to
L&C’s Ecologic model, there are 3
factors that affect health and
illness. These are the AGENT or the
factor the leads to illness, either a
bacteria or an event in life. HOST
are persons that may or may not be
affected by these agents.
ENVIRONMENT are factors external
to the host that may or may not
predispose him to the AGENT.
96. Is a multi dimensional model
developed by PENDER that describes
the nature of persons as they
interact within the environment to
pursue health
A. Ecologic Model
B. Health Belief Model
C. Health Promotion Model
D. Health Prevention Model
Answer: C. Health Promotion
Model. Pender developed the
concept of HEALTH PROMOTION
MODEL which postulated that an
individual engages in health
promotion activities to increase well
being and attain self actualization.
These includes exercise,
immunization, healthy lifestyle,
good food, self responsibility and all
other factors that minimize if not
totally eradicate risks and threats of
health.
97. Defined by Pender as all
activities directed toward increasing
the level of well being and self
actualization.
A. Health prevention
B. Health promotion
C. Health teaching
D. Self actualization
Answer:B. Health promotion. Refer
to question # 96.
98. Defined as an alteration in
normal function resulting in
reduction of capacities and
shortening of life span.
A. Illness
B. Disease
C. Health
D. Wellness
Answer: B. Disease. Disease are
alteration in body functions
resulting in reduction of capabilities
or shortening of life span.
99. Personal state in which a person
feels unhealthy
A. Illness
B. Disease
C. Health
D. Wellness
Answer:A. Illness. Illness is
something PERSONAL. Unlike
disease, Illness are personal state in
which person feels unhealthy. An
old person might think he is ILL but
in fact, he is not due, to diminishing
functions and capabilities, people
might think they are ILL. Disease
however, is something with tangible
basis like lab results, X ray films or
clinical sign and symptoms.
100. According to her, Caring is
defined as a nurturant way of
responding to a valued client
towards whom the nurse feels a
sense of commitment and
responsibility.
A. Benner
B. Watson
C. Leininger
D. Swanson
Answer: B. Watson. This is Jean
Watson’s definition of Nursing as
caring. This was asked word per
word last June 06′ NLE. Benner
defines caring as something that
matters to people. She postulated
the responsibility created by Caring
in nursing. She was also responsible
for the PRIMACY OF CARING MODEL.
Leininger defind the 4 conservation
principle while Swanson introduced
the 5 processes of caring.
PNLE: FON
Practice Exam for
Infection,
Asepsis, Basic
concept of Stress
and Illness
 1. When the General
adaptation syndrome is activated,
FLIGHT OR FIGHT response sets in.
Sympathetic nervous system
releases norepinephrine while the
adrenal medulla secretes
epinephrine. Which of the following
is true with regards to that
statement?
A. Pupils will constrict
B. Client will be lethargic
C. Lungs will bronchodilate
D. Gastric motility will increase
Answer: C. Lungs will
bronchodilate. To better understand
the concept : The autonomic
nervous system is composed of
SYMPATHETIC and
PARASYMPATHETIC Nervous system.
It is called AUTONOMIC Because it is
Involuntary and stimuli based. You
cannot tell your heart to kindly beat
for 60 per minute, Nor, Tell your
blood vessels, Please constrict,
because you need to wear skirt
today and your varicosities are
bulging. Sympathetic Nervous
system is the FIGHT or FLIGHT
mechanism. When people FIGHT or
RUN, we tend to stimulate the ANS
and dominate over SNS. Just
Imagine a person FIGHTING and
RUNNING to get the idea on the
signs of SNS Domination. Imagine a
resting and digesting person to get
a picture of PNS Domination. A
person RUNNING or FIGHTING
Needs to bronchodilate, because
the oxygen need is increased due to
higher demand of the body. Pupils
will DILATE to be able to see the
enemy clearly. Client will be fully
alert to dodge attacks and leap
through obstacles during running.
The client’s gastric motility will
DECREASE Because you cannot
afford to urinate or defecate during
fighting nor running.
2. Which of the following response is
not expected to a person whose GAS
is activated and the FIGHT OR
FLIGHT response sets in?
A. The client will not urinate due to
relaxation of the detrusor muscle
B. The client will be restless and
alert
C. Clients BP will increase, there
will be vasodilation
D. There will be increase
glycogenolysis, Pancrease will
decrease insulin secretion
Answer: C. Clients BP will increase,
there will be vasodilation. If
vasodilation will occur, The BP will
not increase but decrease. It is true
that Blood pressure increases
during SNS Stimulation due to the
fact that we need more BLOOD to
circulate during the FIGHT or
FLIGHT Response because the
oxygen demand has increased, but
this is facilitated by
vasoconstriction and not
vasodilation. A,B and D are all
correct. The liver will increase
glycogenolysis or glycogen store
utilization due to a heightened
demand for energy. Pancrease will
decrease insulin secretion because
almost every aspect of digestion
that is controlled by
Parasympathetic nervous system is
inhibited when the SNS dominates.
3. State in which a person’s physical,
emotional, intellectual and social
development or spiritual functioning
is diminished or impaired compared
with a previous experience.
A. Illness
B. Disease
C. Health
D. Wellness
Answer: A. Illness. Disease is a
PROVEN FACT based on a medical
theory, standards, diagnosis and
clinical feature while ILLNESS Is a
subjective state of not feeling well
based on subjective appraisal,
previous experience, peer advice etc
4. This is the first stage of illness
wherein, the person starts to believe
that something is wrong. Also known
as the transition phase from
wellness to illness.
A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role
Answer: A. Symptom Experience. A
favorite board question are Stages
of Illness. When a person starts to
believe something is wrong, that
person is experiencing signs and
symptoms of an illness. The patient
will then ASSUME that he is sick.
This is called assumption of the sick
role where the patient accepts he is
Ill and try to give up some activities.
Since the client only ASSUMES his
illness, he will try to ask someone to
validate if what he is experiencing
is a disease, This is now called as
MEDICAL CARE CONTACT. The client
seeks professional advice for
validation, reassurance, clarification
and explanation of the symptoms
he is experiencing. client will then
start his dependent patient role of
receiving care from the health care
providers. The last stage of Illness is
the RECOVERY stage where the
patient gives up the sick role and
assumes the previous normal
gunctions.
5. In this stage of illness, the person
accepts or rejects a professionals
suggestion. The person also
becomes passive and may regress to
an earlier stage.
A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role
Answer: D. Dependent patient
role. In the dependent patient role
stage, Client needs professionals for
help. They have a choice either to
accept or reject the professional’s
decisions but patients are usually
passive and accepting. Regression
tends to occur more in this period.
6. In this stage of illness, The person
learns to accept the illness.
A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role
Answer:B. Assumption of sick
role. Acceptance of illness occurs in
the Assumption of sick role phase of
illness.
7. In this stage, the person tries to
find answers for his illness. He wants
his illness to be validated, his
symptoms explained and the
outcome reassured or predicted
A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role
Answer: C. Medical care contact. At
this stage, The patient seeks for
validation of his symptom
experience. He wants to find out if
what he feels are normal or not
normal. He wants someone to
explain why is he feeling these
signs and symptoms and wants to
know the probable outcome of this
experience.
8. The following are true with
regards to aspect of the sick role
except
A. One should be held
responsible for his condition
B. One is excused from his societal
role
C. One is obliged to get well as soon
as possible
D. One is obliged to seek competent
help
Answer: A. One should be held
responsible for his condition. The
nurse should not judge the patient
and not view the patient as the
cause or someone responsible for
his illness. A sick client is excused
from his societal roles, Oblige to get
well as soon as possible and Obliged
to seek competent help.
9. Refers to conditions that increases
vulnerability of individual or group to
illness or accident
A. Predisposing factor
B. Etiology
C. Risk factor
D. Modifiable Risks
Answer: C. Risk factor
10. Refers to the degree of
resistance the potential host has
against a certain pathogen
A. Susceptibility
B. Immunity
C. Virulence
D. Etiology
Answer: A. Susceptibility. Immunity
is the ABSOLUTE Resistance to a
pathogen considering that person
has an INTACT IMMUNITY while
susceptibility is the DEGREE of
resistance. Degree of resistance
means how well would the
individual combat the pathogens
and repel infection or invasion of
these disease causing organisms. A
susceptible person is someone who
has a very low degree of resistance
to combat pathogens. An Immune
person is someone that can easily
repel specific pathogens. However,
Remember that even if a person is
IMMUNE [ Vaccination ] Immunity
can always be impaired in cases of
chemotherapy, HIV, Burns, etc.
11. A group of symptoms that sums
up or constitute a disease
A. Syndrome
B. Symptoms
C. Signs
D. Etiology
Answer: A. Syndrome. Symptoms
are individual manifestation of a
certain disease. For example, In
Tourette syndrome, patient will
manifest TICS, but this alone is not
enough to diagnose the patient as
other diseases has the same tic
manifestation. Syndrome means
COLLECTION of these symptoms
that occurs together to characterize
a certain disease. Tics with
coprolalia, echolalia, palilalia,
choreas or other movement
disorders are characteristics of
TOURETTE SYNDROME.
12. A woman undergoing radiation
therapy developed redness and
burning of the skin around the best.
This is best classified as what type of
disease?
A. Neoplastic
B. Traumatic
C. Nosocomial
D. Iatrogenic
Answer: D. Iatrogenic. Iatrogenic
diseases refers to those that
resulted from treatment of a certain
disease. For example, A child
frequently exposed to the X-RAY
Machine develops redness and
partial thickness burns over the
chest area. Neoplastic are
malignant diseases cause by
proliferation of abnormally growing
cells. Traumatic are brought about
by injuries like Motor vehicular
accidents. Nosocomial are
infections that acquired INSIDE the
hospital. Example is UTI Because of
catheterization, This is commonly
caused by E.Coli.
13. The classification of CANCER
according to its etiology Is best
described as:
1. Nosocomial
2. Idiopathic
3. Neoplastic
4. Traumatic
5. Congenital
6. Degenrative
A. 5 and 2
B. 2 and 3
C. 3 and 4
D. 3 and 5

Answer: B. 2 and 3. Aside from
being NEOPLASTIC, Cancer is
considered as IDIOPATHIC because
the cause is UNKNOWN.
14. Term to describe the
reactiviation and recurrence of
pronounced symptoms of a disease
A. Remission
B. Emission
C. Exacerbation
D. Sub acute
Answer:C. Exacerbation
15. A type of illness characterized by
periods of remission and
exacerbation
A. Chronic
B. Acute
C. Sub acute
D. Sub chronic
Answer: A. Chronic. A good example
is Multiple sclerosis that
characterized by periods of
remissions and exacerbation and it
is a CHRONIC Disease. An acute and
sub acute diseases occurs too short
to manifest remissions. Chronic
diseases persists longer than 6
months that is why remissions and
exacerbation are observable.
16. Diseases that results from
changes in the normal structure,
from recognizable anatomical
changes in an organ or body tissue
is termed as
A. Functional
B. Occupational
C. Inorganic
D. Organic
Answer:D. Organic. As the word
implies, ORGANIC Diseases are
those that causes a CHANGE in the
structure of the organs and
systems. Inorganic diseases is
synonymous with FUNCTIONAL
diseases wherein, There is no
evident structural, anatomical or
physical change in the structure of
the organ or system but function is
altered due to other causes, which
is usually due to abnormal response
of the organ to stressors. Therefore,
ORGANIC BRAIN SYNDROME are
anatomic and physiologic change in
the BRAIN that is NON
PROGRESSIVE BUT IRREVERSIBLE
caused by alteration in structure of
the brain and it’s supporting
structure which manifests different
sign and symptoms of neurological,
physiologic and psychologic
alterations. Mental disorders
manifesting symptoms of psychoses
without any evident organic or
structural damage are termed as
INORGANIC PSYCHOSES while
alteration in the organ structures
that causes symptoms of bizaare
pyschotic behavior is termed as
ORGANIC PSYCHOSES.
17. It is the science of organism as
affected by factors in their
environment. It deals with the
relationship between disease and
geographical environment.
A. Epidemiology
B. Ecology
C. Statistics
D. Geography
Answer: B. Ecology. Ecology is the
science that deals with the
ECOSYSTEM and its effects on living
things in the biosphere. It deals with
diseases in relationship with the
environment. Epidimiology is simply
the Study of diseases and its
occurence and distribution in man
for the purpose of controlling and
preventing diseases. This was asked
during the previous boards.
18. This is the study of the patterns
of health and disease. Its occurrence
and distribution in man, for the
purpose of control and prevention of
disease.
A. Epidemiology
B. Ecology
C. Statistics
D. Geography
Answer: A. Epidemiology. Refer to
number 17.
19. Refers to diseases that produced
no anatomic changes but as a result
from abnormal response to a stimuli.
A. Functional
B. Occupational
C. Inorganic
D. Organic
Answer: C. Inorganic. Refer to
number 16.
20. In what level of prevention
according to Leavell and Clark does
the nurse support the client in
obtaining OPTIMAL HEALTH STATUS
after a disease or injury?
A. Primary
B. Secondary
C. Tertiary
D. None of the above
Answer: C. Tertiary. Perhaps one of
the easiest concept but asked
frequently in the NLE. Primary refers
to preventions that aims in
preventing the disease. Examples
are healthy lifestyle, good nutrition,
knowledge seeking behaviors etc.
Secondary prevention are those
that deals with early diagnostics,
case finding and treatments.
Examples are monthly breast self
exam, Chest X-RAY, Antibiotic
treatment to cure infection, Iron
therapy to treat anemia etc. Tertiary
prevention aims on maintaining
optimum level of functioning during
or after the impact of a disease that
threatens to alter the normal body
functioning. Examples are
prosthetis fitting for an amputated
leg after an accident, Self
monitoring of glucose among
diabetics, TPA Therapy after stroke
etc. The confusing part is between
the treatment in secondary and
treatment in tertiary. To best
differentiate the two, A client with
ANEMIA that is being treated with
ferrous sulfate is considered being
in the SECONDARY PREVENTION
because ANEMIA once treated, will
move the client on PRE ILLNESS
STATE again. However, In cases of
ASPIRING Therapy in cases of
stroke, ASPIRING no longer cure the
patient or PUT HIM IN THE PRE
ILLNESS STATE. ASA therapy is done
in order to prevent coagulation of
the blood that can lead to thrombus
formation and a another possible
stroke. You might wonder why I
spelled ASPIRIN as ASPIRING, Its
side effect is OTOTOXICITY [ CN
VIII ] that leads to TINNITUS or
ringing of the ears.
21. In what level of prevention does
the nurse encourage optimal health
and increases person’s susceptibility
to illness?
A. Primary
B. Secondary
C. Tertiary
D. None of the above
Answer: D. None of the above. The
nurse never increases the person’s
susceptibility to illness but rather,
LESSEN the person’s susceptibility
to illness.
22. Also known as HEALTH
MAINTENANCE prevention.
A. Primary
B. Secondary
C. Tertiary
D. None of the above
Answer: B. Secondary. Secondary
prevention is also known as HEALTH
MAINTENANCE Prevention. Here,
The person feels signs and
symptoms and seeks Diagnosis and
treatment in order to prevent
deblitating complications. Even if
the person feels healthy, We are
required to MAINTAIN our health by
monthly check ups, Physical
examinations, Diagnostics etc.
23. PPD In occupational health
nursing is what type of prevention?
A. Primary
B. Secondary
C. Tertiary
D. None of the above
Answer: A. Primary. PPD or
PERSONAL PROTECTIVE DEVICES
are worn by the workes in a
hazardous environment to protect
them from injuries and hazards.
This is considered as a PRIMARY
prevention because the nurse
prevents occurence of diseases and
injuries.
24. BCG in community health
nursing is what type of prevention?
A. Primary
B. Secondary
C. Tertiary
D. None of the above
Answer: primary
25. A regular pap smear for woman
every 3 years after establishing
normal pap smear for 3 consecutive
years Is advocated. What level of
prevention does this belongs?
A. Primary
B. Secondary
C. Tertiary
D. None of the above
Answer: secondary
26. Self monitoring of blood glucose
for diabetic clients is on what level
of prevention?
A. Primary
B. Secondary
C. Tertiary
D. None of the above
Answer: tertiary
27. Which is the best way to
disseminate information to the
public?
A. Newspaper
B. School bulletins
C. Community bill boards
D. Radio and Television
Answer: D. Radio and Television. An
actual board question, The best way
to disseminate information to the
public is by TELEVISION followed by
RADIO. This is how the DOH
establish its IEC Programs other
than publising posters, leaflets and
brochures. An emerging new way to
disseminate is through the internet.
28. Who conceptualized health as
integration of parts and subparts of
an individual?
A. Newman
B. Neuman
C. Watson
D. Rogers
Answer: B. Neuman. The supra and
subsystems are theories of Martha
Rogers but the parts and subparts
are Betty Neuman’s. She stated
that HEALTH is a state where in all
parts and subparts of an individual
are in harmony with the whole
system. Margarex Newman defined
health as an EXPANDING
CONSCIOUSNESS. Her name is
Margaret not Margarex, I just used
that to help you remember her
theory of health.
29. The following are concept of
health:
1. Health is a state of complete
physical, mental and social
wellbeing and not merely an
absence of disease or infirmity.
2. Health is the ability to maintain
balance
3. Health is the ability to maintain
internal milieu
4. Health is integration of all parts
and subparts of an individual
A. 1,2,3
B. 1,3,4 33. Also known as STERILE
C. 2,3,4 TECHNIQUE
D. 1,2,3,4
A. Surgical Asepsis
Answer: D. 1,2,3,4. All of the B. Medical Asepsis
following are correct statement C. Sepsis
about health. The first one is the D. Asepsis
definition by WHO, The second one
is from Walter Cannon’s Answer: A. Surgical
homeostasis theory. Third one is Asepsis. Surgical Asepsis is also
from Claude Bernard’s concept of known as STERILE TECHNIQUE while
Health as Internal Milieu and the Medical Asepsis is synonymous with
last one is Neuman’s Theory. CLEAN TECHNIQUE.

30. The theorist the advocated that 34. This is a person or animal, who is
health is the ability to maintain without signs of illness but harbors
dynamic equilibrium is pathogen within his body and can be
transferred to another
A. Bernard
B. Selye A. Host
C. Cannon B. Agent
D. Rogers C. Environment
D. Carrier
Answer: C. Cannon. Walter Cannon
advocated health as HOMEOSTASIS Answer: carrier
or the ability to maintain dynamic
equilibrium. Hans Selye postulated 35. Refers to a person or animal,
Concepts about Stress and known or believed to have been
Adaptation. Bernard defined health exposed to a disease.
as the ability to maintain internal
milieu and Rogers defined Health as A. Carrier
Wellness that is influenced by B. Contact
individual’s culture. C. Agent
D. Host
31. Excessive alcohol intake is what
type of risk factor? Answer: contact

A. Genetics 36. A substance usually intended for

B. Age use on inanimate objects, that
C. Environment destroys pathogens but not the
D. Lifestyle spores.

Answer: lifestyle A. Sterilization

B. Disinfectant
32. Osteoporosis and degenerative C. Antiseptic
diseases like Osteoarthritis belongs D. Autoclave
to what type of risk factor?
Answer: B.
A. Genetics Disinfectant. Disinfectants are used
B. Age on inanimate objects while
C. Environment Antiseptics are intended for use on
D. Lifestyle persons and other living things.
Both can kill and inhibit growth of
Answer: age microorganism but cannot kill their
spores. That is when autoclaving or
steam under pressure gets in,
Autoclaving can kill almost ALL type
of microoganism including their
spores.
37. This is a process of removing
pathogens but not their spores
A. Sterilization
B. Auto claving
C. Disinfection
D. Medical asepsis
Answer: C. Disinfection. Both A and
B are capable on killing spores.
Autoclaving is a form of
Sterilization. Medical Asepsis is a
PRACTICE designed to minimize or
reduce the transfer of pathogens,
also known as your CLEAN
TECHNIQUE. Disinfection is the
PROCESS of removing pathogens
but not their spores.
38. The third period of infectious
processes characterized by
development of specific signs and
symptoms
A. Incubation period
B. Prodromal period
C. Illness period
D. Convalescent period
Answer: C. Illness period. In
incubation period, The disease has
been introduced to the body but no
sign and symptom appear because
the pathogen is not yet strong
enough to cause it and may still
need to multiply. The second period
is called prodromal period. This is
when the appearance of non
specific signs and symptoms sets
in, This is when the sign and
symptoms starts to appear. Illness
period is characterized by the
appearance of specific signs and
symptoms or refer tp as time with
the greatest symptom experience.
Acme is the PEAK of illness intensity
while the convalescent period is
characterized by the abatement of
the disease process or it’s gradual
disappearance.
39. A child with measles developed
fever and general weakness after
being exposed to another child with
rubella. In what stage of infectious
process does this child belongs?
A. Incubation period
B. Prodromal period
C. Illness period
D. Convalescent period
Answer: B. Prodromal period. To be
able to categorize MEASLES in the
Illness period, the specific signs of
Fever, Koplik’s Spot and Rashes
must appear. In the situation above,
Only general signs and symptoms
appeared and the Specific signs and
symptoms is yet to appear,
therefore, the illness is still in the
Prodromal period. Signs and
symptoms of measles during the
prodromal phase are Fever, fatigue,
runny nose, cough and
conjunctivitis. Koplik’s spot heralds
the Illness period and cough is the
last symptom to disappear. All of
this processes take place in 10 days
that is why, Measles is also known
as 10 day measles.
40. A 50 year old mailman carried a
mail with anthrax powder in it. A
minute after exposure, he still hasn’t
developed any signs and symptoms
of anthrax. In what stage of
infectious process does this man
belongs?
A. Incubation period
B. Prodromal period
C. Illness period
D. Convalescent period
Answer: A. Incubation
period. Anthrax can have an
incubation period of hours to 7 days
with an average of 48 hours. Since
the question stated exposure, we
can now assume that the mailman
is in the incubation period.
41. Considered as the WEAKEST
LINK in the chain of infection that
nurses can manipulate to prevent
spread of infection and diseases
A. Etiologic/Infectious agent
B. Portal of Entry
C. Susceptible host
D. Mode of transmission
Answer: D. Mode of
transmission. Mode of transmission
is the weakest link in the chain of
infection. It is easily manipulated by
the Nurses using the tiers of
prevention, either by instituting
transmission based precautions,
Universal precaution or Isolation
techniques.
42. Which of the following is the
exact order of the infection chain?
1. Susceptible host
2. Portal of entry
3. Portal of exit
4. Etiologic agent
5. Reservoir
6. Mode of transmission
A. 1,2,3,4,5,6
B. 5,4,2,3,6,1
C. 4,5,3,6,2,1
D. 6,5,4,3,2,1
Answer: C. 4,5,3,6,2,1. Chain of
infection starts with the SOURCE :
The etiologic agent itself. It will first
proliferate on a RESERVOIR and will
need a PORTAL OF EXIT to be able
to TRANSMIT irslef using a PORTAL
OF ENTRY to a SUSCEPTIBLE HOST.
A simple way to understand the
process is by looking at the lives of
a young queen ant that is starting
to build her colony. Imagine the
QUEEN ANT as a SOURCE or the
ETIOLOGIC AGENT. She first need to
build a COLONY, OR the RESERVOIR
where she will start to lay the first
eggs to be able to produce her
worker ants and soldier ants to be
able to defend and sustain the new
colony. They need to EXIT [PORTAL
OF EXIT] their colony and crawl
[MODE OF TRANSMISSION] in search
of foods by ENTERING / INVADING
[PORTAL OF ENTRY] our HOUSE
[SUSCEPTIBLE HOST]. By imagining
the Ant’s life cycle, we can easily
arrange the chain of infection.
43. Markee, A 15 year old high
school student asked you. What is
the mode of transmission of Lyme
disease. You correctly answered him
that Lyme disease is transmitted via
A. Direct contact transmission
B. Vehicle borne transmission
C. Air borne transmission
D. Vector borne transmission
Answer: D. Vector borne
transmission. Lyme disease is
caused by Borrelia Burdorferi and is
transmitted by a TICK BITE.
44. The ability of the infectious
agent to cause a disease primarily
depends on all of the following
except
A. Pathogenicity
B. Virulence
C. Invasiveness
D. Non Specificity
Answer: D. Non Specificity. To be
able to cause a disease, A pathogen
should have a TARGET ORGAN/S.
The pathogen should be specific to
these organs to cause an infection.
Mycobacterium Avium is NON
SPECIFIC to human organs and
therefore, not infective to humans
but deadly to birds. An
immunocompromised individual,
specially AIDS Patient, could be
infected with these NON SPECIFIC
diseases due to impaired immune
system.
45. Contact transmission of
infectious organism in the hospital is
usually cause by
A. Urinary catheterization
B. Spread from patient to patient
C. Spread by cross
contamination via hands of
caregiver
D. Cause by unclean instruments
used by doctors and nurses
Answer: C. Spread by cross
contamination via hands of
caregiver. The hands of the
caregiver like nurses, is the main
cause of cross contamination in
hospital setting. That is why
HANDWASHING is the single most
important procedure to prevent the
occurence of cross contamination
and nosocomial infection. D refers
to Nosocomial infection and UTI is
the most common noscomial
infection in the hospital caused by
urinary catheterization. E.Coli
seems to be the major cause of this
incident. B best fits Cross
Contamination, It is the spread of
microogranisms from patient o
patient.
46. Transmission occurs when an
infected person sneezes, coughs or
laugh that is usually projected at a
distance of 3 feet.
A. Droplet transmission
B. Airborne transmission
C. Vehicle transmission
D. Vector borne transmission
Answer: Droplet transmission
47. Considered as the first line of
defense of the body against
infection
A. Skin
B. WBC
C. Leukocytes
D. Immunization
Answer: A. Skin. Remember that
intact skin and mucus membrane is
our first line of defense against
infection.
48. All of the following contributes to
host susceptibility except
A. Creed
B. Immunization
C. Current medication being taken
D. Color of the skin
Answer: A. Creed. Creed, Faith or
religious belief do not affect
person’s susceptibility to illness.
Medication like corticosteroids could
supress a person’s immune system
that will lead to increase
susceptibility. Color of the skin could
affect person’s susceptibility to
certain skin diseases. A dark
skinned person has lower risk of
skin cancer than a fair skinned
person. Fair skinned person also has
a higher risk for cholecystitis and
cholelithiasis.
49. Graciel has been injected TT5,
her last dosed for tetanus toxoid
immunization. Graciel asked you,
what type of immunity is TT
Injections? You correctly answer her
by saying Tetanus toxoid
immunization is a/an
A. Natural active immunity
B. Natural passive immunity
C. Artificial active immunity
D. Artificial passive immunity
Answer: C. Artificial active
immunity. TT1 ti TT2 are considered
the primary dose, while TT3 to TT5
are the booster dose. A woman with
completed immunization of DPT
need not receive TT1 and TT2.
Tetanus toxoid is the actual toxin
produce by clostridium tetani but on
its WEAK and INACTIVATED form. It
is Artificial because it did not occur
in the course of actual illness or
infection, it is Active because what
has been passed is an actual toxin
and not a ready made
immunoglobulin.
50. Agatha, was hacked and slashed
by a psychotic man while she was
crossing the railway. She suffered
multiple injuries and was injected
Tetanus toxoid Immunoglobulin.
Agatha asked you, What immunity
does TTIg provides? You best
answered her by saying TTIg
provides
A. Natural active immunity
B. Natural passive immunity
C. Artificial active immunity
D. Artificial passive immunity
Answer: D. Artificial passive
immunity. In this scenario, Agatha
was already wounded and has
injuries. Giving the toxin [TT
Vaccine] itself would not help
Agatha because it will take time
before the immune system produce
antitoxin. What agatha needs now is
a ready made anti toxin in the form
of ATS or TTIg. This is artificial,
because the body of agatha did not
produce it. It is passive because her
immune system is not stimulated
but rather, a ready made Immune
globulin is given to immediately
supress the invasion.
51. This is the single most important
procedure that prevents cross
contamination and infection
A. Cleaning
B. Disinfecting
C. Sterilizing
D. Handwashing
Answer: D. Handwashing. When you
see the word HANDWASHING as one
of the options, 90% Chance it is the
correct answer in the local board. Or
should I say, 100% because I have
yet to see question from 1988 to
2005 board questions that has
option HANDWASHING on it but is
not the correct answer.
52. This is considered as the most
important aspect of handwashing
A. Time
B. Friction
C. Water
D. Soap
Answer: B. Friction. The most
important aspect of handwashing is
FRICTION. The rest, will just enhance
friction. The use of soap lowers the
surface tension thereby increasing
the effectiveness of friction. Water
helps remove transient bacteria by
working with soap to create the
lather that reduces surface tension.
Time is of essence but friction is the
most essential aspect of
handwashing
53. In handwashing by medical
asepsis, Hands are held ….
A. Above the elbow, The hands
must always be above the waist
B. Above the elbow, The hands are
cleaner than the elbow
C. Below the elbow, Medical asepsis
do not require hands to be above
the waist
D. Below the elbow, Hands are
dirtier than the lower arms
Answer: D. Below the elbow, Hands
are dirtier than the lower
arms. Hands are held BELOW the
elbow in medical asepsis in contrast
with surgical asepsis, wherein,
nurses are required to keep the
hands above the waist. The
rationale is because in medical
asepsis, Hands are considered
dirtier than the elbow and therefore,
to limit contamination of the lower
arm, The hands should always be
below the elbow.
54. The suggested time per hand on
handwashing using the time method
is
A. 5 to 10 seconds each hand
B. 10 to 15 seconds each hand
C. 15 to 30 seconds each hand
D. 30 to 60 seconds each hand
Answer: C. 15 to 30 seconds each
hand. Each hands requires atleast
15 to 30 seconds of handwashing to
effectively remove transient
microorganisms.
55. The minimum time in washing
each hand should never be below
A. 5 seconds
B. 10 seconds
C. 15 seconds
D. 30 seconds
Answer:B. 10 seconds. According to
Kozier, The minimum time required
for watching each hands is 10
seconds and should not be lower
than that. The recommended time,
again, is 15 to 30 seconds.
56. How many ml of liquid soap is
recommended for handwashing
procedure?
A. 1-2 ml
B. 2-3 ml
C. 2-4 ml
D. 5-10 ml
Answer: C. 2-4 ml. If a liquid soap is
to be used, 1 tsp [ 5ml ] of liquid
soap is recommended for
handwashing procedure.
57. Which of the following is not true
about sterilization, cleaning and
disinfection?
A. Equipment with small lumen
are easier to clean
B. Sterilization is the complete
destruction of all viable
microorganism including spores
C. Some organism are easily
destroyed, while other, with
coagulated protein requires
longer time
D. The number of organism is
directly proportional to the length
of time required for sterilization
Answer: A. Equipment with small
lumen are easier to
clean. Equipments with LARGE
LUMEN are easier to clean than
those with small lumen. B C and D
are all correct.
58. Karlita asked you, How long
should she boil her glass baby bottle
in water? You correctly answered her
by saying
A. The minimum time for boiling
articles is 5 minutes
B. Boil the glass baby bottler and
other articles for atleast 10
minutes
C. For boiling to be effective, a
minimum of 15 minutes is
required
D. It doesn’t matter how long you
boil the articles, as long as the
water reached 100 degree
Celsius
Answer: C. For boiling to be
effective, a minimum of 15 minutes
is required. Boiling is the most
common and least expensive
method of sterilization used in
home. For it to be effective, you
should boil articles for atleast 15
minutes.
59. This type of disinfection is best
done in sterilizing drugs, foods and
other things that are required to be
sterilized before taken in by the
human body
A. Boiling Water
B. Gas sterilization
C. Steam under pressure
D. Radiation
Answer: D. Radiation. Imagine foods
and drugs that are being sterilized
by a boiling water, ethylene oxide
gas and autoclave or steam under
pressure, They will be inactivated
by these methods. Ethylene oxide
gas used in gas sterlization is TOXIC
to humans. Boiling the food will
alter its consistency and nutrients.
Autoclaving the food is never
performed. Radiation using
microwave oven or Ionizing
radiation penetrates to foods and
drugs thus, sterilizing them.
60. A TB patient was discharged in
the hospital. A UV Lamp was placed
in the room where he stayed for a
week. What type of disinfection is
this?
A. Concurrent disinfection
B. Terminal disinfection
C. Regular disinfection
D. Routine disinfection
Answer: B. Terminal
disinfection. Terminal disinfection
refers to practices to remove
pathogens that stayed in the
belongings or immediate
environemnt of an infected client
who has been discharged. An
example would be Killing airborne
TB Bacilli using UV Light.
Concurrent disinfection refers to
ongoing efforts implented during
the client’s stay to remove or limit
pathogens in his supplies,
belongings, immediate environment
in order to control the spread of the
disease. An example is cleaning the
bedside commode of a client with
radium implant on her cervix with a
bleach disinfectant after each
voiding.
61. Which of the following is not true
in implementing medical asepsis
A. Wash hand before and after
patient contact
B. Keep soiled linens from touching
the clothings
C. Shake the linens to remove
dust
D. Practice good hygiene
Answer: C. Shake the linens to
remove dust. NEVER shake the
linens. Once soiled, fold it inwards
clean surface out. Shaking the linen
will further spread pathogens that
has been harbored by the fabric.
62. Which of the following is true
about autoclaving or steam under
pressure?
A. All kinds of microorganism and
their spores are destroyed by
autoclave machine
B. The autoclaved instruments can
be used for 1 month considering
the bags are still intact
C. The instruments are put into
unlocked position, on their
hinge, during the autoclave
D. Autoclaving different kinds of
metals at one time is advisable
Answer: C. The instruments are put
into unlocked position, on their
hinge, during the autoclave. Only C
is correct. Metals with locks, like
clamps and scissors should be
UNLOCKED in order to minimize
stiffening caused by autoclave to
the hinges of these metals. NOT ALL
microorganism are destroyed by
autoclaving. There are recently
discovered microorganism that is
invulnarable to extreme heat.
Autoclaved instruments are to be
used within 2 weeks. Only the same
type of metals should be autoclaved
as this will alteration in plating of
these metals.
63. Which of the following is true
about masks?
A. Mask should only cover the nose
B. Mask functions better if they are
wet with alcohol
C. Masks can provide durable
protection even when worn for a
long time and after each and
every patient care
D. N95 Mask or particulate
masks can filter organism as
mall as 1 micromillimeter
Answer: D. N95 Mask or particulate
masks can filter organism as mall as
1 micromillimeter. Mask should
cover both nose and mouth. Masks
will not function optimally when
wet. Masks should be worn not
greater than 4 hours, as it will lose
effectiveness after 4 hours. N95
mask or particulate mask can filter
organism as small as 1
micromillimeter.
64. Where should you put a wet
adult diaper?
A. Green trashcan
B. Black trashcan
C. Orange trashcan
D. Yellow trashcan
Answer: D. Yellow
trashcan. Infectious waste like blood
and blood products, wet diapers
and dressings are thrown in yellow
trashcans.
65. Needles, scalpels, broken glass
and lancets are considered as
injurious wastes. As a nurse, it is
correct to put them at disposal via
a/an
A. Puncture proof container
B. Reused PET Bottles
C. Black trashcan
D. Yellow trashcan with a tag
“INJURIOUS WASTES”
Answer: A. Puncture proof
container. Needles, scalpels and
other sharps are to be disposed in a
puncture proof container.
66. Miranda Priestly, An executive of
RAMP magazine, was diagnosed with
cancer of the cervix. You noticed
that the radioactive internal implant
protrudes to her vagina where
supposedly, it should be in her
cervix. What should be your initial
action?
A. Using a long forceps, Push it back
towards the cervix then call the
physician
B. Wear gloves, remove it gently
and place it on a lead container
C. Using a long forceps, Remove
it and place it on a lead
container
D. Call the physician, You are not
allowed to touch, re insert or
remove it
Answer: C. Using a long forceps,
Remove it and place it on a lead
container. A dislodged radioactive
cervical implant in brachytherapy
are to be picked by a LONG FORCEP
and stored in a LEAD CONTAINER in
order to prevent damage on the
client’s normal tissue. Calling the
physician is the second most
appropriate action among the
choices. A nurse should never
attempt to put it back nor, touch it
with her bare hands.
67. After leech therapy, Where
should you put the leeches?
A. In specially marked BIO
HAZARD Containers
B. Yellow trashcan
C. Black trashcan
D. Leeches are brought back to the
culture room, they are not thrown
away for they are reusable
Answer: A. In specially marked BIO
HAZARD Containers. Leeches, in
leech therapy or LEECH
PHLEBOTOMY are to be disposed on
a BIO HAZARD container. They are
never re used as this could cause
transfer of infection. These leeches
are hospital grown and not the
usual leeches found in swamps.
68. Which of the following should the
nurse AVOID doing in preventing
spread of infection?
A. Recapping the needle before
disposal to prevent injuries
B. Never pointing a needle towards
a body part
C. Using only Standard precaution
to AIDS Patients
D. Do not give fresh and uncooked
fruits and vegetables to Mr.
Gatchie, with Neutropenia
Answer: A. Recapping the needle
before disposal to prevent
injuries. Never recap needles. They
are directly disposed in a puncture
proof container after used.
Recapping the needles could cause
injury to the nurse and spread of
infection. B C and D are all
appropriate. Standard precaution is
sufficient for an HIV patient. A client
with neutropenia are not given fresh
and uncooked fruits and vegetables
for even the non infective
organisms found in these foods
could cause severe infection on an
immunocompromised patients.
69. Where should you put Mr. Alejar,
with Category II TB?
A. In a room with positive air
pressure and atleast 3 air
exchanges an hour
B. In a room with positive air
pressure and atleast 6 air
exchanges an hour
C. In a room with negative air
pressure and atleast 3 air
exchanges an hour
D. In a room with negative air
pressure and atleast 6 air
exchanges an hour
Answer: D. In a room with negative
air pressure and atleast 6 air
exchanges an hour. TB patients
should have a private room with
negative air pressure and atleast 6
to 12 air exhanges per hour.
Negative pressure room will prevent
air inside the room from escaping.
Air exchanges are necessary since
the client’s room do not allow air to
get out of the room.
70. A client has been diagnosed with
RUBELLA. What precaution is used
for this patient?
A. Standard precaution
B. Airborne precaution
C. Droplet precaution
D. Contact precaution
Answer: C. Droplet
precaution. Droplet precaution is
sufficient on client’s with RUBELLA
or german measles.
71. A client has been diagnosed with
MEASLES. What precaution is used
for this patient?
A. Standard precaution
B. Airborne precaution
C. Droplet precaution
D. Contact precaution
Answer: B. Airborne
precaution. Measles is highly
communicable and more contagious
than Rubella, It requires airborne
precaution as it is spread by small
particle droplets that remains
suspended in air and disperesed by
air movements.
72. A client has been diagnosed with
IMPETIGO. What precaution is used
for this patient?
A. Standard precaution
B. Airborne precaution
C. Droplet precaution
D. Contact precaution
Answer:D. Contact
precaution. Impetigo causes blisters
or sores in the skin. It is generally
caused by GABS or Staph Aureaus.
It is spread by skin to skin contact
or by scratching the lesions and
touching another person’s skin.
73. The nurse is to insert an NG Tube
when suddenly, she accidentally dip
the end of the tube in the client’s
glass containing distilled drinking
water which is definitely not sterile.
As a nurse, what should you do?
A. Don’t mind the incident,
continue to insert the NG
Tube
B. Obtain a new NG Tube for the
client
C. Disinfect the NG Tube before
reinserting it again
D. Ask your senior nurse what to do
Answer: A. Don’t mind the incident,
continue to insert the NG Tube. The
digestive tract is not sterile, and
therefore, simple errors like this
would not cause harm to the
patient. NGT tube need not be
sterile, and so is colostomy and
rectal tubes. Clean technique is
sufficient during NGT and colostomy
care.
74. All of the following are principle
of SURGICAL ASEPSIS except
A. Microorganism travels to moist
surfaces faster than with dry
surfaces
B. When in doubt about the sterility
of an object, consider it not
sterile
C. Once the skin has been
sterilized, considered it
sterile
D. If you can reach the object by
overreaching, just move around
the sterile field to pick it rather
than reaching for it
Answer: C. Once the skin has been
sterilized, considered it
sterile. Human skin is impossible to
be sterilized. It contains normal
flora of microorganism. A B and D
are all correct.
75. Which of the following is true in
SURGICAL ASEPSIS?
A. Autoclaved linens and gowns are
considered sterile for about 4
months as long as the bagging is
intact
B. Surgical technique is a sole effort
of each nurse
C. Sterile conscience, is the best
method to enhance sterile
technique
D. If a scrubbed person leaves the
area of the sterile field, He/she
must do handwashing and
gloving again, but the gown need
not be changed
Answer:C. Sterile conscience, is the
best method to enhance sterile
technique. Sterile conscience, or the
moral imperative of a nurse to be
honest in practicing sterile
technique, is the best method to
enhance sterile technique.
Autoclaved linens are considered
sterile only within 2 weeks even if
the bagging is intact. Surgical
technique is a team effort of each
nurse. If a scrubbed person leave
the sterile field and area, he must do
the process all over again.
76. In putting sterile gloves, Which
should be gloved first?
A. The dominant hand
B. The non dominant hand
C. The left hand
D. No specific order, Its up to the
nurse for her own convenience
Answer: B. The non dominant
hand. Gloves are put on the non
dominant hands first and then, the
dominant hand. The rationale is
simply because humans tend to use
the dominant hand first before the
non dominant hand. Out of 10
humans that will put on their sterile
gloves, 8 of them will put the gloves
on their non dominant hands first.
77. As the scrubbed nurse, when
should you apply the goggles, shoe
cap and mask prior to the operation?
A. Immediately after entering the
sterile field
B. After surgical hand scrub
C. Before surgical hand scrub
D. Before entering the sterile field
Answer: C. Before surgical hand
scrub. The nurse should put his
goggles, cap and mask prior to
washing the hands. If he wash his
hands prior to putting all these
equipments, he must wash his
hands again as these equipments
are said to be UNSTERILE.
78. Which of the following should the
nurse do when applying gloves prior
to a surgical procedure?
A. Slipping gloved hand with all
fingers when picking up the
second glove
B. Grasping the first glove by
inserting four fingers, with
thumbs up underneath the cuff
C. Putting the gloves into the
dominant hand first
D. Adjust only the fitting of the
gloves after both gloves are
on
Answer: D. Adjust only the fitting of
the gloves after both gloves are
on. The nurse should only adjust
fitting of the gloves when they are
both on the hands. Not doing so will
break the sterile technique. Only 4
gingers are slipped when picking up
the second gloves. You cannot slip
all of your fingers as the cuff is
limited and the thumb would not be
able to enter the cuff. The first
glove is grasp by simply picking it
up with the first 2 fingers and a
thumb in a pinching motion. Gloves
are put on the non dominant hands
first.
79. Which gloves should you remove
first?
A. The glove of the non
dominant hand
B. The glove of the dominant hand
C. The glove of the left hand
D. Order in removing the gloves Is
unnecessary
Answer: A. The glove of the non
dominant hand. Gloves are worn in
the non dominant hand first, and is
removed also from the non
dominant hand first. Rationale is
simply because in 10 people
removing gloves, 8 of them will use
the dominant hand first and remove
the gloves of the non dominant
hand.
80. Before a surgical procedure, Give
the sequence on applying the
protective items listed below
1. Eye wear or goggles
2. Cap
3. Mask
4. Gloves
5. Gown
A. 3,2,1,5,4
B. 3,2,1,4,5
C. 2,3,1,5,4
D. 2,3,1,4,5
Answer: D. 2,3,1,4,5. The nurse
should use CaMEy Hand and Body
Lotion in moisturizing his hand
before surgical procedure and after
handwashing. Ca stands for
CAP, Mstands for MASK, Ey stands
for eye goggles. The nurse will do
handwashing and then [HAND], Don
the gloves first and wear the Gown
[BODY]. I created this mnemonic
and I advise you use it because you
can never forget Camey hand and
body lotion. [ Yes, I know it is
spelled as CAMAY ]]
81. In removing protective devices,
which should be the exact
sequence?
1. Eye wear or goggles
2. Cap
3. Mask
4. Gloves
5. Gown
A. 4,3,5,1,2
B. 2,3,1,5,4
C. 5,4,3,2,1
D. 1,2,3,4,5’
Answer: A. 4,3,5,1,2. When the
nurse is about to remove his
protective devices, The nurse will
remove the GLOVES first followed
by the MASK and GOWN then, other
devices like cap, shoe cover, etc.
This is to prevent contamination of
hair, neck and face area.
82. In pouring a plain NSS into a
receptacle located in a sterile field,
how high should the nurse hold the
bottle above the receptacle?
A. 1 inch
B. 3 inches
C. 6 inches
D. 10 inches
Answer: C. 6 inches. Even if you do
not know the answer to this
question, you can answer it
correctly by imagining. If you pour
the NSS into a receptacle 1 to 3
inch above it, Chances are, The
mouth of the NSS bottle would dip
into the receptacle as you fill it,
making it contaminated. If you pour
the NSS bottle into a receptacle 10
inches above it, that is too high,
chances are, as you pour the NSS,
most will spill out because the force
will be too much for the buoyant
force to handle. It will also be
difficult to pour something precisely
into a receptacle as the height
increases between the receptacle
and the bottle. 6 inches is the
correct answer. It is not to low nor
too high.
83. The tip of the sterile forceps is
considered sterile. It is used to
manipulate the objects in the sterile
field using the non sterile hands.
How should the nurse hold a sterile
forceps?
A. The tip should always be
lower than the handle
B. The tip should always be above
the handle
C. The handle and the tip should be
at the same level
D. The handle should point
downward and the tip, always
upward
Answer: A. The tip should always be
lower than the handle. A sterile
forcep is usually dipped into a
disinfectant or germicidal solution.
Imagine, if the tip is HIGHER than
the handle, the solution will go into
the handle and into your hands and
as you use the forcep, you will
eventually lower its tip making the
solution in your hand go BACK into
the tip thus contaminating the
sterile area of the forcep. To prevent
this, the tip should always be lower
than the handle. In situation
questions like this, IMAGINATION is
very important.
84. The nurse enters the room of the
client on airborne precaution due to
tuberculosis. Which of the following
are appropriate actions by the
nurse?
1. She wears mask, covering the
nose and mouth
2. She washes her hands before
and after removing gloves, after
suctioning the client’s secretion
3. She removes gloves and hands
before leaving the client’s room
4. She discards contaminated
suction catheter tip in trashcan
found in the clients room
A. 1,2
B. 1,2,3
C. 1,2,3,4
D. 1,3
Answer: C. 1,2,3,4. All soiled
equipments use in an infectious
client are disposed INSIDE the
client’s room to prevent
contamination outside the client’s
room. The nurse is correct in using
Mask the covers both nose and
mouth. Hands are washed before
and after removing the gloves and
before and after you enter the
client’s room. Gloves and
contaminated suction tip are thrown
in trashcan found in the clients
room.
85. When performing surgical hand
scrub, which of the following nursing
action is required to prevent
contamination?
1. Keep fingernail short, clean and
with nail polish
2. Open faucet with knee or foot
control
3. Keep hands above the elbow
when washing and rinsing
4. Wear cap, mask, shoe cover after
you scrubbed
A. 1,2
B. 2,3
C. 1,2,3
D. 2,3,4
Answer: C. 1,2,3. Cap, mask and
shoe cover are worn BEFORE
scrubbing.
86. When removing gloves, which of
the following is an inappropriate
nursing action?
A. Wash gloved hand first
B. Peel off gloves inside out
C. Use glove to glove skin to skin
technique
D. Remove mask and gown
before removing gloves
Answer: D. Remove mask and gown
before removing gloves. Gloves are
the dirtiest protective item nurses
are wearing and therefore, the first
to be removed to prevent spread of
microorganism as you remove the
mask and gown.
87. Which of the following is TRUE in
the concept of stress?
A. Stress is not always present in
diseases and illnesses
B. Stress are only psychological and
manifests psychological
symptoms
C. All stressors evoke common
adaptive response
D. Hemostasis refers to the dynamic
state of equilibrium
Answer: C. All stressors evoke
common adaptive response. All
stressors evoke common adaptive
response. A psychologic fear like
nightmare and a real fear or real
perceive threat evokes common
manifestation like tachycardia,
tachypnea, sweating, increase
muscle tension etc. ALL diseases
and illness causes stress. Stress can
be both REAL or IMAGINARY.
Hemostasis refers to the ARREST of
blood flowing abnormally through a
damage vessel. Homeostasis is the
one that refers to dynamic state of
equilibrium according to Walter
Cannon.
88. According to this theorist, in his
modern stress theory, Stress is the
non specific response of the body to
any demand made upon it.
A. Hans Selye
B. Walter Cannon
C. Claude Bernard
D. Martha Rogers
answer: A. Hans Selye. Hans Selye
is the only theorist who proposed an
intriguing theory about stress that
has been widely used and accepted
by professionals today. He
conceptualized two types of human
response to stress, The GAS or
general adaptation syndrome which
is characterized by stages of
ALARM, RESISTANCE and
EXHAUSTION. The Local adaptation
syndrome controls stress through a
particular body part. Example is
when you have been wounded in
your finger, it will produce PAIN to
let you know that you should
protect that particular damaged
area, it will also produce
inflammation to limit and control
the spread of injury and facilitate
healing process. Another example is
when you are frequently lifting
heavy objects, eventually, you arm,
back and leg muscles hypertorphies
to adapt to the stress of heavy
lifting.
89. Which of the following is NOT
TRUE with regards to the concept of
Modern Stress Theory?
A. Stress is not a nervous energy
B. Man, whenever he
encounters stresses, always
adapts to it
C. Stress is not always something to
be avoided
D. Stress does not always lead to
distress
Answer: B. Man, whenever he
encounters stresses, always adapts
to it. Man, do not always adapt to
stress. Sometimes, stress can lead
to exhaustion and eventually,
death. A,C and D are all correct.
90. Which of the following is TRUE
with regards to the concept of
Modern Stress Theory?
A. Stress is essential
B. Man does not encounter stress if
he is asleep
C. A single stress can cause a
disease
D. Stress always leads to distress
Answer:A. Stress is essential. Stress
is ESSENTIAL. No man can live
normally without stress. It is
essential because it is evoked by
the body’s normal pattern of
response and leads to a favorable
adaptive mechanism that are
utilized in the future when more
stressors are encountered by the
body. Man can encounter stress
even while asleep, example is
nightmare. Disease are
multifactorial, No diseases are
caused by a single stressors. Stress
are sometimes favorable and are
not always a cause for distress. An
example of favorable stress is when
a carpenter meets the demand and
stress of everyday work. He then
develops calluses on the hand to
lessen the pressure of the hammer
against the tissues of his hand. He
also develop larger muscle and
more dense bones in the arm, thus,
a stress will lead to adaptations to
decrease that particular stress.
91. Which of the following is TRUE in
the stage of alarm of general
adaptation syndrome?
A. Results from the prolonged
exposure to stress
B. Levels or resistance is increased
C. Characterized by adaptation
D. Death can ensue
Answer: D. Death can ensue. Death
can ensue as early as the stage of
alarm. Exhaustion results to a
prolonged exposure to stress.
Resistance is when the levels of
resistance increases and
characterized by being able to
adapt.
92. The stage of GAS where the
adaptation mechanism begins
A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion
Answer: A. Stage of
Alarm. Adaptation mechanisms
begin in the stage of alarm. This is
when the adaptive mechanism are
mobilized. When someone shouts
SUNOG!!! your heart will begin to
beat faster, you vessels constricted
and bp increased.
93. Stage of GAS Characterized by
adaptation
A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion
Answer: Stage of Resistance
94. Stage of GAS wherein, the Level
of resistance are decreased
A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion
Answer: A. Stage of
Alarm. Resistance are decreased in
the stage of alarm. Resistance is
absent in the stage of exhaustion.
Resistance is increased in the stage
of resistance.
95. Where in stages of GAS does a
person moves back into
HOMEOSTASIS?
A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion
Answer: Stage of Resistance
96. Stage of GAS that results from
prolonged exposure to stress. Here,
death will ensue unless extra
adaptive mechanisms are utilized
A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion
Answer:Stage of Exhaustion
97. All but one is a characteristic of
adaptive response
A. This is an attempt to maintain
homeostasis
B. There is a totality of response
C. Adaptive response is
immediately mobilized,
doesn’t require time
D. Response varies from person to
person
Answer: C. Adaptive response is
immediately mobilized, doesn’t
require time. Aside from having
limits that leads to exhaustion.
Adaptive response requires time for
it to act. It requires energy, physical
and psychological taxes that needs
time for our body to mobilize and
utilize.
98. Andy, a newly hired nurse, starts
to learn the new technology and
electronic devices at the hospital.
Which of the following mode of
adaptation is Andy experiencing?
A. Biologic/Physiologic adaptive
mode
B. Psychologic adaptive mode
C. Sociocultural adaptive mode
D. Technological adaptive mode
Answer: Technological adaptive
mode
99. Andy is not yet fluent in French,
but he works in Quebec where
majority speaks French. He is
starting to learn the language of the
people. What type of adaptation is
Andy experiencing?
A. Biologic/Physiologic adaptive
mode
B. Psychologic adaptive mode
C. Sociocultural adaptive mode
D. Technological adaptive mode
Answer: C. Sociocultural adaptive
mode. Sociocultural adaptive
modes include language,
communication, dressing, acting
and socializing in line with the
social and cultural standard of the
people around the adapting
individual.
100. Andy made an error and his
senior nurse issued a written
warning. Andy arrived in his house
mad and kicked the door hard to
shut it off. What adaptation mode is
this?
A. Biologic/Physiologic adaptive
mode
B. Psychologic adaptive mode
C. Sociocultural adaptive mode
D. Technological adaptive mode
Answer: Psychologic adaptive mode
PNLE: FON Practice Exam for
Stress, Crisis, Crisis
Intervention, Communication,
Recording, Learning and
Documentation
1. The coronary vessels, unlike any
other blood vessels in the body,
respond to sympathetic stimulation
by
A. Vasoconstriction
B. Vasodilatation
C. Decreases force of contractility
D. Decreases cardiac output
Answer: Vasodilatation
2. What stress response can you
expect from a patient with blood
sugar of 50 mg / dl?
A. Body will try to decrease the
glucose level
B. There will be a halt in release of
sex hormones
C. Client will appear restless
D. Blood pressure will increase
Answer: Blood pressure will increase
3. All of the following are purpose of
inflammation except
A. Increase heat, thereby
produce abatement of
phagocytosis
B. Localized tissue injury by
increasing capillary permeability
C. Protect the issue from injury by
producing pain
D. Prepare for tissue repair
Answer: A. Increase heat, thereby
produce abatement of phagocytosis
4. The initial response of tissue after
injury is
A. Immediate Vasodilation
B. Transient Vasoconstriction
C. Immediate Vasoconstriction
D. Transient Vasodilation
Answer: C. Immediate
Vasoconstriction
5. The last expected process in the
stages of inflammation is
characterized by
A. There will be sudden redness of
the affected part
B. Heat will increase on the affected
part
C. The affected part will loss its
normal function
D. Exudates will flow from the
injured site
Answer: . The affected part will loss
its normal function
6. What kind of exudates is expected
when there is an antibody-antigen
reaction as a result of
microorganism infection?
A. Serous
B. Serosanguinous
C. Purulent
D. Sanguinous
Answer: Purulent
7. The first manifestation of
inflammation is
A. Redness on the affected area
B. Swelling of the affected area
C. Pain, which causes guarding of
the area
D. Increase heat due to transient
vasodilation
Answer: Redness on the affected
area
8. The client has a chronic tissue
injury. Upon examining the client’s
antibody for a particular cellular
response, Which of the following
WBC component is responsible for
phagocytosis in chronic tissue
injury?
A. Neutrophils
B. Basophils
C. Eosinophils
D. Monocytes
Answer: Monocytes
9. Which of the following WBC
component proliferates in cases of
Anaphylaxis?
A. Neutrophils
B. Basophils
C. Eosinophil
D. Monocytes
Answer: Eosinophil
10. Icheanne, ask you, her Nurse,
about WBC Components. She got an
injury yesterday after she twisted
her ankle accidentally at her
gymnastic class. She asked you,
which WBC Component is
responsible for proliferation at the
injured site immediately following an
injury. You answer:
A. Neutrophils
B. Basophils
C. Eosinophils
D. Monocytes
Answer: Neutrophils
11. Icheanne then asked you, what
is the first process that occurs in the
inflammatory response after injury,
You tell her:
A. Phagocytosis
B. Emigration
C. Pavementation
D. Chemotaxis
Answer: Pavementation
12. Icheanne asked you again, What
is that term that describes the
magnetic attraction of injured tissue
to bring phagocytes to the site of
injury?
A. Icheanne, you better sleep now,
you asked a lot of questions
B. It is Diapedesis
C. We call that Emigration
D. I don’t know the answer,
perhaps I can tell you after I
find it out later
Answer: D. I don’t know the answer,
perhaps I can tell you after I find it
out later
13. This type of healing occurs when
there is a delayed surgical closure of
infected wound
A. First intention
B. Second intention
C. Third intention
D. Fourth intention
Answer: Third intention
14. Type of healing when scars are
minimal due to careful surgical
incision and good healing
A. First intention
B. Second intention
C. Third intention
D. Fourth intention
Answer: First intention
15. Imelda, was slashed and hacked
by an unknown suspects. She
suffered massive tissue loss and
laceration on her arms and elbow in
an attempt to evade the criminal. As
a nurse, you know that the type of
healing that will most likely occur to
Miss Imelda is
A. First intention
B. Second intention
C. Third intention
D. Fourth intention
Answer: Second intention
16. Imelda is in the recovery stage
after the incident. As a nurse, you
know that the diet that will be
prescribed to Miss Imelda is
A. Low calorie, High protein with
Vitamin A and C rich foods
B. High protein, High calorie
with Vitamin A and C rich
foods
C. High calorie, Low protein with
Vitamin A and C rich foods
D. Low calorie, Low protein with
Vitamin A and C rich foods
B. High protein, High calorie with
Vitamin A and C rich foods
17. Miss Imelda asked you, What is
WET TO DRY Dressing method? Your
best response is
A. It is a type of mechanical
debridement using Wet
dressing that is applied and
left to dry to remove dead
tissues
B. It is a type of surgical
debridement with the use of Wet
dressing to remove the necrotic
tissues
C. It is a type of dressing where in,
The wound is covered with Wet
or Dry dressing to prevent
contamination
D. It is a type of dressing where in,
A cellophane or plastic is placed
on the wound over a wet
dressing to stimulate healing of
the wound in a wet medium
Answer: A. It is a type of mechanical
debridement using Wet dressing
that is applied and left to dry to
remove dead tissues
18. The primary cause of pain in
inflammation is
A. Release of pain mediators
B. Injury to the nerve endings
C. Compression of the local
nerve endings by the edema
fluids
D. Circulation is lessen, Supply of
oxygen is insufficient
Answer: C. Compression of the local
nerve endings by the edema fluids
19. The client is in stress because he
was told by the physician he needs
to undergo surgery for removal of
tumor in his bladder. Which of the
following are effects of sympatho-
adreno-medullary response by the
client?
1. Constipation
2. Urinary frequency
3. Hyperglycemia
4. Increased blood pressure
A. 3,4
B. 1,3,4
C. 1,2,4
D. 1,4
Answer: B. 1,3,4
20. The client is on NPO post
midnight. Which of the following, if
done by the client, is sufficient to
cancel the operation in the morning?
A. Eat a full meal at 10:00 P.M
B. Drink fluids at 11:50 P.M
C. Brush his teeth the morning
before operation
D. Smoke cigarette around 3:00
A.M
Answer: D. Smoke cigarette around
3:00 A.M
21. The client place on NPO for
preparation of the blood test.
Adreno-cortical response is activated
and which of the following below is
an expected response?
A. Low BP
B. Decrease Urine output
C. Warm, flushed, dry skin
D. Low serum sodium levels
Answer: Decrease Urine output
22. Which of the following is true
about therapeutic relationship?
A. Directed towards helping an
individual both physically and
emotionally
B. Bases on friendship and mutual
trust
C. Goals are set by the solely nurse
D. Maintained even after the client
doesn’t need anymore of the
Nurse’s help
Answer:A. Directed towards helping
an individual both physically and
emotionally
23. According to her, A nurse patient
relationship is composed of 4
stages : Orientation, Identification,
Exploitation and Resolution
A. Roy
B. Peplau
C. Rogers
D. Travelbee
Answer: Peplau
24. In what phase of Nurse patient
relationship does a nurse review the
client’s medical records thereby
learning as much as possible about
the client?
A. Pre Orientation
B. Orientation
C. Working
D. Termination
Answer: Pre Orientation
25. Nurse Aida has seen her patient,
Roger for the first time. She
establish a contract about the
frequency of meeting and introduce
to Roger the expected termination.
She started taking baseline
assessment and set interventions
and outcomes. On what phase of
NPR Does Nurse Aida and Roger
belong?
A. Pre Orientation
B. Orientation
C. Working
D. Termination
Answer: orientation
26. Roger has been seen agitated,
shouting and running. As Nurse Aida
approaches, he shouts and swear,
calling Aida names. Nurse Aida told
Roger “That is an unacceptable
behavior Roger, Stop and go to your
room now.” The situation is most
likely in what phase of NPR?
A. Pre Orientation
B. Orientation
C. Working
D. Termination
Answer: working
27. Nurse Aida, in spite of the
incident, still consider Roger as
worthwhile simply because he is a
human being. What major ingredient
of a therapeutic communication is
Nurse Aida using?
A. Empathy
B. Positive regard
C. Comfortable sense of self
D. Self awareness
Answer: Positive regard
28. Nurse Irma saw Roger and told
Nurse Aida “ Oh look at that
psychotic patient “ Nurse Aida
should intervene and correct Nurse
Irma because her statement shows
that she is lacking?
A. Empathy
B. Positive regard
C. Comfortable sense of self
D. Self awareness
Answer: Positive regard
29. Which of the following statement
is not true about stress?
A. It is a nervous energy
B. It is an essential aspect of
existence
C. It has been always a part of
human experience
D. It is something each person has
to cope
Answer: A. It is a nervous energy
30. Martina, a Tennis champ was
devastated after many new
competitors outpaced her in the
Wimbledon event. She became
depressed and always seen crying.
Martina is clearly on what kind of
situation?
A. Martina is just stressed out
B. Martina is Anxious
C. Martina is in the exhaustion
stage of GAS
D. Martina is in Crisis
Answer: D. Martina is in Crisis
31. Which of the following statement
is not true with regards to anxiety?
A. It has physiologic component
B. It has psychologic component
C. The source of dread or
uneasiness is from an
unrecognized entity
D. The source of dread or
uneasiness is from a
recognized entity
Answer: D. The source of dread or
uneasiness is from a recognized
entity
32. Lorraine, a 27 year old executive
was brought to the ER for an
unknown reason. She is starting to
speak but her speech is disorganized
and cannot be understood. On what
level of anxiety does this features
belongs?
A. Mild
B. Moderate
C. Severe
D. Panic
Answer: Panic
33. Elton, 21 year old nursing
student is taking the board
examination. She is sweating
profusely, has decreased awareness
of his environment and is purely
focused on the exam questions
characterized by his selective
attentiveness. What anxiety level is
Elton exemplifying?
A. Mild
B. Moderate
C. Severe
D. Panic
Answer: Moderate
34. You noticed the patient chart :
ANXIETY +3 What will you expect to
see in this client?
A. An optimal time for learning,
Hearing and perception is greatly
increased
B. Dilated pupils
C. Unable to communicate
D. Palliative Coping Mechanism
Answer: B. Dilated pupils
35. When should the nurse starts
giving XANAX?
A. When anxiety is +1
B. When the client starts to
have a narrow perceptual
field and selective
inattentiveness
C. When problem solving is not
possible
D. When the client is immobile and
disorganized
Answer: B. When the client starts to
have a narrow perceptual field and
selective inattentiveness
36. Which of the following behavior
is not a sign or a symptom of
Anxiety?
A. Frequent hand movement
B. Somatization
C. The client asks a question
D. The client is acting out
Answer: C. The client asks a
question
37. Which of the following
intervention is inappropriate for
client’s with anxiety?
A. Offer choices
B. Provide a quiet and calm
environment
C. Provide detailed explanation on
each and every procedures and
equipments
D. Bring anxiety down to a
controllable level
Answer:Offer choices
38. Which of the following
statement, if made by the nurse, is
considered not therapeutic?
A. “How did you deal with your
anxiety before?”
B. “It must be awful to feel
anxious.”
C. “How does it feel to be anxious?”
D. “What makes you feel
anxious?”
Answer: D. “What makes you feel
anxious?”
39. Marissa Salva, Uses Benson’s
relaxation. How is it done?
A. Systematically tensing muscle
groups from top to bottom for 5
seconds, and then releasing
them
B. Concentrating on breathing
without tensing the muscle,
 Letting go and repeating a
word or sound after each
exhalation
C. Using a strong positive, feeling-
rich statement about a desired
change
D. Exercise combined with
meditation to foster relaxation
and mental alacrity
Answer: B. Concentrating on
breathing without tensing the
muscle, Letting go and repeating a
word or sound after each exhalation
40. What type of relaxation
technique does Lyza uses if a
machine is showing her pulse rate,
temperature and muscle tension
which she can visualize and assess?
A. Biofeedback
B. Massage
C. Autogenic training
D. Visualization and Imagery
Answer: biofeedback
41. This is also known as Self-
suggestion or Self-hypnosis
A. Biofeedback
B. Meditation
C. Autogenic training
D. Visualization and Imagery
Answer:Autogenic training
42. Which among these drugs is NOT
an anxiolytic?
A. Valium
B. Ativan
C. Milltown
D. Luvox
Answer: Luvox
43. Kenneth, 25 year old diagnosed
with HIV felt that he had not lived up
with God’s expectation. He fears
that in the course of his illness, God
will be punitive and not be
supportive. What kind of spiritual
crisis is Kenneth experiencing?
1. Spiritual Pain
2. Spiritual Anxiety
3. Spiritual Guilt
4. Spiritual Despair
A. 1,2
B. 2,3
C. 3,4
D. 1,4
Answer:
44. Grace, believes that her
relationship with God is broken. She
tried to go to church to ask
forgiveness everyday to remedy her
feelings. What kind of spiritual
distress is Grace experiencing?
A. Spiritual Pan
B. Spiritual Alienation
C. Spiritual Guilt
D. Spiritual Despair
45. Remedios felt “EMPTY” She felt
that she has already lost God’s favor
and love because of her sins. This is
a type of what spiritual crisis?
A. Spiritual Anger
B. Spiritual Loss
C. Spiritual Despair
D. Spiritual Anxiety
46. Budek is working with a
schizophrenic patient. He noticed
that the client is agitated, pacing
back and forth, restless and
experiencing Anxiety +3. Budek said
“You appear restless” What
therapeutic technique did Budek
used?
A. Offering general leads
B. Seeking clarification
C. Making observation
D. Encouraging description of
perception
47. Rommel told Budek “ I SEE DEAD
PEOPLE “ Budek responded “You see
dead people?” This Is an example of
therapeutic communication
technique?
A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification
48. Rommel told Budek, “Do you
think Im crazy?” Budek responded,
“Do you think your crazy?” Budek
uses what example of therapeutic
communication?
A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification
49. Myra, 21 year old nursing
student has difficulty sleeping. She
told Nurse Budek “I really think a lot
about my x boyfriend recently”
Budek told Myra “And that causes
you difficulty sleeping?” Which
therapeutic technique is used in this
situation?
A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification
50. Myra told Budek “I cannot sleep,
I stay away all night” Budek told her
“You have difficulty sleeping” This is
what type of therapeutic
communication technique?
A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification
51. Myra said “I saw my dead
grandmother here at my bedside a
while ago” Budek responded
“Really? That is hard to believe, How
do you feel about it?” What
technique did Budek used?
A. Disproving
B. Disagreeing
C. Voicing Doubt
D. Presenting Reality
52. Which of the following is a
therapeutic communication in
response to “I am a GOD, bow
before me Or ill summon the
dreaded thunder to burn you and
purge you to pieces!”
A. “You are not a GOD, you are
Professor Tadle and you are a PE
Teacher, not a Nurse. I am Glen,
Your nurse.”
B. “Oh hail GOD Tadle, everyone
bow or face his wrath!”
C. “Hello Mr. Tadle, You are here
in the hospital, I am your
nurse and you are a patient
here”
D. “How can you be a GOD Mr.
Tadle? Can you tell me more
about it?”
53. Erik John Senna, Told Nurse
Budek “ I don’t want to that, I don’t
want that thing.. that’s too painful!”
Which of the following response is
NON THERAPEUTIC
A. “ This must be difficult for you,
But I need to inject you this for
your own good”
B. “ You sound afraid”
C. “Are you telling me you don’t
want this injection?”
D. “Why are you so anxious?
Please tell me more about
your feelings Erik”
54. Legrande De Salvaje Y Cobrador
La Jueteng, was caught by the
bacolod police because of his illegal
activities. When he got home after
paying for the bail, He shouted at his
son. What defense mechanism did
Mr. La Jueteng used?
A. Restitution
B. Projection
C. Displacement
D. Undoing
55. Later that day, he bought his son
ice cream and food. What defense
mechanism is Legrande
unconsciously doing?
A. Restitution
B. Conversion
C. Redoing
D. Reaction formation
56. Crisis is a sudden event in ones
life that disturbs a person’s
homeostasis. Which of the following
is NOT TRUE in crisis?
A. The person experiences
heightened feeling of stress
B. Inability to function in the usual
organized manner
C. Lasts for 4 months
 D. Indicates unpleasant emotional
feelings
57. Which of the following is a
characteristic of crisis?
A. Lasts for an unlimited period of
time
B. There is a triggering event
C. Situation is not dangerous to the
person
D. Person totality is not involved
58. Levito Devin, The Italian prime
minister, is due to retire next week.
He feels depressed due to the
enormous loss of influence, power,
fame and fortune. What type of
crisis is Devin experiencing?
A. Situational
B. Maturational
C. Social
D. Phenomenal
59. Estrada, The Philippine
president, has been unexpectedly
impeached and was out of office
before the end of his term. He is in
what type of crisis?
A. Situational
B. Maturational
C. Social
D. Phenomenal
60. The tsunami in Thailand and
Indonesia took thousands of people
and change million lives. The people
affected by the Tsunami are
saddened and do not know how to
start all over again. What type of
crisis is this?
A. Situational
B. Maturational
C. Social
D. Phenomenal
61. Which of the following is the
BEST goal for crisis intervention?
A. Bring back the client in the pre
crisis state
B. Make sure that the client
becomes better
C. Achieve independence
D. Provide alternate coping
mechanism
62. What is the best intervention
when the client has just experienced
the crisis and still at the first phase
of the crisis?
A. Behavior therapy
B. Gestalt therapy
C. Cognitive therapy
D. Milieu Therapy
63. Therapeutic nurse client
relationship is describes as follows
1. Based on friendship and mutual
interest
2. It is a professional relationship
3. It is focused on helping the
patient solve problems and
achieve health-related goals
4. Maintained only as long as the
patient requires professional
helpA. 1,2,3
B. 1,2,4
C. 2,3,4
D. 1,3,4
64. The client is scheduled to have
surgical removal of the tumor on her
left breast. Which of the following
manifestation indicates that she is
experiencing Mild Anxiety?
A. She has increased awareness
of her environmental details
B. She focused on selected aspect
of her illness
C. She experiences incongruence of
action, thoughts and feelings
D. She experiences random motor
activities
65. Which of the following nursing
intervention would least likely be
effective when dealing with a client
with aggressive behavior?
A. Approach him in a calm manner
B. Provide opportunities to
express feelings
C. Maintain eye contact with the
client
D. Isolate the client from others
66. Whitney, a patient of nurse
Budek, verbalizes… “I have nothing,
nothing… nothing! Don’t make me
close one more door, I don’t wanna
hurt anymore!” Which of the
following is the most appropriate
response by Budek?
A. Why are you singing?
B. What makes you say that?
C. Ofcourse you are everything!
D. What is that you said?
67. Whitney verbalizes that she is
anxious that the diagnostic test
might reveal laryngeal cancer. Which
of the following is the most
appropriate nursing intervention?
A. Tell the client not to worry until
the results are in
B. Ask the client to express
feelings and concern
C. Reassure the client everything
will be alright
D. Advice the client to divert his
attention by watching television
and reading newspapers
68. Considered as the most accurate
expression of person’s thought and
feelings
A. Verbal communication
B. Non verbal communication
C. Written communication
D. Oral communication
69. Represents inner feeling that a
person do not like talking about.
A. Overt communication
B. Covert communication
C. Verbal communication
D. Non verbal communication
70. Which of the following is NOT a
characteristic of an effective Nurse-
Client relationship?
A. Focused on the patient
B. Based on mutual trust
C. Conveys acceptance
D. Discourages emotional bond
71. A type of record wherein , each
person or department makes
notation in separate records. A nurse
will use the nursing notes, The
doctor will use the Physician’s order
sheet etc. Data is arranged
according to information source.
A. POMR
B. POR
C. Traditional
D. Resource oriented
72. Type of recording that integrates
all data about the problem, gathered
by members of the health team.
A. POMR
B. Traditional
C. Resource oriented
D. Source oriented
73. These are data that are
monitored by using graphic charts or
graphs that indicated the
progression or fluctuation of client’s
Temperature and Blood pressure.
A. Progress notes
B. Kardex
C. Flow chart
D. Flow sheet
74. Provides a concise method of
organizing and recording data about
the client. It is a series of flip cards
kept in portable file used in change
of shift reports.
A. Kardex
B. Progress Notes
C. SOAPIE
D. Change of shift report
75. You are about to write an
information on the Kardex. There are
4 available writing instruments to
use. Which of the following should
you use?
A. Mongol #2
B. Permanent Ink
C. A felt or fountain pen
D. Pilot Pentel Pen marker
76. The client has an allergy to
Iodine based dye. Where should you
put this vital information in the
client’s chart?
A. In the first page of the client’s
chart
B. At the last page of the client’s
chart
C. At the front metal plate of
the chart
D. In the Kardex
77. Which of the following is NOT
TRUE about the Kardex
 A. It provides readily available
information
B. It is a tool of end of shift reports
C. The primary basis of
endorsement
D. Where Allergies information are
written
78. Which of the following, if seen on
the Nurses notes, violates
characteristic of good recording?
A. The client has a blood
pressure of 120/80,
Temperature of 36.6 C Pulse
rate of 120 and Respiratory
rate of 22
B. Ate 50% of food served
C. Refused administration of
betaxolol
D. Visited and seen By Dr. Santiago
79. The physician ordered : Mannerix
a.c , what does a.c means?
A. As desired
B. Before meals
C. After meals
D. Before bed time
80. The physician ordered, Maalox, 2
hours p.c, what does p.c means?
A. As desired
B. Before meals
C. After meals
D. Before bed time
81. The physician ordered, Maxitrol,
Od. What does Od means?
A. Left eye
B. Right eye
C. Both eye
D. Once a day
82. The physician orderd,
Magnesium Hydroxide cc Aluminum
Hydroxide. What does cc means?
A. without
B. with
C. one half
D. With one half dose
83. Physician ordered, Paracetamol
tablet ss. What does ss means?
A. without
B. with
C. one half
D. With one half dose
84. Which of the following indicates
that learning has been achieved?
A. Matuts starts exercising
every morning and eating a
balance diet after you taught
her mag HL tayo program
B. Donya Delilah has been able to
repeat the steps of insulin
administration after you taught it
to her
C. Marsha said “ I understand “
after you a health teaching about
family planning
D. John rated 100% on your given
quiz about smoking and
alcoholism
Answer: A. Matuts starts exercising
every morning and eating a balance
diet after you taught her mag HL
tayo program
85. In his theory of learning as a
BEHAVIORISM, he stated that
transfer of knowledge occurs if a
new situation closely resembles an
old one.
A. Bloom
B. Lewin
C. Thorndike
D. Skinner
86. Which of the following is TRUE
with regards to learning?
A. Start from complex to simple
B. Goals should be hard to achieve
so patient can strive to attain
unrealistic goals
C. Visual learning is the best for
every individual
D. Do not teach a client when he
is in pain
87. According to Bloom, there are 3
domains in learning. Which of these
domains is responsible for the ability
of Donya Delilah to inject insulin?
A. Cognitive
B. Affective
C. Psychomotor
D. Motivative
88. Which domains of learning is
responsible for making John and
Marsha understand the different
kinds of family planning methods?
A. Cognitive
B. Affective
C. Psychomotor
D. Motivative
89. Which of the following statement
clearly defines therapeutic
communication?
A. Therapeutic communication is an
interaction process which is
primarily directed by the nurse
B. It conveys feeling of warmth,
acceptance and empathy from
the nurse to a patient in relaxed
atmosphere
C. Therapeutic communication
is a reciprocal interaction
based on trust and aimed at
identifying patient needs and
developing mutual goals
D. Therapeutic communication is an
assessment component of the
nursing process
Answer:C. Therapeutic
communication is a reciprocal
interaction based on trust and
aimed at identifying patient needs
and developing mutual goals
90. Which of the following concept is
most important in establishing a
therapeutic nurse patient
relationship?
A. The nurse must fully understand
the patient’s feelings, perception
and reactions before goals can
be established
B. The nurse must be a role model
for health fostering behavior
C. The nurse must recognize that
the patient may manifest
maladaptive behavior after
illness
D. The nurse should understand
that patients might test her
before trust is established
91. Which of the following
communication skill is most effective
in dealing with covert
communication?
A. Validation
B. Listening
C. Evaluation
D. Clarification
92. Which of the following are
qualities of a good recording?
1. Brevity
2. Completeness and chronology
3. Appropriateness
4. Accuracy
A. 1,2
B. 3,4
C. 1,2,3
D. 1,2,3,4
93. All of the following chart entries
are correct except
A. V/S 36.8 C,80,16,120/80
B. Complained of chest pain
C. Seems agitated
D. Able to ambulate without
assistance
94. Which of the following teaching
method is effective in client who
needs to be educated about self
injection of insulin?
A. Detailed explanation
B. Demonstration
C. Use of pamphlets
D. Film showing
95. What is the most important
characteristic of a nurse patient
relationship?
A. It is growth facilitating
B. Based on mutual understanding
C. Fosters hope and confidence
D. Involves primarily emotional
bond
96. Which of the following nursing
intervention is needed before
teaching a client post spleenectomy
deep breathing and coughing
exercises?
A. Tell the patient that deep
breathing and coughing
exercises is needed to
promote good breathing,
 circulation and prevent PNLE: FON Practice Exam for
complication Nursing Process, Physical and
B. Tell the client that deep breathing
and coughing exercises is needed
Health Assessment and
to prevent Thrombophlebitis, Routine Procedures
hydrostatic pneumonia and 1. She is the first one to coin the
atelectasis term “NURSING PROCESS” She
C. Medicate client for pain introduced 3 steps of nursing
D. Tell client that cooperation is vital process which are Observation,
to improve recovery Ministration and Validation.
97. The client has an allergy with
penicillin. What is the best way to A. Nightingale
communicate this information? B. Johnson
C. Rogers
A. Place an allergy alert in the D. Hall
Kardex 2. The American Nurses association
B. Notify the attending formulated an innovation of the
physician Nursing process. Today, how many
C. Write it on the patient’s chart distinct steps are there in the
D. Take note when giving nursing process?
medications
98. An adult client is on extreme A. APIE – 4
pain. He is moaning and grimacing. B. ADPIE – 5
What is the best way to assess the C. ADOPIE – 6
client’s pain? D. ADOPIER – 7
3. They are the first one to suggest a
A. Perform physical assessment 4 step nursing process which are :
B. Have the client rate his pain on APIE , or assessment, planning,
the smiley pain rating scale implementation and evaluation.
C. Active listening on what the
patient says 1. Yura
D. Observe the client’s behavior 2. Walsh
99. Therapeutic communication 3. Roy
begins with? 4. Knowles
A. 1,2
A. Knowing your client B. 1,3
B. Knowing yourself C. 3,4
C. Showing empathy D. 2,3
D. Encoding 4. Which characteristic of nursing
100. The PCS gave new guidelines process is responsible for proper
including leaflets to educate cancer utilization of human resources, time
patients. As a nurse, When using and cost resources?
materials like this, what is your
responsibility? A. Organized and Systematic
B. Humanistic
A. Read it for the patient C. Efficient
B. Give it for the patient to read D. Effective
himself 5. Which characteristic of nursing
C. Let the family member read the process addresses the
material for the patient INDIVIDUALIZED care a client must
D. Read it yourself then, Have receive?
the client read the material
A. Organized and Systematic
B. Humanistic
C. Efficient
 D. Effective
6. A characteristic of the nursing
process that is essential to promote
client satisfaction and progress. The
care should also be relevant with the
client’s needs.
A. Organized and Systematic
B. Humanistic
C. Efficient
D. Effective
7. Rhina, who has Menieres disease,
said that her environment is moving.
Which of the following is a valid
assessment?
1. Rhina is giving an objective data
2. Rhina is giving a subjective data
3. The source of the data is primary
4. The source of the data is
secondary
A. 1,3
B. 2,3
C. 2.4
D. 1,4
8. Nurse Angela, observe Joel who is
very apprehensive over the
impending operation. The client is
experiencing dyspnea, diaphoresis
and asks lots of questions. Angela
made a diagnosis of ANXIETY R/T
INTRUSIVE PROCEDURE. This is what
type of Nursing Diagnosis?
A. Actual
B. Probable
C. Possible
D. Risk
9. Nurse Angela diagnosed Mrs.
Delgado, who have undergone a
BKA. Her diagnosis is SELF ESTEEM
DISTURBANCE R/T CHANGE IN BODY
IMAGE. Although the client has not
yet seen her lost leg, Angela already
anticipated the diagnosis. This is
what type of Diagnosis?
A. Actual
B. Probable
C. Possible
D. Risk
10. Nurse Angela is about to make a
diagnosis but very unsure because
the S/S the client is experiencing is
not specific with her diagnosis of
POWERLESSNESS R/T DIFFICULTY
ACCEPTING LOSS OF LOVED ONE.
She then focus on gathering data to
refute or prove her diagnosis but her
plans and interventions are already
ongoing for the diagnosis. Which
type of Diagnosis is this?
A. Actual
B. Probable
C. Possible
D. Risk
11. Nurse Angela knew that Stephen
Lee Mu Chin, has just undergone an
operation with an incision near the
diaphragm. She knew that this will
contribute to some complications
later on. She then should develop
what type of Nursing diagnosis?
A. Actual
B. Probable
C. Possible
D. Risk
12. Which of the following Nursing
diagnosis is INCORRECT?
A. Fluid volume deficit R/T Diarrhea
B. High risk for injury R/T
Absence of side rails
C. Possible ineffective coping R/T
Loss of loved one
D. Self esteem disturbance R/T
Effects of surgical removal of the
leg
13. Among the following statements,
which should be given the HIGHEST
priority?
A. Client is in extreme pain
B. Client’s blood pressure is 60/40
C. Client’s temperature is 40 deg.
Centigrade
D. Client is cyanotic
14. Which of the following need is
given a higher priority among
others?
A. The client has attempted suicide
and safety precaution is needed
B. The client has disturbance in his
body image because of the
recent operation
C. The client is depressed because
her boyfriend left her all alone
 D. The client is thirsty and
dehydrated
15. Which of the following is TRUE
with regards to Client Goals?
A. They are specific, measurable,
attainable and time bounded
B. They are general and broadly
stated
C. They should answer for WHO,
WHAT ACTIONS, WHAT
CIRCUMSTANCES, HOW WELL and
WHEN.
D. Example is : After discharge
planning, Client demonstrated
the proper psychomotor skills for
insulin injection.
16. Which of the following is a NOT a
correct statement of an Outcome
criteria?
A. Ambulates 30 feet with a cane
before discharge
B. Discusses fears and concerns
regarding the surgical procedure
C. Demonstrates proper coughing
and breathing technique after a
teaching session
D. Reestablishes a normal
pattern of elimination
17. Which of the following is a
OBJECTIVE data?
A. Dizziness
B. Chest pain
C. Anxiety
D. Blue nails
18. A patient’s chart is what type of
data source?
A. Primary
B. Secondary
C. Tertiary
D. Can be A and B
19. All of the following are
characteristic of the Nursing process
except
A. Dynamic
B. Cyclical
C. Universal
D. Intrapersonal
20. Which of the following is true
about the NURSING CARE PLAN?
A. It is nursing centered
B. Rationales are supported by
interventions
C. Verbal
D. Atleast 2 goals are needed for
every nursing diagnosis
21. A framework for health
assessment that evaluates the
effects of stressors to the mind,
body and environment in relation
with the ability of the client to
perform ADL.
A. Functional health framework
B. Head to toe framework
C. Body system framework
D. Cephalocaudal framework
22. Client has undergone Upper GI
and Lower GI series. Which type of
health assessment framework is
used in this situation?
A. Functional health framework
B. Head to toe framework
C. Body system framework
D. Cephalocaudal framework
23. Which of the following statement
is true regarding temperature?
A. Oral temperature is more
accurate than rectal temperature
B. The bulb used in Rectal
temperature reading is pear
shaped or round
C. The older the person, the higher
his BMR
D. When the client is swimming,
BMR Decreases
24. A type of heat loss that occurs
when the heat is dissipated by air
current
A. Convection
B. Conduction
C. Radiation
D. Evaporation
25. Which of the following is TRUE
about temperature?
A. The highest temperature
usually occurs later in a day,
around 8 P.M to 12 M.N
B. The lowest temperature is
usually in the Afternoon, Around
12 P.M
 C. Thyroxin decreases body
temperature
D. Elderly people are risk for
hyperthermia due to the absence
of fats, Decreased
thermoregulatory control and
sedentary lifestyle.
26. Hyperpyrexia is a condition in
which the temperature is greater
than
A. 40 degree Celsius
B. 39 degree Celsius
C. 100 degree Fahrenheit
D. 105.8 degree Fahrenheit
27. Tympanic temperature is taken
from John, A client who was brought
recently into the ER due to frequent
barking cough. The temperature
reads 37.9 Degrees Celsius. As a
nurse, you conclude that this
temperature is
A. High
B. Low
C. At the low end of the normal
range
D. At the high end of the normal
range
28. John has a fever of 38.5 Deg.
Celsius. It surges at around 40
Degrees and go back to 38.5
degrees 6 times today in a typical
pattern. What kind of fever is John
having?
A. Relapsing
B. Intermittent
C. Remittent
D. Constant
29. John has a fever of 39.5 degrees
2 days ago, But yesterday, he has a
normal temperature of 36.5 degrees.
Today, his temperature surges to 40
degrees. What type of fever is John
having?
A. Relapsing
B. Intermittent
C. Remittent
D. Constant
30. John’s temperature 10 hours ago
is a normal 36.5 degrees. 4 hours
ago, He has a fever with a
temperature of 38.9 Degrees. Right
now, his temperature is back to
normal. Which of the following best
describe the fever john is having?
A. Relapsing
B. Intermittent
C. Remittent
D. Constant
31. The characteristic fever in
Dengue Virus is characterized as:
A. Tricyclic
B. Bicyclic
C. Biphasic
D. Triphasic
32. When John has been given
paracetamol, his fever was brought
down dramatically from 40 degrees
Celsius to 36.7 degrees in a matter
of 10 minutes. The nurse would
assess this event as:
A. The goal of reducing john’s fever
has been met with full
satisfaction of the outcome
criteria
B. The desired goal has been
partially met
C. The goal is not completely met
D. The goal has been met but
not with the desired outcome
criteria
33. What can you expect from
Marianne, who is currently at the
ONSET stage of fever?
A. Hot, flushed skin
B. Increase thirst
C. Convulsion
D. Pale,cold skin
34. Marianne is now at the
Defervescence stage of the fever,
which of the following is expected?
A. Delirium
B. Goose flesh
C. Cyanotic nail beds
D. Sweating
35. Considered as the most
accessible and convenient method
for temperature taking
A. Oral
B. Rectal
C. Tympanic
 D. Axillary B. Males have higher pulse rate
36. Considered as Safest and most than females after puberty
non invasive method of temperature C. Digitalis has a positive
taking chronotropic effect
D. In lying position, Pulse rate is
A. Oral higher
B. Rectal 43. The following are correct actions
C. Tympanic when taking radial pulse except:
D. Axillary
37. Which of the following is NOT a A. Put the palms downward
contraindication in taking ORAL B. Use the thumb to palpate the
temperature? artery
C. Use two or three fingers to
A. Quadriplegic palpate the pulse at the inner
B. Presence of NGT wrist
C. Dyspnea D. Assess the pulse rate, rhythm,
D. Nausea and Vomitting volume and bilateral quality
38. Which of the following is a 44. The difference between the
contraindication in taking RECTAL systolic and diastolic pressure is
temperature? termed as

A. Unconscious A. Apical rate

B. Neutropenic B. Cardiac rate
C. NPO C. Pulse deficit
D. Very young children D. Pulse pressure
39. How long should the Rectal 45. Which of the following
Thermometer be inserted to the completely describes PULSUS
clients anus? PARADOXICUS?

A. 1 to 2 inches A. A greater-than-normal increase in

B. 5 to 1.5 inches
C. 3 to 5 inches
D. 2 to 3 inches
40. In cleaning the thermometer
after use, The direction of the
cleaning to follow Medical Asepsis
is :
A. From bulb to stem
B. From stem to bulb
C. From stem to stem
D. From bulb to bulb
41. How long should the
thermometer stay in the Client’s
Axilla?
A. 3 minutes
B. 4 minutes
C. 7 minutes
D. 10 minutes
42. Which of the following statement
is TRUE about pulse?
A. Young person have higher
pulse than older persons
systolic blood pressure with
inspiration
B. A greater-than-normal
decrease in systolic blood
pressure with inspiration
C. Pulse is paradoxically low when
client is in standing position and
high when supine.
D. Pulse is paradoxically high when
client is in standing position and
low when supine.
46. Which of the following is TRUE
about respiration?
A. I:E 2:1
B. I:E : 4:3
C. I:E 1:1
D. I:E 1:2
47. Contains the pneumotaxic and
the apneutic centers
A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies
48. Which of the following is
responsible for deep and prolonged
inspiration
A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies
49. Which of the following is
responsible for the rhythm and
quality of breathing?
A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies
50. The primary respiratory center
A. Medulla oblongata
B. Pons
C. Carotid bodies
D. Aortic bodies
51. Which of the following is TRUE
about the mechanism of action of
the Aortic and Carotid bodies?
A. If the BP is elevated, the RR
increases
B. If the BP is elevated, the RR
decreases
C. Elevated BP leads to Metabolic
alkalosis
D. Low BP leads to Metabolic
acidosis
52. All of the following factors
correctly influence respiration except
one. Which of the following is
incorrect?
A. Hydrocodone decreases RR
B. Stress increases RR
C. Increase temperature of the
environment, Increase RR
D. Increase altitude, Increase RR
53. When does the heart receives
blood from the coronary artery?
A. Systole
B. Diastole
C. When the valves opens
D. When the valves closes
54. Which of the following is more
life threatening?
A. BP = 180/100
B. BP = 160/120
C. BP = 90/60
D. BP = 80/50
55. Refers to the pressure when the
ventricles are at rest
A. Diastole
B. Systole
C. Preload
D. Pulse pressure
56. Which of the following is TRUE
about the blood pressure
determinants?
A. Hypervolemia lowers BP
B. Hypervolemia increases GFR
C. HCT of 70% might decrease or
increase BP
D. Epinephrine decreases BP
57. Which of the following do not
correctly correlates the increase BP
of Ms. Aida, a 70 year old diabetic?
A. Females, after the age 65
tends to have lower BP than
males
B. Disease process like Diabetes
increase BP
C. BP is highest in the morning, and
lowest during the night
D. Africans, have a greater risk of
hypertension than Caucasian and
Asians.
58. How many minutes are allowed
to pass if the client had engaged in
strenuous activities, smoked or
ingested caffeine before taking
his/her BP?
A. 5
B. 10
C. 15
D. 30
59. Too narrow cuff will cause what
change in the Client’s BP?
A. True high reading
B. True low reading
C. False high reading
D. False low reading
60. Which is a preferable arm for BP
taking?
A. An arm with the most
contraptions
 B. The left arm of the client with a
CVA affecting the right brain
C. The right arm
D. The left arm
61. Which of the following is
INCORRECT in assessing client’s BP?
A. Read the mercury at the
upper meniscus, preferably
at the eye level to prevent
error of parallax
B. Inflate and deflate slowly, 2-3
mmHg at a time
C. The sound heard during taking
BP is known as KOROTKOFF
sound
D. If the BP is taken on the left leg
using the popliteal artery
pressure, a BP of 160/80 is
normal.
62. Which of the following is the
correct interpretation of the ERROR
OF PARALLAX
A. If the eye level is higher than the
level of the meniscus, it will
cause a false high reading
B. If the eye level is higher than
the level of the meniscus, it
will cause a false low reading
C. If the eye level is lower than the
level of the meniscus, it will
cause a false low reading
D. If the eye level is equal to that of
the level of the upper meniscus,
the reading is accurate
63. How many minute/s is/are
allowed to pass before making a re-
reading after the first one?
A. 1
B. 5
C. 15
D. 30
64. Which of the following is TRUE
about the auscultation of blood
pressure?
A. Pulse + 4 is considered as FULL
B. The bell of the stethoscope is
use in auscultating BP
C. Sound produced by BP is
considered as HIGH frequency
sound
D. Pulse +1 is considered as
NORMAL
65. In assessing the abdomen,
Which of the following is the correct
sequence of the physical
assessment?
A. Inspection, Auscultation,
Percussion, Palpation
B. Palpation, Auscultation,
Percussion, Inspection
C. Inspection, Palpation,
Auscultation, Percussion
D. Inspection, Auscultation,
Palpation, Percussion
66. The sequence in examining the
quadrants of the abdomen is:
A. RUQ,RLQ,LUQ,LLQ
B. RLQ,RUQ,LLQ,LUQ
C. RUQ,RLQ,LLQ,LUQ
D. RLQ,RUQ,LUQ,LLQ
67. In inspecting the abdomen,
which of the following is NOT DONE?
A. Ask the client to void first
B. Knees and legs are
straighten to relax the
abdomen
C. The best position in assessing
the abdomen is Dorsal
recumbent
D. The knees and legs are externally
rotated
68. Dr. Fabian De Las Santas, is
about to conduct an
ophthalmoscope examination. Which
of the following, if done by a nurse,
is a Correct preparation before the
procedure?
A. Provide the necessary draping to
ensure privacy
B. Open the windows, curtains and
light to allow better illumination
C. Pour warm water over the
ophthalmoscope to ensure
comfort
D. Darken the room to provide
better illumination
69. If the client is female, and the
doctor is a male and the patient is
about to undergo a vaginal and
cervical examination, why is it
necessary to have a female nurse in
attendance?
A. To ensure that the doctor
performs the procedure safely
B. To assist the doctor
C. To assess the client’s response to
examination
D. To ensure that the procedure
is done in an ethical manner
70. In palpating the client’s breast,
Which of the following position is
necessary for the patient to assume
before the start of the procedure?
A. Supine
B. Dorsal recumbent
C. Sitting
D. Lithotomy
71. When is the best time to collect
urine specimen for routine urinalysis
and C/S?
A. Early morning
B. Later afternoon
C. Midnight
D. Before breakfast
72. Which of the following is among
an ideal way of collecting a urine
specimen for culture and sensitivity?
A. Use a clean container
B. Discard the first flow of urine
to ensure that the urine is
not contaminated
C. Collect around 30-50 ml of urine
D. Add preservatives, refrigerate the
specimen or add ice according to
the agency’s protocol
73. In a 24 hour urine specimen
started Friday, 9:00 A.M, which of
the following if done by a Nurse
indicate a NEED for further
procedural debriefing?
A. The nurse ask the client to
urinate at 9:00 A.M, Friday
and she included the urine in
the 24 hour urine specimen
B. The nurse discards the Friday
9:00 A M urine of the client
C. The nurse included the Saturday
9:00 A.M urine of the client to the
specimen collection
D. The nurse added preservatives
as per protocol and refrigerates
the specimen
74. This specimen is required to
assess glucose levels and for the
presence of albumin the the urine
A. Midstream clean catch urine
B. 24 hours urine collection
C. Postprandial urine collection
D. Second voided urine
75. When should the client test his
blood sugar levels for greater
accuracy?
A. During meals
B. In between meals
C. Before meals
D. 2 Hours after meals
76. In collecting a urine from a
catheterized patient, Which of the
following statement indicates an
accurate performance of the
procedure?
A. Clamp above the port for 30 to
60 minutes before drawing the
urine from the port
B. Clamp below the port for 30
to 60 minutes before drawing
the urine from the port
C. Clamp above the port for 5 to 10
minutes before drawing the urine
from the port
D. Clamp below the port for 5 to 10
minutes before drawing the urine
from the port
77. A community health nurse
should be resourceful and meet the
needs of the client. A villager ask
him, Can you test my urine for
glucose? Which of the following
technique allows the nurse to test a
client’s urine for glucose without the
need for intricate instruments.
A. Acetic Acid test
B. Nitrazine paper test
C. Benedict’s test
D. Litmus paper test
78. A community health nurse is
assessing client’s urine using the
Acetic Acid solution. Which of the
following, if done by a nurse,
indicates lack of correct knowledge
with the procedure?
A. The nurse added the Urine as the
2/3 part of the solution
B. The nurse heats the test tube
after adding 1/3 part acetic
acid
C. The nurse heats the test tube
after adding 2/3 part of Urine
D. The nurse determines abnormal
result if she noticed that the test
tube becomes cloudy
79. Which of the following is
incorrect with regards to proper
urine testing using Benedict’s
Solution?
A. Heat around 5ml of Benedict’s
solution together with the urine
in a test tube
B. Add 8 to 10 drops of urine
C. Heat the Benedict’s solution
without the urine to check if the
solution is contaminated
D. If the color remains BLUE, the
result is POSITIVE
80. +++ Positive result after
Benedicts test is depicted by what
color?
A. Blue
B. Green
C. Yellow
D. Orange
81. Clinitest is used in testing the
urine of a client for glucose. Which
of the following, If committed by a
nurse indicates error?
A. Specimen is collected after
meals
B. The nurse puts 1 clinitest tablet
into a test tube
C. She added 5 drops of urine and
10 drops of water
D. If the color becomes orange or
red, It is considered postitive
82. Which of the following nursing
intervention is important for a client
scheduled to have a Guaiac Test?
A. Avoid turnips, radish and
horseradish 3 days before
procedure
B. Continue iron preparation to
prevent further loss of Iron
C. Do not eat read meat 12 hours
before procedure
D. Encourage caffeine and dark
colored foods to produce
accurate results
83. In collecting a routine specimen
for fecalysis, Which of the following,
if done by a nurse, indicates
inadequate knowledge and skills
about the procedure?
A. The nurse scoop the specimen
specifically at the site with blood
and mucus
B. She took around 1 inch of
specimen or a teaspoonful
C. Ask the client to call her for
the specimen after the client
wiped off his anus with a
tissue
D. Ask the client to defecate in a
bedpan, Secure a sterile
container
84. In a routine sputum analysis,
Which of the following indicates
proper nursing action before sputum
collection?
A. Secure a clean container
B. Discard the container if the
outside becomes contaminated
with the sputum
C. Rinse the client’s mouth with
Listerine after collection
D. Tell the client that 4 tablespoon
of sputum is needed for each
specimen for a routine sputum
analysis
85. Who collects Blood specimen?
A. The nurse
B. Medical technologist
C. Physician
D. Physical therapist
86. David, 68 year old male client is
scheduled for Serum Lipid analysis.
Which of the following health
teaching is important to ensure
accurate reading?
A. Tell the patient to eat fatty meals
3 days prior to the procedure
 B. NPO for 12 hours pre
procedure
C. Ask the client to drink 1 glass of
water 1 hour prior to the
procedure
D. Tell the client that the normal
serum lipase level is 50 to 140
U/L
87. The primary factor responsible
for body heat production is the
A. Metabolism
B. Release of thyroxin
C. Muscle activity
D. Stress
88. The heat regulating center is
found in the
A. Medulla oblongata
B. Thalamus
C. Hypothalamus
D. Pons
89. A process of heat loss which
involves the transfer of heat from
one surface to another is
A. Radiation
B. Conduction
C. Convection
D. Evaporation
90. Which of the following is a
primary factor that affects the BP?
A. Obesity
B. Age
C. Stress
D. Gender
91. The following are social data
about the client except
A. Patient’s lifestyle
B. Religious practices
C. Family home situation
D. Usual health status
92. The best position for any
procedure that involves vaginal and
cervical examination is
A. Dorsal recumbent
B. Side lying
C. Supine
D. Lithotomy
93. Measure the leg circumference
of a client with bipedal edema is
best done in what position?
A. Dorsal recumbent
B. Sitting
C. Standing
D. Supine
94. In palpating the client’s
abdomen, Which of the following is
the best position for the client to
assume?
A. Dorsal recumbent
B. Side lying
C. Supine
D. Lithotomy
95. Rectal examination is done with
a client in what position?
A. Dorsal recumbent
B. Sims position
C. Supine
D. Lithotomy
96. Which of the following is a
correct nursing action when
collecting urine specimen from a
client with an Indwelling catheter?
A. Collect urine specimen from the
drainage bag
B. Detach catheter from the
connecting tube and draw the
specimen from the port
C. Use sterile syringe to
aspirate urine specimen from
the drainage port
D. Insert the syringe straight to the
port to allow self sealing of the
port
97. Which of the following is
inappropriate in collecting mid
stream clean catch urine specimen
for urine analysis?
A. Collect early in the morning, First
voided specimen
B. Do perineal care before specimen
collection
C. Collect 5 to 10 ml for urine
D. Discard the first flow of the urine
98. When palpating the client’s neck
for lymphadenopathy, where should
the nurse position himself?
A. At the client’s back
B. At the client’s right side
C. At the client’s left side
D. In front of a sitting client
99. Which of the following is the best Sphenoid
position for the client to assume if Maxillary
the back is to be examined by the Frontal
nurse? 4. Which paranasal sinus is found
over the eyebrow?
A. Standing
B. Sitting Ehtmoid
C. Side lying Sphenoid
D. Prone Maxillary
100. In assessing the client’s chest, Frontal
which position best show chest 5. Gene De Vonne
expansion as well as its movements? Katrouchuacheulujiki wants to
change her surname to something
A. Sitting shorter, The court denied her
B. Prone request which depresses her and
C. Sidelying find herself binge eating. She
D. Supine accidentally aspirate a large piece of
nut and it passes the carina.
Probabilty wise, Where will the nut
PNLE: FON go?

Right main stem bronchus

Practice Exam for Left main stem bronchus
Be dislodged in between the carina

Oxygenation and Be blocked by the closed epiglottis

6. Which cell secretes mucus that
help protect the lungs by trapping
Nutrition debris in the respiratory tract?

Type I pneumocytes
1. Which one of the following is NOT Type II pneumocytes
a function of the Upper airway? Goblet cells
Adipose cells
For clearance mechanism such 7. How many lobes are there in the
as coughing RIGHT LUNG?
Transport gases to the lower
airways One
Warming, Filtration and Two
Humidification of inspired air Three
Protect the lower airway from Four
foreign mater 8. The presence of the liver causes
2. It is the hair the lines the which anatomical difference of the
vestibule which function as a Kidneys and the Lungs?
filtering mechanism for foreign
objects Left kidney slightly lower, Left
lung slightly shorter
Cilia Left kidney slightly higher, Left lung
Nares slightly shorter
Carina Right kidney lower, Right lung
Vibrissae shorter
3. This is the paranasal sinus found Right kidney higher, Right lung
between the eyes and the nose that shorter
extends backward into the skull 9. Surfactant is produced by what
cells in the alveoli?
Ehtmoid
 Type I pneumocytes
Type II pneumocytes
Goblet cells
Adipose cells
10. The normal L:S Ratio to consider
the newborn baby viable is
1:2
2:1
3:1
1:3
11. Refers to the extra air that can
be inhaled beyond the normal tidal
volume
Inspiratory reserve volume
Expiratory reserve volume
Functional residual capacity
Residual volume
12. This is the amount of air
remained in the lungs after a
forceful expiration
Inspiratory reserve volume
Expiratory reserve volume
Functional residual capacity
Residual volume
13. Casssandra, A 22 year old grade
Agnostic, Asked you, how many
spikes of bones are there in my ribs?
Your best response is which of the
following?
We have 13 pairs of ribs Cassandra
We have 12 pairs of ribs
Cassandra
Humans have 16 pairs of ribs, and
that was noted by Vesalius in
1543
Humans have 8 pairs of ribs. 4 of
which are floating
14. Which of the following is
considered as the main muscle of
respiration?
Lungs
Intercostal Muscles
Diaphragm
Pectoralis major
15. Cassandra asked you : How
many air is there in the oxygen and
how many does human requires?
Which of the following is the best
response :
God is good, Man requires 21% of
oxygen and we have 21%
available in our air
Man requires 16% of oxygen and we
have 35% available in our air
Man requires 10% of oxygen and we
have 50% available in our air
Human requires 21% of oxygen
and we have 21% available in
our air
16. Which of the following is TRUE
about Expiration?
A passive process
The length of which is half of the
length of Inspiration
Stridor is commonly heard during
expiration
Requires energy to be carried out
17. Which of the following is TRUE in
postural drainage?
Patient assumes position for 10
to 15 minutes
Should last only for 60 minutes
Done best P.C
An independent nursing action
18. All but one of the following is a
purpose of steam inhalation
Mucolytic
Warm and humidify air
Administer medications
Promote bronchoconstriction
19. Which of the following is NOT
TRUE in steam inhalation?
It is a dependent nursing action
Spout is put 12-18 inches away
from the nose
Render steam inhalation for
atleast 60 minutes
Cover the client’s eye with wash
cloth to prevent irritation
20. When should a nurse suction a
client?
As desired
As needed
Every 1 hour
Every 4 hours
21. Ernest Arnold Hamilton, a 60
year old American client was
mobbed by teen gangsters near New
york, Cubao. He was rushed to John
John Hopio Medical Center and was
Unconscious. You are his nurse and
you are to suction his secretions. In
which position should you place Mr.
Hamilton?
High fowlers
Semi fowlers
Prone
Side lying
22. You are about to set the suction
pressure to be used to Mr. Hamilton.
You are using a Wall unit suction
machine. How much pressure should
you set the valve before suctioning
Mr. Hamilton?
50-95 mmHg
200-350 mmHg
100-120 mmHg
10-15 mmHg
23. The wall unit is not functioning;
You then try to use the portable
suction equipment available. How
much pressure of suction equipment
is needed to prevent trauma to
mucus membrane and air ways in
case of portable suction units?
2-5 mmHg
5-10 mmHg
10-15 mmHg
15-25 mmHg
24. There are four catheter sizes
available for use, which one of these
should you use for Mr. Hamilton?
Fr. 18
Fr. 12
Fr. 10
Fr, 5
25. Which of the following, if done
by the nurse, indicates
incompetence during suctioning an
unconscious client?
Measure the length of the
suction catheter to be
inserted by measuring from
the tip of the nose, to the
earlobe, to the xiphoid
process
Use KY Jelly if suctioning
nasopharyngeal secretion
The maximum time of suctioning
should not exceed 15 seconds
Allow 30 seconds interval between
suctioning
26. Which of the following is the
initial sign of hypoxemia in an adult
client?
Tachypnea
Tachycardia
Cyanosis
Pallor
Irritability
Flaring of NaresA. 1,2
B. 2,5
C. 2,6
D. 3,4
27. Which method of oxygenation
least likely produces anxiety and
apprehension?
Nasal Cannula
Simple Face mask
Non Rebreather mask
Partial Rebreather mask
28. Which of the following oxygen
delivery method can deliver 100%
Oxygen at 15 LPM?
Nasal Cannula
Simple Face mask
Non Rebreather mask
Partial Rebreather mask
29. Which of the following is not true
about OXYGEN?
Oxygen is odorless, tasteless and
colorless gas.
Oxygen can irritate mucus
membrane
Oxygen supports combustion
Excessive oxygen
administration results in
respiratory acidosis
30. Roberto San Andres, A new
nurse in the hospital is about to
administer oxygen on patient with
Respiratory distress. As his senior
nurse, you should intervene if
Roberto will:
 Uses venture mask in oxygen
administration
Put a non rebreather mask in
the patient before opening
the oxygen source
Use a partial rebreather mask to
deliver oxygen
Check for the doctor’s order for
Oxygen administration
31. Which of the following will alert
the nurse as an early sign of
hypoxia?
Client is tired and dyspneic
The client is coughing out blood
The client’s heart rate is 50 BPM
Client is frequently turning
from side to side
32. Miguelito de balboa, An OFW
presents at the admission with an
A:P Diameter ratio of 2:1, Which of
the following associated finding
should the nurse expect?
Pancytopenia
Anemia
Fingers are Club-like
Hematocrit of client is decreased
33. The best method of oxygen
administration for client with COPD
uses:
Cannula
Simple Face mask
Non rebreather mask
Venturi mask
34. Mang dagul, a 50 year old
chronic smoker was brought to the
E.R because of difficulty in
breathing. Pleural effusion was the
diagnosis and CTT was ordered.
What does C.T.T Stands for?
Chest tube thoracotomy
Chest tube thoracostomy
Closed tube thoracotomy
Closed tube thoracostmy
35. Where will the CTT be inserted if
we are to drain fluids accumulated in
Mang dagul’s pleura?
2nd ICS
4th ICS
5th ICS
8th ICS
36. There is a continuous bubbling in
the water sealed drainage system
with suction. And oscillation is
observed. As a nurse, what should
you do?
Consider this as normal findings
Notify the physician
Check for tube leak
Prepare a petrolatum gauze
dressing
37. Which of the following is true
about nutrition?
It is the process in which food are
broken down, for the body to use
in growth and development
It is a process in which digested
proteins, fats, minerals, vitamins
and carbohydrates are
transported into the circulation
It is a chemical process that occurs
in the cell that allows for energy
production, energy use, growth
and tissue repair
It is the study of nutrients and
the process in which they are
use by the body
38. The majority of the digestion
processes take place in the
Mouth
Small intestine
Large intestine
Stomach
39. All of the following is true about
digestion that occurs in the Mouth
except
It is where the digestion process
starts
Mechanical digestion is brought
about by mastication
The action of ptyalin or the
salivary tyrpsin breaks down
starches into maltose
Deglutition occurs after food is
broken down into small pieces
and well mixed with saliva
40. Which of the following foods
lowers the cardiac sphincter
pressure?
Roast beef, Steamed cauliflower
and Rice
 Orange juice, Non fat milk, Dry
crackers
Decaffeinated coffee, Sky flakes
crackers, Suman
Coffee with coffee mate, Bacon
and Egg
41. Where does the digestion of
carbohydrates start?
Mouth
Esophagus
Small intestine
Stomach
42. Protein and Fat digestion begins
where?
Mouth
Esophagus
Small intestine
Stomach
43. All but one is true about
digestion that occurs in the Stomach
Carbohydrates are the fastest to be
digested, in about an hour
Fat is the slowest to be digested, in
about 5 hours
HCl inhibits absorption of
Calcium in the gastric mucosa
HCl converts pepsinogen to pepsin,
which starts the complex process
of protein digestion
44. Which of the following is NOT an
enzyme secreted by the small
intestine?
Sucrase
Enterokinase
Amylase
Enterokinase
45. The hormone secreted by the
Small intestine that stimulates the
production of pancreatic juice which
primarily aids in buffering the acidic
bolus passed by the Stomach
Enterogastrone
Cholecystokinin
Pancreozymin
Enterokinase
46. When the duodenal enzyme
sucrase acts on SUCROSE, which 2
monosaccharides are formed?
Galactose + Galactose
Glucose + Fructose
Glucose + Galactose
Fructose + Fructose
47. This is the enzyme secreted by
the pancrease that completes the
protein digestion
Trypsin
Enterokinase
Enterogastrone
Amylase
48. The end product of protein
digestion or the “Building blocks of
Protein” is what we call
Nucleotides
Fatty acids
Glucose
Amino Acids
49. Enzyme secreted by the small
intestine after it detects a bolus of
fatty food. This will contract the
gallbladder to secrete bile and relax
the sphincter of Oddi to aid in the
emulsification of fats and its
digestion.
Lipase
Amylase
Cholecystokinin
Pancreozymin
50. Which of the following is not true
about the Large Intestine?
It absorbs around 1 L of water
making the feces around 75%
water and 25% solid
The stool formed in the transverse
colon is not yet well formed
It is a sterile body cavity
It is called large intestine because it
is longer than the small intestine
51. This is the amount of heat
required to raise the temperature of
1 kg water to 1 degree Celsius
Calorie
Joules
Metabolism
Basal metabolic rate
52. Assuming a cup of rice provides
50 grams of carbohydrates. How
many calories are there in that cup
of rice?
 150 calories
200 calories
250 calories
400 calories
53. An average adult filipino requires
how many calories in a day?
1,000 calories
1,500 calories
2,000 calories
2,500 calories
54. Which of the following is true
about an individual’s caloric needs?
All individual have the same caloric
needs
Females in general have higher
BMR and therefore, require more
calories
During cold weather, people
need more calories due to
increase BMR
Dinner should be the heaviest meal
of the day
55. Among the following people, who
requires the greatest caloric intake?
An individual in a long state of
gluconeogenesis
An individual in a long state of
glycogenolysis
A pregnant individual
An adolescent with a BMI of 25
56. Which nutrient deficiency is
associated with the development of
Pellagra, Dermatitis and Diarrhea?
Vitamin B1
Vitamin B2
Vitamin B3
Vitamin B6
57. Which Vitamin is not given in
conjunction with the intake of
LEVODOPA in cases of Parkinson’s
Disease due to the fact that
levodopa increases its level in the
body?
Vitamin B1
Vitamin B2
Vitamin B3
Vitamin B6
58. A vitamin taken in conjunction
with ISONIAZID to prevent peripheral
neuritis
Vitamin B1
Vitamin B2
Vitamin B3
Vitamin B6
59. The inflammation of the Lips,
Palate and Tongue is associated in
the deficiency of this vitamin
Vitamin B1
Vitamin B2
Vitamin B3
Vitamin B6
60. Beri beri is caused by the
deficiency of which Vitamin?
Vitamin B1
Vitamin B2
Vitamin B3
Vitamin C
61. Which of the following is the best
source of Vitamin E?
Green leafy vegetables
Vegetable oil
Fortified Milk
Fish liver oil
62. Among the following foods,
which food should you emphasize
giving on an Alcoholic client?
Pork liver and organ meats,
Pork
Red meat, Eggs and Dairy
products
Green leafy vegetables, Yellow
vegetables, Cantaloupe and
Dairy products
Chicken, Peanuts, Bananas, Wheat
germs and yeasts
63. Which food group should you
emphasize giving on a pregnant
mother in first trimester to prevent
neural tube defects?
Broccoli, Guava, Citrus fruits,
Tomatoes
Butter, Sardines, Tuna, Salmon, Egg
yolk
Wheat germ, Vegetable Oil,
soybeans, corn, peanuts
Organ meats, Green leafy
vegetables, Liver, Eggs
64. A client taking Coumadin is to be
educated on his diet. As a nurse,
which of the following food should Raisin
you instruct the client to avoid? Banana
70. A client has HEMOSIDEROSIS.
Spinach, Green leafy Which of the following drug would
vegetables, Cabbage, Liver you expect to be given to the client?
Salmon, Sardines, Tuna
Butter, Egg yolk, breakfast cereals Acetazolamide
Banana, Yeast, Wheat germ, Deferoxamine
Chicken Calcium EDTA
Activated charcoal
65. Vitamin E plus this mineral works 71. Which of the following provides
as one of the best anti oxidant in the the richest source of Iron per area of
body according to the latest their meat?
research. They are combined with 5
Alpha reductase inhibitor to reduce Pork meat
the risk of acquiring prostate cancer Lean read meat
Pork liver
Zinc Green mongo
Iron
Selenium 72. Which of the following is
Vanadium considered the best indicator of
66. Incident of prostate cancer is nutritional status of an individual?
found to have been reduced on a
population exposed in tolerable Height
amount of sunlight. Which vitamin is Weight
associated with this phenomenon? Arm muscle circumference
BMI
Vitamin A 73. Jose Miguel, a 50 year old
Vitamin B business man is 6’0 Tall and weights
Vitamin C 179 lbs. As a nurse, you know that
Vitamin D Jose Miguel is :
67. Micronutrients are those
nutrients needed by the body in a Overweight
very minute amount. Which of the Underweight
following vitamin is considered as a Normal
MICRONUTRIENT Obese
74. Jose Miguel is a little bit
Phosphorous nauseous. Among the following
Iron beverages, Which could help relieve
Calcium JM’s nausea?
Sodium
68. Deficiency of this mineral results Coke
in tetany, osteomalacia, Sprite
osteoporosis and rickets. Mirinda
Orange Juice or Lemon Juice
Vitamin D 75. Which of the following is the first
Iron sign of dehydration?
Calcium
Sodium Tachycardia
69. Among the following foods, Restlessness
which has the highest amount of Thirst
potassium per area of their meat? Poor skin turgor
76. What Specific gravity lab result
Cantaloupe is compatible with a dehydrated
Avocado client?
 1.007 Measure the amount of the
1.020 tube to be inserted from the
1.039 Tip of the nose, to the
1.029 earlobe, to the xiphoid
77. Which hematocrit value is process
expected in a dehydrated male Soak the NGT in a basin of ice water
client? to facilitate easy insertion
Check the placement of the tube by
67% introducing 10 cc of sterile water
50% and auscultating for bubbling
36% sound
45% 84. Which of the following is the
78. Which of the following statement BEST method in assessing for the
by a client with prolonged vomiting correct placement of the NGT?
indicates the initial onset of
hypokalemia? X-Ray
Immerse tip of the tube in water to
My arm feels so weak check for bubbles produced
I felt my heart beat just right now Aspirating gastric content to check
My face muscle is twitching if the content is acidic
Nurse, help! My legs are Instilling air in the NGT and listening
cramping for a gurgling sound at the
79. Which of the following is not an epigastric area
anti-emetic?
85. A terminally ill cancer patient is
Marinol scheduled for an NGT feeding today.
Dramamine How should you position the patient?
Benadryl
Alevaire Semi fowlers in bed
Bring the client into a chair
80. Which is not a clear liquid diet? Slightly elevated right side lying
position
Hard candy Supine in bed
Gelatin 86. A client is scheduled for NGT
Coffee with Coffee mate Feeding. Checking the residual
Bouillon volume, you determined that he has
81. Which of the following is 40 cc residual from the last feeding.
included in a full liquid diet? You reinstill the 40 cc of residual
volume and added the 250 cc of
Popsicles feeding ordered by the doctor. You
Pureed vegetable meat then instill 60 cc of water to clear
Pineapple juice with pulps the lumen and the tube. How much
Mashed potato will you put in the client’s chart as
82. Which food is included in a input?
BLAND DIET?
250 cc
Steamed broccoli 290 cc
Creamed potato 350 cc
Spinach in garlic 310 cc
Sweet potato 87. Which of the following if done by
83. Which of the following if done by a nurse indicates deviation from the
the nurse, is correct during NGT standards of NGT feeding?
Insertion?
Do not give the feeding and notify
Use an oil based lubricant the doctor of residual of the last
 feeding is greater than or equal 3 day diet recall
to 50 ml Eating style and habits
Height of the feeding should be 12
inches about the tube point of 92. The vomiting center is found in
insertion to allow slow the
introduction of feeding
Ask the client to position in Medulla Oblongata
supine position immediately Pons
after feeding to prevent Hypothalamus
dumping syndrome Cerebellum
Clamp the NGT before all of the 93. The most threatening
water is instilled to prevent air complication of vomiting in client’s
entry in the stomach with stroke is
88. What is the most common
problem in TUBE FEEDING? Aspiration
Dehydration
Diarrhea Fluid and electrolyte imbalance
Infection Malnutrition
Hyperglycemia 94. Which among this food is the
Vomiting richest source of Iron?
89. Which of the following is TRUE in
colostomy feeding? Ampalaya
Broccoli
Hold the syringe 18 inches above Mongo
the stoma and administer the Malunggay leaves
feeding slowly 95. Which of the following is a good
Pour 30 ml of water before and after source of Vitamin A?
feeding administration
Insert the ostomy feeding tube 1 Egg yolk
inch towards the stoma Liver
A Pink stoma means that circulation Fish
towards the stoma is all well Peanuts
90. A client with TPN suddenly 96. The most important nursing
develops tremors, dizziness, action before gastrostomy feeding is
weakness and diaphoresis. The
client said “I feel weak” You saw that Check V/S
his TPN is already empty and Assess for patency of the tube
another TPN is scheduled to replace Measure residual feeding
the previous one but its provision is Check the placement of the tube
already 3 hours late. Which of the 97. The primary advantage of
following is the probable gastrostomy feeding is
complication being experienced by
the client? Ensures adequate nutrition
It prevents aspiration
Hyperglycemia Maintains Gastro esophageal
Hypoglycemia sphincter integrity
Infection Minimizes fluid-electrolyte
Fluid overload imbalance
91. To assess the adequacy of food 98. What is the BMI Of Budek,
intake, which of the following weighing 120 lbs and has a height of
assessment parameters is best 5 feet 7 inches.
used?
20
Food likes and dislikes 19
Regularity of meal times 15
 25
99. Which finding is consistent with
PERNICIOUS ANEMIA?
Strawberry tongue
Currant Jelly stool
Beefy red tongue
Pale [ HYPOCHROMIC ] RBC
100. The nurse is browsing the chart
of the patient and notes a normal
serum lipase level. Which of the
following is a normal serum lipase
value?
10 U/L
100 U/L
200 U/L
350 U/L
PNLE
Fundamentals in
Nursing Exam 1
1. Jake is complaining of shortness of
breath. The nurse assesses his
respiratory rate to be 30 breaths per
minute and documents that Jake is
tachypneic. The nurse understands
that tachypnea means:
Pulse rate greater than 100 beats
per minute
Blood pressure of 140/90
Respiratory rate greater than
20 breaths per minute
Frequent bowel sounds
(C) Respiratory rate greater than
20 breaths per minute. A
respiratory rate of greater than
20 breaths per minute is
tachypnea. A blood pressure of
140/90 is considered
hypertension. Pulse greater
than 100 beats per minute is
tachycardia. Frequent bowel
sounds refer to hyper-active
bowel sounds.
2. The nurse listens to Mrs. Sullen’s
lungs and notes a hissing sound or
musical sound. The nurse
documents this as:
Wheezes
Rhonchi
Gurgles
Vesicular
(A) Wheezes. Wheezes are
indicated by continuous, lengthy,
musical; heard during inspiration
or expiration. Rhonchi are usually
coarse breath sounds. Gurgles
are loud gurgling, bubbling
sound. Vesicular breath sounds
are low pitch, soft intensity on
expiration
3. The nurse in charge measures a
patient’s temperature at 101
degrees F. What is the equivalent
centigrade temperature?
36.3 degrees C
37.95 degrees C
40.03 degrees C
38.01 degrees C
(B) 37.95 degrees C. To convert °F
to °C use this formula, ( °F – 32 )
(0.55). While when converting °C
to °F use this formula, ( °C x 1.8)
+ 32. Note that 0.55 is 5/9 and
1.8 is 9/5.
4. Which approach to problem
solving tests any number of
solutions until one is found that
works for that particular problem?
Intuition
Routine
Scientific method
Trial and error
(D) Trial and error. The trial and
error method of problem solving
isn’t systematic (as in the
scientific method of problem
solving) routine, or based on
inner prompting (as in the
intuitive method of problem
solving).
5. What is the order of the nursing
process?
Assessing, diagnosing,
implementing, evaluating,
planning
Diagnosing, assessing, planning,
implementing, evaluating
Assessing, diagnosing,
planning, implementing,
evaluating
Planning, evaluating, diagnosing,
assessing, implementing
(C) Assessing, diagnosing, planning,
implementing, evaluating. The
correct order of the nursing
process is assessing, diagnosing,
planning, implementing,
evaluating.
6. During the planning phase of the
nursing process, which of the
following is the outcome?
Nursing history
Nursing notes
Nursing care plan
Nursing diagnosis
(C) Nursing care plan. The outcome,
or the product of the planning
phase of the nursing process is a
Nursing care plan.
7. What is an example of a
subjective data?
Heart rate of 68 beats per minute
Yellowish sputum
Client verbalized, “I feel pain
when urinating.”
Noisy breathing
(C) Client verbalized, “I feel pain
when urinating.”. Subjective data
are those that can be described
only by the person experiencing
it. Therefore, only the patient can
describe or verify whether he is
experiencing pain or not.
8. Which expected outcome is
correctly written?
“The patient will feel less nauseated
in 24 hours.”
“The patient will eat the right
amount of food daily.”
“The patient will identify all the
high-salt food from a
prepared list by discharge.”
(C) “The patient will identify all the
high-salt food from a prepared
list by discharge.”. Expected
outcomes are specific,
measurable, realistic statements
of goal attainment. The phrases
“right amount”, “less nauseated”
and “enough sleep” are vague
and not measurable.
“The patient will have enough
sleep.”
9. Which of the following behaviors
by Nurse Jane Robles demonstrates
that she understands well th
elements of effecting charting?
She writes in the chart using a no. 2
pencil.
She noted: appetite is good this
afternoon.
She signs on the medication
sheet after administering the
medication.
She signs her charting as follow: J.R
(C) She signs on the medication
sheet after administering the
medication.A nurse should record
a nursing intervention (ex. Giving
medications) after performing
the nursing intervention (not
before). Recording should also be
done using a pen, be complete,
and signed with the nurse’s full
name and title.
10. What is the disadvantage of
computerized documentation of the
nursing process?
Accuracy
Legibility
Concern for privacy
Rapid communication
(C) Concern for privacy. A patient’s
privacy may be violated if
security measures aren’t used
properly or if policies and
procedures aren’t in place that
determines what type of
information can be retrieved, by
whom, and for what purpose.
11. The theorist who believes that
adaptation and manipulation of
stressors are related to foster
change is:
Dorothea Orem
Sister Callista Roy
Imogene King
Virginia Henderson
(B) Sister Callista Roy. Sister Roy’s
theory is called the adaptation
theory and she viewed each
person as a unified biophysical
system in constant interaction
with a changing environment.
Orem’s theory is called self-care
deficit theory and is based on the
belief that individual has a need
for self-care actions. King’s
theory is the Goal attainment
theory and described nursing as
a helping profession that assists
individuals and groups in society
to attain, maintain, and restore
health. Henderson introduced the
nature of nursing model and
identified the 14 basic needs.
12. Formulating a nursing diagnosis
is a joint function of:
Patient and relatives
Nurse and patient
Doctor and family
Nurse and doctor
(B) Nurse and patient. Although
diagnosing is basically the
nurse’s responsibility, input from
the patient is essential to
formulate the correct nursing
diagnosis.
13. Mrs. Caperlac has been
diagnosed to have hypertension
since 10 years ago. Since then, she
had maintained low sodium, low fat
diet, to control her blood pressure.
This practice is viewed as:
Cultural belief
Personal belief
Health belief
Superstitious belief
(C) Health belief. Health belief of an
individual influences his/her
preventive health behavior.
14. Becky is on NPO since midnight
as preparation for blood test.
Adreno-cortical response is
activated. Which of the following is
an expected response?
Low blood pressure
Warm, dry skin
Decreased serum sodium levels
Decreased urine output
(D) Decreased urine output. Adreno-
cortical response involves release
of aldosterone that leads to
retention of sodium and water.
This results to decreased urine
output.
15. What nursing action is
appropriate when obtaining a sterile
urine specimen from an indwelling
catheter to prevent infection?
Use sterile gloves when obtaining
urine.
Open the drainage bag and pour
out the urine.
Disconnect the catheter from the
tubing and get urine.
Aspirate urine from the tubing
port using a sterile syringe.
(D) Aspirate urine from the tubing
port using a sterile syringe. The
nurse should aspirate the urine
from the port using a sterile
syringe to obtain a urine
specimen. Opening a closed
drainage system increase the risk
of urinary tract infection.
16. A client is receiving 115 ml/hr of
continuous IVF. The nurse notices
that the venipuncture site is red and
swollen. Which of the following
interventions would the nurse
perform first?
Stop the infusion
Call the attending physician
Slow that infusion to 20 ml/hr
Place a clod towel on the site
(A) Stop the infusion. The sign and
symptoms indicate extravasation
so the IVF should be stopped
immediately and put warm not
cold towel on the affected site.
17. The nurse enters the room to
give a prescribed medication but the
patient is inside the bathroom. What
should the nurse do?
Leave the medication at the
bedside and leave the room.
After few minutes, return to
that patient’s room and do
not leave until the patient
takes the medication.
Instruct the patient to take the
medication and leave it at the
bedside.
Wait for the patient to return to bed
and just leave the medication at
the bedside.
(B) After few minutes, return to that
patient’s room and do not leave
until the patient takes the
medication. This is to verify or to
make sure that the medication
was taken by the patient as
directed.
18. Which of the following is
inappropriate nursing action when
administering NGT feeding?
Place the feeding 20 inches
above the pint if insertion of
NGT.
Introduce the feeding slowly.
Instill 60ml of water into the NGT
after feeding.
Assist the patient in fowler’s
position.
(A) Place the feeding 20 inches
above the pint if insertion of
NGT. The height of the feeding is
above 12 inches above the point
of insertion, bot 20 inches. If the
height of feeding is too high, this
results to very rapid introduction
of feeding. This may trigger
nausea and vomiting.
19. A female patient is being
discharged after thyroidectomy.
After providing the medication
teaching. The nurse asks the patient
to repeat the instructions. The nurse
is performing which professional
role?
Manager
Caregiver
Patient advocate
Educator
(D) Educator. When teaching a
patient about medications before
discharge, the nurse is acting as
an educator. A caregiver provides
direct care to the patient. The
nurse acts as s patient advocate
when making the patient’s
wishes known to the doctor.
20. Which data would be of greatest
concern to the nurse when
completing the nursing assessment
of a 68-year-old woman hospitalized
due to Pneumonia?
Oriented to date, time and place
Clear breath sounds
Capillary refill greater than 3
seconds and buccal cyanosis
Hemoglobin of 13 g/dl
(C) Capillary refill greater than 3
seconds and buccal
cyanosis. Capillary refill greater
than 3 seconds and buccal
cyanosis indicate decreased
oxygen to the tissues which
requires immediate
attention/intervention. Oriented
 to date, time and place,
hemoglobin of 13 g/dl are normal
data.
21. During a change-of-shift report,
it would be important for the nurse
relinquishing responsibility for care
of the patient to communicate.
Which of the following facts to the
nurse assuming responsibility for
care of the patient?
That the patient verbalized, “My
headache is gone.”
That the patient’s barium enema
performed 3 days ago was
negative
Patient’s NGT was removed 2
hours ago
Patient’s family came for a visit this
morning.
(C) Patient’s NGT was removed 2
hours ago. The change-of-shift
report should indicate significant
recent changes in the patient’s
condition that the nurse
assuming responsibility for care
of the patient will need to
monitor. The other options are
not critical enough to include in
the report.
22. Which statement is the most
appropriate goal for a nursing
diagnosis of diarrhea?
“The patient will experience
decreased frequency of
bowel elimination.”
“The patient will take anti-diarrheal
medication.”
“The patient will give a stool
specimen for laboratory
examinations.”
“The patient will save urine for
inspection by the nurse.
(A) “The patient will experience
decreased frequency of bowel
elimination.” The goal is the
opposite, healthy response of the
problem statement of the nursing
diagnosis. In this situation, the
problem statement is diarrhea.
23. Which of the following is the
most important purpose of planning
care with this patient?
Development of a standardized NCP.
Expansion of the current taxonomy
of nursing diagnosis
Making of individualized patient
care
Incorporation of both nursing and
medical diagnoses in patient care
(C) Making of individualized patient
care. To be effective, the nursing
care plan developed in the
planning phase of the nursing
process must reflect the
individualized needs of the
patient.
24. Using Maslow’s hierarchy of
basic human needs, which of the
following nursing diagnoses has the
highest priority?
Ineffective breathing pattern
related to pain, as evidenced
by shortness of breath.
Anxiety related to impending
surgery, as evidenced by
insomnia.
Risk of injury related to
autoimmune dysfunction
Impaired verbal communication
related to tracheostomy, as
evidenced by inability to speak.
(A) Ineffective breathing pattern
related to pain, as evidenced by
shortness of breath.. Physiologic
needs (ex. Oxygen, fluids,
nutrition) must be met before
lower needs (such as safety and
security, love and belongingness,
self-esteem and self-
actualization) can be met.
Therefore, physiologic needs
have the highest priority.
25. When performing an abdominal
examination, the patient should be
in a supine position with the head of
the bed at what position?
30 degrees
90 degrees
45 degrees
0 degree
(D) 0 degree. The patient should be
positioned with the head of the bed
completely flattened to perform an
abdominal examination. If the head
of the bed is elevated, the
abdominal muscles and organs can
be bunched up, altering the findings
PNLE
Fundamentals in
Nursing Exam 2
1. A patient is wearing a soft wrist-
safety device. Which of the following
nursing assessment is considered
abnormal?
Palpable radial pulse
Palpable ulnar pulse
Capillary refill within 3 seconds
Bluish fingernails, cool and pale
fingers
(D) Bluish fingernails, cool and pale
fingers. A safety device on the
wrist may impair blood
circulation. Therefore, the nurse
should assess the patient for
signs of impaired circulation such
as bluish fingernails, cool and
pale fingers. Palpable radial and
ulnar pulses, capillary refill within
3 seconds are all normal findings.
2. Pia’s serum sodium level is 150
mEq/L. Which of the following food
items does the nurse instruct Pia to
avoid?
broccoli
sardines
cabbage
Tomatoes
(B) sardines. The normal serum
sodium level is 135 to 145
mEq/L, the client is having
hypernatremia. Pia should avoid
food high in sodium like
processed food. Broccoli,
cabbage and tomatoes are good
source of Vitamin C.
3. Jason, 3 years old vomited. His
mom stated, “He vomited 6 ounces
of his formula this morning.” This
statement is an example of:
objective data from a secondary
source
objective data from a primary
source
subjective data from a primary
source
subjective data from a secondary
source
(A) objective data from a secondary
source. Jason is the primary
source; his mother is a secondary
source. The data is objective
because it can be perceived by
the senses, verified by another
person observing the same
patient, and tested against
accepted standards or norms.
4. Which of the following is a nursing
diagnosis?
Hypethermia
Diabetes Mellitus
Angina
Chronic Renal Failure
A) Hypethermia. Hyperthermia is a
NANDA-approved nursing
diagnosis. Diabetes Mellitus,
Angina and Chronic Renal Failure
are medical diagnoses.
5. What is the characteristic of the
nursing process?
stagnant
inflexible
asystematic
goal-oriented
(D) goal-oriented. The nursing
process is goal-oriented. It is also
systematic, patient-centered, and
dynamic.
6. A skin lesion which is fluid-filled,
less than 1 cm in size is called:
papule
vesicle
bulla
Macule
(B) vesicle. Vesicle is a
circumscribed circulation
containing serous fluid or blood
and less than 1 cm (ex. Blister,
chicken pox).
7. During application of medication
into the ear, which of the following is
inappropriate nursing action?
In an adult, pull the pinna upward.
Instill the medication directly
into the tympanic membrane.
Warm the medication at room or
body temperature.
Press the tragus of the ear a few
times to assist flow of medication
into the ear canal.
(B) Instill the medication directly
into the tympanic
membrane. During the
application of medication it is
inappropriate to instill the
medication directly into the
tympanic membrane. The right
thing to do is instill the
medication along the lateral wall
of the auditory canal.
8. Which of the following is
appropriate nursing intervention for
a client who is grieving over the
death of her child?
Tell her not to cry and it will be
better.
Provide opportunity to the
client to tell their story.
Encourage her to accept or to
replace the lost person.
Discourage the client in expressing
her emotions.
(B) Provide opportunity to the client
to tell their story. Providing a
grieving person an opportunity to
tell their story allows the person
to express feelings. This is
therapeutic in assisting the client
resolve grief.
9. It is the gradual decrease of the
body’s temperature after death.
livor mortis
rigor mortis
algor mortis
none of the above
(C) algor mortis. Algor mortis is the
decrease of the body’s
temperature after death. Livor
mortis is the discoloration of the
skin after death. Rigor mortis is
the stiffening of the body that
occurs about 2-4 hours after
death.
10. When performing an admission
assessment on a newly admitted
patient, the nurse percusses
resonance. The nurse knows that
resonance heard on percussion is
most commonly heard over which
organ?
thigh
liver
intestine
Lung
(D) lung. Resonance is loud, low-
pitched and long duration that’s
heard most commonly over an
air-filled tissue such as a normal
lung.
11. The nurse is aware that Bell’s
palsy affects which cranial nerve?
2nd CN (Optic)
3rd CN (Occulomotor)
4th CN (Trochlear)
7th CN (Facial)
(D) 7th CN (Facial). Bells’ palsy is
the paralysis of the motor
component of the 7th caranial
nerve, resulting in facial sag,
inability to close the eyelid or the
mouth, drooling, flat nasolabial
fold and loss of taste on the
affected side of the face.
12. Prolonged deficiency of Vitamin
B9 leads to:
scurvy
pellagra
megaloblastic anemia
pernicious anemia
(C) megaloblastic
anemia. Prolonged Vitamin B9
deficiency will lead to
megaloblastic anemia while
pernicious anemia results in
deficiency in Vitamin B12.
Prolonged deficiency of Vitamin C
leads to scurvy and Pellagra
results in deficiency in Vitamin
B3.
13. Nurse Cherry is teaching a 72
year old patient about a newly
prescribed medication. What could
cause a geriatric patient to have
difficulty retaining knowledge about
the newly prescribed medication?
Absence of family support
Decreased sensory functions
Patient has no interest on learning
Decreased plasma drug levels
(B) Decreased sensory
functions. Decreased in sensory
functions could cause a geriatric
patient to have difficulty
retaining knowledge about the
newly prescribed medications.
Absence of family support and no
interest on learning may affect
compliance, not knowledge
retention. Decreased plasma
levels do not alter patient’s
knowledge about the drug.
14. When assessing a patient’s level
of consciousness, which type of
nursing intervention is the nurse
performing?
Independent
Dependent
Collaborative
Professional
(A) Independent. Independent
nursing interventions involve
actions that nurses initiate based
on their own knowledge and
skills without the direction or
supervision of another member
of the health care team.
15. Claire is admitted with a
diagnosis of chronic shoulder pain.
By definition, the nurse understands
that the patient has had pain for
more than:
3 months
6 months
9 months
1 year
(B) 6 months. Chronic pain s usually
defined as pain lasting longer
than 6 months.
16. Which of the following
statements regarding the nursing
process is true?
It is useful on outpatient settings.
It progresses in separate, unrelated
steps.
It focuses on the patient, not
the nurse.
It provides the solution to all patient
health problems.
(C) It focuses on the patient, not the
nurse. The nursing process is
patient-centered, not nurse-
centered. It can be use in any
setting, and the steps are
related. The nursing process
can’t solve all patient health
problems.
17. Which of the following is
considered significant enough to
require immediate communication to
another member of the health care
team?
Weight loss of 3 lbs in a 120 lb
female patient.
Diminished breath sounds in
patient with previously
normal breath sounds
Patient stated, “I feel less
nauseated.”
Change of heart rate from 70 to 83
beats per minute.
(B) Diminished breath sounds in
patient with previously normal
breath sounds. Diminished
breath sound is a life threatening
problem therefore it is highly
priority because they pose the
greatest threat to the patient’s
well-being.
18. To assess the adequacy of food
intake, which of the following
assessment parameters is best
used?
food preferences
regularity of meal times
3-day diet recall
eating style and habits
(C) 3-day diet recall. 3-day diet
recall is an example of dietary
history. This is used to indicate
the adequacy of food intake of
the client.
19. Van Fajardo is a 55 year old who
was admitted to the hospital with
newly diagnosed hepatitis. The
nurse is doing a patient teaching
with Mr. Fajardo. What kind of role
does the nurse assume?
talker
teacher
thinker
Doer
(B) teacher. The nurse will assume
the role of a teacher in this
therapeutic relationship. The
other roles are inappropriate in
this situation.
20. When providing a continuous
enteral feeding, which of the
following action is essential for the
nurse to do?
Place the client on the left side of
the bed.
Attach the feeding bag to the
current tubing.
Elevate the head of the bed.
Cold the formula before
administering it
(C) Elevate the head of the
bed. Elevating the head of the
bed during an enteral feeding
prevents aspiration. The patient
may be placed on the right side
to prevent aspiration. Enteral
feedings are given at room
temperature to lessen GI
distress. The enteral tubing
should be changed every 24
hours to limit microbial growth.
.
21. Kussmaul’s breathing is;
Shallow breaths interrupted by
apnea.
Prolonged gasping inspiration
followed by a very short, usually
inefficient expiration.
Marked rhythmic waxing and
waning of respirations from very
deep to very shallow breathing
and temporary apnea.
Increased rate and depth of
respiration.
(D) Increased rate and depth of
respiration. Kussmaul breathing
is also called as hyperventilation.
Seen in metabolic acidosis and
renal failure. Option A refers to
Biot’s breathing. Option B is
apneustic breathing and option C
is the Cheyne-stokes breathing.
22. Presty has terminal cancer and
she refuses to believe that loss is
happening ans she assumes artificial
cheerfulness. What stage of grieving
is she in?
depression
bargaining
denial
Acceptance
(C) denial. The client is in denial
stage because she is unready to
face the reality that loss is
happening and she assumes
artificial cheerfulness.
23. Immunization for healthy babies
and preschool children is an
example of what level of preventive
health care?
Primary
Secondary
Tertiary
Curative
(A) Primary. The primary level
focuses on health promotion.
Secondary level focuses on
health maintenance. Tertiary
focuses on rehabilitation. There is
n Curative level of preventive
health care problems.
24. Which is an example of a
subjective data?
Temperature of 38 0C
Vomiting for 3 days
Productive cough
Patient stated, “My arms still
hurt.”
(D) Patient stated, “My arms still
hurt.”. Subjective data are
apparent only to the person
affected and can or verified only
by that person.
25. The nurse is assessing the
endocrine system. Which organ is
part of the endocrine system?
Heart
Sinus
Thyroid
Thymus
(C) Thyroid. The thyroid is part of
the endocrine system. Heart,
sinus and thymus are not.
.
PNLE
Fundamentals in
Nursing Exam 3
1. Nurse Brenda is teaching a
patient about a newly prescribed
drug. What could cause a geriatric
patient to have difficulty retaining
knowledge about prescribed
medications?
Decreased plasma drug levels
Sensory deficits
Lack of family support
History of Tourette syndrome
(B) Sensory deficits. Sensory
deficits could cause a geriatric
patient to have difficulty
retaining knowledge about
prescribed medications.
Decreased plasma drug levels do
not alter the patient’s knowledge
about the drug. A lack of family
support may affect compliance,
not knowledge retention. Toilette
syndrome is unrelated to
knowledge retention.
2. When examining a patient with
abdominal pain the nurse in charge
should assess:
Any quadrant first
The symptomatic quadrant first
The symptomatic quadrant last
The symptomatic quadrant either
second or third
(C) The symptomatic quadrant
last. The nurse should
systematically assess all areas of
the abdomen, if time and the
patient’s condition permit,
concluding with the symptomatic
area. Otherwise, the nurse may
elicit pain in the symptomatic
 area, causing the muscles in
other areas to tighten. This would
interfere with further
assessment.
3. The nurse is assessing a
postoperative adult patient. Which
of the following should the nurse
document as subjective data?
Vital signs
Laboratory test result
Patient’s description of pain
Electrocardiographic (ECG)
waveforms
(C) Patient’s description of
pain. Subjective data come
directly from the patient and
usually are recorded as direct
quotations that reflect the
patient’s opinions or feelings
about a situation. Vital signs,
laboratory test result, and ECG
waveforms are examples of
objective data.
4. A male patient has a soft wrist-
safety device. Which assessment
finding should the nurse consider
abnormal?
A palpable radial pulse
A palpable ulnar pulse
Cool, pale fingers
Pink nail beds
(C) Cool, pale fingers. A safety
device on the wrist may impair
circulation and restrict blood
supply to body tissues.
Therefore, the nurse should
assess the patient for signs of
impaired circulation, such as
cool, pale fingers. A palpable
radial or lunar pulse and pink nail
beds are normal findings.
5. Which of the following planes
divides the body longitudinally into
anterior and posterior regions?
Frontal plane
Sagittal plane
Midsagittal plane
Transverse plane
(A) Frontal plane. Frontal or coronal
plane runs longitudinally at a
right angle to a sagittal plane
dividing the body in anterior and
posterior regions. A sagittal plane
runs longitudinally dividing the
body into right and left regions; if
exactly midline, it is called a
midsagittal plane. A transverse
plane runs horizontally at a right
angle to the vertical axis,
dividing the structure into
superior and inferior regions.
6. A female patient with a terminal
illness is in denial. Indicators of
denial include:
Shock dismay
Numbness
Stoicism
Preparatory grief
(A) Shock dismay. Shock and
dismay are early signs of denial-
the first stage of grief. The other
options are associated with
depression—a later stage of grief.
7. The nurse in charge is transferring
a patient from the bed to a chair.
Which action does the nurse take
during this patient transfer?
Position the head of the bed flat
Helps the patient dangle the
legs
Stands behind the patient
Places the chair facing away from
the bed
(B) Helps the patient dangle the
legs. After placing the patient in
high Fowler’s position and
moving the patient to the side of
the bed, the nurse helps the
patient sit on the edge of the bed
and dangle the legs; the nurse
then faces the patient and places
the chair next to and facing the
head of the bed.
8. A female patient who speaks a
little English has emergency
gallbladder surgery, during
discharge preparation, which nursing
action would best help this patient
understand wound care instruction?
Asking frequently if the patient
understands the instruction
Asking an interpreter to replay the
instructions to the patient.
Writing out the instructions and
having a family member read
them to the patient
Demonstrating the procedure
and having the patient return
the demonstration
(D) Demonstrating the procedure
and having the patient return the
demonstration. Demonstrating
by the nurse with a return
demonstration by the patient
ensures that the patient can
perform wound care correctly.
Patients may claim to understand
discharge instruction when they
do not. An interpreter of family
member may communicate
verbal or written instructions
inaccurately.
9. Before administering the evening
dose of a prescribed medication, the
nurse on the evening shift finds an
unlabeled, filled syringe in the
patient’s medication drawer. What
should the nurse in charge do?
Discard the syringe to avoid a
medication error
Obtain a label for the syringe from
the pharmacy
Use the syringe because it looks like
it contains the same medication
the nurse was prepared to give
Call the day nurse to verify the
contents of the syringe
(A) Discard the syringe to avoid a
medication error. As a safety
precaution, the nurse should
discard an unlabeled syringe that
contains medication. The other
options are considered unsafe
because they promote error.
10. When administering drug
therapy to a male geriatric patient,
the nurse must stay especially alert
for adverse effects. Which factor
makes geriatric patients to adverse
drug effects?
Faster drug clearance
Aging-related physiological
changes
Increased amount of neurons
Enhanced blood flow to the GI tract
(B) Aging-related physiological
changes. Aging-related
physiological changes account
for the increased frequency of
adverse drug reactions in
geriatric patients. Renal and
hepatic changes cause drugs to
clear more slowly in these
patients. With increasing age,
neurons are lost and blood flow
to the GI tract decreases.
11. A female patient is being
discharged after cataract surgery.
After providing medication teaching,
the nurse asks the patient to repeat
the instructions. The nurse is
performing which professional role?
Manager
Educator
Caregiver
Patient advocate
(B) Educator. When teaching a
patient about medications before
discharge, the nurse is acting as
an educator. The nurse acts as a
manager when performing such
activities as scheduling and
making patient care
assignments. The nurse performs
the care giving role when
providing direct care, including
bathing patients and
administering medications and
prescribed treatments. The nurse
acts as a patient advocate when
 making the patient’s wishes
known to the doctor.
12. A female patient exhibits signs of
heightened anxiety. Which response
by the nurse is most likely to reduce
the patient’s anxiety?
“Everything will be fine. Don’t
worry.”
“Read this manual and then ask me
any questions you may have.”
“Why don’t you listen to the radio?”
“Let’s talk about what’s
bothering you.”
(D) “Let’s talk about what’s
bothering you.” Anxiety may
result from feeling of
helplessness, isolation, or
insecurity. This response helps
reduce anxiety by encouraging
the patient to express feelings.
The nurse should be supportive
and develop goals together with
the patient to give the patient
some control over an anxiety-
inducing situation. Because the
other options ignore the patient’s
feeling and block communication,
they would not reduce anxiety.
13. A scrub nurse in the operating
room has which responsibility?
Positioning the patient
Assisting with gowning and gloving
Handling surgical instruments
to the surgeon
Applying surgical drapes
(C) Handling surgical instruments to
the surgeon. The scrub nurse
assist the surgeon by providing
appropriate surgical instruments
and supplies, maintaining strict
surgical asepsis and, with the
circulating nurse, accounting for
all gauze, sponges, needles, and
instruments. The circulating
nurse assists the surgeon and
scrub nurse, positions the
patient, applies appropriate
equipment and surgical drapes,
assists with gowning and gloving,
and provides the surgeon and
scrub nurse with supplies.
14. A patient is in the bathroom
when the nurse enters to give a
prescribed medication. What should
the nurse in charge do?
Leave the medication at the
patient’s bedside
Tell the patient to be sure to take
the medication. And then leave it
at the bedside
Return shortly to the patient’s
room and remain there until
the patient takes the
medication
Wait for the patient to return to bed,
and then leave the medication at
the bedside
(C) Return shortly to the patient’s
room and remain there until the
patient takes the medication. The
nurse should return shortly to the
patient’s room and remain there
until the patient takes the
medication to verify that it was
taken as directed. The nurse
should never leave medication at
the patient’s bedside unless
specifically requested to do so.
15. The physician orders heparin,
7,500 units, to be administered
subcutaneously every 6 hours. The
vial reads 10,000 units per millilitre.
The nurse should anticipate giving
how much heparin for each dose?
¼ ml
½ ml
¾ ml
1 ¼ ml
(C) ¾ ml. The nurse solves the
problem as follows: 10,000
units/7,500 units = 1 ml/X 10,000
X = 7,500 X= 7,500/10,000 or ¾
ml
16. The nurse in charge measures a
patient’s temperature at 102
degrees F. what is the equivalent
Centigrade temperature?
39 degrees C
47 degrees C
38.9 degrees C
40.1 degrees C
(C) 38.9 degrees C. To convert
Fahrenheit degrees to centigrade,
use this formula: C degrees = (F
degrees – 32) x 5/9 C degrees =
(102 – 32) 5/9 + 70 x 5/9 38.9
degrees C
17. To evaluate a patient for
hypoxia, the physician is most likely
to order which laboratory test?
Red blood cell count
Sputum culture
Total hemoglobin
Arterial blood gas (ABG)
analysis
(D) Arterial blood gas (ABG)
analysis. All of these test help
evaluate a patient with
respiratory problems. However,
ABG analysis is the only test
evaluates gas exchange in the
lungs, providing information
about patient’s oxygenation
status.
18. The nurse uses a stethoscope to
auscultate a male patient’s chest.
Which statement about a
stethoscope with a bell and
diaphragm is true?
The bell detects high-pitched
sounds best
The diaphragm detects high-
pitched sounds best
The bell detects thrills best
The diaphragm detects low-pitched
sounds best
(B) The diaphragm detects high-
pitched sounds best. The
diaphragm of a stethoscope
detects high-pitched sound best;
the bell detects low pitched
sounds best. Palpation detects
thrills best.
19. A male patient is to be
discharged with a prescription for an
analgesic that is a controlled
substance. During discharge
teaching, the nurse should explain
that the patient must fill this
prescription how soon after the date
on which it was written?
Within 1 month
Within 3 months
Within 6 months
Within 12 months
(C) Within 6 months. In most cases,
an outpatient must fill a
prescription for a controlled
substance within 6 months of the
date on which the prescription
was written.
20. Which human element
considered by the nurse in charge
during assessment can affect drug
administration?
The patient’s ability to recover
The patient’s occupational hazards
The patient’s socioeconomic status
The patient’s cognitive abilities
(D) The patient’s cognitive
abilities. The nurse must consider
the patient’s cognitive abilities to
understand drug instructions. If
not, the nurse must find a family
member or significant other to
take on the responsibility of
administering medications in the
home setting. The patient’s
ability to recover, occupational
hazards, and socioeconomic
status do not affect drug
administration.
21. When explaining the initiation of
I.V. therapy to a 2-year-old child, the
nurse should:
Ask the child, “Do you want me to
start the I.V. now?”
Give simple directions shortly
before the I.V. therapy is to
start
Tell the child, “This treatment is for
your own good”
Inform the child that the needle will
be in place for 10 days
(B) Give simple directions shortly
before the I.V. therapy is to
start. Because a 2-year-old child
has limited understanding, the
nurse should give simple
directions and explanations of
what will occur shortly before the
procedure. She should try to
avoid frightening the child with
the explanation and allow the
child to make simple choices,
such as choosing the I.V.
insertion site, if possible.
However, she shouldn’t ask the
child if he wants the therapy,
because the answer may be
“No!” Telling the child that the
treatment is for his own good is
ineffective because a 2-year-old
perceives pain as a negative
sensation and cannot understand
that a painful procedure can
have position results. Telling the
child how long the therapy will
last is ineffective because the 2-
year-old doesn’t have a good
understanding of time.
22. All of the following parts of the
syringe are sterile except the:
Barrel
Inside of the plunger
Needle tip
Barrel tip
(A) Barrel. All syringes have three
parts: a tip, which connects the
needle to the syringe; a barrel,
the outer part on which the
measurement scales are printed;
and a plunger, which fits inside
the barrel to expel the
medication. The external part of
the barrel and the plunger and
(flange) must be handled during
the preparation and
administration of the injection.
However, the inside and trip of
the barrel, the inside (shaft) of
the plunger, and the needle tip
must remain sterile until after the
injection.
23. The best way to instill eye drops
is to:
Instruct the patient to lock
upward, and drop the
medication into the center of
the lower lid
Instruct the patient to look ahead,
and drop the medication into the
center of the lower lid
Drop the medication into the inner
canthus regardless of eye
position
Drop the medication into the center
of the canthus regardless of eye
position
(A) Instruct the patient to lock
upward, and drop the medication
into the center of the lower
lid. Having the patient look
upward reduces blinking and
protects the cornea. Instilling
drops in the center of the lower
lid promotes absorption because
the drops are less likely to run
into the nasolacrimal duct or out
of the eye.
24. The difference between an 18G
needle and a 25G needle is the
needle’s:
Length
Bevel angle
Thickness
Sharpness
(C) Thickness. Gauge is a measure
of the needle’s thickness: The
higher the number the thinner
the shaft. Therefore, an 18G
needle is considerably thicker
than a 25G needle.
25. A patient receiving an
anticoagulant should be assessed for
signs of:
Hypotension
Hypertension
An elevated hemoglobin count
An increased number of
erythrocytes
Maternal and Child
Nursing
PNLE Maternal
and Child Health
Nursing Exam 1
1. A client asks the nurse what a third degree
laceration is. She was informed that she had
one. The nurse explains that this is:
a) that extended their anal sphincter
b) through the skin and into the muscles
c) that involves anterior rectal wall
d) that extends through the perineal
muscle.
Answer. (A) that extended their anal
sphincter. Third degree laceration
involves all in the second degree
laceration and the external sphincter of
the rectum. Options B, C and D are under
the second degree laceration.
2. Betina 30 weeks AOG discharged with a
diagnosis of placenta previa. The nurse
knows that the client understands her care at
home when she says:
A. I am happy to note that we can have sex
occasionally when I have no bleeding.
B. I am afraid I might have an operation
when my due comes
C. I will have to remain in bed until my
due date comes
D/ I may go back to work since I stay only at
the office.
Answer. (C) I will have to remain in bed until
my due date comes. Placenta previa means
that the placenta is the presenting part. On
the first and second trimester there is
spotting. On the third trimester there is
bleeding that is sudden, profuse and painless
3. The uterus has already risen out of the
pelvis and is experiencing farther into the
abdominal area at about the:
a. 8th week of pregnancy
b. 10th week of pregnancy
c. 12th week of pregnancy
d. 18th week of pregnancy
(D) 18th week of pregnancy. On the 8th
week of pregnancy, the uterus is still
within the pelvic area. On the 10th week,
the uterus is still within the pelvic area.
On the 12th week, the uterus and
placenta have grown, expanding into the
abdominal cavity. On the 18th week, the
uterus has already risen out of the pelvis
and is expanding into the abdominal
area.
4. Which of the following urinary symptoms
does the pregnant woman most frequently
experience during the first trimester:
a) frequency
b) dysuria
c) incontinence
d) Burning
(A) frequency. Pressure and irritation of the
bladder by the growing uterus during the
first trimester is responsible for causing
urinary frequency. Dysuria, incontinence
and burning are symptoms associated
with urinary tract infection.
5. Mrs. Jimenez went to the health center for
pre-natal check-up. the student nurse took
her weight and revealed 142 lbs. She asked
the student nurse how much should she gain
weight in her pregnancy.
a. 20-30 lbs
b. 25-35 lbs
c. 30- 40 lbs
d. 10-15 lbs
(B) 25-35 lbs. A weight gain of 11. 2 to 15.9
kg (25 to 35 lbs) is currently
recommended as an average weight
gain in pregnancy. This weight gain
consists of the following: fetus- 7.5 lb;
placenta- 1.5 lb; amniotic fluid- 2 lb;
uterus- 2.5 lb; breasts- 1.5 to 3 lb; blood
volume- 4 lb; body fat- 7 lb; body fluid- 7
lb.
6. The nurse is preparing Mrs. Jordan for
cesarean delivery. Which of the following key
concept should the nurse consider when
implementing nursing care?
a) Explain the surgery, expected outcome
and kind of anesthetics.
b) Modify preoperative teaching to
meet the needs of either a planned
or emergency cesarean birth.
c) Arrange for a staff member of the
anesthesia department to explain what
to expect post-operatively.
d) Instruct the mother’s support person to
remain in the family lounge until after
the delivery.
(B) Modify preoperative teaching to meet
the needs of either a planned or
emergency cesarean birth. A key point to
consider when preparing the client for a
cesarean delivery is to modify the
preoperative teaching to meet the needs
of either planned or emergency cesarean
birth, the depth and breadth of
instruction will depend on circumstances
and time available.
7. Bettine Gonzales is hospitalized for the
treatment of severe preecplampsia. Which of
the following represents an unusual finding
for this condition?
a. generalized edema
b. proteinuria 4+
c. blood pressure of 160/110
d. Convulsions
(D) convulsions. Options A, B and C are
findings of severe preeclampsia.
Convulsions is a finding of eclampsia—an
obstetrical emergency.
8. Nurse Geli explains to the client who is 33
weeks pregnant and is experiencing vaginal
bleeding that coitus:
a) Need to be modified in any way by either
partner
b) Is permitted if penile penetration is not
deep.
c) Should be restricted because it may
stimulate uterine activity.
d) Is safe as long as she is in side-lying
position.
(C) Should be restricted because it may
stimulate uterine activity.. Coitus is
restricted when there is watery
discharge, uterine contraction and
vaginal bleeding. Also those women with
a history of spontaneous miscarriage
may be advised to avoid coitus during
the time of pregnancy when a previous
miscarriage occurred.
9. Mrs. Precilla Abuel, a 32 year old mulripara
is admitted to labor and delivery. Her last 3
pregnancies in short stage one of labor. The
nurses decide to observe her closely. The
physician determines that Mrs. Abuel’s cervix
is dilated to 6 cm. Mrs. Abuel states that she
is extremely uncomfortable. To lessen Mrs.
Abuel’s discomfort, the nurse can advise her
to:
a. lie face down
b. not drink fluids
c. practice holding breaths between
contractions
d. assume Sim’s position
(D) assume Sim’s position. When the
woman is in Sim’s position, this puts the
weight of the fetus on bed, not on the
woman and allows good circulation in the
lower extremities.
10. Which is true regarding the fontanels of
the newborn?
a) The anterior is large in shape when
compared to the posterior fontanel.
b) The anterior is triangular shaped; the
posterior is diamond shaped.
c) The anterior is bulging; the posterior
appears sunken.
d) The posterior closes at 18 months; the
anterior closes at 8 to 12 months.
(A) The anterior is large in shape when
compared to the posterior fontanel.. The
anterior fontanel is larger in size than
the posterior fontanel. Additionally, the
anterior fontanel, which is diamond
shaped closes at 18 month, whereas the
posterior fontanel, which is triangular in
shape closes at 8 to 12 weeks. Neither
fontanel should appear bulging, which
may indicate increases ICP or sunken,
which may indicate hydration.
11. Mrs. Quijones gave birth by spontaneous
delivery to a full term baby boy. After a
minute after birth, he is crying and moving
actively. His birth weight is 6.8 lbs. What do
you expect baby Quijones to weigh at 6
months?
a. 13 -14 lbs
b. 16 -17 lbs
c. 22 -23 lbs
d. 27 -28 lbs
A) 13 -14 lbs. The birth weight of an infant is
doubled at 6 months and is tripled at 12
months
12. During the first hours following delivery,
the post partum client is given IVF with
oxytocin added to them. The nurse
understands the primary reason for this is:
a) To facilitate elimination
b) To promote uterine contraction
c) To promote analgesia
d) To prevent infection
B To promote uterine contraction. Oxytocin
is a hormone produced by the pituitary
gland that produces intermittent uterine
contractions, helping to promote uterine
involution.
13. Nurse Luis is assessing the newborn’s
heart rate. Which of the following would be
considered normal if the newborn is
sleeping?
a. 80 beats per minute b) Using gesture to communicate at 18
b. 100 beats per minute months.
c. 120 beats per minute c) Cooing at 3 months.
d. 140 beats per minute d) Saying “mama” or “dada” for the
first time at 18 months of age.
(B) 100 beats per minute. The normal heart
rate for a newborn that is sleeping is (D) Saying “mama” or “dada” for the first
approximately 100 beats per minute. If time at 18 months of age.. A child should
the newborn was awake, the normal say “mama” or “dada” during 10 to 12
heart rate would range from 120 to 160 months of age. Options A, B and C are all
beats per minute. normal assessments of language
development of a child.
14. The infant with Down Syndrome should
go through which of the Erikson’s
developmental stages first? 18. Isabelle, a 2 year old girl loves to move
around and oftentimes manifests negativism
a) Initiative vs. Self doubt and temper tantrums. What is the best way
b) Industry vs. Inferiority to deal with her behavior?
c) Autonomy vs. Shame and doubt
d) Trust vs. Mistrust a. Tell her that she would not be loved by
others is she behaves that way..
D) Trust vs. Mistrust. The child with Down b. Withholding giving her toys until she
syndrome will go through the same first behaves properly.
stage, trust vs. mistrust, only at a slow c. Ignore her behavior as long as she does
rate. Therefore, the nurse should not hurt herself and others.
concentrate on developing on bond d. Ask her what she wants and give it to
between the primary caregiver and the pacify her.
child. (B) Ignore her behavior as long as she
does not hurt herself and others.. If a
15. The child with phenylketonuria (PKU) child is trying to get attention or trying
must maintain a low phenylalanine diet to to get something through tantrums—
prevent which of the following ignore his/her behavio
complications?
19. Baby boy Villanueva, 4 months old, was
a. Irreversible brain damage seen at the pediatric clinic for his scheduled
b. Kidney failure check-up. By this period, baby Villanueva has
c. Blindness already increased his height by how many
d. Neutropenia inches?

(A) Irreversible brain damage. The child a) 3 inches

with PKU must maintain a strict low
phenylalanine diet to prevent central
nervous system damage, seizures and
eventual dea
16. Which age group is with imaginative
minds and creates imaginary friends?
b) 4 inches
c) 5 inches
d) 6 inches
(B) 4 inches. From birth to 6 months, the
infant grows 1 inch (2.5 cm) per month.
From 6 to 12 months, the infant grows ½
inch (1.25 cm) per month.

a) Toddler 20. Alice, 10 years old was brought to the ER

b) Preschool because of Asthma. She was immediately
c) School put under aerosol administration of
d) Adolescence Terbutaline. After sometime, you observe
that the child does not show any relief from
(B) Preschool. During preschool, this is the the treatment given. Upon assessment, you
time when children do imitative play, noticed that both the heart and respiratory
imaginative play—the occurrence of rate are still elevated and the child shows
imaginative playmates, dramatic play difficulty of exhaling. You suspect:
where children like to act, dance and
sing. a. Bronchiectasis
b. Atelectasis
17. Which of the following situations would c. Epiglotitis
alert you to a potentially developmental d. Status Asthmaticus
problem with a child? (D) Status Asthmaticus. Status asthmaticus
leads to respiratory distress and
a) Pointing to body parts at 15 months of bronchospasm despite of treatment and
age.
 interventions. Mechanical ventilation
maybe needed due to respiratory failure.
21. Nurse Jonas assesses a 2 year old boy
with a tentative diagnosis of
nephroblastoma. Symptoms the nurse
observes that suggest this problem include:
a) Lymphedema and nerve palsy
b) Hearing loss and ataxia
c) Headaches and vomiting
d) Abdominal mass and weakness
(D)Abdominal mass and
weakness. Nephroblastoma or Wilm’s tumor
is caused by chromosomal abnormalities,
most common kidney cancer among children
characterized by abdominal mass,
hematuria, hypertension and fever
22. Which of the following danger sings
should be reported immediately during the
antepartum period?
a. blurred vision
b. nasal stuffiness
c. breast tenderness
d. Constipation
(A) blurred vision. Danger signs that require
prompt reporting are leaking of amniotic
fluid, blurred vision, vaginal bleeding,
rapid weight gain and elevated blood
pressure. Nasal stuffiness, breast
tenderness, and constipation are
common discomforts associated with
pregnancy.
23. Nurse Jacob is assessing a 15 month old
child with acute otitis media. Which of the
following symptoms would the nurse
anticipate finding?
a) periorbital edema, absent light reflex and
translucent tympanic membrane
b) irritability, purulent drainage in
middle ear, nasal congestion and
cough
c) diarrhea, retracted tympanic membrane
and enlarged parotid gland
d) Vomiting, pulling at ears and pearly white
tympanic membrane
(B) irritability, purulent drainage in middle
ear, nasal congestion and
cough. Irritability, purulent drainage in
middle ear, nasal congestion and cough,
fever, loss of appetite, vomiting and
diarrhea are clinical manifestations of
otitis media. Acute otitis media is
common in children 6 months to 3 years
old and 8 years old and above. Breast
fed infants have higher resistance due to
protection of Eustachian tubes and
middle ear from breast milk.
24. Which of the following is the most
appropriate intervention to reduce stress in a
preterm infant at 33 weeks gestation?
a. Sensory stimulation including several
senses at a time
b. tactile stimulation until signs of over
stimulation develop
c. An attitude of extension when prone or
side lying
d. Kangaroo care
(D) Kangaroo care. Kangaroo care is the use
of skin-to-skin contact to maintain body
heat. This method of care not only
supplies heat but also encourages
parent-child interaction.
25. The parent of a client with albinism
would need to be taught which preventive
healthcare measure by the nurse:
a) Ulcerative colitis diet
b) Use of a high-SPF sunblock
c) Hair loss monitoring
d) Monitor for growth retardation
(B) Use of a high-SPF sunblock. Without
melanin production, the child with
albinism is at risk for severe sunburns.
Maximum sun protection should be
taken, including use of hats, long
sleeves, minimal time in the sun and
high-SPF sunblock, to prevent any
problems.
PNLE Maternal and
Child Health Nursing
Exam 2
1. Nurse Bella explains to a 28 year old
pregnant woman undergoing a non-stress
test that the test is a way of evaluating the
condition of the fetus by comparing the fetal
heart rate with:
a. Fetal lie
b. Fetal movement
c. Maternal blood pressure
d. Maternal uterine contractions
(B) Fetal movement. Non-stress test
measures response of the FHR to the
fetal movement. With fetal movement,
FHR increase by 15 beats and remain for
15 seconds then decrease to average
rate. No increase means poor
oxygenation perfusion to fetus.
2. During a 2 hour childbirth focusing on
labor and delivery process for primigravida.
The nurse describes the second maneuver
that the fetus goes through during labor
progress when the head is the presenting
part as which of the following:
a. Flexion
b. Internal rotation
c. Descent
d. External rotation
(A) Flexion. The 6 cardinal movements of
labor are descent, flexion, internal
rotation, extension, external rotation and
expulsion.
3. Mrs. Jovel Diaz went to the hospital to
have her serum blood test for alpha-
fetoprotein. The nurse informed her about
the result of the elevation of serum AFP. The
patient asked her what was the test for:
a) Congenital Adrenal Hyperplasia
b) PKU
c) Down Syndrome
d) Neural tube defects
(D)Neural tube defects. Alpha-fetoprotein is a
substance produces by the fetal liver that is
present in amniotic fluid and maternal
serum. The level is abnormally high in the
maternal serum if the fetus has an open
spinal or abdominal defect because the open
defect allows more AFP to appear
4. Fetal heart rate can be auscultated with a
fetoscope as early as:
a. 5 weeks of gestation
b. 10 weeks of gestation
c. 15 weeks of gestation
d. 20 weeks of gestation
(D) 20 weeks of gestation. The FHR can be
auscultated with a fetoscope at about 20
weeks of gestation. FHR is usually
auscultated at the midline suprapubic
region with Doppler ultrasound at 10 to
12 weeks of gestation. FHR cannot be
heard any earlier than 10 weeks of
gestation.
5. Mrs. Bendivin states that she is
experiencing aching swollen, leg veins. The
nurse would explain that this is most
probably the result of which of the following:
a) Thrombophlebitis
b) PIH
c) Pressure on blood vessels from the
enlarging uterus
d) The force of gravity pulling down on the
uterus
(C) Pressure on blood vessels from the
enlarging uterus. Pressure of the growing
fetus on blood vessels results in an
increase risk for venous stasis in the
lower extremities. Subsequently, edema
and varicose vein formation may occur.
6. Mrs. Ella Santoros is a 25 year old
primigravida who has Rheumatic heart
disease lesion. Her pregnancy has just been
diagnosed. Her heart disease has not caused
her to limit physical activity in the past. Her
cardiac disease and functional capacity
classification is:
a. Class I
b. Class II
c. Class III
d. class IV
(A) Class I. Clients under class I has no
physical activity limitation. There is a
slight limitation of physical activity in
class II, ordinary activity causes
fatigue, palpitation, dyspnea or
angina. Class III is moderate limitation
of physical activity; less than ordinary
activity causes fatigue. Unable to
carry on any activity without
experiencing discomfort is under class
IV
7. The client asks the nurse, “When will this
soft spot at the top of the head of my baby
will close?” The nurse should instruct the
mother that the neonate’s anterior fontanel
will normally close by age:
a) 2-3 months
b) 6-8 months
c) 10-12 months
d) 12-18 months
(D) 12-18 months. Anterior fontanel closes
at 12-18 months while posterior fontanel
closes at birth until 2 months.
8. When a mother bleeds and the uterus is
relaxed, soft and non-tender, you can
account the cause to:
a. Atony of the uterus
b. Presence of uterine scar
c. Laceration of the birth canal
d. Presence of retained placenta fragments
A) Atony of the uterus. Uterine atony, or
relaxation of the uterus is the most frequent
cause of postpartal hemorrhage. It is the
inability to maintain the uterus in contracted
state.
9. Mrs. Pichie Gonzales’s LMP began April 4,
2010. Her EDD should be which of the
following:
a) February 11, 2011
b) January 11, 20111
c) December 12, 2010
d) Nowember 14, 2010
(B) January 11, 20111. Using the Nagel’s
rule, he use this formula ( -3 calendar
months + 7 days).
10. Which of the following prenatal
laboratory test values would the nurse
consider as significant?
a. Hematocrit 33.5%
b. WBC 8,000/mm3
c. Rubella titer less than 1:8
d. One hour glucose challenge test 110 g/dL
C Rubella titer less than 1:8. A rubella titer
should be 1:8 or greater. Thus, a finding of a
titer less than 1:8 is significant, indicating
that the client may not possess immunity to
rubella. A hematocrit of 33.5%, WBC of
8,000/mm3, and a 1 hour glucose challenge
test of 110 g/dL are within normal
parameters.
11. Aling Patricia is a patient with
preeclampsia. You advise her about her
condition, which would tell you that she has
not really understood your instructions?
a) “I will restrict my fat in my diet.”
b) “I will limit my activities and rest
more frequently throughout the
day.”
c) “I will avoid salty foods in my diet.”
d) “I will come more regularly for check-up.”
(B) “I will limit my activities and rest more
frequently throughout the day.”Pregnant
woman with preeclampsia should be in a
complete bed rest. When body is in
recumbent position, sodium tends to be
excreted at a faster rate. It is the best
method of aiding increased excretion of
sodium and encouraging diuresis. Rest
should always be in a lateral recumbent
position to avoid uterine pressure on the
vena cava and prevent supine
hypotension.
12. Mrs. Grace Evangelista is admitted with
severe preeclampsia. What type of room
should the nurse select this patient?
a. A room next to the elevator.
b. The room farthest from the nursing
station.
c. The quietest room on the floor.
d. The labor suite.
(C) The quietest room on the floor.A loud
noise such as a crying baby, or a
dropped tray of equipment may be
sufficient to trigger a seizure initiating
eclampsia, a woman with severe
preeclampsia should be admiotted to a
private room so she can rest as
undisturbed as possible. Darken the
room if possible because bright light can
trigger seizures.
13. During a prenatal check-up, the nurse
explains to a client who is Rh negative that
RhoGAM will be given:
a) Weekly during the 8th month because
this is her third pregnancy.
b) During the second trimester, if
amniocentesis indicates a problem.
c) To her infant immediately after delivery if
the Coomb’s test is positive.
d) Within 72 hours after delivery if
infant is found to be Rh positive.
(D) Within 72 hours after delivery if infant is
found to be Rh positive. RhoGAM is given
to Rh-negative mothers within 72 hours
after birth of Rh-positive baby to prevent
development of antibodies in the
maternal blood stream, which will be fata
to succeeding Rh-positive offspring.
14. A baby boy was born at 8:50pm. At
8:55pm, the heart rate was 99 bpm. She has
a weak cry, irregular respiration. She was
moving all extremities and only her hands
and feet were still slightly blue. The nurse
should enter the APGAR score as:
a. 5
b. 6
c. 7
d. 8
(B) 6. Heart rate of 99 bpm-1; weak cry-1;
irregular respiration-1; moving all
extremities-2; extremities are slightly
blue-1; with a total score of 6.
15. Billy is a 4 year old boy who has an IQ of
140 which means:
a. average normal
b. very superior
c. above average
d. Genius

(D) genius. IQ= mental age/chronological
age x 100. Mental age refers to the
typical intelligence level found for people
at a give chronological age. OQ of 140
and above is considered genius.
16. A newborn is brought to the nursery.
Upon assessment, the nurse finds that the
child has short palpebral fissures, thinned
upper lip. Based on this data, the nurse
suspects that the newborn is MOST likely
showing the effects of:
a) Chronic toxoplasmosis
b) Lead poisoning
c) Congenital anomalies
d) Fetal alcohol syndrome
(D) Fetal alcohol syndrome. The newborn
with fetal alcohol syndrome has a
number of possible problems at birth.
Characteristics that mark the syndrome
include pre and postnatal growth
retardation; CNS involvement such as
cognitive challenge, microcephally and
cerebral palsy; and a distinctive facial
feature of a short palpebral fissure and
thin upper lip.
17. A priority nursing intervention for the
infant with cleft lip is which of the following:
a. Monitoring for adequate nutritional
intake
b. Teaching high-risk newborn care
c. Assessing for respiratory distress
d. Preventing injury
(A) Monitoring for adequate nutritional
intake. The infant with cleft lip is unable
to create an adequate seal for sucking.
The child is at risk for inadequate
nutritional intake as well as aspiration.
18. Nurse Jacob is assessing a 12 year old
who has hemophilia A. Which of the following
assessment findings would the nurse
anticipate?
a) an excess of RBC
b) an excess of WBC
c) a deficiency of clotting factor VIII
d) a deficiency of clotting factor IX
C) a deficiency of clotting factor
VIII. Hemophillia A (classic hemophilia) is
a deficiency in factor VIII (an alpha
globulin that stabilizes fibrin clots).
19. Celine, a mother of a 2 year old tells the
nurse that her child “cries and has a fit when
I have to leave him with a sitter or someone
else.” Which of the following statements
would be the nurse’s most accurate analysis
of the mother’s comment?
a. The child has not experienced limit-
setting or structure.
b. The child is expressing a physical need,
such as hunger.
c. The mother has nurtured
overdependence in the child.
d. The mother is describing her child’s
separation anxiety.
(D) The mother is describing her child’s
separation anxiety. Before coming to any
conclusion, the nurse should ask the
mother focused questions; however,
based on initial information, the analysis
of separation anxiety would be most
valid. Separation anxiety is a normal
toddler response. When the child senses
he is being sent away from those who
most provide him with love and security.
Crying is one way a child expresses a
physical need; however, the nurse would
be hasty in drawing this as first
conclusion based on what the mother
has said. Nurturing overdependence or
not providing structure for the toddler
are inaccurate conclusions based on the
information provided.
20. Mylene Lopez, a 16 year old girl with
scoliosis has recently received an invitation
to a pool party. She asks the nurse how she
can disguise her impairment when dressed in
a bathing suit. Which nursing diagnosis can
be justified by Mylene’s statement?
a) Anxiety
b) Body image disturbance
c) Ineffective individual coping
d) Social isolation
(B) Body image disturbance. Mylene is
experiencing uneasiness about the
curvative of her spine, which will be
more evident when she wears a bathing
suit. This data suggests a body image
disturbance. There is no evidence of
anxiety or ineffective coping. The fact
that Mylene is planning to attend a pool
party dispels a diagnosis of social
isolation.
21. The foul-smelling, frothy characteristic of
the stool in cystic fibrosis results from the
presence of large amounts of which of the
following:
a. sodium and chloride
b. undigested fat
c. semi-digested carbohydrates
d. lipase, trypsin and amylase
(B) undigested fat. The client with cystic
fibrosis absorbs fat poorly because of the
think secretions blocking the pancreatic
 duct. The lack of natural pancreatic
enzyme leads to poor absorption of
predominantly fats in the duodenum.
Foul-smelling, frothy stool is termed
steatorrhea.
22. Which of the following would be a
disadvantage of breast feeding?
a) involution occurs rapidly
b) the incidence of allergies increases due
to maternal antibodies
c) the father may resent the infant’s
demands on the mother’s body
d) there is a greater chance of error during
preparation
(C) the father may resent the infant’s
demands on the mother’s body. With
breast feeding, the father’s body is not
capable of providing the milk for the
newborn, which may interfere with
feeding the newborn, providing fewer
chances for bonding, or he may be
jealous of the infant’s demands on his
wife time and body. Breast feeding is
advantageous because uterine involution
occurs more rapidly, thus minimizing
blood loss. The presence of maternal
antibodies in breast milk helps decrease
the incidence of allergies in the newborn.
A greater chance for error is associated
with bottle feeding. No preparation
required for breast feeding.
23. A client is noted to have lymphedema,
webbed neck and low posterior hairline.
Which of the following diagnoses is most
appropriate?
a. Turner’s syndrome
b.
c.
Down’s syndrome
Marfan’s syndrome
d. Klinefelter’s syndrome
(A) Turner’s syndrome. Lymphedema,
webbed neck and low posterior hairline,
these are the 3 key assessment features
in Turner’s syndrome. If the child is
diagnosed early in age, proper treatment
can be offered to the family. All
newborns should be screened for
possible congenital defects.
24. A 4 year old boy most likely perceives
death in which way:
a) An insignificant event unless taught
otherwise
b) Punishment for something the individual
did
c) Something that just happens to older
people
d) Temporary separation from the
loved one.
(D) Temporary separation from the loved
one. The predominant perception of
death by preschool age children is that
death is temporary separation. Because
that child is losing someone significant
and will not see that person again, it’s
inaccurate to infer death is insignificant,
regardless of the child’s response.
25. Catherine Diaz is a 14 year old patient on
a hematology unit who is being treated for
sickle cell crisis. During a crisis such as that
seen in sickle cell anemia, aldosterone
release is stimulated. In what way might this
influence Catherine’s fluid and electrolyte
balance?
a. sodium loss, water loss and potassium
retention
b. sodium loss, water los and potassium
loss
c. sodium retention, water loss and
potassium retention
d. sodium retention, water retention
and potassium loss
(D) sodium retention, water retention and
potassium loss. Stress stimulates the adrenal
cortex to increase the release of aldosterone.
Aldosterone promotes the resorption of
sodium, the retention of water and the loss
of potassium
PNLE Maternal
and Child Health
Nursing Exam 3
1. A pregnant woman who is at term is
admitted to the birthing unit in active
labor. The client has only progressed
from 2cm to 3 cm in 8 hours. She is
diagnosed with hypotonic dystocia and
the physician ordered Oxytocin (Pitocin)
to augment her contractions. Which of
the following is the most important
aspect of nursing intervention at this
time?
a) Timing and recording length of
contractions.
b) Monitoring.
c) Preparing for an emergency cesarean
birth.
d) Checking the perineum for bulging.
A. The oxytocic effect of Pitocin
increases the intensity and durations
of contractions; prolonged
contractions will jeopardize the
safetyof the fetus and necessitate
discontinuing the drug.
2. A client who hallucinates is not in
touch with reality. It is important for the
nurse to:
a. Isolate the client from other patients.
b. Maintain a safe environment.
c. Orient the client to time, place, and
person.
d. Establish a trusting relationship.
B. It is of paramount importance to
prevent the client from hurting
himself or herself or others
3. The nurse is caring to a child client
who has had a tonsillectomy. The child
complains of having dryness of the
throat. Which of the following would the
nurse give to the child?
a) Cola with ice
b) Yellow noncitrus Jello
c) Cool cherry Kool-Aid
d) A glass of milk
B. After tonsillectomy, clear, cool liquids
should be given. Citrus, carbonated,
and hot or cold liquids should be
avoided because they may irritate
the throat. Red liquids should be
avoided because they give the
appearance of blood if the child
vomits. Milk and milk products
including pudding are avoided
because they coat the throat, cause
the child to clear the throat, and
increase the risk of bleeding.
4. The physician ordered Phenylephrine
(Neo-Synephrine) nasal spray to a 13-
year-old client. The nurse caring to the
client provides instructions that the nasal
spray must be used exactly as directed
to prevent the development of:
a. Increased nasal congestion.
b. Nasal polyps.
c. Bleeding tendencies.
d. Tinnitus and diplopia.
A. Phenylephrine, with frequent and
continued use, can cause rebound
congestion of mucous membranes.
5. A client with tuberculosis is to be
admitted in the hospital. The nurse who
will be assigned to care for the client
must institute appropriate precautions.
The nurse should:
a) Place the client in a private room.
b) Wear an N 95 respirator when
caring for the client.
c) Put on a gown every time when
entering the room.
d) Don a surgical mask with a face
shield when entering the room.
B. The N 95 respirator is a high-
particulate filtration mask that meets
the CDC performance criteria for a
tuberculosis respirator.
6. Which of the following is the most
frequent cause of noncompliance to the
medical treatment of open-angle
glaucoma?
a. The frequent nausea and vomiting
accompanying use of miotic drug.
b. Loss of mobility due to severe driving
restrictions.
c. Decreased light and near-vision
accommodation due to miotic
effects of pilocarpine.
d. The painful and insidious progression
of this type of glaucoma.
C. The most frequent cause of
noncompliance to the treatment of
chronic, or open-angle glaucoma is
the miotic effects of pilocarpine.
Pupillary constriction impedes normal
accommodation, making night driving
difficult and hazardous, reducing the
client’s ability to read for extended
periods and making participation in
games with fast-moving objects
impossible.
7. In the morning shift, the nurse is
making rounds in the nursing care units.
The nurse enters in a client’s room and
notes that the client’s tube has become
disconnected from the Pleurovac. What
would be the initial nursing action?
a) Apply pressure directly over the
incision site.
b) Clamp the chest tube near the
incision site.
c) Clamp the chest tube closer to the
drainage system.
d) Reconnect the chest tube to the
Pleurovac.
B. This stops the sucking of air through
the tube and prevents the entry of
contaminants. In addition, clamping
near the chest wall provides for some
stability and may prevent the clamp
from pulling on the chest tube.
8. Which of the following complications
during a breech birth the nurse needs to
be alarmed?
a. Abruption placenta.
b. Caput succedaneum.
c. Pathological hyperbilirubinemia.
d. Umbilical cord prolapse.
D. Because umbilical cord’s insertion
site is born before the fetal head, the
cord may be compressed by the
after-coming head in a breech birth.
9. The nurse is caring to a client
diagnosed with severe depression. Which
of the following nursing approach is
important in depression?
a) Protect the client against harm to
others.
b) Provide the client with motor
outlets for aggressive, hostile
feelings.
c) Reduce interpersonal contacts.
d) Deemphasizing preoccupation with
elimination, nourishment, and sleep.
B. It is important to externalize the
anger away from self.
10. A 3-month-old client is in the
pediatric unit. During assessment, the
nurse is suspecting that the baby may
have hypothyroidism when mother states
that her baby does not:
a. Sit up.
b. Pick up and hold a rattle.
c. Roll over.
d. Hold the head up.
D. Development normally proceeds
cephalocaudally; so the first major
developmental milestone that the
infant achieves is the ability to hold
the head up within the first 8-12
weeks of life. In hypothyroidism, the
infant’s muscle tone would be poor
and the infant would not be able to
achieve this milestone.
11. The physician calls the nursing unit to
leave an order. The senior nurse had
conversation with the other staff. The
newly hired nurse answers the phone so
that the senior nurses may continue their
conversation. The new nurse does not
knowthe physician or the client to whom
the order pertains. The nurse should:
a) Ask the physician to call back after
the nurse has read the hospital policy
manual.
b) Take the telephone order.
c) Refuse to take the telephone order.
d) Ask the charge nurse or one of
the other senior staff nurses to
take the telephone order.
D. Get a senior nurse who know s the
policies, the client, and the doctor.
Generally speaking, a nurse should
not accept telephone orders.
However, if it is necessary to take
one, follow the hospital’s policy
regarding telephone orders. Failure to
followhospital policy could be
considered negligence. In this case,
the nurse was new and did not know
the hospital’s policy concerning
telephone orders. The nurse was also
unfamiliar with the doctor and the
client. Therefore the nurse should not
take the order unless a) no one else
is available and b) it is an emergency
situation.
12. The staff nurse on the labor and
delivery unit is assigned to care to a
primigravida in transition complicated by
hypertension. A new pregnant woman in
active labor is admitted in the same unit.
The nurse manager assigned the same
nurse to the second client. The nurse
feels that the client with hypertension
requires one-to-one care. What would be
the initial actionof the nurse?
a. Accept the new assignment and
complete an incident report
describing a shortage of nursing staff.
b. Report the incident to the nursing
supervisor and request to be floated.
c. Report the nursing assessment of
the client in transitional labor to
the nurse manager and discuss
 misgivings about the new
assignment.
Accept the new assignment and provide
the best care.
C. The nurse is obligated to inform the
nurse manager about changes in the
condition of the client, which may
change the decision made by the
nurse manager.
13. A newborn infant with Down
syndrome is to be discharged today. The
nurse is preparing to give the discharge
teaching regarding the proper care at
home. The nurse would anticipate that
the mother is probably at the:
a) 40 years of age.
b) 20 years of age.
c) 35 years of age.
d) 20 years of age.
A. Perinatal risk factors for the
development of Down syndrome
include advanced maternal age,
especially with the first pregnancy.
14. The emergency department has
shortage of staff. The nurse manager
informs the staff nurse in the critical care
unit that she has to float to the
emergency department. What should the
staff nurse expect under these
conditions?
a. The float staff nurse will be informed
of the situation before the shift
begins.
b. The staff nurse will be able to
negotiate the assignments in the
emergency department.
c. Cross training will be available for the
staff nurse.
d. Client assignments will be equally
divided among the nurses.
B. Assignments should be based on
scope of practice and expertise.
15. The nurse is assigned to care for a
child client admitted in the pediatrics
unit. The client is receiving digoxin.
Which of the following questions will be
asked by the nurse to the parents of the
child in order to assess the client’s risk
for digoxin toxicity?
a) “Has he been exposed to any
childhood communicable diseases in
the past 2-3 weeks?”
b) “Has he been taking diuretics at
home?”
c) “Do any of his brothers and sisters
have history of cardiac problems?”
d) “Has he been going to school
regularly?”
B. The child who is concurrently taking
digoxin and diuretics is at increased
risk for digoxin toxicity due to the
loss of potassium. The child and
parents should be taught what foods
are high in potassium, and the child
should be encouraged to eat a high-
potassium diet. In addition, the
child’s serum potassium level should
be carefully monitored.
16. The nurse noticed that the signed
consent form has an error. The form
states, “Amputation of the right leg”
instead of the left leg that is to be
amputated. The nurse has administered
already the preoperative medications.
What should the nurse do?
a. Call the physician to reschedule
the surgery.
b. Call the nearest relative to come in to
sign a new form.
c. Cross out the error and initial the
form.
d. Have the client sign another form.
A. The responsible for an accurate
informed consent is the physician. An
exception to this answer would be a life-
threatening emergency, but there are no
data to support another response
17. The nurse in the nursing care unit
checks the fluctuation in the water-seal
compartment of a closed chest drainage
system. The fluctuation has stopped, the
nurse would:
a) Vigorously strip the tube to dislodge a
clot.
b) Raise the apparatus above the chest
to move fluid.
c) Increase wall suction above 20 cm
H2O pressure.
d) Ask the client to cough and take
a deep breath.
D. Asking the client to cough and take a
deep breath will help determine if the
chest tube is kinked or if the lungs has
reexpanded
18. The pediatric nurse in the neonatal
unit was informed that the baby that is
brought to the mother in the hospital
room is wrong. The nurse determines
that two babies were placed in the wrong
cribs. The most appropriate nursing
action would be to:
a. Determine who is responsible for the
mistake and terminate his or her
employment.
b. Record the event in an
incident/variance report and
notify the nursing supervisor.
c. Reassure both mothers, report to the
charge nurse, and do not record.
d. Record detailed notes of the event on
the mother’s medical record.
B. Every event that exposes a client to
harm should be recorded in an
incident report, as well as reported to
the appropriate supervisors in order
to resolve the current problems and
permit the institution to prevent the
problem from happening again.
19. Before the administration of digoxin,
the nurse completes an assessment to a
toddler client for signs and symptoms of
digoxin toxicity. Which of the following is
the earliest and most significant sign of
digoxin toxicity?
a) Tinnitus
b) Nausea and vomiting
c) Vision problem
d) Slowing in the heart rate
D. One of the earliest signs of digoxin
toxicity is Bradycardia. For a toddler,
any heart rate that falls below the
norm of about 100-120 bpm would
indicate Bradycardia and would
necessitate holding the medication
and notifying the physician.
20. Which of the following treatment
modality is appropriate for a client with
paranoid tendency?
a. Activity therapy.
b. Individual therapy.
c. Group therapy.
d. Family therapy.
B. This option is least threatening.
21. The client with rheumatoid arthritis is
for discharge. In preparing the client for
discharge on prednisone therapy, the
nurse should advise the client to:
a) Wear sunglasses if exposed to bright
light for an extended period of time.
b) Take oral preparations of prednisone
before meals.
c) Have periodic complete blood counts
while on the medication.
d) Never stop or change the amount
of the medication without
medical advice.
D. In preparing the client for discharge
that is receiving prednisone, the nurse
should caution the client to (a) take oral
preparations after meals; (b) remember
that routine checks of vital signs, weight,
and lab studies are critical; (c) NEVER
STOP OR CHANGE THE AMOUNT OF
MEDICATION WITHOUT MEDICAL ADVICE;
(d) store the medication in a light-
resistant container.
22. A pregnant client tells the nurse that
she is worried about having urinary
frequency. What will be the most
appropriate nursing response?
a. “Try using Kegel (perineal)
exercises and limiting fluids
before bedtime. If you have
frequency associated with fever,
pain on voiding, or blood in the
urine, call your doctor/nurse-
midwife.
b. “Placental progesterone causes
irritability of the bladder sphincter.
Your symptoms will go away after the
baby comes.”
c. “Pregnant women urinate frequently
to get rid of fetal wastes. Limit fluids
to 1L/daily.”
d. “Frequency is due to bladder irritation
from concentrate urine and is normal
in pregnancy. Increase your daily fluid
intake to 3L.”
A. Progesterone also reduces smooth
muscle motility in the urinary tract
and predisposes the pregnant woman
to urinary tract infections. Women
should contact their doctors if they
exhibit signs of infection. Kegel
exercise will help strengthen the
perineal muscles; limiting fluids at
bedtime reduces the possibility of
being awakened by the necessity of
voiding.
23. Which of the following will help the
nurse determine that the expression of
hostility is useful?
a) Expression of anger dissipates the
energy.
b) Energy from anger is used to
accomplish what needs to be
done.
c) Expression intimidates others.
d) Degree of hostility is less than the
provocation.
B. This is the proper use of anger.
24. The nurse is providing an orientation
regarding case management to the
nursing students. Which characteristics
should the nurse include in the
discussion in understanding case
management?
a. Main objective is a written plan that
combines discipline-specific
processes used to measure outcomes
of care.
b. Main purpose is to identify expected
client, family and staff performance
against the timeline for clients with
the same diagnosis.
c. Main focus is comprehensive
coordination of client care, avoid
unnecessary duplication of
services, improve resource
utilization and decrease cost.
d. Primary goal is to understand why
predicted outcomes have not been
met and the correction of identified
problems.
C. There are several models of case
management, but the commonality is
comprehensive coordination of care
to better predict needs of high-risk
clients, decrease exacerbations and
continually monitor progress
overtime.
25. The physician orders a dose of IV
phenytoin to a child client. In preparing in
the administration of the drug, which
nursing action is not correct?
a) Infuse the phenytoin into a
smaller vein to prevent purple
glove syndrome.
b) Check the phenytoin solution to be
sure it is clear or light yellow in color,
never cloudy.
c) Plan to give phenytoin over 30-60
minutes, using an in-line filter.
d) Flush the IV tubing with normal saline
before starting phenytoin.
A. Phenytoin should be infused or
injected into larger veins to avoid the
discoloration know as purple glove
syndrome; infusing into a smaller
vein is not appropriate.
26. The pregnant woman visits the clinic
for check –up. Which assessment findings
will help the nurse determine that the
client is in 8-week gestation?
a. Leopold maneuvers.
b. Fundal height.
c. Positive radioimmunoassay test
(RIA test).
d. Auscultation of fetal heart tones.
C. Serum radioimmunoassay (RIA) is
accurate within 7days of conception.
This test is specific for HCG, and
accuracy is not compromised by
confusion with LH.
27. Which of the following nursing
intervention is essential for the client
who had pneumonectomy?
a) Medicate for pain only when needed.
b) Connect the chest tube to water-seal
drainage.
c) Notify the physician if the chest
drainage exceeds 100mL/hr.
d) Encourage deep breathing and
coughing.
D. Surgery and anesthesia can increase
mucus production. Deep breathing
and coughing are essential to prevent
atelectasis and pneumonia in the
client’s only remaining lung.
28. The nurse is providing a health
teaching to a group of parents regarding
Chlamydia trachomatis. The nurse is
correct in the statement, “Chlamydia
trachomatis is not only an intracellular
bacterium that causes neonatal
conjunctivitis, but it also can cause:
a. Discoloration of baby and adult teeth.
b. Pneumonia in the newborn.
c. Snuffles and rhagades in the
newborn.
d. Central hearing defects in infancy.

B. Newborns can get pneumonia
(tachypnea, mild hypoxia, cough,
eosinophilia) and conjunctivitis from
Chlamydia.
29. The nurse is assigned to care to a 17-
year-old male client with a history of
substance abuse. The client asks the
nurse, “Have you ever tried or used
drugs?” The most correct response of the
nurse would be:
a) “Yes, once I tried grass.”
b) “No, I don’t think so.”
c) “Why do you want to know that?”
d) “How will my answer help you?”
D. The client may perceive this as
avoidance, but it is more important to
redirect back to the client, especially
in light of the manipulative behavior
of drug abusers and adolescents.
30. Which of the following describes a
health care team with the principles of
participative leadership?
a. Each member of the team can
independently make decisions
regarding the client’s care without
necessarily consulting the other
members.
b. The physician makes most of the
decisions regarding the client’s care.
c. The team uses the expertise of
its members to influence the
decisions regarding the client’s
care.
d. Nurses decide nursing care;
physicians decide medical and other
treatment for the client.
C. It describes a democratic process in
which all members have input in the
client’s care.
31. A nurse is giving a health teaching to
a woman who wants to breastfeed her
newborn baby. Which hormone, normally
secreted during the postpartum period,
influences both the milk ejection reflex
and uterine involution?
a) Oxytocin.
b) Estrogen.
c) Progesterone.
d) Relaxin.
A. Contraction of the milk ducts and
let-down reflex occur under the
stimulation of oxytocin released by
the posterior pituitary gland.
32. One staff nurse is assigned to a group
of 5 patients for the 12-hour shift. The
nurse is responsible for the overall
planning, giving and evaluating care
during the entire shift. After the shift,
same responsibility will be endorsed to
the next nurse in charge. This describes
nursing care delivered via the:
a) Primary nursing method.
b) Case method.
c) Functional method.
d) Team method.
B. In case management, the nurse
assumes total responsibility for
meeting the needs of the client
during the entire time on duty.
33. The ambulance team calls the
emergency department that they are
going to bring a client who sustained
burns in a house fire. While waiting for
the ambulance, the nurse will anticipate
emergency care to include assessment
for:
a. Gas exchange impairment.
b. Hypoglycemia.
c. Hyperthermia.
d. Fluid volume excess.
A. Smoke inhalation affects gas
exchange.
34. Most couples are using “natural”
family planning methods. Most accidental
pregnancies in couples preferred to use
this method have been related to
unprotected intercourse before ovulation.
Which of the following factor explains
why pregnancy may be achieved by
unprotected intercourse during the
preovulatory period?
a) Ovum viability.
b) Tubal motility.
c) Spermatozoal viability.
d) Secretory endometrium.
C. Sperm deposited during intercourse
may remain viable for about 3 days.
If ovulation occurs during this period,
conception may result.

35. An older adult client wakes up at 2
o’clock in the morning and comes to the
nurse’s station saying, “I am having
difficulty in sleeping.” What is the best
nursing response to the client?
a. “I’ll give you a sleeping pill to help
you get more sleep now.”
b. “Perhaps you’d like to sit here at
the nurse’s station for a while.”
c. “Would you like me to show you
where the bathroom is?”
d. “What woke you up?”
B. This option shows acceptance (key
concept) of this age-typical sleep
pattern (that of waking in the early
morning).
36. The nurse is taking care of a
multipara who is at 42 weeks of gestation
and in active labor, her membranes
ruptured spontaneously 2 hours ago.
While auscultating for the point of
maximum intensity of fetal heart tones
before applying an external fetal monitor,
the nurse counts 100 beats per minute.
The immediate nursing action is to:
a) Start oxygen by mask to reduce fetal
distress.
b) Examine the woman for signs of a
prolapsed cord.
c) Turn the woman on her left side to
increase placental perfusion.
d) Take the woman’s radial pulse
while still auscultating the FHR.
D. Taking the mother’s pulse while
listening to the FHR will differentiate
between the maternal and fetal heart
rates and rule out fetal Bradycardia.
37. The nurse must instruct a client with
glaucoma to avoid taking over-the-
counter medications like:
a. Antihistamines.
b. NSAIDs.
c. Antacids.
d. Salicylates.
A. Antihistamines cause pupil dilation
and should be avoided with
glaucoma.
38. A male client is brought to the
emergency department due to motor
vehicle accident. While monitoring the
client, the nurse suspects increasing
intracranial pressure when:
a) Client is oriented when aroused
from sleep, and goes back to
sleep immediately.
b) Blood pressure is decreased from
160/90 to 110/70.
c) Client refuses dinner because of
anorexia.
d) Pulse is increased from 88-96 with
occasional skipped beat.
A. This suggests that the level of
consciousness is decreasing.
39. The nurse is conducting a lecture to a
class of nursing students about advance
directives to preoperative clients. Which
of the following statement by the nurse js
correct?
a. “The spouse, but not the rest of the
family, may override the advance
directive.”
b. “An advance directive is required for a
“do not resuscitate” order.”
c. “A durable power of attorney, a form
of advance directive, may only be
held by a blood relative.”
d. “The advance directive may be
enforced even in the face of
opposition by the spouse.”
D. An advance directive is a form of
informed consent, and only a
competent adult or the holder of a
durable power of attorney has the
right to consent or refuse treatment.
If the spouse does not hold the power
of attorney, the decisions of the
holder, even if opposed by the
spouse, are enforced.
40. A client diagnosed with schizophrenia
is shouting and banging on the door
leading to the outside, saying, “I need to
go to an appointment.” What is the
appropriate nursing intervention?
a) Tell the client that he cannot bang on
the door.
b) Ignore this behavior.
c) Escort the client going back into
the room.
d) Ask the client to move away from the
door.
C. Gentle but firm guidance and
nonverbal direction is needed to
 intervene when a client with
schizophrenic symptoms is being
disruptive.
41. Which of the following action is an
accurate tracheal suctioning technique?
a. 25 seconds of continuous suction
during catheter insertion.
b. 20 seconds of continuous suction
during catheter insertion.
c. 10 seconds of intermittent
suction during catheter
withdrawal.
d. 15 seconds of intermittent suction
during catheter withdrawal.
C. Suctioning is only done for 10
seconds, intermittently, as the
catheter is being withdrawn.
42. The client’s jaw and cheekbone is
sutured and wired. The nurse anticipates
that the most important thing that must
be ready at the bedside is:
a) Suture set.
b) Tracheostomy set.
c) Suction equipment.
d) Wire cutters.
D. The priority for this client is being
able to establish an airway.
43. A mother is in the third stage of labor.
Which of the following signs will help the
nurse determine the signs of placental
separation?
a. The uterus becomes globular.
b. The umbilical cord is shortened.
c. The fundus appears at the introitus.
d. Mucoid discharge is increased.
A. Signs of placental separation include
a change in the shape of the uterus
from ovoid to globular.
44. After therapy with the thrombolytic
alteplase (t-PA), what observation will the
nurse report to the physician?
a) 3+ peripheral pulses.
b) Change in level of consciousness
and headache.
c) Occasional dysrhythmias.
d) Heart rate of 100/bpm.
B. This could indicate intracranial
bleeding. Alteplase is a thrombolytic
enzyme that lyses thrombi and
emboli. Bleeding is an adverse effect.
Monitor clotting times and signs of
any gastrointestinal or internal
bleeding.
45. A client who undergone left
nephrectomy has a large flank incision.
Which of the following nursing action will
facilitate deep breathing and coughing?
a. Push fluid administration to loosen
respiratory secretions.
b. Have the client lie on the unaffected
side.
c. Maintain the client in high Fowler’s
position.
d. Coordinate breathing and
coughing exercise with
administration of analgesics.
D. Because flank incision in
nephrectomy is directly below the
diaphragm, deep breathing is painful.
Additionally, there is a greater
incisional pull each time the person
moves than there is with abdominal
surgery. Incisional pain following
nephrectomy generally requires
analgesics administration every 3-4
hours for 24-48 hours after surgery.
Therefore, turning, coughing and
deep-breathing exercises should be
planned to maximize the analgesic
effects.
46. The community nurse is teaching the
group of mothers about the cervical
mucus method of natural family
planning. Which characteristics are
typical of the cervical mucus during the
“fertile” period of the menstrual cycle?
a) Absence of ferning.
b) Thin, clear, good spinnbarkeit.
c) Thick, cloudy.
d) Yellow and sticky.
B. Under high estrogen levels, during
the period surrounding ovulation, the
cervical mucus becomes thin, clear,
and elastic (spinnbarkeit), facilitating
sperm passage.
47. A client with ruptured appendix had
surgery an hour ago and is transferred to
the nursing care unit. The nurse placed
the client in a semi-Fowler’s position
primarily to:
a. Facilitate movement and reduce
complications from immobility.
b. Fully aerate the lungs.
c. Splint the wound.
d. Promote drainage and prevent
subdiaphragmatic abscesses.
D. After surgery for a ruptured appendix,
the client should be placed in a semi-
Fowler’s position to promote drainage
and to prevent possible
complications.
48. Which of the following will best
describe a management function?
a) Writing a letter to the editor of a
nursing journal.
b) Negotiating labor contracts.
c) Directing and evaluating nursing
staff members.
d) Explaining medication side effects to
a client.
C. Directing and evaluation of staff is a
major responsibility of a nursing manager
49. The parents of an infant client ask
the nurse to teach them how to
administer Cortisporin eye drops. The
nurse is correct in advising the parents to
place the drops:
a. In the middle of the lower
conjunctival sac of the infant’s
eye.
b. Directly onto the infant’s sclera.
c. In the outer canthus of the infant’s
eye.
d. In the inner canthus of the infant’s
eye.
A. The recommended procedure for
administering eyedrops to any client
calls for the drops to be placed in the
middle of the lower conjunctival sac.
50. The nurse is assessing on the client
who is admitted due to vehicle accident.
Which of the following findings will help
the nurse that there is internal bleeding?
a) Frank blood on the clothing.
b) Thirst and restlessness.
c) Abdominal pain.
d) Confusion and altered of
consciousness.
B. Thirst and restlessness indicate
hypovolemia and hypoxemia. Internal
bleeding is difficult to recognized and
evaluate because it is not apparent.
51. The nurse is completing an
assessment to a newborn baby boy. The
nurse observes that the skin of the
newborn is dry and flaking and there are
several areas of an apparent macular
rash. The nurse charts this as:
a. Icterus neonatorum
b. Multiple hemangiomas
c. Erythema toxicum
d. Milia
C. Erythema toxicum is the normal,
nonpathological macular newborn
rash
52. The client is brought to the
emergency department because of
serious vehicle accident. After an hour,
the client has been declared brain dead.
The nurse who has been with the client
must now talk to the family about organ
donation. Which of the following
consideration is necessary?
a) Include as many family members as
possible.
b) Take the family to the chapel.
c) Discuss life support systems.
d) Clarify the family’s
understanding of brain death.
D. The family needs to understand what
brain death is before talking about
organ donation. They need time to
accept the death of their family
member. An environment conducive
to discussing an emotional issue is
needed.
53. The nurse is teaching exercises that
are good for pregnant women increasing
tone and fitness and decreasing lower
backache. Which of the following should
the nurse exclude in the exercise
program?
a. Stand with legs apart and touch
hands to floor three times per
day.
b. Ten minutes of walking per day with
an emphasis on good posture.
c. Ten minutes of swimming or leg
kicking in pool per day.
d. Pelvic rock exercise and squats three
times a day.
A. Bending from the waist in pregnancy
tends to make backache worse.

54. A client with obsessive-compulsive
behavior is admitted in the psychiatric
unit. The nurse taking care of the client
knows that the primary treatment goal is
to:
a) Provide distraction.
b) Support but limit the behavior.
c) Prohibit the behavior.
d) Point out the behavior.
B. Support and limit setting decrease
anxiety and provide external control.
55. After ileostomy, the nurse expects
that the drainage appliance will be
applied to the stoma:
a. When the client is able to begin self-
care procedures.
b. 24 hours later, when the swelling
subsided.
c. In the operating room after the
ileostomy procedure.
d. After the ileostomy begins to
function.
C. The stoma drainage bag is applied in
the operating room. Drainage from
the ileostomy contains secretions
that are rich in digestive enzymes
and highly irritating to the skin.
Protection of the skin from the effects
of these enzymes is begun at once.
Skin exposed to these enzymes even
for a short time becomes reddened,
painful and excoriated.
56. A female client who has a 28-day
menstrual cycle asks the community
health nurse when she get pregnant
during her cycle. What will be the best
nursing response?
a) It is impossible to determine the
fertile period reliably. So it is best to
assume that a woman is always
fertile.
b) In a 28-day cycle, ovulation
occurs at or about day 14. The
egg lives for about 24 hours and
the sperm live for about 72
hours. The fertile period would
be approximately between day 11
and day 15.
c) In a 28- day cycle, ovulation occurs at
or about day 14. The egg lives for
about 72 hours and the sperm live for
about 24 hours. The fertile period
would be approximately between day
13 and 17.
d) In a 28-day cycle, ovulation occurs 8
days before the next period or at
about day 20. The fertile period is
between day 20 and the beginning of
the next period.
B. It is the most accurate statement of
physiological facts for a 28-day
menstrual cycle: ovulation at day 14,
egg life span 24 hours, sperm life
span of 72 hours. Fertilization could
occur from sperm deposited before
ovulation.
57. Which of the following statement
describes the role of a nurse as a client
advocate?
a. A nurse may override clients’ wishes
for their own good.
b. A nurse has the moral obligation to
prevent harm and do well for clients.
c. A nurse helps clients gain greater
independence and self-
determination.
d. A nurse measures the risk and
benefits of various health situations
while factoring in cost.
C. An advocate role encourage freedom
of choice, includes speaking out for
the client, and supports the client’s
best interests.
58. A community health nurse is
providing a health teaching to a woman
infected with herpes simplex 2. Which of
the following health teaching must the
nurse include to reduce the chances of
transmission of herpes simplex 2?
a) “Abstain from intercourse until
lesions heal.”
b) “Therapy is curative.”
c) “Penicillin is the drug of choice for
treatment.”
d) “The organism is associated with later
development of hydatidiform mole.
A. Abstinence will eliminate any
unnecessary pain during intercourse
and will reduce the possibility of
transmitting infection to one’s sexual
partner.
59. The nurse in the psychiatric ward
informed the male client that he will be
attending the 9:00 AM group therapy
sessions. The client tells the nurse that
he must wash his hands from 9:00 to
9:30 AM each day and therefore he
cannot attend. Which concept does the
nursing staff need to keep in mind in
planning nursing intervention for this
client?
a. Depression underlines ritualistic
behavior.
b. Fear and tensions are often
expressed in disguised form
through symbolic processes.
c. Ritualistic behavior makes others
uncomfortable.
d. Unmet needs are discharged through
ritualistic behavior.
B. Anxiety is generated by group
therapy at 9:00 AM. The ritualistic
behavioral defense of hand washing
decreases anxiety by avoiding group
therapy.
60. The nurse assesses the health
condition of the female client. The client
tells the nurse that she discovered a
lump in the breast last year and
hesitated to seek medical advice. The
nurse understands that, women who tend
to delay seeking medical advice after
discovering the disease are displaying
what common defense mechanism?
a) Intellectualization.
b) Suppression.
c) Repression.
d) Denial.
D. Denial is a very strong defense
mechanism used to allay the
emotional effects of discovering a
potential threat. Although denial has
been found to be an effective
mechanism for survival in some
instances, such as during natural
disasters, it may in greater pathology
in a woman with potential breast
carcinoma.
61. Which of the following situations
cannot be delegated by the registered
nurse to the nursing assistant?
a. A postoperative client who is stable
needs to ambulate.
b. Client in soft restraint who is
very agitated and crying.
c. A confused elderly woman who needs
assistance with eating.
d. Routine temperature check that must
be done for a client at end of shift.
B. The registered nurse cannot delegate
the responsibility for assessment and
evaluation of clients. The status of
the client in restraint requires further
assessment to determine if there are
additional causes for the behavior.
62. In the admission care unit, which of
the following client would the nurse give
immediate attention?
a) A client who is 3 days postoperative
with left calf pain.
b) A client who is postoperative hip
pinning who is complaining of pain.
c) New admitted client with chest
pain.
d) A client with diabetes who has a
glucoscan reading of 180.
C. The client with chest pain may be
having a myocardial infarction, and
immediate assessment and
intervention is a priority.
63. A couple seeks medical advice in the
community health care unit. A couple has
been unable to conceive; the man is
being evaluated for possible problems.
The physician ordered semen analysis.
Which of the following instructions is
correct regarding collection of a sperm
specimen?
a. Collect a specimen at the clinic, place
in iced container, and give to
laboratory personnel immediately.
b. Collect specimen after 48-72
hours of abstinence and bring to
clinic within 2 hours.
c. Collect specimen in the morning after
24 hours of abstinence and bring to
clinic immediately.
d. Collect specimen at night, refrigerate,
and bring to clinic the next morning.
B. Is correct because semen analysis
requires that a freshly masturbated
specimen be obtained after a rest
(abstinence) period of 48-72 hours.
64. The physician ordered
Betamethasone to a pregnant woman at
34 weeks of gestation with sign of
preterm labor. The nurse expects that the
drug will:
a) Treat infection.
b) Suppress labor contraction.
c) Stimulate the production of
surfactant.
d) Reduce the risk of hypertension.
C. Betamethasone, a form of cortisone,
acts on the fetal lungs to produce
surfactant.
65. A tracheostomy cuff is to be deflated,
which of the following nursing
intervention should be implemented
before starting the procedures?
a. Suction the trachea and mouth.
b. Have the obdurator available.
c. Encourage deep breathing and
coughing.
d. Do a pulse oximetry reading.
A. Secretions may have pooled above
the tracheostomy cuff. If these are
not suctioned before deflation, the
secretions may be aspirated.
66. A client is diagnosed with
Tuberculosis and respiratory isolation is
initiated. This means that:
a) Gloves are worn when handling the
client’s tissue, excretions, and linen.
b) Both client and attending nurse must
wear masks at all times.
c) Nurse and visitors must wear
masks until chemotherapy is
begun. Client is instructed in
cough and tissue techniques.
d) Full isolation; that is, caps and gowns
are required during the period of
contagion.
C. Proper handling of sputum is essential
to allay droplet transference of bacilli
in the air. Clients need to be taught to
cover their nose and mouth with
tissues when sneezing or coughing.
Chemotherapy generally renders the
client noninfectious within days to a
few weeks, usually before cultures for
tubercle bacilli are negative. Until
chemical isolation is established,
many institutions require the client to
wear a mask when visitors are in the
room or when the nurse is in
attendance. Client should be in a
well-ventilated room, without air
recirculation, to prevent air
contamination.
67. A client with lung cancer is admitted
in the nursing care unit. The husband
wants to know the condition of his wife.
How should the nurse respond to the
husband?
a. Find out what information he
already has.
b. Suggest that he discuss it with his
wife.
c. Refer him to the doctor.
d. Refer him to the nurse in charge.
A. It is best to establish baseline
information first.
68. A hospitalized client cannot find his
handkerchief and accuses other cient in
the room and the nurse of stealing them.
Which is the most therapeutic approach
to this client?
a) Divert the client’s attention.
b) Listen without reinforcing the
client’s belief.
c) Inject humor to defuse the intensity.
d) Logically point out that the client is
jumping to conclusions.
C. Listening is probably the most
effective response of the four choices
69. After a cystectomy and formation of
an ileal conduit, the nurse provides
instruction regarding prevention of
leakage of the pouch and backflow of the
urine. The nurse is correct to include in
the instruction to empty the urine pouch:
a. Every 3-4 hours.
b. Every hour.
c. Twice a day.
d. Once before bedtime.
A. Urine flow is continuous. The pouch
has an outlet valve for easy drainage
every 3-4 hours. (the pouch should
be changed every 3-5 days, or sooner
if the adhesive is loose).
70. Which telephone call from a student’s
mother should the school nurse take care
of at once?
a) A telephone call notifying the
school nurse that the child’
pediatrician has informed the
mother that the child will need
cardiac repair surgery within the
next few weeks.
b) A telephone call notifying the school
nurse that the child’s pediatrician has
 informed the mother that the child
has head lice.
c) A telephone call notifying the school
nurse that a child has a temperature
of 102ºF and a rash covering the
trunk and upper extremities of the
body.
d) A telephone call notifying the school
nurse that a child underwent an
emergency appendectomy during the
previous night.
C. A high fever accompanied by a body
rash could indicate that the child has
a communicable disease and would
have exposed other students to the
infection. The school nurse would
want to investigate this telephone
call immediately so that plans could
be instituted to control the spread of
such infection.
71. Which of the following signs and
symptoms that require immediate
attention and may indicate most serious
complications during pregnancy?
a. Severe abdominal pain or fluid
discharge from the vagina.
b. Excessive saliva, “bumps around the
areolae, and increased vaginal
mucus.
c. Fatigue, nausea, and urinary
frequency at any time during
pregnancy.
d. Ankle edema, enlarging varicosities,
and heartburn.
A. Severe abdominal pain may indicate
complications of pregnancy such as
abortion, ectopic pregnancy, or
abruption placenta; fluid discharge
from the vagina may indicate
premature rupture of the membrane.
72. The nurse is assessing the newborn
boy. Apgar scores are 7 and 9. The
newborn becomes slightly cyanotic. What
is the initial nursing action?
a) Elevate his head to promote gravity
drainage of secretions.
b) Wrap him in another blanket, to
reduce heat loss.
c) Stimulate him to cry,, to increase
oxygenation.
d) Aspirate his mouth and nose with
bulb syringe.
D. Gentle aspiration of mucus helps
maintain a patent airway, required
for effective gas exchange.
73. The nurse is formulating a plan of
care to a client with a somatoform
disorder. The nurse needs to have
knowledge of which psychodynamic
principle?
a. The symptoms of a somatoform
disorder are an attempt to adjust
to painful life situations or to
cope with conflicting sexual,
aggressive, or dependent
feelings.
b. The major fundamental mechanism is
regression.
c. The client’s symptoms are imaginary
and the suffering is faked.
d. An extensive, prolonged study of the
symptoms will be reassuring to the
client, who seeks sympathy, attention
and love.
A. Somatoform disorders provide a way
of coping with conflicts.
74. An infant is brought to the health
care clinic for three immunizations at the
same time. The nurse knows that
hepatitis B, DPT, and Haemophilus
influenzae type B immunizations should:
a) Be drawn in the same syringe and
given in one injection.
b) Be mixed and inject in the same sites.
c) Not be mixed and the nurse must
give three injections in three
sites.
d) Be mixed and the nurse must give the
injection in three sites.
C. Immunization should never be mixed
together in a syringe, thus
necessitating three separate
injections in three sites. Note: some
manufacturers make a premixed
combination of immunization that is
safe and effective.
75. A female client with cancer has
radium implants. The nurse wants to
maintain the implants in the correct
position. The nurse should position the
client:
a. Flat in bed.
b. On the side only.
c. With the foot of the bed elevated.
d. With the head elevated 45-degrees
(semi-Fowler’s).
A. Clients with radioactive implants
should be positioned flat in bed to
prevent dislodgement of the vaginal
packing. The client may roll to the
side for meals but the upper body
should not be raised more than 20
degrees.
76. The nurse wants to know if the
mother of a toddler understands the
instructions regarding the administration
of syrup of ipecac. Which of the following
statement will help the nurse to know
that the mother needs additional
teaching?
a) “I’ll give the medicine if my child
gets into some toilet bowl
cleaner.”
b) “I’ll give the medicine if my child gets
into some aspirin.”
c) “I’ll give the medicine if my child gets
into some plant bulbs.”
d) “I’ll give the medicine if my child gets
into some vitamin pills.”
A. Syrup of ipecac is not administered
when the ingested substances is
corrosive in nature. Toilet bowl
cleaners, as a collective whole, are
highly corrosive substances. If the
ingested substance “burned” the
esophagus going down, it will “burn”
the esophagus coming back up when
the child begins to vomit after
administration of syrup of ipecac.
77. To assess if the cranial nerve VII of
the client was damaged, which changes
would not be expected?
a. Drooling and drooping of the mouth.
b. Inability to open eyelids on
operative side.
c. Sagging of the face on the operative
side.
d. Inability to close eyelid on operative
side.
B. Inability to open eyelids on operative
side is seen with cranial nerve III
damage.
78. The community health nurse makes a
home visit to a family. During the visit,
the nurse observes that the mother is
beating her child. What is the priority
nursing intervention in this situation?
a. Assess the child’s injuries.
b. Report the incident to protective
agencies.
c. Refer the family to appropriate
support group.
d. Assist the family to identify stressors
and use of other coping mechanisms
to prevent further incidents.
A. Assessment of physical injuries (like
bruises, lacerations, bleeding and
fractures) is the first priority.
79. The nurse in the neonatal care unit is
supervising the actions of a certified
nursing assistant in giving care to the
newborns. The nursing assistant
mistakenly gives a formula feeding to a
newborn that is on water feeding only.
The nurse is responsible for the mistake
of the nursing assistant:
a) Always, as a representative of the
institution.
b) Always, because nurses who
supervise less-trained individuals are
responsible for their mistakes.
c) If the nurse failed to determine
whether the nursing assistant
was competent to take care of
the client.
d) Only if the nurse agreed that the
newborn could be fed formula.
C. The nurse who is supervising others
has a legal obligation to determine
that they are competent to perform
the assignment, as well as legal
obligation to provide adequate
supervision.
80. The nurse is assigned to care for a
client with urinary calculi. Fluid intake of
2L/day is encouraged to the client. the
primary reason for this is to:
a. Reduce the size of existing stones.
b. Prevent crystalline irritation to the
ureter.
c. Reduce the size of existing stones
d. Increase the hydrostatic pressure
in the urinary tract.
D. Increasing hydrostatic pressure in the
urinary tract will facilitate passage of
the calculi.
81. The nurse is counseling a couple in
their mid 30’s who have been unable to
conceive for about 6 months. They are
concerned that one or both of them may
be infertile. What is the best advice the
nurse could give to the couple?
a) “it is no unusual to take 6-12
months to get pregnant,
especially when the partners are
in their mid-30s. Eat well,
exercise, and avoid stress.”
b) “Start planning adoption. Many
couples get pregnant when they are
trying to adopt.”
c) “Consult a fertility specialist and start
testing before you get any older.”
d) “Have sex as often as you can,
especially around the time of
ovulation, to increase your chances of
pregnancy.”
A. Infertility is not diagnosed until
atleast 12months of unprotected
intercourse has failed to produce a
pregnancy. Older couples will
experience a longer time to get
pregnant.
82. The nurse is caring for a cient who Is
a retired nurse. A 24-hour urine collection
for Creatinine clearance is to be done.
The client tells the nurse, “I can’t
remember what this test is for.” The best
response by the nurse is:
a. “It provides a way to see if you are
passing any protein in your urine.”
b. “It tells how well the kidneys
filter wastes from the blood.”
c. “It tells if your renal insufficiency has
affected your heart.”
d. “The test measures the number of
particles the kidney filters.”
B. Determining how well the kidneys
filter wastes states the purpose of a
Creatinine clearance test.
83. The nurse observes the female client
in the psychiatric ward that she is having
a hard time sleeping at night. The nurse
asks the client about it and the client
says, “I can’t sleep at night because of
fear of dying.” What is the best initial
nursing response?
a) “It must be frightening for you to
feel that way. Tell me more about
it.”
b) “Don’t worry, you won’t die. You are
just here for some test.”
c) “Why are you afraid of dying?”
d) “Try to sleep. You need the rest before
tomorrow’s test.”
A. Acknowledging a feeling tone is the
most therapeutic response and
provides a broad opening for the
client to elaborate feelings.
84. In the hospital lobby, the registered
nurse overhears a two staff members
discussing about the health condition of
her client. What would be the appropriate
action for the registered nurse to take?
a. Join in the conversation, giving her
input about the case.
b. Ignore them, because they have the
right to discuss anything they want
to.
c. Tell them it is not appropriate to
discuss such things.
d. Report this incident to the nursing
supervisor.
C. The behavior should be stopped. The
first is to remind the staff that
confidentiality maybe violated.
85. The client has had a right-sided
cerebrovascular accident. In transferring
the client from the wheelchair to bed, in
what position should a client be placed to
facilitate safe transfer?
a) Weakened (L) side of the cient next to
bed.
b) Weakened (R) side of the client next
to bed.
c) Weakened (L) side of the client
away from bed.
d) Weakened (R) side of the cient away
from bed.
C. With a right-sided cerebrovascular
accident the client would have left-
sided hemiplegia or weakness. The
client’s good side should be closest to
the bed to facilitate the transfer.
86. The child client has undergone hip
surgery and is in a spica cast. Which of
the following toy should be avoided to be
in the child’s bed?
a. A toy gun.
b. A stuffed animal.
c. A ball.
d. Legos.
D. Legos are small plastic building
blocks that could easily slip under the
 child’s cast and lead to a break in
skin integrity and even infection.
Pencils, backscratchers, and marbles
are some other narrow or small items
that could easily slip under the child’s
cast and lead to a break in skin
integrity and infection.
87. The LPN/LVN asks the registered
nurse why oxytocin (Pitocin), 10 units (IV
or IM) must be given to a client after
birth fo the fetus. The nurse is correct to
explain that oxytocin:
a) Minimizes discomfort from
“afterpains.”
b) Suppresses lactation.
c) Promotes lactation.
d) Maintains uterine tone.
D. Oxytocin (Pitocin) is used to maintain
uterine tone.
88. The nurse in the nursing care unit is
aware that one of the medical staff
displays unlikely behaviors like confusion,
agitation, lethargy and unkempt
appearance. This behavior has been
reported to the nurse manager several
times, but no changes observed. The
nurse should:
a. Continue to report observations of
unusual behavior until the problem is
resolved.
b. Consider that the obligation to
protect the patient from harm
has been met by the prior reports
and do nothing further.
c. Discuss the situation with friends who
are also nurses to get ideas .
d. Approach the partner of this medical
staff member with these concerns.
B. The submission of reports about
incidents that expose clients to harm
does not remove the obligation to
report ongoing behavior as long as
the risk to the client continues.
89. The physician ordered tetracycline PO
qid to a child client who weights 20kg.
The recommended PO tetracycline dose
is 25-50 mg/kg/day. What is the
maximum single dose that can be safely
administered to this child?
a) 1g
b) 500 mg
c) 250 mg
d) 125 mg
C. The recommended dosage of
tetracycline is 25-50mg/kg/day. If the
child weighs 20kg and the maximum
dose is 50mg/kg, this would indicate
a total daily dose of 1000mg of
tetracycline. In this case, the child is
being given this medication four
times a day. Therefore the maximum
single dose that can be given is
250mg (1000 mg of tetracycline
divided by four doses.)
90. The nurse is completing an obstetric
history of a woman in labor. Which event
in the obstetric history will help the nurse
suspects dysfunctional labor in the
current pregnancy?
a. Total time of ruptured membranes
was 24 hours with the second birth.
b. First labor lasting 24 hours.
c. Uterine fibroid noted at time of
cesarean delivery.
d. Second birth by cesarean for face
presentation.
C. An abnormality in the uterine muscle
could reduce the effectiveness of
uterine contractions and lengthen the
duration of subsequent labors.
91. The nurse is planning to talk to the
client with an antisocial personality
disorder. What would be the most
therapeutic approach?
a) Provide external controls.
b) Reinforce the client’s self-concept.
c) Give the client opportunities to test
reality.
d) Gratify the client’s inner needs.
A. Personality disorders stem from a
weak superego, implying a lack of
adequate controls.
92. The nurse is teaching a group of
women about fertility awareness, the
nurse should emphasize that basal body
temperature:
a. Can be done with a mercury
thermometer but no a digital one.
b. The average temperature taken each
morning.
c. Should be recorded each morning
before any activity.
d. Has a lower degree of accuracy in
predicting ovulation than the cervical
mucus test.

C. The basal body temperature is the
lowest body temperature of a healthy
person that is taken immediately
after waking and before getting out
of bed. The BBT usually varies from
36.2 ºC to 36.3ºC during menses and
for about 5-7 days afterward. About
the time of ovulation, a slight drop in
temperature may be seen, after
ovulation in concert with the
increasing progesterone levels of the
early luteal phase, the BBT rises 0.2-
0.4 ºC. This elevation remains until 2-
3 days before menstruation, or if
pregnancy has occurred.
93. The nursing applicant has given the
chance to ask questions during a job
interview at a local hospital. What should
be the most important question to ask
that can increase chances of securing a
job offer?
a) Begin with questions about client
care assignments, advancement
opportunities, and continuing
education.
b) Decline to ask questions, because
that is the responsibility of the
interviewer.
c) Ask as many questions about the
facility as possible.
d) Clarify information regarding salary,
benefits, and working hours first,
because this will help in deciding
whether or not to take the job.
A. This choice implies concern for client
care and self-improvement.
94. The nurse advised the pregnant
woman that smoking and alcohol should
be avoided during pregnancy. The nurse
takes into account that the developing
fetus is most vulnerable to environment
teratogens that cause malformation
during:
a. The entire pregnancy.
b. The third trimester.
c. The first trimester.
d. The second trimester.
C. The first trimester is the period of
organogenesis, that is, cell
differentiation into the various
organs, tissues, and structures.
95. A male client tells the nurse that
there is a big bug in his bed. The most
therapeutic nursing response would be:
A. Silence.
B. “Where’s the bug? I’ll kill it for you.”
C. “I don’t see a bug in your bed,
but you seem afraid.”
D. “You must be seeing things.”
C. This response does not contradict the
client’s perception, is honest, and
shows empathy.
96. A pregnant client in late pregnancy is
complaining of groin pain that seems
worse on the right side. Which of the
following is the most likely cause of it?
a. Beginning of labor.
b. Bladder infection.
c. Constipation.
d. Tension on the round ligament.
D. Tension on round ligament occurs
because of the erect human posture
and pressure exerted by the growing
fetus.
97. The nurse is conducting a lecture to a
group of volunteer nurses. The nurse is
correct in imparting the idea that the
Good Samaritan law protects the nurse
from a suit for malpractice when:
a) The nurse stops to render emergency
aid and leaves before the ambulance
arrives.
b) The nurse acts in an emergency at his
or her place of employment.
c) The nurse refuses to stop for an
emergency outside of the scope of
employment.
d) The nurse is grossly negligent at
the scene of an emergency.
D. The Good Samaritan Law does not
impose a duty to stop at the scene of
an emergency outside of the scope of
employment, therefore nurses who
do not stop are not liable for suit.
98. A woman is hospitalized with mild
preeclampsia. The nurse is formulating a
plan of care for this client, which nursing
care is least likely to be done?
a. Deep-tendon reflexes once per shift.
b. Vital signs and FHR and rhythm q4h
while awake.
c. Absolute bed rest.
d. Daily weight.
C. Although reducing environment
stimuli and activity is necessary for a
woman with mild preeclampsia, she
will most probably have bathroom
privileges.

99. While feeding a newborn with an

unrepaired cardiac defect, the nurse
keeps on assessing the condition of the
client. The nurse notes that the
newborn’s respiration is 72 breaths per
minute. What would be the initial nursing
action?

a) Burp the newborn.

b) Stop the feeding.
c)
d)
Continue the feeding.
Notify the physician.
PNLE Pediatric
B. A normal respiratory rate for a Nursing Exam
newborn is 30-40 breaths per minute.
Situation 1: Raphael, a 6 year’s
100. A client who undergone old prep pupil is seen at the
appendectomy 3 days ago is scheduled school clinic for growth and
for discharge today. The nurse notes that development monitoring
the client is restless, picking at
bedclothes and saying, “I am late on my (Questions 1-5)
appointment,” and calling the nurse by
1. Which of the following is characterized
the wrong name. The nurse suspects:
the rate of growth during this period?
a. Panic reaction.
most rapid period of growth
b. Medication overdose.
a decline in growth rate
c. Toxic reaction to an antibiotic.
growth spurt
d. Delirium tremens.
slow uniform growth rate
D. The behavior described is likely to be
B. a decline in growth rate. During the
symptoms of delirium tremens, or
Preschooler stage growth is very
alcohol withdrawal (often
minimal. Weight gain is only 4.5lbs
unsuspected on a surgical unit.)
(2kgs) per year and Height is 3.5in
(6-8cm) per year.
Review:
Most rapid growth and
development- Infancy
Slow growth- Toddler hood and
Preschooler
Slower growth- School age
Rapid growth- Adolescence

2. In assessing Raphael’s growth and

development, the nurse is guided by
principles of growth and development.
Which is not included?

All individuals follow cephalo-caudal and

proximo-distal
Different parts of the body grows at
different rate
All individual follow standard growth rate
Rate and pattern of growth can be
modified

D. Rate and pattern of growth can be
modified. Growth and development
occurs in cephalo-caudal meaning
development occurs through out the
body’s axis. Example: the child must
be able to lift the head before he is
able to lift his chest. Proximo-distal is
development that progresses from
center of the body to the extremities.
Example: a child first develops arm
movement before fine-finger
movement. Different parts of the
body grows at different range
because some body tissue mature
faster than the other such as the
neurologic tissues peaks its growth
during the first years of life while the
genital tissue doesn’t till puberty.
Also G&D is predictable in the
sequence which a child normally
precedes such as motor skills and
behavior. Lastly G&D can never be
modified .
3. What type of play will be ideal for
Raphael at this period?
Make believe
Hide and seek
Peek-a-boo
Building blocks
A. Make believe. Make believe is most
appropriate because it enhances the
imitative play and imagination of the
preschooler. C and D are for infants
while letter A is B is recommended
for schoolers because it enhances
competitive play.
4. Which of the following information
indicate that Raphael is normal for his
age?
Determine own sense self
Develop sense of whether he can trust
the world
Has the ability to try new things
Learn basic skills within his culture
C. Has the ability to try new
things. Erickson defines the
developmental task of a preschool
period is learning Initiative vs. Guilt.
Children can initiate motor activities
of various sorts on their own and no
longer responds to or imitate the
actions of other children or of their
parents.
5. Based on Kohlberg’s theory, what is
the stage of moral development of
Raphael?
Punishment-obedience
“good boy-Nice girl”
naïve instrumental orientation
social contact
C. naïve instrumental
orientation. According to Kohlber, a
preschooler is under Pre-conventional
where a child learns about
instrumental purpose and exchange,
that is they will something do for
another if that that person does
something with the child in return.
Letter A is applicable for Toddlers and
letter B is for a School age child
Situation 2 Baby boy Lacson
delivered at 36 weeks
gestation weighs 3,400 gm and
height of 59 cm (6-10)
6. Baby boy Lacson’s height is
Long
Short
Average
Too short
A. Long. The average length of full-term
babies at birth is 20 in. (51 cm),
although the normal range is 46 cm
(18 in.) to 56 cm (22 in.).
7. Growth and development in a child
progresses in the following ways EXCEPT
From cognitive to psychosexual
From trunk to the tip of the extremities
From head to toe
From general to specific
A. From cognitive to
psychosexual. Growth and
development occurs in cephalo-
caudal (head to toe), proximo-distal
(trunk to tips of the extremities and
general to specific, but it doesn’t
occurs in cognitive to psychosexual
because they can develop at the
same time.
8. As described by Erikson, the major
psychosexual conflict of the above
situation is
Autonomy vs. Shame and doubt
Industry vs. Inferiority
Trust vs. mistrust
Initiation vs. guilt
C. Trust vs. mistrust. According to
Erikson, children 0-18 months are
under the developmental task of
Trust vs. Mistrust.
9. Which of the following is true about
Mongolian Spots?
Disappears in about a year
Are linked to pathologic conditions
Are managed by tropical steroids
Are indicative of parental abuse
A. Disappears in about a year. Mongolian
spots are stale grey or bluish patches
of discoloration commonly seen
across the sacrum or buttocks due to
accumulation of melanocytes and
they disappears in 1 year. They are
not linked to steroid use and
pathologic conditions.
10. Signs of cold stress that the nurse
must be alert when caring for a Newborn
is:
Hypothermia
Decreased activity level
Shaking
Increased RR
D. Increased RR. Hypothermia is
inaccurate cause normally,
temperature of a newborn drop, Also
a child under cold stress will kick and
cry to increase the metabolic rate
thereby increasing heat so B isn’t a
good choice. A newborn doesn’t have
the ability to shiver, so letter B and C
is wrong. A newborn will increase its
RR because the NB will need more
oxygen because of too much activity.
Situation 3 Nursing care after
delivery has an important
aspect in every stages of
delivery
11. After the baby is delivered, the cord
was cut between two clamps using a
sterile scissors and blade, then the baby
is placed at the:
Mother’s breast
Mother’s side
Give it to the grandmother
Baby’s own mat or bed
A. Mother’s breast. Place it at the
mother’s breast for latch-on. (Note:
for NSD breast feed ASAP while for CS
delivery, breast feed after 4 hours)
12. The baby’s mother is RH(-). Which of
the following laboratory tests will
probably be ordered for the newborn?
Direct Coomb’s
Indirect Coomb’s
Blood culture
Platelet count
A. Direct Coomb’s. Coomb’s test is the
test to determine if RH antibodies are
present. Indirect Coomb’s is done to
the mother and Direct Coomb’s is the
one don’t to the baby. Blood culture
and Platelet count doesn’t help
detect RH antibodies.
13. Hypothermia is common in newborn
because of their inability to control heat.
The following would be an appropriate
nursing intervention to prevent heat loss
except:
Place the crib beside the wall
Doing Kangaroo care
By using mechanical pressure
Drying and wrapping the baby
A. Place the crib beside the wall. Placing
the crib beside the wall is
inappropriate because it can provide
heat loss by radiation. Doing
Kangaroo care or hugging the baby,
mechanical pressure or incubators
and drying and wrapping the baby
will help conserve heat.
14. The following conditions are caused
by cold stress except
Hypoglycemia
Increase ICP
Metabolic acidosis
Cerebral palsy
B. Increase ICP. Hypoglycemia may
occur due to increase metabolic rate,
and because of newborns are born
slightly acidic, and they catabolize
brownfat which will produce ketones
which is an acid will cause metabolic
acidosis. Also a NB with severe
hypothermia is in high risk for
kernicterus (too much bilirubin in the
brain) can lead to Cerebral palsy.
 There is no connection in the increase
of ICP with hypothermia. (NOTE:
pathognomonic sign of Kernicterus in
adult- asterexis, or involuntary
flapping of the hand.)
15. During the feto-placental circulation,
the shunt between two atria is called
Ductus venosous
Foramen Magnum
Ductus arteriosus
Foramen Ovale
D. Foramen Ovale. Foramen ovale is
opening between two atria, Ductus
venosus is the shunt from liver to the
inferior vena cava, and your Ductus
Arteriosus is the shunt from the
pulmonary artery to the aorta.
16. What would cause the closure of the
Foramen ovale after the baby had been
delivered?
Decreased blood flow
Shifting of pressures from right
side to the left side of the heart
Increased PO2
Increased in oxygen saturation
B. Shifting of pressures from right side to
the left side of the heart. During feto-
placental circulation, the pressure in
the heart is much higher in the right
side, but once breathing/crying is
established, the pressure will shift
from the R to the L side, and will
facilitate the closure of Foramen
Ovale. (Note: that is why you should
position the NB in R side lying
position to increase pressure in the L
side of the heart.)
Review:
Increase PO2-> closure of ductus
arteriosus
Decreased bloodflow -> closure
of the ductus venosus
Circulation in the lungs is
initiated by -> lung expansion
and pulmonary ventilation
What will sustain 1st breath->
decreased artery pressure
What will complete circulation->
cutting of the cord
17. Failure of the Foramen Ovale to close
will cause what Congenital Heart
Disease?
Total anomalous Pulmunary Artery
Atrial Septal defect
Transposition of great arteries
Pulmunary Stenosis
B. Atrial Septal defect. Foramen ovale is
the opening between two Atria so, if
its will not close Atrial Septal defect
can occur.
Situation 4 Children are
vulnerable to some minor
health problems or injuries
hence the nurse should be able
to teach mothers to give
appropriate home care.
18. A mother brought her child to the
clinic with nose bleeding. The nurse
showed the mother the most appropriate
position for the child which is:
Sitting up
With low back rest
With moderate back rest
Lying semi flat
A. Sitting up. The correct position is
making the child having an upright
sitting position with the head slightly
tilted forward. This position will
minimize the amount of blood
pressure in nasal vessels and keep
blood moving forward not back into
the nasopharynx, which will have the
choking sensation and increase risk
of aspiration. Choices b, c, d, are
inappropriate cause they can cause
blood to enter the nasopharynx.
19. A common problem in children is the
inflammation of the middle ear. This is
related to the malfunctioning of the:
Tympanic membrane
Eustachian tube
Adenoid
Nasopharynx
B. Eustachian tube. This is because
children has short, horizontal
Eustachian tubes. The dysfunction in
the Eustachian tube enables bacterial
invasion of the middle ear and
obstructs drainage of secretions.
20. For acute otitis media, the treatment
is prompt antibiotic therapy. Delayed
treatment may result in complications of:
Tonsillitis
Eardrum Problems
Brain damage
Diabetes mellitus
C. Brain damage. One of the
complication of recurring acute otitis
media is risk for having Meningitis,
thereby causing possible brain
damage. That is why patient must
follow a complete treatment regimen
and follow up care. A,B and D are not
complications of AOM.
21. When assessing gross motor
development in a 3 year old, which of the
following activities would the nurse
expect to finds?
Riding a tricycle
Hopping on one foot
Catching a ball
Skipping on alternate foot.
A. Riding a tricycle. Answer is A, riding a
tricycle is appropriate for a 3 y/o
child. Hopping on one foot can be
done by a 4 y/o child, as well as
catching and throwing a ball over
hand. Skipping can be done by a 5
y/o.
22. When assessing the weight of a 5-
month old, which of the following
indicates healthy growth?
Doubling of birth weight
Tripling of birth weight
Quadrupling of birth weight
Stabilizing of birth weight
A. Doubling of birth weight. During the
first 6 months of life the weight from
birth will be doubled and as soon as
the baby reaches 1 year, its birth
weight is tripled.
23. An appropriate toy for a 4 year old
child is:
Push-pull toys
Card games
Doctor and nurse kits
Books and Crafts
C. Doctor and nurse kits. Letter C is
appropriate because it will enhance
the creativity and imagination of a
pre-school child. Letter B and D are
inappropriate because they are too
complex for a 4 y/o. Push-pull toys
are recommended for infants.
24. Which of the following statements
would the nurse expects a 5-year old boy
to say whose pet gerbil just died
“The boogieman got him”
“He’s just a bit dead”
“Ill be good from now own so I wont die
like my gerbil”
“Did you hear the joke about…”
B. “He’s just a bit dead”. A 5 y/o views
death in “degrees”, so the child most
likely will say that “he is just a bit
dead”. Personification of death like
boogeyman occurs in ages 7 to 9 as
well as denying death can if they will
be good. Denying death using jokes
and attributing life qualities to death
occurs during age 3-5.
25. When assessing the fluid and
electrolyte balance in an infant, which of
the following would be important to
remember?
Infant can concentrate urine at an adult
level
The metabolic rate of an infant is slower
than in adults
Infants have more intracellular water
that adult do
Infant have greater body surface
area than adults
D. Infant have greater body surface area
than adults. Infants have greater
body surface area than adult,
increasing their risk to F&E
imbalances. Also infants cant
concentrate a urine at an adult level
and their metabolic rate, also called
water turnover, is 2 to 3 times higher
than adult. Plus more fluids of the
infants are at the ECF spaces not in
the ICF spaces.
26. When assessing a child with aspirin
overdose, which of the following will be
expected?
Metabolic alkalosis
Respiratory alkalosis
Metabolic acidosis
Respiratory acidosis
C. Metabolic acidosis. Remember that
Aspirin is acid (Acetylsalicylic ACID).
27. Which of the following is not a
possible systemic clinical manifestation
of severe burns?
Growth retardation
Hypermetabolism
Sepsis
Blisters and edema
D. Blisters and edema. The question was
asking for a SYSTEMIC clinical
manifestation, Letters A,B and C are
systemic manifestations while
Blisters and Edema weren’t.
28. When assessing a family for potential
child abuse risks, the nurse would
observe for which of the following?
Periodic exposure to stress
Low socio-economic status
High level of self esteem
Problematic pregnancies
D. Problematic pregnancies. Typical
factors that may be risk for Child
abuse are problematic pregnancies,
chronic exposure to stress not
periodic, low level of self esteem not
high level. Also child abuse can
happen in all socio-economic status
not just on low socio-economic status
29. Which of the following is a possible
indicator of Munchausen syndrome by
proxy type of child abuse?
Bruises found at odd locations, with
different stages of healing
STD’s and genital discharges
Unexplained symptoms of diarrhea,
vomiting and apnea with no
organic basis
Constant hunger and poor hygiene
C. Unexplained symptoms of diarrhea,
vomiting and apnea with no organic
basis. Munchausen syndrome by
Proxy is the fabrication or
inducement of an illness by one
person to another person, usually
mother to child. It is characterized by
symptoms such as apnea and
siezures, which may be due to
suffocation, drugs or poisoning,
vomiting which can be induced with
poisons and diarrhea with the use of
laxatives. Letter A can be seen in a
Physical abuse, Letter B for sexual
abuse and Letter C is for Physical
Neglect.
30. Which of the following is an
inappropriate interventions when caring
for a child with HIV?
Teaching family about disease
transmission
Offering large amount of fresh
fruits and vegetables
Encouraging child to perform at optimal
level
Teach proper hand washing technique
B. Offering large amount of fresh fruits
and vegetables. A child with HIV is
immunocompromised. Fresh fruits
and vegetables, which may be
contaminated with organisms and
pesticides can be harmful, if not fatal
to the child, therefore these items
should be avoided.
Situation 5 Agata, 2 years old
is rushed to the ER due to
cyanosis precipitated by
crying. Her mother observed
that after playing she gets
tired. She was diagnosed with
Tetralogy of Fallot.
31. The goal of nursing care fro Agata is
to:
Prevent infection
Promote normal growth and
development
Decrease hypoxic spells
Hydrate adequately
C. Decrease hypoxic spells. The correct
answer is letter C. Though letter B
would be a good answer too, this goal
is too vague and not specific. Nursing
interventions will not solely promote
normal G&D unless he will undergo
surgical repair. So decreasing Hypoxic
Spells is more SMART. Letter A and D
are inappropriate.
32. The immediate nursing intervention
for cyanosis of Agata is:
Call up the pediatrician
Place her in knee chest position
Administer oxygen inhalation
Transfer her to the PICU
B. Place her in knee chest position. The
immediate intervention would be to
place her on knee-chest or
 “squatting” position because it traps
blood into the lower extremities.
Though also letter C would be a good
choice but the question is asking for
“Immediate” so letter B is more
appropriate. Letter A and D are
incorrect because its normal for a
child who have ToF to have hypoxic or
“tets” spells so there is no need to
transfer her to the NICU or to alert
the Pediatrician.
33. Agata was scheduled for a palliative
surgery, which creates anastomosis of
the subclavian artery to the pulmonary
artery. This procedure is:
Waterston-Cooley
Raskkind Procedure
Coronary artery bypass
Blalock-Taussig
D. Blalock-Taussig. Blalock-Taussig
procedure its just a temporary or
palliative surgery which creates a
shunt between the aorta and
pulmonary artery so that the blood
can leave the aorta and enter the
pulmonary artery and thus
oxygenating the lungs and return to
the left side of the heart, then to the
aorta then to the body. This
procedure also makes use of the
subclavian vein so pulse is not
palpable at the right arm. The full
repair for ToF is called the Brock
procedure. Raskkind is a palliative
surgery for TOGA.
34. Which of the following is not an
indicator that Agata experiences
separation anxiety brought about her
hospitalization?
Friendly with the nurse
Prolonged loud crying, consoled only by
mother
Occasional temper tantrums and always
says NO
Repeatedly verbalizes desire to go home
A. Friendly with the nurse. Because
toddlers views hospitalization is
abandonment, separation anxiety is
common. Its has 3 phases: PDD
(parang c puff daddy LOL) 1. Protest
2. despair 3. detachment (or denial).
Choices B, C, D are usually seen in a
child with separation anxiety (usually
in the protest stage).
REVIEW:
Separation anxiety begin at: 9
months
Peaks: 18 months
35. When Agata was brought to the OR,
her parents where crying. What would be
the most appropriate nursing diagnosis?
Infective family coping r/t situational
crisis
Anxiety r/t powerlessness
Fear r/t uncertain prognosis
Anticipatory grieving r/t gravity of
child’s physical status
D. Anticipatory grieving r/t gravity of
child’s physical status. In this item
letter A and be are inappropriate
response so remove them. The
possible answers are C and D. Fear
defined as the perceived threat (real
or imagined) that is consciously
recognized as danger (NANDA) is
applicable in the situation but its
defining characteristics are not
applicable. Crying per se can not be a
subjective cue to signify fear, and
most of the symptoms of fear in
NANDA are physiological. Anticipatory
grieving on the other hand are
intellectual and EMOTIONAL
responses based on a potential loss.
And remember that procedures like
this cannot assure total recovery. So
letter D is a more appropriate Nursing
diagnosis
36. Which of the following respiratory
condition is always considered a medical
emergency?
Laryngeotracheobronchitis (LTB)
Epiglottitis
Asthma
Cystic Fibrosis
B. Epiglottitis. Acute and sever
inflammation of the epiglottis can
cause life threatening airway
obstruction, that is why its always
treated as a medical emergency. NSG
intervention : Prepare tracheostomy
set at bed side. LTB, can also cause
airway obstruction but its not an
emergency. Asthma is also not an
emergency. CF is a chronic disease,
so its not a medical emergency
37. Which of the following statements by
the family of a child with asthma
indicates a need for additional teaching?
“We need to identify what things
triggers his attacks”
“He is to use bronchodilator inhaler
before steroid inhaler”
“We’ll make sure he avoids exercise
to prevent asthma attacks”
“he should increase his fluid intake
regularly to thin secretions”
C. “We’ll make sure he avoids exercise
to prevent asthma
attacks”. Asthmatic children don’t
have to avoid exercise. They can
participate on physical activities as
tolerated. Using a bronchodilator
before administering steroids is
correct because steroids are just anti-
inflammatory and they don’t have
effects on the dilation
of the bronchioles. OF course letters A
and B are obviously correct.
38. Which of the following would require
careful monitoring in the child with ADHD
who is receiving Methylphenidate
(Ritalin)?
Dental health
Mouth dryness
Height and weight
Excessive appetite
C. Height and weight. Dental problems
are more likely to occur in children
under going TCA therapy. Mouth
dryness is a expected side effects of
Ritalin since it activates the SNS. Also
loss of appetite is more likely to
happen, not increase in appetite. The
correct answer is letter C, because
Ritalin can affect the child’s G&D.
Intervention: medication “holidays or
vacation”. (This means during
weekends or holidays or school
vacations, where the child wont be in
school, the drug can be withheld.)
Situation 6 Laura is assigned
as the Team Leader during the
immunization day at the RHU
39. What program for the DOH is
launched at 1976 in cooperation with
WHO and UNICEF to reduce morbidity
and mortality among infants caused by
immunizable disease?
Patak day
Immunization day on Wednesday
Expanded program on immunization
Bakuna ng kabtaan
C. Expanded program on immunization
40. One important principle of the
immunization program is based on?
Statistical occurrence
Epidemiologic situation
Cold chain management
Surveillance study
B. Epidemiologic situation. Letters A, C
and D are not included in the
principles of EPI.
41. The main element of immunization
program is one of the following?
Information, education and
communication
Assessment and evaluation of the
program
Research studies
Target setting
42. What does herd immunity means?
Interruption of transmission
All to be vaccinated
Selected group for vaccination
Shorter incubation\
43. Measles vaccine can be given
simultaneously. What is the combined
vaccine to be given to children starting at
15 months?
MCG
MMR
BCG
BBR
B. MMR. MMR or Measles, Mumps,
Rubella is a vaccine furnished in one
vial and is routinely given in one
injection (Sub-Q). It can be given at
15 months but can also be given as
early as 12th month.
Situation 7: Braguda brought
her 5-month old daughter in
the nearest RHU because her
baby sleeps most of the time,
with decreased appetite, has
colds and fever for more than a
week. The physician diagnosed
pneumonia.
44. Based on this data given by Braguda,
you can classify Braguda’s daughter to
have:
Pneumonia: cough and colds
Severe pneumonia
Very severe pneumonia
Pneumonia moderate
B. Severe pneumonia. For a child aging
2months up to 5 years old can be
classified to have sever pneumonia
when he have any of the following
danger signs:
Not able to drink
Convulsions
Abnormally sleepy or difficult to
wake
Stridor in calm child or
Severe under-nutrition
45. For a 3-month old child to be
classified to have Pneumonia (not
severe), you would expect to find RR of:
60 bpm
40 bpm
70 bpm
50 pbm
D. 50 pbm. A child can be classified to
have Pneumonia (not severe) if:
the young infant is less than 2
months- 60 bpm or more
if the child is 2 months up to less
than 12 months- 50 bpm or more
if the child is 12 months to 4 y/o- 40
bpm or more
46. You asked Braguda if her baby
received all vaccines under EPI. What
legal basis is used in implementing the
UN’s goal on Universal Child
Immunization?
PD no. 996
PD no. 6
PD no. 46
RA 9173
B. PD no. 6 Presidential Proclamation no.
6 (April 3, 1986) is the “Implementing
a United Nations goal on Universal
Child Immunization by 1990”. PD 996
(September 16, 1976) is “providing
for compulsory basic immunization
for infants and children below 8 years
of age. PD no. 46 (September 16,
1992) is the “Reaffirming the
commitment of the Philippines to the
universal Child and Mother goal of
the World Health Assembly. RA 9173
is of course the “Nursing act of 2002”
47. Braguda asks you about Vitamin A
supplementation. You responded that
giving Vitamin A starts when the infant
reaches 6 months and the first dose is”
200,000 “IU”
100,000 “IU”
500,000 “IU”
10,000 “IU”
B. 100,000 “IU”. An infant aging 6-11
months will be given Vitamin
supplementation of 100, 000 IU and
for Preschoolers ages 12-83 months
200,000 “IU” will be given.
48. As part of CARI program, assessment
of the child is your main responsibility.
You could ask the following question to
the mother except:
“How old is the child?”
“IS the child coughing? For how long?”
“Did the child have chest
indrawing?”
“Did the child have fever? For how
long?”
C. “Did the child have chest
indrawing?”. The CARI program of the
DOH includes the “ASK” and “LOOK,
LISTEN” as part of the assessment of
the child who has suspected
Pneumonia. Choices A, B and D are
included in the “ASK” assessment
while Chest indrawings is included in
the “LOOK, LISTEN” and should not
be asked to the mother.
49. A newborn’s failure to pass
meconium within 24 hours after birth
may indicate which of the following?
Aganglionic Mega colon
Celiac disease
Intussusception
Abdominal wall defect

A. Aganglionic Mega colon. Failure to
pass meconium of Newborn during
the first 24 hours of life may indicate
Hirschsprung disease or Congenital
Aganglionic Megacolon, an anomaly
resulting in mechanical obstruction
due to inadequate motility in an
intestinal segment. B, C, and D are
not associated in the failure to pass
meconium of the newborn
50. The nurse understands that a good
snack for a 2 year old with a diagnosis of
acute asthma would be:
Grapes
Apple slices
A glass of milk
A glass of cola
B. Apple slices. Grapes is in appropriate
because of its “balat” that can cause
choking. A glass of milk is not a good
snack because it’s the most common
cause of Iron-deficiency anemia in
children (milk contains few iron), A
glass of cola is also not appropriate
cause it contains complex sugar.
(walang kinalaman ang asthma dahil
ala naman itong diatery restricted
foods na nasa choices.)
51. Which of the following immunizations
would the nurse expect to administer to
a child who is HIV (+) and severely
immunocomromised?
Varicella
Rotavirus
MMR
IPV
D. IPV. IPV or Inactivated polio vaccine
does not contain live micro organisms
which can be harmful to an
immunocompromised child. Unlike
OPV, IPV is administered via IM route.
52. When assessing a newborn for
developmental dysplasia of the hip, the
nurse would expect to assess which of
the following?
Symmetrical gluteal folds
Trendelemburg sign
Ortolani’s sign
Characteristic limp
C. Ortolani’s sign. Correct answer is
Ortolani’s sign; it is the abnormal
clicking sound when the hips are
abducted. The sound is produced
when the femoral head enters the
acetabulum. Letter A is wrong
because its should be “asymmetrical
gluteal fold”. Letter B and C are not
applicable for newborns because they
are seen in older children.
53. While assessing a male neonate
whose mother desires him to be
circumcised, the nurse observes that the
neonate’s urinary meatus appears to be
located on the ventral surface of the
penis. The physician is notified because
the nurse would suspect which of the
following?
Phimosis
Hydrocele
Epispadias
Hypospadias
D. Hypospadias. Hypospadias is a c
condition in which the urethral
opening is located below the glans
penis or anywhere along the ventral
surface of the penile shaft.
Epispadias, the urethral meatus is
located at the dorsal surface of the
penile shaft. (Para di ka malilto, I-
alphabetesize mo Dorsal, (Above) eh
mauuna sa Ventral (Below) , Epis
mauuna sa Hypo.)
54. When teaching a group of parents
about seat belt use, when would the
nurse state that the child be safely
restrained in a regular automobile
seatbelt?
30 lb and 30 in
35 lb and 3 y/o
40 lb and 40 in
60 lb and 6 y/o
C. 40 lb and 40 in. Basta tandaan ang
rule of 4! 4 years old, 40 lbs and 40
in.
55. When assessing a newborn with cleft
lip, the nurse would be alert which of the
following will most likely be
compromised?
Sucking ability
Respiratory status
Locomotion
GI function
A. Sucking ability. Because of the defect,
the child will be unable to form the
 mouth adequately arounf the nipple
thereby requiring special devices to
allow feeding and sucking
gratification. Respiratory status may
be compromised when the child is fed
improperly or during post op period
56. For a child with recurring nephritic
syndrome, which of the following areas of
potential disturbances should be a prime
consideration when planning ongoing
nursing care?
Muscle coordination
Sexual maturation
Intellectual development
Body image
D. Body image. Because of edema,
associated with nephroitic syndrome,
potential self concept and body
image disturbance related to changes
in appearance and social isolation
should be considered.
57. An inborn error of metabolism that
causes premature destruction of RBC?
G6PD
Hemocystinuria
Phenylketonuria
Celiac Disease
A. G6PD. G6PD is the premature
destruction of RBC when the blood is
exposed to antioxidants, ASA (ano
un? Aspirin), legumes and flava
beans.
58. Which of the following would be a
diagnostic test for Phenylketonuria which
uses fresh urine mixed with ferric
chloride?
Guthrie Test
Phenestix test
Beutler’s test
Coomb’s test
B. Phenestix test. Phenestix test is a
diagnostic test which uses a fresh
urine sample (diapers) and mixed
with ferric chloride. If positive, there
will be a presence of green spots at
the diapers. Guthrie test is another
test for PKU and is the one that
mostly used. The specimen used is
the blood and it tests if CHON is
converted to amino acid.
59. Dietary restriction in a child who has
Hemocystenuria will include which of the
following amino acid?
Lysine
Methionine
Isolensine tryptophase
Valine
B. Methionine. Hemocystenuria is the
elevated excretion of the amino acid
hemocystiene, and there is inability
to convert the amino acid methionine
or cystiene. So dietary restriction of
this amino acids is advised. This
disease can lead to mental
retardation.
60. A milk formula that you can suggest for
a child with Galactosemia:
Lofenalac
Lactum
Neutramigen
Sustagen
C. Neutramigen. Neutramien is
suggested for a child with
Galactosemia. Lofenalac is suggested
for a child with PKU.
PNLE Community
Health Nursing
Exam 1
1. Which is the primary goal of
community health nursing?
A. To support and supplement the
efforts of the medical profession in
the promotion of health and
prevention of illness
B. To enhance the capacity of
individuals, families and
communities to cope with their
health needs
C. To increase the productivity of the
people by providing them with
services that will increase their level
of health
D. To contribute to national
development through promotion of
family welfare, focusing particularly
on mothers and children.
Answer: (B) To enhance the capacity
of individuals, families and
communities to cope with their
health needs
2. CHN is a community-based practice.
Which best explains this statement?
A. The service is provided in the
natural environment of people.
B. The nurse has to conduct
community diagnosis to
determine nursing needs and
problems.
C. The services are based on the
available resources within the
community.
D. Priority setting is based on the
magnitude of the health problems
identified.
Answer: (B) The nurse has to conduct
community diagnosis to determine
nursing needs and problems
3. Population-focused nursing practice
requires which of the following
processes?
A. Community organizing
B. Nursing process
C. Community diagnosis
D. Epidemiologic process
Answer: (C) Community
diagnosis. Population-focused nursing
care means providing care based on the
greater need of the majority of the
population. The greater need is identified
through community diagnosis.
4. R.A. 1054 is also known as the
Occupational Health Act. Aside from
number of employees, what other factor
must be considered in determining the
occupational health privileges to which
the workers will be entitled?
A. Type of occupation: agricultural,
commercial, industrial
B. Location of the workplace in
relation to health facilities
C. Classification of the business
enterprise based on net profit
D. Sex and age composition of
employees
Answer: (B) Location of the
workplace in relation to health
facilities. Based on R.A. 1054, an
occupational nurse must be
employed when there are 30 to 100
employees and the workplace is more
than 1 km. away from the nearest
health center
5. A business firm must employ an
occupational health nurse when it has at
least how many employees?
A. 21
B. 101
C. 201
D. 301
Answer: (B) 101. Again, this is based on
R.A. 1054
6. When the occupational health nurse
employs ergonomic principles, she is
performing which of her roles?
A. Health care provider
B. Health educator
C. Health care coordinator
D. Environmental manager
Answer: (D) Environmental
manager. Ergonomics is improving
efficiency of workers by improving the
worker’s environment through
appropriately designed furniture, for
example
7. A garment factory does not have an
occupational nurse. Who shall provide
the occupational health needs of the
factory workers?
A. Occupational health nurse at the
Provincial Health Office
B. Physician employed by the factory
C. Public health nurse of the RHU
of their municipality
D. Rural sanitary inspector of the RHU
of their municipality
Answer: (C) Public health nurse of
the RHU of their municipality. You’re
right! This question is based on R.A.1054
8. “Public health services are given free
of charge.” Is this statement true or
false?
A. The statement is true; it is the
responsibility of government to
provide basic services.
B. The statement is false; people
pay indirectly for public health
services.
C. The statement may be true or
false, depending on the specific
service required.
D. The statement may be true or
false, depending on policies of the
government concerned.

Answer: (B) The statement is false;
people pay indirectly for public
health services. Community health
services, including public health services,
are pre-paid services, though taxation,
for example.
9. According to C.E.Winslow, which of the
following is the goal of Public Health?
A. For people to attain their
birthrights of health and
longevity
B. For promotion of health and
prevention of disease
C. For people to have access to basic
health services
D. For people to be organized in their
health efforts
Answer: (A) For people to attain their
birthrights of health and
longevity. According to Winslow, all
public health efforts are for people to
realize their birthrights of health and
longevity
10. We say that a Filipino has attained
longevity when he is able to reach the
average lifespan of Filipinos. What other
statistic may be used to determine
attainment of longevity?
A. Age-specific mortality rate
B. Proportionate mortality rate
C. Swaroop’s index
D. Case fatality rate
Answer: (C) Swaroop’s
index. Swaroop’s index is the
percentage of the deaths aged 50 years
or older. Its inverse represents the
percentage of untimely deaths (those
who died younger than 50 years
11. Which of the following is the most
prominent feature of public health
nursing?
A. It involves providing home care to
sick people who are not confined in
the hospital.
B. Services are provided free of
charge to people within the
catchment area.
C. The public health nurse functions
as part of a team providing a public
health nursing services.
D. Public health nursing focuses
on preventive, not curative,
services.
Answer: (D) Public health nursing
focuses on preventive, not curative,
services.The catchment area in PHN
consists of a residential community,
many of whom are well individuals who
have greater need for preventive rather
than curative services.
12. According to Margaret Shetland, the
philosophy of public health nursing is
based on which of the following?
A. Health and longevity as birthrights
B. The mandate of the state to protect
the birthrights of its citizens
C. Public health nursing as a
specialized field of nursing
D. The worth and dignity of man
Answer: (D) The worth and dignity of
man. This is a direct quote from Dr.
Margaret Shetland’s statements on
Public Health Nursing
13. Which of the following is the mission
of the Department of Health?
A. Health for all Filipinos
B. Ensure the accessibility and
quality of health care
C. Improve the general health status
of the population
D. Health in the hands of the Filipino
people by the year 2020
Answer: (B) Ensure the accessibility
and quality of health care
14. Region IV Hospital is classified as
what level of facility?
A. Primary
B. Secondary
C. Intermediate
D. Tertiary
Answer: (D) Tertiary. Regional hospitals
are tertiary facilities because they serve
as training hospitals for the region.
15. Which is true of primary facilities?
A. They are usually government-run.
B. Their services are provided on
an out-patient basis.
C. They are training facilities for
health professionals.
D. A community hospital is an
example of this level of health
facilities.
Answer: (B) Their services are
provided on an out-patient
basis. Primary facilities government
and non-government facilities that
provide basic out-patient services
16. Which is an example of the school
nurse’s health care provider functions?
A. Requesting for BCG from the RHU
for school entrant immunization
B. Conducting random classroom
inspection during a measles
epidemic
C. Taking remedial action on an
accident hazard in the school
playground
D. Observing places in the school
where pupils spend their free time
Answer: (B) Conducting random
classroom inspection during a
measles epidemic. Random classroom
inspection is assessment of
pupils/students and teachers for signs of
a health problem prevalent in the
community
17. When the nurse determines whether
resources were maximized in
implementing Ligtas Tigdas, she is
evaluating
A. Effectiveness
B. Efficiency
C. Adequacy
D. Appropriateness
Answer: (B) Efficiency. Efficiency is
determining whether the goals were
attained at the least possible cost.
18. You are a new B.S.N. graduate. You
want to become a Public Health Nurse.
Where will you apply?
A. Department of Health
B. Provincial Health Office
C. Regional Health Office
D. Rural Health Unit
Answer: (D) Rural Health Unit. R.A.
7160 devolved basic health services to
local government units (LGU’s ). The
public health nurse is an employee of the
LGU.
19. R.A. 7160 mandates devolution of
basic services from the national
government to local government units.
Which of the following is the major goal
of devolution?
A. To strengthen local government
units
B. To allow greater autonomy to local
government units
C. To empower the people and
promote their self-reliance
D. To make basic services more
accessible to the people
Answer: (C) To empower the
people and promote their self-
reliance. People empowerment is
the basic motivation behind
devolution of basic services to
LGU’s.
20. Who is the Chairman of the Municipal
Health Board?
A. Mayor
B. Municipal Health Officer
C. Public Health Nurse
D. Any qualified physician
Answer: (A) Mayor. The local executive
serves as the chairman of the Municipal
Health Board.
21. Which level of health facility is the
usual point of entry of a client into the
health care delivery system?
A. Primary
B. Secondary
C. Intermediate
D. Tertiary
Answer: (A) Primary. The entry of a
person into the health care delivery
system is usually through a consultation
in out-patient services.
22. The public health nurse is the
supervisor of rural health midwives.
Which of the following is a supervisory
function of the public health nurse?
A. Referring cases or patients to the
midwife
B. Providing technical guidance to
the midwife
C. Providing nursing care to cases
referred by the midwife
D. Formulating and implementing
training programs for midwives
Answer: (B) Providing technical
guidance to the midwife. The nurse
provides technical guidance to the
midwife in the care of clients, particularly
in the implementation of management
guidelines, as in Integrated Management
of Childhood Illness.
23. One of the participants in a hilot
training class asked you to whom she
should refer a patient in labor who
develops a complication. You will answer,
to the
A. Public Health Nurse
B. Rural Health Midwife
C. Municipal Health Officer
D. Any of these health professionals
Answer: (C) Municipal Health Officer. A
public health nurse and rural health
midwife can provide care during normal
childbirth. A physician should attend to a
woman with a complication during labor.
24. You are the public health nurse in a
municipality with a total population of
about 20,000. There are 3 rural health
midwives among the RHU personnel.
How many more midwife items will the
RHU need?
A. 1 to people in their own places of
B. 2 residence.
C. 3
D. The RHU does not need any more
midwife item.
Answer: (A) 1. Each rural health midwife
is given a population assignment of
about 5,000.
25. If the RHU needs additional midwife
items, you will submit the request for
additional midwife items for approval to
the
A. Rural Health Unit
B. District Health Office
C. Provincial Health Office
D. Municipal Health Board
Answer: (D) Municipal Health
Board. As mandated by R.A. 7160,
basic health services have been
devolved from the national government
to local government units
26. As an epidemiologist, the nurse is
responsible for reporting cases of
notifiable diseases. What law mandates
reporting of cases of notifiable diseases?
A. Act 3573
B. R.A. 3753
C. R.A. 1054
D. R.A. 1082
Answer: (A) Act 3573. Act 3573, the
Law on Reporting of Communicable
Diseases, enacted in 1929, mandated
the reporting of diseases listed in the
law to the nearest health station
27. According to Freeman and Heinrich,
community health nursing is a
developmental service. Which of the
following best illustrates this statement?
A. The community health nurse
continuously develops himself
personally and professionally.
B. Health education and
community organizing are
necessary in providing
community health services.
C. Community health nursing is
intended primarily for health
promotion and prevention and
treatment of disease.
D. The goal of community health
nursing is to provide nursing services
Answer: (B) Health education and
community organizing are
necessary in providing community
health services. The community
health nurse develops the health
capability of people through health
education and community organizing
activities
28. Which disease was declared through
Presidential Proclamation No. 4 as a
target for eradication in the Philippines?
A. Poliomyelitis
B. Measles
C. Rabies
D. Neonatal tetanus
Answer: (B) Measles. Presidential
Proclamation No. 4 is on the Ligtas Tigdas
Program.
29. The public health nurse is responsible
for presenting the municipal health
statistics using graphs and tables. To
compare the frequency of the leading
causes of mortality in the municipality, A. To educate the people regarding
which graph will you prepare? community health problems
B. To mobilize the people to resolve
A. Line community health problems
B. Bar C. To maximize the community’s
C. Pie resources in dealing with health
D. Scatter diagram problems
D. To maximize the community’s
Answer: (B) Bar. A bar graph is used to resources in dealing with health
present comparison of values, a line problems
graph for trends over time or age, a pie
graph for population composition or Answer: (D) To maximize the
distribution, and a scatter diagram for community’s resources in dealing
correlation of two variables. with health problems. Community
organizing is a developmental service,
30. Which step in community organizing with the goal of developing the people’s
involves training of potential leaders in self-reliance in dealing with community
the community? health problems. A, B and C are
objectives of contributory objectives to
A. Integration this goal.
B. Community organization
C. Community study 3. An indicator of success in community
D. Core group formation organizing is when people are able to

Answer: (D) Core group formation. In A. Participate in community

core group formation, the nurse is able to
transfer the technology of community
organizing to the potential or informal
community leaders through a training
program.
PNLE Community
activities for the solution of a
community problem
B. Implement activities for the solution
of the community problem
C. Plan activities for the solution of the
community problem
D. Identify the health problem as a
common concern

Health Nursing Answer: (A) Participate in

community activities for the
solution of a community
Exam 2 problem. Participation in community
activities in resolving a community
1. In which step are plans formulated for problem may be in any of the
solving community problems? processes mentioned in the other
choices
A. Mobilization
B. Community organization
C. Follow-up/extension 4. Tertiary prevention is needed in which
D. Core group formation stage of the natural history of disease?

Answer: (B) Community A. Pre-pathogenesis

organization. Community organization
is the step when community assemblies
take place. During the community
assembly, the people may opt to
formalize the community organization
and make plans for community action to
resolve a community health problem.
2. The public health nurse takes an
active role in community participation.
What is the primary goal of community
organizing?
B. Pathogenesis
C. Prodromal
D. Terminal
Answer: (D) Terminal. Tertiary
prevention involves rehabilitation,
prevention of permanent disability and
disability limitation appropriate for
convalescents, the disabled,
complicated cases and the terminally ill
(those in the terminal stage of a
disease)
5. Isolation of a child with measles 9. The de los Reyes couple have a 6-year
belongs to what level of prevention? old child entering school for the first
time. The de los Reyes family has a:
A. Primary
B. Secondary A. Health threat
C. Intermediate B. Health deficit
D. Tertiary C. Foreseeable crisis
D. Stress point
Answer: (A) Primary. The purpose of
isolating a client with a communicable Answer: (C) Foreseeable crisis. Entry
disease is to protect those who are not of the 6-year old into school is an
sick (specific disease prevention). anticipated period of unusual demand
on the family.
6. On the other hand, Operation Timbang
is _____ prevention. 10. Which of the following is an
advantage of a home visit?
A. Primary
B. Secondary A. It allows the nurse to provide nursing
C. Intermediate care to a greater number of people.
D. Tertiary B. It provides an opportunity to do
first hand appraisal of the home
Answer: (B) Secondary. Operation situation.
Timbang is done to identify members of C. It allows sharing of experiences
the susceptible population who are among people with similar health
malnourished. Its purpose is early problems.
diagnosis and, subsequently, prompt D. It develops the family’s initiative in
treatment. providing for health needs of its
members.
7. Which type of family-nurse contact will
provide you with the best opportunity to Answer: (B) It provides an
observe family dynamics? opportunity to do first hand
appraisal of the home
A. Clinic consultation situation.. Choice A is not correct since
B. Group conference a home visit requires that the nurse
C. Home visit spend so much time with the family.
D. Written communication Choice C is an advantage of a group
conference, while choice D is true of a
Answer: (C) Home visit. Dynamics of clinic consultation.
family relationships can best be
observed in the family’s natural 11. Which is CONTRARY to the principles
environment, which is the home. in planning a home visit?

8. The typology of family nursing A. A home visit should have a purpose

problems is used in the statement of
nursing diagnosis in the care of families.
The youngest child of the de los Reyes
family has been diagnosed as mentally
retarded. This is classified as a:
A. Health threat
B. Health deficit
C. Foreseeable crisis
D. Stress point
Answer: (B) Health deficit. Failure of
a family member to develop according
to what is expected, as in mental
retardation, is a health deficit.
or objective.
B. The plan should revolve around
family health needs.
C. A home visit should be conducted
in the manner prescribed by the
RHU.
D. Planning of continuing care should
involve a responsible family member.
Answer: (C) A home visit should be
conducted in the manner prescribed
by the RHU.The home visit plan should
be flexible and practical, depending on
factors, such as the family’s needs and
the resources available to the nurse and
the family.
12. The PHN bag is an important tool in
providing nursing care during a home
visit. The most important principle of bag
technique states that it
A. Should save time and effort.
B. Should minimize if not totally
prevent the spread of infection.
C. Should not overshadow concern for
the patient and his family.
D. May be done in a variety of ways
depending on the home situation,
etc.
Answer: (B) Should minimize if not
totally prevent the spread of
infection. Bag technique is performed
before and after handling a client in the
home to prevent transmission of
infection to and from the client.
13. To maintain the cleanliness of the bag
and its contents, which of the following
must the nurse do?
A. Wash his/her hands before and
after providing nursing care to
the family members.
B. In the care of family members, as
much as possible, use only articles
taken from the bag.
C. Put on an apron to protect her
uniform and fold it with the right side
out before putting it back into the
bag.
D. At the end of the visit, fold the lining
on which the bag was placed,
ensuring that the contaminated side
is on the outside.
Answer: (A) Wash his/her hands
before and after providing nursing
care to the family members. Choice
B goes against the idea of utilizing the
family’s resources, which is encouraged
in CHN. Choices C and D goes against
the principle of asepsis of confining the
contaminated surface of objects.
14. The public health nurse conducts a
study on the factors contributing to the
high mortality rate due to heart disease
in the municipality where she works.
Which branch of epidemiology does the
nurse practice in this situation?
A. Descriptive
B. Analytical
C. Therapeutic
D. Evaluation
Answer: (B) Analytical. Analytical
epidemiology is the study of factors or
determinants affecting the patterns of
occurrence and distribution of disease in
a community.
15. Which of the following is a function of
epidemiology?
A. Identifying the disease condition
based on manifestations presented
by a client
B. Determining factors that contributed
to the occurrence of pneumonia in a
3 year old
C. Determining the efficacy of the
antibiotic used in the treatment of
the 3 year old client with pneumonia
D. Evaluating the effectiveness of
the implementation of the
Integrated Management of
Childhood Illness
Answer: (D) Evaluating the
effectiveness of the implementation
of the Integrated Management of
Childhood Illness. Epidemiology is
used in the assessment of a community
or evaluation of interventions in
community health practice.
16. Which of the following is an
epidemiologic function of the nurse
during an epidemic?
A. Conducting assessment of suspected
cases to detect the communicable
disease
B. Monitoring the condition of the cases
affected by the communicable
disease
C. Participating in the investigation
to determine the source of the
epidemic
D. Teaching the community on
preventive measures against the
disease
Answer: (C) Participating in the
investigation to determine the
source of the epidemic. Epidemiology
is the study of patterns of occurrence
and distribution of disease in the
community, as well as the factors that
affect disease patterns. The purpose of
an epidemiologic investigation is to
identify the source of an epidemic, i.e.,
what brought about the epidemic.
17. The primary purpose of conducting
an epidemiologic investigation is to
A. Delineate the etiology of the A. Epidemic occurrence
epidemic B. Cyclical variation
B. Encourage cooperation and support C. Sporadic occurrence
of the community D. Secular variation
C. Identify groups who are at risk of
contracting the disease Answer: (B) Cyclical variation. A
D. Identify geographical location of cyclical variation is a periodic fluctuation
cases of the disease in the in the number of cases of a disease in
community the community.

Answer: (A) Delineate the etiology 21. In the year 1980, the World Health
of the epidemic. Delineating the Organization declared the Philippines,
etiology of an epidemic is identifying its together with some other countries in the
source. Western Pacific Region, “free” of which
disease?
18. Which is a characteristic of person-to-
person propagated epidemics? A. Pneumonic plague
B. Poliomyelitis
A. There are more cases of the disease C. Small pox
than expected. D. Anthrax
B. The disease must necessarily be
transmitted through a vector. Answer: (C) Small pox. The last
C. The spread of the disease can be documented case of Small pox was in
attributed to a common vehicle. 1977 at Somalia.
D. There is a gradual build up of
cases before the epidemic 22. In the census of the Philippines in
becomes easily noticeable. 1995, there were about 35,299,000
males and about 34,968,000 females.
Answer: (D) There is a gradual build What is the sex ratio?
up of cases before the epidemic
becomes easily noticeable. A gradual A. 99.06:100
or insidious onset of the epidemic is B. 100.94:100
usually observable in person-to-person C. 50.23%
propagated epidemics. D. 49.76%

19. In the investigation of an epidemic, Answer: (B) 100.94:100. Sex ratio is

you compare the present frequency of
the disease with the usual frequency at
this time of the year in this community.
This is done during which stage of the
investigation?
A. Establishing the epidemic
B. Testing the hypothesis
C. Formulation of the hypothesis
D. Appraisal of facts
Answer: (A) Establishing the
epidemic. Establishing the epidemic is
determining whether there is an
epidemic or not. This is done by
comparing the present number of cases
with the usual number of cases of the
disease at the same time of the year, as
well as establishing the relatedness of
the cases of the disease.
the number of males for every 100
females in the population
23. Primary health care is a total
approach to community development.
Which of the following is an indicator of
success in the use of the primary health
care approach?
A. Health services are provided free of
charge to individuals and families.
B. Local officials are empowered as the
major decision makers in matters of
health.
C. Health workers are able to provide
care based on identified health needs
of the people.
D. Health programs are sustained
according to the level of
development of the community.

20. The number of cases of Dengue fever Answer: (D) Health programs are
usually increases towards the end of the sustained according to the level
rainy season. This pattern of occurrence of development of the
of Dengue fever is best described as community. Primary health care is
 essential health care that can be
sustained in all stages of development
of the community.
24. Sputum examination is the major
screening tool for pulmonary
tuberculosis. Clients would sometimes
get false negative results in this exam.
This means that the test is not perfect in
terms of which characteristic of a
diagnostic examination?
A. Effectiveness
B. Efficacy
C. Specificity
D. Sensitivity
Answer: (D) Sensitivity. Sensitivity is
the capacity of a diagnostic examination
to detect cases of the disease. If a test is
100% sensitive, all the cases tested will
have a positive result, i.e., there will be
no false negative results.
25. Use of appropriate technology
requires knowledge of indigenous
technology. Which medicinal herb is
given for fever, headache and cough?
A. Sambong
B. Tsaang gubat
C. Akapulko
D. Lagundi
Answer: (D) Lagundi. Sambong is
used as a diuretic. Tsaang gubat is used
to relieve diarrhea. Akapulko is used for
its antifungal property
26. What law created the Philippine
Institute of Traditional and Alternative
Health Care?
A. R.A. 8423
B. R.A. 4823
C. R.A. 2483
D. R.A. 3482
27. In traditional Chinese medicine, the
yielding, negative and feminine force is
termed
A. Yin
B. Yang
C. Qi
D. Chai
Answer: (A) Yin. Yang is the male
dominating, positive and masculine
force.
28. What is the legal basis for Primary
Health Care approach in the Philippines?
A. Alma Ata Declaration on PHC
B. Letter of Instruction No. 949
C. Presidential Decree No. 147
D. Presidential Decree 996
Answer: (B) Letter of Instruction
No. 949. Letter of Instruction 949 was
issued by then President Ferdinand
Marcos, directing the formerly called
Ministry of Health, now the Department
of Health, to utilize Primary Health Care
approach in planning and implementing
health programs
29. Which of the following demonstrates
intersectoral linkages?
A. Two-way referral system
B. Team approach
C. Endorsement done by a midwife to
another midwife
D. Cooperation between the PHN
and public school teacher
Answer: (D) Cooperation
between the PHN and public
school teacher. Intersectoral
linkages refer to working
relationships between the health
sector and other sectors involved in
community development.
30. The municipality assigned to you has
a population of about 20,000. Estimate
the number of 1-4 year old children who
will be given Retinol capsule 200,000 I.U.
every 6 months.
A. 1,500
B. 1,800
C. 2,000
D. 2,300
Answer: (D) 2,300. Based on the
Philippine population composition, to
estimate the number of 1-4 year old
children, multiply total population by
11.5%.
PNLE
Community
Health Nursing Answer: (B) 5.2/1,000. To compute
crude death rate divide total number of
deaths (94) by total population (18,000)
Exam 3 and multiply by 1,000

1. Estimate the number of pregnant 5. Knowing that malnutrition is a frequent

women who will be given tetanus toxoid community health problem, you decided
during an immunization outreach activity to conduct nutritional assessment. What
in a barangay with a population of about population is particularly susceptible to
1,500. protein energy malnutrition (PEM)?

A. 265 A. Pregnant women and the elderly

B. 300 B. Under-5 year old children
C. 375 C. 1-4 year old children
D. 400 D. School age children

Answer: (A) 265. To estimate the
number of pregnant women, multiply
the total population by 3.5%.
2. To describe the sex composition of the
population, which demographic tool may
be used?
Answer: (C) 1-4 year old
children. Preschoolers are the most
susceptible to PEM because they have
generally been weaned. Also, this is the
population who, unable to feed
themselves, are often the victims of poor
intrafamilial food distribution.

A. Sex ratio 6. Which statistic can give the most

B. Sex proportion accurate reflection of the health status of
C. Population pyramid a community?
D. Any of these may be used.
A. 1-4 year old age-specific mortality
Answer: (D) Any of these may be rate
used. Sex ratio and sex proportion are B. Infant mortality rate
used to determine the sex composition of C. Swaroop’s index
a population. A population pyramid is D. Crude death rate
used to present the composition of a
population by age and sex. Answer: (C) Swaroop’s
index. Swaroop’s index is the
3. Which of the following is a natality proportion of deaths aged 50 years
rate? and above. The higher the Swaroop’s
index of a population, the greater the
A. Crude birth rate proportion of the deaths who were
B. Neonatal mortality rate able to reach the age of at least 50
C. Infant mortality rate years, i.e., more people grew old
D. General fertility rate before they died.

Answer: (A) Crude birth rate. Natality 7. In the past year, Barangay A had an
means birth. A natality rate is a birth average population of 1655. 46 babies
rate. were born in that year, 2 of whom died
less than 4 weeks after they were born.
4. You are computing the crude death There were 4 recorded stillbirths. What is
rate of your municipality, with a total the neonatal mortality rate?
population of about 18,000, for last year.
There were 94 deaths. Among those who A. 27.8/1,000
died, 20 died because of diseases of the B. 43.5/1,000
heart and 32 were aged 50 years or C. 86.9/1,000
older. What is the crude death rate? D. 130.4/1,000

A. 4.2/1,000 Answer: (B) 43.5/1,000. To compute for

B. 5.2/1,000 neonatal mortality rate, divide the
C. 6.3/1,000 number of babies who died before
D. 7.3/1,000 reaching the age of 28 days by the total
number of live births, then multiply by
1,000.
8. Which statistic best reflects the
nutritional status of a population?
A. 1-4 year old age-specific
mortality rate
B. Proportionate mortality rate
C. Infant mortality rate
D. Swaroop’s index
Answer: (A) 1-4 year old age-specific
mortality rate. Since preschoolers are
the most susceptible to the effects of
malnutrition, a population with poor
nutritional status will most likely have a
high 1-4 year old age-specific mortality
rate, also known as child mortality rate.
9. What numerator is used in computing
general fertility rate?
A. Estimated midyear population
B. Number of registered live births
C. Number of pregnancies in the year
D. Number of females of reproductive
age
Answer: (B) Number of registered live
births. To compute for general or total
fertility rate, divide the number of
registered live births by the number of
females of reproductive age (15-45
years), then multiply by 1,000.
10. You will gather data for nutritional
assessment of a purok. You will gather
information only from families with
members who belong to the target
population for PEM. What method of data
gathering is best for this purpose?
A. Census
B. Survey
C. Record review
D. Review of civil registry
Answer: (B) Survey. A survey, also
called sample survey, is data gathering
about a sample of the population
11. In the conduct of a census, the
method of population assignment based
on the actual physical location of the
people is termed
A. De jure
B. De locus
C. De facto
D. De novo
Answer: (C) De facto. The other method
of population assignment, de jure, is
based on the usual place of residence of
the people.
12. The Field Health Services and
Information System (FHSIS) is the
recording and reporting system in public
health care in the Philippines. The
Monthly Field Health Service Activity
Report is a form used in which of the
components of the FHSIS?
A. Tally report
B. Output report
C. Target/client list
D. Individual health record
Answer: (A) Tally report. A tally report
is prepared monthly or quarterly by the
RHU personnel and transmitted to the
Provincial Health Office
13. To monitor clients registered in long-
term regimens, such as the Multi-Drug
Therapy, which component will be most
useful?
A. Tally report
B. Output report
C. Target/client list
D. Individual health record
Answer: (C) Target/client list. The MDT
Client List is a record of clients enrolled
in MDT and other relevant data, such as
dates when clients collected their
monthly supply of drugs
14. Civil registries are important sources
of data. Which law requires registration
of births within 30 days from the
occurrence of the birth?
A. P.D. 651
B. Act 3573
C. R.A. 3753
D. R.A. 3375
Answer: (A) P.D. 651. P.D. 651 amended
R.A. 3753, requiring the registry of births
within 30 days from their occurrence
15. Which of the following professionals
can sign the birth certificate?
A. Public health nurse
B. Rural health midwife
C. Municipal health officer
D. Any of these health professionals
Answer: (D) Any of these health
professionals. D. R.A. 3753 states that
any birth attendant may sign the
certificate of live birth.
16. Which criterion in priority setting of
health problems is used only in
community health care?
A. Modifiability of the problem
B. Nature of the problem presented
C. Magnitude of the health problem
D. Preventive potential of the health
problem
Answer: (C) Magnitude of the health
problem. Magnitude of the problem
refers to the percentage of the
population affected by a health problem.
The other choices are criteria considered
in both family and community health
care
17. The Sentrong Sigla Movement has
been launched to improve health service
delivery. Which of the following is/are
true of this movement?
A. This is a project spearheaded by local
government units.
B. It is a basis for increasing funding
from local government units.
C. It encourages health centers to focus
on disease prevention and control.
D. Its main strategy is certification
of health centers able to comply
with standards.
Answer: (D) Its main strategy is
certification of health centers
able to comply with
standards. Sentrong Sigla Movement
is a joint project of the DOH and local
government units. Its main strategy is
certification of health centers that are
able to comply with standards set by
the DOH.
18. Which of the following women should
be considered as special targets for
family planning?
A. Those who have two children or more
B. Those with medical conditions such
as anemia
C. Those younger than 20 years and
older than 35 years
D. Those who just had a delivery
within the past 15 months
Answer: (D) Those who just had a
delivery within the past 15
months. The ideal birth spacing is at
least two years. 15 months plus 9
months of pregnancy = 2 years
19. Freedom of choice is one of the
policies of the Family Planning Program of
the Philippines. Which of the following
illustrates this principle?
A. Information dissemination about the
need for family planning
B. Support of research and development
in family planning methods
C. Adequate information for couples
regarding the different methods
D. Encouragement of couples to take
family planning as a joint
responsibility
Answer: (C) Adequate information
forcouples regarding the different
methods. To enable the couple to
choose freely among different methods
of family planning, they must be given
full information regarding the different
methods that are available to them,
considering the availability of quality
services that can support their choice.
20. A woman, 6 months pregnant, came
to the center for consultation. Which of
the following substances is
contraindicated?
A. Tetanus toxoid
B. Retinol 200,000 IU
C. Ferrous sulfate 200 mg
D. Potassium iodate 200 mg. capsule
Answer: (B) Retinol 200,000
IU. Retinol 200,000 IU is a form of
megadose Vitamin A. This may have a
teratogenic effect
21. During prenatal consultation, a client
asked you if she can have her delivery at
home. After history taking and physical
examination, you advised her against a
home delivery. Which of the following
findings disqualifies her for a home
delivery?
A. Her OB score is G5P3.
B. She has some palmar pallor.
C. Her blood pressure is 130/80.
D. Her baby is in cephalic presentation.
Answer: (A) Her OB score is
G5P3. Only women with less than 5
 pregnancies are qualified for a home
delivery. It is also advisable for a
primigravida to have delivery at a
childbirth facility
22. Inadequate intake by the pregnant
woman of which vitamin may cause
neural tube defects?
A. Niacin
B. Riboflavin
C. Folic acid
D. Thiamine
Answer: (C) Folic acid. It is estimated
that the incidence of neural tube
defects can be reduced drastically if
pregnant women have an adequate
intake of folic acid.
23. You are in a client’s home to attend
to a delivery. Which of the following will
you do first?
A. Set up the sterile area.
B. Put on a clean gown or apron.
C. Cleanse the client’s vulva with soap
and water.
D. Note the interval, duration and
intensity of labor contractions.
Answer: (D) Note the interval,
duration and intensity of labor
contractions.. Assessment of the
woman should be done first to
determine whether she is having true
labor and, if so, what stage of labor
she is in.
24. In preparing a primigravida for
breastfeeding, which of the following will
you do?
A. Tell her that lactation begins within a
day after delivery.
B. Teach her nipple stretching exercises
if her nipples are everted.
C. Instruct her to wash her nipples
before and after each breastfeeding.
D. Explain to her that putting the baby
to breast will lessen blood loss after
delivery.
Answer: (D) Explain to her that
putting the baby to breast will
lessen blood loss after
delivery. Suckling of the nipple
stimulates the release of oxytocin by the
posterior pituitary gland, which causes
uterine contraction. Lactation begins 1 to
3 days after delivery. Nipple stretching
exercises are done when the nipples are
flat or inverted. Frequent washing dries
up the nipples, making them prone to the
formation of fissures.
25. A primigravida is instructed to offer
her breast to the baby for the first time
within 30 minutes after delivery. What is
the purpose of offering the breast this
early?
A. To initiate the occurrence of milk
letdown
B. To stimulate milk production by
the mammary acini
C. To make sure that the baby is able to
get the colostrum
D. To allow the woman to practice
breastfeeding in the presence of the
health worker
Answer: (B) To stimulate milk
production by the mammary
acini. Suckling of the nipple stimulates
prolactin reflex (the release of prolactin
by the anterior pituitary gland), which
initiates lactation
26. In a mothers’ class, you discuss
proper breastfeeding technique. Which is
of these is a sign that the baby has
“latched on” to the breast properly?
A. The baby takes shallow, rapid sucks.
B. The mother does not feel nipple pain.
C. The baby’s mouth is only partly open.
D. Only the mother’s nipple is inside the
baby’s mouth.
Answer: (B) The mother does not feel
nipple pain.. When the baby has
properly latched on to the breast, he
takes deep, slow sucks; his mouth is wide
open; and much of the areola is inside his
mouth. And, you’re right! The mother
does not feel nipple pain.
27. You explain to a breastfeeding
mother that breast milk is sufficient for
all of the baby’s nutrient needs only up
to ____.
A. 3 months
B. 6 months
C. 1 year
D. 2 years
Answer: (B) 6 months. After 6 months,
the baby’s nutrient needs, especially the
baby’s iron requirement, can no longer
be provided by mother’s milk alone
28. What is given to a woman within a
month after the delivery of a baby?
A. Malunggay capsule
B. Ferrous sulfate 100 mg. OD
C. Retinol 200,000 I.U., 1 capsule
D. Potassium iodate 200 mg, 1 capsule
Answer: (C) Retinol 200,000 I.U., 1
capsule. A capsule of Retinol 200,000
IU is given within 1 month after
delivery. Potassium iodate is given
during pregnancy; malunggay capsule
is not routinely administered after
delivery; and ferrous sulfate is taken
for two months after delivery.
29. Which biological used in Expanded
Program on Immunization (EPI) is stored
in the freezer?
A. DPT
B. Tetanus toxoid
C. Measles vaccine
D. Hepatitis B vaccine
Answer: (C) Measles vaccine. Among
the biologicals used in the Expanded
Program on Immunization, measles
vaccine and OPV are highly sensitive to
heat, requiring storage in the freezer
30. Unused BCG should be discarded how
many hours after reconstitution?
A. 2 C.
B. 4 D.
C. 6
D. At the end of the day
Answer: (B) 4. While the unused
portion of other biologicals in EPI may
be given until the end of the day, only
BCG is discarded 4 hours after
reconstitution. This is why BCG
immunization is scheduled only in the
morning.
PNLE Community
Health Nursing
Exam 4
1. In immunizing school entrants with
BCG, you are not obliged to secure
parental consent. This is because of
which legal document?
A. P.D. 996
B. R.A. 7846
C. Presidential Proclamation No. 6
D. Presidential Proclamation No. 46
Answer: (A) P.D. 996. Presidential
Decree 996, enacted in 1976, made
immunization in the EPI compulsory for
children under 8 years of age. Hepatitis B
vaccination was made compulsory for the
same age group by R.A. 7846.
2. Which immunization produces a
permanent scar?
A. DPT
B. BCG
C. Measles vaccination
D. Hepatitis B vaccination
Answer: (B) BCG. BCG causes the
formation of a superficial abscess, which
begins 2 weeks after immunization. The
abscess heals without treatment, with
the formation of a permanent scar
3. A 4-week old baby was brought to the
health center for his first immunization.
Which can be given to him?
A. DPT1
B. OPV1
Infant BCG
Hepatitis B vaccine 1
Answer: (C) Infant BCG. Infant BCG
may be given at birth. All the other
immunizations mentioned can be given
at 6 weeks of age
4. You will not give DPT 2 if the mother
says that the infant had
A. Seizures a day after DPT 1.
B. Fever for 3 days after DPT 1.
C. Abscess formation after DPT 1.
D. Local tenderness for 3 days after DPT
1.
Answer: (A) Seizures a day after DPT
1. Seizures within 3 days after
administration of DPT is an indication of
hypersensitivity to pertussis vaccine, a
component of DPT. This is considered a
specific contraindication to subsequent
doses of DPT.
5. A 2-month old infant was brought to
the health center for immunization.
During assessment, the infant’s
temperature registered at 38.1°C. Which
is the best course of action that you will
take?
A. Go on with the infant’s
immunizations.
B. Give Paracetamol and wait for his
fever to subside.
C. Refer the infant to the physician for
further assessment.
D. Advise the infant’s mother to bring
him back for immunization when he
is well.
Answer: (A) Go on with the infant’s
immunizations. In the EPI, fever up to
38.5°C is not a contraindication to
immunization. Mild acute respiratory
tract infection, simple diarrhea and
malnutrition are not contraindications
either.
6. A pregnant woman had just received
her 4th dose of tetanus toxoid.
Subsequently, her baby will have
protection against tetanus for how long?
A. 1 year
B. 3 years
C. 10 years
D. Lifetime
Answer: (A) 1 year. The baby will have
passive natural immunity by placental
transfer of antibodies. The mother will
have active artificial immunity lasting
for about 10 years. 5 doses will give the
mother lifetime protection
7. A 4-month old infant was brought to
the health center because of cough. Her
respiratory rate is 42/minute. Using the
Integrated Management of Child Illness
(IMCI) guidelines of assessment, her
breathing is considered
A. Fast
B. Slow
C. Normal
D. Insignificant
Answer: (C) Normal. In IMCI, a
respiratory rate of 50/minute or more
is fast breathing for an infant aged 2
to 12 months.
8. Which of the following signs will
indicate that a young child is suffering
from severe pneumonia?
A. Dyspnea
B. Wheezing
C. Fast breathing
D. Chest indrawing
Answer: (D) Chest indrawing. In IMCI,
chest indrawing is used as the positive
sign of dyspnea, indicating severe
pneumonia
9. Using IMCI guidelines, you classify a
child as having severe pneumonia. What
is the best management for the child?
A. Prescribe an antibiotic.
B. Refer him urgently to the
hospital.
C. Instruct the mother to increase fluid
intake.
D. Instruct the mother to continue
breastfeeding.
Answer: (B) Refer him urgently to the
hospital. Severe pneumonia requires
urgent referral to a hospital. Answers A, C
and D are done for a client classified as
having pneumonia.
10. A 5-month old infant was brought by
his mother to the health center because
of diarrhea occurring 4 to 5 times a day.
His skin goes back slowly after a skin
pinch and his eyes are sunken. Using the
IMCI guidelines, you will classify this
infant in which category?
A. No signs of dehydration
B. Some dehydration
C. Severe dehydration
D. The data is insufficient.
Answer: (B) Some dehydration. Using
the assessment guidelines of IMCI, a
child (2 months to 5 years old) with
diarrhea is classified as having SOME
DEHYDRATION if he shows 2 or more of
the following signs: restless or irritable,
sunken eyes, the skin goes back slow
after a skin pinch
11. Based on assessment, you classified
a 3-month old infant with the chief
complaint of diarrhea in the category of
SOME DEHYDRATION. Based on IMCI
management guidelines, which of the
following will you do?
A. Bring the infant to the nearest facility
where IV fluids can be given.
B. Supervise the mother in giving
200 to 400 ml. of Oresol in 4
hours.
C. Give the infant’s mother instructions
on home management.
D. Keep the infant in your health center
for close observation.
Answer: (B) Supervise the mother in
giving 200 to 400 ml. of Oresol in 4
hours. In the IMCI management
guidelines, SOME DEHYDRATION is
treated with the administration of Oresol
within a period of 4 hours. The amount of
Oresol is best computed on the basis of
the child’s weight (75 ml/kg body
weight). If the weight is unknown, the
amount of Oresol is based on the child’s
age.
12. A mother is using Oresol in the
management of diarrhea of her 3-year
old child. She asked you what to do if her
child vomits. You will tell her to
A. Bring the child to the nearest hospital
for further assessment.
B. Bring the child to the health center
for intravenous fluid therapy.
C. Bring the child to the health center
for assessment by the physician.
D. Let the child rest for 10 minutes
then continue giving Oresol more
slowly.
Answer: (D) Let the child rest for 10
minutes then continue giving Oresol
more slowly. If the child vomits
persistently, that is, he vomits
everything that he takes in, he has to be
referred urgently to a hospital.
Otherwise, vomiting is managed by
letting the child rest for 10 minutes and
then continuing with Oresol
administration. Teach the mother to give
Oresol more slowly
13. A 1 ½ year old child was classified as
having 3rd degree protein energy
malnutrition, kwashiorkor. Which of the
following signs will be most apparent in
this child?
A. Voracious appetite
B. Wasting
C. Apathy
D. Edema
Answer: (D) Edema. Edema, a major
sign of kwashiorkor, is caused by
decreased colloidal osmotic pressure of
the blood brought about by
hypoalbuminemia. Decreased blood
albumin level is due a protein-deficient
diet.
14. Assessment of a 2-year old child
revealed “baggy pants”. Using the IMCI
guidelines, how will you manage this
child?
A. Refer the child urgently to a hospital
for confinement.
B. Coordinate with the social worker to
enroll the child in a feeding program.
C. Make a teaching plan for the mother,
focusing on menu planning for her
child.
D. Assess and treat the child for health
problems like infections and intestinal
parasitism.
Answer: (A) Refer the child
urgently to a hospital for
confinement. “Baggy pants” is a sign
of severe marasmus. The best
management is urgent referral to a
hospital.
15. During the physical examination of a
young child, what is the earliest sign of
xerophthalmia that you may observe?
A. Keratomalacia
B. Corneal opacity
C. Night blindness
D. Conjunctival xerosis
Answer: (D) Conjunctival xerosis. The
earliest sign of Vitamin A deficiency
(xerophthalmia) is night blindness.
However, this is a functional change,
which is not observable during physical
examination.The earliest visible lesion is
conjunctival xerosis or dullness of the
conjunctiva due to inadequate tear
production.
16. To prevent xerophthalmia, young
children are given Retinol capsule every
6 months. What is the dose given to
preschoolers?
A. 10,000 IU
B. 20,000 IU
C. 100,000 IU
D. 200,000 IU
Answer: (D) 200,000 IU. Preschoolers
are given Retinol 200,000 IU every 6
months. 100,000 IU is given once to
 infants aged 6 to 12 months. The dose
for pregnant women is 10,000 IU
17. The major sign of iron deficiency
anemia is pallor. What part is best
examined for pallor?
A. Palms
B. Nailbeds
C. Around the lips
D. Lower conjunctival sac
Answer: (A) Palms. The anatomic
characteristics of the palms allow a
reliable and convenient basis for
examination for pallor.
18. Food fortification is one of the
strategies to prevent micronutrient
deficiency conditions. R.A. 8976
mandates fortification of certain food
items. Which of the following is among
these food items?
A. Sugar
B. Bread
C. Margarine
D. Filled milk
Answer: (A) Sugar. R.A. 8976 mandates
fortification of rice, wheat flour, sugar
and cooking oil with Vitamin A, iron
and/or iodine
19. What is the best course of action
when there is a measles epidemic in a
nearby municipality?
A. Give measles vaccine to babies
aged 6 to 8 months.
B. Give babies aged 6 to 11 months one
dose of 100,000 I.U. of Retinol
C. Instruct mothers to keep their babies
at home to prevent disease
transmission.
D. Instruct mothers to feed their babies
adequately to enhance their babies’
resistance.
Answer: (A) Give measles vaccine to
babies aged 6 to 8 months. Ordinarily,
measles vaccine is given at 9 months of
age. During an impending epidemic,
however, one dose may be given to
babies aged 6 to 8 months. The mother is
instructed that the baby needs another
dose when the baby is 9 months old.
20. A mother brought her daughter, 4
years old, to the RHU because of cough
and colds. Following the IMCI assessment
guide, which of the following is a danger
sign that indicates the need for urgent
referral to a hospital?
A. Inability to drink
B. High grade fever
C. Signs of severe dehydration
D. Cough for more than 30 days
Answer: (A) Inability to drink. A sick
child aged 2 months to 5 years must be
referred urgently to a hospital if he/she
has one or more of the following signs:
not able to feed or drink, vomits
everything, convulsions, abnormally
sleepy or difficult to awaken
21. Management of a child with measles
includes the administration of which of
the following?
A. Gentian violet on mouth lesions
B. Antibiotics to prevent pneumonia
C. Tetracycline eye ointment for corneal
opacity
D. Retinol capsule regardless of
when the last dose was given
Answer: (D) Retinol capsule
regardless of when the last dose
was given. An infant 6 to 12 months
classified as a case of measles is given
Retinol 100,000 IU; a child is given
200,000 IU regardless of when the last
dose was given
22. A mother brought her 10 month old
infant for consultation because of fever,
which started 4 days prior to
consultation. To determine malaria risk,
what will you do?
A. Do a tourniquet test.
B. Ask where the family resides.
C. Get a specimen for blood smear.
D. Ask if the fever is present everyday.
Answer: (B) Ask where the family
resides. Because malaria is endemic,
the first question to determine malaria
risk is where the client’s family resides. If
the area of residence is not a known
endemic area, ask if the child had
traveled within the past 6 months, where
he/she was brought and whether he/she
stayed overnight in that area.
23. The following are strategies
implemented by the Department of
Health to prevent mosquito-borne
diseases. Which of these is most
effective in the control of Dengue fever?
A. Stream seeding with larva-eating fish
B. Destroying breeding places of
mosquitoes
C. Chemoprophylaxis of non-immune
persons going to endemic areas
D. Teaching people in endemic areas to
use chemically treated mosquito nets
Answer: (B) Destroying breeding
places of mosquitoes. Aedes aegypti,
the vector of Dengue fever, breeds in
stagnant, clear water. Its feeding time is
usually during the daytime. It has a
cyclical pattern of occurrence, unlike
malaria which is endemic in certain
parts of the country
24. Secondary prevention for malaria
includes
A. Planting of neem or eucalyptus trees
B. Residual spraying of insecticides at
night
C. Determining whether a place is
endemic or not
D. Growing larva-eating fish in mosquito
breeding places
Answer: (C) Determining whether a
place is endemic or not. This is
diagnostic and therefore secondary level
prevention. The other choices are for
primary prevention
25. Scotch tape swab is done to check for
which intestinal parasite?
A. Ascaris
B. Pinworm
C. Hookworm
D. Schistosoma
Answer: (B) Pinworm. Pinworm ova are
deposited around the anal orifice.
26. Which of the following signs indicates
the need for sputum examination for
AFB?
A. Hematemesis
B. Fever for 1 week
C. Cough for 3 weeks
D. Chest pain for 1 week
Answer: (C) Cough for 3 weeks. A
client is considered a PTB suspect when
he has cough for 2 weeks or more, plus
one or more of the following signs: fever
for 1 month or more; chest pain lasting
for 2 weeks or more not attributed to
other conditions; progressive,
unexplained weight loss; night sweats;
and hemoptysis.
27. Which clients are considered targets
for DOTS Category I?
A. Sputum negative cavitary cases
B. Clients returning after a default
C. Relapses and failures of previous PTB
treatment regimens
D. Clients diagnosed for the first time
through a positive sputum exam
\
Answer: (D) Clients diagnosed for the
first time through a positive sputum
exam. Category I is for new clients
diagnosed by sputum examination and
clients diagnosed to have a serious form
of extrapulmonary tuberculosis, such as
TB osteomyelitis.
28. To improve compliance to treatment,
what innovation is being implemented in
DOTS?
A. Having the health worker follow up
the client at home
B. Having the health worker or a
responsible family member
monitor drug intake
C. Having the patient come to the
health center every month to get his
medications
D. Having a target list to check on
whether the patient has collected his
monthly supply of drugs
Answer: (B) Having the health worker
or a responsible family member
monitor drug intake. Directly
Observed Treatment Short Course is so-
called because a treatment partner,
preferably a health worker accessible to
the client, monitors the client’s
compliance to the treatment.
29. Diagnosis of leprosy is highly
dependent on recognition of symptoms.
Which of the following is an early sign of
leprosy?
A. Macular lesions
B. Inability to close eyelids
C. Thickened painful nerves
D. Sinking of the nosebridge
Answer: (C) Thickened painful
nerves. The lesion of leprosy is not
macular. It is characterized by a change
in skin color (either reddish or whitish)
and loss of sensation, sweating and hair
growth over the lesion. Inability to close
the eyelids (lagophthalmos) and sinking
of the nosebridge are late symptoms
30. Which of the following clients should
be classified as a case of multibacillary
leprosy?
A. 3 skin lesions, negative slit skin
smear
B. 3 skin lesions, positive slit skin smear
C. 5 skin lesions, negative slit skin
smear
D. 5 skin lesions, positive slit skin
smear
Answer: (D) 5 skin lesions, positive
slit skin smear. A multibacillary
leprosy case is one who has a positive
slit skin smear and at least 5 skin lesions
PNLE Community
Health Nursing
Exam 5
. In the Philippines, which condition is the
most frequent cause of death associated
with schistosomiasis?
A. Liver cancer
B. Liver cirrhosis
C. Bladder cancer
D. Intestinal perforation
Answer: (B) Liver cirrhosis. The
etiologic agent of schistosomiasis in the
Philippines is Schistosoma japonicum,
which affects the small intestine and the
liver. Liver damage is a consequence of
fibrotic reactions to schistosoma eggs in
the liver
2. What is the most effective way of
controlling schistosomiasis in an endemic
area?
A. Use of molluscicides
B. Building of foot bridges
C. Proper use of sanitary toilets
D. Use of protective footwear, such as
rubber boots
Answer: (C) Proper use of sanitary
toilets. The ova of the parasite get out
of the human body together with feces.
Cutting the cycle at this stage is the
most effective way of preventing the
spread of the disease to susceptible
hosts.
3. When residents obtain water from an
artesian well in the neighborhood, the
level of this approved type of water
facility is
A. I
B. II
C. III
D. IV
Answer: (B) II. A communal faucet or
water standpost is classified as Level II.
4. For prevention of hepatitis A, you
decided to conduct health education
activities. Which of the following is
IRRELEVANT?
A. Use of sterile syringes and
needles
B. Safe food preparation and food
handling by vendors
C. Proper disposal of human excreta and
personal hygiene
D. Immediate reporting of water pipe
leaks and illegal water connections
Answer: (A) Use of sterile syringes
and needles. Hepatitis A is transmitted
through the fecal oral route. Hepatitis B
is transmitted through infected body
secretions like blood and semen.
5. Which biological used in Expanded
Program on Immunization (EPI) should
NOT be stored in the freezer?
A. DPT
B. Oral polio vaccine
C. Measles vaccine
D. MMR
Answer: (A) DPT. DPT is sensitive to
freezing. The appropriate storage
temperature of DPT is 2 to 8° C only. OPV
and measles vaccine are highly sensitive
to heat and require freezing. MMR is not
an immunization in the Expanded
Program on Immunization.
6. You will conduct outreach
immunization in a barangay with a
population of about 1500. Estimate the
number of infants in the barangay.
A. 45
B. 50
C. 55
D. 60
Answer: (A) 45. To estimate the
number of infants, multiply total
population by 3%
7. In Integrated Management of
Childhood Illness, severe conditions
generally require urgent referral to a
hospital. Which of the following severe
conditions DOES NOT always require
urgent referral to a hospital?
A. Mastoiditis
B. Severe dehydration
C. Severe pneumonia
D. Severe febrile disease
Answer: (B) Severe dehydration. The
order of priority in the management of
severe dehydration is as follows:
intravenous fluid therapy, referral to a
facility where IV fluids can be initiated
within 30 minutes, Oresol/nasogastric
tube, Oresol/orem. When the foregoing
measures are not possible or effective,
tehn urgent referral to the hospital is
done.
8. A client was diagnosed as having
Dengue fever. You will say that there is
slow capillary refill when the color of the
nailbed that you pressed does not return
within how many seconds?
A. 3 contact with respiratory secretions.
B. 5
C. 8 12. Among children aged 2 months to 3
D. 10
Answer: (A) 3. Adequate blood supply
to the area allows the return of the color
of the nailbed within 3 seconds.
9. A 3-year old child was brought by his
mother to the health center because of
fever of 4-day duration. The child had a
positive tourniquet test result. In the
absence of other signs, which is the most
appropriate measure that the PHN may
carry out to prevent Dengue shock
syndrome?
A. Insert an NGT and give fluids per NGT.
B. Instruct the mother to give the
child Oresol.
C. Start the patient on intravenous
fluids STAT.
D. Refer the client to the physician for
appropriate management.
Answer: (B) Instruct the mother to
give the child Oresol. Since the child
does not manifest any other danger sign,
maintenance of fluid balance and
replacement of fluid loss may be done by
giving the client Oresol.
10. The pathognomonic sign of measles
is Koplik’s spot. You may see Koplik’s spot
by inspecting the _____.
A. Nasal mucosa
B. Buccal mucosa
C. Skin on the abdomen
D. Skin on the antecubital surface
Answer: (B) Buccal mucosa. Koplik’s
spot may be seen on the mucosa of the
mouth or the throat.
11. Among the following diseases, which
is airborne?
A. Viral conjunctivitis
B. Acute poliomyelitis
C. Diphtheria
D. Measles
Answer: (D) Measles. Viral
conjunctivitis is transmitted by direct or
indirect contact with discharges from
infected eyes. Acute poliomyelitis is
spread through the fecal-oral route and
contact with throat secretions, whereas
diphtheria is through direct and indirect
years, the most prevalent form of
meningitis is caused by which
microorganism?
A. Hemophilus influenzae
B. Morbillivirus
C. Steptococcus pneumoniae
D. Neisseria meningitides
Answer: (A) Hemophilus
influenzae. Hemophilus meningitis is
unusual over the age of 5 years. In
developing countries, the peak
incidence is in children less than 6
months of age. Morbillivirus is the
etiology of measles. Streptococcus
pneumoniae and Neisseria meningitidis
may cause meningitis, but age
distribution is not specific in young
children
13. Human beings are the major
reservoir of malaria. Which of the
following strategies in malaria control is
based on this fact?
A. Stream seeding
B. Stream clearing
C. Destruction of breeding places
D. Zooprophylaxis
Answer: (D)
Zooprophylaxis. Zooprophylaxis is
done by putting animals like cattle or
dogs close to windows or doorways just
before nightfall. The Anopheles
mosquito takes his blood meal from the
animal and goes back to its breeding
place, thereby preventing infection of
humans
14. The use of larvivorous fish in malaria
control is the basis for which strategy of
malaria control?
A. Stream seeding
B. Stream clearing
C. Destruction of breeding places
D. Zooprophylaxis
Answer: (A) Stream seeding. Stream
seeding is done by putting tilapia fry in
streams or other bodies of water
identified as breeding places of the
Anopheles mosquito
15. Mosquito-borne diseases are
prevented mostly with the use of
mosquito control measures. Which of the
following is NOT appropriate for malaria
control?
A. Use of chemically treated mosquito
nets
B. Seeding of breeding places with
larva-eating fish
C. Destruction of breeding places of
the mosquito vector
D. Use of mosquito-repelling soaps, such
as those with basil or citronella
Answer: (C) Destruction of breeding
places of the mosquito
vector. Anopheles mosquitoes breed in
slow-moving, clear water, such as
mountain streams.
16. A 4-year old client was brought to the
health center with the chief complaint of
severe diarrhea and the passage of “rice
water” stools. The client is most probably
suffering from which condition?
A. Giardiasis
B. Cholera
C. Amebiasis
D. Dysentery
Answer: (B) Cholera. Passage of
profuse watery stools is the major
symptom of cholera. Both amebic and
bacillary dysentery are characterized by
the presence of blood and/or mucus in
the stools. Giardiasis is characterized by
fat malabsorption and, therefore,
steatorrhea.
17. In the Philippines, which specie of
schistosoma is endemic in certain
regions?
A. S. mansoni
A.
B. S. malayensis
C. S. haematobium
Answer: (B) S. japonicum. S. mansoni
is found mostly in Africa and South
America; S. haematobium in Africa and
the Middle East; and S. malayensis only
in peninsular Malaysia.
18. A 32-year old client came for
consultation at the health center with the
chief complaint of fever for a week.
Accompanying symptoms were muscle
pains and body malaise. A week after the
start of fever, the client noted yellowish
discoloration of his sclera. History
showed that he waded in flood waters
about 2 weeks before the onset of
symptoms. Based on his history, which
disease condition will you suspect?
A. Hepatitis A
B. Hepatitis B
C. Tetanus
D. Leptospirosis
Answer: (D)
Leptospirosis. Leptospirosis is
transmitted through contact with the skin
or mucous membrane with water or
moist soil contaminated with urine of
infected animals, like rats.
19. MWSS provides water to Manila and
other cities in Metro Manila. This is an
example of which level of water facility?
A. I
B. II
C. III
D. IV
Answer: (C) III. Waterworks systems,
such as MWSS, are classified as level III.
20. You are the PHN in the city health
center. A client underwent screening for
AIDS using ELISA. His result was positive.
What is the best course of action that
you may take?
A. Get a thorough history of the client,
focusing on the practice of high risk
behaviors.
B. Ask the client to be accompanied by
a significant person before revealing
the result.
C. Refer the client to the physician since
he is the best person to reveal the
result to the client.
D. Refer the client for a
supplementary test, such as
Western blot, since the ELISA
result may be false.
Answer: (D) Refer the client for a
supplementary test, such as
Western blot, since the ELISA result
may be false. A client having a reactive
ELISA result must undergo a more
specific test, such as Western blot. A
negative supplementary test result
means that the ELISA result was false
and that, most probably, the client is not
infected.
21. Which is the BEST control measure
for AIDS?
A. Being faithful to a single sexual
partner
B. Using a condom during each sexual
contact
C. Avoiding sexual contact with
commercial sex workers
D. Making sure that one’s sexual partner
does not have signs of AIDS
\ underlying immunodeficiency
Answer: (A) Being faithful to a
single sexual partner. Sexual fidelity
rules out the possibility of getting the
disease by sexual contact with another
infected person. Transmission occurs
mostly through sexual intercourse and
exposure to blood or tissues
22. The most frequent causes of death
among clients with AIDS are
opportunistic diseases. Which of the
following opportunistic infections is
characterized by tonsillopharyngitis?
A. Respiratory candidiasis
B. Infectious mononucleosis
C. Cytomegalovirus disease
D. Pneumocystis carinii pneumonia
Answer: (B) Infectious
mononucleosis. Cytomegalovirus
disease is an acute viral disease
characterized by fever, sore throat and
lymphadenopathy.
23. To determine possible sources of
sexually transmitted infections, which is
the BEST method that may be
undertaken by the public health nurse?
A. Contact tracing
B. Community survey
C. Mass screening tests
D. Interview of suspects
Answer: (A) Contact tracing. Contact
tracing is the most practical and reliable
method of finding possible sources of
person-to-person transmitted infections,
such as sexually transmitted diseases
24. Antiretroviral agents, such as AZT,
are used in the management of AIDS.
Which of the following is NOT an action
expected of these drugs.
A. They prolong the life of the client
with AIDS.
B. They reduce the risk of opportunistic
infections
C. They shorten the period of
communicability of the disease.
D. They are able to bring about a
cure of the disease condition.
Answer: (D) They are able to bring
about a cure of the disease
condition. There is no known treatment
for AIDS. Antiretroviral agents reduce
the risk of opportunistic infections and
prolong life, but does not cure the
25. A barangay had an outbreak of
German measles. To prevent congenital
rubella, what is the BEST advice that you
can give to women in the first trimester
of pregnancy in the barangay?
A. Advice them on the signs of German
measles.
B. Avoid crowded places, such as
markets and moviehouses.
C. Consult at the health center where
rubella vaccine may be given.
D. Consult a physician who may give
them rubella immunoglobulin.
 pneumonia, are higher in incidence in
Answer: (D) Consult a physician who adults.
may give them rubella
immunoglobulin. Rubella vaccine is 28. Complications to infectious parotitis
made up of attenuated German measles (mumps) may be serious in which type of
viruses. This is contraindicated in clients?
pregnancy. Immune globulin, a specific
prophylactic against German measles, A. Pregnant women
may be given to pregnant women. B. Elderly clients
C. Young adult males
26. You were invited to be the resource D. Young infants
person in a training class for food Answer: (C) Young adult
handlers. Which of the following would males. Epididymitis and orchitis are
you emphasize regarding prevention of possible complications of mumps. In
staphylococcal food poisoning? post-adolescent males, bilateral
inflammation of the testes and
A. All cooking and eating utensils must epididymis may cause sterility.
be thoroughly washed.
B. Food must be cooked properly to
destroy staphylococcal
microorganisms.
C. Food handlers and food servers must
have a negative stool examination
result.
D. Proper handwashing during food
preparation is the best way of
preventing the condition.

Answer: (D) Proper handwashing

during food preparation is the best
way of preventing the
condition. Symptoms of this food
poisoning are due to staphylococcal
enterotoxin, not the microorganisms
themselves. Contamination is by food
handling by persons with staphylococcal
skin or eye infections

27. In a mothers’ class, you discussed

childhood diseases such as chicken pox.
Which of the following statements about
chicken pox is correct?
PNLE Medical
A. The older one gets, the more
susceptible he becomes to the
Surgical
complications of chicken pox.
B. A single attack of chicken pox will Nursing Exam 1
prevent future episodes, including
conditions such as shingles.
SITUATION : Arthur, A registered nurse,
C. To prevent an outbreak in the
witnessed an old woman hit by a
community, quarantine may be
motorcycle while crossing a train railway.
imposed by health authorities.
The old woman fell at the railway. Arthur
D. Chicken pox vaccine is best given
rushed at the scene.
when there is an impending outbreak
1. As a registered nurse, Arthur knew
in the community.
that the first thing that he will do at the
scene is
Answer: (A) The older one gets, the
more susceptible he becomes to the
A. Stay with the person, Encourage
complications of chicken pox. Chicken
her to remain still and Immobilize the
pox is usually more severe in adults than
leg while While waiting for the
in children. Complications, such as
ambulance.
B. Leave the person for a few B. On his left hand, because of
moments to call for help. reciprocal motion.
C. Reduce the fracture manually. C. On his right hand, to support the
D. Move the person to a safer right leg.
place. D. On his right hand, because only his
right leg is weak.
2. Arthur suspects a hip fracture when he 7. You also told Mr. Rojas to hold the cane
noticed that the old woman’s leg is
A. 1 Inches in front of the foot.
A. A. Lengthened, Abducted and B. 3 Inches at the lateral side of the
Internally Rotated. foot.
B. Shortened, Abducted and C. 6 Inches at the lateral side of
Externally Rotated. the foot.
C. Shortened, Adducted and Internally D. 12 Inches at the lateral side of the
Rotated. foot.
D. Shortened, Adducted and
Externally Rotated. 8. Mr. Rojas was discharged and 6
months later, he came back to the
3. The old woman complains of pain. John emergency room of the hospital because
noticed that the knee is reddened, warm he suffered a mild stroke. The right side
to touch and swollen. John interprets that of the brain was affected. At the
this signs and symptoms are likely rehabilitative phase of your nursing care,
related to you observe Mr. Rojas use a cane and
you intervene if you see him
A. Infection
B. Thrombophlebitis A. Moves the cane when the right
C. Inflammation leg is moved.
D. Degenerative disease B. Leans on the cane when the right
4. The old woman told John that she has leg swings through.
osteoporosis; Arthur knew that all of the C. keeps the cane 6 Inches out to the
following factors would contribute to side of the right foot.
osteoporosis except D. Holds the cane on the right side.

A. Hypothyroidism SITUATION: Alfred, a 40 year old

B. End stage renal disease construction worker developed cough,
C. Cushing’s Disease night sweats and fever. He was brought
D. Taking Furosemide and Phenytoin. to the nursing unit for diagnostic studies.
5. Martha, The old woman was now He told the nurse he did not receive a
Immobilized and brought to the BCG vaccine during childhood
emergency room. The X-ray shows a 9. The nurse performs a Mantoux Test.
fractured femur and pelvis. The ER Nurse The nurse knows that Mantoux Test is
would carefully monitor Martha for which also known as
of the following sign and symptoms?
A. PPD
A. Tachycardia and Hypotension B. PDP
B. Fever and Bradycardia C. PDD
C. Bradycardia and Hypertension D. DPP
D. Fever and Hypertension
SITUATION: Mr. D. Rojas, An obese 35 10. The nurse would inject the solution in
year old MS Professor of OLFU Lagro is what route?
admitted due to pain in his weight
bearing joint. The diagnosis was A. IM
Osteoarthritis. B. IV
6. As a nurse, you instructed Mr. Rojas C. ID
how to use a cane. Mr. Rojas has a D. SC
weakness on his right leg due to self
immobilization and guarding. You plan to 11. The nurse notes that a positive result
teach Mr. Rojas to hold the cane for Alfred is

A. On his left hand, because his right A. 5 mm wheal

side is weak. B. 5 mm Induration
C. 10 mm Wheal D. Pyridoxine
D. 10 mm Induration
18. According to the DOH, the most
12. The nurse told Alfred to come back hazardous period for development of
after clinical disease is during the first

A. a week A. 6-12 months after

B. 48 hours B. 3-6 months after
C. 1 day C. 1-2 months after
D. 4 days D. 2-4 weeks after

13. Mang Alfred returns after the 19. This is the name of the program of
Mantoux Test. The test result read the DOH to control TB in the country
POSITIVE. What should be the nurse’s
next action? A. DOTS
B. National Tuberculosis Control
A. Call the Physician Program
B. Notify the radiology dept. for CXR C. Short Coursed Chemotherapy
evaluation D. Expanded Program for
C. Isolate the patient Immunization
D. Order for a sputum exam
20. Susceptibility for the disease [ TB ] is
14. Why is Mantoux test not routinely increased markedly in those with the
done in the Philippines? following condition except

A. It requires a highly skilled nurse to A. 23 Year old athlete with

perform a Mantoux test diabetes insipidus
B. The sputum culture is the gold B. 23 Year old athlete taking long
standard of PTB Diagnosis and it will term Decadron therapy and anabolic
definitively determine the extent of steroids
the cavitary lesions C. 23 Year old athlete taking illegal
C. Chest X Ray Can diagnose the drugs and abusing substances
specific microorganism responsible D. Undernourished and Underweight
for the lesions individual who undergone
D. Almost all Filipinos will test gastrectomy
positive for Mantoux Test
21. Direct sputum examination and Chest
15. Mang Alfred is now a new TB patient X ray of TB symptomatic is in what level
with an active disease. What is his of prevention?
category according to the DOH?
A. Primary
A. I B. Secondary
B. II C. Tertiary
C. III D. Quarterly
D. IV
SITUATION: Michiel, A male patient
16. How long is the duration of the diagnosed with colon cancer was newly
maintenance phase of his treatment? put in colostomy.
22. Michiel shows the BEST adaptation
A. 2 months with the new colostomy if he shows
B. 3 months which of the following?
C. 4 months
D. 5 months A. Look at the ostomy site
B. Participate with the nurse in
17. Which of the following drugs is his daily ostomy care
UNLIKELY given to Mang Alfred during the C. Ask for leaflets and contact
maintenance phase? numbers of ostomy support groups
D. Talk about his ostomy openly to the
A. Rifampicin nurse and friends
B. Isoniazid
C. Ethambutol
23. The nurse plans to teach Michiel D. Protruding stoma with swollen
about colostomy irrigation. As the nurse appearance
prepares the materials needed, which of
the following item indicates that the 29. Michiel asked the nurse, what foods
nurse needs further instruction? will help lessen the odor of his colostomy.
The nurse best response would be
A. Plain NSS / Normal Saline
B. K-Y Jelly A. Eat eggs
C. Tap water B. Eat cucumbers
D. Irrigation sleeve C. Eat beet greens and parsley
24. The nurse should insert the D. Eat broccoli and spinach
colostomy tube for irrigation at
approximately 30. The nurse will start to teach Michiel
about the techniques for colostomy
A. 1-2 inches irrigation. Which of the following should
B. 3-4 inches be included in the nurse’s teaching plan?
C. 6-8 inches
D. 12-18 inches A. Use 500 ml to 1,000 ml NSS
25. The maximum height of irrigation B. Suspend the irrigant 45 cm
solution for colostomy is above the stoma
C. Insert the cone 4 cm in the stoma
A. 5 inches D. If cramping occurs, slow the
B. 12 inches irrigation
C. 18 inches
D. 24 inches 31. The nurse knew that the normal color
of Michiel’s stoma should be
26. Which of the following behavior of the
client indicates the best initial step in A. Brick Red
learning to care for his colostomy? B. Gray
C. Blue
A. Ask to defer colostomy care to D. Pale Pink
another individual SITUATION: James, A 27 basketball player
B. Promises he will begin to listen the sustained inhalation burn that required
next day him to have tracheostomy due to
C. Agrees to look at the massive upper airway edema.
colostomy 32. Wilma, His sister and a nurse is
D. States that colostomy care is the suctioning the tracheostomy tube of
function of the nurse while he is in James. Which of the following, if made by
the hospital Wilma indicates that she is committing
an error?
27. While irrigating the client’s
colostomy, Michiel suddenly complains of A. Hyperventilating James with 100%
severe cramping. Initially, the nurse oxygen before and after suctioning
would B. Instilling 3 to 5 ml normal saline to
loosen up secretion
A. Stop the irrigation by clamping C. Applying suction during catheter
the tube withdrawal
B. Slow down the irrigation D. Suction the client every hour
C. Tell the client that cramping will
subside and is normal 33. What size of suction catheter would
D. Notify the physician Wilma use for James, who is 6 feet 5
inches in height and weighing
28. The next day, the nurse will assess approximately 145 lbs?
Michiel’s stoma. The nurse noticed that a
prolapsed stoma is evident if she sees A. Fr. 5
which of the following? B. Fr. 10
C. Fr. 12
A. A sunken and hidden stoma D. Fr. 18
B. A dusky and bluish stoma
C. A narrow and flattened stoma
34. Wilma is using a portable suction unit
at home, What is the amount of suction SITUATION : Juan Miguel Lopez Zobel
required by James using this unit? Ayala de Batumbakal was diagnosed with
Acute Close Angle Glaucoma. He is being
A. 2-5 mmHg seen by Nurse Jet.
B. 5-10 mmHg 40. What specific manifestation would
C. 10-15 mmHg nurse Jet see in Acute close angle
D. 20-25 mmHg glaucoma that she would not see in an
open angle glaucoma?
35. If a Wall unit is used, What should be
the suctioning pressure required by A. Loss of peripheral vision
James? B. Irreversible vision loss
C. There is an increase in IOP
A. 50-95 mmHg D. Pain
B. 95-110 mmHg
C. 100-120 mmHg 41. Nurse jet knew that Acute close angle
D. 155-175 mmHg glaucoma is caused by
36. Wilma was shocked to see that the
Tracheostomy was dislodged. Both the A. Sudden blockage of the
inner and outer cannulas was removed anterior angle by the base of the
and left hanging on James’ neck. What iris
are the 2 equipment’s at james’ bedside B. Obstruction in trabecular
that could help Wilma deal with this meshwork
situation? C. Gradual increase of IOP
D. An abrupt rise in IOP from 8 to 15
A. New set of tracheostomy tubes and mmHg
Oxygen tank
B. Theophylline and Epinephrine 42. Nurse jet performed a TONOMETRY
C. Obturator and Kelly clamp test to Mr. Batumbakal. What does this
D. Sterile saline dressing test measures
37. Which of the following method if used
by Wilma will best assure that the A. It measures the peripheral vision
tracheostomy ties are not too tightly remaining on the client
placed? B. Measures the Intra Ocular
Pressure
A. Wilma places 2 fingers between C. Measures the Client’s Visual Acuity
the tie and neck D. Determines the Tone of the eye in
B. The tracheotomy can be pulled response to the sudden increase in
slightly away from the neck IOP.
C. James’ neck veins are not engorged
D. Wilma measures the tie from the 43. The Nurse notices that Mr.
nose to the tip of the earlobe and to Batumbakal cannot anymore determine
the xiphoid process. RED from BLUE. The nurse knew that
38. Wilma knew that James have an which part of the eye is affected by this
adequate respiratory condition if she change?
notices that
A. IRIS
A. James’ respiratory rate is 18 B. PUPIL
B. James’ Oxygen saturation is 91% C. RODS [RETINA]
C. There are frank blood suction from D. CONES [RETINA]
the tube
D. There are moderate amount of 44. Nurse Jet knows that Aqueous Humor
tracheobronchial secretions is produce where?

39. Wilma knew that the maximum time A. In the sub arachnoid space of the
when suctioning James is meninges
B. In the Lateral ventricles
A. 10 seconds C. In the Choroids
B. 20 seconds D. In the Ciliary Body
C. 30 seconds
D. 45 seconds
45. Nurse Jet knows that the normal IOP A. Atropine Sulfate
is B. Pindolol [Visken]
C. Naloxone Hydrochloride [Narcan]
A. 8-21 mmHg D. Mesoridazine Besylate [Serentil]
B. 2-7 mmHg
C. 31-35 mmHg SITUATION : Wide knowledge about the
D. 15-30 mmHg human ear, it’s parts and it’s functions
will help a nurse assess and analyze
46. Nurse Jet wants to measure Mr. changes in the adult client’s health.
Batumbakal’s CN II Function. What test
would Nurse Jet implement to measure 52. Nurse Anna is doing a caloric testing
CN II’s Acuity? to his patient, Aida, a 55 year old
university professor who recently went
A. Slit lamp into coma after being mauled by her
B. Snellen’s Chart disgruntled 3rd year nursing students
C. Wood’s light whom she gave a failing mark. After
D. Gonioscopy instilling a warm water in the ear, Anna
noticed a rotary nystagmus towards the
47. The Doctor orders pilocarpine. Nurse irrigated ear. What does this means?
jet knows that the action of this drug is to A. Indicates a CN VIII Dysfunction
B. Abnormal
A. Contract the Ciliary muscle C. Normal
B. Relax the Ciliary muscle D. Inconclusive
C. Dilate the pupils
D. Decrease production of Aqueous 53. Ear drops are prescribed to an infant,
Humor The most appropriate method to
administer the ear drops is
48. The doctor orders timolol [timoptic].
Nurse jet knows that the action of this A. Pull the pinna up and back and
drug is direct the solution towards the
eardrum
A. Reduce production of CSF B. Pull the pinna down and back
B. Reduce production of Aquesous and direct the solution onto the
Humor wall of the canal
C. Constrict the pupil C. Pull the pinna down and back and
D. Relaxes the Ciliary muscle direct the solution towards the
eardrum
49. When caring for Mr. Batumbakal, Jet D. Pull the pinna up and back and
teaches the client to avoid direct the solution onto the wall of
the canal
A. Watching large screen TVs
B. Bending at the waist 54. Nurse Jenny is developing a plan of
C. Reading books care for a patient with Menieres disease.
D. Going out in the sun What is the priority nursing intervention
in the plan of care for this particular
50. Mr. Batumbakal has undergone eye patient?
angiography using an Intravenous dye
and fluoroscopy. What activity is A. Air, Breathing, Circulation
contraindicated immediately after B. Love and Belongingness
procedure? C. Food, Diet and Nutrition
D. Safety
A. Reading newsprint
B. Lying down 55. After mastoidectomy, Nurse John
C. Watching TV should be aware that the cranial nerve
D. Listening to the music that is usually damage after this
procedure is
51. If Mr. Batumbakal is receiving
pilocarpine, what drug should always be A. CN I
available in any case systemic toxicity B. CN II
occurs? C. CN VII
D. CN VI

56. The physician orders the following for
the client with Menieres disease. Which
of the following should the nurse
question?
A. Dipenhydramine [Benadryl]
B. Atropine sulfate
C. Out of bed activities and
ambulation
D. Diazepam [Valium]
57. Nurse Anna is giving dietary
instruction to a client with Menieres
disease. Which statement if made by the
client indicates that the teaching has
been successful?
A. I will try to eat foods that are
low in sodium and limit my fluid
intake
B. I must drink atleast 3,000 ml of
fluids per day
C. I will try to follow a 50%
carbohydrate, 30% fat and 20%
protein diet
D. I will not eat turnips, red meat and
raddish
58. Peachy was rushed by his father,
Steven into the hospital admission.
Peachy is complaining of something
buzzing into her ears. Nurse Joemar
assessed peachy and found out It was an
insect. What should be the first thing that
Nurse Joemar should try to remove the
insect out from peachy’s ear?
A. Use a flashlight to coax the
insect out of peachy’s ear
B. Instill an antibiotic ear drops
C. Irrigate the ear
D. Pick out the insect using a sterile
clean forceps
59. Following an ear surgery, which
statement if heard by Nurse Oca from the
patient indicates a correct understanding
of the post operative instructions?
A. Activities are resumed within 5
days
B. I will make sure that I will clean my
hair and face to prevent infection
C. I will use straw for drinking
D. I should avoid air travel for a
while
60. Nurse Oca will do a caloric testing to
a client who sustained a blunt injury in
the head. He instilled a cold water in the
client’s right ear and he noticed that
nystagmus occurred towards the left ear.
What does this finding indicates?
A. Indicating a Cranial Nerve VIII
Dysfunction
B. The test should be repeated again
because the result is vague
C. This is Grossly abnormal and
should be reported to the
neurosurgeon
D. This indicates an intact and
working vestibular branch of CN
VIII
61. A client with Cataract is about to
undergo surgery. Nurse Oca is preparing
plan of care. Which of the following
nursing diagnosis is most appropriate to
address the long term need of this type
of patient?
A. Anxiety R/T to the operation and its
outcome
B. Sensory perceptual alteration
R/T Lens extraction and
replacement
C. Knowledge deficit R/T the pre
operative and post operative self care
D. Body Image disturbance R/T the
eye packing after surgery
62. Nurse Joseph is performing a WEBERS
TEST. He placed the tuning fork in the
patients forehead after tapping it onto his
knee. The client states that the fork is
louder in the LEFT EAR. Which of the
following is a correct conclusion for nurse
Josph to make?
A. He might have a sensory hearing
loss in the left ear
B. Conductive hearing loss is possible
in the right ear
C. He might have a sensory
hearing loss in the right hear,
and/or a conductive hearing loss
in the left ear.
D. He might have a conductive
hearing loss in the right ear, and/or a
sensory hearing loss in the left ear.
63. Aling myrna has Menieres disease.
What typical dietary prescription would
nurse Oca expect the doctor to
prescribe?
A. A low sodium , high fluid intake
B. A high calorie, high protein dietary
intake
C. low fat, low sodium and high
calorie intake
D. low sodium and restricted fluid 68. After nursing intervention, you will
intake expect the patient to have

SITUATION : [ From DEC 1991 NLE ] A 45 1. Maintain body temperature at 36.5

year old male construction worker was C
admitted to a tertiary hospital for 2. Exhibit return of BP and Pulse to
incessant vomiting. Assessment normal
disclosed: weak rapid pulse, acute 3. Manifest normal skin turgor of skin
weight loss of .5kg, furrows in his and tongue
tongue, slow flattening of the skin was 4. Drinks fluids as prescribed
noted when the nurse released her A. 1,3
pinch. B. 2,4
Temperature: 35.8 C , BUN Creatinine C. 1,3,4
ratio : 10 : 1, He also complains for D. 2,3,4
postural hypotension. There was no
infection. SITUATION: A 65 year old woman was
admitted for Parkinson’s Disease. The
64. Which of the following is the charge nurse is going to make an initial
appropriate nursing diagnosis? assessment.
A. Fluid volume deficit R/T furrow 69. Which of the following is a
tongue characteristic of a patient with advanced
B. Fluid volume deficit R/T Parkinson’s disease?
uncontrolled vomiting
C. Dehydration R/T subnormal body A. Disturbed vision
temperature B. Forgetfulness
D. Dehydration R/T incessant vomiting C. Mask like facial expression
D. Muscle atrophy
65. Approximately how much fluid is lost
in acute weight loss of .5kg? 70. The onset of Parkinson’s disease is
between 50-60 years old. This disorder is
A. 50 ml caused by
B. 750 ml
C. 500 ml A. Injurious chemical substances
D. 75 ml B. Hereditary factors
C. Death of brain cells due to old age
66. Postural Hypotension is D. Impairment of dopamine
producing cells in the brain
A. A drop in systolic pressure less
than 10 mmHg when patient changes 71. The patient was prescribed with
position from lying to sitting. levodopa. What is the action of this drug?
B. A drop in systolic pressure
greater than 10 mmHg when A. Increase dopamine availability
patient changes position from B. Activates dopaminergic receptors
lying to sitting in the basal ganglia
C. A drop in diastolic pressure less C. Decrease acetylcholine availability
than 10 mmHg when patient changes D. Release dopamine and other
position from lying to sitting catecholamine from neurological
D. A drop in diastolic pressure greater storage sites
than 10 mmHg when patient changes 72. You are discussing with the dietician
position from lying to sitting what food to avoid with patients taking
levodopa?
67. Which of the following measures will
not help correct the patient’s condition A. Vitamin C rich food
B. Vitamin E rich food
A. Offer large amount of oral fluid C. Thiamine rich food
intake to replace fluid lost D. Vitamin B6 rich food
B. Give enteral or parenteral fluid
C. Frequent oral care 73. One day, the patient complained of
D. Give small volumes of fluid at difficulty in walking. Your response would
frequent interval be
A. You will need a cane for SITUATION : Knowledge of the drug
support PROPANTHELINE BROMIDE [Probanthine]
B. Walk erect with eyes on horizon Is necessary in treatment of various
C. I’ll get you a wheelchair disorders.
D. Don’t force yourself to walk 79. What is the action of this drug?

SITUATION: Mr. Dela Isla, a client with A. Increases glandular secretion for
early Dementia exhibits thought process clients affected with cystic fibrosis
disturbances. B. Dissolve blockage of the urinary
74. The nurse will assess a loss of ability tract due to obstruction of cystine
in which of the following areas? stones
C. Reduces secretion of the
A. Balance glandular organ of the body
B. Judgment D. Stimulate peristalsis for treatment
C. Speech of constipation and obstruction
D. Endurance
80. What should the nurse caution the
75. Mr. Dela Isla said he cannot client when using this medication
comprehend what the nurse was saying.
He suffers from: A. Avoid hazardous activities like
driving, operating machineries
A. Insomnia etc.
B. Aphraxia B. Take the drug on empty stomach
C. Agnosia C. Take with a full glass of water in
D. Aphasia treatment of Ulcerative colitis
D. I must take double dose if I missed
76. The nurse is aware that in the previous dose
communicating with an elderly client, the
nurse will 81. Which of the following drugs are not
compatible when taking Probanthine?
A. Lean and shout at the ear of the
client A. Caffeine
B. Open mouth wide while talking to B. NSAID
the client C. Acetaminophen
C. Use a low-pitched voice D. Alcohol
D. Use a medium-pitched voice
82. What should the nurse tell clients
77. As the nurse talks to the daughter of when taking Probanthine?
Mr. Dela Isla, which of the following
statement of the daughter will require A. Avoid hot weathers to prevent
the nurse to give further teaching? heat strokes
B. Never swim on a chlorinated pool
A. I know the hallucinations are parts C. Make sure you limit your fluid
of the disease intake to 1L a day
B. I told her she is wrong and I D. Avoid cold weathers to prevent
explained to her what is right hypothermia
C. I help her do some tasks he cannot
do for himself 83. Which of the following disease would
D. Ill turn off the TV when we go to Probanthine exert the much needed
another room action for control or treatment of the
disorder?
78. Which of the following is most
important discharge teaching for Mr. Dela A. Urinary retention
Isla B. Peptic Ulcer Disease
C. Ulcerative Colitis
A. Emergency Numbers D. Glaucoma
B. Drug Compliance
C. Relaxation technique SITUATION : Mr. Franco, 70 years old,
D. Dietary prescription suddenly could not lift his spoons nor
speak at breakfast. He was rushed to the
hospital unconscious. His diagnosis was
CVA.
84. Which of the following is the most
important assessment during the acute
stage of an unconscious patient like Mr.
Franco?
A. Level of awareness and response to
pain
B. Papillary reflexes and response to
sensory stimuli
C. Coherence and sense of hearing
D. Patency of airway and
adequacy of respiration
85. Considering Mr. Franco’s conditions,
which of the following is most important
to include in preparing Franco’s bedside
equipment?
D. Clients orientation to time and
space will be much affected
SITUATION : a 20 year old college
student was rushed to the ER of PGH
after he fainted during their ROTC drill.
Complained of severe right iliac pain.
Upon palpation of his abdomen, Ernie
jerks even on slight pressure. Blood test
was ordered. Diagnosis is acute
appendicitis.
89. Which result of the lab test will be
significant to the diagnosis?
A. RBC : 4.5 TO 5 Million / cu. mm.
B. Hgb : 13 to 14 gm/dl.
C. Platelets : 250,000 to 500,000
cu.mm.
D. WBC : 12,000 to 13,000/cu.mm

A. Hand bell and extra bed linen 90. Stat appendectomy was indicated.
B. Sandbag and trochanter rolls Pre op care would include all of the
C. Footboard and splint following except?
D. Suction machine and gloves
A. Consent signed by the father
86. What is the rationale for giving Mr. B. Enema STAT
Franco frequent mouth care? C. Skin prep of the area including the
pubis
A. He will be thirsty considering that D. Remove the jewelries
he is doesn’t drink enough fluids
B. To remove dried blood when 91. Pre-anesthetic med of Demerol and
tongue is bitten during a seizure atrophine sulfate were ordered to :
C. The tactile stimulation during
mouth care will hasten return to A. Allay anxiety and apprehension
consciousness B. Reduce pain
D. Mouth breathing is used by C. Prevent vomiting
comatose patient and it’ll cause D. Relax abdominal muscle
oral mucosa dying and cracking. 92. Common anesthesia for
appendectomy is
87. One of the complications of
prolonged bed rest is decubitus ulcer. A. Spinal
Which of the following can best prevent B. General
its occurrence? C. Caudal
D. Hypnosis
A. Massage reddened areas with
lotion or oils 93. Post op care for appendectomy
B. Turn frequently every 2 hours include the following except
C. Use special water mattress
D. Keep skin clean and dry A. Early ambulation
B. Diet as tolerated after fully
88. If Mr. Franco’s Right side is weak, conscious
What should be the most accurate C. Nasogastric tube connect to
analysis by the nurse? suction
D. Deep breathing and leg exercise
A. Expressive aphasia is
prominent on clients with right 94. Peritonitis may occur in ruptured
sided weakness appendix and may cause serious
B. The affected lobe in the patient is problems which are
the Right lobe
C. The client will have problems in 1. Hypovolemia, electrolyte
judging distance and proprioception imbalance
2. Elevated temperature, weakness A. Occurs suddenly and reversible
and diaphoresis B. Is progressive and reversible
3. Nausea and vomiting, rigidity of C. tends to be progressive and
the abdominal wall irreversible
4. Pallor and eventually shock D. Occurs suddenly and irreversible
A. 1 and 2 100. Which behavior results from organic
B. 2 and 3 psychoses?
C. 1,2,3
D. All of the above A. Memory deficit
B. Disorientation
95. If after surgery the patient’s C. Impaired Judgement
abdomen becomes distended and no D. Inappropriate affect
bowel sounds appreciated, what would
be the most suspected complication?

A. Intussusception
B. Paralytic Ileus
C. Hemorrhage
D. Ruptured colon

96. NGT was connected to suction. In

caring for the patient with NGT, the nurse
must

A. Irrigate the tube with saline as

ordered
B. Use sterile technique in irrigating
the tube
C. advance the tube every hour to
avoid kinks
D. Offer some ice chips to wet lips

97. When do you think the NGT tube be

removed?

A. When patient requests for it

B. Abdomen is soft and patient asks
for water
C. Abdomen is soft and flatus has PNLE Medical
been expelled
D. B and C only
Surgical Nursing
Situation: Amanda is suffering from
chronic arteriosclerosis Brain syndrome
she fell while getting out of the bed one
Exam 2
morning and was brought to the hospital, 1. After a cerebrovascular accident, a 75
and she was diagnosed to have yr old client is admitted to the health
cerebrovascular thrombosis thus care facility. The client has left-sided
transferred to a nursing home. weakness and an absent gag reflex. He’s
98. What do you call a STROKE that incontinent and has a tarry stool. His
manifests a bizarre behavior? blood pressure is 90/50 mm Hg, and his
hemoglobin is 10 g/dl. Which of the
A. Inorganic Stroke following is a priority for this client?
B. Inorganic Psychoses
C. Organic Stroke A. checking stools for occult blood
D. Organic Psychoses B. performing range-of-motion
exercises to the left side
99. The main difference between chronic C. keeping skin clean and dry
and organic brain syndrome is that the D. elevating the head of the bed
former to 30 degrees
 ANS: D
Because the client’s gag reflex is
absent, elevating the head of the bed
to 30 degrees helps minimize the
client’s risk of aspiration. Checking
the stools, performing ROM exercises,
and keeping the skin clean and dry
are important, but preventing
aspiration through positioning is the
priority
2. The nurse is caring for a client with a
colostomy. The client tells the nurse that
he makes small pin holes in the drainage
bag to help relieve gas. The nurse should
teach him that this action:
A. destroys the odor-proof seal
B. wont affect the colostomy system
C. is appropriate for relieving the gas
in a colostomy system
D. destroys the moisture barrier seal
ANS: A
Any hole, no matter how small, will
destroy the odor-proof seal of a
drainage bag. Removing the bag or
unclamping it is the only appropriate
method for relieving gas.
3. When assessing the client with celiac
disease, the nurse can expect to find
which of the following?
A. steatorrhea
B. jaundiced sclerae
C. clay-colored stools
D. widened pulse pressure
ANS: A
because celiac disease destroys the
absorbing surface of the intestine, fat
isn’t absorbed but is passed in the
stool. Steatorrhea is bulky, fatty stools
that have a foul odor. Jaundiced
sclerae result from elevated bilirubin
levels. Clay-colored stools are seen
with biliary disease when bile flow is
blocked. Celiac disease doesn’t cause
a widened pulse pressure.
4. A client is hospitalized with a diagnosis
of chronic glomerulonephritis. The client
mentions that she likes salty foods. The
nurse should warn her to avoid foods
containing sodium because:
A. reducing sodium promotes urea
nitrogen excretion
B. reducing sodium improves her
glomerular filtration rate
C. reducing sodium increases
potassium absorption
D. reducing sodium decreases
edema
ANS: D
Reducing sodium intake reduces fluid
retention. Fluid retention increases blood
volume, which changes blood vessel
permeability and allows plasma to move
into interstitial tissue, causing edema.
Urea nitrogen excretion can be increased
only by improved renal function. Sodium
intake doesn’t affect the glomerular
filtration rate. Potassium absorption is
improved only by increasing the
glomerular filtration rate; it isn’t affected
by sodium intake.
5. The nurse is caring for a client with a
cerebral injury that impaired his speech
and hearing. Most likely, the client has
experienced damage to the:
A. frontal lobe
B. parietal lobe
C. occipital lobe
D. temporal lobe
ANS: D
The portion of the cerebrum that
controls speech and hearing is the
temporal lobe. Injury to the frontal lobe
causes personality changes, difficulty
speaking, and disturbance in memory,
reasoning, and concentration. Injury to
the parietal lobe causes sensory
alterations and problems with spatial
relationships. Damage to the occipital
lobe causes vision disturbances
6. The nurse is assessing a
postcraniotomy client and finds the urine
output from a catheter is 1500 ml for the
1st hour and the same for the 2nd hour.
The nurse should suspect:
A. Cushing’s syndrome
B. Diabetes mellitus
C. Adrenal crisis
D. Diabetes insipidus
ANS: D
Diabetes insipidus is an abrupt onset
of extreme polyuria that commonly
occurs in clients after brain surgery.
Cushing’s syndrome is excessive
glucocorticoid secretion resulting in
sodium and water retention. Diabetes
mellitus is a hyperglycemic state
marked by polyuria, polydipsia, and
 polyphagia. Adrenal crisis is
undersecretion of glucocorticoids
resulting in profound hypoglycemia,
hypovolemia, and hypotension
7. The nurse is providing postprocedure
care for a client who underwent
percutaneous lithotripsy. In this
procedure, an ultrasonic probe inserted
through a nephrostomy tube into the
renal pelvis generates ultra-high-
frequency sound waves to shatter renal
calculi. The nurse should instruct the
client to:
A. limit oral fluid intake for 1 to 2
weeks
B. report the presence of fine,
sandlike particles through the
nephrostomy tube.
C. Notify the physician about
cloudy or foul smelling urine
D. Report bright pink urine within 24
hours after the procedure
ANS: C
The client should report the presence of
foulsmelling or cloudy urine. Unless
contraindicated, the client should be
instructed to drink large quantities of
fluid each day to flush the kidneys. Sand-
like debris is normal because of residual
stone products. Hematuria is common
after lithotripsy.
8. A client with a serum glucose level of
618 mg/dl is admitted to the facility. He’s
awake and oriented, has hot dry skin,
and has the following vital signs:
temperature of 100.6º F (38.1º C), heart
rate of 116 beats/minute, and blood
pressure of 108/70 mm Hg. Based on
these assessment findings, which nursing
diagnosis takes the highest priority?
A. deficient fluid volume related
to osmotic diuresis
B. decreased cardiac output related to
elevated heart rate
C. imbalanced nutrition: Less than
body requirements related to insulin
deficiency
D. ineffective thermoregulation
related to dehydration
ANS: A
A serum glucose level of 618 mg/dl
indicates hyperglycemia, which causes
polyuria and deficient fluid volume. In
this client, tachycardia is more likely to
result from deficient fluid volume than
from decreased cardiac output because
his blood pressure is normal. Although
the client’s serum glucose is elevated,
food isn’t a priority because fluids and
insulin should be administered to lower
the serum glucose level. Therefore, a
diagnosis of Imbalanced Nutrition: Less
then body requirements isn’t appropriate.
A temperature of 100.6º F isn’t life
threatening, eliminating ineffective
thermoregulation as the top priority.
9. Capillary glucose monitoring is being
performed every 4 hours for a client
diagnosed with diabetic ketoacidosis.
Insulin is administered using a scale of
regular insulin according to glucose
results. At 2 p.m., the client has a
capillary glucose level of 250 mg/dl for
which he receives 8 U of regular insulin.
The
nurse should expect the dose’s:
A. onset to be at 2 p.m. and its peak
at 3 p.m.
B. onset to be at 2:15 p.m. and its
peak at 3 p.m.
C. onset to be at 2:30 p.m. and its
peak at 4 p.m.
D. onset to be at 4 p.m. and its peak
at 6 p.m.
ANS: C
Regular insulin, which is a short-acting
insulin, has an onset of 15 to 30 minutes
and a peak of 2 to 4 hours. Because the
nurse gave the insulin at 2 p.m., the
expected onset would be from 2:15 to
2:30 p.m. and the peak from 4 p.m. to 6
p.m.
10. A client with a head injury is being
monitored for increased intracranial
pressure (ICP). His blood pressure is
90/60 mmHG and the ICP is 18 mmHg;
therefore his cerebral perfusion pressure
(CPP) is:
A. 52 mm Hg
B. 88 mm Hg
C. 48 mm Hg
D. 68 mm Hg
ANS: A
CPP is derived by subtracting the ICP
from the mean arterial pressure (MAP).
For adequate cerebral perfusion to take
place, the minimum goal is 70 mmHg.
The MAP is derived using the following
formula:
MAP = ((diastolic blood pressure x 2) +
systolic blood pressure) / 3
MAP = ((60 x2) + 90) / 3
MAP = 70 mmHg
To find the CPP, subtract the client’s ICP
from the MAP; in this case , 70 mmHg –
18 mmHg = 52 mmHg.
11. A 52 yr-old female tells the nurse that
she has found a painless lump in her
right breast during her monthly self-
examination. Which assessment finding
would strongly suggest that this client’s
lump is cancerous?
A. eversion of the right nipple and a
mobile mass
B. nonmobile mass with irregular
edges
C. mobile mass that is oft and easily
delineated
D. nonpalpable right axillary lymph
nodes
ANS: B
Breast cancer tumors are fixed, hard, and
poorly delineated with irregular edges.
Nipple retraction —not eversion—may be
a sign of cancer. A mobile mass that is
soft and easily delineated is most often a
fluid-filled benigned cyst. Axillary lymph
nodes may or may not be palpable on
initial detection of a cancerous mass.
12. A Client is scheduled to have a
descending colostomy. He’s very anxious
and has many questions regarding the
surgical procedure, care of stoma, and
lifestyle changes. It would be most
appropriate for the nurse to make a
referral to which member of the health
care team?
A. Social worker
B. registered dietician
C. occupational therapist
D. enterostomal nurse therapist
ANS: D
An enterostomal nurse therapist is a
registered nurse who has received
advance education in an accredited
program to care for clients with stomas.
The enterostomal nurse therapist can
assist with selection of an appropriate
stoma site, teach about stoma care, and
provide emotional support.
13. Ottorrhea and rhinorrhea are most
commonly seen with which type of skull
fracture?
A. basilar
B. temporal
C. occipital
D. parietal
ANS: A
Ottorrhea and rhinorrhea are classic
signs of basilar skull fracture. Injury to
the dura commonly occurs with this
fracture, resulting in cerebrospinal fluid
(CSF) leaking through the ears and nose.
Any fluid suspected of being CSF should
be checked for glucose or have a halo
test done
14. A male client should be taught about
testicular examinations:
A. when sexual activity starts
B. after age 60
C. after age 40
D. before age 20
ANS: D
Testicular cancer commonly occurs in
men between ages 20 and 30. A male
client should be taught how to perform
testicular self-examination before age 20,
preferably when he enters his teens.
15. Before weaning a client from a
ventilator, which assessment parameter
is most important for the nurse to
review?
A. fluid intake for the last 24 hours
B. baseline arterial blood gas
(ABG) levels
C. prior outcomes of weaning
D. electrocardiogram (ECG) results
ANS: B
Before weaning a client from mechanical
ventilation, it’s most important to have a
baseline ABG levels. During the weaning
process, ABG levels will be checked to
assess how the client is tolerating the
procedure. Other assessment parameters
are less critical. Measuring fluid volume
intake and output is always important
when a client is being mechanically
ventilated. Prior attempts at weaning and
ECG results are documented on the
client’s record, and the nurse can refer to
them before the weaning process begins.
16. The nurse is speaking to a group of
women about early detection of breast
cancer. The average age of the women in
the group is 47. Following the American
Cancer Society (ACS) guidelines, the
nurse should recommend that the
women:
A. perform breast self-examination
annually
B. have a mammogram annually
C. have a hormonal receptor assay
annually
D. have a physician conduct a clinical
evaluation every 2 years
ANS: B
According to the ACS guidelines, “Women
older than age 40 should perform breast
selfexamination monthly (not annually).”
The hormonal receptor assay is done on
a known breast tumor to determine
whether the tumor is estrogen- or
progesterone-dependent.
17. When caring for a client with
esophageal varices, the nurse knows that
bleeding in this disorder usually stems
from:
A. esophageal perforation
B. pulmonary hypertension
C. portal hypertension
D. peptic ulcers
ANS: C
Increased pressure within the portal
veins causes them to bulge, leading to
rupture and bleeding into the lower
esophagus. Bleeding associated with
esophageal varices doesn’t stem from
esophageal perforation, pulmonary
hypertension, or peptic ulcers
18. A 49-yer-old client was admitted for
surgical repair of a Colles’ fracture. An
external fixator was placed during
surgery. The surgeon explains that this
method of repair:
A. has very low complication rate
B. maintains reduction and
overall hand function
C. is less bothersome than a cast
D. is best for older people
ANS: B
Complex intra-articular fractures are
repaired with external fixators because
they have a better long-term outcome
than those treated with casting. This is
especially true in a young client. The
incidence of complications, such as pin
tract infections and neuritis, is 20% to
60%. Clients must be taught how to do
pin care and assess for development of
neurovascular complications.
19. A client is hospitalized with a
diagnosis of chronic renal failure. An
arteriovenous fistula was created in his
left arm for hemodialysis. When
preparing the client for discharge, the
nurse should reinforce which dietary
instruction?
A. “Be sure to eat meat at every
meal.”
B. “Monitor your fruit intake and eat
plenty of bananas.”
C. “Restrict your salt intake.”
D. “Drink plenty of fluids.”
20. The nurse is caring for a client who
has just had a modified radical
mastectomy with immediate
reconstruction. She’s in her 30s and has
tow children. Although she’s worried
about her future, she seems to be
adjusting well to her diagnosis. What
should the nurse do to support
her coping?
A. Tell the client’s spouse or partner
to be supportive while she recovers.
B. Encourage the client to proceed
with the next phase of treatment.
C. Recommend that the client remain
cheerful for the sake of her children.
D. Refer the client to the American
Cancer Society’s Reach for Recovery
program or another support program.
21. A 21 year-old male has been seen in
the clinic for a thickening in his right
testicle. The physician ordered a human
chorionic gonadotropin (HCG) level. The
nurse’s explanation to the client should
include the fact that:
A. The test will evaluate prostatic
function.
B. The test was ordered to identify the
site of a possible infection.
C. The test was ordered because
clients who have testicular cancer
has elevated levels of HCG.
D. The test was ordered to evaluate
the testosterone level.
22. A client is receiving captopril
(Capoten) for heart failure. The nurse
should notify the physician that the
medication therapy is ineffective if an
assessment reveals:
A. A skin rash.
B. Peripheral edema.
C. A dry cough.
 D. Postural hypotension.
23. Which assessment finding indicates
dehydration?
A. Tenting of chest skin when pinched.
B. Rapid filling of hand veins.
C. A pulse that isn’t easily obliterated.
D. Neck vein distention
24. The nurse is teaching a client with a
history of atherosclerosis. To decrease
the risk of atherosclerosis, the nurse
should encourage the client to:
A. Avoid focusing on his weight.
B. Increase his activity level.
C. Follow a regular diet.
D. Continue leading a high-stress
lifestyle.
25. For a client newly diagnosed with
radiationinduced thrombocytopenia, the
nurse should include which intervention
in the plan of care?
A. Administer aspirin if the
temperature exceeds 38.8º C.
B. Inspect the skin for petechiae once
every shift.
C. Provide for frequent periods of rest.
D. Place the client in strict isolation.
26. A client is chronically short of breath
and yet has normal lung ventilation, clear
lungs, and an arterial oxygen saturation
(SaO2) 96% or better. The client most
likely has:
A. poor peripheral perfusion
B. a possible Hematologic problem
C. a psychosomatic disorder
D. left-sided heart failure
27. For a client in addisonian crisis, it
would be very risky for a nurse to
administer:
diabetes mellitus. Which technique
demonstrates surgical asepsis?
A. Putting on sterile gloves then
opening a container of sterile saline.
B. Cleaning the wound with a circular
motion, moving from outer circles
toward the center.
C. Changing the sterile field after
sterile water is spilled on it.
D. Placing a sterile dressing ½” (1.3
cm) from the edge of the sterile field.
30. A client with a forceful, pounding
heartbeat is diagnosed with mitral valve
prolapse. This client should avoid which
of the following?
A. high volumes of fluid intake
B. aerobic exercise programs
C. caffeine-containing products
D. foods rich in protein
31. A client with a history of hypertension
is diagnosed with primary
hyperaldosteronism. This diagnosis
indicates that the client’s hypertension is
caused by excessive hormone secretion
from which organ?
A. adrenal cortex
B. pancreas
C. adrenal medulla
D. parathyroid
32. A client has a medical history of
rheumatic fever, type 1 (insulin
dependent) diabetes mellitus,
hypertension, pernicious anemia, and
appendectomy. She’s admitted to the
hospital and undergoes mitral valve
replacement surgery. After discharge, the
client is scheduled for a tooth extraction.
Which history finding is a major risk
factor for infective endocarditis?

A. potassium chloride A. appendectomy

B. normal saline solution B. pernicious anemia
C. hydrocortisone C. diabetes mellitus
D. fludrocortisone D. valve replacement
28. The nurse is reviewing the laboratory 33. A 62 yr-old client diagnosed with
report of a client who underwent a bone pyelonephritis and possible septicemia
marrow biopsy. The finding that would has had five urinary tract infections over
most strongly support a diagnosis of the past two years. She’s fatigued from
acute leukemia is the existence of a large lack of sleep; urinates frequently, even
number of immature: during the night; and has lost weight
recently. Test reveal the following:
A. lymphocytes sodium level 152 mEq/L, osmolarity 340
B. thrombocytes mOsm/L, glucose level 125 mg/dl, and
C. reticulocytes potassium level 3.8 mEq/L. which of the
D. leukocytes following nursing diagnoses is most
29. The nurse is performing wound care appropriate for this client?
on a foot ulcer in a client with type 1
A. Deficient fluid volume related to
inability to conserve water
B. Imbalanced nutrition: less than
body requirements related to
hypermetabolic state
C. Deficient fluid volume related to
osmotic diuresis induced by
hypernatremia
D. Imbalanced nutrition: less than
body requirements related to
catabolic effects of insulin deficiency
34. A 20 yr-old woman has just been
diagnosed with Crohn’s disease. She has
lost 10 lb (4.5 kg) and has cramps and
occasional diarrhea. The nurse should
include which of the following when
doing a nutritional assessment?
A. Let the client eat as desired during
the hospitalization.
B. Weight the client daily.
C. Ask the client to list what she eats
during a typical day.
D. Place the client on I & O status and
draw blood for electrolyte levels.
35. When instructions should be included
in the discharge teaching plan for a client
after thyroidectomy for Grave’s disease?
A. Keep an accurate record of intake
and output.
B. Use nasal desmopressin acetate
DDAVP).
C. Be sure to get regulate follow-up
care.
D. Be sure to exercise to improve
cardiovascular fitness.
36. A client comes to the emergency
department with chest pain, dyspnea,
and an irregular heartbeat. An
electrocardiogram shows a heart rate of
110 beats/minute (sinus tachycardia)
with frequent premature ventricular
contractions. Shortly after admission, the
client has ventricular tachycardia and
becomes unresponsive. After successful
resuscitation, the client is taken to the
intensive care unit. Which nursing
diagnosis is appropriate at this time?
A. Deficient knowledge related to
interventions used to treat acute
illness
B. Impaired physical mobility related
to complete bed rest
C. Social isolation related to restricted
visiting hours in the intensive care
unit
D. Anxiety related to the threat of
death
37. A client is admitted to the health care
facility with active tuberculosis. The
nurse should include which intervention
in the plan of care?
A. Putting on a mask when entering
the client’s room.
B. Instructing the client to wear a
mask at all times
C. Wearing a gown and gloves when
providing direct care
D. Keeping the door to the client’s
room open to observe the client
38. The nurse is caring for a client who
underwent a subtotal gastrectomy 24
hours earlier. The client has a nasogastric
(NG) tube. The nurse should:
A. Apply suction to the NG tube every
hour.
B. Clamp the NG tube if the client
complains of nausea.
C. Irrigate the NG tube gently with
normal saline solution.
D. Reposition the NG tube if pulled
out.
39. Which statement about fluid
replacement is accurate for a client with
hyperosmolar hyperglycemic nonketotic
syndrome (HHNS)?
A. administer 2 to 3 L of IV fluid
rapidly
B. administer 6 L of IV fluid over the
first 24 hours
C. administer a dextrose solution
containing normal saline solution
D. administer IV fluid slowly to
prevent circulatory overload and
collapse
40. Which of the following is an adverse
reaction to glipizide (Glucotrol)?
A. headache
B. constipation
C. hypotension
D. photosensitivity
41. The nurse is caring for four clients on
a stepdown intensive care unit. The client
at the highest risk for developing
nosocomial pneumonia is the one who:
A. has a respiratory infection
B. is intubated and on a ventilator
C. has pleural chest tubes
D. is receiving feedings through a
jejunostomy tube
42. The nurse is teaching a client with
chronic bronchitis about breathing
exercises. Which of the following should
the nurse include in the teaching?
A. Make inhalation longer than
exhalation.
B. Exhale through an open mouth.
C. Use diaphragmatic breathing.
D. Use chest breathing.
43. A client is admitted to the hospital
with an exacerbation of her chronic
systemic lupus erythematosus (SLE). She
gets angry when her call bell isn’t
answered immediately. The most
appropriate response to her would be:
A. “You seem angry. Would you like to
talk about it?”
B. “Calm down. You know that stress
will make your symptoms worse.”
C. “Would you like to talk about the
problem with the nursing
supervisor?”
D. “I can see you’re angry. I’ll come
back when you’ve calmed down.”
44. On a routine visit to the physician, a
client with chronic arterial occlusive
disease reports stopping smoking after
34 years. To relive symptoms of
intermittent claudication, a condition
associated with chronic arterial occlusive
disease, the nurse should recommend
which additional measure?
A. Taking daily walks.
B. Engaging in anaerobic exercise.
C. Reducing daily fat intake to less
than 45% of total calories
D. Avoiding foods that increase levels
of highdensity lipoproteins (HDLs)
45. A physician orders gastric
decompression for a client with small
bowel obstruction. The nurse should plan
for the suction to be:
A. low pressure and intermittent
B. low pressure and continuous
C. high pressure and continuous
D. high pressure and intermittent
46. Which nursing diagnosis is most
appropriate for an elderly client with
osteoarthritis?
A. Risk for injury
B. Impaired urinary elimination
C. Ineffective breathing pattern
D. Imbalanced nutrition: less than
body requirements
47. Parathyroid hormone (PTH) has which
effects on the kidney?
A. Stimulation of calcium reabsorption
and phosphate excretion
B. Stimulation of phosphate
reabsorption and calcium excretion
C. Increased absorption of vit D and
excretion of vit E
D. Increased absorption of vit E and
excretion of Vit D
48. A visiting nurse is performing home
assessment for a 59-yr old man recently
discharged after hip replacement surgery.
Which home assessment finding warrants
health promotion teaching from the
nurse?
A. A bathroom with grab bars for the
tub and toilet
B. Items stored in the kitchen so that
reaching up and bending down aren’t
necessary
C. Many small, unsecured area rugs
D. Sufficient stairwell lighting, with
switches to the top and bottom of the
stairs
49. A client with autoimmune
thrombocytopenia and a platelet count of
800/uL develops epistaxis and melena.
Treatment with corticosteroids and
immunoglobulins has been unsuccessful,
and the physician recommends a
splenectomy. The client states, “I don’t
need surgery—this will go away on its
own.” In considering her response to the
client, the nurse must depend on the
ethical principle of:
A. beneficence
B. autonomy
C. advocacy
D. justice
50. Which of the following is t he most
critical intervention needed for a client
with myxedema coma?
A. Administering and oral dose of
levothyroxine (Synthroid)
B. Warming the client with a warming
blanket
C. Measuring and recording accurate
intake and output
D. Maintaining a patent airway
51. Because diet and exercise have failed
to control a 63 yr-old client’s blood
glucose level, the client is prescribed
glipizide (Glucotrol). After oral
administration, the onset of action is:
A. 15 to 30 minutes
B. 30 to 60 minutes
C. 1 to 1 ½ hours
D. 2 to 3 hours
52. A client with pneumonia is receiving
supplemental oxygen, 2 L/min via nasal
cannula. The client’s history includes
chronic obstructive pulmonary disease
(COPD) and coronary artery disease. D. order soft restraints from the
Because of these findings, the nurse storeroom
closely monitors the oxygen flow and the 57. For the first 72 hours after
client’s respiratory status. Which thyroidectomy surgery, the nurse would
complication may arise if the client assess the client for Chvostek’s sign and
receives a high oxygen concentration? Trousseau’s sign because they indicate
which of the following?
A. Apnea
B. Anginal pain A. hypocalcemia
C. Respiratory alkalosis B. hypercalcemia
D. Metabolic acidosis C. hypokalemia
53. A client with type 1 diabetes mellitus D. Hyperkalemia
has been on a regimen of multiple daily 58. In a client with enteritis and frequent
injection therapy. He’s being converted to diarrhea, the nurse should anticipate an
continuous subcutaneous insulin therapy. acidbase imbalance of:
While teaching the client bout continuous
subcutaneous insulin therapy, the nurse A. respiratory acidosis
would be accurate in telling him the B. respiratory alkalosis
regimen includes the use of: C. metabolic acidosis
D. metabolic alkalosis
A. intermediate and long-acting 59. When caring for a client with the
insulins nursing diagnosis Impaired swallowing
B. short and long-acting insulins related to neuromuscular impairment,
C. short-acting only the nurse should:
D. short and intermediate-acting
insulins A. position the client in a supine
54. a client who recently had a position
cerebrovascular accident requires a cane B. elevate the head of the bed 90
to ambulate. When teaching about cane degrees during meals
use, the rationale for holding a cane on C. encourage the client to remove
the uninvolved side is to: dentures
D. encourage thin liquids for dietary
A. prevent leaning intake
B. distribute weight away from the 60. A nurse is caring for a client who has
involved side a tracheostomy and temperature of 39º
C. maintain stride length C. which intervention will most likely
D. prevent edema lower the client’s arterial blood oxygen
55. A client with a history of an anterior saturation?
wall myocardial infarction is being
transferred from the coronary care unit A. Endotracheal suctioning
(CCU) to the cardiac stepdown unit B. Encouragement of coughing
(CSU). While giving report to the CSU C. Use of cooling blanket
nurse, the CCU nurse says, “His D. Incentive spirometry
pulmonary artery wedge pressures have 61. A client with a solar burn of the chest,
been in the high normal range.” The CSU back, face, and arms is seen in urgent
nurse should be especially observant for: care. The nurse’s primary concern should
be:
A. hypertension
B. high urine output A. fluid resuscitation
C. dry mucous membranes B. infection
D. pulmonary crackles C. body image
56. The nurse is caring for a client with a D. pain management
fractures hip. The client is combative, 62. Which statement is true about
confused, and trying to get out of bed. crackles?
The nurse should:
A. They’re grating sounds.
A. leave the client and get help B. They’re high-pitched, musical
B. obtain a physician’s order to squeaks.
restrain the client C. They’re low-pitched noises that
C. read the facility’s policy on sound like snoring.
restraints
D. They may be fine, medium, or to the hair shafts close to the scalp.
course. These findings suggest that the client
63. A woman whose husband was suffers from:
recently diagnosed with active
pulmonary tuberculosis (TB) is a A. scabies
tuberculin skin test converter. B. head lice
Management of her care would include: C. tinea capitis
D. impetigo
A. scheduling her for annual 68. Following a small-bowel resection, a
tuberculin skin testing client develops fever and anemia. The
B. placing her in quarantine until surface surrounding the surgical wound is
sputum cultures are negative warm to touch and necrotizing fasciitis is
C. gathering a list of persons with suspected. Another manifestation that
whom she has had recent contact would most suggest necrotizing fasciitis
D. advising her to begin prophylactic is:
therapy with isoniazid (INH)
64. The nurse is caring for a client who A. erythema
ahs had an above the knee amputation. B. leukocytosis
The client refuses to look at the stump. C. pressure-like pain
When the nurse attempts to speak with D. swelling
the client about his surgery, he tells the 69. A 28 yr-old nurse has complaints of
nurse that he doesn’t wish to discuss it. itching and a rash of both hands. Contact
The client also refuses to have his family dermatitis is initially suspected. The
visit. The nursing diagnosis that best diagnosis is confirmed if the rash
describes the client’s problem is: appears:

A. Hopelessness A. erythematous with raised papules

B. Powerlessness B. dry and scaly with flaking skin
C. Disturbed body image C. inflamed with weeping and crusting
D. Fear lesions
65. A client with three children who is still D. excoriated with multiple fissures
I the child bearing years is admitted for 70. When assessing a client with partial
surgical repair of a prolapsed bladder. thickness burns over 60% of the body,
The nurse would find that the client which of the following should the nurse
understood the surgeon’s preoperative report immediately?
teaching when the client states:
A. Complaints of intense thirst
A. “If I should become pregnant B. Moderate to severe pain
again, the child would be delivered C. Urine output of 70 ml the 1st hour
by cesarean delivery.” D. Hoarseness of the voice
B. “If I have another child, the 71. A client is admitted to the hospital
procedure may need to be repeated.” following a burn injury to the left hand
C. “This surgery may render me and arm. The client’s burn is described as
incapable of conceiving another white and leathery with no blisters.
child.” Which degree of severity is this burn?
D. “This procedure is accomplished in
two separate surgeries.” A. first-degree burn
66. A client experiences problems in B. second-degree burn
body temperature regulation associated C. third-degree burn
with a skin impairment. Which gland is D. fourth-degree burn
most likely involved? 72. The nurse is caring for client with a
new donor site that was harvested to
A. Eccrine treat a new burn. The nurse position the
B. Sebaceous client to:
C. Apocrine
D. Endocrine A. allow ventilation of the site
67. A school cafeteria worker comes to B. make the site dependent
the physician’s office complaining of C. avoid pressure on the site
severe scalp itching. On inspection, the D. keep the site fully covered
nurse finds nail marks on the scalp and 73. a 45-yr-old auto mechanic comes to
small light-colored round specks attached the physician’s office because an
exacerbation of his psoriasis is making it 78. The nurse is caring for a bedridden,
difficult to work. He tells the nurse that elderly adult. To prevent pressure ulcers,
his finger joints are stiff and sore in the which intervention should the nurse
morning. The nurse should respond by: include in the plan of care?

A. Inquiring further about this A. Turn and reposition the client a

problem because psoriatic arthritis minimum of every 8 hours.
can accompany psoriasis vulgaris B. Vigorously massage lotion into
B. Suggesting he take aspirin for relief bony prominences.
because it’s probably early C. Post a turning schedule at the
rheumatoid arthritis client’s bedside.
C. Validating his complaint but D. Slide the client, rather than lifting
assuming it’s an adverse effect of his when turning.
vocation 79. Following a full-thickeness (3rd
D. Asking him if he has been degree) burn of his left arm, a client is
diagnosed or treated for carpal treated with artificial skin. The client
tunnel syndrome understands postoperative care of the
74. The nurse is providing home care artificial skin when he states that during
instructions to a client who has recently the first 7 days after the procedure, he’ll
had a skin graft. Which instruction is restrict:
most important for the client to
remember? A. range of motion
B. protein intake
A. Use cosmetic camouflage C. going outdoors
techniques. D. fluid ingestion
B. Protect the graft from direct 80. A client received burns to his entire
sunlight. back and left arm. Using the Rule of
C. Continue physical therapy. Nines, the nurse can calculate that he
D. Apply lubricating lotion to the graft has sustained burns on what percentage
site. of his body?
75. a 28 yr-old female nurse is seen in
the employee health department for mild A. 9%
itching and rash of both hands. Which of B. 18%
the following could be causing this C. 27%
reaction? D. 36%
81. The nurse is providing care for a
A. possible medication allergies client who has a sacral pressure ulcer
B. current life stressors she may be with wet-to-dry dressing. Which guideline
experiencing is appropriate for a wet-to-dry dressing?
C. chemicals she may be using and
use of latex gloves A. The wound should remain moist
D. recent changes made in laundry form the dressing.
detergent or bath soap. B. The wet-to-dry dressing should be
76. The nurse assesses a client with tightly packed into the wound.
urticaria. The nurse understands that C. The dressing should be allowed to
urticaria is another name for: dry out before removal.
D. A plastic sheet-type dressing
A. hives should cover the wet dressing.
B. a toxin 82. While in skilled nursing facility, a
C. a tubercle client contracted scabies, which is
D. a virus diagnosed the day after discharge. The
77. A client with psoriasis visits the client is living at her daughter’s home
dermatology clinic. When inspecting the with six other persons. During her visit to
affected areas, the nurse expects to see the clinic, she asks a staff nurse, “What
which type of secondary lesion? should my family do?” the most accurate
response from the nurse is:
A. scale
B. crust A. “All family members will need to be
C. ulcer treated.”
D. scar
B. “If someone develops symptoms,
tell him to see a physician right
away.”
C. “Just be careful not to share linens
and towels with family members.”
D. “After you’re treated, family
members won’t be at risk for
contracting scabies.”
83. In an industrial accident, client who
weighs 155 lb (70.3 kg) sustained full-
thickness burns over 40% of his body.
He’s in the burn unit receiving fluid
resuscitation. Which observation shows
that the fluid resuscitation is benefiting
the client?
A. A urine output consistently above
100 ml/hour.
B. A weight gain of 4 lb (1.8 kg) in 24
hours.
C. Body temperature readings all
within normal limits
D. An electrocardiogram (ECG)
showing no arrhythmias.
84. The nurse is reviewing the laboratory
results of a client with rheumatoid
arthritis. Which of the following
laboratory results should the nurse
expect to find?
A. Increased platelet count
B. Elevated erythrocyte sedimentation
rate (ESR)
C. Electrolyte imbalance
D. Altered blood urea nitrogen (BUN)
and creatinine levels
85. Which nursing diagnosis takes the
highest priority for a client with
Parkinson’s crisis?
A. Imbalanced nutrition: less than
body requirements
B. Ineffective airway clearance
C. Impaired urinary elimination
D. Risk for injury
86. A client with a spinal cord injury and
subsequent urine retention receives
intermittent catheterization every 4
hours. The average catheterized urine
volume has been 550 ml. The nurse
should plan to:
A. Increase the frequency of the
catheterizations.
B. Insert an indwelling urinary
catheter
C. Place the client on fluid restrictions
D. Use a condom catheter instead of
an invasive one.
87.The nurse is caring for a client who is
to undergo a lumbar puncture to assess
for the presence of blood in the
cerebrospinal fluid (CSF) and to measure
CSF pressure. Which result would
indicate n abnormality?
A. The presence of glucose in the CSF.
B. A pressure of 70 to 200 mm H2O
C. The presence of red blood cells
(RBCs) in the first specimen tube
D. A pressure of 00 to 250 mmH2O
88. The nurse is administering eyedrops
to a client with glaucoma. To achieve
maximum absorption, the nurse should
instill the eyedrop into the:
A. conjunctival sac
B. pupil
C. sclera
D. vitreous humor
89. A 52 yr-old married man with two
adolescent children is beginning
rehabilitation following a cerebrovascular
accident. As the nurse is planning the
client’s care, the nurse should recognize
that his condition will affect:
A. only himself
B. only his wife and children
C. him and his entire family
D. no one, if he has complete
recovery
90. Which action should take the highest
priority when caring for a client with
hemiparesis caused by a cerebrovascular
accident (CVA)?
A. Perform passive range-of-motion
(ROM) exercises.
B. Place the client on the affected
side.
C. Use hand rolls or pillows for
support.
D. Apply antiembolism stockings
91. The nurse is formulating a teaching
plan for a client who has just experienced
a transient ischemic attack (TIA). Which
fact should the nurse include in the
teaching plan?
A. TIA symptoms may last 24 to 48
hours.
B. Most clients have residual effects
after having a TIA.
C. TIA may be a warning that the
client may have cerebrovascular
accident (CVA)
D. The most common symptom of TIA
is the inability to speak.
92. The nurse has just completed
teaching about postoperative activity to
a client who is going to have a cataract
surgery. The nurse knows the teaching
has been effective if the client:
A. coughs and deep breathes
postoperatively
B. ties his own shoes
C. asks his wife to pick up his shirt
from the floor after he drops it.
D. States that he doesn’t need to
wear an eyepatch or guard to bed
93. The least serious form of brain
trauma, characterized by a brief loss of
consciousness and period of confusion, is
called:
A. contusion
B. concussion
C. coup
D. contrecoup
94. When the nurse performs a
neurologic assessment on Anne Jones,
her pupils are dilated and don’t respond
to light.
A. glaucoma
B. damage to the third cranial nerve
C. damage to the lumbar spine
D. Bell’s palsy
95. A 70 yr-old client with a diagnosis of
leftsided cerebrovascular accident is
admitted to the facility. To prevent the
development of diffuse osteoporosis,
which of the following objectives is most
appropriate?
A. Maintaining protein levels.
B. Maintaining vitamin levels.
C. Promoting weight-bearing exercises
D. Promoting range-of-motion (ROM)
exercises
96. A client is admitted with a diagnosis
of meningitis caused by Neisseria
meningitides. The nurse should institute
which type of isolation precautions?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions
97. A young man was running along an
ocean pier, tripped on an elevated area
of the decking, and struck his head on
the pier railing. According to his friends,
“He was unconscious briefly and then
became alert and behaved as though
nothing had happened.” Shortly
afterward, he began complaining of a
headache and asked to be taken to the
emergency department. If the client’s
intracranial pressure (ICP) is increasing,
the nurse would expect to observe which
of the
following signs first?
A. pupillary asymmetry
B. irregular breathing pattern
C. involuntary posturing
D. declining level of consciousness
98. Emergency medical technicians
transport a 28 yr-old iron worker to the
emergency department. They tell the
nurse, “He fell from a two-story building.
He has a large contusion on his left chest
and a hematoma in the left parietal area.
He has compound fracture of his left
femur and he’s comatose. We intubated
him and he’s maintaining an arterial
oxygen saturation of 92% by pulse
oximeter with a manual-resuscitation
bag.” Which intervention by the nurse
has the highest priority?
A. Assessing the left leg
B. Assessing the pupils
C. Placing the client in
Trendelenburg’s position
D. Assessing the level of
consciousness
99. Alzheimer’s disease is the secondary
diagnosis of a client admitted with
myocardial infarction. Which nursing
intervention should appear on this
client’s plan of care?
A. Perform activities of daily living for
the client to decease frustration.
B. Provide a stimulating environment.
C. Establish and maintain a routine.
D. Try to reason with the client as
much as possible.
100. For a client with a head injury whose
neck has been stabilized, the preferred
bed position is:
A. Trendelenburg’s
B. 30-degree head elevation
C. flat
D. side-lying
Answers and Rationales
1. ANS: D
Because the client’s gag reflex is
absent, elevating the head of the bed
to 30 degrees helps minimize the
client’s risk of aspiration. Checking
the stools, performing ROM exercises,
and keeping the skin clean and dry
are important, but preventing
aspiration through positioning is the
priority.
2. ANS: A
Any hole, no matter how small, will
 destroy the odor-proof seal of a
drainage bag. Removing the bag or
unclamping it is the only appropriate
method for relieving gas.
3. ANS: A
because celiac disease destroys the
absorbing surface of the intestine, fat
isn’t absorbed but is passed in the
stool. Steatorrhea is bulky, fatty
stools that have a foul odor.
Jaundiced sclerae result from
elevated bilirubin levels. Clay-colored
stools are seen with biliary disease
when bile flow is blocked. Celiac
disease doesn’t cause a widened
pulse pressure.
4. ANS: D
Reducing sodium intake reduces fluid
retention. Fluid retention increases
blood volume, which changes blood
vessel permeability and allows
plasma to move into interstitial
tissue, causing edema. Urea nitrogen
excretion can be increased only by
improved renal function. Sodium
intake doesn’t affect the glomerular
filtration rate. Potassium absorption
is improved only by increasing the
glomerular filtration rate; it isn’t
affected by sodium intake.
5. ANS: D
The portion of the cerebrum that
controls speech and hearing is the
temporal lobe. Injury to the frontal
lobe causes personality changes,
difficulty speaking, and disturbance
in memory, reasoning, and
concentration. Injury to the parietal
lobe causes sensory alterations and
problems with spatial relationships.
Damage to the occipital lobe causes
vision disturbances.
6. ANS: D
Diabetes insipidus is an abrupt onset
of extreme polyuria that commonly
occurs in clients after brain surgery.
Cushing’s syndrome is excessive
glucocorticoid secretion resulting in
sodium and water retention. Diabetes
mellitus is a hyperglycemic state
marked by polyuria, polydipsia, and
polyphagia. Adrenal crisis is
undersecretion of glucocorticoids
resulting in profound hypoglycemia,
hypovolemia, and hypotension.
7. ANS: C
The client should report the presence
of foulsmelling or cloudy urine.
Unless contraindicated, the client
should be instructed to drink large
quantities of fluid each day to flush
the kidneys. Sand-like debris is
normal because of residual stone
products. Hematuria is common after
lithotripsy.
8. ANS: A
A serum glucose level of 618 mg/dl
indicates hyperglycemia, which
causes polyuria and deficient fluid
volume. In this client, tachycardia is
more likely to result from deficient
fluid volume than from decreased
cardiac output because his blood
pressure is normal. Although the
client’s serum glucose is elevated,
food isn’t a priority because fluids
and insulin should be administered to
lower the serum glucose level.
Therefore, a diagnosis of Imbalanced
Nutrition: Less then body
requirements isn’t appropriate. A
temperature of 100.6º F isn’t life
threatening, eliminating ineffective
thermoregulation as the top priority.
9. ANS: C
Regular insulin, which is a short-
acting insulin, has an onset of 15 to
30 minutes and a peak of 2 to 4
hours. Because the nurse gave the
insulin at 2 p.m., the expected onset
would be from 2:15 to 2:30 p.m. and
the peak from 4 p.m. to 6 p.m.
10. ANS: A
CPP is derived by subtracting the ICP
from the mean arterial pressure
(MAP). For adequate cerebral
perfusion to take place, the minimum
goal is 70 mmHg. The MAP is derived
using the following formula:
MAP = ((diastolic blood pressure x 2)
+ systolic blood pressure) / 3
MAP = ((60 x2) + 90) / 3
MAP = 70 mmHg
To find the CPP, subtract the client’s
ICP from the MAP; in this case , 70
mmHg – 18 mmHg = 52 mmHg.
11. ANS: B
Breast cancer tumors are fixed, hard,
and poorly delineated with irregular
edges. Nipple retraction —not
eversion—may be a sign of cancer. A
mobile mass that is soft and easily
delineated is most often a fluid-filled
benigned cyst. Axillary lymph nodes
may or may not be palpable on initial
detection of a cancerous mass.
12. ANS: D
An enterostomal nurse therapist is a
registered nurse who has received
advance education in an accredited
program to care for clients with
stomas. The enterostomal nurse
 therapist can assist with selection of
an appropriate stoma site, teach
about stoma care, and provide
emotional support.
13. ANS: A
Ottorrhea and rhinorrhea are classic
signs of basilar skull fracture. Injury
to the dura commonly occurs with
this fracture, resulting in
cerebrospinal fluid (CSF) leaking
through the ears and nose. Any fluid
suspected of being CSF should be
checked for glucose or have a halo
test done.
14. ANS: D
Testicular cancer commonly occurs in
men between ages 20 and 30. A male
client should be taught how to
perform testicular self-examination
before age 20, preferably when he
enters his teens.
15. ANS: B
Before weaning a client from
mechanical ventilation, it’s most
important to have a baseline ABG
levels. During the weaning process,
ABG levels will be checked to assess
how the client is tolerating the
procedure. Other assessment
parameters are less critical.
Measuring fluid volume intake and
output is always important when a
client is being mechanically
ventilated. Prior attempts at weaning
and ECG results are documented on
the client’s record, and the nurse can
refer to them before the weaning
process begins.
16. ANS: B
According to the ACS guidelines,
“Women older than age 40 should
perform breast selfexamination
monthly (not annually).” The
hormonal receptor assay is done on a
known breast tumor to determine
whether the tumor is estrogen- or
progesterone-dependent.
17. ANS: C
Increased pressure within the portal
veins causes them to bulge, leading
to rupture and bleeding into the
lower esophagus. Bleeding
associated with esophageal varices
doesn’t stem from esophageal
perforation, pulmonary hypertension,
or peptic ulcers.
18. ANS: B
Complex intra-articular fractures are
repaired with external fixators
because they have a better long-term
outcome than those treated with
casting. This is especially true in a
young client. The incidence of
complications, such as pin tract
infections and neuritis, is 20% to
60%. Clients must be taught how to
do pin care and assess for
development of neurovascular
complications.
19. ANS: C
In a client with chronic renal failure,
unrestricted intake of sodium,
protein, potassium, and fluids may
lead to a dangerous accumulation of
electrolytes and protein metabolic
products, such as amino acids and
ammonia. Therefore, the client must
limit his intake of sodium, meat (high
in Protein), bananas (high in
potassium), and fluid because the
kidneys can’t secrete adequate urine.
20. ANS: D
The client isn’t withdrawn or showing
other signs of anxiety or depression.
Therefore, the nurse can probably
safely approach her about talking
with others who have had similar
experiences, either through Reach for
Recovery or another formal support
group. The nurse may educate the
client’s spouse or partner to listen to
concerns, but the nurse shouldn’t tell
the client’s spouse what to do. The
client must consult with her physician
and make her own decisions
about further treatment. The client
needs to express her sadness,
frustration, and fear. She can’t be
expected to be cheerful at all times.
21. ANS: C
HCG is one of the tumor markers for
testicular cancer. The HCG level
won’t identify the site of an infection
or evaluate prostatic function or
testosterone level.
22. ANS: B
Peripheral edema is a sign of fluid
volume overload and worsening heart
failure. A skin rash, dry cough, and
postural hypotension are adverse
reactions to captopril, but the don’t
indicate that therapy isn’t effective.
23. ANS: A
Tenting of chest skin when pinched
indicates decreased skin elasticity
due to dehydration. Hand veins fill
slowly with dehydration, not rapidly.
A pulse that isn’t easily obliterated
and neck vein distention indicate
fluid overload, not dehydration.
24. ANS: B
The client should be encouraged to
 increase his activity level.
Maintaining an ideal weight; following
a low-cholesterol, low-sodium diet;
and avoiding stress are all important
factors in decreasing the risk of
atherosclerosis.
25. ANS: B
Because thrombocytopenia impairs
blood clotting, the nurse should
assess the client regularly for signs of
bleeding, such as petechiae, purpura,
epistaxis, and bleeding gums. The
nurse should avoid administering
aspirin because it can increase the
risk of bleeding. Frequent rest periods
are indicated for clients with anemia,
not thrombocytopenia. Strict isolation
is indicated only for clients who have
highly contagious or virulent
infections that are spread by air or
physical contact.
26. ANS: B
SaO2 is the degree to which
hemoglobin is saturated with oxygen.
It doesn’t indicate the client’s overall
Hgb adequacy. Thus, an individual
with a subnormal Hgb level could
have normal SaO2 and still be short
of breath. In this case, the nurse
could assume that the client has a
Hematologic problem. Poor peripheral
perfusion would cause subnormal
SaO2. There isn’t enough data to
assume that the client’s problem is
psychosomatic. If the problem were
left-sided heart failure, the client
would exhibit pulmonary crackles.
27. ANS: A
Addisonian crisis results in
Hyperkalemia; therefore,
administering potassium chloride is
contraindicated. Because the client
will be hyponatremic, normal saline
solution is indicated. Hydrocortisone
and fludrocortisone are both useful in
replacing deficient adrenal cortex
hormones.
28. ANS: D
Leukemia is manifested by an
abnormal overpopulation of immature
leukocytes in the bone marrow.
29. ANS: C
A sterile field is considered
contaminated when it becomes wet.
Moisture can act as a wick, allowing
microorganisms to contaminate the
field. The outside of containers, such
as sterile saline bottles, aren’t sterile.
The containers should be opened
before sterile gloves are put on and
the solution poured over the sterile
dressings placed in a sterile basin.
Wounds should be cleaned from the
most contaminated area to the least
contaminated area—for example,
from the center outward. The outer
inch of a sterile field shouldn’t be
considered sterile.
30. ANS: C
Caffeine is a stimulant, which can
exacerbate palpitations and should
be avoided by a client with
symptomatic mitral valve prolapse.
High fluid intake helps maintain
adequate preload and cardiac output.
Aerobic exercise helps in increase
cardiac output and decrease heart
rate. Protein-rich foods aren’t
restricted but high calorie foods are.
31. ANS: A
Excessive of aldosterone in the
adrenal cortex is responsible for the
client’s hypertension. This hormone
acts on the renal tubule, where it
promotes reabsorption of sodium and
excretion of potassium and hydrogen
ions. The pancreas mainly secretes
hormones involved in fuel
metabolism. The adrenal medulla
secretes the cathecolamines—
epinephrine and norepinephrine. The
parathyroids secrete parathyroid
hormone.
32. ANS: D
A heart valve prosthesis, such as a
mitral valve replacement, is a major
risk factor for infective endocarditis.
Other risk factors include a history of
heart disease (especially mitral valve
prolapse), chronic debilitating
disease, IV drug abuse, and
immunosuppression. Although
diabetes mellitus may predispose a
person to cardiovascular disease, it
isn’t a major risk factor for infective
endocarditis, nor is an appendectomy
or pernicious anemia.
33. ANS: A
The client has signs and symptoms of
diabetes insipidus, probably caused
by the failure of her renal tubules to
respond to antidiuretic hormone as a
consequence of pyelonephritis. The
hypernatremia is secondary to her
water loss. Imbalanced nutrition
related to hypermetabolic state or
catabolic effect of insulin deficiency is
an inappropriate nursing diagnosis
for the client.
34. ANS: C
When performing a nutritional
assessment, one of the first things
 the nurse should do is to assess what
the client typically eats. The client
shouldn’t be permitted to eat as
desired. Weighing the client daily,
placing her on I & O status, and
drawing blood to determine
electrolyte level aren’t part of a
nutritional assessment.
35. Ans. C
Regular follow-up care for the client
with Grave’s disease is critical
because most cases eventually result
in hypothyroidism. Annual thyroid-
stimulating hormone tests and the
client’s ability to recognize signs and
symptoms of thyroid dysfunction will
help detect thyroid abnormalities
early. Intake and output is important
for clients with fluid and electrolyte
imbalances but not thyroid disorders.
DDAVP is used to treat diabetes
insipidus. While exercise to improve
cardiovascular fitness is important,
for this client the importance of
regular follow-up is most critical.
36. ANS: D
Anxiety related to the threat of death
is an appropriate nursing diagnosis
because the client’s anxiety can
adversely affect hear rate and
rhythm by stimulating the autonomic
nervous system. Also, because the
client required resuscitation, the
threat of death is a real and
immediate concern. Unless anxiety is
dealt with first, the client’s emotional
state will impede learning. Client
teaching should be limited to clear
concise explanations that reduce
anxiety and promote cooperation. An
anxious client has difficulty learning,
so the deficient knowledge would
continue despite attempts teaching.
Impaired physical mobility and social
isolation are necessitated by the
client’s critical condition; therefore,
they aren’t considered problems
warranting nursing diagnoses.
37. ANS: A
Because tuberculosis is transmitted
by droplet nuclei from the respiratory
tract, the nurse should put on a mask
when entering the client’s room.
Having the client wear a mask at all
the times would hinder sputum
expectoration and make the mask
moist from respirations. If no contact
with the client’s blood or body fluids
is anticipated, the nurse need not
wear a gown or gloves when
providing direct care. A client with
tuberculosis should be in a room with
laminar air flow, and the door should
be closed at all times.
38. ANS: C
The nurse can gently irrigate the tube
but must take care not to reposition
it. Repositioning can cause bleeding.
Suction should be applied
continuously, not every hour. The NG
tube shouldn’t be clamped
postoperatively because secretions
and gas will accumulate, stressing
the suture line.
39. ANS: A
Regardless of the client’s medical
history, rapid fluid resuscitation is
critical for maintaining cardiovascular
integrity. Profound intravascular
depletion requires aggressive fluid
replacement. A typical fluid
resuscitation protocol is 6 L of fluid
over the first 12 hours, with more
fluid to follow over the next 24 hours.
Various fluids can be used, depending
on the degree of hypovolemia.
Commonly prescribed fluids include
dextran (in case of hypovolemic
shock), isotonic normal saline
solution and, when the client is
stabilized, hypotonic half-normal
saline solution.
40. ANS: D
Glipizide may cause adverse skin
reactions, such as pruritus, and
photosensitivity. It doesn’t cause
headache, constipation, or
hypotension.
41. ANS: B
When clients are on mechanical
ventilation, the artificial airway
impairs the gag and cough reflexes
that help keep organisms out of the
lower respiratory tract. The artificial
airway also prevents the upper
respiratory system from humidifying
and heating air to enhance
mucociliary clearance. Manipulations
of the artificial airway sometimes
allow secretions into the lower
airways. Whit standard procedures
the other choices wouldn’t be at high
risk.
42. ANS: C
In chronic bronchitis, the
diaphragmatic is flat and weak.
Diaphragmatic breathing helps to
strengthen the diaphragm and
maximizes ventilation. Exhalation
should longer than inhalation to
prevent collapse of the bronchioles.
The client with chronic bronchitis
 should exhale through pursed lips to
prolong exhalation, keep the
bronchioles from collapsing, and
prevent air trapping. Diaphragmatic
breathing—not chest breathing—
increases lung expansion.
43. ANS: A
Verbalizing the observed behavior is
a therapeutic communication
technique in which the nurse
acknowledges what the client is
feeling. Offering to listen to the client
express her anger can help the nurse
and the client understand its cause
and begin to deal with it. Although
stress can exacerbate the symptoms
of SLE, telling the client to calm down
doesn’t acknowledge her feelings.
Offering to get the nursing supervisor
also doesn’t acknowledge the client’s
feelings. Ignoring the client’s feelings
suggest that the nurse has no
interest in what the client has said.
44. ANS: A
Daily walks relieve symptoms of
intermittent claudication, although
the exact mechanism is unclear.
Anaerobic exercise may exacerbate
these symptoms. Clients with chronic
arterial occlusive disease must
reduce daily fat intake to 30% or less
of total calories. The client should
limit dietary cholesterol because
hyperlipidemia is associated with
atherosclerosis, a known cause of
arterial occlusive disease. However,
HDLs have the lowest cholesterol
concentration,
so this client should eat foods that
raise HDL levels.
45. ANS: A
Gastric decompression is typically
low pressure and intermittent. High
pressure and continuous gastric
suctioning predisposes the gastric
mucosa to injury and ulceration.
46. ANS: A
In osteoarthritis, stiffness is common
in large, weight bearing joints such as
the hips. This joint stiffness alters
functional ability and range of
motion, placing the client at risk for
falling and injury. Therefore, client
safety is in jeopardy. Osteoporosis
doesn’t affect urinary elimination,
breathing, or nutrition.
47. ANS: A
PTH stimulates the kidneys to
reabsorb calcium and excrete
phosphate and converts vit D to its
active form: 1 , 25 dihydroxy vitamin
D. PTH doesn’t have a role in the
metabolism of Vit E.
48. ANS: C
The presence of unsecured area rugs
poses a hazard in all homes,
particularly in one with a resident at
high risk for falls.
49. ANS: B
Autonomy ascribes the right of the
individual to make his own decisions.
In this case, the client is capable of
making his own decision and the
nurse should support his autonomy.
Beneficence and justice aren’t the
principles that directly relate to the
situation. Advocacy is the nurse’s role
in supporting the principle of
autonomy.
50. ANS: D
Because respirations are depressed
in myxedema coma, maintaining a
patent airway is the most critical
nursing intervention. Ventilatory
support is usually needed. Thyroid
replacement will be administered IV.
Although myxedema coma is
associated with severe hypothermia,
a warming blanket shouldn’t be used
because it may cause vasodilation
and shock. Gradual warming blankets
would be appropriate. Intake and
output are very important but aren’t
critical
interventions at this time.
51. ANS: A
Glipizide begins to act in 15 to 30
minutes. The other options are
incorrect.
52. ANS: A
Hypoxia is the main breathing
stimulus for a client with COPD.
Excessive oxygen administration may
lead to apnea by removing that
stimulus. Anginal pain results from a
reduced myocardial oxygen supply. A
client with COPD may have anginal
pain from generalized
vasoconstriction secondary to
hypoxia; however, administering
oxygen at any concentration dilates
blood vessels, easing anginal pain.
Respiratory alkalosis results from
alveolar hyperventilation, not
excessive oxygen administration. In a
client with COPD, high oxygen
concentrations decrease the
ventilatory drive, leading to
respiratory acidosis, not alkalosis.
High oxygen concentrations don’t
cause metabolic acidosis.
53. ANS: C
Continuous subcutaneous insulin
regimen uses a basal rate and
boluses of short-acting insulin.
Multiple daily injection therapy uses a
combination of short-acting and
intermediate or long-acting insulins.
54. ANS: B
Holding a cane on the uninvolved
side distributes weight away from the
involved side. Holding the cane close
to the body prevents leaning. Use of
a cane won’t maintain stride length
or prevent edema.
55. ANS: D
High pulmonary artery wedge
pressures are diagnostic for left-sided
heart failure. With leftsided heart
failure, pulmonary edema can
develop causing pulmonary crackles.
In leftsided heart failure, hypotension
may result and urine output will
decline. Dry mucous membranes
aren’t directly associated with
elevated pulmonary artery wedge
pressures.
56. ANS: B
It’s mandatory in most settings to
have a physician’s order before
restraining a client. A client should
never be left alone while the nurse
summons assistance. All staff
members require annual instruction
on the use of restraints, and the
nurse should be familiar with the
facility’s policy.
57. ANS: A
The client who has undergone a
thyroidectomy is t risk for developing
hypocalcemia from inadvertent
removal or damage to the
parathyroid gland. The client with
hypocalcemia will exhibit a positive
Chvostek’s sign (facial muscle
contraction when the facial nerve in
front of the ear is tapped) and a
positive Trousseau’s sign (carpal
spasm when a blood pressure cuff is
inflated for few minutes). These signs
aren’t present with hypercalcemia,
hypokalemia, or Hyperkalemia.
58. ANS: C
Diarrhea causes a bicarbonate deficit.
With loss of the relative alkalinity of
the lower GI tract, the relative acidity
of the upper GI tract predominates
leading to metabolic acidosis.
Diarrhea doesn’t lead to respiratory
acid-base imbalances, such as
respiratory acidosis and respiratory
alkalosis. Loss of acid, which occurs
with severe vomiting, may lead to
metabolic alkalosis.
59. ANS: B
The head of the bed must be
elevated while the client is eating.
The client should be placed in a
recumbent position—not a supine
position— when lying down to reduce
the risk of aspiration. Encourage the
client to wear properly fitted dentures
to enhance his chewing ability.
Thickened liquids, not thin liquids,
decrease aspiration risk.
60. ANS: A
Endotracheal suctioning secretions as
well as gases from the airway and
lowers the arterial oxygen saturation
(SaO2) level. Coughing and incentive
spirometry improve oxygenation and
should raise or maintain oxygen
saturation. Because of superficial
vasoconstriction, using a cooling
blanket can lower peripheral oxygen
saturation readings, but SaO2 levels
wouldn’t be affected.
61. ANS: D
With a superficial partial thickness
burn such as a solar burn (sunburn),
the nurse’s main concern is pain
management. Fluid resuscitation and
infection become concerns if the burn
extends to the dermal and
subcutaneous skin layers. Body
image disturbance is a concern that
has a lower priority than pain
management.
62. ANS: D
Crackles result from air moving
through airways that contain fluid.
Heard during inspiration and
expiration, crackles are discrete
sounds that vary in pitch and
intensity. They’re classified as fine,
medium, or coarse. Pleural friction
rubs have a distinctive grating sound.
As the name indicates, these breath
sounds result when inflamed pleurae
rub together. Continuous,
highpitched, musical squeaks, called
wheezes, result when air moves
rapidly through airways narrowed by
asthma or infection or when an
airway is partially obstructed by a
tumor or foreign body. Wheezes, like
gurgles, occur on expiration and
sometimes on inspiration. Loud,
coarse, low-pitched sounds
resembling snoring are called
gurgles. These sounds develop when
thick secretions partially obstruct
 airflow through the large upper
airways.
63. Ans. D
Individuals who are tuberculin skin
test converters should begin a 6-
month regimen of an antitubercular
drug such as INH, and they should
never have another skin test. After an
individual has a positive tuberculin
skin test, subsequent skin tests will
cause severe skin reactions but won’t
provide new information about the
client’s TB status. The client doesn’t
have active TB, so can’t transmit, or
spread, the bacteria. Therefore, she
shouldn’t be quarantined or asked for
information about recent contacts.
64. ANS: C
Disturbed body image is a negative
perception of the self that makes
healthful functioning more difficult.
The defining characteristics for this
nursing diagnosis include undergoing
a change in body structure or
function, hiding or overexposing a
body part, not looking at a body part,
and responding verbally or
nonverbally to the actual or
perceived change in structure or
function. This client may have any of
the other diagnoses, but the signs
and symptoms described in he case
most closely match the defining
characteristics for disturbed body
image.
65. ANS: B
Because the pregnant uterus exerts a
lot of pressure on the urinary bladder,
the bladder repair may need to be
repeated. These clients don’t
necessarily have to have a cesarean
delivery if they become pregnant,
and this procedure doesn’t render
them sterile. This procedure is
completed in one surgery.
66. ANS: A
Eccrine glands are associated with
body temperature regulation.
Sebaceous glands lubricate the skin
and hairs, and apocrine glands are
involved in bacteria decomposition.
Endocrine glands secrete hormones
responsible for the regulation of body
processes, such as metabolism and
glucose regulation.
67. ANS: B
The light-colored spots attached to
the hair shafts are nits, which are the
eggs of head lice. They can’t be
brushed off the hair shaft like
dandruff. Scabies is a contagious
dermatitis caused by the itch mite,
Sacoptes scabiei, which lives just
beneath the skin. Tinea capitis, or
ringworm, causes patchy hair loss
and circular lesions with healing
centers. Impetigo is an infection
caused by Staphylococcus or
Sterptococcus, manifested by
vesicles or pustules that form a thick,
honey-colored crust.
68. ANS: C
Severe pressure-like pain out of
proportion to visible signs
distinguishes necrotizing fasciitis
from cellulites. Erythema,
leukocytosis, and swelling are present
in both cellulites and necrotizing
fasciitis.
69. ANS: A
Contact dermatitis is caused by
exposure to a physical or chemical
allergen, such as cleaning products,
skin care products, and latex gloves.
Initial symptoms of itching,
erythema, and raised papules occur
at the site of the exposure and can
begin within 1 hour of exposure.
Allergic reactions tend to be red and
not scaly or flaky. Weeping, crusting
lesions are also uncommon unless
the reaction is quite severe or has
been present for a long time.
Excoriation is more common in skin
disorders associated with a moist
environment.
70. ANS: D
Hoarseness indicate injury to the
respiratory system and could indicate
the need for immediate intubation.
Thirst following burns is expected
because of the massive fluid shifts
and resultant loss leading to
dehydration. Pain, either severe or
moderate, is expected with a burn
injury. The client’s output is
adequate.
71. ANS: C
Third-degree burn may appear white,
red, or black and are dry and leathery
with no blisters. There may be little
pain because nerve endings have
been destroyed. First-degree burns
are superficial and involve the
epidermis only. There is local pain
and redness but no blistering.
Second-degree burn appear red and
moist with blister formation and are
painful. Fourth-degree burns involve
underlying muscle and bone tissue.
72. ANS: C
A universal concern I the care of
 donor sites for burn care is to keep
the site away from sources of
pressure. Ventilation of the site and
keeping the site fully covered are
practices in some institutions but
aren’t hallmarks of donor site care.
Placing the site in a position of
dependence isn’t a justified aspect of
donor site care.
73. ANS: A
Anyone with psoriasis vulgaris who
reports joint pain should be evaluated
for psoriaic arthritis. Approximately
15% to 20% of individuals with
psoriasis will also develop psoriatic
arthritis, which can be painful and
cause deformity. It would be incorrect
to assume that his pain is caused by
early rheumatoid arthritis or his
vocation without asking more
questions or performing diagnostic
studies. Carpal tunnel syndrome
causes sensory and motor changes in
the fingers rather than localized pain
in the joints.
74. ANS: B
To avoid burning and sloughing, the
client must protect the graft from
sunlight. The other three
interventions are all helpful to the
client and his recovery but are less
important.
75. ANS: C
Because the itching and rash are
localized, an environmental cause in
the workplace should be suspected.
With the advent of universal
precautions, many nurses are
experiencing allergies to latex gloves.
Allergies to medications, laundry
detergents, or bath soaps or a
dermatologic reaction to stress
usually elicit a more generalized or
widespread rash.
76. ANS: A
Hives and urticaria are two names for
the same skin lesion. Toxin is a
poison. A tubercle is a tiny round
nodule produced by the tuberculosis
bacillus. A virus is an infectious
parasite.
77. ANS: A
A scale is the characteristic
secondary lesion occurring in
psoriasis. Although crusts, ulcers, and
scars also are secondary lesions in
skin disorders, they don’t accompany
psoriasis.
78. ANS: C
A turning schedule with a signing
sheet will help ensure that the client
gets turned and thus, help prevent
pressure ulcers. Turning should occur
every 1-2 hours—not every 8 hours—
for clients who are in bed for
prolonged periods. The nurse should
apply lotion to keep the skin moist
but should avoid vigorous massage,
which could damage capillaries.
When moving the client, the nurse
should lift rather than slide the client
to void shearing.
79. ANS: A
To prevent disruption of the artificial
skin’s adherence to the wound bed,
the client should restrict range of
motion of the involved limb. Protein
intake and fluid intake are important
for healing and regeneration and
shouldn’t be restricted. Going
outdoors is acceptable as long as the
left arm is protected from direct
sunlight.
80. ANS: C
According to the Rule of Nines, the
posterior and anterior trunk, and legs
each make up 18% of the total body
surface. The head, neck, and arms
each make up 9% of total body
durface, and the perineum makes up
1%. In this case, the client received
burns to his back (18%) and one arm
(9%), totaling 27%.
81. ANS: A
A wet-to-dry saline dressing should
always keep the wound moist. Tight
packing or dry packing can cause
tissue damage and pain. A dry gauze
—not a plastic-sheet-type dressing—
should cover the wet dressing.
82. ANS: A
When someone in a group of persons
sharing a home contracts scabies,
each individual in the same home
needs prompt treatment whether
he’s symptomatic or not. Towels and
linens should be washed in hot water.
Scabies can be transmitted from one
person to another before symptoms
develop
83. ANS: A
In a client with burns, the goal of fluid
resuscitation is to maintain a mean
arterial blood pressure that provides
adequate perfusion of vital
structures. If the kidneys are
adequately perfused, they will
produce an acceptable urine output
of at least 0.5 ml/kg/hour. Thus, the
expected urine output of a 155-lb
client is 35 ml/hour, and a urine
output consistently above 100
 ml/hour is more than adequate.
Weight gain from fluid resuscitation
isn’t a goal. In fact, a 4 lb weight gain
in 24 hours suggests third spacing.
Body temperature readings and ECG
interpretations may demonstrate
secondary benefits of fluid
resuscitation but aren’t primary
indicators.
84. ANS: B
The ESR test is performed to detect
inflammatory processes in the body.
It’s a nonspecific test, so the health
care professional must view results in
conjunction with physical signs and
symptoms. Platelet count,
electrolytes, BUN, and creatinine
levels aren’t usually affected by the
inflammatory process.
85. ANS: B
In Parkinson’s crisis, dopamine-
related symptoms are severely
exacerbated, virtually immobilizing
the client. A client who is confined to
bed during a crisis is at risk for
aspiration and pneumonia. Also,
excessive drooling increases the risk
of airway obstruction. Because of
these concerns, ineffective airway
clearance is the priority diagnosis for
this client. Although imbalanced
nutrition:less than body
requirements, impaired urinary
elimination and risk for injury also are
appropriate diagnoses for this client,
they aren’t immediately
lifethreatening and thus are less
urgent.
86. ANS: A
As a rule of practice, if intermittent
catheterization for urine retention
typically yields 500 ml or more, the
frequency of catheterization should
be increased. Indwelling
catheterization is less preferred
because of the risk of urinary tract
infection and the loss of bladder tone.
Fluid restrictions aren’t indicated for
this case; the problem isn’t
overhydration, rather it’s urine
retention. A condom catheter doesn’t
help empty the bladder of a client
with urine retention.
87. ANS: D
The normal pressure is 70 to 200 mm
H2O are considered abnormal. The
presence of glucose is an expected
finding in CSF, and RBCs typically
occur in the first specimen tube from
the trauma caused by the procedure.
88. ANS: A
The nurse should instill the eyedrop
into the conjunctival sac where
absorption can best take place. The
pupil permits light to enter the eye.
The sclera maintains the eye’s shape
and size. The vitreous humor
maintains the retina’s placement and
the shape of the eye.
89. ANS: C
According to family theory, any
change in a family member, such as
illness, produces role changes in all
family members and affects the
entire family, even if the client
eventually recovers completely.
90. ANS: B
To help prevent airway obstruction
and reduce the risk of aspiration, the
nurse should position a client with
hemiparesis on the affected side.
Although performing ROM exercises,
providing pillows for support, and
applying antiembolism stockings can
be appropriate for a client with CVA,
the first concern is to maintain a
patent airway.
91. ANS: C
TIA may be a warning that the client
will experience a CVA, or stroke, in
the near future. TIA aymptoms last
no longer than 24 hours and clients
usually have complete recovery after
TIA. The most common symptom of
TIA is sudden, painless loss of vision
lasting up to 24 hours.
92. ANS: C
Bending to pick up something from
the floor would increase intraocular
pressure, as would bending to tie his
shoes. The client needs to wear eye
protection to bed to prevent
accidental injury during sleep.
93. ANS: B
Concussions are considered minor
with no structural signs of injury. A
contusion is bruising of the brain
tissue with small hemorrhages in the
tissue. Coup and contrecoup are type
of injuries in which the damaged area
on the brain forms directly below that
site of impact (coup) or at the
site opposite the injury (contrecoup)
due to movement of the brain within
the skull.
94. ANS: B
The third cranial nerve (oculomotor)
is responsible for pupil constriction.
When there is damage to the nerve,
the pupils remain dilated and don’t
respond to light. Glaucoma, lumbar
 spine injury, and Bell’s palsy won’t
affect pupil constriction.
95. ANS: C
When the mechanical stressors of
weight bearing are absent, diffuse
osteoporosis can occur. Therefore, if
the client does weight-bearing
exercises, disuse complications can
be prevented. Maintaining protein
and vitamins levels is important, but
neither will prevent osteoporosis.
ROM exercises will help prevent
muscle atrophy and contractures.
96. ANS: B
This client requires droplet
precautions because the organism
can be transmitted through airborne
droplets when the client coughs,
sneezes, or doesn’t cover his mouth.
Airborne precautions would be
instituted for a client infected with
tuberculosis. Standard precautions
would be instituted for a client when
contact with body substances is
likely. Contact precautions would be
instituted for a client infected with an
organism that is transmitted through
skin-to-skin
contact.
97. ANS: D
With a brain injury such as an
epidural hematoma (a diagnosis that
is most likely based on this client’s
symptoms), the initial sign of
increasing ICP is a change in the level
of consciousness. As neurologic
deterioration progresses,
manifestations involving pupillary
symmetry, breathing patterns, and
posturing will
occur.
98. ANS: A
In the scenario, airway and breathing
are established so the nurse’s next
priority should be circulation. With a
compound fracture of the femur,
there is a high risk of profuse
bleeding; therefore, the nurse should
assess the site. Neurologic
assessment is a secondary concern
to airway, breathing and circulation.
The nurse doesn’t have enough data
to warrant putting the client in
Trendelenburg’s position.
99. ANS: C
Establishing and maintaining a
routine is essential to decreasing
extraneous stimuli. The client should
participate in daily care as much as
possible. Attempting to reason with
such clients isn’t successful, because
they can’t participate in abstract
thinking.
100. ANS: B
For clients with increased intracranial
pressure (ICP), the head of the bed is
elevated to promote venous outflow.
Trendelenburg’s position is
contraindicated because it can raise
ICP. Flat or neutral positioning is
indicated when elevating the head of
the bed would increase the risk of
neck injury or airway obstruction.
Sidelying isn’t specifically a
therapeutic treatment for increased
ICP.
PNLE Medical
Surgical Nursing
Exam 3
1. Lisa is newly diagnosed with asthma
and is being discharged from the hospital
after an episode of status asthmaticus.
Discharge teaching should include which
of the following:
A. Limitations in sports that will be
imposed by the illness
B. Specific instructions on staying cal
during an attack
C. The relationship of symptoms and
a specific trigger such as physical
exercise
D. Incidence of status asthmaticus in
children and teens
2. Which of the following symptoms is
most characteristic of a client with a
cancer of the lung?
A. air hunger
B. exertional dyspnea
C. cough with night sweats
D. persistent changing cough
3. The client has ST segment depression
on his 12-lead ECG. The nurse
determines that this would indicate the
following:
A. necrosis
B. injury
C. ischemia
D. nothing significant
4. Red has just returned from the
postanesthesia care unit (PACU) from a
hemorrhidectomy. His postoperative D. Avoiding lesions on the feet
orders include sitz baths every morning. 10. Mr. Roberto Robles complains of a
The nurse understands that sitz bath is severe headache and is extremely
use for: anxious. The nurse checks his vital signs
and finds him to have a heart rate of 57
A. promote healing bpm and a blood pressure of 230/110
B. relive tension mmHg. The nurse should also assess for?
C. lower body temperature
D. cause swelling A. presence of bowel sounds
5. Trousseau’s sign is associated with B. presence of babinski reflex
which electrolyte imbalance? C. fecal incontinence
D. urinary catheter patency
A. hyponatremia 11. A 40n year old male patient is
B. hypocalcemia complaining of chronic progressive and
C. hypernatremia mental deterioration is admitted to the
D. hypercalcemia unit. The nurse recognizes that these
6. A 36 year old female complains of characteristics indicate a disease that
headache and neck pain. The nurse’s results in degeneration of the basal
assessments reveal painful flexion of the ganglia and cerebral cortex. The disease
neck to the chest. The nurse understands is called:
that nuchal rigidity is associated with:
A. multiple sclerosis
A. brain tumor B. myasthenia gravis
B. CVA C. Huntington’s disease
C. meningitis D. Guillain-Barre syndrome
D. subdural hematoma 12. Dianne Hizon is a 27 year old woman
7. The nurse teaching the client about who has been admitted to the ER due to
behavioral changes, which can affect severe vomiting. Her ABG values are pH=
development of atherosclerosis, should 7.50, PaCO2= 85, HCO3= 31, and SaO2=
discuss which of the following as a non- 93%. The nurse interpretation of this ABG
modifiable risk factor for atherosclerosis? analysis is:

A. cigarette smoking A. respiratory acidosis

B. hyperlipidemia B. respiratory alkalosis
C. female over 55 years of age C. metabolic acidosis
D. sedentary lifestyle D. metabolic alkalosis
8. A 76 year old man enters the ER with 13. Mr. Perkson has a parkinson’s disease
complaints of back pain and feeling and he finds the resting tremor he is
fatigued. Upon examination, his blood experiencing in his right hand very
pressure is 190/100, pulse is 118, and frustrating. The nurse advises him to:
hematocrit and hemoglobin are both low.
The nurse palpates the abdomen which is A. take a warm bath
soft, non-tender and auscultates an B. hold an object
abdominal pulse. The most likely C. practice deep breathing
diagnosis is: D. take diazepam as needed
14. A shuffling gait is typically associated
A. Buerger’s disease with the patient who has:
B. CHF
C. Secondary hypertension A. Parkinson’s disease
D. Aneurysm B. Multiple sclerosis
9. Nurse Fiona is caring a patient with C. Raynaud’s disease
Raynaud’s disease. Which of the D. Myasthenia gravis
following outcomes concerning 15. The priority in preparing the room for
medication regimen is of highest priority? a client with a C7 spinal cord injury is
having:
A. Controlling the pain once
vasospasm occur A. the halo brace device
B. Relaxing smooth muscle to avoid B. a catheterization tray
vasospasms C. a ventilator on stand by
C. Preventing major disabilities that D. the spinal kinetic bed
may occur
16. A 47 year old man with liver failure
who has developed ascites. The nurse
understands that ascites is due to:
A. dehydration
B. protein deficiency
C. bleeding disorders
D. vitamin deficiency
17. A client with rheumatoid arthritis may
reveal which of the following assessment
data:
A. Heberden’s nodes
B. Morning stiffness no longer than 30
minutes
C. Asymmetric joint swelling
D. Swan neck deformities
18. Elsa Santos is a 18 year old student
admitted to the ward with a diagnosis of
epilepsy. She tells the nurse that she is
experiencing a generalized tingling
sensation and is “smelling roses”. The
nurse understands that Esla is probably
experiencing:
A. an acute alcohol withdrawal
B. an acute CVA
C. an aura
D. an olfactory hallucination
19. Mr. Lucas, a 63 year old, went to the
clinic complaining of hoarseness of voice
and a cough. His wife states that his
voice has changed in the last few
months. The nurse interprets that Mr.
Lucas’s symptoms are consistent with
which of the following disorders:
A. chronic sinusitis
B. laryngeal cancer
C. gastroesophageal reflux disease
D. coronary artery disease
20. Sarah complains of a nursing
sensation, cramping pain in the top part
of her abdomen that becomes worse in
the afternoon and sometimes awakes her
at night. She reports that when she eats,
it helps the pain go away but that pain is
now becoming more intense. Which of
the following is the best condition for the
nurse to draw:
A. these symptoms are consistent
with an ulcer
B. The client probably has indigestion
C. A snack before going to bed should
be advised
D. The client probably developing
cholelithiasis
21. Nurse Cynthia is providing a
discharge teaching to a client with
chronic cirrhosis. His wife asks her to
explain why there is so much emphasis
on bleeding precautions. Which of the
following provides the most appropriate
response?
A. “The low protein diet will result in
reduced clotting.”
B. “The increased production of bile
decreases clotting factors.”
C. “The liver affected by cirrhosis is
unable to produce clotting factors.”
D. “The required medications reduce
clotting factors.”
22. Betty Lee is a 58 year old woman
who is being admitted to the medical
ward with trigeminal neuralgia. The nurse
anticipates that Mr. Lee will demonstrate
which of the following major complaints?
A. excruciating, intermittent,
paroxysmal facial pain
B. unilateral facial droop
C. painless eye spasm
D. mildly painful unilateral eye
twitching
23. A 38 year old woman returns from a
subtotal thryroidectomy for the
treatment of hyperthyroidism. Upon
assessment, the immediate priority that
the nurse would include is:
A. Assess for pain
B. Assess for neurological status
C. Assess fluid volume status
D. Assess for respiratory distress
24. Nurse Shiela is teaching self-care to a
client with psoriasis. The nurse should
encourage which of the following for his
scaled lesion?
A. Importance of follow-up
appointments
B. Emollients and moisturizers to
soften scales
C. Keep occlusive dressings on the
lesions 24 hours a day
D. Use of a clean razor blade each
time he shaves
25. A 48 year old woman presents to the
hospital complaining of chest pain,
tachycardia and dyspnea. On exam,
heart sounds are muffled. Which of the
following assessment findings would
support a diagnosis of cardiac
tamponade?
A. A deviated trachea
B. Absent breath sounds to the lower
lobes
C. Pulse 40 with inspiration
D. Blood pressure 140/80
Answers and Rationales
1. C. The relationship of symptoms
and a specific trigger such as
physical exercise. COPD clients have
low oxygen and high carbon dioxide
levels. Therefore, hypoxia is the main
stimulus for ventilation is persons
with chronic hypercapnea. Increasing
the level of oxygen would decrease
the stimulus to breathe.
2. D. persistent changing cough. The
most common sign of lung cancer is a
persistent cough that changes. Other
signs are dyspnea, bloody sputum
and long term pulmonary infection.
Option A is common with asthma,
option B is common with COPD and
option C is common with TB.
3. C. ischemia. Depressed ST
segment and inverted T-waves
represent myocardial ischemia. Injury
has a ST segment elevation.
4. A. promote healing. Sitz bath
provides moist heat to the perineal
and anal area to clean, promote
healing and drainage and reduce
soreness to the area. Sitz bath helps
healing with cleaning action and
promotion of circulation, thereby
reducing swelling. Sitz bath usually
has no therapeutic value in lowering
body temperature. Although relief of
tension can occur, this effect is
secondary to the promotion of
healing.
5. B. hypocalcemia. Trousseau’s sign
is a carpal pedal spasm elicited when
a blood pressure cuff is inflated on
the arm of a patient with
hypocalcemia.
6. C. meningitis. A patient with
meningitis will exhibit signs that
include photophobia and nuchal
rigidity, which is pain on the flexion
of the chin to chest.
7. C. female over 55 years of
age. Lifestyle, cigarette smoking and
hyperlipidemia can be changed by
changing behaviors.
8. D. Aneurysm. The symptoms
exhibited by the client are typical of
an abdominal aortic aneurysm. The
most significant sign is the audible
pulse in the abdominal area. If
hemorrhage were present, the
abdomen would be tender and firm.
9. B. Relaxing smooth muscle to
avoid vasospasms. The major task of
the health care team is to medicate
the client drugs that produce smooth
muscle relaxation, which will
decrease the vasospasm and
increase the arterial flow to the
affected part. The drugs used are
calcium antagonists.
10. D. urinary catheter patency. The
patient is complaining of symptoms
of autonomic dysreflexia, which
consists of the triad of hypertension,
bradycardia and a headache. Major
causes of autonomic dysreflexia
include urinary bladder distention
and fecal impaction. Checking the
patency of the urinary catheter will
check for bladder distention.
11. C. Huntington’s
disease. Huntington’s disease is a
hereditary disease in which
degeneration of the basal ganglia
and cerebral cortex causes chronic
progressive chorea (muscle
twitching) and mental deterioration,
ending in dementia. Huntington’s
disease usually strikes people ages
25 to 55.
12. D. metabolic alkalosis. Ms. Hizon’s
pH is above 7.45, which makes it
alkalatic, and her bicarbonate is high
which is also makes it basic. Thus,
the diagnosis is metabolic alkalosis.
13. B. hold an object. The resting or
non-intentional tremor may be
controlled with purposeful movement
such as holding an object. A warm
bath, deep breathing and diazepam
will promote relaxation but are not
specific interventions for tremor.
14. A. Parkinson’s disease. A shuffling
gait from the musculoskeletal rigidity
of the patient with Parkinson’s
disease is common. Patients
experiencing a stroke usually exhibit
loss of voluntary control over motor
movements associated with
generalized weakness; a shuffling
gait is usually not observed in stroke
patient.
15. C. a ventilator on stand
by. Although a ventilator is not
required for injury below C3, the
innervation of intercostal muscles is
affected. Hemorrhage and cord
swelling extends the level of injury
making it likely that this client will
need a ventilator.
16. B. protein deficiency. Protein
deficiency allows fluid to leak out of
the vascular system and third space
into the tissues and spaces in the
body such as the peritoneal space.
Bleeding tendencies, dehydration and
 vitamin deficiency can occur but
don’t cause ascites.
17. D. Swan neck deformities. Swan
neck deformities of the hand are
classic deformities associated with
rheumatoid arthritis secondary to the
presence of fibrous connective tissue
within the joint space. Clients with RA
do experience morning stiffness, but
it can last from 30 minutes up to
several hours. RA is characterized by
symmetrical joint movement, and
heberden’s nodes are characteristic
of osteoarthritis.
18. C. an aura. An aura frequently
precedes an epileptic seizure and
may manifest as vague physic
discomfort or specific aromas.
Patients experiencing auras aren’t
having a CVA, substance withdrawal
or hallucination.
19. B. laryngeal cancer. These
symptoms, along with dysphagia,
foul-smelling breath, and pain when
drinking hot or acidic, are common
signs of laryngeal cancer.
20. A. these symptoms are consistent
with an ulcer. The description of pain
is consistent with ulcer pain. The pain
is epigastric and is worse when the
stomach is empty and is relived by
food.
21. C. “The liver affected by cirrhosis is
unable to produce clotting
factors.” When bile production is
reduced, the body has reduced ability
to absorb fat-soluble vitamins.
Without adequate Vitamin K
absorption, clotting factors II, VII, IX,
and X are not produced in sufficient
amounts.
22. A. excruciating, intermittent,
paroxysmal facial pain. Trigeminal
neuralgia is a syndrome of
excruciating, intermittent,
paroxysmal facial pain. It manifests
as intense, periodic pain in the lips,
gums, teeth or chin. The other
symptoms aren’t characteristic of
trigeminal neuralgia.
23. D. Assess for respiratory
distress. Though fluid volume status,
neurological status and pain are all
important assessment, the
immediate priority for postoperative
is the airway management.
Respiratory distress may result from
hemorrhage, edema, laryngeal
damage or tetany.
24. B. Emollients and moisturizers to
soften scales. Emollients will ease dry
skin that increases pruritus and
causes psoriasis to be worse.
Washing and drying the skin with
rough linens or pressure may cause
excoriation. Constant occlusion may
increase the effects of the medication
and increase the risk of infection.
25. C. Pulse 40 with
inspiration. Paradoxical pulse is a
hallmark symptom of cardiac
tamponade. As pressure is exerted on
the left ventricle from fluid, the
natural increase in pressure from the
right ventricle during inspiration
creates even more pressure,
diminishing cardiac output.
PNLE Medical
Surgical Nursing
Exam 4
1. A patient is admitted to the medical
surgical unit following surgery. Four days
after surgery, the patient spikes a 38.9
degrees C oral temperature and exhibits
a wet, productive cough. The nurse
assesses the patient with understanding
that an infection that is acquired during
hospitalization is known as:
A. a community acquired infection
B. an iatrogenic infection
C. a nosocomial infection
D. an opportunistic infection
2. A client with anemia has a hemoglobin
of 6.5 g/dL. The client is experiencing
symptoms of cerebral tissue hypoxia.
Which of the following nursing
interventions would be most important in
providing care?
A. Providing rest periods throughout
the day
B. Instituting energy conservation
techniques
C. Assisting in ambulation to the
bathroom
D. Checking temperature of water
prior to bathing
3. A client was involved in a motor
vehicular accident in which the seat belt
was not worn. The client is exhibiting
crepitus, decrease breath sounds on the
left, complains of shortness of breath,
and has a respiratory rate of 34 breaths
per minute. Which of the following A. Hold the Lanoxin
assessment findings would concern the B. Give the half dose now, wait an
nurse most? hour and give the other half
C. Call the physician
A. Temperature of 102 degrees F and D. Give the Lanoxin as ordered
productive cough 9. Nurse Marian is caring for a client with
B. ABG with PaO2 of 92 and PaCO2 of haital hernia, which of the following
40 mmHg should be included in her teaching plan
C. Trachea deviating to the right regarding causes:
D. Barrel-chested appearance
4. The proper way to open an envelop- A. To avoid heavy lifting
wrapped sterile package after removing B. A dietary plan based on soft foods
the outer package or tape is to open the C. Its prevalence in young adults
first position of the wrapper: D. Its prevalence in fair-skinned
individuals
A. away from the body 10. Joseph has been diagnosed with
B. to the left of the body hepatic encephalopathy. The nurse
C. to the right of the body observes flapping tremors. The nurse
D. toward the body understands that flapping tremors
5. Assessment of a client with possible associated with hepatic encephalopathy
thrombophlebitis to the left leg and a are also known as:
deep vein thrombosis is done by pulling
up on the toes while gently holding down A. aphasia
on the knee. The client complains of B. ascites
extreme pain in the calf. This should be C. astacia
documented as: D. asterixis
11. Hyperkalemia can be treated with
A. positive tourniquet test administration of 50% dextrose and
B. positive homan’s sign insulin. The 50% dextrose:
C. negative homan’s sign
D. negative tourniquet test A. causes potassium to be excreted
6. Thomas Elison is a 79 year old man B. causes potassium to move into the
who is admitted with diagnosis of cell
dementia. The doctor orders a series of C. causes potassium to move into the
laboratory tests to determine whether Mr. serum
Elison’s dementia is treatable. The nurse D. counteracts the effects of insulin
understands that the most common 12. Which of the following findings would
cause of dementia in this population is: strongly indicate the possibility of
cirrhosis?
A. AIDS
B. Alzheimer’s disease A. dry skin
C. Brain tumors B. hepatomegaly
D. Vascular disease C. peripheral edema
7. Which of the following nursing D. pruritus
interventions is contraindicated in the 13. Aling Puring has just been diagnosed
care of a client with acute osteomyelitis? with close-angle (narrow-angle)
glaucoma. The nurse assesses the client
A. Apply heat compress to the for which of the following common
affected area presenting symptoms of the disorder?
B. Immobilize the affected area
C. Administer narcotic analgesics for A. halo vision
pain B. dull eye pain
D. Administer OTC analgesics for pain C. severe eye and face pain
8. A client with congestive heart failure D. impaired night vision
has digoxin (Lanoxin) ordered everyday. 14. Chvostek’s sign is associated with
Prior to giving the medication, the nurse which electrolyte impabalnce?
checks the digoxin level which is
therapeutic and ausculates an apical A. hypoclacemia
pulse. The apical pulse is 63 bpm for 1 B. hypokalemia
full minute. The nurse should: C. hyponatremia
D. hypophosphatenia
15. What laboratory test is a common
measure of the renal function?
A. CBC
B. BUN/Crea
C. Glucose
D. Alanine amino transferase (ALT)
16. Nurse Edward is performing
discharge teaching for a newly diagnosed
diabetic patient scheduled for a fasting
blood glucose test. The nurse explains to
the patient that hyperglycemia is defined
as a blood glucose level above:
21. Hazel Murray, 32 years old complains
of abrupt onset of chest and back pain
and loss of radial pulses. The nurse
suspects that Mrs. Murray may have:
A. Acute MI
B. CVA
C. Dissecting abdominal aorta
D. Dissecting thoracic aneurysm
22. Nurse Alexandra is establishing a
plan of care for a client newly admitted
with SIADH. The priority diagnosis for this
client would be which of the following?

A. 100 mg/dl A. Fluid volume deficit

B. 120 mg/dl B. Anxiety related to disease process
C. 130 mg/dl C. Fluid volume excess
D. 150 mg/dl D. Risk for injury
17. Mang Edison is on bed rest has 23. Nursing management of the client
developed an ulcer that is full thickness with a UTI should include:
and is penetrating the subcutaneous
tissue. The nurse documents that this A. Taking medication until feeling
ulcer is in which of the following stages? better
B. Restricting fluids
A. Stage 1 C. Decreasing caffeine drinks and
B. Stage 2 alcohol
C. Stage 3 D. Douching daily
D. Stage 4 24. Felicia Gomez is 1 day postoperative
18. A 24 year old male patient comes to from coronary artery bypass surgery. The
the clinic after contracting genital nurse understands that a postoperative
herpes. Which of the following patient who’s maintained on bed rest is
intervention would be most appropriate? at high risk for developing:

A. Encourage him to maintain bed A. angina

rest for several days B. arterial bleeding
B. Monitor temperature every 4 hours C. deep vein thrombosis (DVT)
C. Instruct him to avoid sexual D. dehiscence of the wound
contact during acute phases of illness 25. Which of the following statement is
D. Encourage him to use antifungal true regarding the visual changes
agents regularly associated with cataracts?
19. An 8 year old boy is brought to the
trauma unit with a chemical burn to the A. Both eyes typically cataracts at the
face. Priority assessment would include same time
which of the following? B. The loss of vision is experienced as
a painless, gradual blurring
A. Skin integrity C. The patient is suddenly blind
B. BP and pulse D. The patient is typically experiences
C. Patency of airway a painful, sudden blurring of vision.
D. Amount of pain Answers and Rationales
20. A client with anemia due to
chemotherapy has a hemoglobin of 7.0 1. C. a nosocomial
g/dL. Which of the following complaints infection. Nosocomial, or hospital-
would be indicative of tissue hypoxia acquired are infections acquired
related to anemia? during hospitalization for which the
patient isn’t being primarily treated.
A. dizziness Community acquired or opportunistic
B. fatigue relieved by rest infections may not be acquired during
C. skin that is warm and dry to the hospitalization. An iatrogenic
touch infection is caused by the doctor or
D. apathy by medical therapy. And an
 opportunistic infection affects a
compromised host.
2. C. Assisting in ambulation to the
bathroom. Cerebral tissue hypoxia is
commonly associated with dizziness.
The greatest potential risk to the
client with dizziness is injury,
especially with changes in position.
Planning for periods of rest and
conserving energy are important with
someone with anemia because of his
or her fatigue level but most
important is safety.
3. C. Trachea deviating to the right. A
mediastinal shift is indicative of a
tension pneumothorax along with the
other symptoms in the question.
Since the individual was involved in a
MVA, assessment would be targeted
at acute traumatic injuries to the
lungs, heart or chest wall rather than
other conditions indicated in the
other answers. Option A is common
with pneumonia; values in option B
are not alarming; and option D is
typical of someone with COPD.
4. A. away from the body. When
opening an envelop-wrapped sterile
package, reaching across the
package and using the first motion to
open the top cover away from the
body eliminates the need to later
reach across the steri9le field while
opening the package. To remove
equipment from the package,
opening the first portion of the
package toward, to the left, or to the
right of the body would require
reaching across a sterile field.
5. B. positive homan’s sign. Pain in
the calf while pulling up on the toes is
abnormal and indicates a positive
test. If the client feels nothing or just
feels like the calf muscle is
stretching, it is considered negative.
A tourniquet test is used to measure
for varicose veins.
6. B. Alzheimer’s disease. Alzheimer’s
disease is the most common cause of
dementia in the elderly population.
AIDS, brain tumors and vascular
disease are all less common causes
of progressive loss of mental function
in elderly patients.
7. A. Apply heat compress to the
affected area. Options B, C and D are
appropriate nursing interventions
when caring for a client diagnosed
with osteomyelitis. The application of
heat can increase edema and pain in
the affected area and spread bacteria
through vasodilation.
8. D. Give the Lanoxin as ordered. The
Lanoxin should be held for a pulse of
60 bpm. Nurses cannot arbitrarily
give half of a dose without a
physician’s order. Unless specific
parameters are given concerning
pulse rate, most resources identify 60
as the reference pulse.
9. A. To avoid heavy lifting. Heavy
lifting is one factor that leads to
development of a hiatal hernia.
Dietary factors involve limiting fat
intake, not restricting client to soft
foods. It is more prevalent in
individuals who are middle-aged or
older. Fair-skinned individuals are not
prone to this condition.
10. D. asterixis. Flapping tremors
associated with hepatic
encephalophaty are asterixis.
Aphasia is the inability to speak.
Ascites is an accumulation of fluid in
the peritoneal cavity. Astacia is the
inability to stand or sit still.
11. D. counteracts the effects of
insulin. The 50% dextrose is given to
counteract the effects of insulin.
Insulin drives the potassium into the
cell, thereby lowering the serum
potassium levels. The dextrose
doesn’t directly cause potassium
excretion or any movement of
potassium.
12. B. hepatomegaly. Although option
D is correct, it is not a strong
indicator of cirrhosis. Pruritus can
occur for many reasons. Options A
and C are incorrect, fluid
accumulations is usually in the form
of ascites in the abdomen.
Hepatomegaly is an enlarged liver,
which is correct. The spleen may also
be enlarged.
13. C. severe eye and face
pain. Narrow-angle glaucoma
develops abruptly and manifests with
acute face and eye pain and is a
medial emergency. Halo vision, dull
eye pain and impaired night vision
are symptoms associated with open-
angle glaucoma.
14. A. hypoclacemia. Chvostek’s sign is
a spasm of the facial muscles elicited
by tapping the facial nerve and is
associated with hypocalcemia.
Clinical signs of hypokalemia are
muscle weakness, leg cramps,
fatigue, nausea and vomiting. Muscle
cramps, anorexia, nausea and
 vomiting are clinical signs of dissecting abdominal aneurysm are
hyponatremia. Clinical manifestations incorrect responses.
associated with hypophosphatemia 22. C. Fluid volume excess. SIADH
include muscle pain, confusion, results in fluid retention and
seizures and coma. hyponatremia. Correction is aimed at
15. B. BUN/Crea. The BUN is primarily restoring fluid and electrolyte
used as indicator of kidney function balance. Anxiety and risk for injury
because most renal diseases should be addressed following fluid
interfere with its excretion and cause volume excess.
blood vessels to rise. Creatinine is 23. C. Decreasing caffeine drinks and
produced in relatively constant alcohol. Caffeine and alcohol can
amounts, according to the amount of increase bladder spasms and
muscle mass and is excreted entirely mucosal irritation, thus increase the
by the kidneys making it a good signs and symptoms of UTI. All
indicator of renal function. antibiotics should be taken
16. B. 120 mg/dl. Hyperglycemia is completely to prevent resistant
defined as a blood glucose level strains of organisms.
greater than 120 mg/dl. Blood 24. C. deep vein thrombosis
glucose levels of 120 mg/dl, 130 (DVT). DVT, is the most probable
mg/dl and 150 mg/dl are considered complication for postoperative
hyperglycemic. A blood glucose of patients on bed rest. Options A, B and
100 mg/dl is normal. D aren’t likely complications of the
17. C. Stage 3. A stage 3 ulcer is full post operative period.
thickness involving the subcutaneous 25. B. The loss of vision is experienced
tissue. A stage 1 ulcer has a defined as a painless, gradual
area of persistent redness in lightly blurring. Typically, a patient with
pigmented skin. A stage 2 ulcer cataracts experiences painless,
involves partial thickness skin loss. gradual loss of vision. Although both
Stage 4 ulcers extend through the eyes may develop at different rates.
skin and exhibit tissue necrosis and
muscle or bone involvement.
18. C. Instruct him to avoid sexual
contact during acute phases of
illness. Herpes is a virus and is
spread through direct contact. An
antifungal would not be useful; bed
rest and temperature measurement
are usually not necessary.
19. C. Patency of airway. A burn face,
neck or chest may cause airway
closure because of the edema that
occurs within hours. Remember the
ABC’s: airway, breathing and
circulation. Airway always comes
first, even before pain. The nurse will
also assess options B and D, but
these are not the highest priority
assessments.
20. A. dizziness. Central tissue hypoxia
is commonly associated with
dizziness. Recognition of cerebral
hypoxia is critical since the body will
attempt to shunt oxygenated blood
to vital organs.
21. D. Dissecting thoracic aneurysm. A
dissecting thoracic aneurysm may
cause loss of radical pulses and
severe chest and back pain. An MI
typically doesn’t cause loss of radial
pulses or severe back pain. CVA and
 troubled by he child’s emotional illness.
The nurse’s most therapeutic initial
response would be:

A. “You may be able to lessen your

feelings of guilt by seeking
counseling”
B. “It would be helpful if you become
involved in volunteer work at this
time”
C. “I recognize it’s hard to deal with
this, but try to remember that this
too shall pass”

PNLE Exam 1 D. “Joining a support group of parents

who are coping with this problem can
be quite helpful.
1. A 10 year old who has sustained a
5. To check for wound hemorrhage after a
head injury is brought to the emergency
client has had a surgery for the removal
department by his mother. A diagnosis of
of a tumor in the neck, nurse grace
a mild concussion is made. At the time of
should:
discharge, nurse Ron should instruct the
mother to:
A. Loosen an edge of the dressing and
lift it to see the wound
A. Withhold food and fluids for 24
B. Observe the dressing at the back of
hours.
the neck for the presence of blood
B. Allow him to play outdoors with his
C. Outline the blood as it appears on
friends.
the dressing to observe any
C. Arrange for a follow up visit with
progression
the child’s primary care provider in
D. Press gently around the incision to
one week.
express accumulated blood from the
D. Check for any change in
wound
responsiveness every two hours until
6. A 16-year-old primigravida arrives at
the follow-up visit.
the labor and birthing unit in her 38th
2. A male client has suffered a motor
week of gestation and states that she is
accident and is now suffering from
labor. To verify that the client is in true
hypovolemic shock. Nurse Helen should
labor nurse Trina should:
frequency assess the client’s vital signs
during the compensatory stage of shock,
A. Obtain sides for a fern test
because:
B. Time any uterine contractions
C. Prepare her for a pelvic
A. Arteriolar constriction occurs
examination
B. The cardiac workload decreases
D. Apply nitrazine paper to moist
C. Decreased contractility of the heart
vaginal tissue
occurs
7. As part of the diagnostic workup for
D. The parasympathetic nervous
pulmonic stenosis, a child has cardiac
system is triggered
catheterization. Nurse Julius is aware that
3. A paranoid male client with
children with pulmonic stenosis have
schizophrenia is losing weight, reluctant
increased pressure:
to eat, and voicing concerns about being
poisoned. The best intervention by nurse
A. In the pulmonary vein
Dina would be to:
B. In the pulmonary artery
C. On the left side of the heart
A. Allow the client to open canned or
D. On the right side of the heart
pre-packaged food
8. An obese client asks nurse Julius how
B. Restrict the client to his room until
to lose weight. Before answering, the
2 lbs are gained
nurse should remember that long-term
C. Have a staff member personally
weight loss occurs best when:
taste all of the client’s food
D. Tell the client the food has been x-
A. Eating patterns are altered
rayed by the staff and is safe
B. Fats are limited in the diet
4. One day the mother of a young adult
C. Carbohydrates are regulated
confides to nurse Frida that she is very
 D. Exercise is a major component
9. As a very anxious female client is
talking to the nurse May, she starts
crying. She appears to be upset that she
cannot control her crying. The most
appropriate response by the nurse would
be:
A. “Is talking about your problem
upsetting you?”
B. “It is Ok to cry; I’ll just stay with
you for now”
C. “You look upset; lets talk about why
you are crying.”
D. “Sometimes it helps to get it out of
your system.”
10. A patient has partial-thickness burns
to both legs and portions of his trunk.
Which of the following I.V. fluids is given
first?
A. Albumin
B. D5W
C. Lactated Ringer’s solution
D. 0.9% sodium chloride solution with
2 mEq of potassium per 100 ml
11. During the first 48 hours after a
severe burn of 40% of the clients body
surface, the nurse’s assessment should
include observations for water
intoxication. Associated adaptations
include:
A. Sooty-colored sputum
B. Frothy pink-tinged sputum
C. Twitching and disorientation
D. Urine output below 30ml per hour
12. After a muscle biopsy, nurse Willy
should teach the client to:
A. Change the dressing as needed
B. Resume the usual diet as soon as
desired
C. Bathe or shower according to
preference
D. Expect a rise in body temperature
for 48 hours
13. Before a client whose left hand has
been amputated can be fitted for a
prosthesis, nurse Joy is aware that:
A. Arm and shoulder muscles must be
developed
B. Shrinkage of the residual limb must
be completed
C. Dexterity in the other extremity
must be achieved
D. Full adjustment to the altered body
image must have occurred
14. Nurse Cathy applies a fetal monitor
to the abdomen of a client in active labor.
When the client has contractions, the
nurse notes a 15 beat per minute
deceleration of the fetal heart rate below
the baseline lasting 15 seconds. Nurse
Cathy should:
A. Change the maternal position
B. Prepare for an immediate birth
C. Call the physician immediately
D. Obtain the client’s blood pressure
15. A male client receiving prolonged
steroid therapy complains of always
being thirsty and urinating frequently.
The best initial action by the nurse would
be to:
A. Perform a finger stick to test the
client’s blood glucose level
B. Have the physician assess the
client for an enlarged prostate
C. Obtain a urine specimen from the
client for screening purposes
D. Assess the client’s lower
extremities for the presence of pitting
edema
16. Nurse Bea recognizes that a
pacemaker is indicated when a client is
experiencing:
A. Angina
B. Chest pain
C. Heart block
D. Tachycardia
17. When administering pancrelipase
(Pancreases capsules) to child with cystic
fibrosis, nurse Faith knows they should be
given:
A. With meals and snacks
B. Every three hours while awake
C. On awakening, following meals,
and at bedtime
D. After each bowel movement and
after postural draianage
18. A preterm neonate is receiving
oxygen by an overhead hood. During the
time the infant is under the hood, it
would be appropriate for nurse Gian to:
A. Hydrate the infant q15 min
B. Put a hat on the infant’s head
C. Keep the oxygen concentration
consistent
D. Remove the infant q15 min for
stimulation
19. A client’s sputum smears for acid fast
bacilli (AFB) are positive, and
transmission-based airborne precautions
are ordered. Nurse Kyle should instruct
visitors to:
A. Limit contact with non-exposed
family members
B. Avoid contact with any objects
present in the client’s room
C. Wear an Ultra-Filter mask when
they are in the client’s room
D. Put on a gown and gloves before
going into the client’s room
20. A client with a head injury has a
fixed, dilated right pupil; responds only to
painful stimuli; and exhibits decorticate
posturing. Nurse Kate should recognize
that these are signs of:
A. Meningeal irritation
B. Subdural hemorrhage
C. Medullary compression
D. Cerebral cortex compression
21. After a lateral crushing chest injury,
obvious right-sided paradoxic motion of
the client’s chest demonstrates multiple
rib fraactures, resulting in a flail chest.
The complication the nurse should
carefully observe for would be:
A. Mediastinal shift
B. Tracheal laceration
C. Open pneumothorax
D. Pericardial tamponade
22. When planning care for a client at 30-
weeks gestation, admitted to the hospital
after vaginal bleeding secondary to
placenta previa, the nurse’s primary
objective would be:
A. Provide a calm, quiet environment
B. Prepare the client for an immediate
cesarean birth
C. Prevent situations that may
stimulate the cervix or uterus
D. Ensure that the client has regular
cervical examinations assess for
labor
23. When planning discharge teaching for
a young female client who has had a
pneumothorax, it is important that the
nurse include the signs and symptoms of
a pneumothorax and teach the client to
seek medical assistance if she
experiences:
A. Substernal chest pain
B. Episodes of palpitation
C. Severe shortness of breath
D. Dizziness when standing up
24. After a laryngectomy, the most
important equipment to place at the
client’s bedside would be:
A. Suction equipment
B. Humidified oxygen
C. A nonelectric call bell
D. A cold-stream vaporizer
25. Nurse Oliver interviews a young
female client with anorexia nervosa to
obtain information for the nursing history.
The client’s history is likely to reveal a:
A. Strong desire to improve her body
image
B. Close, supportive mother-daughter
relationship
C. Satisfaction with and desire to
maintain her present weight
D. Low level of achievement in school,
with little concerns for grades
26. Nurse Bea should plan to assist a
client with an obsessive-compulsive
disorder to control the use of ritualistic
behavior by:
A. Providing repetitive activities that
require little thought
B. Attempting to reduce or limit
situations that increase anxiety
C. Getting the client involved with
activities that will provide distraction
D. Suggesting that the client perform
menial tasks to expiate feelings of
guilt
27. A 2 ½ year old child undergoes a
ventriculoperitoneal shunt revision.
Before discharge, nurse John, knowing
the expected developmental behaviors
for this age group, should tell the parents
to call the physician if the child:
A. Tries to copy all the father’s
mannerisms
B. Talks incessantly regardless of the
presence of others
C. Becomes fussy when frustrated
and displays a shortened attention
span
D. Frequently starts arguments with
playmates by claiming all toys are
“mine”
28. A urinary tract infection is a potential
danger with an indwelling catheter. Nurse
Gina can best plan to avoid this
complication by:
A. Assessing urine specific gravity
B. Maintaining the ordered hydration
C. Collecting a weekly urine specimen
D. Emptying the drainage bag
frequently
29. A client has sustained a fractured
right femur in a fall on stairs. Nurse Troy
with the emergency response team
assess for signs of circulatory impairment
by:
A. Turning the client to side lying 35. The laboratory calls to state that a
position client’s lithium level is 1.9 mEq/L after 10
B. Asking the client to cough and days of lithium therapy. Nurse Reese
deep breathe should:
C. Taking the client’s pedal pulse in
the affected limb A. Notify the physician of the findings
D. Instructing the client to wiggle the because the level is dangerously high
toes of the right foot B. Monitor the client closely because
30. To assess orientation to place in a the level of lithium in the blood is
client suspected of having dementia of slightly elevated
the alzheimers type, nurse Chris should C. Continue to administer the
ask: medication as ordered because the
level is within the therapeutic range
A. “Where are you?” D. Report the findings to the physician
B. “Who brought you here?” so the dosage can be increased
C. “Do you know where you are?” because the level is below
D. “How long have you been there?” therapeutic range
31. Nurse Mary assesses a postpartum 36. A client has a regular 30-day
client who had an abruption placentae menstrual cycles. When teaching about
and suspects that disseminated the rhythm method, Which the client and
intravascular coagulation (DIC) is her husband have chosen to use for
occurring when assessments family planning, nurse Dianne should
demonstrate: emphasize that the client’s most fertile
days are:
A. A boggy uterus
B. Multiple vaginal clots A. Days 9 to 11
C. Hypotension and tachycardia B. Days 12 to 14
D. Bleeding from the venipuncture C. Days 15 to 17
site D. Days 18 to 20
32. When a client on labor experiences 37. Before an amniocentesis, nurse
the urge to push a 9cm dilation, the Alexandra should:
breathing pattern that nurse Rhea should
instruct the client to use is the: A. Initiate the intravenous therapy as
ordered by the physiscian
A. Expulsion pattern B. Inform the client that the procedure
B. Slow paced pattern could precipitate an infection
C. Shallow chest pattern C. Assure that informed consent has
D. blowing pattern been obtained from the client
33. Nurse Ronald should explain that the D. Perform a vaginal examination on
most beneficial between-meal snack for a the client to assess cervical dilation
client who is recovering from the full- 38. While a client is on intravenous
thickness burns would be a: magnesium sulfate therapy for
preeclampsia, it is essential for nurse
A. Cheeseburger and a malted Amy to monitor the client’s deep tendon
B. Piece of blueberry pie and milk reflexes to:
C. Bacon and tomato sandwich and
tea A. Determine her level of
D. Chicken salad sandwich and soft consciousness
drink B. Evaluate the mobility of the
34. Nurse Wilma recognizes that failure extremities
of a newborn to make the appropriate C. Determine her response to painful
adaptation to extrauterine life would be stimuli
indicated by: D. Prevent development of respiratory
distress
A. flexed extremities 39. A preschooler is admitted to the
B. Cyanotic lips and face hospital with a diagnosis of acute
C. A heart rate of 130 beats per glomerulonephritis. The child’s history
minute reveals a 5-pound weight gain in one
D. A respiratory rate of 40 breath per week and peritoneal edema. For the most
minute accurate information on the status of the
child’s edema, nursing intervention
should include:
A. Obtaining the child’s daily weight
B. Doing a visual inspection of the
child
C. Measuring the child’s intake and
output
D. Monitoring the child’s electrolyte
values
40. Nurse Mickey is administering
dexamethasome (Decadron) for the early
management of a client’s cerebral
edema. This treatment is effective
because:
A. Acts as hyperosmotic diuretic
B. Increases tissue resistance to
infection
C. Reduces the inflammatory
response of tissues
D. Decreases the information of
cerebrospinal fluid
41. During newborn nursing assessment,
a positive Ortolani’s sign would be
indicated by:
A. A unilateral droop of hip
B. A broadening of the perineum
C. An apparent shortening of one leg
D. An audible click on hip
manipulation
42. When caring for a dying client who is
in the denial stage of grief, the best
nursing approach would be to:
A. Agree and encourage the client’s
denial
B. Allow the denial but be available to
discuss death
C. Reassure the client that everything
will be OK
D. Leave the client alone to confront
the feelings of impending loss
43. To decrease the symptoms of
gastroesophageal reflux disease (GERD),
the physician orders dietary and
medication management. Nurse Helen
should teach the client that the meal
alteration that would be most
appropriate would be:
A. Ingest foods while they are hot
B. Divide food into four to six meals a
day
C. Eat the last of three meals daily by
8pm
D. Suck a peppermint candy after
each meal
44. After a mastectomy or hysterectomy,
clients may feel incomplete as women.
The statement that should alert nurse
Gina to this feeling would be:
A. “I can’t wait to see all my friends
again”
B. “I feel washed out; there isn’t much
left”
C. “I can’t wait to get home to see my
grandchild”
D. “My husband plans for me to
recuperate at our daughter’s home”
45. A client with obstruction of the
common bile duct may show a prolonged
bleeding and clotting time because:
A. Vitamin K is not absorbed
B. The ionized calcium levels falls
C. The extrinsic factor is not absorbed
D. Bilirubin accumulates in the plasma
46. Realizing that the hypokalemia is a
side effect of steroid therapy, nurse
Monette should monitor a client taking
steroid medication for:
A. Hyperactive reflexes
B. An increased pulse rate
C. Nausea, vomiting, and diarrhea
D. Leg weakness with muscle cramps
47. When assessing a newborn suspected
of having Down syndrome, nurse Rey
would expect to observe:
A. long thin fingers
B. Large, protruding ears
C. Hypertonic neck muscles
D. Simian lines on the hands
48. A 10 year old girl is admitted to the
pediatric unit for recurrent pain and
swelling of her joints, particularly her
knees and ankles. Her diagnosis is
juvenile rheumatoid arthritis. Nurse Janah
recognizes that besides joint
inflammation, a unique manifestation of
the rheumatoid process involves the:
A. Ears
B. Eyes
C. Liver
D. Brain
49. A disturbed client is scheduled to
begin group therapy. The client refuses to
attend. Nurse Lolit should:
A. Accept the client’s decision without
discussion
B. Have another client to ask the
client to consider
C. Tell the client that attendance at
the meeting is required
D. Insist that the client join the group
to help the socialization process
50. Because a severely depressed client A. “I need a lot of help with my
has not responded to any of the troubles”
antidepressant medications, the B. “Society makes people react in old
psychiatrist decides to try ways”
electroconvulsive therapy (ECT). Before C. “I decided that it’s time I own up to
the treatment the nurse should: my problems”
D. “My life needs straightening out
A. Have the client speak with other and this might help”
clients receiving ECT 55. A child visits the clinic for a 6-week
B. Give the client a detailed checkup after a tonsillectomy and
explanation of the entire procedure adenoidectomy. In addition to assessing
C. Limit the client’s intake to a light hearing, the nurse should include an
breakfast on the days of the assessment of the child’s:
treatment
D. Provide a simple explanation of the A. Taste and smell
procedure and continue to reassure B. Taste and speech
the client C. Swallowing and smell
51. Nurse Vicky is aware that teaching D. Swallowing and speech
about colostomy care is understood when 56. A client is diagnosed with cancer of
the client states, “I will contact my the jaw. A course of radiation therapy is
physician and report ____”: to be followed by surgery. The client is
concerned about the side effects related
A. If I notice a loss of sensation to to the radiation treaments. Nurse Ria
touch in the stoma tissue” should explain that the major side effects
B. When mucus is passed from the that will experienced is:
stoma between irrigations”
C. The expulsion of flatus while the A. Fatigue
irrigating fluid is running out” B. Alopecia
D. If I have difficulty in inserting the C. Vomiting
irrigating tube into the stoma” D. Leucopenia
52. The client’s history that alerts nurse 57. Nurse Katrina prepares an older-adult
Henry to assess closely for signs of client for sleep, actions are taken to help
postpartum infection would be: reduce the likelihood of a fall during the
night. Targeting the most frequent cause
A. Three spontaneous abortions of falls, the nurse should:
B. negative maternal blood type
C. Blood loss of 850 ml after a vaginal A. Offer the client assistance to the
birth bathroom
D. Maternal temperature of 99.9° F 12 B. Move the bedside table closer to
hours after delivery the client’s bed
53. A client is experiencing stomatitis as C. Encourage the client to take an
a result of chemotherapy. An appropriate available sedative
nursing intervention related to this D. Assist the client to telephone the
condition would be to: spouse to say “goodnight”
58. When evaluating a growth and
A. Provide frequent saline development of a 6 month old infant,
mouthwashes nurse Patty would expect the infant to be
B. Use karaya powder to decrease able to:
irritation
C. Increase fluid intake to compensate A. Sit alone, display pincer grasp,
for the diarrhea wave bye bye
D. Provide meticulous skin care of the B. Pull self to a standing position,
abdomen with Betadine release a toy by choice, play peek-a-
54. During a group therapy session, one boo
of the clients ask a male client with the C. Crawl, transfer toy from one hand
diagnosis of antisocial personality to the other, display of fear of
disorder why he is in the hospital. strangers
Considering this client’s type of D. Turn completely over, sit
personality disorder, the nurse might momentarily without support, reach
expect him to respond: to be picked up
59. A breastfeeding mother asks the
nurse what she can do to ease the
discomfort caused by a cracked nipple.
Nurse Tina should instruct the client to:
A. Manually express milk and feed it
to the baby in a bottle
B. Stop breastfeeding for two days to
allow the nipple to heal
C. Use a breast shield to keep the
baby from direct contact with the
nipple
D. Feed the baby on the unaffected
breast first until the affected breast
heals
60. Nurse Sandy observes that there is
blood coming from the client’s ear after
head injury. Nurse Sandy should:
A. Turn the client to the unaffected
side
B. Cleanse the client’s ear with sterile
gauze
C. Test the drainage from the client’s
ear with Dextrostix
D. Place sterile cotton loosely in the
external ear of the client
61. Nurse Gio plans a long term care for
parents of children with sickle-cell
anemia, which includes periodic group
conferences. Some of the discussions
should be directed towards:
A. Finding special school facilities for
the child
B. Making plans for moving to a more
therapeutic climate
C. Choosing a means of birth control
to avoid future pregnancies
D. Airing their feelings regarding the
transmission of the disease to the
child
62. The central problem the nurse might
face with a disturbed schizophrenic client
is the client’s:
A. Suspicious feelings
B. Continuous pacing
C. Relationship with the family
D. Concern about working with others
63. When planning care with a client
during the postoperative recovery period
following an abdominal hysterectomy
and bilateral salpingo-oophorectomy,
nurse Frida should include the
explanation that:
A. Surgical menopause will occur
B. Urinary retention is a common
problem
C. Weight gain is expected, and
dietary plan are needed
D. Depression is normal and should be
expected
64. An adolescent client with anorexia
nervosa refuses to eat, stating, “I’ll get
too fat.” Nurse Andrea can best respond
to this behavior initially by:
A. Not talking about the fact that the
client is not eating
B. Stopping all of the client’s
priviledges until food is eaten
C. Telling the client that tube feeding
will eventually be necessary
D. Pointing out to the client that death
can occur with malnutrition.
65. A pain scale is used to assess the
degree of pain. The client rates the pain
as an 8 on a scale of 10 before
medication and a 7 on a scale of 10 after
being medicated. Nurse Glenda
determines that the:
A. Client has a low pain tolerance
B. Medication is not adequately
effective
C. Medication has sufficiently
decreased the pain level
D. Client needs more education about
the use of the pain scale
66. To enhance a neonate’s behavioral
development, therapeutic nursing
measures should include:
A. Keeping the baby awake for longer
periods of time before each feeding
B. Assisting the parents to stimulate
their baby through touch, sound, and
sight.
C. Encouraging parental contact for at
least one 15-minute period every four
hours.
D. Touching and talking to the baby at
least hourly, beginning within two to
four hours after birth
67. Before formulating a plan of care for
a 6 year old boy with attention deficit
hyperactivity disorder (ADHD), nurse Kyla
is aware that the initial aim of therapy is
to help the client to:
A. Develop language skills
B. Avoid his own regressive behavior
C. Mainstream into a regular class in
school
D. Recognize himself as an
independent person of worth
68. Nurse Wally knows that the most
important aspect of the preoperative
care for a child with Wilms’ tumor would A. It involves providing home care to
be: sick people who are not confined in
the hospital
A. Checking the size of the child’s B. Services are provided free of
liver charge to people within the
B. Monitoring the child’s blood catchment area.
pressure C. The public health nurse functions
C. Maintaining the child in a prone as part of a team providing a public
position health nursing services.
D. Collecting the child’s urine for D. Public health nursing focuses on
culture and sensitivity preventive, not curative, services.
69. At 11:00 pm the count of 74. Which of the following is the mission
hydrocodone (Vicodin) is incorrect. After of the Department of Health?
several minutes of searching the
medication cart and medication A. Health for all Filipinos
administration records, no explanation B. Ensure the accessibility and quality
can be found. The primary nurse should of health care
notify the: C. Improve the general health status
of the population
A. Nursing unit manager D. Health in the hands of the Filipino
B. Hospital administrator people by the year 2020
C. Quality control manager 75. Nurse Pauline determines whether
D. Physician ordering the medication resources were maximized in
70. When caring for the a client with a implementing Ligtas Tigdas, she is
pneumothorax, who has a chest tube in evaluating:
place, nurse Kate should plan to:
A. Effectiveness
A. Administer cough suppressants at B. Efficiency
appropriate intervals as ordered C. Adequacy
B. Empty and measure the drainage D. Appropriateness
in the collection chamber each shift 76. Lissa is a B.S.N. graduate. She want
C. Apply clamps below the insertion to become a Public Health Nurse. Where
site when ever getting the client out will she apply?
of bed
D. Encourage coughing, deep A. Department of Health
breathing, and range of motion to the B. Provincial Health Office
arm on the affected side C. Regional Health Office
71. According to C.E.Winslow, which of D. Rural Health Unit
the following is the goal of Public Health? 77. As an epidemiologist, Nurse Celeste
is responsible for reporting cases of
A. For people to attain their notifiable diseases. What law mandates
birthrights of health and longevity reporting of cases of notifiable diseases?
B. For promotion of health and
prevention of disease A. Act 3573
C. For people to have access to basic B. R.A. 3753
health services C. R.A. 1054
D. For people to be organized in their D. R.A. 1082
health efforts 78. Nurse Fay is aware that isolation of a
72. What other statistic may be used to child with measles belongs to what level
determine attainment of longevity? of prevention?

A. Age-specific mortality rate A. Primary

B. Proportionate mortality rate B. Secondary
C. Swaroop’s index C. Intermediate
D. Case fatality rate D. Tertiary
73. Which of the following is the most 79. Nurse Gina is aware that the
prominent feature of public health following is an advantage of a home
nursing? visit?
A. It allows the nurse to provide A. Checking with the relative of the
nursing care to a greater number of patient
people. B. Preparing a nursing care plan in
B. It provides an opportunity to do collaboration with the patient
first hand appraisal of the home C. Consulting with the physician
situation. D. Coordinating with other members
C. It allows sharing of experiences of the team
among people with similar health 85. Nurse Tony stresses the need for all
problems. the employees to follow orders and
D. It develops the family’s initiative in instructions from him and not from
providing for health needs of its anyone else. Which of the following
members. principles does he refer to?
80. The PHN bag is an important tool in
providing nursing care during a home A. Scalar chain
visit. The most important principle of bag B. Discipline
technique states that it: C. Unity of command
D. Order
A. Should save time and effort. 86. Nurse Joey discusses the goal of the
B. Should minimize if not totally department. Which of the following
prevent the spread of infection. statements is a goal?
C. Should not overshadow concern for
the patient and his family. A. Increase the patient satisfaction
D. May be done in a variety of ways rate
depending on the home situation, B. Eliminate the incidence of delayed
etc. administration of medications
81. Nurse Willy reads about Path Goal C. Establish rapport with patients
theory. Which of the following behaviors D. Reduce response time to two
is manifested by the leader who uses this minutes
theory? 87. Nurse Lou considers shifting to
transformational leadership. Which of the
A. Recognizes staff for going beyond following statements best describes this
expectations by giving them citations type of leadership?
B. Challenges the staff to take
individual accountability for their own A. Uses visioning as the essence of
practice leadership
C. Admonishes staff for being B. Serves the followers rather than
laggards being served
D. Reminds staff about the sanctions C. Maintains full trust and confidence
for non performance in the subordinates
82. Nurse Cathy learns that some leaders D. Possesses innate charisma that
are transactional leaders. Which of the makes others feel good in his
following does NOT characterize a presence.
transactional leader? 88. Nurse Mae tells one of the staff, “I
don’t have time to discuss the matter
A. Focuses on management tasks with you now. See me in my office later”
B. Is a caretaker when the latter asks if they can talk
C. Uses trade-offs to meet goals about an issue. Which of the following
D. Inspires others with vision conflict resolution strategies did she use?
83. Functional nursing has some
advantages, which one is an EXCEPTION? A. Smoothing
B. Compromise
A. Psychological and sociological C. Avoidance
needs are emphasized. D. Restriction
B. Great control of work activities. 89. Nurse Bea plans of assigning
C. Most economical way of delivering competent people to fill the roles
nursing services. designed in the hierarchy. Which process
D. Workers feel secure in dependent refers to this?
role
84. Which of the following is the best A. Staffing
guarantee that the patient’s priority B. Scheduling
needs are met? C. Recruitment
 D. Induction 96. The use of larvivorous fish in malaria
90. Nurse Linda tries to design an control is the basis for which strategy of
organizational structure that allows malaria control?
communication to flow in all directions
and involve workers in decision making. A. Stream seeding
Which form of organizational structure is B. Stream clearing
this? C. Destruction of breeding places
D. Zooprophylaxis
A. Centralized 97. In Integrated Management of
B. Decentralized Childhood Illness, severe conditions
C. Matrix generally require urgent referral to a
D. Informal hospital. Which of the following severe
91. When documenting information in a conditions DOES NOT always require
client’s medical record, the nurse should: urgent referral to a hospital?

A. erase any errors. A. Mastoiditis

B. use a #2 pencil. B. Severe dehydration
C. leave one line blank before each C. Severe pneumonia
new entry. D. Severe febrile disease
D. end each entry with the nurse’s 98. A mother brought her daughter, 4
signature and title. years old, to the RHU because of cough
92. Which of the following factors are and colds. Following the IMCI assessment
major components of a client’s general guide, which of the following is a danger
background drug history? sign that indicates the need for urgent
referral to a hospital?
A. Allergies and socioeconomic status
B. Urine output and allergies A. Inability to drink
C. Gastric reflex and age B. High grade fever
D. Bowel habits and allergies C. Signs of severe dehydration
93. Which procedure or practice requires D. Cough for more than 30 days
surgical asepsis? 99. Food fortification is one of the
strategies to prevent micronutrient
A. Hand washing deficiency conditions. R.A. 8976
B. Nasogastric tube irrigation mandates fortification of certain food
C. I.V. cannula insertion items. Which of the following is among
D. Colostomy irrigation these food items?
94. The nurse is performing wound care
using surgical asepsis. Which of the A. Sugar
following practices violates surgical B. Bread
asepsis? C. Margarine
D. Filled milk
A. Holding sterile objects above the 100. The major sign of iron deficiency
waist anemia is pallor. What part is best
B. Pouring solution onto a sterile field examined for pallor?
cloth
C. Considering a 1″ (2.5-cm) edge A. Palms
around the sterile field contaminated B. Nailbeds
D. Opening the outermost flap of a C. Around the lips
sterile package away from the body D. Lower conjunctival sac
95. On admission, a client has the Answers and Rationales
following arterial blood gas (ABG) values:
PaO2, 50 mm Hg; PaCO2, 70 mm Hg; pH, 1. C. Check for any change in
7.20; HCO3–, 28 mEq/L. Based on these responsiveness every two hours until
values, the follow-up visit. Signs of an
the nurse should formulate which nursing epidural hematoma in children
diagnosis for this client? usually do not appear for 24 hours or
more hours; a follow-up visit usually
A. Risk for deficient fluid volume is arranged for one to two days after
B. Deficient fluid volume the injury.
C. Impaired gas exchange 2. A. Arteriolar constriction occurs.The
D. Metabolic acidosis early compensation of shock is
 cardiovascular and is seen in changes
in pulse, BP, and pulse pressure;
blood is shunted to vital centers,
particularly heart and brain.
3. A. Allow the client to open canned
or pre-packaged food. The client’s
comfort, safety, and nutritional status
are the priorities; the client may feel
comfortable to eat if the food has
been sealed before reaching the
mental health facility.
4. D. “Joining a support group of
parents who are coping with this
problem can be quite helpful. Taking
with others in similar circumstances
provides support and allows for
sharing of experiences.
5. B. Observe the dressing at the back
of the neck for the presence of
blood. Drainage flows by gravity.
6. C. Prepare her for a pelvic
examination. Pelvic examination
would reveal dilation and effacement
7. D. On the right side of the
heart. Pulmonic stenosis increases
resistance to blood flow, causing right
ventricular hyperthropy; with right
ventricular failure there is an increase
in pressure on the right side of the
heart.
8. A. Eating patterns are altered. A
new dietary regimen, with a balance
of foods from the food pyramid, must
be established and continued for
weight reduction to occur and be
maintained.
9. B. “It is Ok to cry; I’ll just stay with
you for now”. This portrays a
nonjudgmental attitude that
recognizes the client’s needs.
10. C. Lactated Ringer’s
solution. Lactated Ringer’s solution
replaces lost sodium and corrects
metabolic acidosis, both of which
commonly occur following a burn.
Albumin is used as adjunct therapy,
not primary fluid replacement.
Dextrose isn’t given to burn patients
during the first 24 hours because it
can cause pseudodiabetes. The
patient is hyperkalemic from the
potassium shift from the intracellular
space to the plasma, so potassium
would be detrimental.
11. C. Twitching and
disorientation. Excess extracellular
fluid moves into cells (water
intoxication); intracellular fluid excess
in sensitive brain cells causes altered
mental status; other signs include
anorexia nervosa, nausea, vomiting,
twitching, sleepiness, and
convulsions.
12. B. Resume the usual diet as soon
as desired. As long as the client has
no nausea or vomiting, there are no
dietary restriction.
13. B. Shrinkage of the residual limb
must be completed. Shrinkage of the
residual limb, resulting from
reduction of subcutaneous fat and
interstitial fluid, must occur for an
adequate fit between the limb and
the prosthesis.
14. A. Change the maternal
position. Stimulation of the
sympathetic nervous system is an
initial response to mild hypoxia that
accompanies partial cord
compression (umbilical vein) during
contractions; changing the maternal
position can alleviate the
compression.
15. A. Perform a finger stick to test the
client’s blood glucose level. The client
has signs of diabetes, which may
result from steroid therapy, testing
the blood glucose level is a method of
screening for diabetes, thus
gathering more data.
16. C. Heart block. This is the primary
indication for a pacemaker because
there is an interfere with the
electrical conduction system of the
heart.
17. A. With meals and
snacks. Pancreases capsules must be
taken with food and snacks because
it acts on the nutrients and readies
them for absorption.
18. B. Put a hat on the infant’s
head. Oxygen has cooling effect, and
the baby should be kept warm so that
metabolic activity and oxygen
demands are not increased.
19. C. Wear an Ultra-Filter mask when
they are in the client’s room. Tubercle
bacilli are transmitted through air
currents; therefore personal
protective equipment such as an
Ultra-Filter mask is necessary.
20. D. Cerebral cortex
compression. Cerebral compression
affects pyramidal tracts, resulting in
decorticate rigidity and cranial nerve
injury, which cause pupil dilation.
21. A.Mediastinal shift. Mediastinal
structures move toward the uninjured
lung, reducing oxygenation and
venous return.
22. C. Prevent situations that may
stimulate the cervix or
 uterus. Stimulation of the cervix or
uterus may cause bleeding or
hemorrhage and should be avoided.
23. C. Severe shortness of breath. This
could indicate a recurrence of the
pneumothorax as one side of the lung
is inadequate to meet the oxygen
demands of the body.
24. A. Suction equipment. Respiratory
complications can occur because of
edema of the glottis or injury to the
recurrent laryngeal nerve.
25. A. Strong desire to improve her
body image. Clients with anorexia
nervosa have a disturbed self image
and always see themselves as fat
and needing further reducing.
26. B. Attempting to reduce or limit
situations that increase
anxiety. Persons with high anxiety
levels develop various behaviors to
relieve their anxiety; by reducing
anxiety, the need for these
obsessive-compulsive action is
reduced.
27. C. Becomes fussy when frustrated
and displays a shortened attention
span. Shortened attention span and
fussy behavior may indicate a change
in intracranial pressure and/or shunt
malfunction.
28. B. Maintaining the ordered
hydration. Promoting hydration
maintains urine production at a
higher rate, which flushes the bladder
and prevents urinary stasis and
possible infection.
29. C. Taking the client’s pedal pulse in
the affected limb. Monitoring a pedal
pulse will assess circulation to the
foot.
30. A. “Where are you?”. “Where are
you?” is the best question to elicit
information about the client’s
orientation to place because it
encourages a response that can be
assessed.
31. D. Bleeding from the venipuncture
site. This indicates a fibrinogenemia;
massive clotting in the area of the
separation has resulted in a lowered
circulating fibrinogen.
32. D. blowing pattern. Clients should
use a blowing pattern to overcome
the premature urge to push.
33. A. Cheeseburger and a malted. Of
the selections offered, this is the
highest in calories and protein, which
are needed for increased basal
metabolic rate and for tissue repair.
34. B. Cyanotic lips and face. Central
cyanosis (blue lips and face) indicates
lowered oxygenation of the blood,
caused by either decreased lung
expansion or right to left shunting of
blood.
35. A. Notify the physician of the
findings because the level is
dangerously high. Levels close to 2
mEq/L are dangerously close to the
toxic level; immediate action must be
taken.
36. C. Days 15 to 17. Ovulation occurs
approximately 14 days before the
next menses, about the 16th day in
30 day cycle; the 15th to 17th days
would be the best time to avoid
sexual intercourse.
37. C. Assure that informed consent
has been obtained from the client. An
invasive procedure such as
amniocentesis requires informed
consent.
38. D. Prevent development of
respiratory distress. Respiratory
distress or arrest may occur when the
serum level of magnesium sulfate
reaches 12 to 15 mg/dl; deep tendon
reflexes disappear when the serum
level is 10 to 12 mg/dl; the drug is
withheld in the absence of deep
tendon reflexes; the therapeutic
serum level is 5 to 8 mg/dl.
39. A. Obtaining the child’s daily
weight. Weight monitoring is the
most useful means of assessing fluid
balance and changes in the
edematous state; 1 liter of fluid
weighs about 2.2 pounds.
40. C. Reduces the inflammatory
response of tissues. Corticosteroids
act to decrease inflammation which
decreases edema.
41. D. An audible click on hip
manipulation. With specific
manipulation, an audible click may be
heard of felt as he femoral head slips
into the acetabulum.
42. B. Allow the denial but be available
to discuss death. This does not
remove client’s only way of coping,
and it permits future movement
through the grieving process when
the client is ready.
43. B. Divide food into four to six meals
a day. The volume of food in the
stomach should be kept small to limit
pressure on the cardiac sphincter.
44. B. “I feel washed out; there isn’t
much left”. The client’s statement
 infers an emptiness with an
associated loss.
45. A. Vitamin K is not
absorbed. Vitamin K, a fat soluble
vitamin, is not absorbed from the GI
tract in the absence of bile; bile
enters the duodenum via the
common bile duct.
46. D. Leg weakness with muscle
cramps. Impulse conduction of
skeletal muscle is impaired with
decreased potassium levels,
muscular weakness and cramps may
occur with hypokalemia.
47. D. Simian lines on the hands. This
is characteristic finding in newborns
with Down syndrome.
48. B. Eyes. Rheumatoid arthritis can
cause inflammation of the iris and
ciliary body of the eyes which may
lead to blindness.
49. A. Accept the client’s decision
without discussion. This is all the
nurse can do until trust is
established; facing the client to
attend will disrupt the group.
50. D. Provide a simple explanation of
the procedure and continue to
reassure the client. The nurse should
offer support and use clear, simple
terms to allay client’s anxiety.
51. D. If I have difficulty in inserting the
irrigating tube into the stoma”. This
occurs with stenosis of the stoma;
forcing insertion of the tube could
cause injury.
52. C. Blood loss of 850 ml after a
vaginal birth. Excessive blood loss
predisposes the client to an increased
risk of infection because of decreased
maternal resistance; they expected
blood loss is 350 to 500 ml.
53. A. Provide frequent saline
mouthwashes. This is soothing to the
oral mucosa and helps prevent
infection.
54. B. “Society makes people react in
old ways”. The client is incapable of
accepting responsibility for self-
created problems and blames society
for the behavior.
55. A. Taste and smell. Swelling can
obstruct nasal breathing, interfering
with the senses of taste and smell.
56. A. Fatigue. Fatigue is a major
problem caused by an increase in
waste products because of catabolic
processes.
57. A. Offer the client assistance to the
bathroom. Statistics indicate that the
most frequent cause of falls by
hospitalized clients is getting up or
attempting to get up to the bathroom
unassisted.
58. D. Turn completely over, sit
momentarily without support, reach
to be picked up. These abilities are
age-appropriate for the 6 month old
child.
59. D. Feed the baby on the unaffected
breast first until the affected breast
heals. The most vigorous sucking will
occur during the first few minutes of
breastfeeding when the infant would
be on the unaffected breast; later
suckling is less traumatic.
60. D. Place sterile cotton loosely in
the external ear of the client. This
would absorb the drainage without
causing further trauma.
61. D. Airing their feelings regarding
the transmission of the disease to the
child. Discussion with parents who
have children with similar problems
helps to reduce some of their
discomfort and guilt.
62. A. Suspicious feelings. The nurse
must deal with these feelings and
establish basic trust to promote a
therapeutic milieu.
63. A. Surgical menopause will
occur. When a bilateral oophorectomy
is performed, both ovaries are
excised, eliminating ovarian
hormones and initiating response.
64. D. Pointing out to the client that
death can occur with
malnutrition. The client expects the
nurse to focus on eating, but the
emphasis should be placed on
feelings rather than actions.
65. B. Medication is not adequately
effective. The expected effect should
be more than a one point decrease in
the pain level.
66. B. Assisting the parents to
stimulate their baby through touch,
sound, and sight. Stimuli are provided
via all the senses; since the infant’s
behavioral development is enhanced
through parent-infant interactions,
these interactions should be
encouraged.
67. D. Recognize himself as an
independent person of
worth. Academic deficits, an inability
to function within constraints
required of certain settings, and
negative peer attitudes often lead to
low self-esteem.
68. B. Monitoring the child’s blood
pressure. Because the tumor is of
 renal origin, the rennin angiotensin
mechanism can be involved, and
blood pressure monitoring is
important.
69. A. Nursing unit manager. Controlled
substance issues for a particular
nursing unit are the responsibility of
that unit’s nurse manager.
70. D. Encourage coughing, deep
breathing, and range of motion to the
arm on the affected side. All these
interventions promote aeration of the
re-expanding lung and maintenance
of function in the arm and shoulder
on the affected side.
71. A. For people to attain their
birthrights of health and
longevity. According to Winslow, all
public health efforts are for people to
realize their birthrights of health and
longevity.
72. C. Swaroop’s index. Swaroop’s
index is the percentage of the deaths
aged 50 years or older. Its inverse
represents the percentage of
untimely deaths (those who died
younger than 50 years).
73. D. Public health nursing focuses on
preventive, not curative,
services.. The catchment area in PHN
consists of a residential community,
many of whom are well individuals
who have greater need for preventive
rather than curative services.
74. B. Ensure the accessibility and
quality of health care. Ensuring the
accessibility and quality of health
care is the primary mission of DOH.
75. B. Efficiency. Efficiency is
determining whether the goals were
attained at the least possible cost.
76. D. Rural Health Unit. R.A. 7160
devolved basic health services to
local government units (LGU’s ). The
public health nurse is an employee of
the LGU.
77. A. Act 3573. Act 3573, the Law on
Reporting of Communicable Diseases,
enacted in 1929, mandated the
reporting of diseases listed in the law
to the nearest health station.
78. A. Primary. The purpose of isolating
a client with a communicable disease
is to protect those who are not sick
(specific disease prevention).
79. B. It provides an opportunity to do
first hand appraisal of the home
situation. Choice A is not correct
since a home visit requires that the
nurse spend so much time with the
family. Choice C is an advantage of a
group conference, while choice D is
true of a clinic consultation.
80. B. Should minimize if not totally
prevent the spread of infection. Bag
technique is performed before and
after handling a client in the home to
prevent transmission of infection to
and from the client.
81. A. Recognizes staff for going
beyond expectations by giving them
citations. Path Goal theory according
to House and associates rewards
good performance so that others
would do the same.
82. D. Inspires others with
vision. Inspires others with a vision is
characteristic of a transformational
leader. He is focused more on the
day-to-day operations of the
department/unit.
83. A. Psychological and sociological
needs are emphasized. When the
functional method is used, the
psychological and sociological needs
of the patients are neglected; the
patients are regarded as ‘tasks to be
done”
84. B. Preparing a nursing care plan in
collaboration with the patient. The
best source of information about the
priority needs of the patient is the
patient himself. Hence using a
nursing care plan based on his
expressed priority needs would
ensure meeting his needs effectively.
85. C. Unity of command. The principle
of unity of command means that
employees should receive orders
coming from only one manager and
not from two managers. This averts
the possibility of sowing confusion
among the members of the
organization.
86. A. Increase the patient satisfaction
rate. Goal is a desired result towards
which efforts are directed. Options
AB, C and D are all objectives which
are aimed at specific end.
87. A. Uses visioning as the essence of
leadership. Transformational
leadership relies heavily on visioning
as the core of leadership.
88. C. Avoidance. This strategy shuns
discussing the issue head-on and
prefers to postpone it to a later time.
In effect the problem remains
unsolved and both parties are in a
lose-lose situation.
89. A. Staffing. Staffing is a
management function involving
putting the best people to accomplish
 tasks and activities to attain the
goals of the organization.
90. B. Decentralized. Decentralized
structures allow the staff to make
decisions on matters pertaining to
their practice and communicate in
downward, upward, lateral and
diagonal flow.
91. D. end each entry with the nurse’s
signature and title. The end of each
entry should include the nurse’s
signature and title; the signature
holds the nurse accountable for the
recorded information. Erasing errors
in documentation on a legal
document such as a client’s chart
isn’t permitted by law. Because a
client’s medical record is considered
a legal document, the nurse should
make all entries in ink. The nurse is
accountable for the information
recorded and therefore shouldn’t
leave any blank lines in which
another health care worker could
make additions.
92. A. Allergies and socioeconomic
status. General background data
consist of such components as
allergies, medical history, habits,
socioeconomic status, lifestyle,
beliefs, and sensory deficits. Urine
output, gastric reflex, and bowel
habits are significant only if a disease
affecting these functions is present.
93. C. I.V. cannula insertion. Caregivers
must use surgical asepsis when
performing wound care or any
procedure in which a sterile body
cavity is entered or skin integrity is
broken. To achieve surgical asepsis,
objects must be rendered or kept free
of all pathogens. Inserting an I.V.
cannula requires surgical asepsis
because it disrupts skin integrity and
involves entry into a sterile cavity (a
vein). The other options are used to
ensure medical asepsis or clean
technique to prevent the spread of
infection. The GI tract isn’t sterile;
therefore, irrigating a nasogastric
tube or a colostomy requires only
clean technique.
94. B. Pouring solution onto a sterile
field cloth. Pouring solution onto a
sterile field cloth violates surgical
asepsis because moisture
penetrating the cloth can carry
microorganisms to the sterile field via
capillary action. The other options are
practices that help ensure surgical
asepsis.
95. C. Impaired gas exchange. The
client has a below-normal value for
the partial pressure of arterial oxygen
(PaO2) and an above-normal value
for the partial pressure of arterial
carbon dioxide (PaCO2), supporting
the nursing diagnosis of Impaired gas
exchange. ABG values can’t indicate
a diagnosis of Fluid volume deficit (or
excess) or Risk for deficient fluid
volume. Metabolic acidosis is a
medical, not nursing, diagnosis; in
any event, these ABG values indicate
respiratory, not metabolic, acidosis.
96. A. Stream seeding. Stream seeding
is done by putting tilapia fry in
streams or other bodies of water
identified as breeding places of the
Anopheles mosquito.
97. B. Severe dehydration. The order of
priority in the management of severe
dehydration is as follows: intravenous
fluid therapy, referral to a facility
where IV fluids can be initiated within
30 minutes, Oresol/nasogastric tube,
Oresol/orem. When the foregoing
measures are not possible or
effective, tehn urgent referral to the
hospital is done.
98. A. Inability to drink. A sick child
aged 2 months to 5 years must be
referred urgently to a hospital if
he/she has one or more of the
following signs: not able to feed or
drink, vomits everything, convulsions,
abnormally sleepy or difficult to
awaken.
99. A. Sugar. R.A. 8976 mandates
fortification of rice, wheat flour, sugar
and cooking oil with Vitamin A, iron
and/or iodine.
100. A. Palms. The anatomic
characteristics of the palms allow a
reliable and convenient basis for
examination for pallor.
 B. Incubation period is 1 week
C. Incubation period is 1 month
D. Incubation period varies
depending on the site of the bite

4. Which of the following should Nurse

Cherry do first in taking care of a male
client with rabies?

A. Encourage the patient to take a

bath
B. Cover IV bottle with brown
paper bag
C. Place the patient near the comfort
room
D. Place the patient near the door

5. Which of the following is the screening

test for dengue hemorrhagic fever?

A. Complete blood count

B. ELISA
C. Rumpel-leede test
D. Sedimentation rate

PNLE Exam 2 6. Mr. Dela Rosa is suspected to have

1. A woman in a child bearing age malaria after a business trip in Palawan.
receives a rubella vaccination. Nurse Joy The most important diagnostic test in
would give her which of the following malaria is:
instructions?
A. WBC count
A. Refrain from eating eggs or egg B. Urinalysis
products for 24 hours C. ELISA
B. Avoid having sexual intercourse D. Peripheral blood smear
C. Don’t get pregnant at least 3
months
D. Avoid exposure to sun 7. The Nurse supervisor is planning for
patient’s assignment for the AM shift.
The nurse supervisor avoids assigning
2. Jonas who is diagnosed with which of the following staff members to a
encephalitis is under the treatment of client with herpes zoster?
Mannitol. Which of the following patient
outcomes indicate to Nurse Ronald that A. Nurse who never had chicken
the treatment of Mannitol has been pox
effective for a patient that has increased B. Nurse who never had roseola
intracranial pressure? C. Nurse who never had german
measles
A. Increased urinary output D. Nurse who never had mumps
B. Decreased RR
C. Slowed papillary response
D. Decreased level of consciousness 8. Clarissa is 7 weeks pregnant. Further
examination revealed that she is
susceptible to rubella. When would be
3. Mary asked Nurse Maureen about the the most appropriate for her to receive
incubation period of rabies. Which rubella immunization?
statement by the Nurse Maureen is
appropriate? A. At once
B. During 2nd trimester
A. Incubation period is 6 months C. During 3rd trimester
D. After the delivery of the baby 15. Which is the primary characteristic
lesion of syphilis?

9. A female child with rubella should be A. Sore eyes

isolated from a: B. Sore throat
C. Chancroid
A. 21 year old male cousin living in D. Chancre
the same house 16. What is the fast breathing of Jana
B. 18 year old sister who recently who is 3 weeks old?
got married
C. 11 year old sister who had rubeola A. 60 breaths per minute
during childhood B. 40 breaths per minute
D. 4 year old girl who lives next door C. 10 breaths per minute
D. 20 breaths per minute
10. What is the primary prevention of 17. Which of the following signs and
leprosy? symptoms indicate some dehydration?

A. Nutrition A. Drinks eagerly

B. Vitamins B. Restless and irritable
C. BCG vaccination C. Unconscious
D. DPT vaccination D. A and B
11. A bacteria which causes diphtheria is 18. What is the first line for dysentery?
also known as?
A. Amoxicillin
A. Amoeba B. Tetracycline
B. Cholera C. Cefalexin
C. Klebs-loeffler bacillus D. Cotrimoxazole
D. Spirochete 19. In home made oresol, what is the
12. Nurse Ron performed mantoux skin ratio of salt and sugar if you want to
test today (Monday) to a male adult prepare with 1 liter of water?
client. Which statement by the client
indicates that he understood the A. 1 tbsp. salt and 8 tbsp. sugar
instruction well? B. 1 tbsp. salt and 8 tsp. sugar
C. 1 tsp. salt and 8 tsp. sugar
A. I will come back later D. 8 tsp. salt and 8 tsp. sugar
B. I will come back next month 20. Gentian Violet is used for:
C. I will come back on Friday
D. I will come back on Wednesday, A. Wound
same time, to read the result B. Umbilical infections
13. A male client had undergone C. Ear infections
Mantoux skin test. Nurse Ronald notes an D. Burn
8mm area of indurations at the site of 21. Which of the following is a live
the skin test. The nurse interprets the attenuated bacterial vaccine?
result as:
A. BCG
A. Negative B. OPV
B. Uncertain and needs to be C. Measles
repeated D. None of the above
C. Positive 22. EPI is based on?
D. Inconclusive
14. Tony will start a 6 month therapy with A. Basic health services
Isoniazid (INH). Nurse Trish plans to teach B. Scope of community affected
the client to: C. Epidemiological situation
D. Research studies
A. Use alcohol moderately 23. TT? provides how many percentage
B. Avoid vitamin supplements while o of protection against tetanus?
therapy
C. Incomplete intake of dairy products A. 100
D. May be discontinued if symptoms B. 99
subsides C. 80
D. 90
24. Temperature of refrigerator to A. Survey
maintain potency of measles and OPV B. Close ended
vaccine is: C. Questionnaire
D. Demographic
A. -3c to -8c 33. A researcher that makes a
B. -15c to -25c generalization based on observations of
C. +15c to +25c an individuals behavior is said to be
D. +3c to +8c which type of reasoning:
25. Diptheria is a:
A. Inductive
A. Bacterial toxin B. Logical
B. Killed bacteria C. Illogical
C. Live attenuated D. Deductive
D. Plasma derivatives 34. The balance of a research’s benefit
26. Budgeting is under in which part of vs. its risks to the subject is:
management process?
A. Analysis
A. Directing B. Risk-benefit ratio
B. Controlling C. Percentile
C. Organizing D. Maximum risk
D. Planning 35. An individual/object that belongs to a
27. Time table showing planned work general population is a/an:
days and shifts of nursing personnel is:
A. Element
A. Staffing B. Subject
B. Schedule C. Respondent
C. Scheduling D. Author
D. Planning 36. An illustration that shows how the
28. A force within an individual that members of an organization are
influences the strength of behavior? connected:

A. Motivation A. Flowchart
B. Envy B. Bar graph
C. Reward C. Organizational chart
D. Self-esteem D. Line graph
29. “To be the leading hospital in the 37. The first college of nursing that was
Philippines” is best illustrate in: established in the Philippines is:

A. Mission A. Fatima University

B. Philosophy B. Far Eastern University
C. Vision C. University of the East
D. Objective D. University of Sto. Tomas
30. It is the professionally desired norms 38. Florence nightingale is born on:
against which a staff performance will be
compared? A. France
B. Britain
A. Job descriptions C. U.S
B. Survey D. Italy
C. Flow chart 39. Objective data is also called:
D. Standards
31. Reprimanding a staff nurse for work A. Covert
that is done incorrectly is an example of B. Overt
what type of reinforcement? C. Inference
D. Evaluation
A. Feedback 40. An example of subjective data is:
B. Positive reinforcement
C. Performance appraisal A. Size of wounds
D. Negative reinforcement B. VS
32. Questions that are answerable only C. Lethargy
by choosing an option from a set of given D. The statement of patient “My hand
alternatives are known as? is painful”
41. What is the best position in palpating C. Impaired urinary elimination
the breast? related to fluid loss
D. Risk for infection related to
A. Trendelenburg epidermal disruption
B. Side lying 49. In assessing a client’s incision 1 day
C. Supine after the surgery, Nurse Betty expect to
D. Lithotomy see which of the following as signs of a
42. When is the best time in performing local inflammatory response?
breast self examination?
A. Greenish discharge
A. 7 days after menstrual period B. Brown exudates at incision edges
B. 7 days before menstrual period C. Pallor around sutures
C. 5 days after menstrual period D. Redness and warmth
D. 5 days before menstrual period 50. Nurse Ronald is aware that the
43. Which of the following should be amiotic fluid in the third trimester weighs
given the highest priority before approximately:
performing physical examination to a
patient? A. 2 kilograms
B. 1 kilograms
A. Preparation of the room C. 100 grams
B. Preparation of the patient D. 1.5 kilograms
C. Preparation of the nurse 51. After delivery of a baby girl. Nurse
D. Preparation of environment Gina examines the umbilical cord and
44. It is a flip over card usually kept in expects to find a cord to:
portable file at nursing station.
A. Two arteries and two veins
A. Nursing care plan B. One artery and one vein
B. Medicine and treatment record C. Two arteries and one vein
C. Kardex D. One artery and two veins
D. TPR sheet 52. Myrna a pregnant client reports that
45. Jose has undergone thoracentesis. her last menstrual cycle is July 11, her
The nurse in charge is aware that the expected date of birth is
best position for Jose is:
A. November 4
A. Semi fowlers B. November 11
B. Low fowlers C. April 4
C. Side lying, unaffected side D. April 18
D. Side lying, affected side 53. Which of the following is not a good
46. The degree of patients abdominal source of iron?
distension may be determined by: A. Butter
B. Pechay
A. Auscultation C. Grains
B. Palpation D. Beef
C. Inspection 54. Maureen is admitted with a diagnosis
D. Percussion of ectopic pregnancy. Which of the
47. A male client is addicted with following would you anticipate?
hallucinogen. Which physiologic effect
should the nurse expect? A. NPO
B. Bed rest
A. Bradyprea C. Immediate surgery
B. Bradycardia D. Enema
C. Constricted pupils 55. Gina a postpartum client is diagnosed
D. Dilated pupils with endometritis. Which position would
48. Tristan a 4 year old boy has suffered you expect to place her based on this
from full thickness burns of the face, diagnosis?
chest and neck. What will be the priority
nursing diagnosis? A. Supine
B. Left side lying
A. Ineffective airway clearance related C. Trendelinburg
to edema D. Semi-fowlers
B. Impaired mobility related to pain
56. Nurse Hazel knows that Myrna
understands her condition well when she
remarks that urinary frequency is caused
by:
A. Pressure caused by the ascending
uterus
B. Water intake of 3L a day
C. Effect of cold weather
D. Increase intake of fruits and
vegetables
57. How many ml of blood is loss during
the first 24 hours post delivery of Myrna?
100
500
200
400
58. Which of the following hormones
stimulates the secretion of milk?
Progesterone
Prolactin
Oxytocin
Estrogen
59. Nurse Carla is aware that Myla’s
second stage of labor is beginning when
the following assessment is noted:
Bay of water is broken
Contractions are regular
Cervix is completely dilated
Presence of bloody show
60. The leaking fluid is tested with
nitrazine paper. Nurse Kelly confirms that
the client’s membrane have ruptures
when the paper turns into a:
Pink
Violet
Green
Blue
61. After amniotomy, the priority nursing
action is:
Document the color and consistency
of amniotic fluid
Listen the fetal heart tone
Position the mother in her left side
Let the mother rest
62. Which is the most frequent reason for
postpartum hemorrhage?
Perineal lacerations
Frequent internal examination (IE)
CS
Uterine atomy
63. On 2nd postpartum day, which height
would you expect to find the fundus in a
woman who has had a caesarian birth?
1 finger above umbilicus
2 fingers above umbilicus
2 fingers below umbilicus
1 finger below umbilicus
64. Which of the following criteria allows
Nurse Kris to perform home deliveries?
Normal findings during assessment
Previous CS
Diabetes history
Hypertensive history
65. Nurse Carla is aware that one of the
following vaccines is done by
intramuscular (IM) injection?
Measles
OPV
BCG
Tetanus toxoid
66. Asin law is on which legal basis:
RA 8860
RA 2777
RI 8172
RR 6610
67. Nurse John is aware that the herbal
medicine appropriate for urolithiasis is:
Akapulco
Sambong
Tsaang gubat
Bayabas
68. Community/Public health bag is
defined as:
An essential and indispensable
equipment of the community health
nurse during home visit
It contains drugs and equipment used
by the community health nurse
Is a requirement in the health center
and for home visit
It is a tool used by the community
health nurse in rendering effective
procedures during home visit
69. TT4 provides how many percentage
of protection against tetanus?
70
80
90
99
70. Third postpartum visit must be done
by public health nurse:
Within 24 hours after delivery
After 2-4 weeks
Within 1 week
After 2 months
71. Nurse Candy is aware that the family
planning method that may give 98%
protection to another pregnancy to Sheltered workshop
women Custodial
Educational
Pills 79. Nurse Judy is aware that following
Tubal ligation condition would reflect presence of
Lactational Amenorrhea method congenital G.I anomaly?
(LAM)
IUD Cord prolapse
72. Which of the following is not a part of Polyhydramios
IMCI case management process Placenta previa
Oligohydramios
Counsel the mother 80. Nurse Christine provides health
Identify the illness teaching for the parents of a child
Assess the child diagnosed with celiac disease. Nurse
Treat the child Christine teaches the parents to include
73. If a young child has pneumonia when which of the following food items in the
should the mother bring him back for child’s diet:
follow up?
Rye toast
After 2 days Oatmeal
In the afternoon White bread
After 4 days Rice
After 5 days 81. Nurse Randy is planning to
74. It is the certification recognition administer oral medication to a 3 year
program that develop and promotes old child. Nurse Randy is aware that the
standard for health facilities: best way to proceed is by:

Formula “Would you like to drink your

Tutok gamutan medicine?”
Sentrong program movement “If you take your medicine now, I’ll
Sentrong sigla movement give you lollipop”
75. Baby Marie was born May 23, 1984. “See the other boy took his
Nurse John will expect finger thumb medicine? Now it’s your turn.”
opposition on: “Here’s your medicine. Would you like
a mango or orange juice?”
April 1985 82. At what age a child can brush her
February 1985 teeth without help?
March 1985
June 1985 6 years
76. Baby Reese is a 12 month old child. 7 years
Nurse Oliver would anticipate how many 5 years
teeth? 8 years
83. Ribivarin (Virazole) is prescribed for a
9 female hospitalized child with RSV. Nurse
7 Judy prepare this medication via which
8 route?
6
77. Which of the following is the primary Intra venous
antidote for Tylenol poisoning? Oral
Oxygen tent
Narcan Subcutaneous
Digoxin 84. The present chairman of the Board of
Acetylcysteine Nursing in the Philippines is:
Flumazenil
78. A male child has an intelligence Maria Joanna Cervantes
quotient of approximately 40. Which kind Carmencita Abaquin
of environment and interdisciplinary Leonor Rosero
program most likely to benefit this child Primitiva Paquic
would be best described as: 85. The obligation to maintain efficient
ethical standards in the practice of
Habit training nursing belong to this body:
 BON 93. Which of the following is formal
ANSAP continuing education?
PNA
RN Conference
86. A male nurse was found guilty of Enrollment in graduate school
negligence. His license was revoked. Re- Refresher course
issuance of revoked certificates is after Seminar
how many years? 94. The BSN curriculum prepares the
graduates to become?
1 year
2 years Nurse generalist
3 years Nurse specialist
4 years Primary health nurse
87. Which of the following information Clinical instructor
cannot be seen in the PRC identification 95. Disposal of medical records in
card? government hospital/institutions must be
done in close coordination with what
Registration Date agency?
License Number
Date of Application Department of Health
Signature of PRC chairperson Records Management Archives Office
88. Breastfeeding is being enforced by Metro Manila Development Authority
milk code or: Bureau of Internal Revenue
96. Nurse Jolina must see to it that the
EO 51 written consent of mentally ill patients
R.A. 7600 must be taken from:
R.A. 6700
P.D. 996 Nurse
89. Self governance, ability to choose or Priest
carry out decision without undue Family lawyer
pressure or coercion from anyone: Parents/legal guardians
97. When Nurse Clarence respects the
Veracity client’s self-disclosure, this is a gauge for
Autonomy the nurses’
Fidelity
Beneficence Respectfulness
90. A male patient complained because Loyalty
his scheduled surgery was cancelled Trustworthiness
because of earthquake. The hospital Professionalism
personnel may be excused because of: 98. The Nurse is aware that the following
tasks can be safely delegated by the
Governance nurse to a non-nurse health worker
Respondent superior except:
Force majeure
Res ipsa loquitor Taking vital signs
91. Being on time, meeting deadlines Change IV infusions
and completing all scheduled duties is Transferring the client from bed to
what virtue? chair
Irrigation of NGT
Fidelity 99. During the evening round Nurse Tina
Autonomy saw Mr. Toralba meditating and
Veracity afterwards started singing prayerful
Confidentiality hymns. What would be the best response
92. This quality is being demonstrated by of Nurse Tina?
Nurse Ron who raises the side rails of a
confused and disoriented patient? Call the attention of the client and
encourage to sleep
Responsibility Report the incidence to head nurse
Resourcefulness Respect the client’s action
Autonomy Document the situation
Prudence
100. In caring for a dying client, you
should perform which of the following
activities
Do not resuscitate
Assist client to perform ADL
Encourage to exercise
Assist client towards a peaceful death
101. The Nurse is aware that the ability
to enter into the life of another person
and perceive his current feelings and
their meaning is known:
Belongingness
Genuineness
Empathy
Respect
102. The termination phase of the NPR is
best described one of the following:
Review progress of therapy and
attainment of goals
Exploring the client’s thoughts,
feelings and concerns
Identifying and solving patients
problem
Establishing rapport
103. During the process of cocaine
withdrawal, the physician orders which of
the following:
Haloperidol (Haldol)
Imipramine (Tofranil)
Benztropine (Cogentin)
Diazepam (Valium)
104. The nurse is aware that cocaine is
classified as:
Hallucinogen
Psycho stimulant
Anxiolytic
Narcotic
105. In community health nursing, it is
the most important risk factor in the
development of mental illness?
Separation of parents
Political problems
Poverty
Sexual abuse
106. All of the following are
characteristics of crisis except
The client may become resistive and
active in stopping the crisis
It is self-limiting for 4-6 weeks
It is unique in every individual
It may also affect the family of the
client
107. Freud states that temper tantrums
is observed in which of the following:
Oral
Anal
Phallic
Latency
108. The nurse is aware that ego
development begins during:
Toddler period
Preschool age
School age
Infancy
109. Situation: A 19 year old nursing
student has lost 36 lbs for 4 weeks. Her
parents brought her to the hospital for
medical evaluation. The diagnosis was
ANOREXIA NERVOSA. The Primary gain of
a client with anorexia nervosa is:
Weight loss
Weight gain
Reduce anxiety
Attractive appearance
110. The nurse is aware that the primary
nursing diagnosis for the client is:
Altered nutrition : less than body
requirement
Altered nutrition : more than body
requirement
Impaired tissue integrity
Risk for malnutrition
111. After 14 days in the hospital, which
finding indicates that her condition in
improving?
She tells the nurse that she had no
idea that she is thin
She arrives earlier than scheduled
time of group therapy
She tells the nurse that she eat 3
times or more in a day
She gained 4 lbs in two weeks
112. The nurse is aware that ataractics or
psychic energizers are also known as:
Anti manic
Anti depressants
Antipsychotics
Anti anxiety
113. Known as mood elevators:
Anti depressants
Antipsychotics
Anti manic
Anti anxiety
114. The priority of care for a client with
Alzheimer’s disease is
Help client develop coping
mechanism
 Encourage to learn new hobbies and Repression
interest Projection
Provide him stimulating environment 123. Nurse John is aware that self
Simplify the environment to eliminate mutilation among Bipolar disorder
the need to make chores patients is a means of:
115. Autism is diagnosed at:
Overcoming fear of failure
Infancy Overcoming feeling of insecurity
3 years old Relieving depression
5 years old Relieving anxiety
School age 124. Which of the following may cause an
116. The common characteristic of increase in the cystitis symptoms?
autism child is:
Water
Impulsitivity Orange juice
Self destructiveness Coffee
Hostility Mango juice
Withdrawal 125. In caring for clients with renal
117. The nurse is aware that the most calculi, which is the priority nursing
common indication in using ECT is: intervention?

Schizophrenia Record vital signs

Bipolar Strain urine
Anorexia Nervosa Limit fluids
Depression Administer analgesics as prescribed
118. A therapy that focuses on here and 126. In patient with renal failure, the diet
now principle to promote self- should be:
acceptance?
Low protein, low sodium, low
Gestalt therapy potassium
Cognitive therapy Low protein, high potassium
Behavior therapy High carbohydrate, low protein
Personality therapy High calcium, high protein
119. A client has many irrational 127. Which of the following cannot be
thoughts. The goal of therapy is to corrected by dialysis?
change her:
Hypernatremia
Personality Hyperkalemia
Communication Elevated creatinine
Behavior Decreased hemoglobin
Cognition 128. Tony with infection is receiving
120. The appropriate nutrition for Bipolar antibiotic therapy. Later the client
I disorder, in manic phase is: complaints of ringing in the ears. This
ototoxicity is damage to:
Low fat, low sodium
Low calorie, high fat 4th CN
Finger foods, high in calorie 8th CN
Small frequent feedings 7th CN
121. Which of the following activity would 9th CN
be best for a depressed client? 129. Nurse Emma provides teaching to a
patient with recurrent urinary tract
Chess infection includes the following:
Basketball
Swimming Increase intake of tea, coffee and
Finger painting colas
122. The nurse is aware that clients with Void every 6 hours per day
severe depression, possess which Void immediately after intercourse
defense mechanism: Take tub bath everyday
130. Which assessment finding indicates
Introjection circulatory constriction in a male client
Suppression with a newly applied long leg cast?
 Blanching or cyanosis of legs 138. The ANA recognized nursing
Complaints of pressure or tightness informatics heralding its establishment
Inability to move toes as a new field in nursing during what
Numbness of toes year?
131. During acute gout attack, the nurse
administer which of the following drug: 1994
1992
Prednisone (Deltasone) 2000
Colchicines 2001
Aspirin 139. When is the first certification of
Allopurinol (Zyloprim) nursing informatics given?
132. Information in the patients chart is
inadmissible in court as evidence when: 1990-1993
2001-2002
The client objects to its use 1994-1996
Handwriting is not legible 2005-2008
It has too many unofficial 140. The nurse is assessing a female
abbreviations client with possible diagnosis of
The clients parents refuses to use it osteoarthritis. The most significant risk
133. Nurse Karen is revising a client plan factor for osteoarthritis is:
of care. During which step of the nursing
process does such revision take place? Obesity
Race
Planning Job
Implementation Age
Diagnosing 141. A male client complains of vertigo.
Evaluation Nurse Bea anticipates that the client may
134. When examining a client with have a problem with which portion of the
abdominal pain, Nurse Hazel should ear?
assess:
Tymphanic membranes
Symptomatic quadrant either second Inner ear
or first Auricle
The symptomatic quadrant last External ear
The symptomatic quadrant first 142. When performing Weber’s test,
Any quadrant Nurse Rosean expects that this client will
135. How long will nurse John obtain an hear
accurate reading of temperature via oral
route? On unaffected side
Longer through bone than air
3 minutes conduction
1 minute On affected side by bone conduction
8 minutes By neither bone or air conduction
15 minutes 143. Toy with a tentative diagnosis of
136. The one filing the criminal care myasthenia gravis is admitted for
against an accused party is said to be diagnostic make up. Myasthenia gravis
the? can confirmed by:

Guilty Kernigs sign

Accused Brudzinski’s sign
Plaintiff A positive sweat chloride test
Witness A positive edrophonium (Tensilon)
137. A male client has a standing DNR test
order. He then suddenly stopped 144. A male client is hospitalized with
breathing and you are at his bedside. You Guillain-Barre Syndrome. Which
would: assessment finding is the most
significant?
Call the physician
Stay with the client and do nothing Even, unlabored respirations
Call another nurse Soft, non distended abdomen
Call the family Urine output of 50 ml/hr
 Warm skin D. Incubation period varies
145. For a female client with suspected depending on the site of the bite
intracranial pressure (ICP), a most B. Cover IV bottle with brown paper
appropriate respiratory goal is: bag
C. Rumpel-leede test
Maintain partial pressure of arterial D. Peripheral blood smear
oxygen (Pa O2) above 80mmHg A. Nurse who never had chicken pox
Promote elimination of carbon dioxide D. After the delivery of the baby
Lower the PH B. 18 year old sister who recently got
Prevent respiratory alkalosis married
146. Which nursing assessment would C. BCG vaccination
identify the earliest sign of ICP? C. Klebs-loeffler bacillus
D. I will come back on Wednesday,
Change in level of consciousness same time, to read the result
Temperature of over 103°F C. Positive
Widening pulse pressure B. Avoid vitamin supplements while o
Unequal pupils therapy
147. The greatest danger of an D. Chancre
uncorrected atrial fibrillation for a male A. 60 breaths per minute
patient will be which of the following: D. A and B
D. Cotrimoxazole
Pulmonary embolism C. 1 tsp. salt and 8 tsp. sugar
Cardiac arrest B. Umbilical infections
Thrombus formation A. BCG
Myocardial infarction C. Epidemiological situation
148. Linda, A 30 year old post D. 90
hysterectomy client has visited the B. -15c to -25c
health center. She inquired about BSE A. Bacterial toxin
and asked the nurse when BSE should be D. Planning
performed. You answered that the BSE is B. Schedule
best performed: A. Motivation
C. Vision
7 days after menstruation D. Standards
At the same day each month D. Negative reinforcement
During menstruation B. Close ended
Before menstruation A. Inductive
149. An infant is ordered to recive 500 ml B. Risk-benefit ratio
of D5NSS for 24 hours. The Intravenous A. Element
drip is running at 60 gtts/min. How many C. Organizational chart
drops per minute should the flow rate D. University of Sto. Tomas
be? D. Italy
B. Overt
60 gtts/min. D. The statement of patient “My hand
21 gtts/min is painful”
30 gtts/min C. Supine
15 gtts/min A. 7 days after menstrual period
150. Mr. Gutierrez is to receive 1 liter of B. Preparation of the patient
D5RL to run for 12 hours. The drop factor C. Kardex
of the IV infusion set is 10 drops per C. Side lying, unaffected side
minute. Approximately how many drops D. Percussion
per minutes should the IV be regulated? D. Dilated pupils
A. Ineffective airway clearance
related to edema
13-14 drops
D. Redness and warmth
17-18 drops
B. 1 kilograms
10-12 drops
C. Two arteries and one vein
15-16 drops
D. April 18
Answers A. Butter
C. Don’t get pregnant at least 3 C. Immediate surgery
months D. Semi-fowlers
A. Increased urinary output
A. Pressure caused by the ascending C. Reduce anxiety
uterus A. Altered nutrition : less than body
B. 500 requirement
D. Estrogen D. She gained 4 lbs in two weeks
C. Cervix is completely dilated C. Antipsychotics
D. Blue A. Anti depressants
B. Listen the fetal heart tone D. Simplify the environment to
D. Uterine atomy eliminate the need to make chores
C. 2 fingers below umbilicus B. 3 years old
A. Normal findings during assessment D. Withdrawal
D. Tetanus toxoid D. Depression
C. RI 8172 A. Gestalt therapy
B. Sambong D. Cognition
A. An essential and indispensable C. Finger foods, high in calorie
equipment of the community health D. Finger painting
nurse during home visit A. Introjection
D. 99 B. Overcoming feeling of insecurity
B. After 2-4 weeks C. Coffee
C. Lactational Amenorrhea method D. Administer analgesics as
(LAM) prescribed
B. Identify the illness A. Low protein, low sodium, low
A. After 2 days potassium
D. Sentrong sigla movement D. Decreased hemoglobin
B. February 1985 B. 8th CN
D. 6 C. Void immediately after intercourse
C. Acetylcysteine A. Blanching or cyanosis of legs
A. Habit training B. Colchicines
B. Polyhydramios A. The client objects to its use
D. Rice D. Evaluation
D. “Here’s your medicine. Would you B. The symptomatic quadrant last
like a mango or orange juice?” A. 3 minutes
A. 6 years C. Plaintiff
C. Oxygen tent B. Stay with the client and do nothing
B. Carmencita Abaquin A. 1994
A. BON B. 2001-2002
D. 4 years D. Age
C. Date of Application B. Inner ear
A. EO 51 C. On affected side by bone
B. Autonomy conduction
C. Force majeure D. A positive edrophonium (Tensilon)
A. Fidelity test
D. Prudence A. Even, unlabored respirations
B. Enrollment in graduate school B. Promote elimination of carbon
C. Primary health nurse dioxide
A. Department of Health A. Change in level of consciousness
D. Parents/legal guardians C. Thrombus formation
C. Trustworthiness B. At the same day each month
B. Change IV infusions B. 21 gtts/min
C. Respect the client’s action A. 13-14 drops
D. Assist client towards a peaceful
death
C. Empathy
A. Review progress of therapy and
attainment of goals
D. Diazepam (Valium)
B. Psycho stimulant
C. Poverty
A. The client may become resistive
and active in stopping the crisis
B. Anal
D. Infancy