PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 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
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
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.
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.
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.
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.
7. A male client was on warfarin (Coumadin)
before admission, and has been receiving
heparin I.V. for 2 days. The partial
thromboplastin time (PTT) is 68 seconds. What
should Nurse Carla do?
A. Stop the I.V. infusion of heparin and notify
the physician.
B. Continue treatment as ordered.
C. Expect the warfarin to increase the PTT.
D. Increase the dosage, because the level is
lower than normal.
8. A client undergone ileostomy, when should
the drainage appliance be applied to the stoma?
A. 24 hours later, when edema has subsided.
B. In the operating room.
C. After the ileostomy begin to function.
D. When the client is able to begin self-care
procedures.
9. A client undergone spinal anesthetic, it will
be important that the nurse immediately
position the client in:
A. On the side, to prevent obstruction of
airway by tongue.
B. Flat on back.
C. On the back, with knees flexed 15 degrees.
D. Flat on the stomach, with the head turned
to the side.
10.While monitoring a male client several hours
after a motor vehicle accident, which
assessment data suggest increasing
intracranial pressure?
A. Blood pressure is decreased from 160/90
to 110/70.
B. Pulse is increased from 87 to 95, with an
occasional skipped beat.
C. The client is oriented when aroused from
sleep, and goes back to sleep immediately.
D. The client refuses dinner because of
anorexia.
11.Mrs. Cruz, 80 years old is diagnosed with
pneumonia. Which of the following symptoms
may appear first?
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)
A. Altered mental status and dehydration
B. Fever and chills
C. Hemoptysis and Dyspnea
D. Pleuritic chest pain and cough
12. A male client has active tuberculosis (TB).
Which of the following symptoms will be
exhibit?
A. Chest and lower back pain
B. Chills, fever, night sweats, and hemoptysis
C. Fever of more than 104°F (40°C) and
nausea
D. Headache and photophobia
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
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
15. A 77-year-old male client is admitted for
elective knee surgery. Physical examination
reveals shallow respirations but no sign of
respiratory distress. Which of the following is a
normal physiologic change related to aging?
A. Increased elastic recoil of the lungs
B. Increased number of functional capillaries
in the alveoli
C. Decreased residual volume
D. Decreased vital capacity
16. Nurse John is caring for a male client
receiving lidocaine I.V. Which factor is the most
relevant to administration of this medication?
A. Decrease in arterial oxygen saturation
(SaO2) when measured with a pulse
oximeter.
B. Increase in systemic blood pressure.
C. Presence of premature ventricular
contractions (PVCs) on a cardiac monitor.
D. Increase in intracranial pressure (ICP).
17. Nurse Ron is caring for a male client taking
an anticoagulant. The nurse should teach the
client to:
A. Report incidents of diarrhea.
B. Avoid foods high in vitamin K
C. Use a straight razor when shaving.
D. Take aspirin to pain relief.
18. Nurse Lhynnette is preparing a site for the
insertion of an I.V. catheter. The nurse should
treat excess hair at the site by:
A. Leaving the hair intact
B. Shaving the area
C. Clipping the hair in the area
D. Removing the hair with a depilatory.
19. Nurse Michelle is caring for an elderly
female with osteoporosis. When teaching the
client, the nurse should include information
about which major complication:
A. Bone fracture
B. Loss of estrogen
C. Negative calcium balance
D. Dowager’s hump
20. Nurse Len is teaching a group of women to
perform BSE. The nurse should explain that the
purpose of performing the examination is to
discover:
A. Cancerous lumps
B. Areas of thickness or fullness
C. Changes from previous examinations.
D. Fibrocystic masses
21. When caring for a female client who is being
treated for hyperthyroidism, it is important to:
A. Provide extra blankets and clothing to
keep the client warm.
B. Monitor the client for signs of restlessness,
sweating, and excessive weight loss during
thyroid replacement therapy.
C. Balance the client’s periods of activity and
rest.
D. Encourage the client to be active to
prevent constipation.
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)
22. Nurse Kris is teaching a client with history of
atherosclerosis. To decrease the risk of
atherosclerosis, the nurse should encourage the
client to:
A. Avoid focusing on his weight.
B. Increase his activity level.
C. Follow a regular diet.
D. Continue leading a high-stress lifestyle.
23. Nurse Greta is working on a surgical floor.
Nurse Greta must logroll a client following a:
A. Laminectomy
B. Thoracotomy
C. Hemorrhoidectomy
D. Cystectomy.
24. A 55-year old client underwent cataract
removal with intraocular lens implant. Nurse
Oliver is giving the client discharge instructions.
These instructions should include which of the
following?
A. Avoid lifting objects weighing more than 5
lb (2.25 kg).
B. Lie on your abdomen when in bed
C. Keep rooms brightly lit.
D. Avoiding straining during bowel movement
or bending at the waist.
25. George should be taught about testicular
examinations during:
A. when sexual activity starts
B. After age 69
C. After age 40
D. Before age 20.
26. A male client undergone a colon resection.
While turning him, wound dehiscence with
evisceration occurs. Nurse Trish first response is
to:
A. Call the physician
B. Place a saline-soaked sterile dressing on
the wound.
C. Take a blood pressure and pulse.
D. Pull the dehiscence closed.
27. Nurse Audrey is caring for a client who has
suffered a severe cerebrovascular accident.
During routine assessment, the nurse notices
Cheyne- 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.
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
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.
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.
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
32. Nurse Maureen is talking to a male client,
the client begins choking on his lunch. He’s
coughing forcefully. The nurse should:
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)
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.
33. Nurse Ron is taking a health history of an 84
year old client. Which information will be most
useful to the nurse for planning care?
A. General health for the last 10 years.
B. Current health promotion activities.
C. Family history of diseases.
D. Marital status.
34. When performing oral care on a comatose
client, Nurse Krina should:
A. Apply lemon glycerin to the 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.
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
36. Nurse Oliver is working in a out patient
clinic. He has been alerted that there is an
outbreak of tuberculosis (TB). Which of the
following clients entering the clinic today most
likely to have TB?
A. A 16-year-old female high school student
B. A 33-year-old day-care worker
C. A 43-yesr-old homeless man with a history
of alcoholism
D. A 54-year-old businessman
37. Virgie with a positive Mantoux test result
will be sent for a chest X-ray. The nurse is aware
that which of the following reasons this is done?
A. To confirm the diagnosis
B. To determine if a repeat skin test is
needed
C. To determine the extent of lesions
D. To determine if this is a primary or
secondary infection
38. Kennedy with acute asthma showing
inspiratory and expiratory wheezes and a
decreased forced expiratory volume should be
treated with which of the following classes of
medication right away?
A. Beta-adrenergic blockers
B. Bronchodilators
C. Inhaled steroids
D. Oral steroids
39. Mr. Vasquez 56-year-old client with a 40-
year history of smoking one to two packs of
cigarettes per day has a chronic cough
producing thick sputum, peripheral edema and
cyanotic nail beds. Based on this information,
he most likely has which of the following
conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Asthma
C. Chronic obstructive bronchitis
D. Emphysema
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.
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
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)
B. Document the patient’s status in his
charts.
C. Prepare oxygen treatment
D. Raise the side rails
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.
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
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
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)
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
47. A 51-year-old female client tells the nurse
in-charge that she has found a painless lump in
her right breast during her monthly self-
examination. Which assessment finding would
strongly suggest that this client’s lump is
cancerous?
A. Eversion of the right nipple and mobile
mass
B. Nonmobile mass with irregular edges
C. Mobile mass that is soft and easily
delineated
D. Nonpalpable right axillary lymph nodes
48. A 35-year-old client with vaginal cancer asks
the nurse, “What is the usual treatment for this
type of cancer?” Which treatment should the
nurse name?
A. Surgery
B. Chemotherapy
C. Radiation
D. Immunotherapy
49. Cristina undergoes a biopsy of a suspicious
lesion. The biopsy report classifies the lesion
according to the TNM staging system as follows:
TIS, N0, M0. What does this classification mean?
A. No evidence of primary tumor, no
abnormal regional lymph nodes, and no
evidence of distant metastasis
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)
B. Carcinoma in situ, no abnormal regional
lymph nodes, and no evidence of distant
metastasis
C. Can’t assess tumor or regional lymph
nodes and no evidence of metastasis
D. Carcinoma in situ, no demonstrable
metastasis of the regional lymph nodes,
and ascending degrees of distant
metastasis
50. Lydia undergoes a laryngectomy to treat
laryngeal cancer. When teaching the client how
to care for the neck stoma, the nurse should
include which instruction?
A. “Keep the stoma uncovered.”
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.”
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
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.
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.
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.”
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
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
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)
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.
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)
C. The client hears thumping sounds.
D. The client wears a watch and wedding
band.
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.
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
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
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
63. A 76-year-old male client had a
thromboembolic right stroke; his left arm
is swollen. Which of the following conditions
may cause swelling after a stroke?
A. Elbow contracture secondary to spasticity
B. Loss of muscle contraction decreasing
venous return
C. Deep vein thrombosis (DVT) due to
immobility of the ipsilateral side
D. Hypoalbuminemia due to protein escaping
from an inflamed glomerulus
64. 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.
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
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
67. A male client with type 1 diabetes is
scheduled to receive 30 U of 70/30 insulin.
There is no 70/30 insulin available. As a
substitution, the nurse may give the client:
A. 9 U regular insulin and 21 U neutral
protamine Hagedorn (NPH).
B. 21 U regular insulin and 9 U NPH.
C. 10 U regular insulin and 20 U NPH.
D. 20 U regular insulin and 10 U NPH.
68. Nurse Len should expect to administer
which medication to a client with gout?
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)
A. aspirin
B. furosemide (Lasix)
C. colchicines
D. calcium gluconate (Kalcinate)
69. Mr. Domingo with a history of hypertension
is diagnosed with primary hyperaldosteronism.
This diagnosis indicates that the client’s
hypertension is caused by excessive hormone
secretion from which of the following glands?
A. Adrenal cortex
B. Pancreas
C. Adrenal medulla
D. Parathyroid
70. For a diabetic male client with a foot ulcer,
the doctor orders bed rest, a 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.
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
72. A client is admitted for treatment of the
syndrome of inappropriate
antidiuretic hormone (SIADH). Which nursing
intervention is appropriate?
A. Infusing I.V. fluids rapidly as ordered
B. Encouraging increased oral intake
C. Restricting fluids
D. Administering glucose-containing I.V. fluids
as ordered
73. A female client tells nurse Nikki that she has
been working hard for the last 3 months to
control her type 2 diabetes mellitus with diet
and exercise. To determine the effectiveness of
the client’s efforts, the nurse should check:
A. urine glucose level.
B. fasting blood glucose level.
C. serum fructosamine level.
D. glycosylated hemoglobin level.
74. Nurse Trinity administered neutral
protamine Hagedorn (NPH) insulin to a diabetic
client at 7 a.m. At what time would the nurse
expect the client to be most at risk for a
hypoglycemic reaction?
A. 10:00 am
B. Noon
C. 4:00 pm
D. 10:00 pm
75. The adrenal cortex is responsible for
producing which substances?
A. Glucocorticoids and androgens
B. Catecholamines and epinephrine
C. Mineralocorticoids and catecholamines
D. Norepinephrine and epinephrine
76. On the third day after a partial
thyroidectomy, Proserfina exhibits
muscle twitching and hyperirritability of the
nervous system. When questioned, the
client reports numbness and tingling of the
mouth and fingertips. Suspecting a
lifethreatening electrolyte disturbance, the
nurse notifies the surgeon immediately. Which
electrolyte disturbance most commonly follows
thyroid surgery?
A. Hypocalcemia
B. Hyponatremia
C. Hyperkalemia
D. Hypermagnesemia
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
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
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)
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.”
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.”
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
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.
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.
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
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.
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.
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).
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)
D. Western blot test with ELISA.
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
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
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
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.”
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.
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.
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.
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
96. Nurse Jannah teaches an elderly client with
right-sided weakness how to use cane. Which of
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)

the following behaviors, if demonstrated by the 99. Nurse Deric is supervising a group of elderly
client to the nurse, indicates that the teaching clients in a residential home setting. The nurse
was effective? knows that the elderly are at greater risk of
A. The client holds the cane with his right developing sensory deprivation for what
hand, moves the can forward followed by reason?
the right leg, and then moves the left leg. A. Increased sensitivity to the side effects of
B. The client holds the cane with his right medications.
hand, moves the cane forward followed by B. Decreased visual, auditory, and gustatory
his left leg, and then moves the right leg. abilities.
C. The client holds the cane with his left C. Isolation from their families and familiar
hand, moves the cane forward followed by surroundings.
the right leg, and then moves the left leg. D. Decrease musculoskeletal function and
D. The client holds the cane with his left mobility.
hand, moves the cane forward followed by 100. A male client with emphysema becomes
his left leg, and then moves the right leg. restless and confused. What step should nurse
97. An elderly client is admitted to the nursing Jasmine take next?
home setting. The client is occasionally A. Encourage the client to perform pursed lip
confused and her gait is often unsteady. Which breathing.
of the following actions, if taken by the nurse, is B. Check the client’s temperature.
most appropriate? C. Assess the client’s potassium level.
A. Ask the woman’s family to provide D. Increase the client’s oxygen flow rate.
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.
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.
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)
Answers and Rationales
1. 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. 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. Answer: (C) Check respirations, stabilize
spine, and check circulation. Checking the
airway would be priority, and a neck injury
should be suspected.
4. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Answer: (B) Respiratory arrest. Narcotics
can cause respiratory arrest if given in
large quantities. It’s unlikely the client will
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)
have asthma attack or a seizure or wake up
on his own.
15. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Answer: (D) Before age 20. Testicular
cancer commonly occurs in men between
ages 20 and 30. A male client should be
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)
taught how to perform testicular
selfexamination before age 20, preferably
when he enters his teens.
26. 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. 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. 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. 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. 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. 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. 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. 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. 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.
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)
35. 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. 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. 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. 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. 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.
40. 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. 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. 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. 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. 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. 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
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)
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. 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. 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. 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. 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. 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. 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. 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. Answer: (A) prostate-specific antigen,
which is used to screen for
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)
prostate cancer. PSA stands for prostate-
specific antigen, which is used to screen
for prostate cancer. The other answers are
incorrect.
54. 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. 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. 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. 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. 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. 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. 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. 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.
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)
62. 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. 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. 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. 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. 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. 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. 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. 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. 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. Answer: (A) Hyperkalemia. In adrenal
insufficiency, the client has hyperkalemia
due to reduced aldosterone secretion.
BUN increases as the glomerular
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)
filtration rate is reduced. Hyponatremia is
caused by reduced aldosterone secretion.
Reduced cortisol secretion leads to
impaired glyconeogenesis and a reduction
of glycogen in the liver and muscle,
causing hypoglycemia.
72. Answer: (C) Restricting fluids. To reduce
water retention in a client with the SIADH,
the nurse should restrict fluids.
Administering fluids by any route would
further increase the client’s already
heightened fluid load.
73. Answer: (D) glycosylated hemoglobin
level. Because some of the glucose in the
bloodstream attaches to some of the
hemoglobin and stays attached during the
120-day life span of red blood cells,
glycosylated hemoglobin levels provide
information about blood glucose levels
during the previous 3 months. Fasting
blood glucose and urine glucose levels only
give information about glucose levels at
the point in time when they were
obtained. Serum fructosamine levels
provide information about blood glucose
control over the past 2 to 3 weeks.
74. Answer: (C) 4:00 pm. NPH is an
intermediate-acting insulin that peaks 8 to
12 hours after administration. Because the
nurse administered NPH insulin at 7 a.m.,
the client is at greatest risk for
hypoglycemia from 3 p.m. to 7 p.m.
75. Answer: (A) Glucocorticoids and
androgens. The adrenal glands have two
divisions, the cortex and medulla. The
cortex produces three types of hormones:
glucocorticoids, mineralocorticoids, and
androgens. The medulla produces
catecholamines — epinephrine and
norepinephrine.
76. Answer: (A) Hypocalcemia. 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. 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. 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. Answer: (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. Answer: (C) “Avoid sharing such articles as
toothbrushes and razors.” The human
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)
immunodeficiency virus (HIV), which
causes AIDS, is most concentrated in the
blood. For this reason, the client shouldn’t
share personal articles that may be blood-
contaminated, such as toothbrushes and
razors, with other family members. HIV
isn’t transmitted by bathing or by eating
from plates, utensils, or serving dishes
used by a person with AIDS.
81. Answer: (B) Pallor, tachycardia, and a sore
tongue. 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. 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. 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. 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. 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. 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. 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
PNLE IIi for Community Health Nursing and Care of the Mother and Child (set 1)
infection. The Western blot test —
electrophoresis of antibody proteins — is
more than 98% accurate in detecting HIV
antibodies when used in conjunction with
the ELISA. It isn’t specific when used alone.
Erosette immunofluorescence is used to
detect viruses in general; it
doesn’t confirm HIV infection.
Quantification of T-lymphocytes is a
useful monitoring test but isn’t diagnostic
for HIV. The ELISA test detects
HIV antibody particles but may yield
inaccurate results; a positive ELISA
result must be confirmed by the Western
blot test.
88. Answer: (C) Abnormally low hematocrit
(HCT) and hemoglobin (Hb) levels. Low
preoperative HCT and Hb levels indicate
the client may require a blood transfusion
before surgery. If the HCT and Hb
levels decrease during surgery because of
blood loss, the potential need for
a transfusion increases. Possible renal
failure is indicated by elevated BUN or
creatinine levels. Urine constituents aren’t
found in the blood. Coagulation is
determined by the presence of
appropriate clotting factors, not
electrolytes.
89. Answer: (A) Platelet count, prothrombin
time, and partial thromboplastin time. The
diagnosis of DIC is based on the results of
laboratory studies of prothrombin time,
platelet count, thrombin time,
partial thromboplastin time, and
fibrinogen level as well as client history
and other assessment factors. Blood
glucose levels, WBC count, calcium levels,
and potassium levels aren’t used to
confirm a diagnosis of DIC.
90. Answer: (D) Strawberries. Common food
allergens include berries, peanuts, Brazil
nuts, cashews, shellfish, and eggs. Bread,
carrots, and oranges rarely cause allergic
reactions.
91. Answer: (B) A client with cast on the right
leg who states, “I have a funny feeling in
my right leg.” It may indicate
neurovascular compromise, requires
immediate assessment.
92. Answer: (D) A 62-year-old who had an
abdominal-perineal resection three days
ago; client complaints of chills. The client is
at risk for peritonitis; should be assessed
for further symptoms and infection.
93. Answer: (C) The client spontaneously
flexes his wrist when the blood pressure is
obtained. Carpal spasms indicate
hypocalcemia.
94. 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. 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. 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. 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. 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. Answer: (C) Isolation from their families
and familiar surroundings. Gradual loss of
sight, hearing, and taste interferes with
normal functioning.
100. 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.