The Purple Book

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THE PURPLE BOOK

BOARD SENSITIVE QUESTIONS AND RATIONALIZATIONS
SUPREME BULLETS
COVID-19
• COVID-19 is transmitted from person to person via droplets, contact, and fomites.
• It is transmitted when one individual talks, sneezes, or coughs producing
‘droplets’ of saliva containing the COVID-19 virus.
• It is therefore important to maintain a distance of more than 1 meter away from
any person who has respiratory symptoms.
• COVID- 19 is prevented through:
✓ Wear face mask and face shield
✓ Sanitize your hands
✓ Practice one-meter physical distancing and limit physical interaction
✓ Ensure good indoor ventilation and air flow
• Who are considered as close contact?
✓ Interacted with a person with COVID-19 within one meter for more than 15
minutes
✓ Had direct physical interaction with probable or confirmed COVID-19 case
✓ Had interaction with a person with COVID-19 without wearing protective
equipment
• Close contacts should:
Get tested if you are a close contact. Tell your Barangay Health Emergency
Response Team (BHERT) that you are a close contact. This is to inform your next
steps:
✓ COVID-19 Testing
✓ Referral to the Temporary Treatment and Monitoring Facility (TTMF) or
hospital (if needed)
• Diagnostic Tests
✓ RT-PCR (gold standard)
✓ Antigen (for those specified places with rising cases of COVID-19, wherein RT-
PCR tests are lacking)
• Quarantine vs. Isolation
✓ Quarantine - period to monitor well-being after being identified as a close
contact with a person with COVID-19
✓ Isolation - separating people with symptoms or confirmed COVID-19 cases
Home Quarantine:
• If you have severe or critical symptoms, you will be referred to a hospital
• If you are asymptomatic or with mild/moderate symptoms, you may isolate yourself
at your home or you may go to a Temporary Treatment and Monitoring Facility
(TTMF)
• You may only isolate yourself at home if:
✓ You have a separate room with other members of the family
✓ You have a separate bathroom/comfort room in your room
✓ You are not living with people who belong to the vulnerable population
THE PURPLE BOOK ALVIZ 2021

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• If you are allowed to isolate at home, make sure to:

✓ Practice one-meter physical distancing, wear face mask, and sanitize your
hands every time you interact with your family member/s
✓ Eat right and drink medicines prescribed by your doctor
✓ Disinfect properly your things, wash hands before and after you use them
Home Management for mild to moderate symptoms

If you have fever, you may do the following:
• Check temperature every four (4) hours; You may drink paracetamol if your
temperature reaches above 37.5-degree Celsius, every four (4) hours.
• Take a bath daily if you can and if possible
• Ensure good ventilation and airflow in your room
• Do not wear more layers of clothes
• Drink a lot of water, fresh fruit juices, and mild teas
If you have cough or sore throat, you do the following:

• Make sure to drink your prescribed medicines
• Drink a lot of water
• Keep away from those that can heighten your symptoms such as dust, pollen,
perfume, and animal fur
Watch out for (WOF):

• Difficulty in breathing, even when sitting
• Cough, fever, and difficulty in breathing
• Severe coughing
• Confusion or sudden change in mental well-being
• Pain in the chest
• Low oxygen level
• Excessive sleepiness or cannot be woken up
• Bluish or darkened face or lips
***If you are experiencing other severe symptoms, call your BHERT immediately.
Corona Virus
Coronaviruses are a large family of viruses causing a range of illnesses, from the
common cold to more serious infections such as those caused by Middle East
Respiratory Syndrome-related Coronavirus (MERS-CoV) and Severe Acute
Respiratory Syndrome-related Coronavirus (SARS-CoV). Coronavirus can also
cause a variety of diseases in farm animals and domesticated pets.

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Novel Corona Virus

The novel coronavirus is a new strain of coronavirus that has not been previously
identified in humans. The novel coronavirus has caused severe pneumonia in
several cases in China and has been exported to a range of countries and cities.
Last February 12, 2020, the World Health Organization (WHO) announced that the
novel disease is officially called Coronavirus Disease 19 or COVID-19, and the
virus infecting it is referred to as COVID-19 virus.
COVID- 19 Origin
Last 31 December 2019, a clustering of pneumonia cases of unknown etiology in

Wuhan, China was reported to the WHO Country Office. The outbreak was later
determined to be caused by a new coronavirus strain that has not been previously
identified in humans.
Duration of how long can the virus survive on surfaces
According to WHO, there is no confirmed timeline how long a COVID-19 virus

survives in surfaces. However, most likely it behaves like other coronaviruses.
Studies show that coronaviruses can survive on surfaces for a few hours up to
several days depending on varied conditions (e.g. type of surface, temperature or
humidity of the environment).
If you suspect that a surface is infected, clean it with disinfectant; clean your hands
with alcohol-based hand sanitizer or wash them with soap and water; and if
possible, minimize touching your eyes, mouth or nose.
Is it safe to receive packages from China?
Yes, it is. From what we know about the coronaviruses so far, they do not survive
long on objects, such as packages and letters. As such, receiving packages from
China does not pose risk of contracting the virus to the recipient. -DOH
COVID 19 vs Severe Acute Respiratory Syndrome (SARS)
The COVID-19 virus and the SARS-CoV are both coronaviruses and are
genetically related to each other, but they are different. SARS is more fatal and
deadly but less infectious than COVID-19.

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Prevention of Transfer
DOH advises the public to practice protective measures. It is still the best way to protect
oneself against COVID-19.
a. Practice frequent and proper handwashing - wash hands often with soap and
water for at least 20 seconds. Use an alcohol-based hand sanitizer if soap and
water are not available.
b. Practice proper cough etiquette.
o Cover mouth and nose using tissue or sleeves/bend of the elbow when
coughing or sneezing.
o Move away from people when coughing.
o Do not spit.
o Throw away used tissues properly.
o Always wash your hands after sneezing or coughing.
o Use alcohol/sanitizer.
c. Maintain distance of at least one meter away from individual/s experiencing

respiratory symptoms.
d. Avoid unprotected contact with farm or wild animals (alive or dead), animal
markets, and products that come from animals (such as uncooked meat).
e. Ensure that food is well-cooked.

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NURSING PRACTICE I- QUESTIONS
1. Cost-effective health care emphasizes the primary prevention of illness. Which of the following
is an example of a primary prevention activity?
A. Antibiotic treatment of a suspected urinary tract infection
B. Occupational therapy to assist a client in adapting his or her home environment following
a stroke
C. Nutrition counseling for young adults with a strong family history of high cholesterol
D. Removal of tonsils for client with recurrent tonsillitis
2. A client needs a low-fat, low-salt diet because of his hypertension. He should be referred to a:
A. dietitian
B. nutritionist
C. physician
D. paramedical technologist
3. Surveillance of infectious diseases is governed by:

A. Provincial or state government
B. National Institute of Health
C. Public health services
D. Centers for Disease Control and Prevention
4. The case manager for the oncology unit is a professional nurse responsible for:
A. arranging home care
B. assisting with financial arrangements
C. coordinating all aspects of client care
D. prescribing client outcomes
5. Which of the following is true about discharge planning?

A. Discharge plans involve referral to community resources
B. Basic discharge plans involve referral to community resources
C. Simple referral involves use of a discharge planner
D. Complex referral involves interdisciplinary collaboration
6. “At risk” groups are identified in a community so that:

A. all residents can be alerted to possible problems
B. health care workers can be trained to deal with health and social problems
C. measures can be taken to prevent problems or deal with them in the early stages
D. health and economic matters are given adequate funds for solution of those problems
7. A bilateral amputee is assisted by his wife and children from the wheelchair to the commode
for bowel evacuation. This example best demonstrates the family’s assistance to meet which
needs?
A. Nutrition and metabolism
B. Activity
C. Health perception and health maintenance
D. Elimination

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8. The nurse asks a client to describe his community. Such assessment focuses discharge
planning on:
A. maximizing individual and family potentials and reducing healthcare costs
B. a method the client finds acceptable and a method using community resources maximally
C. an individual method of client education and a method of quick referral
D. minimizing of hospitalization and reducing family stress
9. Understanding family dynamics and the community context will assist the nurse in planning
care that is:
A. compatible with the client’s everyday life and therefore has the greatest chance of success
B. regimented according to predetermined medical and social regulations and policies
C. in harmony with the financial resources of the family and community
D. reasonable, inexpensive, current, and compatible with high technology
10. One role of the nurse in a community-based setting focuses on primary intervention. An
example of primary intervention would be:
A. Screening children for vision in a preschool
B. Teaching bicycle safety in an after- school program
C. Identifying head lice in a child in elementary school
D. Exploring financial help for a client in a home setting
11. One role of the nurse in a community-based setting focuses on secondary intervention.
An example of secondary intervention would be:
A. Screening children for hearing loss in a preschool
B. Teaching bicycle safety in an after-school program
C. Recommending a group home setting for an adolescent
D. Administering immunizations to infants in a clinic
12. One role of a nurse in a community-based setting focuses on tertiary intervention. An example
of tertiary intervention would be:
A. Screening children for hearing loss in a preschool
B. Teaching bicycle safety in an after-school program
C. Administering immunizations to infants in a clinic
D. Exploring financial help for a client in a home setting
13. The concept of homeostasis is most like the concept of:

A. equilibrium
B. holism
C. needs
D. exchange
14. In Maslow’s hierarchy of needs, the self-actualized person:

A. is other-directed
B. Possesses above-normal intelligence
C. has a future-time orientation
D. has realized his/her full potential

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15. A major sociologic risk factor developing health problem is:

A. poverty
B. adolescent mothers
C. lack of daily exercise
D. genetic predisposition to disease
16. Patients may move among different care settings to:

A. Maintain psychologic integrity
B. Adhere to physician orders for treatment
C. Maximize dependence on health care providers
D. Ensure the physical, emotional and psychological needs are met
17. Mr. Mateh Lopez, age 24, has been admitted to a medical unit with the diagnosis of hepatitis
A and placed in contact isolation. The purpose of this is to:
A. Prevent transmission of infectious microorganisms
B. Control the environment of the patient
C. Protect the patient form infectious microorganisms
D. Protect only the family
18. Mr. Alphaphi, R.N. is working on a clinical medical area with a census of 15. Each patient has
a different illness. The most important method Mr. Alphaphi can use to protect each patient from
microorganisms is:
A. Wearing a gown
B. Placing each patient in isolation
C. Handwashing
D. Wearing gloves
19. Identification of the chain of infection allows health care providers to:
A. Test patients for resistance to communicable diseases
B. Request more money for building isolation hospitals
C. Work with the physician to identify the most appropriate antibiotic
D. Determine points at which the infection can be stopped or prevented
20. Mr. Pineda, age 45, was admitted to the hospital with cellulites of the right foot. Three days
later he developed bacterial pneumonia. This type of an infection is classified as:
A. Acute primary
B. Nosocomial
C. Interstitial
D. Mycoplasmic
21. A patient is admitted with herpes zoster. The nurse should plan to administer which type of
medication on a frequent basis?
A. Zovirax
B. Ceclor
C. Tylenol
D. Tagamet

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22. The most common symptom of patients with scabies is:

A. nausea
B. nocturnal pruritus
C. localized pain
D. skin paresthesia
23. The nurse must observe Ms. Hannah for a symptom of tetanus that could be life threatening.
The nurse should assess Ms. Hannah for:
A. Muscle rigidity
B. Spastic voluntary muscle contractions
C. Restlessness and irritability
D. Respiratory tract spasms
24. The nurse is reviewing Mr. McDonald’s physical examination and laboratory test. An
important finding in malaria is:
A. Splenomegaly
B. Leukocytes
C. Elevated sedimentation rate
D. Erythrocytes
25. A serious complication of acute malaria is:

A. Anemia and cachexia
B. Congested lungs
C. Changes in water and electrolyte balance
D. Impaired peristalsis
26. The nurse understands that gonorrhea is highly infectious and:

A. is easily cured
B. can produce sterility
C. occurs very rarely
D. is limited to the external genitalia
27. The drug of choice for the treatment of gonorrhea is:

A. Ceftriaxone
B. Actinomycin
C. Chloramphenicol
D. Colistin
28. Which would most likely confirm Mr. John’s diagnosis of tuberculosis (TB)?
A. Creatinine kinase (CK) test
B. Chest X-ray
C. Sputum smear and culture
D. White blood cell count
29. Which clinical manifestations would the nurse expect in a patient with TB?
A. Hemoptysis and weight gain
B. Drug cough and blood – streaked sputum
C. Productive cough and afternoon elevated temperature
D. Night sweats and urticaria

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30. Tess, 19 years old, came to the clinic because of fever and appearance of vesicular skin
eruptions on her chest and face. The physician gave a diagnosis of chicken pox. The nursing
diagnosis to be considered in the presence of the vesicles is/are the following:
A. Disturbance in body image and impairment of skin integrity
B. Disturbance in body image
C. Alteration of fluid volume
D. Actual impairment of skin integrity
31. A viral infection characterized by red blotchy rash and Koplik’s spots in the mouth is:
A. Rubeola
B. Rubella
C. Chicken pox
D. Mumps
32. Loy, 1-month old child is brought to the health center for consultation. Assessment findings
are as follows: temperature – 35.5 0C, respiratory rate – 60 breaths per minute, chest indrawing
is present; child does not feed well and is always sleepy. These signs indicated that Loy has
A. cold but no pneumonia
B. mild pneumonia
C. bronchiolitis
D. severe pneumonia
33. Nursing care of the patient with diphtheria should include the following:
A. Encouragement of fluids
B. Omission of bath in severe cases
C. Planned nursing care to conserve patient’s energy
D. Early ambulation
34. The most effective measure of controlling schistosomiasis is:

A. case finding and prompt treatment of cases
B. provision of sanitary toile
C. environment sanitation and environmental control
D. practice personal hygiene
35. The most commonly used model that assists in the understanding of the patient’s place on
the wellness/illness continuum is:
A. Abraham Maslow
B. Dorothea Dix
C. Clara Barton
D. Theodor Fliedner
36. A patient is fearful concerning upcoming surgery. Which of the following statements by the
nurse would be most therapeutic?
A. “Sometimes anxiety is not easy to deal with. Can you tell me what is bothering you the
most?”
B. “Don’t worry. Everybody has some anxiety about having surgery.”
C. “Just try to think about the positive results from the surgery. You’ll recover quickly.”
D. “I had surgery once and it still scares me to think about it, so I know how you feel.

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37. The patient states, “I’m so nervous about being hospitalized.” Which of the following
statements would be the nurse’s best response best response to get the patient to elaborate?
A. “It’s normal to be nervous, but we’ll take good care of you.”
B. “You’re feeling especially nervous?”
C. “How many times have you been hospitalized?”
D. “There will be nurses here all the time to check on you.”
38. Abdominal surgery has revealed that Mrs. Gonzales, a young mother, has advanced
metastatic colon cancer. While the nurse is changing her dressing, Mrs. Gonzales begins to cry
and states, “If I had just gone to the doctor sooner, my kids wouldn’t have to grow up without a
mother.” Which of the following responses by the nurse would be most therapeutic?
A. “It’s natural to blame yourself in situations like this.”
B. “Is their father available to care for the children?”
C. “Don’t give up. The chemotherapy and radiation might be very effective.”
D. “You feel that if you had been diagnosed earlier, the situation might be different?”
39. During his admission interview Mr. James, an older patient, states, “I can’t hear you very well.”
After determining that Mr. James does not have a hearing aid, the nurse should:
A. Speak in a higher-pitched voice
B. Speak loudly into his “good” ear
C. Exaggerate lip movement while speaking
D. Face Mr. James and speak slowly and distinctly
40. A patient is admitted with severe hypertension. The nurse assesses the patient and
gathers the following data: statements of blurred vision, headache, and numbness of the left side
of the face and blood pressure of 180/120. Which of these is an objective cue?
A. Statements of blurred vision
B. Statements describing the headache
C. Statements indicating the facial numbness
D. Blood pressure measurements of 180/120
41. Basing your answers on Maslow’s hierarchy, which of the following nursing diagnosis labels
has the highest priority?
A. Risk for aspiration
B. Deficient fluid volume
C. Acute pain
D. Stress incontinence
42. Which patient outcome statement meets the necessary criteria?

A. The patient will identify the types of foods to include in a high-fiber diet
B. The nurse will teach the patient about constipation prevention
C. The nurse will increase total fluids during hospitalization
D. The patient will have a soft, formed bowel movement on the third day after nursing
interventions
43. A patient who describes his illness is providing:

A. Subjective data
B. Objective data
C. Overt data
D. Signs of his illness

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44. Documentation is part of what phase of the nursing process?

A. Assessment
B. Planning
C. Implementation
D. Evaluation
45. When documenting care and observations in a patient record:

A. Approved medical terms and abbreviations can be used
B. Any locally used abbreviations can be used
C. To prevent errors no abbreviations should be used
D. A nurse does not worry about the use of abbreviations
46. Mr. Winner, 52 years old, is being transferred to the surgical unit from the recovery room
following extensive surgery as the result of trauma from an automobile accident. As the nurse
assigned to complete his care you know that an important principle to remember when admitting,
transferring, or discharging a patient is that:
A. The patient is a human being deserving dignity, courtesy, and respect
B. The patient is ill and unable to make decisions or give accurate information
C. The nurse knows best and should tell the patient what to do
D. Families get in the way and should be encouraged not to get involved in the patient’s care
47. Ms. Bautista, 45-years-old, has been recently diagnosed and hospitalized for type I diabetes
mellitus. The multidisciplinary health care team has been preparing her for dismissal. The nurse
knows the purpose of discharge planning is to:
A. Make certain she takes her medication as prescribed
B. Provide medical treatment
C. Provide ongoing patient education
D. Ensure continuity of care
48. Mr. Peralta, 84-years-old, has been hospitalized for 6 days with a diagnosis of a stroke. The
nurse knows planning for Mr. Peralta’s dismissal should begin:
A. When his condition has stabilized
B. On his admission to the hospital
C. When he begins to ask questions
D. When his family asks for information
49. Mr. Vergara is determined to leave the hospital. His physician is not aware of his intent to
leave, nor is it within his best interest to be dismissed at this time. The nurse recalls that when a
patient chooses to leave a health care facility without a physician’s written order, the nurse should:
A. Call the family so they can expect the patient at home
B. Allow the patient to leave because no one can be held against his or her will
C. Call security because there must be a physician’s order before a patient may leave
D. Explain the risk of leaving and request that the patient sign a paper accepting responsibility
for problems that may occur
50. Mr. Jimenez, age 44, is undergoing antibiotic therapy for pneumonia. His rectal temperature
reading is 101.6ºF. His oral temperature would be considered as:
A. 101.6º F
B. 100.6ºF
C. 99.6ºF
D. 97.6ºF
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51. Ms. Rosario, age 30, develops a postpartum temperature that is elevated in the evening but
returns to a normal reading in the morning. This has occurred for several days. This pattern of
fever would be classified as:
A. Constant
B. Intermittent
C. Remittent
D. Relapsing
52. Mr. Salvador, age 66, has a 10-year history of coronary artery disease. He is presently
recovering from a myocardial infarction. The most accurate assessment of pulse rate would be to
obtain a (n):
A. Carotid pulse
B. Radial pulse
C. Apical pulse
D. Brachial pulse
53. Ms. Jharliemagne is 48-years-old. During a routine physical her blood pressure is noted a
180/90. She fears she is hypertensive. The nurse would explain that the diagnosis of
hypertension is made when there is a sustained elevated blood pressure of over:
A. 160/100
B. 140/90
C. 130/70
D. 120/80
54. Mr. Zamora, RN, has been assigned several patients. Which one of the following patients
would most likely have a higher than normal temperature?
A. The depressed, apathetic patient
B. The patient assessed with hemorrhage
C. The patient who is recovering from surgery
D. The patient experiencing strong emotions
55. Ms. Marbs, a 16-year-old, has been admitted after suffering a motorcycle accident. The nurse
is assessing his pulse pressure. His blood pressure reading is 140/102. Which of the following is
the correct pulse pressure?
A. 40
B. 38
C. 140
D. 102
56. The nurse is preparing to assess a 2-day-old infant’s pulse rate. Which of the following sites
should be used?
A. The brachial artery
B. The femoral artery
C. The apex of the heart
D. The radial site

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57. The physician has ordered an orthostatic blood pressure measurement. Which of the following
is correct concerning the orthostatic method of assessing blood pressure?
A. The measurement is taken in the lying position, then sitting up and last when the patient
is standing.
B. The measurement is taken first with the patient sitting up and then lying down.
C. The nurse should wait 5 minutes between assessing the blood pressure in the sitting
position from the lying position.
D. The patient should be lying down for at least 10 minutes before the nurse performs the
procedure.
58. The nurse is directed to obtain a type C fire extinguisher. A type C fire extinguisher is required
for which type of the following types of fire?
A. Paper
B. Cloth
C. Grease
D. Electrical
59. Ms. Gregorio is an 82-year-old patient who has had a right total hip replacement. On the first
postoperative day, the nurse repositions Ms. Gregorio to her left side, placing a pillow between
legs and another to her back. The nurse assesses the proper placement of Ms. Gregorio’s body
to evaluate:
A. Base support
B. Body alignment
C. Head/chin tilt
D. Gluteal pressure
60. The nurse explains to the patient that the logrolling technique will be used to help the patient
change position by stating:
A. “Logrolling will keep your hips slightly flexed toward your chest.”
B. “By having you dangle your legs at the bedside, you will be more comfortable.”
C. “Because of your injury, it is extremely important that the head of your bed remain up at
all times.”
D. “It is important to keep your neck and spine in straight alignment while we help you move
onto your side.”
61. The patient’s ask the nurse about different herbal therapies that may promote physical
endurance and reduce stress. Information may be provided on:
A. Ginseng
B. Ginger
C. Echinacea
D. Chamomile
62. A method of stimulating certain points on the body by the insertion of special needles to modify
the perception of pain, normalize physiologic functions, or treat or prevent disease is called:
A. Acupressure
B. Magnet therapy
C. Acupuncture
D. Chiropractic therapy

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63. Which of the following patients assigned to the nurse for A.M. care would be at greatest risk
for skin impairment?
A. Child on bed rest
B. Infant with cool skin temperature
C. Young man with diarrhea
D. 60-year-old patient in a body cast
64. A sputum specimen has been ordered for Mr. Buenaventura; a 75-year-old patient admitted
with possible pneumonia of the right lower lobe. Mr. Buenaventura is not able to cough. The nurse
is aware that for patients who cannot expectorate sputum from deep in the bronchial tree, the
specimen must be collected by:
A. Pharyngeal suctioning
B. Tracheal suctioning
C. Oropharyngeal suctioning
D. Percussion and vibration
65. To obtain a 24-hour urine specimen, the patient should be given which of the following
instructions?
A. Collect each voiding in separate containers for the next 24 hours
B. Discard the first voided specimen and then collect the total volume of each voiding for 24
hours
C. For the next 24 hours, retain a 30ml specimen of each voiding after recording the amount
voided
D. Keep a record of the time and amount of each voiding for 24 hours
66. Ms. Cristobal, age 72, has an indwelling urinary catheter. A sterile urine specimen has been
ordered for a culture and sensitivity. The sterile specimen should be obtained by:
A. Obtaining 60 ml of urine from the collection bag
B. Removing the present catheter, having the patient void, and then re-catheterizing
C. Disconnecting the tubing from the catheter and draining 2 ml of urine
D. Aspirating 10 ml of urine with a sterile syringe from the tubing port
67. A patient performing a finger stick for blood glucose determination asks why the side of the
fingertip is advised as the preferred site. The nurse is aware that it is because:
A. The blood supply is greater in this area
B. It is easier for the self-determination method
C. The side of the finger is less responsive to pain
D. It leaves more room for other site selection
68. The patient tells the nurse, “I have a very hard time getting a drop of blood from my finger for
the blood sugar test.” The nurse:
A. Asks the physician to order a different type of blood glucose monitoring system
B. Suggests that the patient use warm water on the finger just before using the blood lancet
C. Instructs the patient to use the same puncture site several times in a row for best results
D. Reminds the patient that it is acceptable to skip blood glucose monitoring once in a while
69. After inserting a nasogastric tube, the nurse can be certain it is in the proper place if:
A. The patient no longer complains of pain or nausea
B. 30 ml of normal saline can be injected with ease
C. Bubbles occur when the tube is submerged into water
D. Gastric contents are aspirated with cone tipped syringe
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70. Mr. Aragon, diagnosed with throat cancer, is a 2-day postoperative patient with a
tracheostomy. Which part of the tracheostomy tube is removed by the nurse for cleaning?
A. Outer cannula
B. Inner cannula
C. Single-lumen tube
D. Double-lumen tube
71. If, when suctioning Mr. Aragon, the nurse finds it necessary to repeat the interventions, it is
recommended that the nurse wait at least 3 minutes. This is to allow for:
A. Overcoming fatigue
B. Numbing of mucous membranes
C. Replenishing oxygen
D. Subsiding of pain
72. Preoperatively the physician orders “enemas until clear.” The maximum number of enemas
the nurse should give is:
A. Two
B. Three
C. Five
D. Unlimited
73. Ms. Javier has just returned from the PAC unit. During a report the nurse is told Ms. Javier
has a Penrose drain in the LLQ. The purpose of a Penrose drain is:
A. To instill solution for wound irrigation
B. To prevent blockage of a passageway
C. To drain the wound area by suction
D. To drain the wound area by gravity
74. A nurse is attending a cardiopulmonary resuscitation training to review her previous CPR
training as a requirement in the new hospital where she was recently employed. This is an
example of:
A. Continuing education
B. Advanced training
C. In-service training
D. Professional training
75. A nurse believes that health is a fundamental right of every individual. He believes in the worth
and dignity of each human being and recognizes the primary responsibility to preserve health at
all costs. These statements are part of the:
A. Philippine Nursing Act of 2002
B. Code of Ethics for Registered Nurses
C. Code of Good Governance for the Professions
D. Standards of Nursing Practice

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76. The nurse is attending to a client brought to the Emergency Department for treatment of acute
abdominal pain. Which of the following actions of the nurse demonstrates respect of client’s
autonomy?
A. Complying when the physician attempts to delegate obtaining informed consent
B. Facilitating and supporting client’s choices regarding treatment options
C. Describing the risks and benefits of the reasonable alternative treatments
D. Notifying appropriate parties if a patient has not given adequate information
77. Which of the following statements is correct regarding informed consent?

A. Nurse may not be legally liable if they know that informed consent was not obtained
B. It is ethical or legal for nurses to obtain informed consent for procedures are to be
performed by a physician
C. It is an ethical responsibility of nurses to provide client with opportunities to give informed
consent
D. It is not within a nurse’s domain of responsibility to notify the health team if a client has
not given an informed consent for the procedure
78. Which of the following is the most appropriate for the researcher to study if she would do a
correlational study?
A. Humor experienced by hospitalized patients
B. Humor, a basis for reducing anxiety among hospitalized patients
C. Effect of humor on anxiety of hospitalized patients
D. Anxiety among hospitalized patients experiencing humor
79. To obtain 30 appropriate samples for the study, the researcher decided to use simple random
sampling. Which of the following should the researcher do?
A. Include post-operative clients only
B. Select every 3rd hospitalized client in the list
C. Pick out 30 from the list of hospitalized clients
D. Choose 15 male and 15 female hospitalized clients
80. While teaching colostomy clients to do ostomy care, the nurse does problem solving when
she:
A. Discusses diet and nutrition with the client with colostomy
B. Gives equal number of supplies to all the colostomy clients
C. Requests suppliers to give lowest price to her clients
D. Observes which among the supplies work best for the clients
81. The treatment plan has been implemented. Which of the following is the MOST appropriate
action based on clinical decision?
A. Ask the client what he feels about the treatment
B. Conduct physical assessment and gather more data
C. Evaluate how effective the clinical decision is with the client
D. Generate more information by doing literature search

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82. A 70-year-old client is admitted to the hospital for difficulty of breathing and chest pain. He is
accompanied by his son who asks the nurse what he should do about his father’s hearing
problem. Which of the following responses by the nurse reflects therapeutic communication?
A. “I will ask your father for more information”
B. “What kind of hearing problems does your father have?”
C. “Your father will be referred to a specialist after a hearing test is done.”
D. “Hearing problems occur as people get older.”
83. While conducting nursing rounds, the nurse found a 30-year-old, post mastectomy client lying
on her side facing the wall. When the nurse approached her, she says “leave me alone, I need
rest.” The nurse responds by saying:
A. “I understand you.”
B. “I will be back.”
C. “You sound upset.”
D. “Don’t worry you can cover up the loss.”
84. An order to discontinue catheterization of the client was implemented. She complains of
difficulty in her first attempt to urinate. The nurse explains that this is due to:
A. Attempt of the body to adjust to normal reflex mechanism
B. Fluid and electrolyte imbalance
C. Irritation of the urethra
D. Irritation of the urinary bladder
85. The nurse is correctly performing the removal of the inner cannula when he/she:
A. Rinses the neck plate of the tracheostomy tube then pulling the inner cannula gently in
line with its curvature
B. Pulls gently the inner cannula clockwise
C. Unlocks inner cannula by turning counterclockwise and gently withdrawing in line with its
curvature
D. Picks up the inner cannula with glove that is considered sterile.
86. A client on bed rest is rolled to a lateral position by the nurse. The nurse is negotiating the
move correctly when he:
A. Positions himself at the midpart of the bed and places both hands at the back of the client
and roll client onto side.
B. Places one hand on the client’s far hip and the other on the client’s far shoulder rock
backward and roll onto side of the body facing him.
C. Assumes a broad stance with the foot nearest the bed placing his arms under the client’s
thighs and shoulder and roll client onto side
D. Supports the back and buttocks of the client and shifts his own weight from the forward to
the backward foot and roll onto his side.
87. Which of the following interventions must be carried out by the nurse to improve the client’s
sensory stimulation during isolation?
A. Provide a telephone inside the isolation room
B. Maintain a clean and pleasant environment and allow recreational activities
C. Talk with family members to avoid expression of disgust
D. Provide all the personal items needed by the client

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88. When he enters the room, he finds the client in bed. She says that she is “afraid to choke on
her medications because she sometimes has a hard time swallowing.” Which nursing action is
most appropriate?
A. Mix the medication in client’s soup
B. Put the client in supine position
C. Ask the client to assume sitting position
D. Mix the capsule in a banana for her to chew
89. The nurse will next administer an intramuscular injection preparation to another client. The
nurse safely administers the drug using the Z track technique of injection for the following reasons
EXCEPT:
A. This method leaves a zigzag path to seal the needle track
B. The skin is pulled sideways and the needle is injected at 45-degree angle
C. This technique is best when medication for IM injection is irritating to tissue
D. This technique requires that the medication be injected slowly to allow it to disperse evenly
in muscle tissue
90. The nurse prepares Penicillin for skin test. He uses a tuberculin syringe with gauge 25 needle
and performs the procedure correctly by:
A. Withdrawing needle quickly to minimize bleeding
B. Stretching skin over site and inserting needle slowly at 10 to 15-degree angle
C. Massaging the injection site
D. Pinching the skin over site and injecting medication slowly
91. The process in the community health nursing assessment is very essential to be able to
accurately diagnose the contemporary conditions within the community. A very vital part of the
process is?
A. Carrying out nursing procedures as per plan of action
B. Coordination with other sectors in relation to health concerns
C. Evaluation structures and qualifications of health concerns
D. The application of professional judgment in estimating the importance of facts to family
and community
92. The public health bag contains basic medications and articles, which are necessary for giving
care. Which of the following best describes the Public Health Bag?
A. The public health bag is an essential and indispensable equipment of the PHN.
B. The public health bag is used to minimize if not totally prevent the spread of infection.
C. The public health bag is a tool-making use of a public health bag through which the nurse
can perform nursing procedure.
D. The public health bag is used to render effective nursing care to clients and or members
of the family.

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93. In the implementation of Reproductive Health, the nurse is guided by the following principles:
1. Partnership and Networking
2. Family-Centered
3. Gender Sensitive
4. Evidence-Based
5. Life Course Approach
A. all except 4
B. all except 5
C. 2, 3, and 5
D. 1, 2, 3, 4, and 5
94. Which of the following is used to monitor particular groups that are qualified as eligible to a
certain program of the DOH?
A. Target Client list
B. Output record
C. Family treatment record
D. Reporting forms
95. Nurse Hannah is caring for a family with a 5-year-old child with scabies. Nurse Hannah should
include in the health teaching the treatment of scabies using what herbal plant?
A. Bayabas
B. Niyog-niyogan
C. Akapulko
D. Lagundi
96. Which information about recommended adult immunizations is accurate to include in health
teaching?
A. Influenza A and B vaccine are given one time, unless the client is high risk.
B. Measles and mumps vaccines are given to college-age students only.
C. Tetanus and diphtheria booster are needed at least every 5 years.
D. Pneumococcal pneumonia vaccine may be given once for lifetime protection.
97. A new mother verbalizes her concern about being afraid for her infant to feel pain during
vaccination that is why she will just continue breastfeeding her infant. The appropriate response
of the nurse is?
A. Most protection comes from colostrum just after birth and is enough to protect the infant.
B. Breastfeeding will only give temporary protection to the infant against diseases.
C. Vaccinations are not needed if breastfeeding is continued until 12 months.
D. The infant still needs to be vaccinated against DPT, measles, and polio before the infant
is 6 months old.
98. The occurrence of an unusually large number of cases in a relatively short period of time is
called:
A. Endemic
B. Pandemic
C. Sporadic
D. Epidemic

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99. In the newborn care interventions under the Essential Newborn Care program, after
thorough drying the newborn, early skin-to-skin contact should be initiated to provide
warmth and bonding. Which intervention should be included?
A. Counseling the mother regarding positioning in breastfeeding
B. Placing an identification on the wrist
C. Not removing the vernix
D. Cutting the cord clamp
100. When teaching the mother about potential adverse reactions of immunization for her child
who was just given his scheduled vaccination, the nurse should instruct the mother to quickly
report
A. mild temperature elevation.
B. local swelling at the injection site.
C. generalized urticaria.
D. pain at the injection site.

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NURSING PRACTICE I- ANSWERS AND RATIONALIZATIONS
1. Correct Answer: C
Primary prevention includes activities that prevent a problem before it occurs. Example is
option C. secondary prevention are activities that provide early detection and intervention
example is option A. Tertiary prevention include activities to correct a disease state and
prevent it from further deteriorating such as options B and D.
2. Correct Answer: A
The dietitian provides proper nutrients and food source requirements in patient’s diets,
instructs patients on meal planning and diet restrictions. Nutritionist is a person who
specialize in the study of nutrition.
3. Correct Answer: D
The centers for Disease and Control and prevention is an agency in the US Department
of Health and Human Services. It works to protect public health and safety by providing
information to enhance health decisions and it promotes health through partnerships with
state health departments and other organizations. It also governs surveillance of infectious
diseases, environmental health, health promotion and education activities designed to
improve the health of people.
A case manager is responsible for organizing client care through an episode of illness to
achieve specific clinical and financial outcomes within an allotted timeframe. He/she
coordinates all aspects of client care.
Discharge planning is the systematic process of planning for patient care after discharge
from the hospital often a patient will require the services of various disciplines. Complex
referrals involve interdisciplinary collaboration of various health disciplines.
The “at risk” groups are the population/group of individuals who are vulnerable to a certain
disease condition and nurses must identify them in the community so that measures can
be taken to prevent problems or deal with them in the early stages.
The family is assisting the patient who is a bilateral amputee, meet his elimination needs.
8. Correct Answer: B
Discharge planning is the process that enables the client to resume self-care activities
before leaving the health care environment. The nurse must take into account the possible
problems the client may encounter when he/she goes back to his/her home. That is the
reason why the nurse asked the client to describe his community so that the client can
make use of his available resources in the community.
When community health nurses assess the family, they not only examine the health status
of individual family members but look at the family dynamics as well. The purpose of
understanding family dynamics is to determine the level of family functioning, to clarify
family interaction patterns, to identify family strengths and weakness so that the plan of
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care of the family is compatible with the client’s everyday life and therefore has the
greatest chance of success.

Primary prevention such as case finding, disease prevention, and health teachings are
activities armed prior to the appearance of first signs and symptoms of disease or
problems.

Secondary prevention focuses on early detection and treatment.

Tertiary prevention focuses on rehabilitation and prevention of complications after a
disease condition.

Homeostasis is the balance between physiological, psychological, sociocultural,
intellectual and spiritual needs. It is a state of equilibrium.

In Abraham Maslow’s hierarchy of needs theory or the final level of psychological
development that can be achieved when all basic and mental needs are fulfilled then
realization of the full personal potential takes place.

People with low incomes, particularly those who live in poverty, face particular challenges
in maintaining their health. They are more likely than those with higher incomes to become
ill and to die at younger ages. They are also more likely to live in poor environmental
situations with limited health care resources.

Patient’s move from different care setting so as to cater and satisfy their physical,
emotional and psychological needs

Hepatitis A is transmitted through contact (direct and indirect) he was placed in contact
isolation to prevent transmission of infectious microorganisms.

Handwashing is the most important and basic preventive technique for interrupting the
infectious process. A 2-minute handwashing will provide the necessary protection before
the nurse cares for a patient. A 30-second handwashing before caring for another patient
should be sufficient to ensure minimal transmission of microorganisms between patients.

For a microorganism to be transported and be effective in continuing contamination, it
follows a definite cycle or chain. Nurses must determine the points at which the infection
can be stopped or prevented.

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Nosocomial infection is an infection acquired in a hospital or any other health care facility,
it is an infection acquired at least 72 hours after admission.

Acyclovir (Zovirax) is an antiviral drug that is primarily used for the treatment of herpes
simplex virus infections, as well as in the treatment of herpes zoster (shingles).

Scabies is an infectious parasitic disorder caused by a mite. The scabies mite burrows
under the skin, leaving behind debris, feces and eggs. The condition causes a popular
rash and intense pruritus especially at night. Transmission occurs by direct contact with
an infected person, linen or clothing.

Infection generally occurs through wound contamination and often involves a cut or deep
puncture wound. As the infection progresses, muscle spasms in the jaw develop. This is
followed by difficulty swallowing and spasm in other parts of the body such as respiratory
tract spasm which can be life threatening.

The tropical Splenomegaly syndrome or big spleen disease is massive enlargement of the
spleen resulting from abnormal immune response to repeated attacks of malaria.

In malaria, there is an extensive, hemolysis or destruction of RBC which can leave the
patient with severe anemia. The growing parasite consumes and degrades the
intracellular protein, mainly hemoglobin. Malarial cachexia is the physical signs resulting
from antecedent attacks of severe malaria, including anemia, shallow skin, yellow sclera,
splenomegaly, hepatomegaly, retardation of growth and puberty (in children).

Gonorrhea is a very common and highly infectious disease. It can produce sterility.

The drug of choice for the treatment of gonorrhea is Ceftiraxone. All Ceftriaxone are Beta-
lactam antibiotics and are now used in the treatment of bacterial infections caused by
susceptible usually Gram-positive organisms. Actinomycin is the first antibiotic shown to
have anti-cancer activity. Chloramphenicol is effective against a wide variety of Gram-
positive and Gram-negative bacteria but due to resistance and safety concerns, it is no
longer a first-line agent. Colistin are usually used to treat intestinal infection or to suppress
colonic flora.

Sputum smear and culture must be collected on 3 different days to increase the chance
of identifying the mycobacterium.

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Presenting symptoms of TB in adults are often vague and consistent of a cough over 3
weeks duration, pleuritic chest pain, hemoptysis, fatigue, malaise, anorexia, night sweats
and elevated afternoon temperature.

Disturbed in body image and impairment of skin integrity is the appropriate nursing
diagnosis considering that she is an adolescent and that pockmarks or small open sores
damages skin integrity

Clinical manifestations of Measles (Rubeola) are fever, malaise, cough, coryza,
conjunctivitis, Koplik’s spots (pinpoint red spots with central white speck in buccal cavity
opposite lower molars) 3-4 days before rash.

The child has severe pneumonia that needs urgent attention and referral or admission for
in-patient care. According to IMCI resource manual this is a very severe classification that
needs urgent attention.

Diphtheria toxin attacks the tonsils and causes fever, red sore throat, weakness and
headache. Hospitalization is usually required, as intravenous fluid, increased fluid intake,
supplementary oxygen, bed rest, and careful monitoring of heart function is needed.

Schistosomiasis or snail fever is a parasitic disease caused by several flukes. It is a
chronic illness that can damage internal organs and in children, it impairs growth and
cognitive development. Prevention is best accomplished by eliminating the water-dwelling
snails that are the natural reservoir of the disease, thus environmental sanitation and
environmental control are very essential in controlling schistosomiasis.

Abraham’s Maslow’s hierarchy of needs is most commonly used model that assists in the
understanding of the patient’s place in the wellness/illness continuum. Dorothea Dix was
an American activist on behalf of the indigent insane who through a vigorous program,
created the first generation of American Mental asylums. Clara Barton was a school
teacher who volunteered as a nurse during American Civil War. Barton is noted for her
role in establishing the American Red Cross. Theodor Fliedner was a minister who
developed a plan whereby young woman would find and care for the needy sick.

The client is acknowledging the feelings of the client and she is also asking the client to
explore the underlying cause of the fear.

Option B is restating, that is repeating the main idea expressed. This restatement lets the
client know that he or she communicated the idea effectively. This encourages the client
to continue.

Option D is reflecting, that is directing client actions, thoughts & feelings back to the client.
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Older adults may have physical or cognitive problems that necessitate the nurse to be
considerate. If the client is deaf, the nurse must face the client, & should speak slowly in
a low-pitched voice. There is no need to speak loudly into his “good” ear nor exaggerate
lip movement while speaking.

Objective data/cues are observable and measurable data that are obtained through both
standard assessment techniques performed during the physical examination & diagnostic
tests. Subjective data are data from the client’s point of view and include feelings,
perceptions & concerns. The method of collecting subjective information is primarily the
interview.

The risk for aspiration or risk for respiratory functioning is an immediate threat to the
client’s survival, second to this is deficient fluid volume.

In creating an outcome statement, it must describe observable client response, what the
nurse hopes to achieve by implementing the nursing intervention. Outcome statement
must be measurable, realistic and time limited.

Subjective data are data from the clients’ point of view including feelings, perceptions and
concerns. So therefore, a person who is describing his illness is providing a subjective
data.

In the nursing process, implementing is the action phase in which the nurse performs the
nursing interventions. Implementing consists of doing and documenting the activities that
are the specific nursing actions needed to carry out the interventions.

After carrying out the nursing activities, the nurse completes the implementing phase by
recording the interventions and client responses in the patient’s chart. One general
guideline for recording or charting is to use only commonly accepted abbreviations,
symbols, and terms that are specified by the agency. Many health care facilities supply as
approved list of abbreviations and symbols to prevent confusion.

Nurses must remember that when taking care of patients awake/conscious or unconscious
dead or alive, our patient is a human being deserving dignity, courtesy and respect at all
times.

Discharge planning is the process of anticipating and planning for client needs after
discharge to ensure continuity of care.

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Discharge planning needs to begin when a client is admitted to an agency, especially in

hospitals where stays are considerably shortened. Effective discharge planning involves
ongoing assessment to obtain comprehensive information about the client’s ongoing
needs and nursing care plans to ensure the client’s and caregiver’s needs are met.

If the client decides or chooses to leave a health care facility without a physician’s written
order the nurse should explain the risk of leaving and the client must sign a waiver or
Absence without authority (AWA) or Against Medical Advice (AMA) form accepting
responsibility for problems that may occur. The nurse must not restrain the client since
this will amount to battery/illegal detention. The client has a right to insist on leaving even
though it may be detrimental to health.

The oral temperature is 1 degree lower than the rectal temperature. Rectal temperature
readings are considered to be very accurate.

During an intermittent fever, the body temperature alternates at regular intervals between
periods of fever and periods of normal or subnormal temperature. During a remittent fever,
a wide range of temperature fluctuations occurs over the 24-hr period. Relapsing fever,
short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal
temperature. Constant fever, the body temperature fluctuates minimally but always
remains above normal.

Taking the apical pulse for a 66-year-old, recovering from MI would be the most accurate
pulse site. According to Kozier, assessment of apical pulse is indicated for clients whose
peripheral pulse is irregular or unavailable as well as for clients with known cardiovascular,
pulmonary and renal diseases.

Hypertension is when either the diastolic blood pressure is 90 mm Hg or higher or when
the systolic blood pressure is higher than 140 mmHg. Factors associated with
hypertension include thickening of the arterial walls, which reduces the size of the arterial
lumen, and in elasticity of the arteries as well as such lifestyle factors as cigarette smoking
obesity, heavy alcohol consumption, lack of physical exercise, high blood cholesterol
levels and continued exposure to stress.

The patient experiencing strong emotions or under stress may likely have a higher than
normal temperature. This is because stimulation of the sympathetic nervous system can
increase the production of epinephrine and norepinephrine, thereby increasing metabolic
activity and heat production.

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The difference of 38 between the diastolic & the systolic pressure is called the pulse
pressure. A normal pulse pressure is about 40 mmHg. A consistently elevated pulse
pressure occurs in arteriosclerosis

To obtain the pulse rate of a 2-year-old infant, the nurse uses the apical pulse or use the
apex of the heart.

Orthostatic hypotension is a blood pressure that falls when the client sits or stands. It is
usually the result of peripheral vasodilation. When assessing for orthostatic hypotension:
– place the client in a supine position for 10 minutes
– Record the client’s pulse & BP
– Assist the client to slowly sit or stand
– Then recheck the pulse and BP in the same site
– Repeat the Pulse & BP after 3 minutes
– Record Results

Extinguishing the fire requires knowledge of 3 categories of fire, classified according to
the type of material that is burning:
Class A: paper, wood, upholstery, rags, ordinary rubbish
Class B: Flammable liquid and gases
Class C: electrical

Body alignment is the position of body parts in relation to each other. Base of support is
the foundation of which a person or object rests. Head/chin tilt is a maneuver in opening
the airway in cases of emergency to check for airway patency.

When a nurse assists a person to move, correct body mechanics need to be employed so
that the nurse is not injured. Correct body alignment (neck & spine in straight alignment)
for the client must also be maintained so that undue stress is not placed on the
musculoskeletal system

Ginseng is thought to increase physical endurance and reduce stress. Ginger effectively
decreases nausea and vomiting of pregnancy and it also alleviates sore throat. Echinacea
extracts may limit the length and severity of rhinovirus colds. Chamomile extracts or tea
aids in sleeping improves wound healing, treat common cold and diarrhea.

Acupuncture is a technique of inserting and manipulating fine filiform needles into specific
points on the body to relieve pain. Acupuncture points are believed to stimulate the central
nervous system to release chemicals to the muscles, spinal cord, and brain. The
biochemical changes may stimulate the body’s natural healing abilities and promote
physical and emotional well-being.

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A 60-year-old patient in a body cast is at high risk for skin impairment. As one ages,
subcutaneous tissue and elastin fibers diminished causing the skin to become thinner.
Added to that, the elderly client is on body cast making the patient at high risk for
compromised circulation, movement and sensation therefore increasing the risk for skin
impairment.

Since the patient is unable to cough, specimen can be obtained through tracheal
suctioning, with the use of the sputum trap. The nurse attaches the suction catheter to the
tubing of the sputum trap, then attaches the suction tubing to the sputum trap air vent,
then suction the client. The sputum trap will collect the mucus during suctioning.

To obtain a 24-hour urine specimen, the nurse must instruct the patient to discard the 1st
voided specimen. Place the collection receptacle on ice and carefully add each void to the
collection. If the patient has an individually catheter, place the catheter bag on ice and
empty regularly into the collection bottle. End the collection by having the patient void or
by emptying the drainage system and adding the specimen to the collection receptacle.
Label and keep on ice for delivery to the laboratory.

Sterile urine specimens can be obtained from closed drainage systems by inserting a
sterile needle attached to syringe through a drainage port in the tubing. Aspiration of urine
from catheters can be done only with self-sealing rubber catheters – not plastic, silicone
or silastic catheters.

Capillary blood specimens are commonly obtained from the lateral aspect or side of the
finger in adults. This site avoids the nerve endings and calloused areas at the fingertip.
The earlobe may be used if the client is in shock or the finger are edematous.

The patient can also wrap the finger in a warm cloth, aside from suggesting to patient to
use warm water on a finger just before using the blood lancet. These actions increase the
blood flow to the area, ensuring adequate specimen and reduce the need for a repeat
puncture.

To ascertain correct placement of the tube, aspirate stomach contents and check the pH
which should be acidic. Testing pH is a reliable way to determine location of a feeding
tube.

The inner cannula is removed and is soaked in a sterile normal saline. The nurse cleans
the lumen and entire cannula thoroughly using the brush or pipe cleaners moistened with
sterile normal saline.

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Suction is done for a minimum of 10 seconds. Do not suction longer than 10 seconds.
Prolonged suctioning depletes oxygen supply. If suctioning needs to be repeated, allow
patient to rest between each episode of suctioning. Suctioning can be exhausting and
frightening for patient. Resting helps regain depleted oxygen and renew strength.

When enemas are ordered “until clear” in preparation for surgery, enemas are repeated
until patient passes fluid that is clear and contains no fecal matter. Usually, 3 consecutive
enemas are adequate. If after 3 enemas the water is highly colored or contains solid fecal
material, notify physician before continuing. Excessive loss of electrolytes is a dangerous
possibility.

Surgical drains, like a Penrose drain, are inserted to permit the drainage of excessive
serosanguineous fluid and purulent material and to promote healing of underlying tissue.
Without a drain, some wounds would heal on the surface and trap the discharge inside
and an abscess night form.

Option C – CORRECT. In-service education is a planned program provided by an
employing agency to its employees. Specifically, the employing agencies offer the in-
service programs to equip the new employee with the basic organizational information to
enable him/her to adapt to the new situation (such as the agency’s mission and vision, the
organizational structure), and further enhance the skills of nurses to provide quality patient
care.
Option A – INCORRECT. Continuing education in nursing consists of planned learning
experiences beyond the basic education program. Although this option is a correct
answer, this is a general concept and involves numerous activities, such as in-service
education and advanced trainings. Option C is more specific and directly answers the
question.
Option B – INCORRECT. Advanced training refers to continuing education programs
offered by professional organizations representing various nursing specialties such as,
Critical Care Nurse Association of the Philippines (CCNAPI), Association of Nursing
Service Administrators of the Philippines (ANSAP), and the like. The nurse may not
necessarily be employed in the said institution for him/her to receive said training. This
aims to.
Option D – INCORRECT. Professional training is THE SAME as Continuing Education.

Option B – CORRECT. Article I, Section 1 of the Amended Code of Ethics for Nurses
states that “Health is a fundamental right of every individual. The Filipino registered nurse,
believing in the worth and dignity of each human being, recognizes the primary
responsibility to preserve health at all cost. This responsibility encompasses promotion of
health, prevention of illness, alleviation of suffering, and restoration of health. However,
when the foregoing is not possible, assistance towards a peaceful death shall be his/her
obligation.
Option A – INCORRECT. The Philippine Nursing Act of 2002, commonly known as
Republic Act 9173 (RA 9173), defines the scope of the Nursing Profession in the
Philippines – Organization of the Board of Nursing, Examination and Registration, Nursing
Education, and Nursing Practice.

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Option C – INCORRECT. The Code of Good Governance states that the hallmark of all
professionals is their willingness to accept a set of professional and ethical principles
which they will follow in the conduct of their daily lives. The acceptance of these principles
requires the maintenance of a standard of conduct higher than what is required by law.
Option D – INCORRECT. Standards of Nursing Practice provide guidelines to describe
what a reasonably prudent person would do under similar circumstances.

Option B – CORRECT. By definition, Autonomy involves self-determination and freedom
to choose and implement one’s decision, free from deceit, duress, constraint or coercion.
Facilitating and supporting client’s choices regarding treatment options (this includes
allowing the patient to refuse treatment if he so decides), disclosure of his ailment,
prognosis, mode of treatment, and maintaining confidentiality are all part of this principle.
This principle is also called INFORMED CONSENT.
Option A – INCORRECT. Obtaining an informed consent is done by the PHYSICIAN, not
the nurse. Nurses have the duty to clarify any concerns or questions that the patient has
after the physician has explained a certain medical procedure or treatment. Once the
patient fully understands the risks and benefits of the regimen, the nurse calls the
physician to let the patient sign the consent.
Option C – INCORRECT. This is under the principle of VERACITY. By definition, Veracity
binds both the health practitioner and the patient in an association of truth. The patient
must tell the truth in order to provide appropriate care. On the other hand, the practitioner
needs to disclose factual information (diagnosis, plan of care, treatment and possible risks
involved, etc.) so that the patient can exercise personal autonomy.
Option D – INCORRECT. Notifying the appropriate parties if the patient provided
inadequate information is part of the collaborative role of a nurse.

Option C – CORRECT. Informed consent is the name for a general principle of law that a
physician has a duty to disclose what a reasonably prudent physician in the medical
community in the exercise of reasonable care would disclose to his patient as to whatever
grave risks of injury might be incurred from a proposed course of treatment. Although it is
the NURSE who actually makes sure that there is consent from the patient upon
admission, the PHYSICIAN is responsible for obtaining the consent after disclosing all
information about a certain treatment regimen. Therefore, nurses have the responsibility
to clarify the patient’s concerns and provide the best time and opportunity for them to give
an informed consent.

Option C – CORRECT. The appropriate title for this study is “The effect of humor on the
anxiety of hospitalized clients” since the basic purpose of correlational research is the
same as that of experimental research: to study relationships among variables. However,
unlike experimental research, it is difficult to infer causal relationships in correlational
studies. Experimental studies deliberately manipulate the independent variable resulting
to changes in the dependent variable. On the other hand, investigators using correlational
studies do not control the independent variable – the presumed causative factor – because
it has already occurred.
Option A – INCORRECT. This title is applicable for a Phenomenological Research.
Option B – INCORRECT. This is applicable for an Experimental Research.
Option D – INCORRECT. This title is unrelated and is incorrect.

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Option C – CORRECT. Simple random sampling is the most basic probability sampling
design. This consists of respondents taken from a sampling frame, the technical name for
the actual list of the population elements which are numbered consecutively, and is
selected using a “fish-bowl” technique. In this situation, the sampling frame is the list of
hospitalized clients in the unit.
Option A – INCORRECT. This is a form of Purposive sampling. This sampling technique
is based on the belief that researchers’ knowledge about their population can be used to
hand pick the cases (or types of cases) to be included in the sample using an INCLUSION
criterion.
Option B – INCORRECT. This is a form of Systematic sampling.
Option D – INCORRECT. This is a form of Stratified random sampling.

Option D – CORRECT. Decision making is a critical-thinking process for choosing the best
actions to meet a desired goal, such as selecting the best supplies for the patient. In
addition, decision making is also used when nurses make decisions and assist clients to
make decisions. When a client is trying to make a decision about what course of treatment
to follow, the nurse may provide information or resources the client can use in making a
decision.
Option A – INCORRECT. Although diet and nutrition with the client promotes decision-
making abilities of the nurse, diet and nutrition is NOT RELATED to ostomy care. It does
not involve decision-making.
Option B – INCORRECT. This option focuses on allocation of equal supplies. It does not
require decision-making.
Option C – INCORRECT. This option focuses on the suppliers.

Evaluating is a planned, ongoing, purposeful activity in which clients and health care
professionals determine (a) the client’s progress toward achievement of goals/outcomes
and (b) the effectiveness of the nursing care plan. Therefore, the most important act of
evaluation performed by nurses is evaluating outcome achievement with the patient.

Asking broad (open-ended) questions lead or invite the client to explore thoughts or
feelings. Open-ended questions specify not only the topic to be discussed and invite
answers that are longer than one or two words.

Making observations, directing ideas, feelings, questions, or content back to clients,
enable them to explore their own ideas and feelings about a situation.

It is normal for the client to experience some dysuria, especially if the catheter has been
in place for several days or weeks. With an indwelling catheter in place, the bladder muscle
does not stretch and contract regularly as it does when the bladder fills and empties in
voiding.

Using a gloved hand, unlock the inner cannula counterclockwise and remove it by gently
pulling it toward you in line with its curvature. This moistens and loosens dried secretions.
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When pulling or rolling the client to the lateral position, the nurse places one hand on the
client’s far hip and the other hand on the client’s far shoulder. This position of the hands
supports the client at the two heaviest parts of the body, providing greater control in
movement during the roll.

The nurse takes measures to improve the client’s sensory stimulation during isolation. The
room environment should be clean and pleasant. Drapes or shades should be opened,
and excess supplies and equipment removed. Regular communication and comfort
measures (e.g. repositioning, a back massage, or assisting the patient with bathing)
provide mental and physical stimulation. Recreational activities such as board games or
cards may be an option to keep the client mentally stimulated.

If the client has difficulty swallowing, crush the tablets to a fine powder then mix the powder
with a small amount of soft food (e.g. custard, applesauce, soup) unless the medication is
time-released or enteric coated (these medications should NOT be crushed).
Administering Intramuscular (IM) injections requires piercing the skin at a 90-degree
angle. A smooth manipulation of syringe reduces discomfort from needle movement.

A 5 to 15-degree angle insertion ensures that the needle tip is in the dermis. Stretching
the skin ensures that needle pierces tight skin more easily.

In the assessment part in the community, the salience of the family and the community
itself is very important. The nurse may apply a professional judgment to estimate the
importance of the assessment and facts to the people. Salience is how the community
gives importance and interprets the existing problems as problems. Carrying out
nursing procedures and coordination with other sectors are part of the intervention
phase and not assessment. Evaluation structures and qualifications of health concerns
are part of the evaluation phase.

The best description of the public health bag is that it is an essential and indispensable
equipment of the public health nurse, which he/she can carry along during home visit. The
public health bag contains basic medications and articles, which are necessary for giving
care.

The nurse is guided by all these principles. Reproductive Health is developed to care for
the couple, the children, and the young. All of these principles should be the guide of the
nurse.

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The target client list monitors the particular group that are qualified as eligible to certain
programs of the Department of Health such as care for the pregnant mother, tuberculosis,
and leprosy. The target client list serves as the second building block for the monitoring
and supervision of the mentioned programs.

Akapulko is used as anti-fungal. It can be used as treatment for tinea flava, ringworm,
athlete's foot, and scabies. Bayabas is indicated for washing wounds and diarrhea. Niyog-
niyogan is used as anti-helminthic such as for round worms and ascariasis. Lagundi is
indicated for asthma, fever and cough.

Pneumoccocal pneumonia vaccine is given to anyone at high risk for pneumococcal
pneumonia or its complications. One immunization is recommended for lifetime protection,
although revaccination every 6 years should be considered for clients who are high-risk.
Influenza A and B vaccine are given one time for high-risk individuals. Measles and
mumps are indicated for anyone born after 1956 with an uncertain immune status. A
booster for tetanus and diphtheria is only needed every 10 years.

Only disease-specific antibodies produced by the mother in response to that infection can
be produced through breast milk to the infant and the antibodies provide passive and
temporary immunity only, therefore vaccinations are still needed. Vaccinations develop
active immunity compared to breastmilk.

Epidemic or outbreak is a situation when there is a marked upward fluctuation in disease
incidence. Endemic occurrence is the continuous occurrence throughout a period of time,
of the usual number of cases in a given locality. Pandemic is shared occurrence of a
disease in several countries. Sporadic is the occasional occurrence of a disease in a few
isolated places.

The Essential New Born Care protocols include the provision of warmth and
bonding. These is attained by thorough drying the newborn and then put the
newborn to prone position on chest or abdomen, allow skin-to-skin contact,
cover with blanket or bonnet, and do not remove vernix. The identification band
is placed on the ankle and not on the wrist. Counseling the mother about
breastfeeding is done prior to delivery.
Generalized urticaria is a classic symptom of allergic reaction, which could progress to

anaphylactic reaction when the body of the child did not compensate. This reaction can

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herald the onset of a life-threatening episode, therefore medical assistance should be

sought immediately. Mild temperature elevation, localized swelling, and pain at the injection
site are expected and non-life-threatening symptoms that can be managed appropriately.

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NURSING PRACTICE II- QUESTIONS

1. Women may occasionally develop bizarre eating habits during pregnancy, eating such
non-edible items as coal or laundry detergent. This type of behavior is referred to as:
A. couvade
B. delusions
C. pica
D. prenatal psychosis
2. A diabetic client who currently takes oral antidiabetic agents to control her blood glucose
level is planning to become pregnant. The nurse should advise her to:
A. talk to her physician about beginning insulin
B. quit taking the oral antidiabetic agents
C. increase her morning dose of oral antidiabetic agent to ensure low blood glucose levels
throughout the day
D. make no changes in her daily diabetes management
3. A 22-year-old client has been admitted to the hospital with severe preeclampsia. An
infusion of magnesium sulfate is started to decrease the incidence of seizure activity. The
nurse assesses the client frequently to monitor for signs of magnesium toxicity. Which
assessment finding is a sign of possible magnesium toxicity?
A. Urine output of 30 to 40 ml/hour
B. Blood pressure of 140/80 mm Hg
C. Respiratory rate of 10 breaths/minute
D. Uterine contractions every 3 to 5 minutes
4. The nurse is caring for a 15-year-old pregnant client. The client weighs 100 lbs (45.4 kg)
and has a history of pyelonephritis, which puts her at high risk for:
A. polyhydramnios
B. chromosomal abnormalities
C. post-term labor
D. pre-term labor
5. Pamela, who is 10 weeks pregnant complains of morning sickness. To promote relief, the
nurse should suggest:
A. eating dry crackers before arising
B. increasing her fat intake before bedtime
C. having two small meals daily and snack at noon
D. drinking more high-carbohydrate fluids with her meals
6. A couple attended childbirth classes to prepare for labor. The nurse reinforces what they
learned about breathing techniques as the woman progresses through labor. During
contractions in the latent phase of labor, the type of breathing generally called for is:
A. panting breaths during contractions
B. slow paced breathing at a rate of 6 to 8 breaths/minute
C. modified paced breathing at a rate of 32 to 40 breaths/minute
D. patterned paced breathing at a rate of 32 to 40 breaths/minute

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7. When measuring the frequency of contractions, the nurse notes the time between:
A. the number of contractions in 1 hour
B. the beginning of a contraction and the end of that contraction
C. the end of one contraction and the beginning of the next contraction
D. the beginning of one contraction and the beginning of the next contraction
8. A 23-year-old woman is in the active phase of labor. The nurse notes variable
decelerations on the fetal monitor and observes the cord protruding out of the vagina.
Which intervention should the nurse perform immediately?
A. Instruct the client to push
B. Stimulate the fetal scalp or use acoustic stimulation
C. Help the woman to roll over and assume a side-lying position
D. Insert two fingers into the vagina to the cervix and press upward on the presenting part
9. A woman is admitted to the hospital with a second episode of bleeding from a placenta
previa. Which intervention is indicated?
A. Use a scalp electrode to record fetal heart rate
B. Get the client out of bed to empty her bladder before surgery
C. Perform frequent vaginal examinations to record cervical changes
D. Obtain a complete blood count (CBC) and an order for packed red blood cells (RBCs).
10. When assessing a client who gave birth 2 hours earlier, you palpate an indefinite fundus
two fingerbreadths above and to the right of the umbilicus. The client is bleeding heavily.
You should:
A. increase the I.V. flow rate or encourage oral fluid intake
B. encourage the client to ambulate
C. assist the client to urinate
D. take no action; these findings are normal\
11. Which statement by a postpartum woman after cesarean delivery indicates that further
discharge teaching is needed?
A. “Being tired may increase the pain I feel.”
B. “I need to hold my incision when I cough.”
C. “My mother will come to help me when I get home.”
D. “The incision needs to be covered with a bandage.”
12. What nursing intervention would be most helpful in providing emotional support to a
woman and her family after a cesarean delivery?
A. Encouraging the father to observe the infant’s first bath.
B. Positioning the infant with pillows during feeding.
C. Providing opportunities to discuss reaction to the birth experience.
D. Recommending frequent rest periods for the new mother.

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13. An example of methods used in natural family planning includes:

A. Calendar Method and Billings Method
B. Calendar Method and Condom
C. Contraceptive pills and Cervical Mucus
D. Tubal ligation and vasectomy
14. Vitamin K is administered to all neonates immediately after birth because:

A. their fetal blood cells are prone to coagulation problems
B. their immature livers predispose them to low vitamin K levels
C. they lack intestinal organisms to synthesize vitamin K
D. they all experience avitaminosis
15. While evaluating a neonate in the surgery, you check his hips for signs of dislocation.
Which of the following signs indicates that the hips are in the normal position?
A. Both legs abduct easily
B. Skin folds are asymmetrical
C. A click is heard when hip integrity is assessed
D. The femur head is felt to slip forward in the acetabulum
16. Upon analysis, according to this theory, health promoting behaviors are results of
perceived susceptibility, severity, cost and benefit in relation to the health problem:
A. Self- Efficacy Theory
B. Health Promotion Theory
C. Health Belief Model
D. None of the Above
17. The Philippine Health Care Delivery System is correctly described in which of the following
statements?
A. The PHCDS is composed only of the medical doctors and nurses.
B. The Department of Interior and Local Government is the country’s foremost health
coordinating agency because of the implementation of the devolution.
C. Health insurance companies dictate the current referral system in the country.
D. Health care delivery system in the country was specifically designed for the poor in
congruence with the Primary Health Care concept.
18. 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 breast feeding.
19. What are the basic phases of the CO-PAR process?

A. pre-entry, entry, community organization and capability building, community study,
community action phase, sustenance and strengthening phase
B. pre-entry, entry, community study, community organization and capability building,
community action phase, sustenance and strengthening phase
C. pre-entry, entry, community study, community organization and capability building,
sustenance and strengthening phase, community action phase
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D. pre-entry, entry, community study, community action phase, sustenance and

strengthening phase, community organization and capability building
20. A nonstress test is performed on a client who is pregnant, and the results of the test
indicate nonreactive findings. The physician prescribes a contraction stress test and the
results are documented as negative. A nurse interprets the finding of the contraction stress
test as indicating;
A. A normal test result
B. An abnormal test result
C. A high risk for fetal demise
D. The need for a cesarean delivery
21. A postpartum nurse is taking the vital signs of a client who delivered a healthy infant 4
hours ago. The nurse notes that the client’s temperature is 100.2 F which of the following
actions would be appropriate?
A. Notify the physician
B. Document the findings
C. Retake the temperature in 15 minutes
D. Increase hydration by encouraging oral fluids
22. A postpartum nurse is assessing a client who delivered a healthy infant by cesarean
section for signs and symptoms of superficial venous thrombosis. Which of the following
signs or symptoms would the nurse note if superficial venous thrombosis were present?
A. Paleness of the calf area
B. Coolness of the calf area
C. Enlarged hardened veins
D. Palpable dorsalis pedis pulse
23. A nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago.
The client had a midline episiotomy and has several hemorrhoids. What is the priority
nursing diagnosis for this client?
A. Acute pain
B. Disturbed body image
C. Impaired urinary elimination
D. Risk for imbalanced fluid volume
24. A postpartum nurse is providing instructions to a client after delivery of a healthy infant.
The nurse instructs the client that she should expect normal bowel elimination to return
A. 3 days postpartum
B. 7 days postpartum
C. On the day of delivery
D. within 2 weeks postpartum
25. Fetal distress is occurring with a laboring client. As the nurse prepares the client for a
cesarean birth, what other interventions should be performed?
A. Slow the intravenous flow rate
B. Place the client in a high fowler’s position
C. Continue the oxytocin drip if infusing
D. Administer oxygen 8 to 10 L/min via face mask

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26. A maternity nurse is preparing for the admission of a client in the third trimester of
pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of
placenta previa. The nurse reviews the physician’s prescription and would question which
prescription?
A. Prepare the client for an ultrasound
B. Obtain equipment for a manual pelvic examination
C. Prepare to draw a hemoglobin and hemoglobin and hematocrit
D. Obtain equipment for external electronic fetal heart rate monitoring
27. A nurse in the labor room is caring for a client in the active stage of labor. The nurse is
assessing the fetal patterns and notes a late deceleration on the monitor strip. The
appropriate nursing action is to:
A. Administer oxygen via face mask
B. Place the mother in a supine position
C. Increase the rate of oxytocin intravenous infusion
D. Document the findings and continue to monitor the fetal patterns
28. A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if
which of the following is noted on the external monitor tracing during a contraction?
A. Variability
B. Accelerations
C. Early decelerations
D. Variable decelerations
29. A pregnant client in the last trimester has been admitted to the hospital with a diagnosis
of severe preeclampsia. A nurse monitors for complications associated with the diagnosis
and assesses the client for:
A. Enlargement of the breasts
B. Complaints of feeling hot when the room is cool
C. Periods of fetal movement followed by quiet periods
D. Evidence of bleeding such as in the gums petechiae and purpura
30. A nurse has performed a nonstress test on a pregnant client and is reviewing the fetal
monitor strip. The nurse interprets the test as reactive and understands that this indicates:
A. Normal findings
B. Abnormal findings
C. The need for further evaluation
D. That the findings on the monitor were difficult to interpret
31. A maternity nurse is providing instructions to a new mother regarding the psychosocial
development of the newborn infant. Using Erickson’s psychosocial development theory,
the nurse instructs the mother to:
A. Allow the newborn infant to signal a need
B. Anticipate all the needs of the newborn infant
C. Attend to the newborn infant immediately when crying
D. Avoid the newborn infant during the first 10 minutes of crying

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32. A nurse-midwife is assessing a pregnant client for the presence of ballottement. To make
this determination, the nurse-midwife does which of the following?
A. Auscultates for fetal heart sounds
B. Assesses the cervix for compressibility
C. Palpates the abdomen for fetal movement
D. Initiates a gentle upward tap on the cervix
33. A pregnant client asks a nurse in the clinic when she will be able to begin to feel the fetus
move. The nurse responds by telling the mother that fetal movement will be noted between
which of the following weeks of gestation?
A. 6 and 8
B. 8 and 10
C. 10 and 12
D. 16 and 20
34. A nurse prepares to administer digoxin (Lanoxin) to a 3-year-old child with a diagnosis of
congestive heart failure and notes that the apical heart rate is 110 beats/min. Based on
this finding which nursing action is appropriate?
A. Hold the medication
B. Notify the physician
C. Administer the digoxin
D. Recheck the apical rate in 15 minutes
35. A day care nurse is observing a 2-year-old child and suspects that the child may have
strabismus. Which observation made by the nurse might indicate this condition?
A. The child has difficulty hearing
B. The child consistently tilts the head to see
C. The child consistently turns the head to see
D. The child does not respond when spoken to
36. A nurse receives a telephone call from the admitting office and is told that a child with
rheumatic fever will be arriving in the nursing unit for admission. On admission, the nurse
prepares to ask the mother which question to elicit assessment information specific to the
development of rheumatic fever?
A. “Has the child complained of back pain?”
B. “Has the child complained of headaches?”
C. “Has the child had any nausea or vomiting?”
D. “Did the child have a sore throat or fever within the last 2 months?”
37. A nurse is preparing to care for a child with a diagnosis of intussusception. The nurse
reviews the child’s record and expects to note which symptom of this disorder
documented?
A. Watery diarrhea
B. Ribbon like stools
C. Profuse projectile vomiting
D. Bright red blood and mucus in the stools

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38. A clinic nurse reviews the record of an infant and notes that the physician has documented
a diagnosis of suspected Hirschsprung’s disease. The nurse reviews the assessment
findings documented in the record, knowing that which symptom most likely led the mother
to seek health care for the infant?
A. Diarrhea
B. Projectile vomiting
C. Regurgitation of feedings
D. Foul smelling ribbon like stools
39. A nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal
atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most
likely sign of this condition documented in the record?
A. Incessant crying
B. Coughing at nighttime
C. Choking with feedings
D. Severe projectile vomiting
40. A nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On admission
assessment, which data would the nurse expect to obtain when asking the mother about
the child’s symptoms?
A. Watery diarrhea
B. Projectile vomiting
C. Increased urine output
D. Vomiting large amounts of bile
41. A child has a right femur fracture caused by a motor vehicle accident and is placed in skin
traction temporarily until surgery can be performed. During assessment the nurse notes
that the dorsalis pedal pulse is absent on the right foot. What action should the nurse take?
A. Notify the physician
B. Administer an analgesic
C. Release the skin traction
D. Apply ice to the extremity
42. A nurse caring for an infant with congenital heart failure (CHF) is monitoring the infant
closely for signs of congestive heart failure. The nurse assesses the infant for which early
signs of CHF?
A. Pallor
B. Cough
C. Tachycardia
D. Slow and shallow breathing
43. In developing a teaching plan for a type 1 diabetic in pregnancy, the nurse will include
which of the following?
A. Insulin requirements increase as pregnancy progresses
B. Glucosuria levels are good indicators of metabolic regulation
C. Exercise will increase insulin requirements during pregnancy
D. Complex carbohydrates need to be restricted

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44. When caring for a newly diagnoses primigravid patient at 10 week’s gestation who is
experiencing breast tenderness, amenorrhea, nausea and vomiting, and urinary
frequency, which of the following would the nurses identifies a s priority nursing diagnosis?
A. Readiness for Enhanced Family Coping related to pregnancy confirmation.
B. Compromised Family Coping related to the discomforts of pregnancy.
C. Ineffective Sexuality Patterns related to fear of spontaneous abortion.
D. Imbalanced nutrition: less than body requirements related to increased demands
of pregnancy
45. Examination of a primigravid patient complaining of increased vaginal secretions since

becoming pregnant reveals clear, highly acidic vaginal secretions. The patient denies any
perineal itching or burning. The nurse interprets these findings as a response related to
A. Control of the growth of pathologic bacteria.
B. A decrease in vaginal glycogen stores.
C. Development of a sexually transmitted disease.
D. Prevention of expulsion of the cervical mucus plug.
46. When developing a teaching plan for a patient who is 8 weeks pregnant, which of the
following foods would the nurse suggest to meet the patient’s need for increased folic
acid?
A. Spinach
B. Bananas
C. Seafood
D. Yogurt
47. The nurse instructs a primigravid patient about the importance of sufficient vitamin A in
her diet. The nurse knows that the instructions have been effective when the patient
indicates that she should include which of the following in her diet?
A. Strawberries and watermelon
B. Buttermilk and cheese
C. Oranges and tomatoes
D. Egg yolks and squash
48. Which of the following statements by a primigravid patient scheduled for chorionic villi
sampling indicates effective teaching about the procedure?
A. “A fiberoptic fetoscope will be inserted through a small incision into my uterus.”
B. “I can’t have anything to eat or drink after midnight on the day of the procedure.”
C. “The procedure involves the insertion of a thin catheter into my uterus.”
D. “I need to drink 32 to 40 ounces of fluid 1 to 2 hours before the procedure.”
49. A desire for which of the following diagnostic tests would be most important to ascertain
for a primigravid patient in the second trimester of her pregnancy?
A. Chorionic villi sampling
B. Culdocentesis to detect abnormalities
C. Ultrasound testing
D. α-Fetoprotein (AFP) testing

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50. Which of the following recommendations would be the most appropriate preventive
measure to suggest to a primigravid patient at 30 weeks’ gestation who is experiencing
occasional heartburn?
A. Take a pinch of baking soda with water before meals.
B. Eat smaller and more frequent meals during the day.
C. Decrease fluid intake to four glasses daily.
D. Drink several cups of regular tea throughout the day.
51. When teaching a primigravid patient how to do Kegel exercises several times a day, the
nurse explains that the primary purpose of these exercises is to accomplish which of the
following?
A. Alleviate lower back discomfort.
B. Prevent vaginal swelling.
C. Strengthen the perineal muscles.
D. Strengthen the abdominal muscles.
52. A primigravid patient at 36 weeks’ gestation tells the nurse that she has been experiencing
insomnia for the past 2 weeks. Which of the following suggestions would be most helpful?
A. Practice relaxation techniques before bedtime.
B. Drink a cup of hot chocolate before bedtime.
C. Drink a small glass of wine with dinner.
D. Exercise for 30 minutes just before bedtime.
53. During a 2-hour childbirth preparation class focusing on the labor and delivery process for
primigravid patients, the nurse describes the first maneuver that the fetus goes through
during the labor process when the head is the presenting part as which of the following?
A. Descent
B. Flexion
C. Internal rotation
D. Engagement
54. A primigravid patient in a Preparation for Parenting class asks how much blood is lost
during an uncomplicated delivery. Which of the following would be the nurse’s best
response?
A. “The maximum blood loss considered within normal limits is 500 ml.”
B. “The minimum blood loss considered within normal limits is 1,000 ml.”
C. “Blood loss during a delivery is rarely estimated unless there is a hemorrhage.”
D. “It would be very unusual if you lost more than 100 ml of blood during the
delivery.”
55. After a “Preparation for Parenting” class session, a pregnant patient tells the nurse that
she has had some yellow-gray frothy vaginal discharge and local itching. The nurse’s best
action is to advise the patient to which of the following?
A. Use an over-the-counter cream for yeast infection.
B. Prepare for preterm labor and delivery.
C. Schedule an appointment at the clinic for an examination.
D. Administer a vinegar douche under low pressure.

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56. A dilation and curettage (D & C) is scheduled for a primigravid patient admitted to the
hospital at 10 weeks’ gestation with abdominal cramping, bright red vaginal spotting and
passage of some of the products of conception. The nurse anticipates that the patient will
most likely express which of the following feelings?
A. Guilt
B. Anxiety
B. Fear
C. Ambivalence
57. A multigravida patient who stands for long periods while working in a factory visits the
prenatal clinic at 35 weeks’ gestation, stating, “The varicose veins in my legs have really
been bothering me lately.” Which of the following instructions would be most helpful?
A. Take frequent rest periods with the legs elevated above the hips.
B. Avoid support hose that reach above the leg varicosities.
C. Perform slow contraction and relaxation of the feet and ankles twice daily.
D. Take a leave of absence from your job to avoid prolonged standing.
58. At 32 weeks’ gestation, a 15-year-old primigravid patient who is 5 feet, 2 inches tall has
gained a total of 20 pounds, with a 1-pound gain in the last 2 weeks. Urinalysis reveals
negative glucose and a trace of protein. The nurse determines that which of the following
factors increases this patient risk for preeclampsia?
A. Total weight gain
B. Short stature
C. Adolescent age group
D. Proteinuria
59. When making a home visit to a 19-year-old primigravid patient at 38 weeks’ gestation
diagnosed with mild preeclampsia and mild peripheral edema requiring bed rest at home
for the past 2 weeks, which of the following would the nurse identify as the patient’s priority
nursing diagnosis?
A. Noncompliance related to poor nutrition and lack of exercise during pregnancy.
B. Delayed Growth and Development related to required bed rest and
subsequent immobility.
C. Deficient Fluid Volume related to fluid shift from intravascular to extravascular
space.
D. Situational Low Self-esteem related to prolonged bed rest and pregnancy
complications.
60. An 18-year-old patient at 33 weeks’ gestation diagnosed with mild preeclampsia is

prescribed bed rest at home. The nurse instructs the patient to contact the health care
provider immediately if she experiences which of the following?
A. Mild backache
B. Blurred vision
C. Ankle edema
D. Increased energy levels

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61. The physician orders intravenous magnesium sulfate for a primigravid patient at 38 weeks’
gestation diagnosed with severe preeclampsia. Which of the following medications would
the nurse have readily available at the patient’s bedside?
A. Calcium gluconate
B. Hydralazine (Apresoline)
C. Diazepam (Valium)
D. Phenytoin (Dilantin)
62. Soon after admission of a primigravid patient at 38 weeks’ gestation with severe
preeclampsia, the physician orders a continuous intravenous infusion of 5% dextrose in
Ringer’s solution and 4 g of magnesium sulfate. While the medication is being
administered, which of the following assessment findings should the nurse report
immediately?
A. Patellar reflex of +2.
B. Blood pressure of 160/88 mm Hg.
C. Urinary output exceeding intake.
D. Respiratory rate of 12 bpm
63. If a patient at 36 weeks’ gestation with eclampsia begins to exhibit signs of labor after an
eclamptic seizure, for which of the following would the nurse assess?
A. Transverse lie.
B. Abruptio placentae.
C. Uterine atony.
D. Placenta accreta.
64. A 26-year-old patient, G3P1, at 32 weeks’ gestation, is admitted to the hospital because
of vaginal bleeding. After reviewing the patient’s history, which of the following factors
might lead the nurse to suspect abruption placentae?
A. History of cocaine use.

B. Several hypotensive episodes.
C. Previous low transverse cesarean delivery.
D. One induced abortion.
65. The nurse is preparing to administer terbutaline (Brethine) to a multigravid patient in

preterm labor. Before administering this drug intravenously, the nurse should assess
A. Weight gain.
B. Urinary output.
C. Hematocrit level.
D. Heart rate.
66. The physician orders betamethasone (Celestone) for a 36-year-old multigravida patient at
32 weeks’ gestation who is experiencing preterm labor. Previously, the patient has
experienced one infant death due to preterm birth at 28 weeks’ gestation. The nurse
explains that this drug is given for which of the following reasons?
A. To enhance fetal lung maturity.
B. To decrease neonatal production of surfactant.
C. To counter the effects of tocolytic therapy.

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D. To treat chorioamnionitis.
67. The nurse is planning care for a multigravida patient hospitalized at 36 weeks’ gestation
with confirmed rupture of membranes and no evidence of labor. Which of the following
would the nurse expect the physician to order?
A. Vaginal culture for Neisseria gonorrhoeae.
B. Frequent assessments of cervical dilation.
C. Intravenous oxytocin administration.
D. Sonogram for amniotic fluid volume index
68. On arrival at the emergency department, a patient tells the nurse that she suspects that
she may be pregnant but has been having a small amount of bleeding and has severe
pain in the lower abdomen. The patient’s blood pressure is 70/50 mm Hg and her pulse
rate is 120 bpm. The nurse notifies the physician immediately because which of the
following is suspected?
A. Complete abortion
B. Gestational trophoblastic disease
C. Abruptio placentae
D. Ectopic pregnancy
69. When preparing a multigravida patient who has undergone evacuation of a hydatidiform
mole for discharge, the nurse explains the need for follow-up care. The nurse determines
that the patient understands the instructions when she says that she is at risk for
developing which of the following?
A. Choriocarcinoma.
B. Multifetal pregnancies.
C. Ectopic pregnancy.
D. Infertility.
70. During a pelvic examination. The physician notes a definite softening of the lower uterine
segment, discoloration of the mucous membranes of the vagina, and softening of the
cervix. These signs are referred to respectively as:
A. hegar’s; chadwick’s’ goodell’s
B. goodell’s; chadwick’s; hegar’s
C. chadwick’s; goodell’s; hegar’s
D. none of the above
71. Which one of the following hormones most likely inhibits uterine contractions throughout
pregnancy?
A. Progesterone
B. Prostaglandin
C. Estrogen
D. Oxytocin
72. A client in the active phase of labor has reactive fetal monitor strip and has been
encouraged to walk. When she returns to bed for a monitor check, she complains of an
urge to push. When performing vaginal examination, the nurse accidentally ruptures the
amniotic membranes, the umbilical cord comes out. What should be done next?
A. Put the client in a knee-chest position
B. Call the physician or midwife

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C. Push down on the uterine fundus

D. Set up for a fetal blood sampling to assess for fetal acidosis
73. A client is attempting to deliver vaginally despite the fact that her previous delivery was by
cesarean section. Her contractions are 2 to 3 minutes apart, lasting from 75 to 100
seconds. Suddenly, the client complaints of intense abdominal pain and the fetal monitor
stops picking up contractions. The nurse recognizes that which of the following has
occurred?
A. Abruptio placentae
B. Prolapsed cord
C. Partial placenta previa
D. Complete uterine rupture
74. A mother who brings her 6-month-old infant to the clinic for a regular checkup is concerned
that her infant is not developing appropriately. When assessing the infant, which of the
following would the nurse expect to find?
A. Sitting up with support
B. Reaching for a toy.
C. Finger-to-thumb grasping.
D. Saying mama or dada.
75. The mother asks the nurse for advice about discipline for her 18-month-old. Which of the
following would the nurse suggest that the mother use first?
A. Spanking.
B. Reasoning.
C. Structured interactions.
D. Time out.
76. The nurse asks a 9-year-old child and mother about the child’s best friend to assess which
of the following about the child?
A. Social development.
B. Neurologic development.
C. Motor development.
D. Language development.
77. After teaching a group of parents about temper tantrums, the nurse knows the teaching
has been effective when one of the parent’s states which of the following?
A. “I’ll talk to my daughter during the tantrum.”
B. “I should pick up the child during the tantrum.”
C. “I will ignore the temper tantrum.”
D. “I should put my child in time out.”
78. After insertion of bilateral tympanostomy tubes, which of the following instructions would
the nurse include in a child’s discharge plan for the parents?
A. Insert ear plugs into the canals when the child bathes.
B. Blow the nose forcibly during a cold.
C. Disregard any drainage from the ear after 1 week.
D. Administer the prescribed antibiotic while the tubes are in place.

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79. In preparation for discharge, the nurse teaches the mother of an infant diagnosed with
bronchiolitis about the condition and its treatment. Which of the following statements by
the mother indicates successful teaching?
A. “I need to be sure to take my child’s temperature every day.”
B. “I hope I don’t get a cold from my child.”
C. “Next time my child gets a cold I need to listen to the chest.”
D. “I need to wash my hands more often.”
80. When assessing a child after heart surgery to correct tetralogy of fallot, which of the
following would alert the nurse to suspect a low cardiac output?
A. Capillary refill of 2 seconds and blood pressure of 97/67 mm Hg.
B. Altered level of consciousness and thread pulse.
C. Bounding pulses and mottled skin.
D. Extremities warm to touch and pale skin.
81. A 16-month-old child diagnosed with Kawasaki Disease (KD) is very irritable, refuses to
eat, and exhibits peeling skin on the hands and feet. Which of the following would the
nurse interpret as the priority?
A. Offering foods, the toddler likes.
B. Applying lotion to the hands and feet.
C. Encouraging the parents to get some rest.
D. Placing the toddler in a quiet environment.
82. While caring for a neonate with an imperforated anus, the nurse assesses the neonate’s
urine output for which of the following?
A. Meconium.
B. Bile.
C. Blood.
D. Acetone.
83. Which of the following patient actions would the nurse judge to be a healthy coping
behavior for a male adolescent after an appendectomy?
A. Not taking telephone calls from friends so he can rest.
B. Refusing to fill out the menu, and allowing the nurse to do so.
C. Avoiding interactions with other adolescents on the nursing unit.
D. Insisting on wearing a T-shirt and gym shorts rather than pajamas.
84. Which of the following statements by a mother would suggest to the nurse that her child
has celiac disease?
A. “He is so short.”
B. “His belly is so small.”
C. “His stools are large and smelly.”
D. “His urine is so dark in color.”
85. When developing the discharge teaching plan for a child with chronic renal failure and the
family, the nurse would emphasize restriction of which of the following nutrients?
A. Phosphorus.
B. Magnesium.
C. Ascorbic acid.
D. Calcium.

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86. When teaching an adolescent with a seizure disorder who is receiving valproic acid
(Depakene), which of the following would the nurse instruct the patient to report to the
health care provider?
A. Three episodes of diarrhea.
B. Loss of appetite.
C. Jaundice.
D. Sore throat.
87. A 9-year-old child with Guillain-Barré syndrome requires mechanical ventilation. Which of
the following would the nurse do?
A. Turn the child slowly and gently from side to side to prevent respiratory
complications.
B. Maintain the child in a supine position to prevent unnecessary nerve stimulation.
C. Engage the child in vigorous passive range-of-motion exercises to prevent loss
of muscle function.
D. Transfer the child to a bedside chair 3 times a day to prevent postural
hypotension.
88. Which of the following would the nurse do first when noting clear drainage on the child’s
dressing and bed linen after a craniotomy for a brain tumor?
A. Change the dressing.
B. Elevate the head of the bed.
C. Test the fluid for glucose.
D. Notify the physician.
89. . When assessing a female adolescent for scoliosis, the nurse would ask the patient to do
A. Lie flat on the floor and extend her legs straight from the trunk.
B. Bend forward at the waist with arms hanging freely.
C. Stand against a wall while pressing the length of her back against the wall.
D. Sit in a chair while lifting her feet and legs to a right angle with the trunk.
90. The nurse observes as a child with Duchenne’s muscular dystrophy attempts to rise from
a sting position on the floor. After attaining a kneeling position, the child “walks” his hands
up his legs to stand. The nurse documents this as which of the following?
A. Goodenough’s sign.
B. Gower’s sign.
C. Galeazzi’s sign.
D. Goodell’s sign.
91. Shane, an adolescent that just had surgery and has a dressing on the abdomen. Which
of the following questions would the nurse expect the patient to ask initially?
A. “Will I have a large scar?”
B. “What complications can I expect?”
C. “When can I return to school?”
D. “Did the surgery go okay?”

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92. Before a routine checkup in the pediatrician’s office, Ara, an 8-month-old infant is sitting
contentedly on her mother’s lap, chewing on a toy. When preparing to examine this infant,
which of the following actions should the nurse do first?
A. Obtain body weight.
B. Measure the head circumference.
C. Auscultate heart and lung sounds.
D. Elicit papillary reaction.
93. A mother is inquiring about her child’s ability to potty train. Which of the following factors
is the most important aspect of toilet training?
A. The age of the child
B. The child ability to understand instruction.
C. The overall mental and physical abilities of the child.
D. Frequent attempts with positive reinforcement
94. Twinkle, a toddler is admitted with a cardiac anomaly. The nurse is aware that the infant
with a ventricular septal defect will:
A. tire easily
B. grow normally
C. need more calories
D. be more susceptible to viral infections
95. Parents of a child with Kawasaki disease should be taught the importance of keeping
follow-up appointments to monitor and prevent which complication?
A. Myocardial infarction.
B. Idiopathic thrombocytopenia.
C. Encephalitis.
D. Glomerulonephritis.
96. Which of the following signs is most characteristic of a child with croup?
A. Fever.
B. Low heart rate.
C. Respiratory distress.
D. “Barking” cough.
97. Which of the following assessment data indicates nuchal rigidity?

A. Positive Kernig’s sign.
B. Negative Brudzinki’s sign.
C. Positive Homan’s sign.
D. Negative Kernig’s sign
98. The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed
with celiac disease. Which of the following foods, if selected by the mother, would indicate
her understanding of the dietary instructions?
A. ham sandwich on whole-wheat toast
B. spaghetti and meatballs
C. hamburger with ketchup
D. cheese omelet

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99. Diagnosis of congenital hip dislocation can best be confirmed by which of the following
diagnostic techniques?
A. Positive T-burg gait.
B. Audible clicking with adduction.
C. X-ray.
D. Positive Ortolani’s sign.
100. Which of the following terms describes a fungal infection found on the upper arm?
A. Tinea capitis.
B. Tinea cruris.
C. Tinea corporis.
D. Tinea pedis.

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NURSING PRACTICE II- ANSWERS AND RATIONALIZATIONS

Pica is the term for eating substances generally not considered edible. Usually, the client
won’t tell the nurse about cravings for nonfood substances unless directly asked. She
may fear that others will find her behavior odd. Pica often accompanies iron deficiency
anemia. Couvade refers to the unintentional development of pregnancy symptoms by the
nonpregnant partner. Delusions occur when a person perceives objects or people that
aren’t present. Prenatal psychosis isn’t usually related to bizarre eating habits.
The client will probably begin treatment with insulin because oral antidiabetic agents are
associated with fetal anomalies and shouldn’t be used during pregnancy.
Signs and symptoms of magnesium toxicity include respiratory depression, oliguria,
respiratory arrest, cardiac arrest, and the loss of patellar reflexes. A respiratory rate less
than 12 breaths/minute may indicate magnesium toxicity.
This client has three risk factors for preterm labor: age younger than 16, pyelonephritis,
and weight of less than 110 lbs (50 kg).
It may occur as a systemic reaction to the increase in the estrogen level or decrease
glucose level because glucose is being utilized in great quantity by the growing fetus.
Increasing carbohydrates intake relieves nausea and traditionally women takes saltines
crackers prior to getting out of bed then have a light breakfast only at around 10 AM
During the latent phase (dilation of 0 to 3 cm), slow paced breathing is recommended.
This type of breathing uses less energy and is less apt to result in fatigue early in the labor
process. Panting generally isn’t used until the transitional phase of labor (8 to 10 cm).
Frequency is measured from the beginning of one contraction to the beginning of the next
contraction
The goal here is to relieve pressure on the cord from the presenting part. This can be
accomplished by manually holding the presenting part off the cord through exerting
upward pressure on the presenting part.

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A client with a second episode of bleeding from a placenta previa usually needs to undergo
cesarean delivery, and a CBC is necessary to determine hemoglobin level before surgery;
an order for packed RBCs will ensure replacement blood is available in case it’s needed.

A full bladder displaces the uterus, which can prevent it from contracting adequately,
causing excessive bleeding.

To prevent infection, the incision should be exposed to air.

Encouraging discussion of reactions to the birth experience allows expression of negative
feelings and helps in the acceptance of the cesarean deliveries

Calendar and Billings Method are both natural family planning methods. Condom and
contraceptive pills are artificial methods whereas Tubal ligation and vasectomy are
permanent methods of family planning.

Neonates have sterile GI tracts at birth and, therefore, are incapable of synthesizing
vitamin K until about 8 days after birth.

Inspection of a neonate’s hips during assessment should reveal symmetrical skin folds,
easy abduction of both legs, and absence of a click or sense that the femur is moving
within the acetabulum.

The model describes people’s motivation and readiness to change their health-related
behavior. Specifically, people’s behavior is influenced by their perception that taking action
will result in a desirable outcome, belief in their ability to perform the behavior, (self-
efficacy) that they are susceptible and that the consequences can be serious, that the
barriers to taking action are outweighed by the benefits, and belief that others whom they
value would approve.

This is the actual definition of Health Care delivery system in the Philippines by Public
Health Nursing in the Philippines 10th Edition

Severe pneumonia requires urgent referral to a hospital. Answers A, C and D are done
for a client classified as having pneumonia

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.
The basic phases of the CO-PAR process are: pre-entry, entry, community study,
community organization and capability building, community action phase, sustenance and
strengthening phase.

Contraction stress test results may be interpreted as negative or positive or equivocal. A
negative test results indicates that no late decelerations occurred in the fetal heart rate
although the fetus was stressed by three contractions of at least 40 seconds duration in a
10-minute period.

The client’s temperature should be taken every 4 hours while she is awake. Temperatures
up to 100.4 F° in the first 24 hours after birth often are related to the dehydrating effects
of labor

Thrombosis of superficial veins usually is accompanied by signs and symptoms of
inflammation including swelling, redness, tenderness and warmth of the involved
extremity.

The priority nursing diagnosis for a client who delivered 2 hours ago and who has a midline
episiotomy and hemorrhoids is acute pain.

After birth the nurse should auscultate the client’s abdomen in all four quadrants to
determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3
days postpartum.

Oxygen is administered 8 to 10 L/min via face mask to optimize oxygenation of the
circulating blood.

Placenta previa is an improperly implanted placenta in the lower uterine segment near
over the internal cervical os. Manual pelvic examination is contraindicated when vaginal
bleeding is apparent until a diagnosis is made and placenta previa is ruled out.

Late deceleration is due to uteroplacental insufficiency and occur because of decreased
blood flow and oxygen to the fetus during the uterine contractions. If hypoxemia results
oxygen 8 to 10 L/min via face mask is necessary.

Variable decelerations occur if the umbilical cord becomes compressed reducing blood
flow between the placenta and the fetus.

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Severe preeclampsia can trigger disseminated intravascular coagulation because of the
widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be
reported to the health care provider.

A reactive nonstress test is a normal result. To be considered reactive the baseline fetal
heart rate must be within normal range (120-160beats/min) with good long-term variability.

According to Erickson, the caregiver should not try to anticipate the newborn infant’s
needs at all times but must allow the newborn infant to signal needs. If a newborn infant
is not allowed to signal a need, the infant will not learn how to control the environment.
Erickson believed that a delayed or prolonged response to a newborn infant’s signal would
inhibit the development of trust and mistrust of others.

Ballotement is a technique of palpating a floating structure by bouncing it gently and
feeling it rebound. In the technique used to palpate the fetus, the examiner places a finger
in the vagina and taps gently upward causing the fetus to rise

Quickening is fetal movement and may occur by the 16 to 20 weeks gestation.

The normal apical heart rate for a 3-year-old is 80 to 120 beats/min.

Strabismus is a condition in which the eyes are not aligned because of lack of coordination
of the extraocular muscles

Rheumatic fever is an inflammatory autoimmune disease that affects the connective
tissues of the heart, joints, subcutaneous tissues and blood vessels of the central nervous
system. Sore throat is associated with rheumatic heart disease because of its causative
agent group A beta hemolytic streptococcus (GABHS).

Intussusception is a telescoping of one portion of the bowel into another causing bloody
mucoid stools.

Hirschsprung’s disease is a congenital anomaly also known as congenital aganglionosis
or aganglionic megacolon and it is characterized by ribbon like stools.

In esophageal atresia and tracheoesophageal fistula, the esophagus terminates before it
reaches the stomach ending in a blind pouch

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In pyloric stenosis, hypertrophy of the circular muscles of the of the pylorus causes
narrowing of the pyloric canal bet the stomach and the duodenum

An absent pulse to an extremity of the affected limb after a bone fracture could mean that
the child is developing or experiencing compartment syndrome. This is an emergency
situation and the physician should be notified immediately.

Congestive heart failure is the inability of the heart to pump a sufficient amount of oxygen
to meet the metabolic needs of the body. The early signs of CHF include tachycardia,
tachypnea, profuse scalp sweating, fatigue and irritability.

Early in pregnancy a woman with DM need less insulin. Later in pregnancy increase
amount because of increased metabolic rate.

The priority nursing diagnosis at this time relates to nutrition, and the necessary health
teaching involves a definite need for appropriate nutrition to meet the needs of the growing
fetus. Pregnancy places additional demands on the body and adequate nutrition is
important for fetal well-being throughout pregnancy.

An increase in clear, highly acidic vaginal secretions is a normal finding during pregnancy
that aids in controlling the growth of pathologic bacteria. Vaginal secretions increase
because of the influence of estrogen secretion and increased vaginal and cervical
vascularity. The increased acidity helps to make the vagina resistant to bacterial growth.

Green leafy vegetables, such as asparagus, spinach, brussels sprouts, and broccoli, are
rich sources of folic acid. The pregnant woman needs to eat foods high in folic acid to
prevent folic acid deficits, which may result in neural tube defects in the newborn.

Egg yolks and squash and other yellow vegetables are rich sources of vitamin A. Pregnant
woman should avoid megadose of vitamin A because fetal malformations may occur.

Chorionic villi sampling, which can be performed between 8- and 10-weeks’ gestation,
involves the insertion of a thin catheter into the vagina and uterus to obtain a sample of
the chorionic cells.

AFP testing is usually performed between the 15th and 18th weeks of gestation. Abnormally
high levels found in maternal serum may be indicative of neural tube defects such as
anencephaly and spina bifida. Low levels may indicate trisomy 21.

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Eating small and more frequent meals may help prevent heartburn because acid
production is decreased and stomach displacement is reduced. Heartburn can occur at
any time during pregnancy.

The purpose of Kegel exercises is to strengthen the perineal muscles in preparation for
the labor process. These movements strengthen the pubococcygeal muscle, which
surrounds the urinary meatus and vagina.

Insomnia in the later par of pregnancy is not uncommon because the client has difficulty
getting into a position of comfort. This is further compounded by frequent nocturia. The
best suggestion would be to advise the patient to practice relaxation techniques before
bedtime

If the head is the presenting part, the normal maneuvers during labor and delivery are
descent, flexion, internal rotation, extension, external rotation, and expulsion. These
maneuvers are called the cardinal movements. They occur as the fetal head passes
through the maternal pelvis during the normal labor process.

In a normal delivery and for the first 24 hours postpartum, a total blood loss not exceeding
500 mL is considered normal. Blood loss during delivery is almost always estimated
because it provides a valuable indicator for possible hemorrhage. A blood loss of 1,000
mL is considered hemorrhage.

Increased vaginal discharge is normal during pregnancy, but yellow-gray frothy discharge
with local itching is associated with infection.

With a spontaneous abortion, many clients and their parents feel an acute sense of loss.
Their grieving often includes feelings of guilt, which may be expressed as wondering
whether the woman could have done something to prevent the loss. Anger, sadness, and
disappointment are also common emotions after a pregnancy loss.

The client with varicosities should take frequent rest periods with the legs elevated above
the hips to promote venous circulation.

Clients with increased risk for preeclampsia include primigravid clients younger than 20
years or older than 40 years, clients with five or more pregnancies, women of color, women
with multifetal pregnancies, women with diabetes or heart disease, and women with
hydramnios.

Because the client has peripheral edema with preeclampsia, the most appropriate nursing
diagnosis is Option C. The scenario supplies no data for Option A and B.
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Severe headache, visual disturbances such as blurred vision, and epigastric pain are
associated with the development of severe preeclampsia and possibly eclampsia. These
danger signs and symptoms must be reported immediately. Severe headache and visual
disturbances are related to severe vasoconstriction and a severe increase in blood
pressure. Epigastric pain is related to hepatic dysfunction.

The client receiving magnesium sulfate intravenously is at risk for possible toxicity. The
antidote for magnesium toxicity is calcium gluconate, which should be readily available at
the client’s bedside.

A respiratory rate of 12 bpm suggests potential respiratory depression, an adverse effect
of magnesium sulfate therapy. The medication must be stopped and the physician should
be notified immediately

After an eclamptic seizure, the client is at risk for abruption placentae due to severe
vasoconstriction resulting in hemorrhage into the decidua basalis.

Although the exact cause of abruption placentae is unknown, possible contributing factors
include excessive intrauterine pressure caused by hydramnios or multiple pregnancy,
cocaine use, cigarette smoking, alcohol ingestion, trauma, increased maternal age and
parity and amniotomy.

Tachycardia is a common side effect of terbutaline therapy. If the client’s heart rate is 130
bpm or faster, the nurse should contact the physician before administering the medication.

Betamethasone therapy is indicated when the fetal lungs are immature. It increases the
production of neonatal surfactant. The fetus must be between 28- and 34-weeks’ gestation
and delivery must be delayed for 24 to 48 hours for the drug to achieve a therapeutic
effect.

Because an intrauterine infection may occur when membranes have ruptured, vaginal
cultures from N. gonorrhoeae, β-streptococci, and Chlamydia are usually taken.
Prophylactic antibiotics may be prescribed to reduce the risk of infection in the newborn.

The client’s signs and symptoms indicate a probable ectopic pregnancy, which can be
confirmed by UTZ examination or by culdocentesis. The physician is notified immediately
because hypovolemic shock may develop without external bleeding. Once the fallopian
tube ruptures, blood will enter the pelvic cavity, resulting in shock.

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A client who has had a hydatidiform mole removed should have regular check-ups to rule
out the presence of choriocarcinoma, which may complicate the client’s clinical picture.
The client’s HCG levels are monitored for 1 year.

A definite softening of the lower uterine segment is called Hegar’s sign. Discoloration of
mucous membranes of the vagina is called Chadwick’s sign. Softening of the cervix is
called Goodell’s sign.

Progesterone inhibits uterine contractions throughout pregnancy.

The knee–to–chest position gets the weight off the baby and umbilical cord, which would
prevent blood flow.

In complete uterine rupture, the client would feel a sharp pain in the lower abdomen and
contractions would cease. Fetal heart rate would also cease within a few minutes.

Typically, a 6-month-old infant should be able to sit with support from a person holding the
infant lightly in the area of the hips or lower chest.

Time out is the most appropriate discipline for toddlers. It helps to remove them from the
situation and allows them to regain control.

During the school-aged years, a child learns to socialize with children of the same age.
Therefore, the nurse is assessing the child's social development. The "best friend" stage,
which occurs at about 9 or 10 years of age, is very important in providing a foundation for
self-esteem and later relationships

Children who have temper tantrums should be ignored as long as they are safe. They
should not receive either positive or negative reinforcement to avoid perpetuating the
behavior. Temper tantrums are a toddler's way of achieving independence.

Placing ear plugs in the ears will prevent contaminated bathwater from entering the middle
ear through the tympanostomy tube and causing an infection.

Handwashing is the best way to prevent respiratory illnesses and the spread of disease.
Bronchiolitis, a viral infection primarily affecting the bronchioles, causes swelling and
mucus accumulation of the lumina and subsequent hyperinflation of the lung with air
trapping. It is transmitted primarily by direct contact with respiratory secretions as a result
of eye-to-hand or nose-to-hand contact or from contaminated fomites. Therefore,
handwashing minimizes the risk for transmission.
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With a low cardiac output and subsequent poor tissue perfusion, signs and symptoms
would include pale, cool extremities; cyanosis; weak, thready pulses; delayed capillary
refill; and decrease in level of consciousness.

One of the characteristics of children with KD is irritability. They are often inconsolable.
Placing the child in a quiet environment may help quiet the child and reduce the workload
of the heart.

Passage of meconium in the urine is a sign of recto urinary fistula, in which the rectum
and bladder communicate.

Adolescents struggle for independence and identity, needing to feel in control of situations
and to conform with peers. Control and conformity are often manifested in appearance,
including clothing, and this carries over into the hospital experience. They feel best when
they are able to look and act as they normally do – for example, wearing T-shirt and gym
shorts.

Celiac disease is a disorder involving intolerance to the protein gluten, which is found in
wheat, rye, oats and barley. The stools of a child with celiac disease are characteristically
malodorous, pale, large (bulky), and soft (loose).

With minimal or absent kidney function, the serum phosphate level rises, and the ionized
calcium level falls in response. This causes increased secretion of parathyroid hormone,
which releases calcium from the bones. Therefore, the intake of foods high in phosphorus
is restricted.

A toxic effect of valproic acid (Depakene) is liver toxicity, which may manifest with jaundice
and abdominal pain. If jaundice occurs, the client needs to notify the health care provider
as soon as possible.

Even in the absence of respiratory problems or distress, the child must be turned
frequently to help prevent the cardiopulmonary complications associated with immobility,
such as atelectasis and pneumonia

Glucose in this clear, colorless fluid indicates the presence of CSF. Excessive fluid
leakage should be reported to the physician.

Scoliosis, a lateral deviation of the spine, is assessed by having the client bend forward at
the waist with arms hanging freely, then looking for lateral curvature of the spine and a rib
hump
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With Gower’s sign, the child walks the hands up the legs in an attempt to stand, a common
approach used by children with Duchenne’s muscular dystrophy when rising from a sitting
to a standing position. Galeazzi’s sign refers to the shortening of the affected limb in
congenital hip dislocation. Goodell’s sign refers to the softening of the cervix, considered
a sign of probable pregnancy. Goodenough’s sign refers to a test of mental age.

Adolescents are deeply concerned about their image and how they appear to others.

Heart and lung auscultation shouldn’t distress the infant, so it should be done early in the
assessment. The remaining options may cause distress, making the rest of the
examination more difficult.

Age is not the greatest factor in potty training. The overall mental and physical ability of
the child is the most important factor.

The toddler with a ventricular septal defect will tire easily because of insufficient oxygen
supply.

In Kawasaki disease, inflammation of small and medium blood vessels can result in
weakening of the vessels and aneurysm formation, especially in the heart. Blood flow
through damaged vessels can cause thrombus formation and MI.

A resonant cough described as “barking” is the most characteristic sign of croup. The child
may have varying degrees of respiratory distress related to swelling or obstruction.

A positive Kernig’s sign indicates nuchal rigidity, caused by an irritative lesion of the
subarachnoid space. Brudzinski’s sign is also indicative of the condition.

The child with celiac disease should be on a gluten-free diet.

X-ray will confirm the diagnosis of CHD. All of the options are positive signs of dislocation,
but only the X-ray will confirm the diagnosis.
100.Correct Answer: C
Tinea corporis describes fungal infections of the body. Tinea capitis describes fungal
infections of the scalp. Tinea pedis is the term for fungal infections of the foot. Tinea cruris
is used to describe fungal infections of the inner thigh and inguinal creases.

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NURSING PRACTICE III- QUESTIONS

1. Propylthiouracil (PTU) is prescribed for a patient with Grave’s disease to decrease
circulating thyroid hormone. The nurse should teach the patient to immediately report
which of the following signs and symptoms?
A. Painful, excessive menstruation.
B. Constipation.
C. Increased urine output.
D. Sore throat.
2. Which of the following measures is most often recommended when preparing saturated
solution of potassium iodide (SSKI) for administration?
A. Dilute the solution with water, milk or fruit juice and have the client drink it with straw.
B. Disguise the solution in a pureed fruit or vegetable.
C. Pour the solution over ice chips.
D. Mix the solution with an antacid.
3. A patient with DM asks the nurse to recommend something to remove corns from his toes.
The nurse should advise him to
A. apply iodine to the corns before peeling them off.
B. apply high-quality corn plaster to the area.
C. soak his feet in borax solution to peel off the corns.
D. consult his physician or podiatrist about removing the corns.
4. The nurse should caution the patient with DM who is taking a sulfonylurea medication that
alcoholic beverages should be avoided while taking these drugs because they can cause
A. Disulfiram-like symptoms.
B. Hypocalcemia.
C. Hyperkalemia.
D. Hypokalemia.
5. The nurse should teach the diabetic patient that which of the following is the most common
symptom of hypoglycemia?
A. Bradycardia.
B. Kussmaul’s respirations.
C. Anorexia.
D. Nervousness.
6. The nurse is assessing the patient’s use of medications. Which of the following
medications may cause a complication with the treatment plan of patient with diabetes?
A. ACE inhibitors.
B. Sulfonylureas.
C. Steroids.
D. Aspirin.
7. Which statement should the nurse make when teaching the patient about taking oral
glucocorticoids?
A. “Take your medication with a full glass of water.”
B. “Take your medication on an empty stomach.”
C. “Take your medication at bedtime to increase absorption.”

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THE PURPLE BOOK
D. “Take your medication with meals or with antacid.”
8. The patient with Addison’s disease should anticipate the need for increased glucocorticoid
supplementation in which of the following situations?
A. Going on vacation.
B. Having oral surgery.
C. Having a routine medical check-up.
D. Returning to work after a weekend.
9. The patient with Cushing’s disease needs to modify dietary intake to control symptoms. In
addition to increasing protein, which strategy would be most appropriate?
A. Increase calories.
B. Restrict potassium.
C. Reduce fat to 10%.
D. Restrict sodium.
10. The patient with pheochromocytoma is scheduled for surgical resection of the tumor in the
adrenal medulla. The nurse monitors the patient postoperatively for which of the following
potential complications?
A. Hemorrhage.
B. Postural hypotension.
C. Hypoglycemia.
D. Hypertensive crisis.
11. Which of the following therapeutic classes of drugs is used to treat tachycardia and angina
in a patient with pheochromocytoma?
A. Diuretics.
B. Calcium channel blockers.
C. ACE inhibitors.
D. β-blockers.
12. A female adult client with a history of chronic hyperparathyroidism admits to being
noncompliant. Based on initial assessment findings, nurse Julia formulates the nursing
diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client,
which “related-to” phrase should the nurse add?
A. Related to bone demineralization resulting in pathologic fractures
B. Related to exhaustion secondary to an accelerated metabolic rate
C. Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces
D. Related to tetany secondary to a decreased serum calcium level
13. Rotating injection sites when administering insulin prevent which of the following
complications?
a. Insulin resistance.
b. Systemic allergic reactions.
c. Insulin edema.
d. Insulin lipodystrophy.
14. Josie, with hypothyroidism (myxedema), is receiving levothyroxine (Synthroid), 25 mcg

P.O. daily. Which finding should nurse Hans recognize as an adverse drug effect?
A. Dysuria
B. Leg cramps
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THE PURPLE BOOK
C. Tachycardia
D. Blurred vision
15. An incoherent female client with a history of hypothyroidism is brought to the emergency
department by the rescue squad. Physical and laboratory findings reveal hypothermia,
hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of
the face and pretibial area. Knowing that these findings suggest severe hypothyroidism,
nurse Libby prepares to take emergency action to prevent the potential complication of:
A. Thyroid storm.
B. Cretinism.
C. myxedema coma.
D. Hashimoto’s thyroiditis.
16. When caring for a male client with diabetes insipidus, nurse Juliet expects to administer:
A. vasopressin (Pitressin Synthetic).
B. furosemide (Lasix).
C. regular insulin.
D. 10% dextrose.
17. During preoperative teaching for a female client who will undergo subtotal thyroidectomy,
the nurse should include which statement?
A. “The head of your bed must remain flat for 24 hours after surgery.”
B. “You should avoid deep breathing and coughing after surgery.”
C. “You won’t be able to swallow for the first day or two.”
D. “You must avoid hyperextending your neck after surgery.”
18. When caring for a female client with a history of hypoglycemia, nurse Ruby should avoid
administering a drug that may potentiate hypoglycemia. Which drug fits this description?
A. sulfisoxazole (Gantrisin)
B. mexiletine (Mexitil)
C. prednisone (Orasone)
D. lithium carbonate (Lithobid)
19. A male client with type 1 diabetes mellitus has a highly elevated glycosylated hemoglobin
(Hb) test result. In discussing the result with the client, nurse Sharmaine would be most
accurate in stating:
A. “The test needs to be repeated following a 12-hour fast.”
B. “It looks like you aren’t following the prescribed diabetic diet.”
C. “It tells us about your sugar control for the last 3 months.”
D. “Your insulin regimen needs to be altered significantly.”
20. Which instruction about insulin administration should nurse Sophie give to a client?
A. “Always follow the same order when drawing the different insulins into the syringe.”
B. “Shake the vials before withdrawing the insulin.”
C. “Store unopened vials of insulin in the freezer at temperatures well below freezing.”
D. “Discard the intermediate-acting insulin if it appears cloudy.”

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21. Capillary glucose monitoring is being performed every 4 hours for Maria, a female 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 Percy 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.
22. For a diabetic male client with a foot ulcer, the physician orders bed rest, a wet-to-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
23. Claire whose physical findings suggest a hyperpituitary condition undergoes an extensive
diagnostic workup. Test results reveal a pituitary tumor, which necessitates a
transphenoidal hypophysectomy. The evening before the surgery, nurse King reviews
preoperative and postoperative instructions given to the client earlier. Which postoperative
instruction should the nurse emphasize?
A. “You must lie flat for 24 hours after surgery.”
B. “You must avoid coughing, sneezing, and blowing your nose.”
C. “You must restrict your fluid intake.”
D. “You must report ringing in your ears immediately.”
24. A female client with a history of pheochromocytoma is admitted to the hospital in an acute
hypertensive crisis. To reverse hypertensive crisis caused by pheochromocytoma, nurse
Lyka expects to administer:
A. phentolamine (Regitine).
B. methyldopa (Aldomet).
C. mannitol (Osmitrol).
D. felodipine (Plendil).
25. A male 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 of the following glands?
A. Adrenal cortex
B. Pancreas
C. Adrenal medulla
D. Parathyroid
26. During the assessment of a patient’s mouth, the nurse notes the absence of saliva. The
patient is also complaining of pain in the area of the ear. The patient has been NPO for
several days because of the insertion of NGT. Based on these findings, the nurse suspects
that the patient may be developing which of the following mouth conditions?
A. Stomatitis.
B. Oral candidiasis.
C. Parotitis.
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D. Gingivitis.
27. A patient is admitted to the hospital after vomiting bright red blood and is diagnosed with
a bleeding duodenal ulcer. The patient develops a sudden, sharp pain in the midepigastric
region along with a rigid, boardlike abdomen. These clinical manifestations most likely
indicate which of the following?
A. An intestinal obstruction has developed.
B. The ulcer has perforated.
C. Additional ulcers have developed.
D. The esophagus has become inflamed.
28. The patient asks the nurse what causes a peptic ulcer to develop. The nurse responds
that recent research indicates that many peptic ulcers are the result of which of the
following?
A. Helicobacter pylori infection.
B. Diets high in fat.
C. Work-related stress.
D. A genetic defect in the gastric mucosa.
29. A patient is to take one daily dose of ranitidine (Zantac) at home to treat her peptic ulcer.
The nurse knows that the patient understands proper drug administration of ranitidine
when she says that she will take the drug at which of the following times?
A. When pain occurs.
B. Before meals.
C. With meals.
D. At bedtime.
30. The nurse understands that the best position for the patient who has undergone a
gastrectomy is
A. supine.
B. prone.
C. low Fowler’s.
D. right or left Sim’s.
31. To reduce the risk of dumping syndrome, the nurse should teach the patient which of the
following interventions?
A. Decrease the carbohydrate content of meals.
B. Avoid milk and other dairy products.
C. Drink liquids with meals, avoiding caffeine.
D. Sit upright for 30 minutes after meals.
32. Which of the following symptoms would be indicative of the dumping syndrome?
A. Diaphoresis.
B. Vomiting.
C. Hunger.
D. Heartburn.

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33. A patient who has been diagnosed with gastroesophageal reflux disease complains of
heartburn. To decrease the heartburn, the nurse should instruct the patient to eliminate
which of the following items from the diet?
A. Hot chocolate.
B. Air-popped popcorn.
C. Raw vegetables.
D. Lean beef.
34. Which of the following factors would most likely contribute to the development of a patient’s
hiatal hernia?
A. Using laxatives frequently.
B. Being 40 years old.
C. Having a sedentary desk job.
D. Being 5’3’’ tall and weighing 190 pounds.
35. The patient has been taking magnesium hydroxide (milk of magnesia) at home in an
attempt to control hiatal hernia symptoms. The nurse should assess the patient for which
of the following conditions most commonly associated with the ongoing use of
magnesium-based antacids?
A. Diarrhea.
B. Constipation.
C. Anorexia.
D. Weight gain.
36. The nurse should instruct the patient to avoid which of the following drugs while taking
metoclopramide hydrochloride (Reglan)?
A. Alcohol.
B. Antacids.
C. Anticoagulants.
D. Antihypertensives.
37. Which goal for the patient’s care should take priority during the first day of hospitalization
for an exacerbation of ulcerative colitis?
A. Maintaining adequate nutrition.
B. Managing diarrhea.
C. Promoting self-care and independence.
D. Promoting rest and comfort.
38. Which of the following would be a priority focus of care for a patient experiencing an
exacerbation of his Crohn’s disease?
A. Decreasing episodes of rectal bleeding.
B. Promoting bowel rest.
C. Maintaining current weight.
D. Encouraging regular ambulation.
39. A patient who is scheduled for an ileostomy has an order for oral neomycin to be
administered before surgery. The nurse understands that the rationale for administering
oral neomycin before surgery is to
A. increase the body’s immunologic response to the stressors of surgery.
B. decrease the potential for postoperative hypostatic pneumonia.
C. reduce the number of intestinal bacteria.
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D. prevent postoperative bladder infection.
40. The nurse should instruct the patient with an ileostomy to report which of the following
symptoms immediately?
A. Occasional presence of undigested food in the effluent.
B. Passage of liquid stool from the stoma.
C. Temperature of 37.7oC.
D. Absence of drainage from the ileostomy for 6 or more hours.
41. Which of the following interventions should the nurse include in the patient’s care plan to
prevent complications associated with TPN administered through a central line?
A. Tape all connections of the system.
B. Encourage bed rest.
C. Cover the insertion site with a moisture-proof dressing.
D. Use a clean technique for all dressing changes.
42. Which of the following medications would the nurse anticipate administering to a patient
with diverticular disease?
A. Diazepam (Valium).
B. Aluminum hydroxide (Amphojel).
C. Psyllium hydrophilic mucilloid (Metamucil).
D. Diphenoxylate with atropine sulfate (Lomotil).
43. In a patient with acute appendicitis, the nurse should anticipate which of the following
treatments?
A. Insertion of a NGT.
B. Placement of patient on NPO status.
C. Administration of enemas to clean bowel.
D. Administration of heat to the abdomen.
44. Which of the following positions should Kiarra with appendicitis assume to help relieve the
pain?
A. Supine, stretched out.
B. Lying with legs drawn up.
C. Prone.
D. Sitting.
45. Which of the following tasks should be included in the immediate postoperative
management of Hades who has undergone gastric resection?
A. Providing nutritional support.
B. Monitoring for symptoms of hemorrhage.
C. Assessing for bowel sounds.
D. Monitoring gastric pH to detect complications
46. Which of the following tests should be administered to Hera suspected of having
diverticulosis?
A. Barium enema.
B. Barium swallow.
C. Gastroscopy.
D. Abdominal ultrasound.

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47. Which of the following assessments is most relevant with the diagnosis of hemorrhoids?
A. Digital rectal examination.
B. Sexual history.
C. Abdominal assessment.
D. Diet history.
48. The client is diagnosed with chronic pancreatitis, and pancrelipase (Lipancreatin) is
prescribed. Which of the following instructions should the nurse give to this client about
the administration of this medication?
A. “Take the drug with meals”
B. “Take the drug with a large glass of milk”
C. “Take the drug between meals”
D. “Take the drug after it is crushed and mixed with ice cream”
49. Cedric is admitted to the hospital with acute pancreatitis. The nurse taking a history should
question the client about which of this risk for developing pancreatitis?
A. inflammatory bowel disease
B. alcoholism
C. diabetes mellitus
D. high-fiber diet
50. The nurse is aware that the symptoms of portal hypertension in clients with liver cirrhosis
are chiefly the result of:
A. Infection of the liver parenchyma
B. Fatty degeneration of Kupffer cells
C. Obstruction of the portal circulation
D. Obstruction of the cystic and hepatic ducts
51. Rosario is being treated for chronic cholecystitis should be given which of the following
instructions?
a. Increase protein in diet.
b. Increase rest.
c. Avoid antacids.
d. Use anticholinergics as prescribed.
52. Atlas who has percutaneous endoscopic gastrostomy tube inserted for tube feedings.
Before staring a continuous feeding, the nurse should place the client in which position?
A. Semi-Fowler’s.
B. Supine.
C. Reverse T-burg.
D. High Fowler’s.
53. A 50-year-old woman is hospitalized due to intermittent gnawing epigastric pain. The
admitting nurse obtains health history and suspects that the client is suffering from peptic
ulcer. Based on the suspected diagnosis, the nurse would expect that the gnawing
epigastric pain will DECREASE with which of the following activities of the client?
A. Going to bed after meals.
B. Eating a bland diet
C. Eating slowly.
D. Taking a glass of milk

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54. The initial diagnosis of pancreatitis is confirmed if the patient’s blood work shows a
significant elevation in which of the following serum values?
A. Amylase.
B. Potassium.
C. Glucose.
D. Trypsin.
55. A patient with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is

prescribed to treat the ascites. The nurse should monitor the patient closely for which of
the following drug-related side effects?
A. Hyperkalemia.
B. Constipation.
C. Dysuria.
D. Irregular pulse.
56. A patient with cirrhosis vomits bright red blood and the physician suspects bleeding
esophageal varices. The physician decided to insert a Sengstaken-Blakemore tube. The
nurse should explain to the patient that the tube acts by
A. blocking blood flow to the stomach and esophagus.
B. applying direct pressure to the esophagus.
C. providing a large diameter for effective gastric lavage.
D. applying direct pressure to gastric bleeding sites.
57. A patient’s serum ammonia level is elevated, and the physician orders 30 mL of lactulose
(Cephulac). Which of the following side effects of this drug would the nurse expect to see?
A. Nausea and vomiting.
B. Increased bowel movements.
C. Improved level of consciousness.
D. Increased urine output.
58. Which of the following medications would most likely be given to the patient with acute
pancreatitis to augment pain control?
A. Magnesium hydroxide (Maalox).
B. Propanolol (Inderal).
C. Propantheline bromide (Pro-Banthine).
D. Ibuprofen (Motrin).
59. A 55-year-old patient is receiving chemotherapy that has the potential to cause pulmonary
toxicity. Which of the following symptoms indicates a toxic response to the chemotherapy?
A. Drowsiness.
B. Decrease in appetite.
C. Cough and shortness of breath.
D. Spasms of the diaphragm
60. The son of a 78-year-old patient with metastatic prostate cancer is asking the nurse about
the purpose of hospice care. Which of the following statements by the nurse best
describes hospice care?
A. The patient’s physician coordinates all the care.
B. All hospice patients will die at home.
C. Hospice care uses a team approach to direct hospice activity.
D. Patients and their families are the focus of care.

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61. The nurse is preparing Cyclophosphamide (Cytoxan). Safe handling of the drug should be
implemented to protect the nurse from injury. Which of the following action by the nurse
should be corrected?
A. The nurse should wear mask and gloves.
B. Air bubbles should be expelled on wet cotton.
C. Label the hanging IV bottle with ANTINEOPLASTIC CHEMOTHERAPY sign.
D. Vent vials after mixing.
62. Specific classification of the chemotherapeutic agent, Vincristine (Oncovin) is

a. Hormone modulator
b. Mitotic inhibitor
c. Antineoplastic antibiotic
d. Antimetabolite
63. Surgical procedure to treat breast cancer involves the removal of the entire breast,
pectoralis major muscle and the axillary lymph nodes is:
A. Simple mastectomy
B. Modified radical mastectomy
C. Halstead Surgery
D. Radical mastectomy
64. In staging and grading neoplasm TNM system is used. TNM stands for
A. Time, neoplasm, mode of growth
B. Tumor, node, metastasis
C. Tumor, neoplasm, mode of growth
D. Time, node, metastasis
65. Skin reactions are common in radiation therapy. Nursing responsibilities on promoting skin
integrity should be promoted apart from
A. Avoiding the use of ointments, powders and lotion to the area
B. Using soft cotton fabrics for clothing
C. Washing the area with a mild soap and water and patting it dry not rubbing it.
D. Avoiding direct sunshine or cold.
66. A client is taking Cyclophosphamide (Cytoxan) for the treatment of lymphoma. The nurse
is very cautious in administering the medication because this drug poses the fatal side
effect of:
A. Alopecia
B. Myeloma
C. CNS toxicity
D. Hemorrhagic cystitis
67. Which of the following is the best way for the nurse to begin the preoperative interview?
A. Walk in and ask, “Are you Ms. Garcia?”
B. Walk in, sit down, and take the patient’s blood pressure.
C. Walk in, sit down, maintain eye contact, and introduce yourself.
D. Walk in and ask the patient her name.

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68. A patient will receive intravenous midazolam hydrochloride during surgery. Which of the
following would the nurse determine as a therapeutic effect?
a. Blurred vision.
b. Amnesia.
c. Nausea.
d. Mild agitation.
69. Which of the following nursing interventions is most important in preventing postoperative
complications?
A. Pain management.
B. Early ambulation.
C. Progressive diet planning.
D. Bowel and elimination monitoring.
70. Which of the following is not a sign of thromboembolism?

A. Swelling.
B. Coolness.
C. Redness.
D. Edema.
71. When a patient cannot read or write but is of sound mind, the nurse should read the
consent to the patient in the presence of two witnesses and
A. have a hospital quality management coordinator sign for the patient.
B. have the patient’s next-of-kin sign the consent.
C. have the patient put an “X” on the signature line.
D. have a court appoint a guardian for the patient.
72. Following surgery for a total knee replacement, Ms. Diaz was given an epidural catheter
for fentanyl epidural analgesia. An important nursing intervention for the nurse caring for
Ms. Diaz would be to:
A. Administer additional analgesic medications prn
B. Change epidural dressing every shift
C. Assess respiratory rate carefully
D. Encourage unassisted ambulation
73. Ms. Cruz is recovering from the right lobectomy. The nurse is going to assist in
splinting her incision so she can cough and breathe deeply. The most therapeutic
administration of an analgesic for Ms. Cruz would be:
A. after the procedure so she can rest
B. 15 minutes before the procedure
C. 1 hour before the procedure
D. 30 minutes before the procedure
74. When preparing the patient for surgery, the nurse should:
A. provide the patient with sips of water for a dry mouth
B. remove the patient’s make-up and nail polish
C. remove the patient’s gown before transport to the operating room
D. leave all of the patient’s jewelry intact

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75. Ms. Barcelo is a 44-year-old patient who is admitted for an abdominal hysterectomy. She
is instructed that she will have a Foley catheter in place postoperatively. She asks the
nurse how many days she will have the catheter in place. The best response by the nurse
would be that:
A. the indwelling catheter will probably remain in place for 1 week
B. the indwelling catheter will be removed after you are fully awake from the anesthesia
C. the indwelling catheter will generally remain in place 1 to 2 days after surgery
D. the indwelling catheter will remain in place for a few days post discharge
76. Ms. Ledesma, 49 years of age, is an obese diabetic who has had a total abdominal
hysterectomy. On the third postoperative day, Ms. Ledesma complains of increased pain
in the operative site. She states, “It feels like something suddenly popped.” With the
symptoms presented, it would be likely that when the nurse removes the abdominal
dressing, she may note that:
A. the wound has purulent exudate
B. dehiscence has occurred
C. the wound is indurated and tender
D. the wound is well approximated
77. Nursing interventions with COPD clients includes many self-care approaches in order to
maintain optimal health. This often involves managing medications at home at the onset
of symptoms. Which self-care technique might suggest the need for beginning antibiotic
therapy?
A. Receiving annual flu vaccine.
B. Practicing postural drainage.
C. Observing changes in sputum color and amount.
D. Awareness of increasingly labored respirations.
78. In the post anesthesia care unit, the nurse determines that the client has active reflexes,
increased heart rate, irregular breathing, increased BP, pupils widely dilated and
divergent. The nurse recognizes that the client is in which stage of general anesthesia?
A. Stage of analgesia
B. Stage of dreams and excitement
C. Stage of surgical anesthesia
D. Medullary stage
79. When obtaining data from a client with thromboangitis obliterans, the nurse would expect
the client to demonstrate or report:
A. Easy fatigue of extremities, continuous claudication.
B. General blanching of skin and intermittent claudication.
C. Intermittent claudication, burning pain after exposure to cold.
D. Burning pain precipitated by cold exposure, fatigue, blanching of skin.
80. During the evening after a paracentesis, the nurse notices that the client, although denying
any discomfort, seems very anxious. The best nursing approach should be to:
A. Offer the client a back rub
B. Administer the prescribed opiate
C. Reinforce the physician’s explanation of the procedure
D. Explore the client’s concerns while administering the ordered anxiolytic

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81. The nurse is admitting a client with suspected tuberculosis (TB) to the acute care unit. The
nurse places the client in airborne precautions until a confirmed diagnosis of TB can be
made. Which of the following tests is a priority to confirm the diagnosis?
A. Chest X-ray that is positive for lung lesions
B. Positive purified protein derivative (PPD)
C. Sputum positive for Blood (Hemoptysis)
D. Sputum culture positive for Mycobacterium Tuberculosis
82. The nurses assess fluctuations in the water seal chamber of a client’s closed chest
drainage system. The nurse evaluates this finding as indicating:
A. The system is functioning properly
B. An air leak is present
C. The tubing is kinked
D. The lung has re-expanded
83. A 24-year-old client has diminished popliteal and pedal pulses; his lower extremities are
dusky red in the dependent position; and his skin is cool to touch, shiny, thin and atrophic,
with hair loss over the feet and toes. Based on these characteristics, the nurse suspects:
A. Arterial insufficiency
B. Venous insufficiency
C. Varicose veins
D. Raynaud’s disease
84. A client with coronary artery disease complains of substernal chest pain. After assessing
the client’s vital signs, the nurse administers nitroglycerine sublingually (SL) 1/150. After
5 minutes, the client indicates that he is still having chest pain. If his vital signs are stable
following the usual dosage regimen (ordered by the physician), the nurse should:
A. Wait 5 more minutes and then reassess
B. Apply O2 per nasal cannula
C. Administer another nitroglycerin tablet SL
D. Wait 10 minutes, and then administer a second nitroglycerin tablet
85. A client was admitted to the cardiac unit for congestive heart failure (CHF), and digitalis
therapy was initiated. During his hospitalization, he began to complain frequently about
many things, including the poor color on his TV and how he has lost his appetite. The
client’s behavior should alert the nurse to consider which of the following?
A. Digitalis toxicity
B. Anxiety related to CHF
C. Low cardiac output
D. Hypokalemia
86. The nurse assesses a client who has a hepatic encephalopathy for asterixis by:
A. Asking a client to extend an arm, dorsiflex the wrist and extend the finger
B. Assessing the client for azotemia, oliguria and intractable ascites.
C. Assessing the client for a musty sweet breath odor
D. Asking the client to draw a cross noting any deterioration in the figure construction

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87. Nurse Pedro admitted a client with a diagnosis of Cancer and he is in the terminal stage.
He is experiencing severe pain. The doctor has written an order for pain medication every
3 hours PRN. How will the nurse plan to administer the pain medication?
A. Wait until the client complains of pain, and then administer medication.
B. Evaluate client and determine need of pain medication every 3 hours.
C. Administer the pain medication every 3 hours.
D. Try to increase time between injections during the night
88. Nurse ALPHAPHI is responding to a post-operative client on a mechanical ventilator who

begins to fight the ventilator. Which medication will be ordered for the client?
A. Sublimaze (fentanyl)
B. Pavulon (pancuronium bromide)
C. Versed (Midazolam)
D. Atarax (Hydroxyzine)
89. The patient with Emphysema is taught about pursed-lip breathing. Which of the following
statements by patient indicates understanding of the mechanics behind this technique?
A. “I get more oxygen if I inhale long and hard through my nose.”
B. “When I puff out of my cheeks with each breath, I don’t work as hard to breathe.”
C. “When I breathe through pursed lips, my airways don’t collapse between breaths.”
D. “When I inhale through pursed lips, my oxygen exchange is more effective.”
90. Before discharge, Alice with a Colostomy questions the nurse about resuming prior
activities. What is the nurse’s response?
A. “Most sport activities, except for swimming, can be resumed based on your overall
physical condition.”
B. “With counseling and medical guidance, a near normal lifestyle, including complete
sexual function, is possible.”
C. “Activities of daily living should be resumed as quickly as possible to avoid depression
and further dependency.”
D. “After surgery, changes in lifestyle must be made to accommodate the physiologic
changes caused by the operation.”
91. A hospitalized client develops a nosocomial upper respiratory infection. After being
informed of this fact the client asks the nurse what this means. The nurse should reply:
A. "The infection you had prior to hospitalization has flared up"
B. "You acquired the infection after being admitted to the hospital"
C. "This is a highly contagious infection requiring complete isolation"
D. "As a result of medical treatment, you have developed a secondary infection"
92. Mr. Cymon has a nursing diagnosis of Decreased Cardiac Output related to decreased
plasma volume. Which assessment finding supports this nursing diagnosis?
A. Flattened neck veins when the client is in the supine position
B. Full and bounding pedal and post tibial pulses
C. Pitting edema located in the feet, ankles, and calves
D. Shallow respirations with crackles on auscultation
93. The nurse involved in a legal case against the hospital. Which judgment error by the nurse
would be considered most damaging?
A. Making illegal changes in the chart
B. Arguing with the plaintiff over the case
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C. Withholding information from the hospital attorney

D. Being argumentative while on the witness stand
94. The Nurse enters data on a chart and discovers she has written on the wrong chart. How
this error is best corrected?
A. White out the wrong information and write over it.
B. Recopy the page with the error so chart will be neat
C. Draw a straight line through the error, initial, and date
D. Obliterate the error so it will not be confusing
95. The circulating nurse welcomes the client to the OR suite. Which of the following is the
PRIORITY nursing intervention at this point?
A. Validate if the client is observed NPO appropriately.
B. Validate the OR schedule.
C. Check the client for presence of denture, ring and nail polish.
D. Check the ID bracelet and call the client by name.
96. The client inquired about esophagoscopy. Which statement of the nurse describes the
procedure CORRECTLY?
A. It is a surgical procedure of the esophagus by using fiberoptic tube.
B. It is a diagnostic procedure by instilling normal saline with a dye into the esophagus
before taking x-ray.
C. It involves passing a nasogastric tube down the esophagus to remove any obstruction
of any form.
D. It is a diagnostic procedure that involves inserting a flexible fiberoptic tube through the
mouth down the esophagus.
97. Vham, 29, who uses diuretics for blood pressure control, is scheduled for
cholecystectomy. As her nurse in charge, you read the following data in the patient’s chart.
Which data must the nurse communicate to the surgeon immediately?
A. Serum potassium of 3.2 mEq/L.
B. Hematocrit 35%.
C. Blood pressure of 142/78.
D. Pulse rate of 102 beats/min.
98. 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.
99. Mrs. Maricel 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

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100.Rowena’s husband is under your care and he is recovering from myocardial infarction.
Rowena is concerned about food, exercise and when her husband asks about sexual
activity, which is the appropriate response of the nurse?
A. “The doctor should be consulted”
B. “The next cardiac test will tell you when is the time to resume sexual activity”
C. “Usually sexual activity can be resumed when your husband is able to climb two flight
of stairs comfortably”
D. “Continue with the sexual practice when you are both comfortable”

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NURSING PRACTICE III- ANSWERS AND RATIONALIZATIONS

The most serious side effect of PTU are leukopenia and agranulocytosis, which usually
occur within the first three months of treatment. The classic sign of agranulocytosis is
sore throat because of the increased risk of infection.
SSKI should be diluted well in milk, water, juice, or carbonated beverage before
administration so as not to taste the strong, bitter taste of the drug.
A client with diabetes should be advised to consult a physician or podiatrist for corn
removal because of the danger or traumatizing the foot tissue and potential development
of ulcers. The diabetic client should never self-treat foot problems but should consult a
physician or podiatrist.
A client with diabetes who takes any first-or second-generation sulfonylurea should be
advised to avoid alcohol intake. Sulfonylurea in combination with alcohol can cause
serious reactions of disulfiram (Antabuse)-like reactions including flushing, angina,
palpitations, and vertigo.
The four most commonly reported signs and symptoms of hypoglycemia are
nervousness, weakness, perspiration and confusion.
Steroids can cause hyperglycemia because of their effects on carbohydrate metabolism,
making diabetic control more difficult.
Oral steroids can cause gastric irritation and ulcers and should be administered with
meals, if possible, or otherwise with an antacid.
Illness or surgery places tremendous stress on the body, necessitating increased
glucocorticoid dosage. Extreme emotional or psychological stress also necessitates
dosage adjustment. This is in order to prevent drug-induced adrenal insufficiency.
A primary dietary intervention is to restrict sodium, thereby reducing fluid retention.

Postoperative management is directed at maintaining a normal blood pressure, because
the client may be hypertensive immediately after surgery

Pheochromocytomas release catecholamines both epinephrine and norepinephrine. A β-
blocker such as propanolol is administered to block the cardiac-stimulating effects of
epinephrine.

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Poorly controlled hyperparathyroidism may cause an elevated serum calcium level. This,
in turn, may diminish calcium stores in the bone, causing bone demineralization and
setting the stage for pathologic fractures and a risk for injury.

Insulin lipodystrophy produces fatty masses at the injection sites, causing unpredictable
absorption of insulin injected into these sites.

Levothyroxine, a synthetic thyroid hormone, is given to a client with hypothyroidism to
simulate the effects of thyroxine. Adverse effects of this agent include tachycardia

Severe hypothyroidism may result in myxedema coma, in which a drastic drop in the
metabolic rate causes decreased vital signs, hypoventilation (possibly leading to
respiratory acidosis), and nonpitting edema.

Because diabetes insipidus results from decreased antidiuretic hormone (vasopressin)
production, the nurse should expect to administer synthetic vasopressin for hormone
replacement therapy. Furosemide, a diuretic, is contraindicated because a client with
diabetes insipidus experiences polyuria

To prevent undue pressure on the surgical incision after subtotal thyroidectomy, the
nurse should advise the client to avoid hyperextending the neck. The client may elevate
the head of the bed as desired and should perform deep breathing and coughing to help
prevent pneumonia.

Sulfisoxazole and other sulfonamides are chemically related to oral antidiabetic agents
and may precipitate hypoglycemia.

The glycosylated Hb test provides an objective measure of glycemic control over a 3-
month period. The test helps identify trends or practices that impair glycemic control.

The client should be instructed always to follow the same order when drawing the
different insulins into the syringe.

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.

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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.

After a transsphenoidal hypophysectomy, the client must refrain from coughing,
sneezing, and blowing the nose for several days to avoid disturbing the surgical graft
used to close the wound.

Pheochromocytoma causes excessive production of epinephrine and norepinephrine,
natural catecholamines that raise the blood pressure. Phentolamine, an alpha-
adrenergic blocking agent that reduces blood pressure.

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 lack of saliva, pain near the area of the ear, and the prolonged NPO status of the
client will signal the nurse to suspect the inflammation of the parotid gland or parotitis.

When duodenal ulcer has perforated, the intestinal contents and blood will go to the
peritoneum thereby causing peritonitis as evidenced by a rigid, board like abdomen.

Helicobacter pylori infection is the leading cause for the development of peptic ulcer
disease. Work-related stress is an aggravating factor. Diets high in fat do not cause peptic
ulcer disease.

Ranitidine is a histamine-2 blocker that blocks secretion of hydrochloric acid. Clients who
take only one daily dose of ranitidine are usually advised to take it at bedtime to inhibit
nocturnal secretion of acid. Clients who take the drug twice a day are advised to take it in
the morning and at bedtime.

A client who has had abdominal surgery is best placed in a low-Fowler’s position
postoperatively. This positioning relaxes abdominal muscles and provides for maximum
respiratory and cardiovascular function.

Dumping syndrome is due to increased peristaltic movement that leads to diarrhea.
Carbohydrate intake should be reduced since carbohydrates empties faster than protein
and fats. It is also necessary eat dry foods, not to take large fluids with meals, and lie down
after meals.

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Symptoms of dumping syndrome usually begin 15 to 30 minutes after eating and include
weakness, dizziness, diaphoresis, palpitations, a sense of fullness, abdominal cramps,
and diarrhea.

With GERD, eating substances that decrease lower esophageal sphincter pressure
causes heartburn. Foods that can cause a decrease in esophageal sphincter pressure
include fatty foods, chocolate, caffeinated beverages, peppermint, and alcohol.

Obesity increases abdominal pressure which predisposes the development of hiatal
hernia.

The magnesium salts in magnesium hydroxide are related to those found in laxatives and
may cause diarrhea. Aluminum salts can cause constipation. They are given as antacids.

Metoclopramide hydrochloride can cause sedation. Alcohol and other CNS depressants
add to this sedation.

Diarrhea is the primary symptom in an exacerbation of ulcerative colitis, and decreasing
the frequency of stools is the first goal of treatment. The other goals are ongoing and will
be best achieved by halting the exacerbation.

The priority is to promote bowel rest to prevent further inflammation. This is accomplished
through decreasing activity, encouraging rest, and initially placing the client on NPO status
while maintaining nutritional needs parenterally.

Neomycin is indicated before surgery to make the tract sterile by decreasing the intestinal
bacteria and thereby decreased the potential for peritonitis and wound infection
postoperatively.

Absence of drainage from the ileostomy indicates obstruction and should be reported to
the physician immediately.

When the TPN is administered through the central line, the most common complication is
air embolism and infection, which necessitates proper securing of the catheter and the
insertion site is covered with an air-occlusive dressing, and all connections of the system
are taped.
42. Correct Answer:

To prevent accumulation of fecal materials in the outpouchings, bulk forming laxatives
such as Psyllium hydrophilic mucilloid (Metamucil) are given to the client.
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A client who is diagnosed with acute appendicitis is placed on NPO status in anticipation
of surgery. Both options c and d can cause perforation of the appendix.

The position of comfort of clients with appendicitis is fetal position or lying with legs drawn
up. This position helps relieve tension on the abdominal muscles, which helps to reduce
the amount of discomfort felt.

The client should be monitored closely for signs and symptoms of hemorrhage, such as
bright red blood in the NGT suction, tachycardia, or a drop in blood pressure.

A barium enema will cause diverticula to fill with barium and be easily seen on x-ray.

Digital rectal examination is performed to assess for internal hemorrhoids

Pancrelipase (Lipancreatin) aids in the digestion of starches and fats and should be
taken with meals. It should not be crushed since hydrochloric acid destroys the drug and
it should not be mixed with alkaline foods.

Acute pancreatitis is most associated with alcoholism in men and gallstones in women.

Portal hypertension is caused by the obstructed flow of blood through the damaged liver.
The two major consequences of portal hypertension are ascites and varices.

Conservative therapy for chronic cholecystitis includes weight reduction by increasing
physical activity, a low-fat diet, antacid use to treat dyspepsia, and anticholinergic use to
relax smooth muscles and reduce ductal tone and spasm, thereby reducing pain.

To prevent aspiration of stomach contents, the nurse should place the client in semi-
Fowler’s position

This is to avoid over secretion of acid and hypermotility of GI tract

The primary diagnostic tests for pancreatitis are serum amylase, lipase, and urine
amylase. All three laboratory results are typically elevated. Serum amylase is the most
common test.

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Spironolactone is a potassium-sparing diuretic; therefore, clients should be monitored
closely for hyperkalemia.

The Sengstaken-Blakemore tube has a small gastric balloon that anchors the tube and
applies pressure to the area of the cardiac sphincter. The large esophageal balloon
applies direct pressure on the bleeding sites in the esophagus.

Lactulose is a laxative that increases intestinal motility thereby trapping and expelling
ammonia in the feces. An increased in the number of bowel movements is expected as a
side effect.

Antispasmodic drugs such as propantheline bromide may be administered along with
narcotics to deal with the intense pain associated with pancreatitis. It relaxes smooth
muscles and decrease gastric motility and pancreatic enzyme secretion, thereby
decreasing pain.

Cough and SOB are significant symptoms because they may indicate decreasing
pulmonary function secondary to drug toxicity.

The most important central component of hospice care is focus of care on the patient as
well as their family or significant other. The team approach and the physician’s
coordination of the hospice team are important, but they are not the focus.

The nurse should be corrected if she is only wearing mask and glove because gowns
should also be worn in handling chemotherapeutic drugs.

Vincristine is a mitotic inhibitor.

Removal of the entire breast, pectoralis major muscle and the axillary lymph nodes is a
surgical procedure called modified radical mastectomy. Simple mastectomy is the removal
of the entire breast but the pectoralis muscles and nipples remain intact. Halstead surgery
also called radical mastectomy involves the removal of entire breast, pectoralis major and
minor muscles and neck lymph nodes. It is followed by skin grafting.

TNM stands for tumor, node, and metastasis.

No soap should be used on the skin of the client undergoing radiation. Soap and irritants
and may cause dryness of the patient’s skin. Only water should be used in washing the
area.

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Hemorrhagic cystitis is the potentially fatal side effect of Cytoxan.

Nurses should provide the preoperative client individual and sincere attention by meeting
the client at eye level and introducing themselves by name and role. The nurse should ask
the client to tell her full name.

Midazolam hydrochloride causes antegrade amnesia or decreased ability to remember
events that occurred around the time of sedation.

Early ambulation is the most significant general nursing measure to prevent postoperative
complications and has been advocated for more than 40 years. Walking increases vital
capacity and maintains normal respiratory functioning, stimulates circulation, prevents
venous stasis, improves gastrointestinal and genitourinary function, increase muscle tone,
and increases wound healing.

The client with thromboembolism does not have coolness. The client will have redness,
swelling, increased warmth along the vein, edema, and pain and may have hemoptysis,
chest pain, tachycardia, dyspnea, and restlessness.

When the client cannot read or write, the consent can be read to the client and the client
can sign in the presence of two witnesses. The client should always sign for himself unless
he is a minor or not of sound mind.

One of the side effects of the epidural opioid is respiratory depression. Thus, Respiratory
rate is monitored carefully every 15 minutes during infusion.

It is vital that pain be managed if the client is to comply with instructions for coughing, deep
breathing and splinting. Analgesia will take effect after 30 minutes of administration.

The patient should wear no cosmetics because observation of skin color will be important.
Nail polish should be removed because the pulse oximeter, used to monitor oxygenation,
will be placed on the patient’s fingertip and cannot distinguish blood oxygen through
colored nail polish.

The bladder may be decompressed to prevent trauma during the surgery. The indwelling
catheter will generally remain in place for 1 to 2 days after surgery.

Dehiscence is the interruption of previously intact suture line. Sharp pain in the suture
line or a cough and increased Serosanguineous drainage from the wound frequently will
precede dehiscence.
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Changes in color and/or amount of sputum often signal onset of infection indicating need
for antibiotics.

The stage characterized in the question falls under the excitement stage of anesthesia.

Buerger’s disease is characterized by vascular inflammation, usually in the lower
extremities, leading to thrombus formation. As a result of impaired circulation, there is
burning pain and intermittent claudication.

Sharing and discussing concerns often release anxieties; giving the ordered anxiolytic
would produce relaxation.

The most accurate way to diagnose TB is by sputum culture. Identifying the presence of
tubercle bacilli is essential for a definitive diagnosis.

In closed drainage chest tube system, fluctuations in the water seal chamber during
inhalation and exhalation (called tidaling) is a normal finding until the lung re-expands.

These are symptoms of arterial insufficiency because of decreased circulation of the distal
parts of the body, especially to the toes of the lower extremities.

SL nitroglycerin tablets are usually prescribed as one tablet SL for chest pain every 5
minutes, for a total of three doses.

Signs of digitalis toxicity include visual disturbances and anorexia

Asking the client to extend the arm, dorsiflex the wrist, and extend the finger is asterixis,
or liver flap, which is a clinical manifestation that occurs as coma approaches in hepatic
encephalopathy.

Relief of pain in the client with the terminal cancer is palliative. Medications should be
given around the clock, and the client should be evaluated frequently to determine the
level of pain control. The nurse should not wait until the client complains of pain should
assesses the level of pain control frequently. The medication should not be administered
every 3 hours; it is to be given on an as- needed basis.

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Pavulon (pancuronium bromide) is a neuromuscular blocking agent that paralyzes skeletal
muscles, making it impossible for the client to fight the ventilator. Sublimaze is an
analgesic used to control operative pain; therefore, answer A is incorrect. Versed is a
benzodiazepine used to produce conscious sedation; therefore, answer C is incorrect.
Answer D is wrong because Atarax is used to treat post-operative nausea.

Breathing through pursed lips slow exhalation and maintain inflation of the distal airways,
which enhance respiration.

Few physical restraints on activity are required postoperatively after colostomy, but the
client may have emotional problems as a result of body image changes.

A nosocomial infection, by definition, is acquire during hospitalization.

Normally, neck veins are distended when the client is in the supine position. These veins
flatten as the client moves to a sitting position.

The chart is considered a legal document. Any illegal alterations can be considered fraud.

Errors in charting should never be obliterated, recopied, or covered with correction fluid.
When the erroneous information is not legible, it raises questions as to what the person
was trying to cover up.

In the OR suite, checking the ID bracelet and calling the client by name is the first
procedure a nurse must do to check if the right client.

Esophagoscopy is the visualization of the esophagus using a probe. The probe or
fiberoptic tube is inserted into the mouth down the esophagus. This is not a form or surgery
nor normal saline or dye is instilled.

Normal potassium level is 3.5-5.5 mEq/L and the client’s potassium level indicates
hypokalemia and should be addressed promptly.

Heberden’s nodes appear on the distal interphalangeal joint on both men and women.
Bouchard’s node appears on the dorsolateral aspect of the proximal interphalangeal
joint.

A cane should be used on the unaffected side.

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100.Correct Answer: C
The client should be taught that sexual activity is crucial after an MI attack. Going up two
flights of stairs without chest pain or DOB is necessary before the sexual act is resumed
normally. The client should assume a passive role when doing the activity.

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NURSING PRACTICE IV- QUESTIONS

1. A nurse should be aware that benign prostatic hyperplasia (BPH):
A. Is a congenital abnormality
B. Usually becomes malignant
C. Predisposes to hydronephrosis
D. Causes an elevated acid phosphatase
2. When irrigating an indwelling urinary catheter, the nurse should:

A. Use sterile equipment
B. Instill the fluid under high pressure
C. Warm the solution to body temperature
D. Aspirate immediately to ensure return flow
3. To obtain an accurate urine output for a client with a continuous bladder irrigation (CBI),
the nurse should:
A. Measure the contents of the bedside drainage bag
B. Stop irrigation until the urine output is determined
C. Subtract the volume of the irrigant from the total drainage
D. Ensure that urine and irrigant drain into two separate bags
4. Fluid and electrolyte changes in the emergent phase of burn injury include all of the
following except:
A. base-bicarbonate deficit
B. elevated hematocrit
C. Potassium deficit
D. Sodium deficit
5. Elias is to receive a very low-protein diet. This diet is based on the principle that:
A. A high-protein intake ensures an adequate daily supply of all amino acids to
compensate for loses
B. Essential and nonessential amino acids are necessary in the diet to supply materials
for tissue protein synthesis
C. This supply only essential amino acids reducing the amount of metabolic waste
products, thus decreasing stress on the kidneys
D. Urea nitrogen cannot be used to synthesize amino acids in the body, so the nitrogen
for amino acid synthesis must come from the dietary protein
6. A client with chronic kidney failure is to be treated with continuous ambulatory peritoneal
dialysis (CAPD). The nurse realizes this is done because it:
A. Provides continuous contact of dialyzer and blood to clear toxins by ultrafiltration
B. Exchanges and cleanses blood by correction of electrolytes and excretion of creatinine
C. Uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and
diffusion
D. Decreases the need for immobility of the client because it clears toxins in short
intermittent periods

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7. The nurse notes that a client’s serum potassium level is 5.8 mEq/L. The nurse should first
A. call the laboratory and repeat the test
B. call the cardiac arrest team to alert them
C. obtain an ECG strip and have lidocaine available
D. take the client’s vital signs and inform the physician
8. An IV solution containing potassium inadvertent infuses too rapidly. The physician

prescribed insulin added to D10W solution. The rationale for the order is
A. potassium moves into body cells with glucose and insulin
B. increased insulin accelerates excretion of glucose and potassium
C. glucose and insulin increase metabolism and accelerate potassium excretion
D. increased potassium causes temporary slowing of pancreatic production of insulin
9. The nurse identifies which of the following diagnostic therapy laboratory test as the one
nurse should assess first to establish a diagnosis for renal disease?
A. Blood urea nitrogen (BUN)
B. Serum creatinine
C. Serum uric acid
D. Serum Potassium
10. A client who is found unresponsive has arterial blood gas drawn and the results indicate
the following pH is 7.12 Pco2 is 90 mmHg and HCO3 is 22 mEq/L. The nurse interprets
the results as indicating which conditions?
A. Metabolic acidosis with compensation
B. Respiratory acidosis with compensation
C. Metabolic acidosis without compensation
D. Respiratory acidosis without compensation
11. A nurse plans care for a client with chronic obstructive pulmonary disease (COPD)
understanding that the client is most likely to experience what type of acid-base
imbalance?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
12. The nurse is teaching a class on urinary infections. Which of the following should the
nurse include?
A. The urinary tract below the urethra is sterile
B. Pyelonephritis is a common infection of the lower urinary tract
C. E. coli is the most common cause of urinary infections
D. Males are more prone to urinary tract infections than females
13. The postoperative orders for a client who has had the parathyroid gland removed include
using Chvostek ‘s signs to assess for signs of tetany. Which of the following is the
appropriate assessment technique the nurse should implement?
A. Occlude the blood flow in the wrist
B. Observe respiratory rate and depth

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C. Listen for crowing sound with inspiration

D. Tap sharply over the facial nerves
14. Which medication may be included in the medical treatment plan of care for a client
experiencing a severe exacerbation of Systemic Lupus Erythematosus (SLE)?
A. Chlordiazidepoxide (Librium)
B. Ampicillin (Amoxil)
C. Acyclovir (Zovirax)
D. Methotrexate (Maxate)
15. Mrs. Lorna, a new client has a diagnosis of Discoid Lupus Erythematosus (DLE). The
nurse recognizes that discoid lupus differs from Systemic Lupus Erythematosus (SLE)
because it:
A. Produce changes in the kidneys
B. Is confined to changes in the skin
C. Results in damage to the heart and lungs
D. Affects both joints and muscles
16. Within 4 to 6 hours after a client has had a myocardial infarction the laboratory finding the
nurse would expect to be elevated is the:
A. Lactic dehydrogenase (LDH-1)
B. Eosinophil sedimentation rate (ESR)
C. Creatinine phosphokinase (CPK-2 or MB)
D. Serum aspartate aminotransferase (AST)
17. The drug most commonly used to provide analgesia for the client who has had a
Myocardial Infarction is:
A. Diazepam (Valium)
B. Meperidine (Demerol)
C. Morphine (MS Contin)
D. Flurazepam (Dalmane)
18. The most common symptom of Acute Myocardial Infarction is which of the following?
A. shortness of breath
B. pain in shoulder and left arm
C. substernal chest pain unrelieved by rest
D. pain relieved by nitroglycerin
19. A client is in acute renal failure. The nurse must assess the client carefully for which of the
following potential complications?
A. Tetany
B. Hypernatremia
C. Vascular collapse
D. Cardiac arrhythmias
20. A client with Acute renal failure is being assessed to determine if the cause is prerenal,
renal, or postrenal. If the cause is prerenal, which condition most likely caused the renal
failure?
A. Heart failure
B. Glomerulonephritis
C. Ureterolithiasis
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D. Aminoglycoside toxicity
21. A client in Acute Renal failure becomes severely anemic and the physician prescribed two
units of packed red blood cells (RBCs). The nurse should plan to administer each unit:
A. as quickly as the client can tolerate the infusions.
B. over 30 minutes to an hour.
C. Between 1 and 4 hours.
D. up to 7 hours but no longer.
SITUATION: The following four patients are in the triage area at the same time. Patient 1 is a 2-
week-old neonate carried in by his mother who states that the baby has a fever. The Baby’s skin
is pink and he is sucking a bottle of formula. Patient 2 is a 25-year-old construction worker who
has amputated the distal third of his left fifth finger. He has no other injuries but states it is very
painful (7/10). Patient 3 is a 60-year-old man with chronic obstructive pulmonary disease (COPD)
and increasing shortness of breath. ”since the weather become hot last week.” He can speak in
complete sentences but can take only 5 to 6 steps before stopping to rest. Patient 4 is an 80-year-
old man complaining that he hasn’t had a bowel movement for 3 days.
22. Which of the following patient should the triage nurse assess first?
A. The 2-week-old infant with history of a fever.
B. The 25-year-old construction worker with a fingertip amputation.
C. The 60-year-old patient with COPD who is experiencing increasing dyspnea
D. The 80-year-old man with constipation.
23. In the triage area, what should you do with the construction worker’s amputated fingertip?
A. Pack it in ice and label the container with his name and put it in a refrigerator
B. Nothing, it probably will not be planted anyway because it is a construction accident.
C. Wrap the piece in moist gauze, place in a plastic bag, and place the bag on ice.
D. Wrap the fingertip in dry gauze, place it in a plastic bag, and place on dry ice.
24. A 43-year-old male is admitted with sickle cell anemia. The nurse plans to assess
circulation in the lower extremities every 2 hours. Which of the following outcome criteria
would the Nurse use?
A. Body temperature of 99°F less
B. Toes moved in active range of motion
C. Sensation reported when soles of feet are touched
D. Capillary refill of 3 seconds\
25. The client undergoing whole-body radiation for Hodgkin's disease may have destruction
of bone marrow, making it unable to function normally. As a result of this, the nurse would
expect the client to develop:
A. Increased blood viscosity
B. Increased tendency for fractures
C. Decreased number of erythrocytes
D. Decreased susceptibility to infections
26. Art, a 58 year old male client is admitted with suspected Hodgkin’s lymphoma. A rare
malignancy that has impressive cure rate. The diagnosis is confirmed by the:
A. Over proliferation of immature white cells
B. Presence of Reed-Sternberg cells
C. Increased incidence of microcytosis
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D. Reduction in the number of platelets
27. When administering a thrombolytic drug to Marko experiencing an MI, the nurse explains
to him that the purpose of the drug is to
A. treat potential cardiac dysrhythmias.
B. prevent kidney failure.
C. dissolve clots that he may have.
D. help keep him well hydrated.
28. Aspirin is administered to the patient experiencing an MI because of its

A. antipyretic action.
B. analgesic action.
C. antithrombotic action.
D. antiplatelet action.
29. A 65-year-old female patient on day 2 after hip surgery has no cardiac history but starts
to complain of chest heaviness. The first nursing action should be to
A. inform the physician of the chest heaviness.
B. inquire about the onset, duration, severity, and precipitating factors of the heaviness.
C. offer pain medication for the chest heaviness.
D. administer oxygen via nasal cannula.
30. In which of the following positions should the nurse place a patient with suspected heart
failure?
A. Sitting almost upright (high Fowler’s position).
B. Semi-sitting (low Fowler’s position).
C. Lying on the right side (Sim’s position).
D. Lying on the back with the head lowered (T-burg position).
31. Digoxin is administered intravenously to a patient with heart failure, primarily because the
drug acts to
A. dilate coronary arteries.
B. decrease electrical conductivity in the heart.
C. increase myocardial contractility.
D. decrease cardiac dysrhythmias.
32. When teaching the patient about complications of atrial fibrillation like pulmonary
embolism, the nurse understands that the complications can be caused by
A. decreased pulse rate.
B. increased cardiac output.
C. stasis of blood in the atria.
D. elevated blood pressure.
33. Which of the following signs and symptoms would most likely be found in a patient with
mitral regurgitations?
A. Chest pain.
B. Confusion.
C. Exertional dyspnea.
D. Elevated CPK concentration.

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34. The nurse teaches the patient who is receiving warfarin sodium that
A. the international normalized ration (INR) is used to assess effectiveness.
B. warfarin sodium will facilitate clotting of the blood.
C. protamine sulfate is used to reverse the effects of warfarin sodium.
D. partial thromboplastin time values determine the dosage of warfarin sodium.
35. The patient with hypertension is prone to long-term complications of the disease. Which
of the following is a long-term complication of hypertension?
A. Endocarditis.
B. Renal insufficiency and failure.
C. Valvular heart disease.
D. Peptic ulcer disease.
36. A patient with angina asks the nurse, “What information does an ECG provide?” The nurse
would respond that an ECG primarily gives information about the
A. contractile status of the ventricles.
B. oxygenation and perfusion of the heart.
C. electrical conduction of the myocardium.
D. physical integrity of the heart muscle.
37. The nurse teaches the patient with angina about the common expected side effects of
nitroglycerin, including
A. headache.
B. stomach cramps.
C. high blood pressure.
D. shortness of breath.
38. The patient who had a permanent pacemaker implanted 2 days earlier is being discharged
from the hospital. Outcomes include that the patient
A. verbalizes safety precautions needed to prevent pacemaker malfunction.
B. states a need for bed rest for 1 week after discharge.
C. selects a low-cholesterol diet to control coronary artery disease.
D. explains signs and symptoms of myocardial infarction.
39. The patient receives epinephrine during resuscitation in the emergency department. This
drug is administered primarily because of its ability to
A. dilate bronchioles.
B. constrict arterioles.
C. free glycogen from the liver.
D. enhance myocardial contractility.
40. When performing external chest compression on an adult during CPR, the rescuer should
depress the sternum
A. 0.5 to 1 inch.
B. 1 to 1.5 inches.
C. 1.5 to 2 inches.
D. 2 to 2.5 inches.

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41. The monitor technician informs the nurse that the patient has started having premature
ventricular contractions every other beat. What is the priority nursing action?
A. Give the patient a bolus of lidocaine.
B. Call the physician.
C. Assess the patient’s orientation and vital signs.
D. Call a “code blue” emergency.
42. With which of the following disorders is jugular vein distention most prominent?
A. Pneumothorax.
B. Abdominal aortic aneurysm.
C. Heart failure.
D. Myocardial infarction.
43. Which of the following conditions is most closely associated with weight gain, nausea, and
a decrease in urine output?
A. Cardiomyopathy.
B. Angina pectoris.
C. Left-sided heart failure.
D. Right-sided heart failure.
44. Which of the following sounds is distinctly heard on auscultation over the abdominal region
of an abdominal aortic aneurysm patient?
A. Dullness.
B. Crackles.
C. Bruit.
D. Friction rubs.
45. Which of the following types of cardiomyopathy can be associated with childbirth?
a. Hypertrophic.
b. Myocarditis.
c. Restrictive.
d. Dilated.
46. Which of the following results is the primary treatment goal for angina?
A. Reduction of stress and anxiety.
B. Reduction of associated risk factors.
C. Reversal of ischemia.
D. Reversal of infarction.
47. Which of the following terms is used to describe reduced cardiac output and perfusion
impairment due to ineffective pumping of the heart?
A. Distributive shock.
B. Cardiogenic shock.
C. Anaphylactic shock.
D. Myocardial infarction.
48. A paradoxical pulse occurs to Fred who had coronary artery bypass graft (CABG) surgery
2 days ago. Which of the following surgical complications should the nurse suspect?
A. Complete heart block.
B. Pericardial tamponade.
C. Left-sided heart failure.
D. Aortic regurgitation.
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49. A client who has an enlarged right ventricle due to a pulmonary disease has what
disorder?
A. Bronchitis
B. Pneumonia
C. Pericarditis
D. Cor pulmonale
50. Lung dysfunction impacts physical and mental performance because of the lungs’ critical
role in maintaining the body’s acid-base balance. Specifically, the lung plays a primary
role in controlling:
A. Arterial O2 and blood urea.
B. Arterial CO2 and cholesterol.
C. Arterial CO2, serum albumin, and pH.
D. Arterial CO2 and pH.
51. The nurse provides care to a client newly diagnosed with tuberculosis who is beginning
antibiotics. Which of the following medication regimens will the nurse anticipate for this
client?
A. A single drug (monotherapy) is common if the infection is mild.
B. Because the mycobacterium grows slowly, duration of treatment will be 9–18 months.
C. Medication will include the use of three antiviral agents such as AZT, Saquinivir,
Ritonavir.
D. Typically the medication regimen will include 3 or 4 drugs such as Isoniazid,
Rifampin, Pyrazinamide, Ethambutol.
52. Patients receiving theophylline for reactive airway disease (asthma) should be
counseled that the following item can decrease the clearance of theophylline resulting in
an increased serum theophylline level:
A. Viral infection
B. E-mycin (erythromycin)
C. Fever
D. Penicillin
53. Immediate post procedure care of the client who has undergone a bronchoscopy
includes all of the following except:
A. monitoring vital signs
B. ensuring siderails are up
C. pushing fluids
D. assessing breath sounds
54. Why is monitoring respiratory status a nursing priority when a client with COPD is
receiving oxygen?
A. Hyperventilation leading to respiratory alkalosis and loss of consciousness is a risk.
B. Sudden increase in arterial oxygen can precipitate diaphragmatic spasm.
C. Decreased arterial oxygen is the stimulus for breathing in a client with COPD.
D. Oxygen administration can trigger reflex bronchospasm.

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55. Following insertion of a CVP line, a client suddenly complains of a sharp pain in the right
chest that worsens on inspiration. Which assessment data would support the conclusion
that the client had developed a pneumothorax?
A. Tracheal shift with unilateral decreased chest expansion
B. Increased PaCO2 and decreased PO2
C. Crackles on affected side
D. Hyporesonance on affected side
56. Which would be the priority expected outcome when caring for an infant with croup?
A. Infant remains free of infection.
B. Infant takes clear fluids as prescribed.
C. Infant’s temperature returns to normal within 24 hours of antibiotic therapy.
D. Infant remains free of laryngospasm.
57. Dr. Alviz is about to defibrillate a client in ventricular fibrillation and says in a loud voice
“clear”. What should be the action of the nurse?
A. Places conductive gel pads for defibrillation on the client’s chest
B. Turn off the mechanical ventilator
C. Shuts off the client’s IV infusion
D. Steps away from the bed and make sure all others have done the same
58. A client has undergone right pneumonectomy. When turning the client, the nurse should
plan to position the client either:
A. Right side-lying position or supine
B. High fowlers
C. Right or left side lying position
D. Low fowler’s position
59. The nurse is assessing a client with pleural effusion. The nurse expects to find:
A. Deviation of the trachea towards the involved side
B. Reduced or absent of breath sounds at the base of the lung
C. Moist crackles at the posterior of the lungs
D. Increased resonance with percussion of the involved area
60. The nurse enters the room of a client diagnosed with COPD. The client’s skin is pink,
and respirations are 8 per minute. The client’s oxygen is running at 6 liters per minute.
What should be the nurse’s first action?
A. Call the health care provider
B. Put the client in Fowler’s position
C. Lower the oxygen rate
D. Take the vital signs
61. A client with asthma has low pitched wheezes present on the final half of exhalation.
One hour later the client has high pitched wheezes extending throughout exhalation.
This change in assessment indicates to the nurse that the client
A. Has increased airway obstruction
B. Has improved airway obstruction
C. Needs to be suctioned
D. Exhibits hyperventilation

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62. In caring for a patient with a tracheostomy which of the following would be an
INCORRECT action by the nurse when providing tracheostomy care?
A. Checking the cuff pressure
B. Provide humidified oxygen
C. Remove the outer cannula for cleaning q. shift
D. Place sterile gauze between the outer wings of the tube before tying strings or tape to
secure it
63. You are assisting a physician in removing a chest tube from a patient. Which of the
following will the patient are asked to do when the physician is ready to remove the
tube?
A. Exhale and hold breath, or bear down
B. Inhale and hold breath, or bear down
C. Breathe normally
D. Inhale and cough
64. A patient is receiving Incentive Spirometry post-operatively. Which of the following

would demonstrate misunderstanding on the part of the nurse regarding this treatment
modality?
A. The patient should be medicated for pain, PRN prior to beginning the treatment
B. The head of the bed should be elevated to at least 45 degrees
C. The therapy should begin on the second or third post-op day
D. The patient should be taught to hold their breath following inspiration, and then to
exhale slowly
65. Which of the following antituberculosis drugs can damage the 8th cranial nerve?
A. Isoniazid (INH)
B. Paraaminosalicylic acid (PAS)
C. Ethambutol hydrochloride (Myambutol)
D. Streptomycin
66. The client has been scheduled for a computed tomography (CT) scan. Which
information is most important for the nurse to obtain before the procedure?
A. The assessment of the client’s pain.
B. Vital signs are within normal limits.
C. Whether client has allergies to seafood.
D. Type of intravenous fluid being administered.
67. While working in the day surgery department, the nurse is caring for the client 2 hours
after having a right knee arthroscopy. Which intervention should the nurse implement?
A. Encourage the client to perform range-of-motion exercises.
B. Monitor the amount and color of the urinary output hourly.
C. Check the client’s pulses distally and assess the toes.
D. Monitor the client’s vital signs every eight (8) hours.
68. A nurse is analyzing the laboratory studies on a client receiving dantrolene sodium
(Dantrium). Which of the following laboratory tests would identify an adverse effect
associated with the administration of this medication?
A. Creatinine level determination
B. Platelet count determination
C. Blood urea nitrogen level determination
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D. Liver function tests
69. In preparing a plan of care for a client diagnosed with carpal tunnel syndrome, which
intervention should the nurse include?
A. Teach hyperextension exercises to increase flexibility.
B. Monitor safety during occupational hazards.
C. Prepare for the insertions of pins or screws.
D. Monitor dressing and drain after the fasciotomy.
70. The student nurse asks the emergency department nurse why the nurse is careful to
maintain asepsis when caring for the client with an open fracture of the right humerus.
Which rationale explains the nurse’s actions?
A. It is a policy to prevent the transmission of blood borne pathogens.
B. Clients who have open fractures are at a high risk for osteomyelitis.
C. Failure to maintain asepsis may result in a malpractice lawsuit.
D. The client has compromised immunity based on the laboratory values.
71. The client with a right open fractured elbow has a long arm cast and is complaining of
unrelenting severe pain and feeling as if the fingers are asleep. Which complication
should the nurse suspect that the client is experiencing?
A. Fat embolism.
B. Compartment syndrome.
C. Pressure ulcer under cast.
D. Surgical incision infection
72. A nurse is one of several persons who witness a vehicle hit a pedestrian at fairly low
speed on a small street. The person is dazed and tries to get up. The leg appears
fractured. The nurse would plan to:
A. Try to reduce the fracture manually.
B. Assist the person to get up and walk to the sidewalk.
C. Leave the person for a few moments to call an ambulance.
D. Stay with the person and encourage the person to remain still.
73. The nurse is caring for a 13-year-old following spinal fusion for scoliosis. Which of the
following interventions is appropriate in the immediate post-operative period?
A. Raise the head of the bed at least 30 degrees
B. Encourage ambulation within 24 hours
C. Maintain in a flat position, logrolling as needed
D. Encourage leg contraction and relaxation after 48 hours
74. A client has Buck's extension traction applied to the right leg. The nurse would plan
which of the following interventions to prevent complications of the device?
A. Give pin care once a shift.
B. Massage the skin of the right leg with lotion every 8 hours.
C. Inspect the skin on the right leg at least once every 8 hours.
D. Release the weights on the right leg for daily range-of-motion exercises.

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75. The 27-year-old client has a right above-the-elbow amputation secondary to a boating
accident. Which statement by the rehabilitation nurse indicates the client has accepted
the amputation?
A. “I am going to sue the guy that hit my boat.”
B. “The therapist is going to help me get retrained for another job.”
C. “I decided not to get prosthesis. I don’t think I need it.”
D. “My wife is so worried about me and I wish she wouldn’t.”
76. The 62-year-old client diagnosed with Type 2 diabetes who has a gangrenous right toe
is being admitted for a BKA amputation. Which nursing intervention should the nurse
implement?
A. Assess the client’s nutritional status.
B. Refer the client to an occupational therapist.
C. Determine if the client is allergic to IVP dye.
D. Start a 22-gauge Angiocath in the right arm.
77. When caring for a client with a Spica cast for a hip injury, what intervention should the
nurse include in the plan of care?
A. Assess client’s popliteal pulses every shift.
B. Elevate the leg on pillows and apply ice packs.
C. Teach the client how to ambulate with a tripod walker.
D. Assess the client for distention and vomiting.
78. A nurse is assessing the casted extremity of a client. The nurse would assess for which
of the following signs and symptoms indicative of infection?
A. Dependent edema
B. Diminished distal pulse
C. Presence of a “hot spot” on the cast
D. Coolness and pallor of the extremity
79. Swing- through crutch gait is done by:

A. Advancing both legs at the level of the crutches.
B. Advancing both crutches and affected leg together followed by the unaffected leg.
C. Advancing both crutches together and the client moves both legs past the level of the
of the crutches
D. Advancing the left crutch and the right foot together followed by the right crutch and
left foot together.
80. The physician orders non-weight bearing with crutches for Joy, who had surgery for a
fractured hip. The most important activity to facilitate walking with crutches before
ambulation begun is:
A. Exercising the triceps, finger flexors, and elbow extensors
B. Sitting up at the edge of the bed to help strengthen back muscles
C. Doing isometric exercises on the unaffected leg
D. Exercising the biceps, flexion and extension of the unaffected leg
81. The nurse recognizes that a client understood the demonstration of crutch walking when
she places her weight on:
A. The palms and axillary regions
B. Both feet placed wide apart

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C. The palms of her hands

D. Her axillary regions
82. The standard walker is used when clients:

A. have poor balance, cannot stand up, have weak arms, and have good hand strength.
B. have poor balance, broken leg, or amputation.
C. have poor balance, cardiac problems, and cannot use crutches or cane.
D. have poor balance, autoimmune diseases, and weak arms.
83. Following Total Hip Replacement, the nurse should position the patient:
A. Recumbent with the affected extremity in abduction
B. Recumbent with the affected extremity in adduction
C. Recumbent on unoperated side with affected leg straight
D. Recumbent on operated side with unaffected leg at 45 degrees
84. The client is diagnosed with polycythemia vera. The nurse would prepare to perform
which intervention?
a. Type and cross-match for a transfusion.
b. Assess for petechiae and purpura.
c. Perform phlebotomy of 500 mL of blood.
d. Monitor for low hemoglobin and hematocrit.
85. The client is placed on neutropenia precautions. Which information should the nurse
teach the client?
A. Shave with an electric razor and use a soft toothbrush.
B. Eat plenty of fresh fruits and vegetables.
C. Perform perineal care after every bowel movement
D. Some blood in the urine is not unusual.
86. The 24-year-old female client is diagnosed with idiopathic thrombocytopenia purpura
(ITP). Which question would be important for the nurse to ask during the admission
interview?
A. “Do you become short of breath during activity?”
B. “How heavy are your menstrual periods?”
C. “Do you have a history of deep vein thrombosis?”
D. “How often do you have migraine headaches?”
87. The client diagnosed with atrial fibrillation is admitted with warfarin (Coumadin) toxicity.
Which HCP order would the nurse anticipate?
A. Protamine sulfate, an anticoagulant antidote.
B. Heparin sodium, an anticoagulant.
C. Lovenox, a low molecular weight anticoagulant.
D. Vitamin K, an anticoagulant antagonist.
88. Fifteen minutes after the nurse has initiated a transfusion of packed red blood cells the
client becomes restless and complains of itching on the trunk and arms. Which
intervention should the nurse implement first?
A. Collect urine for analysis.
B. Notify the lab of the reaction.
C. Administer diphenhydramine, an antihistamine.
D. Stop the transfusion at the hub.
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89. What documentation is best for the nurse in the case of a client who refuses a blood
transfusion?
A. Have the client sign a refusal form.
B. Document the client’s refusal.
C. Chart notification of the charge nurse.
D. Document a quote from the client.
90. Which of the following conditions may lead to anemia?

A. gastritis
B. pneumonitis
C. arthritis
D. tonsillitis
91. Epoetin alfa (Epogen, Procrit) is a recombinant form of erythropoietin, a hematopoietic

growth hormone produced by the kidneys. It is administered to patients undergoing
chemotherapy to stimulate the production of:
A. Platelets.
B. White blood cells.
C. Red blood cells.
D. Macrophages.
92. A client is suspected of having systemic lupus erythematous. The nurse monitors the
client, knowing that which of the following is one of the initial characteristic signs of
systemic lupus erythematous?
A. Weight gain
B. Subnormal temperature
C. Elevated red blood cell count
D. Rash on the face across the bridge of the nose and on the cheeks
93. A nurse is at the lake when a person experiences a near-drowning event. People at the
scene remove the victim from the water. After breathing, which should the nurse assess
first?
A. Possibility of drug use.
B. Spinal cord injury.
C. Level of confusion.
D. Amount of alcohol.
94. The ED nurse is caring for the client who has taken an overdose of cocaine. Which
intervention should the nurse delegate to the unlicensed assistive personnel?
a. Evaluate the airway and breathing.
b. Monitor the rate of intravenous fluids.
c. Place the cardiac monitor on the client.
d. Assess the vital signs every 15 minutes.
95. He thinks of an appropriate theoretical framework. Whose theory addresses the four
modes of adaptation?
A. Martha Rogers
B. Sr. Callista Roy
C. Florence Nightingale
D. Jean Watson
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96. He checks if his instruments meet the criteria for evaluation. Which of the following
criteria refers to the consistency or the ability to yield the same response upon its
repeated administration?
A. Validity
B. Reliability
C. Sensitivity
D. Objectivity
97. Which criteria refer to the ability of the instrument to detect fine differences among the
subjects being studied?
A. Sensitivity
B. Reliability
C. Validity
D. Objectivity
98. Which of the following terms refer to the degree to which an instrument measures what it
is supposed to be measure?
A. Validity
B. Reliability
C. Meaningfulness
D. Sensitivity
99. Archie is interested to learn more about transcultural nursing because he is assigned at
the family suites where most patients come from different cultures and countries. Which
of the following designs is appropriate for this study?
A. Grounded theory
B. Ethnography
C. Case study
D. Phenomenology
100.Which of the following is NOT true about a hypothesis? Hypothesis is:

A. testable
B. proven
C. stated in a form that it can be accepted or rejected
D. states a relationship between variables

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NURSING PRACTICE IV- ANSWERS AND RATIONALIZATIONS

Inability to empty the bladder, as a result of pressure exerted by the enlarging prostate
on the urethra, causes a backup of urine into the ureters and finally the kidneys
(hydronephrosis).
The bladder is a sterile body cavity; when introducing a solution/catheter surgical
asepsis is required.
Because the urine and irrigant are mixed, the amount of infused irrigant must be
measured accurately and subtracted from the total output to determine the urinary
output.
Client with burns suffer from hyperkalemia, not hypokalemia
The amount of protein permitted in the diet (usually below 50 grams) depends on the
extent of kidney function; excess protein causes a rise in urea, which should be avoided;
adequate calories are also provided to prevent tissue catabolism that also results in an
increase in metabolic waste products.
Diffusion moves particles from an area of greater concentration to an area of lesser
concentration, osmosis moves fluid from an area of lesser to an area of greater
concentration of particles.
Vital signs monitor cardiovascular status; hyperkalemia causes serious cardiac
dysrhythmias
Potassium follows insulin into the cells of the body, thereby raising the cellular potassium
and preventing fatal dysrhythmias.
Although serum potassium, uric acid and blood urea nitrogen are all useful diagnostic tests
in the diagnosis of renal drainage disease, the serum creatinine is the most definitive
diagnostic procedure

The acid-base disturbance is respiratory acidosis without compensation.

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Respiratory acidosis is most often caused by hypoventilation in a client with COPD

E. coli is the most common organism causing urinary infection. The urinary tract above
the urethra is sterile. Pyelonephritis is an infection of the kidneys or upper urinary tract.
The incidence of urinary tract infectious is greater in the female because the urethra is
shorter than that of the male ad also is closer to the vagina and rectum.

Tetany is neuromuscular irritability characterized by tremors and spasms. Chvostek’s sign
is performed by tapping sharply over the facial nerves and is positive if that causes
twitching or spasms in the region of the eyes, nose, and mouth.

Immunosuppressants, such as methotrexate and cytoxan, are used to treat exacerbations
of systemic lupus erythematosus that are not responsive to other medication.

Discoid lupus produces discoid or “coinlike” lesions on the skin.

This is an isoenzyme of CPK found only in cardiac muscle that rises 4 to 6 hours after
chest pain and reaches a peak in 12 hours; thus, this is the earliest indicator of a
myocardial infarction.

For severe myocardial infarction Morphine is the drug of choice because it relieves pain
quickly and reduces anxiety.

The hallmark manifestation of Myocardial infarction is chest pain unrelieved by rest

An elevated serum potassium level (hyperkalemia) is common in acute renal failure and
puts the client at risk for cardiac arrhythmias.

By causing inadequate renal perfusion, heart failure can lead to prerenal failure.
Glomerulonephritis and aminoglycoside toxicity are causes and ureterolithiasis is a
postrenal cause.

It’s standard practice to infuse a unit of packed RBCs between 1 to 4 hours.

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The 2-week-old infant with a history of fever. Infant less than 3 months old with a
temperature of 38’C (101’F) or greater are at risk for sepsis, Infants are more difficult to
assess than older children and adults and may decompensate more quickly.

Wrap the part in moist gauze, place it in a plastic bag, and place the bag on ice. The
amputated part must be kept moist and cool but protected from freezing.

It is important to assess the extremities for blood vessel occlusion in the client with sickle
cell anemia because a change in capillary refill would indicate a change in circulation.

Depression of the bone marrow interferes with hemopoiesis and result in anemia.

The presence of Reed-Sternberg cells, sometimes referred to as “owl’s eyes,” is the
diagnostic procedure to confirm for Hodgkin’s lymphoma

Thrombolytic medications are administered to dissolve the clot in the coronary artery that
causes the abrupt cessation of blood supply and allow reperfusion to the in myocardium
before cellular death occurs.

Aspirin is administered to the patient since it has an antiplatelet action which prevents the
aggregation of platelet that can lead to clot formation.

Further data collection is needed in this situation. Other options are done after pertinent
data are gathered from the client. Inquiring about the onset, duration, location, severity
and precipitating factors of the chest heaviness will provide pertinent information to convey
to the physician.

Sitting almost upright in bed with the feet and legs resting on the bed decreases venous
return to the heart and decreasing cardiac workload. This also facilitates maximum lung
expansion for adequate oxygenation.

Digoxin, a cardiac glycoside, has positive inotropic effect to the heart, which increases the
strength of its contraction thereby decreasing congestion and increases output of blood
from the left ventricle.

Due to rapid and chaotic atrial beats, not all blood from the atrial are delivered to the
ventricles. This could lead to blood stasis in the atria, which could coagulate and leads to
a thrombus and eventually emboli.

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Mitral regurgitation leads to the backflow of blood from the left ventricle to the left atrium
and eventually back to the lungs. This may lead to pulmonary congestion thus interfering
with oxygenation. Exertional dyspnea will be experienced due to the problem of
oxygenation.

Before and after the administration of warfarin sodium, it is necessary to assess the INR
value, which reflects the effectiveness of the therapy. INR is also known as prothrombin
time. The normal value is 11-16 seconds and is maintained at 1.5 to 2.5 times the control
value when on warfarin sodium therapy.

Renal disease, including renal insufficiency and failure is a complication of hypertension.
The kidneys are very sensitive to a decrease in blood volume and supply. Hypertension
is a pre-renal cause of renal failure.

ECG monitoring reflects the conduction system of the heart. This information makes it
possible to evaluate indirectly the functional status of the heart muscle and the contractile
response of the ventricles as reflected by the QRS complex and the T wave.

Headache is an expected side effect when taking nitroglycerin because of its widespread
vasodilating effects. Other effects include hypotension and dizziness.

Education is a major component of the discharge plan for a client with an artificial
pacemaker. The client with a permanent pacemaker needs to be able to state specific
information about safety precautions necessary to maintain proper pacemaker function.

Epinephrine is an adrenergic drug that is administered during resuscitation efforts primarily
for its ability to improve cardiac activity. It acts to strengthen and speed the heart rate as
well as to increase impulses conduction from atria to ventricles.

An adult’s sternum must be depressed 1.5 to 2 inches with each compression to ensure
adequate heart compression.

Assessment is the priority during PVC episodes. Assessment of the patient’s orientation
and vital signs are needed as well as the frequency of the rhythm. Before calling a code,
6 PVCs are required.

Heart failure is one of the causes for having jugular vein distention. This is due to the
congestion of the heart which can lead to systemic backflow to the superior vena cave
and eventually upward to the jugular veins.

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Right-sided heart failure leads to systemic backflow of blood as evidenced by weight gain,
nausea, and a decrease in urine output. Cardiomyopathy is usually identified as a
symptom of left-sided heart failure. Left-sided heart failure causes primarily pulmonary
symptoms rather than systemic ones.

A bruit, a vascular sound resembling heart murmur, suggests partial arterial occlusion.
Crackles are indicative of fluid in the lungs. Dullness is heard over solid organs, such as
the liver. Friction rubs indicate inflammation of the peritoneal surface.

Cardiac dilation and heart failure may develop during the last month of pregnancy of the
first few months after birth. The condition may result from a preexisting cardiomyopathy
not apparent prior to pregnancy. Hypertrophic cardiomyopathy is an abnormal symmetry
of the ventricles that has an unknown etiology but a strong familial tendency. Restrictive
cardiomyopathy indicates constrictive pericarditis; the underlying cause is usually
myocardial.

Reversal of the ischemia is the primary goal, achieved by reducing oxygen consumption
and increasing oxygen supply. An infarction is permanent and cannot be reversed.

Cardiogenic shock is shock related to ineffective pumping of the heart. Since the heart
has no effective contraction, there will be decreased cardiac output and decreased
systemic perfusion.

A paradoxical pulse signals pericardial tamponade, a complication of CABG surgery.

Cor pulmonale refers to a disorder resulting in an enlarged right ventricle due to a
pulmonary disease, not the other options.

CO2 and H2O in differing concentrations, react to form carbonic acid (H2CO3), which in
turn dissociates to form bicarbonate (HCO3) and hydrogen (H+) ions. This reaction
determines the pH of arterial blood and the acid-base balance of the human body. CO2
is blown off or conserved by the lungs as one variable in keeping this balance.

Treatment of tuberculosis is multi-drug therapy typically isoniazid, rifampin, pyrazinamide
and ethambutol.
Treatment is long term usually over a period of six months if the client is not drug
resistant, but up to 24 months if there is drug resistance.

Erythromycin is a macrolide antibiotic that causes down-regulation of the cytochrome-
450 system in the liver, thus reducing theophylline clearance resulting in an increased
theophylline plasma concentration.
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The client is not to have fluids until the nurse is certain the gag reflex is intact.

Decreased oxygen in the blood is the stimulus for breathing in a client with COPD.
Therefore, if oxygen is administered there is the risk that respiratory arrest will occur
because high oxygen saturation levels in the blood eliminate the stimulus for breathing.

As air or fluid collects in the pleural space, the trachea is forced out of the midline toward
the unaffected side.

Croup is a condition that results from acute obstruction at or just below the larynx.
Laryngospasm, which is the spasmodic closure of the larynx produces the brassy or
barking cough, hoarseness, and respiratory distress that are the signs of croup and
therefore must be prevented.

For the safety of all personnel, if the defibrillator paddles are being discharged, all
personnel must stand back and be clear of all the contact with the client or the client’s
bed.

Right side lying position or supine position permits ventilation of the remaining lung and
prevent fluid from draining into sutured bronchial stump.

Compression of the lung by fluid that accumulates at the base of the lungs reduces
expansion and air exchange.

In client’s diagnosed with COPD, the drive to breathe is hypoxia. If oxygen is delivered at
too high of a concentration, this drive will be eliminated and the client’s depth and rate of
respirations will decrease. Therefore, the first action should be to lower the oxygen rate.

The higher pitched a sound is, the narrower the airway. Therefore, the obstruction has
increased or worsened

In tracheostomy tubes with both an inner and outer cannula, it is only the inner cannula
which is removed for cleaning. Newer plastic tubes have disposable inner cannulas that
are changed as ordered.

When removing a chest tube the physician will ask the patient to exhale and hold their
breath, or exhale and bear down. This will serve to increase intrathoracic pressure, as
well as prevent air from entering the pleural space.

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Incentive Spirometry is used post-operatively especially after thoracic and abdominal
surgery to prevent collapse of the air passages or atelectasis. It should be started
immediately as atelectasis can start as soon as one hour post-operatively.

Streptomycin is an aminoglycoside and damage on the 8th cranial nerve (ototoxicity) is a
common side effect of aminoglycosides.

This is the most important information the nurse should obtain. Any client who is allergic
to seafood cannot be injected with the iodine-based contrast. This contrast would cause
an allergic response that could endanger the client’s life.

Pulses and circulation checks should be done every one (1) to two (2) hours
postoperatively.

Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce
the risk of liver damage, tests of liver function should be performed before treatment and
throughout the treatment interval. Dantrolene is administered in the lowest effective
dosage for the shortest time necessary.

The nurse should monitor for potential injuries resulting from the alterations in motor,
sensory, and autonomic function of the first three digits of the hand and palmar surface
of the fourth. These alterations can interfere with pinching or grasping, which, in turn,
increases the risk for injury in clients whose occupations require the use of equipment
such as jackhammers and computers.

The open skin and exposure of the bone is a direct pathway for infection and
osteomyelitis.

These are the classic signs/symptoms of compartment syndrome.

With a suspected fracture, the client is not moved unless it is dangerous to remain in that
spot. The nurse should remain with the client and have someone else call for emergency
help. A fracture is not reduced at the scene. Before the client is moved, the site of
fracture is immobilized to prevent further injury.

Maintain in a flat position, logrolling as needed. The bed should remain flat for at least
the first 24 hours to prevent injury. Logrolling is the best way to turn for the client while
on bed rest.

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Buck's extension traction is a type of skin traction. The nurse inspects the skin of the
limb in traction at least once every 8 hours for irritation or inflammation.

Looking toward the future and problem solving indicate that the client is accepting the
loss.

For wound healing, a balanced diet with adequate protein and vitamins is essential,
along with meals appropriate for Type 2 diabetes.

The nurse should assess the client for signs and symptoms of cast syndrome—vomiting
after meals, epigastric pain, and abdominal distention. This is caused by a partial bowel
obstruction from compression and can lead to complete obstruction. The client may still
have bowel sounds present with this syndrome.

Signs and symptoms of infection under a casted area include odor or purulent drainage
from the cast or the presence of “hot spots,” which are areas of the cast that are warmer
than others. The physician should be notified if any of these occur.

Swing through gait is performed by advancing both crutches together and the client
moves both legs past the level of the of the crutches

Exercising the triceps, finger flexors, and elbow extensors. These sets of muscles are
used when walking with crutches and therefore need strengthening prior to ambulation.

The palms should bear the client’s weight to avoid damage to the nerves in the axilla
(brachial plexus)

The use of the walker is used for clients who have balance, cardiac problems, or who
cannot use crutches or cane. The client needs to be partial weight bearing and have
strength in wrists and arms. The client uses upper body to propel the walker forward.

Following Total Hip Replacement, the patient should be kept flat when in the recumbent
position with the affected extremity placed in abduction. The nurse can accomplish this
by placing a wedge or pillow between the patient's legs. Dislocation could result if the
affected leg were to be placed in adduction

The client has too many red blood cells, which can cause as much damage as too few.
The treatment for this disease is to remove the excess blood; 500 mL at a time is
removed.

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Perineal care after each bowel movement, preferably with an antimicrobial soap, is
performed to reduce bacteria on the skin.

Because thrombocytopenia causes bleeding the nurse should assess for any type of
bleeding that may be occurring. A young female client would present with excessive
menstrual bleeding.

The antidote for warfarin (Coumadin) is vitamin K

Any time the nurse suspects the client is having a reaction to blood or blood products,
the nurse should stop the infusion at the spot closest to the client and not allow any
more of the blood to enter the client’s body.

Agencies have a refusal form for the client to sign in the event of refusal of a blood
transfusion

Gastritis may lead to anemia, due to blood loss

Administration of epoetin alfa stimulates red blood cell production in anemia states.

Skin lesions or rash on the face across the bridge of the nose and on the cheeks is an
initial characteristic sign of systemic lupus erythematosus (SLE).

The nurse should assess the victim for hypoxia. Signs and symptoms of hypoxia include
confusion or irritability and alterations in level of consciousness, such as lethargy.

Unlicensed assistive personnel who have been trained can attach the cardiac monitor to
the clients.

Sr. Callista Roy developed the Adaptation Model which involves the physiologic mode,
self-concept mode, role function mode and dependence mode

Reliability is repeatability of the instrument; it can elicit the same responses even with
varied administration of the instrument

Sensitivity is an attribute of the instrument that allow the respondents to distinguish
differences of the options.

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Validity is ensuring that the instrument contains appropriate questions about the
research topic

Ethnography is focused on patterns of behavior of selected people within a culture

Hypothesis is not proven; it is either accepted or rejected. Hypothesis is testable and is
defined as a statement that predicts the relationship between variables

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NURSING PRACTICE V- QUESTIONS

1. Which of the following illustrates the defense mechanism of rationalization?
A. A man cheats on his income tax return and tells himself it’s all right because everyone
does it
B. A manager tells an employee he may have to fire him. On the way home, the employee
shops for a new care
C. A man is jealous of a good friend’s success but is unaware of his feelings
D. A woman who dislikes her aunt is always nice to her
2. Carlo tells you about his trip to the grocery store. He spends 10 minutes talking about the
produce department in great detail. Ten minutes later he finally gets to the main point of
the story, which was meeting an old friend. You describe Carlo’s form of thought as
A. confabulation
B. blocking
C. circumstantiality
D. loose association
3. Carbamazepine and valproic acid taken during pregnancy are associated with
A. premature labor
B. neonatal hypothyroidism
C. increased risk of neural tube defects
D. polyhydramnios
4. Ajie says to you, “Where did you come from? Mars is in outer space. Do you work for the
government? I like your shirt. When can I go home?” This is an example of
A. loose association
B. tangential speech
C. circumstantial speech
D. concrete thinking
5. Which of the following neurotransmitters tends to control the activity of the other
neurotransmitters and is the key player in circadian rhythms?
A. dopamine
B. norepinephrine
C. acetylcholine
D. serotonin
6. Which of the following is a benefit of seclusion?

A. The client is relieved of the need to relate to others
B. The unit can be managed with fewer staff
C. Clients are encouraged to communicate with others
D. Clients are forced to be responsible for themselves
7. Your client is experiencing parkinsonism side effects of antipsychotic medication. Which

of the following agents will be ordered to counteract these effects?
A. Paxil (paroxetine)
B. Ativan (lorazepam)
C. Clozaril (clozapine)
D. Benadryl (diphenhydramine)

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8. Which of the following medications will decrease both positive and negative characteristics
of schizophrenia?
A. Thorazine (chlorpromazine)
B. Olanzapine (zyprexa)
C. Haldol (haloperidol)
D. Mellaril (thioridazine)
9. Your client who is taking Haldol (haloperidol) suddenly develops severe muscle spasm in
his head and neck. How would you describe this reaction in your documentation?
A. Akathisia
B. Tardive dyskinesia
C. Acute dystonic reaction
D. Neuroleptic malignant syndrome
10. Your client is taking Tofranil (imipramine) for treatment of his panic disorder. Which of the
following statements would be included in your teaching plan?
A. Do not drink alcohol because both alcohol and Tofranil lower the seizure threshold
B. Do not drink alcohol because both alcohol and Tofranil cause CNS depression
C. If you are diabetic, you must closely monitor your blood glucose levels while taking
Tofranil
D. You will not feel the effect of this medication for 4-6 days
11. Pamela is experiencing the panic level of anxiety. What is the most appropriate nursing
intervention?
A. Leave her alone so she can get control of herself
B. Stay with her to reassure her of her safety
C. Have her join a group of people so she will feel better
D. Put her in a waist restraint until she calms down
12. Which of the following assessment questions would be best to ask a client with obsessive-
compulsive disorder?
A. Do you dislike being controlled by your fear?
B. How much time during a day do you spend on checking activities?
C. In what ways have you been re-experiencing the original trauma?
D. How aware are you of bodily sensations?
13. Which of the following interventions is part of cognitive restructuring?

A. Mapping all the known personalities
B. Providing information about the disorder
C. Challenging thoughts that are unrealistic and exaggerated
D. Encouraging clients to express their thought and feelings directly
14. Your client says to you, “If I’m not thin, I’m fat.” You would document this as which type
of cognitive distortion?
A. Selective abstraction
B. Superstitious thinking
C. Overgeneralization
D. Dichotomous thinking

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15. Which of the following medications will likely be ordered for Karen, who is suffering from
bulimia?
A. Thorazine, an antipsychotic agent
B. Xanax, an antianxiety agent
C. BuSpar, an antianxiety agent
D. Prozac, an antidepressant
16. Tom is unable to experience pleasure as a result of his depression. You would document
this as
A. anhedonia
B. catastrophizing
C. somatization
D. secondary gain
17. Sacho states that he has a rat in his stomach that can come all the way up to his throat.
You would document this as which type of delusion?
A. Grandiosity
B. Control
C. Somatic
D. Ideas of reference
18. John hears voices telling him that he is a terrible person who would be better off dead.
Which of the following would be the priority nursing diagnosis?
A. Impaired verbal communication
B. High risk for violence, self-directed
C. Sensory-perceptual alteration
D. Impaired social interaction
19. Pilar is taking conventional antipsychotic medications. Her mother notices one evening
that she is experiencing muscle rigidity and respiratory problems. When she takes her
temperature, it is 104°F. Which of the following problems is Pilar experiencing?
A. Neuroleptic malignant syndrome
B. Dystonia
C. Akathisia
D. Tardive dyskinesia
20. Your client in the emergency department has overdosed on cocaine. Which of the
following interventions would be most appropriate?
A. Determine blood pressure since hypotension may result from ruptured esophageal
varices
B. Use activated charcoal or gastric lavage
C. Reassure the client that he is not losing his mind and that the effects of the drug will
wear off
D. Treat for hyperthermia and seizures
21. An affective characteristic common to persons with personality disorders form Cluster B
is:
A. flat or blunted affect
B. intense and changing expression
C. passive affect
D. minimal expression
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22. Carmelito, who has Dementia of the Alzheimer’s Type (DAT), often wanders out of her
house during the night in search of her infant children. What safety suggestion would be
best for the family to implement?
A. Put an alarm system on all exit doors
B. Put Oscar in a waist restraint at night
C. Alert neighborhood people to the problem
D. Have family members alternate staying awake at night
23. Which of the following statements is most indicative of the potential for suicide?
A. “I know you’ve been worried about me. You won’t have to worry too much longer
B. “I think I’ve found a solution to my problem. I’m going to check it out with my doctor.”
C. “I’m looking forward to the holiday season and the kids coming home from school.”
D. “The voices have been decreasing in intensity and frequency over the past weeks.”
24. A rape victim has just been admitted to the emergency department. It has been determined
that she does not have any critical injuries from the sexual assault. The next step in the
assessment process is to
A. perform a vaginal examination
B. refer her to DSWD
C. inform her of her rights
D. take swabs for diagnosis of sexually transmitted infections
25. Kenneth is 3 years old and has diagnosed with attention deficit hyperactivity disorder
(ADHD). Which medication is most likely to be prescribed?
A. Elavil (amitripryline)
B. Dexedrine (dextroamphetamine)
C. Ritalin (methylphenidate)
D. Cylert (pemoline)
26. The nurse caring for a client diagnosed with Parkinson’s disease writes a problem of
“Impaired Nutrition.” Which nursing intervention would be included in the plan of care?
A. Consult the occupational therapists for adaptive appliances for eating
B. Request a low-fat, low-sodium diet from the dietary department
C. Provide three meals per day that include nuts and whole-grain breads
D. Offer six meals per day with a soft consistency
27. A patient with Parkinson’s disease is started on Levodopa. The nurse explains that this
drug
A. stimulates dopamine receptors in the basal ganglia
B. promotes the release of dopamine from brain neurons
C. is a precursor of dopamine that is converted into dopamine in the brain
D. prevents the excessive breakdown of dopamine in the perineal tissues
28. For a client with Meniere’s disease whose nursing diagnosis is “Risk for injury related to
vertigo,” which of these interventions is essential?
A. Administer medications for vertigo when the symptoms begin
B. Avoid glaring, bright lights
C. Have a family member stay with the client at all times

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D. Teach the client to ambulate slowly when moving around the room or the hallway
29. A patient is diagnosed with a sensorineural hearing loss and asks if a hearing aid will help
return his hearing to normal. Which statement about hearing aids is correct?
A. Hearing aids only help patterns with conductive hearing loss.
B. Hearing aids increase volume but not clarity of sounds.
C. Hearing aids will assist patient to hear sounds as normal.
D. Hearing aids will eliminate background noise.
30. The client is scheduled for right-eye cataract removal surgery in five (5) days. Which
preoperative instruction should be discussed with the client?
A. Administer dilating drops to both eyes for 72 hours prior to surgery
B. Prior to surgery, do not lift or push any objects heavier than 15 pounds
C. Make arrangements for being in the hospital for at least three (3) days
D. Avoid taking any type of medication that causes bleeding, such as aspirin
31. The first symptom a client with open-angle glaucoma is most likely to exhibit is:
A. Constant blurred vision
B. Sudden attacks of acute pain
C. Impairment of peripheral vision
D. A sudden, complete loss of vision
32. The nurse is caring for a client who is experiencing escalating levels of anxiety. The doctor
orders medication to be given. Which medication would the nurse expect to administer in
this situation?
A. Alprazolam (Xanax) 0.5 mg p.o. t.i.d.
B. Meclizine hydrochloride (Antivert) 25 mg p.o. t.i.d.
C. Ranitidine hydrochloride (Zantac) 150 mg p.o. b.i.d.
D. Sertraline hydrochloride (Zoloft) 50 mg p.o. every day.
33. When caring for a client with schizoid personality disorder, the nurse primarily focuses on
A. expanding the client’s interest in objects and things
B. increasing the client’s ability to experience pleasure
C. increasing solitary activities
D. improving the client’s functional relationships
34. You are assigned to a client with schizotypal personality disorder. Your assessment would
likely reveal which of the following behaviors?
A. seeks attention and engages in erratic behavior
B. withdrawn and engages in odd, eccentric behavior
C. overtly psychotic and experiencing hallucinations and delusions
D. active participation in activities with other clients and staff

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35. A young male patient is brought to the emergency department with a diagnosis of
traumatic head injury following a motor vehicle accident. Upon admission, vital signs are
within normal limits, pupils are equal but react sluggishly, Glasgow coma score = 5, and
intracranial pressure (ICP) is 30 mm Hg. Based on this initial assessment, the nurse
understands that:
A. Further evaluation is warranted before care is provided.
B. The patient is comatose and has elevated ICP.
C. The patient is unlikely to survive because of the head injury.
D. The patient needs a head CT scan immediately.
36. A 15-month-old boy Nicky, is admitted to the pediatric unit with a diagnosis of bilateral
serous Otitis media and bacterial meningitis. All of the following rooms are available on a
pediatric unit. Nurse Kelly should plan to put the client in which one?
A. An isolation room off the main hallway.
B. A private room two doors away from the nurses’ station.
C. A semiprivate room with a 15-month-old child who has meningitis.
D. A four-bed room with two toddlers who have croup.
37. An 8-year-old child is admitted with a diagnosis of epilepsy. The patients exhibit brief
lapses of consciousness and vacant stares. Nurse Lito suspects that the patient is
experiencing what type of seizures?
A. Grand mal
B. Petit mal
C. Jacksonian
D. Psychomotor
38. A psychiatric mental health professional who predominantly uses the intervention mode
of group and family therapies has the goal of:
A. changing the dynamics of the client’s behavior
B. improving the quality of the individual’s interpersonal interactions
C. developing insight
D. managing the symptoms
39. The symptom the nurse can expect a patient with dissociative fugue to manifest is:
A. the notion that some part of the body is ugly or disproportionate.
B. a feeling of detachment from one’s body.
C. worry about having a serious disease.
D. travel away from home and assumption of a new identify
40. Archie, 28 years old, is scheduled for mastoid surgery. He is anxious and expressed his
concerns regarding the outcome of surgery. The following nursing intervention is the most
appropriate to prepare Achilles for his surgery?
A. Allow the wife to stay close with the client
B. Talk with the client
C. Reinforce the information discussed by the surgeon
D. Administer the pre anesthetic medication
41. Amikacin (Amikin) is prescribed for a client with a bacterial infection. The nurse instructs
the client to contact the physician immediately if which of the following occurs?
A. Nausea
B. Hearing loss
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C. Lethargy
D. Muscle aches
42. The client diagnosed with ALS asks the nurse, “I know this disease is going to kill me.
What will happen to me in the end?” Which statement by the nurse would be most
appropriate?
A. “You are afraid of how you will die?”
B. “Most people with ALS die of respiratory failure.”
C. “Don’t talk like that. You have to stay positive.”
D. “ALS is not a killer. You can live a long life.”
43. Which situation would make the nurse think the client has glaucoma?
A. An automobile accident because the client is not seeing the car in the next lane.
B. The cake tasted funny because the client could not read the recipe.
C. The client has been wearing mismatched clothes and socks.
D. The client ran a stoplight and hit a pedestrian walking in the crosswalk.
44. How should the nurse position the television set for the nursing home resident who has
macular degeneration in both eyes?
A. As close to the client’s face as possible, because the client can no longer adjust for
distance vision
B. On the side with the best hearing ear, because this client has only light perception vision
C. Directly in front of the client, because he or she no longer has peripheral vision
D. On either side of the client, because he or she no longer has central vision
45. Archie who has been hospitalized with schizophrenia tells Nurse Hannah, “My heart has
stopped and my veins have turned to glass!” Nurse Hannah is aware that this is an
example of:
A. Somatic delusions
B. Depersonalization
C. Hypochondriasis
D. Echolalia
46. When being admitted to a mental health facility, a young female adult tells Nurse Mylene
that the voices she hears frighten her. Nurse Mylene understands that the client tends to
hallucinate more vividly:
A. While watching TV
B. During meal time
C. During group activities
D. After going to bed
47. Nurse EJ is aware that the defense mechanism commonly used by clients who are
alcoholics is:
A. Displacement
B. Denial
C. Projection
D. Compensation

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48. Within a few hours of alcohol withdrawal, nurse John should assess the male client for the
presence of:
A. Disorientation, paranoia, tachycardia
B. Tremors, fever, profuse diaphoresis
C. Irritability, heightened alertness, jerky movements
D. Yawning, anxiety, convulsions
49. A client with a diagnosis of borderline personality disorder tells her nurse that she wishes
the night shift nurses were as kind as the day shift nurses. This is an example of:
A. confrontation
B. defensiveness
C. negativism
D. splitting
50. A client is receiving Haloperidol (Haldol) for his symptoms of psychiatric disorder. There
is evidence that he understands the nurse health instruction when he says:
A. “I will only walk in shady areas or wear hat outdoors.”
B. “I will avoid eating cheese and processed foods while taking this medication.”
C. “I will only eat high caloric meat and vegetable to get well soon.”
D. “I will stop taking medications when I have difficulty urinating.”
51. A schizophrenic client is for discharge from a psychiatric institution. He has a history of
noncompliance with oral medications so the psychiatrist orders a long acting injectable
antipsychotic medication every 4 weeks. This antipsychotic drug would be:
A. Clozapine (Clozaril)
B. Perphenazine (Trilafon)
C. Chlorpromazine (Thorazine)
D. Fluphenazine Decanoate (Prolixin Decanoate)
52. John Anthony, 40 years old is a chronic Schizophrenic who is considered by a psychiatrist
as having a “treatment resistant illness”. He is receiving Clozapine (Clozaril), an atypical
antipsychotic drug. A serious side effect of Clozapine that the nurse should be watchful
for is:
A. Extrapyramidal effects
B. Weight gain
C. Sedation
D. Agranulocytosis
53. Tin tin’s anxiety is coupled with a depressive episode and was prescribed Zoloft (Sertraline
HCl), a Selective Serotonin Reuptake Inhibitor. She has taken this drug for a week already
but reports no beneficial effect. It is most important for the nurse to:
A. Instruct patient to take Sertraline Hydrochloride on an empty stomach for efficient
absorption.
B. Refer the doctor for a dosage change.
C. Inform patient that it may take 2-4 weeks or longer for drug effects to be apparent.
D. Advise nutritional supplements to enhance efficacy of Sertraline.

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Situation:
Hera is admitted to the hospital because of mood changes. She used to be quiet and retiring,
but now has become outspoken and aggressive. She seems to have limitless supply of
energy and cannot be stopped from talking and moving about a lot.
54. In the situation above, Hera appeared to be in a/an?

A. Hostile mood
B. Manic mood
C. Mixed mood
D. Neurotic mood
55. Which of the following would be an important part of the nursing care for Hera?
A. Provide activities that provide little or no physical exertion
B. Isolate her from other patients
C. Allow her to watch a boxing competition
D. Promote adequate hygiene and nutrition
56. What possible drug would Hera be given to stabilize her mood?
A. Carbamazepine (Tegretol)
B. Haloperidol (Haldol)
C. Venlafaxine (Effexor)
D. Flouxetine (Prozac)
57. Which activity would be most appropriate for a severely withdrawn client?
A. Art activity with a staff member
B. Board game with a small group of clients
C. Team sport in the gym
D. Watching TV in the dayroom
58. Which is the priority when caring for potentially hostile, aggressive, or violent clients?
A. providing a safe environment for self, clients, and others
B. administering a prescribed medication to address the client’s behavior
C. exploring with the client reasons for the hostility, aggression, or violence
D. assisting the client to develop alternative methods for expressing feelings
59. You admit a new client to the unit and, upon initial assessment, find the client’s remarks
to reveal a grandiose sense of self-importance. The client is preoccupied with ideas of
making it big in the stock market and being highly successful because of her power. The
client seems to have little or no empathy for others and has a sense of entitlement,
immediately indicating that the rules are for other people. The behaviors you have
identified are characteristics of which of the following personality?
A. Narcissistic
B. Histrionic
C. Avoidant
D. Schizotypal
60. A client who recently was diagnosed as having myelocytic leukemia discusses the
diagnosis by referring to statistics, facts and figures. The nurse recognizes that the client
is using the defense mechanism known as:
A. projection
B. sublimation
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C. intellectualization
D. reaction formation
61. The nurse instructs a client receiving the Mono-amino oxidase inhibitor (MAOI) agent
phenelzine (Nardil) about dietary restrictions for foods high in tyramine to prevent which
adverse effect?
A. Gastrointestinal upset
B. Hypertensive crisis
C. Neuromuscular effects
D. Urinary retention
62. The most therapeutic nursing intervention for Owa with major Depression shortly
after admission to the hospital is:
A. Introducing the client to another client
B. Requiring participation in therapy sessions
C. Encouraging interaction with others in small groups
D. Conveying an attitude of concern that is not intrusive
63. Maricel, 45 years old is admitted to the psychiatric hospital after many self-inflicted
nonlethal injuries over the last month. The nurse identifies that these injuries are
documented on the admission history as suicidal:
A. Threats
B. Gestures
C. Attempts
D. Ideations
64. During a client’s periods of extreme Mania and hyperactivity, how should the
nursing staff provide for the client’s nutritional needs?
A. Accept the fact that the client will eat if hungry.
B. Follow the client around the dining room with a tray.
C. Allow the client to prepare own meals to eat when desired.
D. Provide the client with frequent, high-calorie feedings that can be hand-held.
65. What nursing intervention may redirect a hyperactive Manic client therapeutically?
A. Asking the client to guide other clients as they clean their rooms
B. Suggesting the client to initiate social activities on the unit for the client group
C. Encouraging the client to tear pictures out of magazines for a scrap book
D. Providing a pencil and paper to encourage the client to write a short story
66. The physician prescribed Olanzapine (Zyprexa) for a client with disorder, Manic
episode. What cautionary advice should the nurse give the client?
A. Sit up slowly
B. Report double vision
C. Expect increased salivation
D. Take the medication on an empty stomach
67. Flor has a diagnosis of histrionic personality disorder. Which behavior can the
nurse expect when assessing this client?
A. Dramatic and theatrical
B. Boastful and egotistical

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C. Rigid and perfectionist

D. Aggressive and manipulative
68. The nurse is performing an admission assessment with Fernando with a diagnosis of
detached retina. Which of the following is associated with this eye disorder?
A. Total loss of vision
B. Pain in the affected eye
C. A yellow discoloration of the sclera
D. Sense of a curtain falling across the field of vision
69. A Nurse in a Neurology unit received a female client from the ward with a massive cerebral
hemorrhage and loss of consciousness. She is scheduled for an EEG. The nurse is
discussing the purpose of the test with the family members. It is accurate for the nurse to
tell the family members that the test will measure:
A. Extent of intracranial bleeding.
B. Sites of brain injury.
C. Electrical activity of the brain.
D. Percent of functional of the brain tissue.
70. A client seeks information from Nurse Tess who has Multiple Sclerosis (MS), regarding
plasmapheresis. Which would be the appropriate response of Nurse Tess? “This
diminishes symptoms by removing:
A. Catecholamines.”
B. Antibodies.
C. Plasma proteins”
D. Lymphocytes.”
71. A nurse is assessing a client with Dementia. Which client assessment is
unexpected?
A. Acts pessimistic
B. Has a short attention span
C. Appears agitated
D. Exhibits disorder reasoning
72. Geriatric clients with behavioral changes are often admitted to the psychiatric unit
for screening and evaluation. As part of the nursing assessment, it is important to
observe for sign s of Dementia. The four “A’s” of Alzheimer’s disease are:
A. Amnesia, apraxia, agnosia, aphasia
B. Avoidance, aloofness, asocial, asexual
C. Autism, loose association, apathy affect
D. Aggressive, amoral, ambivalent, attractive
73. The nurse teaches a client who is undergoing a neurologic evaluation that the test
that might be ordered to help confirm the diagnosis of Myasthenia Gravis involves
the use of the medication:
A. Prednisolone
B. Phenytoin (Dilantin)
C. Disodium EDTA
D. Edrophonium (Tensilon)

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THE PURPLE BOOK
74. A client with right hemiplegia is awake and alert. The client is given exercises to do during
the day. One afternoon the client seems very discouraged, so the nurse plans to motivate
her by:
A. Reassuring her that there is no need for her to feel discouraged
B. Reinforcing the small gains, she has made
C. Suggesting that she could rest today and exercise again tomorrow
D. Explaining that exercise is necessary to get better
75. A female client with CVA sometimes has difficulty “finding” the words she wants to say.
The nurse will encourage the client’s visitors to:
A. Be patient with client while she thinks of a word
B. End the visit if she becomes frustrated and angry
C. Finish her sentence for her if they know what she wants to say
D. Tactfully change the subject when she cannot find the word, she wants to use
76. To strengthen muscles in a client’s unaffected leg in preparation for crutch walking, the
nurse would encourage the client to periodically:
A. Flex and extend the unaffected knee while prone
B. Press the back of unaffected knee into the mattress while supine
C. Squeeze the buttocks together when sitting
D. Change position frequently
77. The nurse is admitting a client in the emergency room with a foreign body in the ear and
identified as an insect. Which of the following interventions is the priority for the nurse to
perform?
A. Irrigate the affected ear
B. Instill diluted alcohol in the affected ear
C. Instill an antibiotic ointment into the affected ear
D. Instill a cortisone ointment into the affected ear
78. The nurse is caring for a client who just returned from surgery with a long leg cast. Which
of the following interventions is the priority in the first 24 hours?
A. Position the client supine to facilitate drying of the cast
B. Dangle the client on the side of the bed in the evening
C. Elevate the leg on the pillow above heart level
D. Assess the cast for rough edges and smoothness
79. The nurse is caring for a client who has aphasia following a cerebrovascular accident.
Which of the following nursing interventions should the nurse include in the plan of care?
A. Assume that the client cannot understand what is said
B. Establish long term goals with the client
C. Attempt repetition with phrases when speaking to the client
D. Speak to the client in a louder than usual voice
80. Which of the following should the nurse assess to provide the most accurate information
regarding a client suspected of C4 injury?
A. Ask the client to shrug the shoulders while applying a downward pressure
B. Ask the client to straighten flexed arms while applying resistance
C. Ask the client to grasp an object and make a fist
D. Ask the client to lift the arms while applying the resistance

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THE PURPLE BOOK
81. A client has difficulty communicating because of expressive aphasia following a

cerebrovascular accident. When the nurse asks how the client is feeling, the spouse
answers for the client. The nurse should:
A. Ask how the spouse knows the client is feeling
B. Acknowledge the spouse but look at the client for a response
C. Instruct the spouse to let the client answer
D. Return later to speak to the client after the spouse has gone home
82. The nurse reviews the report of a client’s cerebrospinal fluid analysis. Which of the
following findings should the nurse report?
A. Glucose 60mg/dl
B. Total protein 30 mg/dl
C. Clear, colorless appearance
D. White blood cells 100µl
83. The nurse provides care to a client who experienced a brain attack. Which statement best
reflects a basic concept associated with the rehabilitation of this client?
A. Rehabilitation needs are best met by the client’s family and community resources.
B. Rehabilitation is a specialty area with unique method for meeting the client’s needs.
C. Rehabilitation needs, immediate or potential, are exhibited by all clients with a health
problem.
D. Rehabilitation is unnecessary for clients returning to their usual activities following
hospitalization.
84. When planning the discharge of a client with chronic anxiety, the nurse directs
the goal at promoting a safe environment at home. The appropriate
maintenance goal should focus on which of the following?
A. Ignoring feelings of anxiety
B. Identifying anxiety-producing situations.
C. Continued contact with a crisis counselor
D. Eliminating all anxiety from daily situations
85. The client is unwilling to go out of the house for fear of “doing something crazy in
public.” Because of this fear, the client remains homebound, except when
accompanied outside by the spouse. Based on this data, the nurse
determines that the client is experiencing:
A. Agoraphobia
B. Social phobia
C. Claustrophobia
D. Hypochondriasis
86. A client reports experiencing nightmares and constant worry about the weather
since typhoon Yolanda destroyed the client’s house. The nurse assesses that this
client is experiencing:
A. Hallucinations
B. Panic attacks
C. flashbacks
D. delusions
87. Incidents of a child molestation that come out years later when the victims is an adult are
best explained the ego defense mechanism of:
A. Repression
B. Regression
C. Rationalization
D. Reaction formation

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THE PURPLE BOOK
88. A nurse working in the emergency department is conducting an interview with a

victim of spousal abuse. Which step should the nurse take first?
A. Contact appropriate legal service
B. Ensure privacy for interviewing the victim away from the abuser
C. Establish rapport with the victim and abuser
D. Call security guard
89. The depressed client verbalizes feelings of low self-esteem and self-worth typified
by statements such as “I’m such a failure. I can’t do anything right.” The best nursing
response would be to:
A. Tell the client that this is not true, that we all have a purpose in life.
B. Identify recent behaviors or accomplishments that demonstrate the client’s skill.
C. Reassure the client that you know how the client is feeling and that things will get better.
D. Remain with the client and sit in silence; this will encourage the client to verbalize
feelings.
90. A client who has been raped tells the nurse that the rape was her fault because
she walked down an alley on her way to school. Which response by the nurse
would be best in this situation?
A. Accept the client’s statement that this was risk-taking behavior
B. Ask the client what other behaviors may have been risky
C. Emphasize that the rapist, not the client is responsible
D. Suggest that the client discuss this issue later
91. The client is admitted to the mental health unit with a diagnosis of schizophrenia. A nursing
diagnosis formulated for the client is thought processes, disturbed related to paranoia. In
formulating nursing interventions with the members of the health care team, the nurse
provides instructions to:
A. Increase socialization of the client with peers.
B. Avoid laughing or whispering in front of the client.
C. Begin to educate the client about social supports in the community.
D. Have the client sign a release of information to appropriate parties so that
adequate date can be obtained for assessment purposes.
92. During a manic state, a client paced around the dayroom for 3 days. He talked to
the furniture, proclaimed he was a king, and refused to partake in unit activities.
Which of the following nursing diagnoses has priority?
A. Hypertension related to hyperactivity
B. Risk for violence related to manic state
C. Altered nutrition related to hyperactivity
D. Ineffective individual coping related to manic state
93. A nurse believes that health is a fundamental right of every individual. He believes in the
worth and dignity of each human being and recognizes the primary responsibility to
preserve health at all costs. Where can we find these statements?
A. Code of Ethics for Registered Nurses
B. Philippine Nursing Act of 2002
C. Standards of Nursing Practice
D. Code of Good Governance for the Professions
94. Prohibitions of Article VIII of Republic Act 9173 includes among others and imposes a fine
or imprisonment upon the nurse following which offenses? Select all that apply.
1. Who gives any false evidence to the Board to obtain certificate of registration
2. Who appends BSN/RN/MAN or any similar appendages to his or her name without
having conferred the degree.
3. Who volunteers in the hospital for additional experience.
4. Who abets or assist the illegal practice of a person who is not licensed.

15
THE PURPLE BOOK
5. Who advertises as a registered and licensed nurse.

6. Who uses a revoked or suspended certificate of registration.
7. Who do not have continuing education units.
A. All except 3 and 7.

B. 1 to 5 only.
C. All except 2, 3, and 7.
D. All of the above.
95. Regardless of the significance of the study, the feasibility of the study needs to be
considered. Which of the following is considered a priority?
A. Availability of research subjects
B. Budgetary allocation
C. Time frame
D. Experience of the researcher
96. A meeting was called by the hospital director to seek the cooperation of all hospital
personnel to cut cost. They were requested to save on water, electricity, and unnecessary
IDD calls. Which budget can they save on?
A. Operating budget
B. Personnel budget
C. Capital budget
D. Fixed ceiling budget
97. You see a nurse in the emergency department (ED) remove meperidine from the
medication cart and replace it with saline. She then pockets the syringe. Your eyes make
contact with her, and she panics, begging you to not report her because she could lose
her job. You’re deeply troubled and speak with the charge nurse about this incident. She
points out that the ED is so short-staffed right now, it can’t afford to lose this nurse. The
charge nurse suggests that it would be best to let this incident drop because no harm has
been done and she’s confident that the nurse won’t repeat this behavior now that she has
been caught. What’s your responsibility in this situation?
A. Inform the charge nurse that you feel bad about the situation, but this incident can’t be
overlooked; if she doesn’t address it, you’ll go to the next person in the chain of command
B. Assume the charge nurse will report it if it happens again
C. Comply with the charge nurse’s wishes
D. Consider that it’s none of your business
98. A staff nurse made a medication error this morning and reported it to you, the charge
nurse. What’s the best initial response for you to make?
A. Inquire about the client’s physiologic response to the error
B. Remind the nurse about the importance of medication safety
C. Write up an incident report
D. Discuss process changes with the nurse manager

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THE PURPLE BOOK
99. A nurse’s use of ethical responsibility can best be seen in which of the following ways?
A. Delivery of competent care
B. Formation of interpersonal relationships
C. Application of the nursing process
D. Evaluation of new computerized technologies
100. Why are nonexperimental correlational studies used frequently in nursing

research?
A. Findings of nonexperimental correlational studies can be generalized to larger
populations
B. Independent variables can be manipulated very precisely in correlational studies
C. Many of the phenomena of clinical interest do not lend themselves to manipulation,
control, or randomization
D. To determine the best clinical practices, nurses must be aware of cause-and-effect
relationships.

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THE PURPLE BOOK
NURSING PRACTICE V- ANSWERS AND RATIONALIZATIONS

Rationalization is excusing own behavior to avoid guilt, responsibility, conflict, anxiety or
loss of self-respect.
Circumstantiality is when a client eventually answers a question but only after giving
excessive unnecessary detail
Carbamazepine and valproic acid are anti-manic/mood stabilizers agents given to patients
experiencing mania. It is contraindicated to patients who are pregnant because it has a
teratogenic effect and increased risk for neural tube defects.
Loose association is when there is no apparent relationship between thoughts.
Serotonin plays an important role in mood and emotional behavior. It is the anti-impulsive
neurotransmitter. It acts to balance dopamine and decreases a person’s focus and the
flow of information. It also regulates temperature and sleep cycle a precursor to melatonin,
which plays a role in circadian rhythms.
Seclusion decreases stimulation, such as the noises from other patients, protects others
from the client, prevents property destruction and provides privacy for the client. The goal
is to give the client the opportunity to regain physical and emotional self-control.
Benadryl is used to counteract the parkinsonism side effects of antipsychotic medications.
Olanzapine (Zyprexa) is most effective in decreasing both positive and negative
characteristic of schizophrenia. The rest are typical antipsychotics and treat only positive
symptoms.
Acute dystonic reaction or dystonia has an abrupt onset with frightening muscle spasms
in the head and neck. Akathisia is the inability to sit or stand still, along with an intense
feeling of anxiety. Tardive dyskinesia, a form of EPS. The symptoms of strange face and
body movement make it very difficult for others to interact with them. Symptoms include
blinking, grimacing and smacking. Neuroleptic malignant syndrome develops suddenly
and include muscle rigidity and respiratory problem, hyperpyrexia, tachycardia, respiratory
problem, confusion and delirium develops.

2
THE PURPLE BOOK

One side effect of tricyclic antidepressant is seizure. It is never a good practice to combine
alcohol and Tofranil (imipramine) because it lowers seizure threshold, thus increasing
seizure episodes.

Priority nursing intervention for client experiencing panic level of anxiety is safety so
remain with the client at all times. A highly anxious client should not be left alone – his or
her anxiety will escalate.

To be diagnosed with OCD a person experiences an unwanted, repetitive thoughts that
lead to feelings of fear, anxiety or guilt called obsessions. He/she will also manifest
compulsions behaviors (repetitive behaviors) used to decrease the fear or guilt associated
with obsessions. Asking on activities will give the nurse an idea how severe the obsessions
and compulsions are.

Cognitive restructuring is a technique useful in changing patterns of thinking by helping
clients to recognize negative thoughts and feelings and to replace them with positive
patterns of thinking.

In Dichotomous thinking, situations are viewed in all-or-nothing, black or white, good or
bad terms.

Fluoxetine (Prozac) has been found to be useful in the treatment of bulimia nervosa. It is
an SSRI, which decreases the craving for carbohydrate, thereby decreasing the incidence
of binge eating which is often associated with consumption of large amounts of
carbohydrates.

Anhedonia is the inability to experience or even imagine any pleasant emotion.
Catastrophizing is a distorted thinking process that exaggerates failure in one’s life.
Somatization is a method of coping with psychological stress by developing physical
symptoms. Secondary gain is an advantage from, or reward for, being ill that is outside
conscious awareness.

Somatic delusions occur when people believe something abnormal and dangerous is
happening to their bodies. Grandiosity is an exaggerated sense of importance or self-
worth. It is often accompanied by beliefs of magical thinking. Delusion of control occurs
when the person believes that feelings, impulses, thoughts or actions are not his/her own
but are being imposed by some external force. Ideas of reference are remarks or actions
by someone else that in no way refer to the person with schizophrenia but that are
interpreted as related to him or her.

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THE PURPLE BOOK

An important priority of care is client safety. Command hallucinations may order clients to
harm, mutilate, or kill themselves or others.

Neuroleptic Malignant syndrome is an emergency situation and should be reported
immediately to the physician. Any of the antipsychotic medications can cause NMS, which
is treated by stopping the medication.

Signs of cocaine overdose may include tachycardia, elevated blood pressure perspiration,
or chills, nausea and vomiting, respiratory depression, cardiac, seizure arrhythmias,
hyperpyrexia and death. Treatment of cocaine overdose may require ventilation of the
client. Acetaminophen or dantrolene (Dantrium) for hyperthermia, calcium blockers for
tachycardia, nitroprusside for hypertension and diazepam or phenobarbital for seizures.

An affective characteristic common to person diagnosed with Cluster B personality
disorder is intense and changing expression. Remember these people are dramatic,
emotional and erratic in their dealings.

Most clients with dementia exhibits wandering episodes especially at night. It is best to
doors to the house should be kept locked and an alarm system should be connected to
the doors. This is to prevent client from slipping out the house unnoticed.

Saying “you won’t have to worry too much longer” means the person will end his life soon.

After reassuring patient’s safety and assessing the sexually assaulted patient the nurse
must inform her of her rights. It is her right to be informed about benefits, qualifications of
all providers, available treatment options and appeals and grievance procedures.

The most common medication is methylphenidate (Ritalin). Research have found out that
methylphenidate is effective in 70% to 80% of children with ADHD; it reduces hyperactivity,
impulsivity and mood liability and helps the child to pay attention more appropriately.

The client’s energy levels will not sustain eating for long periods. Offering frequent and
easy-to-chew (soft) meals of small proportions is the preferred dietary plan.

Peripheral dopamine does not cross the blood-brain barrier, but its precursor, levodopa,
is able to enter the brain, where it is converted to dopamine, increasing the supply that is
deficient in Parkinson’s disease.

4
THE PURPLE BOOK

Glaring and bright lights causes extreme stimulation to a client with Meniere’s disease
which causes vertigo to exacerbate.

Most hearing aids will increase the volume of sound but will not make it clearer. The
hearing aid is an assistive device and will not return the patient’s hearing to normal.

To reduce retrobulbar hemorrhage, any anticoagulant therapy is withheld, including
aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and warfarin (Coumadin).

Open-angle glaucoma has an insidious onset, with increased intraocular pressure causing
pressure on the retina and blood vessels in the eye. Peripheral vision is decreased as the
visual field progressively diminishes.

The nurse would expect to administer alprazolam, a benzodiazepine anxiolytic agent used
to manage anxiety disorders or to provide short-term relief of anxiety symptoms.

Schizoid personality disorder is characterized by pervasive pattern of detachment from
social relationships and a restricted range of emotional expression in interpersonal setting.
Clients with schizoid personality disorder display a constricted affect little if any, emotion.
They are aloof and indifferent appearing emotionally cold, uncaring or unfeeling. The
nurse primarily focuses on improving the client’s functional relationships in the community.

The client with schizotypal personality disorder is often withdrawn and engages in odd,
eccentric behavior.

The nurse understands that the patient is in a coma and has elevated ICP. In general, it
is widely accepted that a Glasgow coma score of less than 8 indicates coma. Any
prolonged ICP of greater than 15 mm Hg is considered to be elevated ICP.

The best room for this client is a private room two doors away from the nurses’ station.
With bacterial meningitis, he should be in isolation for at least the first 24 hours after
admission. In addition, during the initial acute phase, he should be as close as possible to
the nurses’ station for maximum observation.

Seizures that include brief lapses in consciousness and vacant stares would be petit mal.

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THE PURPLE BOOK

Group and family therapies are for the purpose of enhanced quality of interpersonal
interactions

Dissociative fugue involves unplanned travel away from one’s usual quarters and either
confusion about identity or assumption of a new identity.

The role of nurses is not to discuss the surgical procedure, but to reinforce that the surgeon
has explained. If anxiety was observed in the client of the client verbalized concerns, the
nurse should entertain the queries and answer based on what has been explained only

Amikacin (Amikin) is an aminoglycoside. Adverse effects of aminoglycosides include
ototoxicity (hearing problems), gastrointestinal irritation, palpitations, blood pressure
changes. The nurse instructs the client to report hearing loss to the physician immediately.

About 50% of clients die within 2 to 5 years from respiratory failure, aspiration pneumonia,
or another infectious process.

Loss of peripheral vision as a result of glaucoma causes the client problems with seeing
things on each side, resulting in a “blind spot.” This problem can lead to the client having
car accidents when switching lanes.

Macular degeneration decreases central vision but usually does not affect peripheral
vision.

Somatic delusion is a fixed false belief about one’s body.

Auditory hallucinations are most troublesome when environmental stimuli are diminished
and there are few competing distractions.

Denial is a method of resolving conflict or escaping unpleasant realities by ignoring their
existence.

Alcohol is a central nervous system depressant. These symptoms are the body’s
neurologic adaptation to the withdrawal of alcohol.

The client is exhibiting the coping mechanism of splitting, in which the individual views the
world in terms of “all bad” vs. “all good.”

6
THE PURPLE BOOK

Typical antipsychotic medications such as Haloperidol, causes photosensitivity therefore
the patient’s response of walking in shady areas or wearing hat is appropriate and signifies
understanding of the medication he is taking.

Fluphenazine Decanoate (Prolixin Decanoate) is and antipsychotic drug used for non-
compliant clients because of its action because of its long-term duration of action and does
not need frequent administration. It is only given every 4 weeks.

The most common side effect of Clozapine is agranulocytosis.

Health teaching about the effects of the drug is very important to be provided to the client.
SSRI, an antidepressant, takes 2-4 weeks before improvement of manifestations can be
achieved.

Manifestations from being on a depressive state to being outspoken, aggressive and
limitless supply of energy signifies manic behaviors.

Manic clients usually have limitless supply of energy and are continuously interacting with
others that is why they often forget their nutrition and hygiene.

The third line of medication for mania is carbamazepine (Tegretol). The first line is lithium,
followed by valproic acid, as the second line.

The best approach with a withdrawn client is to initiate brief, nondemanding activities on
a one-to-one basis. This approach gives the nurse an opportunity to establish a trusting
relationship with the client.

The priority nursing intervention with a client who is potentially hostile, aggressive, or
violent is to provide a safe environment for client, self, and others.

Grandiose sense of self-entitlement and little or no empathy for others are characteristics
listed in DSM-V for narcissistic personality disorder.

Intellectualization is the use of reasoning and thought process to avoid emotional aspects
of a situation: this is a defense against anxiety.

MAOI’s in combination with Tyramine containing foods are known to develop hypertensive
crisis

7
THE PURPLE BOOK

This approach allows the client to control the pace of development of the nurse-
client relationship.

Suicidal gestures involve superficial nonlethal injuries; the client has no intent to
die as a result of injuries.

Hyperactive clients burn up large quantities of calories, which must be replenished.
Since these clients will not take the time to sit down to eat, providing them with
food they can carry with them sometimes helps.

Physical activity will help use some of the excess energy without requiring the
client to make decisions or forcing other clients to deal with the behavior.

Zyprexa, a thienobenzodiazepine/atypical antipsychotic, can cause orthostatic
hypotension.

Clients with histrionic personality disorder draw attention to themselves and
demonstrate emotionality and attention-seeking behavior.

A characteristics manifestation of retinal detachment described by the client is the
feeling that a shadow or curtain is falling across the field of vision

An EEG measures the electrical activity of the brain.

In plasmapheresis, antibodies are removed from a client’s plasma. Antibodies
attack the myelin sheath of the neuron causing MS symptoms.

A client who acts apathetic and pessimistic is demonstrating characteristics of
depression, not dementia

Neurofibrillary tangles in the hippocampus cause recent memory loss (amnesia);
temporoparietal deterioration causes cognitive deficiencies in speech (aphasia),
purposeful movements (apraxia), and comprehension of visual, auditory, and other
sensation (agnosia).

Tensilon is an anticholinesterase compound that increases muscle strength when
administered to an individual with myasthenia gravis
\

8
THE PURPLE BOOK

The client is discouraged, she needs to be supported by helping the client raise
self esteem

The goal for this client is independence with the communication

Pressing the back of the knee into the mattress while supine (quadriceps setting
exercises) as well as straight leg-raising exercises help to strengthen muscle for
crutch walking.

Insects are killed before they can be removed unless a flashlight can coax them out.
Mineral oil or diluted alcohol will suffocate the insect so that removal by forceps is possible.
If the foreign object is vegetable matter it is not irrigated, because this would cause the
object to expand and cause a worse impaction. Instilling an antibiotic or cortisone ointment
into the affected ear may be done if an infection or inflammation is present.

The priority nursing intervention for a client with a long leg cast in the first 24 hours is to
elevate the extremity above the level of the heart by placing the leg on several pillows to
prevent edema

When aphasia occurs with a cerebrovascular accident, repetition proves beneficial in
enhancing the client’s understanding of what is said

Asking a client to shrug the shoulders while applying resistance will provide the most
accurate information in a client suspected of a C4 injury. Asking a client to straighten the
flexed arms while applying resistance would assess for a C7 injury. Asking the client to
grasp an object and make a fist would assess for a C8 injury. Asking the client to lift the
arms while applying resistance would assess for a C5 injury.

Expressive aphasia is a difficulty in both writing and speech. It is important to allow a client
with expressive aphasia sufficient time to speak. No one should speak for the client
because this serves only to increase the client’s frustration.

Normal cerebrospinal fluid should have a clear and colorless appearance. Protein should
be 15 to 45 mg/dl. Protein levels higher may indicate a tumor or an infection. Normal
glucoses range between 45 to 75 mg/dl. Glucose levels higher than 75 mg/ml indicate the
presence of an infection, leukemia, or cancer. The white blood cells range is 0.8/ul. Levels
higher indicate an infection or a tumor.

All nursing interventions aims to assist an individual in maximizing capabilities and coping
with modifications in lifestyle.

9
THE PURPLE BOOK
84. Correct Answer; B

Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety
or avoid specific stimulus.
Agoraphobia is the fear of open spaces and the fear of being trapped in a situation from
which there may not be an escape. Agoraphobia includes the possibility of experiencing a
sense of helplessness or embarrassment if an attack occurs.
A client who repeatedly experiences nightmares and constantly worries about the weather
since a typhoon destroyed his house is experiencing flashbacks. Clients who have
flashbacks have recurrent intrusive recollections of the traumatic event.
Repression is a coping mechanism in which unacceptable feelings are kept out of
conscious awareness; later under stress or anxiety, thoughts or feelings surface and come
into one’s conscious awareness
Privacy away from the abuser is important. This allows the victim to discuss the problem
freely, without fear of retaliation from the abuser
Feeling of low self-esteem and worthlessness are common symptoms of the depressed
client. An effective plan of care to enhance the client’s personal self-esteem is to provide
experiences for the client that are challenging but that will not be met with failure. Silence
may be interpreted as agreement
The client’s feeling of self-blame is a common response to rape-trauma crisis. However,
this is not realistic perception of the event, and the nurse should point out reality (telling the
victim that the rapist is responsible)
Disturbed thought process related to paranoia is the client’s problem, and the plan of care
must address this problem. The client is experiencing paranoia and is distrustful and
suspicious of others. The members of the health care team need to establish a rapport and
trust with the client. therefore, laughing or whispering in front of the client would be
counterproductive
During a manic state, clients are at risk for malnutrition due to not taking in enough calories
for the energy they’re expending.
Article I, Section 1 of the Amended Code of Ethics for Nurses states that “Health is a
fundamental right of every individual. The Filipino registered nurse, believing in the worth
and dignity of each human being, recognizes the primary responsibility to preserve health
at all cost.

Item number 3, a nurse who volunteers in the hospital for additional experience and item
number 7, a nurse who do not have continuing education units, do not reflect misconduct
of a nurse which necessitates payment of fine or imprisonment.

Availability is the most important criteria to be considered by the researcher in determining
whether the study is feasible or not. No matter how significant the study may be if there
are no available subjects/respondents, the study cannot push through.

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THE PURPLE BOOK

Operating budget reflects expenses that change in response to the volume of service. It
includes daily expenses, cost of electricity, repairs, maintenance, and supplies. Personnel
budget is expenditure used for the work force. Capital budget are large expenditures for
equipment, building cost, etc. Fixed-ceiling budget: is constrained by the amount that is
specifically stated for each department

If you, who witnessed the incident, believe that it’s a mandatory reportable event, it’s your
responsibility to report it to the next authority in the chain of command, even if the charge
nurse disagrees.

Client safety is always the greatest concern; first do whatever is necessary to minimize
harm to the client. The nurse is probably already aware of the importance of medication
safety; that’s why she’s reporting the incident. Although an incident report or process
changes may be required, it can be done after ensuring that the client is all right.

The term responsibility refers to the characteristics of reliability and dependability. In
professional nursing, responsibility includes a duty to perform actions well and
thoughtfully. When the nurse provides competent care, the nurse is demonstrating ethical
responsibility.

Researchers cannot manipulate, control, or randomize many phenomena of concern to
nurses.

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1

THE PURPLE BOOK ALVIZ 2021

• If you are allowed to isolate at home, make sure to:

Home Management for mild to moderate symptoms

If you have cough or sore throat, you do the following:

Watch out for (WOF):

THE PURPLE BOOK ALVIZ 2021

Novel Corona Virus

Last 31 December 2019, a clustering of pneumonia cases of unknown etiology in

Duration of how long can the virus survive on surfaces

According to WHO, there is no confirmed timeline how long a COVID-19 virus

Is it safe to receive packages from China?

COVID 19 vs Severe Acute Respiratory Syndrome (SARS)

THE PURPLE BOOK ALVIZ 2021

b. Practice proper cough etiquette.

c. Maintain distance of at least one meter away from individual/s experiencing

e. Ensure that food is well-cooked.

THE PURPLE BOOK ALVIZ 2021

NURSING PRACTICE I- QUESTIONS

3. Surveillance of infectious diseases is governed by:

5. Which of the following is true about discharge planning?

6. “At risk” groups are identified in a community so that:

THE PURPLE BOOK ALVIZ 2021

13. The concept of homeostasis is most like the concept of:

14. In Maslow’s hierarchy of needs, the self-actualized person:

THE PURPLE BOOK ALVIZ 2021

15. A major sociologic risk factor developing health problem is:

16. Patients may move among different care settings to:

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22. The most common symptom of patients with scabies is:

25. A serious complication of acute malaria is:

26. The nurse understands that gonorrhea is highly infectious and:

27. The drug of choice for the treatment of gonorrhea is:

THE PURPLE BOOK ALVIZ 2021

34. The most effective measure of controlling schistosomiasis is:

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42. Which patient outcome statement meets the necessary criteria?

43. A patient who describes his illness is providing:

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44. Documentation is part of what phase of the nursing process?

45. When documenting care and observations in a patient record:

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THE PURPLE BOOK ALVIZ 2021

THE PURPLE BOOK ALVIZ 2021

77. Which of the following statements is correct regarding informed consent?

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THE PURPLE BOOK ALVIZ 2021

THE PURPLE BOOK ALVIZ 2021

THE PURPLE BOOK ALVIZ 2021

THE PURPLE BOOK ALVIZ 2021

NURSING PRACTICE I- ANSWERS AND RATIONALIZATIONS

10. Correct Answer: B

11. Correct Answer: A

12. Correct Answer: D

13. Correct Answer: A

14. Correct Answer: D

15. Correct Answer: A