BSN II COMPREHENSIVE EXAMINATION 2ND SEM 2017 1

1. The nurse uses a diagram to demonstrate how Dunns theory of health and illness can be compared with a:
a. Plant that grows from a seed, blossoms, wilts, and dies.
b. Continuum, with peak wellness and death at opposite ends; the person moves back and forth in a dynamic
state of change.
c. Ladder; from birth to death the individual moves progressively downward a ladder to eventual death.
d. State of mind dependent on the individual perception of their own health or illness.

2. In 1946, the World Health Organization redefined health as the:

a. absence of disease or infirmity. c. state of complete physical, mental, and social well
b. presence of disease or infirmity. being.
d. state of incomplete physical, mental, and social well
being.

3. The Nursing Diagnosis is Sleep Pattern Disturbance Related to Noisy Environment. The concepts for this nursing
diagnosis would be supported by the theory of:
a. Florence Nightingale. c. Myra Levine.
b. Dorothy Johnson. d. Dorothea Orem.

4. The nursing theorist who focuses on the interpersonal relationship between the nurse and the client where the
three phases of this relationship are orientation, working, and termination is:
a. Hildegard Peplau. c. Ida Jean Orlando.
b. Ernestine Weidenbach. d. Joyce Travelbee.

5. The nurse is reviewing Virginia Henderson’s definition of nursing. Which of the following statements by the nurse
indicates an accurate understanding about Henderson’s theory?
a. “Her major focus about communication with patients is regarding the information that is shared verbally
between the nurse and client.”
b. “She didn’t feel that the physical sciences were important for the nurse to understand when providing
nursing care.”
c. “She did a great job of defining specific concepts and their relationship to other concepts that she used in
this theory.”
d. “Her idea surrounding the 14 basic components of nursing care fits really well with Maslow’s hierarchy of
human needs.”

6. Which statement would the nurse include in a report on Jean Watson’s theory of human caring?
a. There should be guidelines for including the family in client care
b. There are ten adaptive mechanisms commonly used by clients
c. There are environmental factors related to client care
d. There are ten creative factors related to human care

7. A patient with diabetes is controlling the disease with insulin and diet. The nursing health care provider is focusing
efforts to teach the patient self-management. Which of the following nursing theories is useful in promoting self-
management?
a. Neuman c. Roy
b. Orem d. Peplau

8. Which of the following is closely aligned with Leininger’s theory?

a. Caring for patients from unique cultures
b. Understanding the humanistic aspects of life
c. Variables affecting a patient’s response to a stressor
d. Caring for patients who cannot adapt to internal and external environmental demands

9. Which intervention would the nurse use to implement Imogene King’s theory of goal attainment?
a. Listing self-care deficits c. Purposeful transactions
b. Interactions with the environment d. Determining how the client adapts to stress

10. A communication skill is one of the important competencies expected of a nurse. Interpersonal process is viewed
as human to human relationship. This statement is an application of whose nursing model?
a. Joyce Travelbee c. Callista Roy
b. Martha Rogers d. Imogene King

11. The nurse is reviewing Dorothea Orem’s Self-Care Deficit Theory. Which of the following statements by the nurse
indicates further education is required regarding the nurse’s function according to Orem?
a. “The nurse steps in to help the client when the client can’t take care of his or her own needs.”
b. “A nurse will provide assistance to a child when the caregiver cannot provide the care that the child requires.”
c. “The nurse is noted to take over as another parent for the adult client when they are unable to meet their own
needs.”
d. “When individuals are able, they take care of their own needs.”

12. The nursing students are discussing Dorothy Johnson’s Behavioral System Model. Which of the following
statements regarding the way this model can be related to patients is most accurate?
 BSN II COMPREHENSIVE EXAMINATION 2ND SEM 2017 2

a. “The nurse attempts to help the client meet all of their behavioral needs, which are not necessarily aligned
well with the client’s biological needs.”
b. “This model is easily applicable when guiding caring for large groups of clients with similar issues.”
c. “The nurse finds that this model is easily applied to the quadriplegic client.”
d. “This model is not appropriate to use in clients with psychiatric disorders.”

Situation: During a physical examination, a health care provider studies your body to determine if you do or do not
have a physical problem.

13. The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess
the underlying tissue:
a. Turgor c. Texture
b. Density d. Consistency

14. The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the
stethoscope and its use?
a. The slope of the earpieces should point (toward the occiput)
b. The stethoscope does not magnify sound but does block out extraneous room noise.
c. The fit and quality of the stethoscope are not as important as its ability to magnify sound.
d. The ideal tubing length should be 22 inches to dampen distortion of sound

15. The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:
a. Auscultate over the area with a fetuscope c. Use a goniometer to measure the pulsations.
b. Use a Doppler device to check for pulsations d. Check for the presence of pulsations with
over the area stethoscope

16. The nurse would use which of the following methods of examination to assess for the presence of bruit in the
abdomen?
a. Inspection c. Auscultation
b. Palpation d. Percussion

17. An HRM student is late for his appointment for physical assessment and has rushed across WCC campus to the
health clinic. Before assessing his vital signs, the nurse Ayla who should:
a. Allow him 5 minutes to relax and rest before checking his vital signs
b. Check the blood pressure in both arms, expecting a difference in the readings because of his recent exercise.
c. Monitor his vital signs immediately on his arrival at the clinic, then 5 minutes later, and notice any differences.
d. Check his blood pressure in the supine position because this will give a more accurate reading and will allow
him to relax at the same time.

18. After completing the health history, the nurse begins to ask more detailed questions to clarify points and follow up
on concerns expressed by the client during the interview. This portion of the health assessment is known as:
a. Informal teaching c. A focused interview
b. Objective data d. Interpretation of findings

19. As part of a complete health assessment, the nurse reviews the client's laboratory data. Laboratory data is an
example of:
a. constant data c. Subjective data
b. primary source data d. Secondary source data

20. After conducting the health interview, the nurse begins to measure the client's vital signs. Vital signs are
considered:
a. Subjective data c. Secondary data
b. Objective data d. Constant data

21. Which assessment finding does the nurse identify as one that would be obtained during the subjective assessment
of a client?
a. "It hurts when I put weight on my leg." c. Blood pressure 110/68
b. Abdomen soft and non-tender to palpation d. Pulses present in lower extremities

22. The nursing process is considered a form of critical thinking. The stages of the nursing process, placed in the
correct order, are:
a. Diagnosis, outcome, evaluation, assessment, planning, implementation.
b. Assessment, diagnosis, outcomes, planning, implementation, evaluation.
c. Assessment, diagnosis, outcomes, implementation, planning, evaluation.
d. Assessment, evaluation, planning, outcomes, implementation, diagnosis.

23. While caring for a client who is immobile, the nurse documents the following information in the client’s chart:
“Turned the client from side to back every 2 hours”; “Skin intact; no redness noted”; “Client up in chair three time
today”; “Improved skin turgor noted”. Which nursing diagnosis accurately reflects this information?
a. Risk for impaired skin integrity related to immobility
b. Impaired skin integrity related to immobility
 BSN II COMPREHENSIVE EXAMINATION 2ND SEM 2017 3

c. Constipation related to immobility

d. Disturbed body image related to immobility

24. While performing a physical assessment, the nurse explains, “I’ll be placing my stethoscope on your abdomen to
listen for bowel sounds. The presence of bowel sounds indicates that the intestines are working.” This nurse is
functioning as a:
a. Teacher c. Client advocate
b. Caregiver d. Manager

25. The nurse is collecting data about a client's occupation and the reliability of the source of information. In which
section of the health history will the nurse document this information?
a. Past history c. Biographical data
b. Family history d. Psychosocial history

26. A client has been having headaches for the past 3 days. The nurse should document the client’s reason for
seeking care as:
a. "headaches" for the past 3 days c. "headaches"
b. "migraines" for the past 3 days d. headaches for 3 days

27. A client comes into the clinic with the complaint of swollen ankles. The nurse will utilize which assessment
technique to find out more information about this client?
a. Inspection c. Palpation
b. Percussion d. Auscultation

28. The nurse is preparing to conduct a physical assessment on a young adult with a gaping wound on the right
forearm. Before beginning this assessment, the nurse should first:
a. Wash hands c. Put on a sterile gown
b. Put on goggles d. Put on a gloves

29. During the assessment of an obese client, it is necessary for the nurse to place the client in the supine position.
The nurse understands while the client is supine, it is most important to monitor this client for:
a. Abdominal pain c. Difficulty swallowing
b. Respiratory distress d. Fatigue

30. A nurse is preparing to enter an isolation room. Which technique, if done by the nurse, indicates a good
understanding of infection control principles?
a. The nurse pulls the gloves up to cover the c. The nurse fastens the ties on the gown
cuffs of the gown. without overlapping the gown edges.
b. The nurse’s mask covers the mouth but d. The nurse applies a mask that is
not the nose. hanging from the neck

31. The body part that would most likely display jaundice in the dark skinned individual is the:
a. Conjunctiva of the eye c. Roof of the mouth
b. Soles of the feet d. Shins

32. Where is the best site for examining for the presence of petechiae in a dark skin client?
a. The abdomen c. The earlobes
b. The thorax d. The soles of the feet

TOPIC: Nursing Pharmacology

33. The nurse is caring for a client with acute respiratory distress secondary to pulmonary edema and heart failure.
The primary care provider orders Lasix 40 mg IV to be given immediately. The nurse knows this is what type of
medication order?
a. A standing order c. A prn order
b. A stat order d. A single order

34. The nurse is transcribing the primary care provider’s orders and finds the following medication order on a client’s
chart: Morphine 8 mg prn every 2 hours. Which of the “rights” of medication administration would the nurse need to
clarify?
a. Right drug c. Right route
b. Right dose d. Right time

35. The nurse is preparing to administer a medication via the oral route. Place the following steps the nurse would
take in the correct order of implementation.
1. Pour medication. 4. Performs hand hygiene
2. Check the client’s ID band. 5. Determine what allergies the client may have
3. Check the medication administration record.

a. 4, 3, 5, 1, 2 b. 2, 4, 3, 4, 1 c. 5, 3, 4, 2, 1 d. 3, 4, 2, 3, 5, 1
 BSN II COMPREHENSIVE EXAMINATION 2ND SEM 2017 4

36. A nurse is teaching the parents of a 2-year-old how to administer an otic medication. The parents are performing
a return demonstration. Which action would require immediate intervention by the nurse?
a. The mother is gently pulling the child’s pinna c. The mother uses a cotton-tipped applicator and
upward and backward. solution to wipe the pinna and auditory
b. The father is assisting with the immobilization d. The father warms the medication container
of the child’s head. in his hand

37. A nurse is teaching a teenager how to administer nasal drops for allergies. Which technique, if done by the
teenager, demonstrates effective teaching by the nurse?
a. Directs the solution medially toward the midline of the superior concha
b. Touches the mucous membranes of the nares with the solution
c. Knows that immediate movement is permitted after administration
d. Breathes through the mouth while administering the medication

38. The nurse is preparing to administer a thick and viscous medication via the intramuscular route. The nurse
decides to use which needle?
a. #18 gauge c. #20 gauge
b. #22 gauge d. #24 gauge

39. The nurse is preparing a medication that is supplied in a vial. Place the following steps in the correct order for the
nurse to prepare the medication.
1. Withdraw the medication. 4. Clean the top with alcohol
2. Remove the plastic cap 5. Inject air into the vial.
3. Perform hand hygiene

a. 3, 4, 2, 5, 1 b. 3, 2, 4, 5, 1 c. 2, 4, 5, 1, 3 d. 2, 4, 5, 1, 3

40. The nurse is preparing to administer an intradermal injection. Which is the best angle for the nurse to hold the
needle when inserting it into the client’s skin?
a. 90 degree c. 45 degree
b. 30 degree d. 15 degree

41. The nurse is preparing to administer an intramuscular injection to a 10-month-old client. Which is the best site for
the nurse to choose?
a. The deltoid muscle c. The ventrogluteal muscle
b. The vastus lateralis muscle d. The dorsogluteal site

42. The nurse is administering an intramuscular injection. After inserting the needle, while drawing back on the
plunger, the nurse sees blood in the syringe. Which is the nurse’s next action?
a. Move the position of the needle slightly and pull back on the plunger again.
b. Withdraw the needle, choose a new site, and inject the medication
c. Withdraw the needle, place a clean needle on the syringe, choose a new site, and inject the medication.
d. Withdraw the needle, discard the syringe, and prepare a new injection for a different site.

43. A client is receiving an anticoagulant for a pulmonary embolism. Which drug should the nurse instruct the client to
avoid taking without speaking with the physician?
a. Ferrous Sulfate c. Isoxsuprine (Vasodilan)
b. Acetylsalicylic acid d. Chlorpromazine (Thorazine)

44. When teaching a client who is to take Nitroglycerin tablets, what instructions should the nurse give the client?
a. Limit the number of tablets per day. c. Discontinue the medication if a headache develops
b. Make certain in the medication is stored d. Increase the number of tablets if dizziness is
In a dark container. Experienced.

45. The physician orders Ranitidine (Zantac) for a client wit peptic ulcer disease. The client asks the nurse what this
medication does. On which action of Ranitidine does the nurse base a response?
a. Increases gastric motility c. Facilitates histamine release
b. Neutralizes gastric acidity d. Inhibits gastric acid secretion

46. The reason why it is necessary to aspirate during an intramuscular injection is to:
a. avoid placement of the needle into a blood vessel. c. avoid nerve puncture.
b. produce an air pocket for better drug distribution. d. remove air from the syringe.

47. Which of the following routes of drug administration has the fastest onset of action?
a. Transdermal c. Intravenous
b. Intramuscular d. Ophthalmic

48. Based on an understanding of beta blockers used for unstable angina, the nurse administers a beta blocker
because of which of the following actions?
a. To increase myocardial contractility c. To decrease heart rate
b. To promote cardiovascular fluid shift d. Coronary artery vasodilation

49. A client with chronic heart failure has atrial fibrillation and a left ventricular ejection fraction of 15%. The client is
 BSN II COMPREHENSIVE EXAMINATION 2ND SEM 2017 5

taking Warfarin (Coumadin). The expected outcome of this drug is to:

a. Decrease circulatory overload. c. Prevent thrombus formation.
b. Improve the myocardial workload. d. Regulate cardiac rhythm.

50. In order to ensure that a medication is given to the right patient, the nurse must perform which action?
a. Ask the patient to spell their last name. c. Swipe a bar code on the patient’s ID bracelet.
b. Match the patient with a photo ID. d. Verify the patient using two identifiers.

51. The nurse is caring for a patient who will begin taking a thiazide diuretic to treat hypertension. The patient says,
“I know this will lower my blood pressure, but how does it work?” How will the nurse respond?
a. “It can cause orthostatic hypotension, c. “The actions are complicated, but it’s
so be careful.” an effective drug.”
b. “It reduces the volume of fluid in your blood to d. “Your provider should explain this stream
lower blood pressure.” medication to you.”

52. Which of the following is the priority for the nurse to assess before administering Digoxin (Lanoxin)?
a. Auscultate the apical pulse for 1 full minute c. Palpate the radial pulse for 60 seconds
b. Monitor the renal function tests d. Assess the serum potassium

53. Which of the following classes of medications maximizes cardiac performance in clients with heart failure by
increasing ventricular contractility?
a. Beta-adrenergic blockers c. Diuretics
b. Calcium channel blockers d. Inotropic agents

54. Intravenous heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures
that which medication is available on the nursing unit?
a. Vitamin K c. Potassium chloride
b. Protamine sulfate d. Aminocaproic acid (Amicar)

55. One hour after receiving Pyridostigmine Bromide (Mestinon), a client reports difficulty swallowing and excessive
respiratory secretions. The nurse notifies the physician and prepares to administer which of the following medications?
a. Additional Mestinon c. Atropine
b. Edrophonium (Tensilon) d. Neostigmine (Prostigmin)

56. The nurse should anticipate administration of which of the following medications to a client with hypothyroidism?
a. Dexamethasone c. Lactulose
b. Levothyroxine d. Lidocaine

57. The client receiving heparin therapy asks how the "blood thinner" works. The best response by the nurse would
be:
a. "Heparin makes the blood less viscous."
b. "Heparin dissolves the clot."
c. "Heparin does not thin the blood, but prevents platelets from clumping."
d. "Heparin decreases the number of platelets so that blood clots slower."

58. A client has been prescribed ciprofloxacin (Cipro). Important information that the nurse must know includes:
a. This medicine must be taken on an empty stomach to increase absorption.
b. This medicine is classified as an aminoglycoside and is given for systemic bacterial infections.
c. This medicine should be given with an antacid to increase the absorption and effectiveness of the medicine.
d. This medicine should not be given with the ordered multivitamin.

59. A nurse is preparing to administer a broad-spectrum antibiotic medication to a client. An important nursing
intervention prior to administration regarding anti-infectives is:
a. Obtaining the culture report before starting any medication.
b. Performing a culture within 24 hours after starting the medication.
c. Performing the culture for evidence before administering the first dose of the anti-infective.
d. Administering medicine, and omitting performing cultures

60. The client is using intranasal sympathomimetics for treatment of nasal congestion. The nurse teaches that the use
of this drug:
a. Reduces mucus production. c. Liquefies mucus.
b. Is limited to 3-5 days for nasal congestion. d. Reduces cough.

61. The nurse teaches the client that the primary purpose of mucolytics is to:
a. Achieve bronchodilation. c. Relax bronchial smooth muscles.
b. Loosen thick, viscous bronchial secretions. d. Aid in the ability to cough up mucus.

62. What natural therapy should the nurse encourage patients to use to strengthen the upper GI tract?
a. Ginger c. Basil
b. Peppermint d. Chocolate
 BSN II COMPREHENSIVE EXAMINATION 2ND SEM 2017 6

Situation: Mrs. San Juan, a nurse professor is conducting a didactic lecture to nursing students about male sexual
development.

63. Which of the following statements indicates that the nursing students has an understanding of male reproduction?
a. Spermatozoa are produced in the seminal vesicles c. Spermatozoa are produced in the testes
b. Spermatozoa are produced in the prostate gland d. Spermatozoa are produced in the epididymis

64. An adolescent boy asks, "Does the scrotum have a function?" The nurse's best response is:
a. "The scrotum maintains a higher temperature then the core body temperature."
b. "The scrotum is an insensitive structure that houses the testicles."
c. "The scrotum is the source of ejaculation."
d. "The scrotum helps to protect the testes and provides an ideal environment to create sperm."

65. The nurse, speaking with a couple trying to conceive a child, reminds the patients that a factor that can decrease
sperm production is:
a. Infrequent sexual intercourse c. The penis and testes are small
b. The man is not circumcised d. The testes are too warm

66. What microorganism, that is part of the normal vaginal flora, is responsible for making the usual pH of the vagina
acidic?
a. Candida albicans c. Chlamydia trachomatis
b. Döderleins bacillus d. Hemophilus ducreyi

67. What is the primary purpose why the vaginal pH is acidic?

a. To reduce odor c. To maintain sterility of the vaginal canal
b. To increase sperm survival d. To prevent infection

68. Which statement made by a preteen girl indicates successful adaptation to menarche?
a. "My cycle should occur every 28 days and last about five days."
b. "I won't need to wear protection on the last few days of my period."
c. "My cycle should occur every 20 days and last about three days."
d. "Super-absorbent tampons are the best for teenagers."

69. A nurse is teaching a class on the anatomy of the reproductive system. A student states that she has pain during
menstruation. The nurse knows that painful menstruations may be due to which of the following ligaments?
a. Uterosacral ligament c. Ovarian ligament
b. Round ligament d. Broad ligament

70. A woman’s obstetric history indicates that she is pregnant for the fourth time and all of her children from previous
pregnancies are living. One was born at 39 weeks of gestation, twins were born at 34 weeks of gestation, and another
child was born at 35 weeks of gestation. What is her gravidity and parity using the GTPAL system?
a. 3-1-1-1-3 c.3-0-3-0-3
b. 4-1-2-0-4 d.4-2-1-0-3

71. When is the earliest time in pregnancy that heartbeat can be heard by a Doppler?
a. 10 weeks c. 14 weeks
b. 12 weeks d. 18 weeks

72. The client tells the nurse that her last menstrual period started on January 14 and ended on January 20. Using
Nagele’s rule, the nurse determines her EDD to be which of the following?
a. September 27 c. November 7
b. October 21 d. December 27

75. Which of the following answers best describes the stage of pregnancy in which maternal and fetal blood are
exchanged?
a. conception c. 32-34 weeks gestation 3rd Trimester
b. 9 weeks gestation when the fetal heart is well developed d. maternal and fetal blood are never
exchanged

76. A pregnant patient is concerned about a blow to the abdomen if she continues to play basketball during her
pregnancy. The nurse's response is based upon her knowledge of which of the following facts concerning amniotic
fluid?
a. The total amount of amniotic fluid during pregnancy is 300 mL.
b. Amniotic fluid functions as a cushion to protect against mechanical injury.
c. The fetus does not contribute to the production of amniotic fluid.
d. Amniotic fluid is slightly acidic.

77. Community Health Center provide health service package for the needs of pregnant women one of which is
micronutrient supplementation. Vitamin A, given to prevent deficiency, is in the form of a capsule or tablet of 10,000
IU and is given BID. This is given as early as the:
a. 2nd month of pregnancy c. 6th month of pregnancy
b. 4th month of pregnancy d. 8th month of pregnancy
 BSN II COMPREHENSIVE EXAMINATION 2ND SEM 2017 7

78. The nurse caring for the pregnant client must understand that the hormone essential for maintaining pregnancy
is:
a. Estrogen c. Oxytocin
b. Human chorionic gonadotropin (hCG). d. Progesterone

79. A woman at 10 weeks of gestation who is seen in the prenatal clinic with presumptive signs and symptoms of
pregnancy likely will have:
a. Amenorrhea. c. Chadwick’s sign.
b. Positive pregnancy test. d. Hegar’s sign.

80. As a nurse, you know that these are probable signs of pregnancy except:
a. Quickening c. Ballottement
b. Hegar’s Sign d. McDonald’s Sign

82. A client, approximately 11 weeks pregnant, and her husband are seen in the antepartal clinic. The client’s
husband tells the nurse that he has been experiencing nausea and vomiting and fatigue along with his wife. The nurse
interprets these findings as suggesting that the client’s husband is experiencing which of the following?
a. Ptyalism. c. Couvade syndrome.
b. Mittelschmerz. d. Pica

83. When is the earliest time the baby can be born?

a. 30 weeks c. 26 weeks
b. 35 weeks d. 38 weeks

85. You performed the leopold’s maneuver and found the following: breech presentation, fetal back at the right side of
the mother. Based on these findings, you can hear the fetal heart beat (PMI) BEST in which location?
a. Left lower quadrant c. Left upper quadrant
b. Right lower quadrant d. Right upper quadrant

86. The nurse knows that a lecithin/sphingomyelin (L/S) ratio finding of 2:1 on amniotic fluid means:
a. Fetal lungs are still immature. c. Fetal lungs are mature.
b. The fetus has a congenital anomaly. d. The fetus is small for gestational age.

87. The nursing student is preparing to teach a prenatal class about fetal circulation. Which statement should be
included in the teaching plan?
a. “One artery carries oxygenated blood from the placenta to the fetus.”
b. “Two arteries carry oxygenated blood from the placenta to the fetus.”
c. “Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta.”
d. “Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the
placenta.”

88. A nursing student is assigned to care for a client in labor. The nursing instructor asks the student to describe fetal
circulation, specifically the ductus venosus. Which statement is correct regarding the ductus venosus?
a. Connects the pulmonary artery to the aorta c. Connects the umbilical vein to the inferior vena cava
b. Is an opening between the right and left atria d. Connects the umbilical artery to the inferior vena
cava

91. The nurse is taking care of a multipara who is at 42 weeks of gestation and in active labor, her membranes
ruptured spontaneously 2 hours ago. While auscultating for the point of maximum intensity of fetal heart tones before
applying an external fetal monitor, the nurse counts 100 beats per minute. The immediate nursing action is to:
a. Start oxygen by mask to reduce fetal distress.
b. Examine the woman for signs of a prolapsed cord.
c. Turn the woman on her left side to increase placental perfusion.
d. Take the woman’s radial pulse while still auscultating the FHR.

92. A mother is in the third stage of labor. Which of the following signs will help the nurse determine the signs of
placental separation?
a. The uterus becomes globular. c. The fundus appears at the introitus.
b. The umbilical cord is shortened. d. Mucoid discharge is increased.

93. The nurse measures the frequency of a laboring woman’s contractions by noting:
a. How long the patient states the contractions last
b. The time between the end of one contraction and the beginning of the next
c. The time between the beginning and the end of one contraction
d. The time between the beginning of one contraction and the beginning of the next

94. The relaxation phase between contractions is important because:

a. The laboring woman needs to rest c. The uterine muscles fatigue without relaxation
b. The contractions can interfere with fetal oxygenation d. The infant progresses toward delivery at these times

95. The nurse recognizes the contraction duration and interval that could result in fetal compromise is:
a. Duration shorter than 30 seconds, interval longer than 75 seconds
b. Duration shorter than 90 seconds, interval longer than 120 seconds
 BSN II COMPREHENSIVE EXAMINATION 2ND SEM 2017 8

c. Duration longer than 90 seconds, interval shorter than 60 seconds

d. Duration longer than 60 seconds, interval shorter than 90 seconds

96. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the nurse in-charge
to discontinue I.V. infusion of Pitocin is:
a. Contractions every 1 ½ minutes lasting 70-80 seconds. c. Early decelerations in the fetal heart rate.
b. Maternal temperature 101.2 d. Fetal heart rate baseline 140-160 bpm.

98. When the infant is in a vertex presentation, meconium-stained amniotic fluid indicates:
a. Fetal distress c. Intact gastrointestinal tract
b. Fetal maturity d. Dehydration in the mother

99. The student nurse asks the registered nurse why oxytocin (Pitocin), 10 units (IV or IM) must be given to a client
after birth fo the fetus. The nurse is correct to explain that oxytocin:
a. Minimizes discomfort from “afterpains.” c. Promotes lactation.
b. Suppresses lactation. d. Maintains uterine tone.

Situation: A current initiative of the Department of Health (DOH) is the program called Essential Newborn Care or
ENC. This outlines simple yet meaningful measures to be undertaken by healthcare workers in doing immediate
newborn care management. The following situations apply.

100. Nurse Eliza is a member of the birthing team the day Mrs. Paz gave birth to her 1 st born. Inside the delivery
room, Nurse Eliza assisted the attending obstetrician. To address the concerns of keeping the baby warm, her first
step in obtaining thermal protection for the newborn was.
a. Drying the baby thoroughly immediately after c. Covering the baby with clean, dry cloth
birth immediately after birth
b. Covering the baby with a clean, dry cloth after the d. Drying the baby thoroughly after the cord has been
cord has been cut cut

101. Nurse Eliza observe other details as essential part of the immediate care of a normal newborn included:
a. Skin-to-skin contact follow by placing the baby in c. Stimulating the baby by slapping the soles of the
a warming incubator baby’s feet.
b. Removing used wet cloth, and covering the baby d. Deep suctioning of the airway to remove mucus.
with clean, dry cloth

102. In further applying essential newborn care (ENC), Nurse Eliza keeps in mind that care of the umbilicus should
include:
a. Cleansing with cooled, boiled water and leaving c. Covering with a sterile compress.
umbilicus uncovered
b. Applying antibiotic cream d. Cleansing with alcohol

103. Administering of Vitamin K to the newborn is necessary since:

a. Newborn have no intestinal bacteria c. The newborn’s liver is incapable of producing
Sufficient vitamin K yet.
b. Hemolysis of the fetal red blood cells destroys d. Newborn are susceptible to Avitaminosis
vitamin K

104. The essential newborn care package is a four-step newborn care time-bound intervention undertaken to lessen
newborn death. This include, EXCEPT:
a. Provision of appropriate thermal care through mother and newborn skin to skin contact maintaining a
delivery room temperature of 25-28 degrees centigrade and wrapping the newborn with clean, dry cloth.
b. Non-separation of the newborn and mother for early breast feeding. Immediate latching on the initiation of
breastfeeding with first hour after birth.
c. Immediate and thorough drying to stimulate breathing after delivery of the baby.
d. Proper time clamping and cutting of the umbilical cord.

105. Which law requires the registration of births within 30 days from the occurrence of delivery?
a. E.O 2009 c. R.A. 2382
b. P.D. 651 d. R.A. 9255

TOPIC: Nursing Care of Women with Complications during Labor and Birth

106. A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and begins to
have contractions every 90 seconds. What is the nurse’s initial action?
a. Stop the oxytocin infusion. c. Turn her on her left side and reassess
b. Continue the infusion and report the findings the contractions.
to the physician. d. Administer oxygen by mask.

107. What nursing care should be provided to a woman with a third-degree laceration immediately after delivery?
a. Warm compresses to the perineum c. Warm sitz bath
b. Cold pack to the perineum d. Elevation of hips to prevent edema
 BSN II COMPREHENSIVE EXAMINATION 2ND SEM 2017 9

108. A frustrated patient in labor has been affected by decreased uterine muscle tone and reports, My doctor wont
induce my labor because of some silly score. He said I was a 4. What kind of magic number do I need? What is the
lowest Bishop score the patient should have prior to induction?
a. 6 b. 8 c. 10 d. 12

109. A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured
spontaneously. What complication should the nurse closely assess for with this patient?
a. Chorioamnionitis c. Hypotension
b. Hemorrhage d. Amniotic fluid embolism

110. How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine
contractions?
1. Place a warm, moist washcloth over the breast.
2. Brush the nipples with a dry washcloth.
3. Gently pull on the nipples.
4. Apply suction to the nipples with a breast pump.
5. Press the palms of her hands down on her breasts.

a. 1, 2, 3, b. 2, 3, 4 c. 3, 4, 5, d. 1, 2, 4

111. A woman who is 9 weeks pregnant is experiencing heavy bleeding and cramping. She reports passing some
tissue. Cervical dilation is noted on examination. This woman most likely had:
a. An inevitable abortion c. A complete abortion
b. An incomplete abortion d. A missed abortion

112. An ultrasound on a woman who is 32 weeks pregnant reveals the placenta implanted over the entire cervical os.
The nurse understands that this condition is known as:
a. Low-lying placenta c. Partial placenta previa
b. Marginal placenta previa d. Total placenta previa

113. At 32 weeks' gestation, a client is admitted to the facility with a diagnosis of pregnancy-induced hypertension
(PIH). Based on this diagnosis, the nurse expects assessment to reveal:
a. Edema. b. Fever. c. Glycosuria. d. Vomiting.

114. The patient with gestational hypertension has all the signs below. The nurse immediately reports:
a. Diarrhea c. Blurred vision
b. Decreased urine output d. Backache

115. The nurse would suspect abruptio placentae when the pregnant woman presents with:
a. Painless vaginal bleeding c. Vaginal bleeding and back pain
b. Uterine irritability with contractions d. Premature rupture of membranes

116. Rh incompatibility occurs in which of the following situations:

a. Rh-negative mother, Rh-positive fetus c. Rh-positive mother, Rh-negative fetus
b. Rh-negative mother, Rh-negative fetus d. Rh-positive mother, Rh-positive fetus

117. A primigravida in her first trimester is Rh-negative. To prevent anti-Rh antibodies from forming, this woman
would receive:
a. Rh immune globulin during labor
b. Intrauterine transfusions with O-negative blood
c. Rh immune globulin at 28 weeks and within 72 hours after the birth of an Rh-positive infant
d. Rh immune globulin now and again in the last trimester

118. Which symptoms should alert the nurse to the possibility of an ectopic pregnancy?
a. Abdominal pain, vaginal bleeding, and a positive pregnancy test
b. Hyperemesis and weight loss
c. Amenorrhea and a negative pregnancy test
d. Copious discharge of clear mucous and prolonged epigastric pain

119. A woman seeking prenatal care relates a history of macrosomic infants, two stillbirths, and polyhydramnios with
each pregnancy. The nurse recognizes that these factors are highly suggestive of:
a. Toxoplasmosis c. Hydatidiform mole
b. Abruptio placentae d. Diabetes mellitus

120. The pregnant woman comes to the clinic stating that she has been exposed to hepatitis B. She is afraid that her
baby will also contract hepatitis B. The nurse counsels that the baby:
a. Will be given a single dose of hepatitis immune globulin at birth after the first bath
b. Will be able to use the antibodies from the immunizations given to the patient before delivery
c. Will not have hepatitis B because the virus does not pass through the placental barrier
d. Will be immune to hepatitis B because of the mothers infection

121. The nurse explains that the objective of magnesium sulfate therapy for the patient with preeclampsia is to:
a. Prevent convulsions c. Increase reflex irritability
b. Promote diaphoresis d. Act as a saline cathartic
 BSN II COMPREHENSIVE EXAMINATION 2ND SEM 2017 10

122. A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning
this client's care?
a. patellar reflex 4+ c. four hour urine output 240 ml
b. blood pressure 158/80 d. respiration 12/minute

123. The nurse caring for a pregnant woman who is receiving an intravenous infusion with magnesium sulfate will:
a. Count respirations and report a rate of less than 12 breaths per minute.
b. Count respirations and report a rate of more than 20 breaths per minute.
c. Check blood pressure and report a rate of less than 100/60.
d. Monitor urinary output and report a rate of less than 100 ml per hour.

124. The drug the nurse plans to have available for immediate IV administration whenever magnesium sulfate is
administered to a maternity patient is:
a. Ergonovine maleate (Ergotrate) c. Oxytocin
b. Calcium gluconate d. Hydralazine (Apresoline)

125. The nurse educates prenatal patients about the threat of TORCH infections. These infections include:
1. Toxoplasmosis 4. Rubella
2. Toxemia 5. Herpes simplex
3. Cytomegalovirus 6. Candidiasis

a. 1, 2, ,3, 4 b. 2, 3, 4, 6 c. 1, 3, 4, 5 d. 2, 3, 4, 5

126. A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the
presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action?
a. Find the closest telephone and stat page the physician
b. Place the client in Trendelenburg's position
c. Call the delivery room to notify the staff that the client will be transported immediately
d. Gently push the cord into the vagina

127. Rho(D) immune globulin (RhoGAM) is ordered for a client before she is discharged after a spontaneous abortion.
The nurse instructs the client that this drug is used to prevent which of the following?
a. Development of a future Rh-positive fetus. c. A future pregnancy resulting in abortion.
b. An antibody response to Rh-negative blood. d. Development of Rh-positive antibodies..

TOPIC: Pediatric Disorders

128. Which assessment would lead the nurse to suspect that a newborn infant has a ventricular septal defect?
a. A loud, harsh murmur with a systolic thrill c. Blood pressure higher in the arms than in the legs
b. Cyanosis when crying d. A machinery-like murmur

129. A child diagnosed with tetralogy of Fallot becomes upset, crying and thrashing around when a blood specimen is
obtained. The child’s color becomes blue and the respiratory rate increases to 44 breaths/minute. Which of the
following actions should the nurse do first?
a. Obtain an order for sedation for the child c. Explain to the child that it will only hurt for a short
time.
b. Assess for an irregular heart rate and rhythm d. Place the child in a knee-to-chest position.

130. Dietary treatment of children with PKU includes a:

a. Protein-free diet c. Phenylalanine-free diet
b. Low-phenylalanine diet d. Protein-enriched diet

131. A mother brings her 3 week old infant to a clinic for a phenylketonuria (PKU) screening blood test. The test
indicates a serum phenylalamine level of 1 mg/dl. The nurse interprets this result as:
a. Positive c. Inconclusive
b. Negative d. Requiring rescreening at age 6 weeks

132. A parent of an infant with patent ductus arteriosus (PDA) ask the nurse to explain once again what PDA is. The
nurse explain that it is:
a. An enlarged diameter of the aorta
b. A narrowing of the entrance to the pulmonary artery
c. A connection between the pulmonary artery and the aorta
d. An opening in the wall between the right and left ventricles

133. A nurse is assessing a child who may have a seizure disorder. Which option is a description of an absence
seizure?
a. Sudden, momentary loss of muscle tone
b. Minimal or no alteration in muscle tone, with a brief loss of consciousness
c. Muscle tone maintained and child frozen into position
d. Brief, sudden contracture of a muscle or muscle group

134. Which nursing intervention takes highest priority when caring for this child who’s experiencing a seizure?
a. Protect the child from injury. c. Shout at the child to end the seizure.
b. Use a padded tongue blade to protect the airway. d. Allow seizure activity to end without interference.
 BSN II COMPREHENSIVE EXAMINATION 2ND SEM 2017 11

135. A nurse is caring for an infant with spina bifida. Which assessment findings suggest hydrocephalus?
a. Depressed fontanels and suture lines c. Rapid increase in head size and irritability
b. Deep-set eyes, which appear to look upward d. Motor and sensory dysfunction in the foot and leg
only

Situation: Management of resources and environment includes every potential and existing resources which the
nurse can utilize to promote and maintain health, prevent illness and assist in the task of cure and rehabilitation. The
(M) Chart prescribed by the World Health Organization is one such resources. The following questions apply.

136. In the IMCI classification tables, color yellow indicates that a:

a. A child needs an appropriate antibiotic or other c. A child complaint that needs an urgent attention
treatment
b. A child does not need specific medical treatment d. A referral or admission is needed.

137. The integrated Management of Childhood Illness chart provides the necessary procedure when identifying the
appropriate interventions to be done. However, the community health nurse should be aware that the following factor
should be considered in utilizing the case management chart.
a. Danger signs c. Ninong of the child
b. Chief complain d. Problem of the child

138 Which of the following laboratory test would classify the presence of fever as positive for malaria?
a. CBC c. Blood smear
b. Tourniquet d. Occult blood

139. Upon assessment, nurse notes that the child has fever. In the presence of mosquito bites she would suspect the
following illnesses, EXCEPT:
a. DHF c. Measles
b. Malaria d. Hemorrhagic fever

140. All of the following illnesses are caused by virus, EXCEPT:

a. H-Fever c. Parotitis
b. Malaria d. Measles

141. Immunizing children against measles is an example of which of the following levels of preventive care?
a. Primary b. Secondary c. Tertiary

142. Referring an HIV-positive patient to a local support group is an example of which of the following levels of
preventive care?
a. Primary b. Secondary c. Tertiary

143. A 1 ½ year old child was classified as having 3rd degree protein energy malnutrition, kwashiorkor. Which of the
following signs will be most apparent in this child?
a. Voracious appetite c. Apathy
b. Wasting d. Edema

144. Assessment of a 2-year old child revealed “baggy pants”. Using the IMCI guidelines, how will you manage this
child?
a. Refer the child urgently to a hospital for confinement.
b. Coordinate with the social worker to enroll the child in a feeding program.
c. Make a teaching plan for the mother, focusing on menu planning for her child.
d. Assess and treat the child for health problems like infections and intestinal parasitism.

145. During the physical examination of a young child, what is the earliest sign of xerophthalmia that you may
observe?
a. Keratomalacia c. Night blindness
b. Corneal opacity d. Conjunctival xerosis

146. To prevent xerophthalmia, young children are given Retinol capsule every 6 months. What is the dose given to
preschoolers?
a. 10,000 IU c. 100,000 IU
b. 20,000 IU d. 200,000 IU

147. The major sign of iron deficiency anemia is pallor. What part is best examined for pallor?
a. Palms c. Around the lips
b. Nailbeds d. Lower conjunctival sac

148. Food fortification is one of the strategies to prevent micronutrient deficiency conditions. R.A. 8976 mandates
fortification of certain food items. Which of the following is among these food items?
a. Sugar c. Margarine
b. Bread d. Filled milk

149. What is the best course of action when there is a measles epidemic in a nearby municipality?
a. Give measles vaccine to babies aged 6 to 8 months.
 BSN II COMPREHENSIVE EXAMINATION 2ND SEM 2017 12

b. Give babies aged 6 to 11 months one dose of 100,000 I.U. of Retinol

c. Instruct mothers to keep their babies at home to prevent disease transmission.
d. Instruct mothers to feed their babies adequately to enhance their babies’ resistance.

150. Management of a child with measles includes the administration of which of the following?
a. Gentian violet on mouth lesions
b. Antibiotics to prevent pneumonia
c. Tetracycline eye ointment for corneal opacity
d. Retinol capsule regardless of when the last dose was given

Prepared by:

Nursing Faculty
College of Nursing

Approved by:

Ma. Crisitna Estioco, RN,MAN

AVP for Academic Affairs/
Dean College of Nursing

Reference:

http://health-conditions.com/nursing-health-assessment-nclex-
questions/?wpvqas=d3B2cWFzJTVCJTVEPTEmd3B2cWFzJTVCJTVEPTYmd3B2cWFzJTVCJTVEPTExJndwdnFhcyU1QiU1RD
0xNSZ3cHZxYXMlNUIlNUQ9MTcmd3B2cW49NyZ3cHZxY3E9Nw==