Beruflich Dokumente
Kultur Dokumente
A 10 year old who has sustained a head injury is brought to the emergency department
by his mother. A diagnosis of a mild concussion is made. At the time of discharge, nurse
Ron should instruct the mother to:
2. A male client has suffered a motor accident and is now suffering from hypovolemic shock.
Nurse Helen should frequency assess the client’s vital signs during the compensatory stage
of shock, because:
3. A paranoid male client with schizophrenia is losing weight, reluctant to eat, and voicing
concerns about being poisoned. The best intervention by nurse Dina would be to:
4. One day the mother of a young adult confides to nurse Frida that she is very troubled by
he child’s emotional illness. The nurse’s most therapeutic initial response would be:
5. To check for wound hemorrhage after a client has had a surgery for the removal of a
tumor in the neck, nurse grace should:
6. A 16-year-old primigravida arrives at the labor and birthing unit in her 38th week of
gestation and states that she is labor. To verify that the client is in true labor nurse Trina
should:
A. Obtain sides for a fern test
B. Time any uterine contractions
C. Prepare her for a pelvic examination
D. Apply nitrazine paper to moist vaginal tissue
7. As part of the diagnostic workup for pulmonic stenosis, a child has cardiac
catheterization. Nurse Julius is aware that children with pulmonic stenosis have increased
pressure:
8. An obese client asks nurse Julius how to lose weight. Before answering, the nurse should
remember that long-term weight loss occurs best when:
9. As a very anxious female client is talking to the nurse May, she starts crying. She
appears to be upset that she cannot control her crying. The most appropriate response by
the nurse would be:
10. A patient has partial-thickness burns to both legs and portions of his trunk. Which of the
following I.V. fluids is given first?
A. Albumin
B. D5W
C. Lactated Ringer’s solution
D. 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml
11. During the first 48 hours after a severe burn of 40% of the clients body surface, the
nurse’s assessment should include observations for water intoxication. Associated
adaptations include:
A. Sooty-colored sputum
B. Frothy pink-tinged sputum
C. Twitching and disorientation
D. Urine output below 30ml per hour
12. After a muscle biopsy, nurse Willy should teach the client to:
13. Before a client whose left hand has been amputated can be fitted for a prosthesis, nurse
Joy is aware that:
14. Nurse Cathy applies a fetal monitor to the abdomen of a client in active labor. When the
client has contractions, the nurse notes a 15 beat per minute deceleration of the fetal heart
rate below the baseline lasting 15 seconds. Nurse Cathy should:
15. A male client receiving prolonged steroid therapy complains of always being thirsty and
urinating frequently. The best initial action by the nurse would be to:
16. Nurse Bea recognizes that a pacemaker is indicated when a client is experiencing:
A. Angina
B. Chest pain
C. Heart block
D. Tachycardia
17. When administering pancrelipase (Pancreases capsules) to child with cystic fibrosis,
nurse Faith knows they should be given:
19. A client’s sputum smears for acid fast bacilli (AFB) are positive, and transmission-based
airborne precautions are ordered. Nurse Kyle should instruct visitors to:
20. A client with a head injury has a fixed, dilated right pupil; responds only to painful
stimuli; and exhibits decorticate posturing. Nurse Kate should recognize that these are signs
of:
A. Meningeal irritation
B. Subdural hemorrhage
C. Medullary compression
D. Cerebral cortex compression
21. After a lateral crushing chest injury, obvious right-sided paradoxic motion of the client’s
chest demonstrates multiple rib fraactures, resulting in a flail chest. The complication the
nurse should carefully observe for would be:
A. Mediastinal shift
B. Tracheal laceration
C. Open pneumothorax
D. Pericardial tamponade
22. When planning care for a client at 30-weeks gestation, admitted to the hospital after
vaginal bleeding secondary to placenta previa, the nurse’s primary objective would be:
23. When planning discharge teaching for a young female client who has had a
pneumothorax, it is important that the nurse include the signs and symptoms of a
pneumothorax and teach the client to seek medical assistance if she experiences:
A. Substernal chest pain
B. Episodes of palpitation
C. Severe shortness of breath
D. Dizziness when standing up
24. After a laryngectomy, the most important equipment to place at the client’s bedside
would be:
A. Suction equipment
B. Humidified oxygen
C. A nonelectric call bell
D. A cold-stream vaporizer
25. Nurse Oliver interviews a young female client with anorexia nervosa to obtain
information for the nursing history. The client’s history is likely to reveal a:
26. Nurse Bea should plan to assist a client with an obsessive-compulsive disorder to control
the use of ritualistic behavior by:
27. A 2 ½ year old child undergoes a ventriculoperitoneal shunt revision. Before discharge,
nurse John, knowing the expected developmental behaviors for this age group, should tell
the parents to call the physician if the child:
28. A urinary tract infection is a potential danger with an indwelling catheter. Nurse Gina
can best plan to avoid this complication by:
29. A client has sustained a fractured right femur in a fall on stairs. Nurse Troy with the
emergency response team assess for signs of circulatory impairment by:
A. Turning the client to side lying position
B. Asking the client to cough and deep breathe
C. Taking the client’s pedal pulse in the affected limb
D. Instructing the client to wiggle the toes of the right foot
30. To assess orientation to place in a client suspected of having dementia of the alzheimers
type, nurse Chris should ask:
31. Nurse Mary assesses a postpartum client who had an abruption placentae and suspects
that disseminated intravascular coagulation (DIC) is occurring when assessments
demonstrate:
A. A boggy uterus
B. Multiple vaginal clots
C. Hypotension and tachycardia
D. Bleeding from the venipuncture site
32. When a client on labor experiences the urge to push a 9cm dilation, the breathing
pattern that nurse Rhea should instruct the client to use is the:
A. Expulsion pattern
B. Slow paced pattern
C. Shallow chest pattern
D. blowing pattern
33. Nurse Ronald should explain that the most beneficial between-meal snack for a client
who is recovering from the full-thickness burns would be a:
34. Nurse Wilma recognizes that failure of a newborn to make the appropriate adaptation to
extrauterine life would be indicated by:
A. flexed extremities
B. Cyanotic lips and face
C. A heart rate of 130 beats per minute
D. A respiratory rate of 40 breath per minute
35. The laboratory calls to state that a client’s lithium level is 1.9 mEq/L after 10 days of
lithium therapy. Nurse Reese should:
A. Notify the physician of the findings because the level is dangerously high
B. Monitor the client closely because the level of lithium in the blood is slightly elevated
C. Continue to administer the medication as ordered because the level is within the
therapeutic range
D. Report the findings to the physician so the dosage can be increased because the level is
below therapeutic range
36. A client has a regular 30-day menstrual cycles. When teaching about the rhythm
method, Which the client and her husband have chosen to use for family planning, nurse
Dianne should emphasize that the client’s most fertile days are:
A. Days 9 to 11
B. Days 12 to 14
C. Days 15 to 17
D. Days 18 to 20
40. Nurse Mickey is administering dexamethasome (Decadron) for the early management of
a client’s cerebral edema. This treatment is effective because:
A. Acts as hyperosmotic diuretic
B. Increases tissue resistance to infection
C. Reduces the inflammatory response of tissues
D. Decreases the information of cerebrospinal fluid
41. During newborn nursing assessment, a positive Ortolani’s sign would be indicated by:
42. When caring for a dying client who is in the denial stage of grief, the best nursing
approach would be to:
43. To decrease the symptoms of gastroesophageal reflux disease (GERD), the physician
orders dietary and medication management. Nurse Helen should teach the client that the
meal alteration that would be most appropriate would be:
44. After a mastectomy or hysterectomy, clients may feel incomplete as women. The
statement that should alert nurse Gina to this feeling would be:
45. A client with obstruction of the common bile duct may show a prolonged bleeding and
clotting time because:
46. Realizing that the hypokalemia is a side effect of steroid therapy, nurse Monette should
monitor a client taking steroid medication for:
A. Hyperactive reflexes
B. An increased pulse rate
C. Nausea, vomiting, and diarrhea
D. Leg weakness with muscle cramps
47. When assessing a newborn suspected of having Down syndrome, nurse Rey would
expect to observe:
48. A 10 year old girl is admitted to the pediatric unit for recurrent pain and swelling of her
joints, particularly her knees and ankles. Her diagnosis is juvenile rheumatoid arthritis.
Nurse Janah recognizes that besides joint inflammation, a unique manifestation of the
rheumatoid process involves the:
A. Ears
B. Eyes
C. Liver
D. Brain
49. A disturbed client is scheduled to begin group therapy. The client refuses to attend.
Nurse Lolit should:
50. Because a severely depressed client has not responded to any of the antidepressant
medications, the psychiatrist decides to try electroconvulsive therapy (ECT). Before the
treatment the nurse should:
51. Nurse Vicky is aware that teaching about colostomy care is understood when the client
states, “I will contact my physician and report ____":
54. During a group therapy session, one of the clients ask a male client with the diagnosis
of antisocial personality disorder why he is in the hospital. Considering this client’s type of
personality disorder, the nurse might expect him to respond:
55. A child visits the clinic for a 6-week checkup after a tonsillectomy and adenoidectomy.
In addition to assessing hearing, the nurse should include an assessment of the child’s:
56. A client is diagnosed with cancer of the jaw. A course of radiation therapy is to be
followed by surgery. The client is concerned about the side effects related to the radiation
treaments. Nurse Ria should explain that the major side effects that will experienced is:
A. Fatigue
B. Alopecia
C. Vomiting
D. Leucopenia
57. Nurse Katrina prepares an older-adult client for sleep, actions are taken to help reduce
the likelihood of a fall during the night. Targeting the most frequent cause of falls, the nurse
should:
A. Offer the client assistance to the bathroom
B. Move the bedside table closer to the client’s bed
C. Encourage the client to take an available sedative
D. Assist the client to telephone the spouse to say “goodnight”
58. When evaluating a growth and development of a 6 month old infant, nurse Patty would
expect the infant to be able to:
59. A breastfeeding mother asks the nurse what she can do to ease the discomfort caused
by a cracked nipple. Nurse Tina should instruct the client to:
60. Nurse Sandy observes that there is blood coming from the client’s ear after head injury.
Nurse Sandy should:
61. Nurse Gio plans a long term care for parents of children with sickle-cell anemia, which
includes periodic group conferences. Some of the discussions should be directed towards:
62. The central problem the nurse might face with a disturbed schizophrenic client is the
client’s:
A. Suspicious feelings
B. Continuous pacing
C. Relationship with the family
D. Concern about working with others
63. When planning care with a client during the postoperative recovery period following an
abdominal hysterectomy and bilateral salpingo-oophorectomy, nurse Frida should include
the explanation that:
64. An adolescent client with anorexia nervosa refuses to eat, stating, “I’ll get too fat.”
Nurse Andrea can best respond to this behavior initially by:
A. Not talking about the fact that the client is not eating
B. Stopping all of the client’s priviledges until food is eaten
C. Telling the client that tube feeding will eventually be necessary
D. Pointing out to the client that death can occur with malnutrition.
65. A pain scale is used to assess the degree of pain. The client rates the pain as an 8 on a
scale of 10 before medication and a 7 on a scale of 10 after being medicated. Nurse Glenda
determines that the:
A. Keeping the baby awake for longer periods of time before each feeding
B. Assisting the parents to stimulate their baby through touch, sound, and sight.
C. Encouraging parental contact for at least one 15-minute period every four hours.
D. Touching and talking to the baby at least hourly, beginning within two to four hours after
birth
67. Before formulating a plan of care for a 6 year old boy with attention deficit hyperactivity
disorder (ADHD), nurse Kyla is aware that the initial aim of therapy is to help the client to:
68. Nurse Wally knows that the most important aspect of the preoperative care for a child
with Wilms’ tumor would be:
69. At 11:00 pm the count of hydrocodone (Vicodin) is incorrect. After several minutes of
searching the medication cart and medication administration records, no explanation can be
found. The primary nurse should notify the:
70. When caring for the a client with a pneumothorax, who has a chest tube in place, nurse
Kate should plan to:
71. According to C.E.Winslow, which of the following is the goal of Public Health?
73. Which of the following is the most prominent feature of public health nursing?
A. It involves providing home care to sick people who are not confined in the hospital
B. Services are provided free of charge to people within the catchment area.
C. The public health nurse functions as part of a team providing a public health nursing
services.
D. Public health nursing focuses on preventive, not curative, services.
75. Nurse Pauline determines whether resources were maximized in implementing Ligtas
Tigdas, she is evaluating:
A. Effectiveness
B. Efficiency
C. Adequacy
D. Appropriateness
76. Lissa is a B.S.N. graduate. She want to become a Public Health Nurse. Where will she
apply?
A. Department of Health
B. Provincial Health Office
C. Regional Health Office
D. Rural Health Unit
A. Act 3573
B. R.A. 3753
C. R.A. 1054
D. R.A. 1082
78. Nurse Fay is aware that isolation of a child with measles belongs to what level of
prevention?
A. Primary
B. Secondary
C. Intermediate
D. Tertiary
79. Nurse Gina is aware that the following is an advantage of a home visit?
80. The PHN bag is an important tool in providing nursing care during a home visit. The
most important principle of bag technique states that it:
81. Nurse Willy reads about Path Goal theory. Which of the following behaviors is
manifested by the leader who uses this theory?
82. Nurse Cathy learns that some leaders are transactional leaders. Which of the following
does NOT characterize a transactional leader?
84. Which of the following is the best guarantee that the patient’s priority needs are met?
85. Nurse Tony stresses the need for all the employees to follow orders and instructions
from him and not from anyone else. Which of the following principles does he refer to?
A. Scalar chain
B. Discipline
C. Unity of command
D. Order
86. Nurse Joey discusses the goal of the department. Which of the following statements is a
goal?
87. Nurse Lou considers shifting to transformational leadership. Which of the following
statements best describes this type of leadership?
88. Nurse Mae tells one of the staff, “I don’t have time to discuss the matter with you now.
See me in my office later” when the latter asks if they can talk about an issue. Which of the
following conflict resolution strategies did she use?
A. Smoothing
B. Compromise
C. Avoidance
D. Restriction
89. Nurse Bea plans of assigning competent people to fill the roles designed in the
hierarchy. Which process refers to this?
A. Staffing
B. Scheduling
C. Recruitment
D. Induction
90. Nurse Linda tries to design an organizational structure that allows communication to
flow in all directions and involve workers in decision making. Which form of organizational
structure is this?
A. Centralized
B. Decentralized
C. Matrix
D. Informal
91. When documenting information in a client's medical record, the nurse should:
92. Which of the following factors are major components of a client's general background
drug history?
A. Allergies and socioeconomic status
B. Urine output and allergies
C. Gastric reflex and age
D. Bowel habits and allergies
A. Hand washing
B. Nasogastric tube irrigation
C. I.V. cannula insertion
D. Colostomy irrigation
94. The nurse is performing wound care using surgical asepsis. Which of the following
practices violates surgical asepsis?
95. On admission, a client has the following arterial blood gas (ABG) values: PaO2, 50 mm
Hg; PaCO2, 70 mm Hg; pH, 7.20; HCO3–, 28 mEq/L. Based on these values,
the nurse should formulate which nursing diagnosis for this client?
96. The use of larvivorous fish in malaria control is the basis for which strategy of malaria
control?
A. Stream seeding
B. Stream clearing
C. Destruction of breeding places
D. Zooprophylaxis
A. Mastoiditis
B. Severe dehydration
C. Severe pneumonia
D. Severe febrile disease
98. A mother brought her daughter, 4 years old, to the RHU because of cough and colds.
Following the IMCI assessment guide, which of the following is a danger sign that indicates
the need for urgent referral to a hospital?
A. Inability to drink
B. High grade fever
C. Signs of severe dehydration
D. Cough for more than 30 days
99. Food fortification is one of the strategies to prevent micronutrient deficiency conditions.
R.A. 8976 mandates fortification of certain food items. Which of the following is among
these food items?
A. Sugar
B. Bread
C. Margarine
D. Filled milk
100. The major sign of iron deficiency anemia is pallor. What part is best examined for
pallor?
A. Palms
B. Nailbeds
C. Around the lips
D. Lower conjunctival sac