GENERAL INSTRUCTIONS: 1. This test booklet contains 100 test questions 2.

Read INTRUCTIONS TO EXAMINEES printed on your answer sheet 3. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer. 4. AVOID ERASURES. INSTRUCTIONS: 1. Detach one (1) answer sheet from the bottom of your Examinee ID/ Answer sheet set. 2. Write the subject title Examination XXII on the box provided. 3. Shade Set Box A on your answer sheet if your test booklet is Set A; Set Box B if your test booklet is Set 1. The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society guidelines, the nurse should recommend that the women: A. perform breast self-examination annually. -monthly B. have a mammogram annually. C. have a hormonal receptor assay annually. D. have a physician conduct a clinical examination every 2 years.

2. To combat the most common adverse effects of chemotherapy, the nurse would administer an:

A. antiemetic. B. antimetabolite. C. antibiotic. D. anticoagulant. 3. A client receives a sealed radiation implant to treat cervical cancer. When caring for this client, the nurse should: A. consider the client's urine, feces, and vomitus to be highly radioactive. Unsealed radiation B. consider the client to be radioactive for 10 days after implant removal. C. allow soiled linens to remain in the room until after the client is discharged. D. maintain the client on complete bed rest with bathroom privileges only. 4. What should a male client over age 50 do to help ensure early identification of prostate cancer? A. Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly. PSA first B. Have a transrectal ultrasound every 5 years. C. Perform monthly testicular self-examinations, especially after age 50. D. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels checked yearly. 5. Victoria suspects that she has a lump in her breast. She approaches a nurse and the nurse informs her that a diagnosis of breast cancer is confirmed by: A. BSE b. Chest X-ray c. Fine needle aspiration d. Mammography 6. Richard is undergoing a diagnostic workup for suspected thyroid cancer. The nurse is aware that the most common form of thyroid cancer in adults is? A. Follicular carcinoma c. Anaplastic carcinoma B. Papillary carcinoma d. Medullary carcinoma 7. Faith, a patient with vaginal cancer asks the oncology nurse, What is the usual treatment for this type of cancer? The nurse appropriately answers the patient by saying? A. Surgery c. Radiation B. Immunotherapy d. Chemotherapy

8. The community health nurse is instructing Mrs. Natividad, a premenopausal woman, about breast self-examination. The nurse should tell the patient to do her self-examination: A. At the end of her menstrual cycle C. On the 1st day of the menstrual cycle B. Immediately after her D. On the same day each month menstrual period 9. The wife of a governor is receiving chemotherapy to treat breast cancer. Which of the following assessment findings made by the oncology nurse indicate a fluid and electrolyte imbalance induced by chemotherapy?

A. Urine output of 400 mL in 8 hours B. Dry oral mucous membranes and cracked lips C. Blood pressure of 120/64 to 130/72 mmHg D. Serum potassium level of 3.6 mEq/L 10. Carrie is suspected of having multiple myeloma. She is undergoing tests Diagnostic study findings in multiple myeloma include: A. A decreased serum creatinine level c. Bence Jones protein in urine B. A low serum protein level d. Hypocalcemia SITUATION 1 : Roy, a Clinical Instructor is reviewing the different Nursing Theorists to his 4th year nursing students. 11. Which of the following statements regarding Orems Theory would indicate a correct understanding regarding the said theory: a. b. c. d. Orems theory is also known as the Goal-Attainment Theory. It is also called the Self-Care Deficit theory It is somewhat similar to the Adaptation Model It is also known as the Conservation Model

12. Orems model supports nursing through the following central theories EXCEPT; a. Theory of Nursing Systems b. Supportive-Educative c. Partially Compensatory d. Theory of Agency

13. A nursing theorist who identified the 21 nursing problem areas a. Faye Abdellah b. Virginia Henderson c. Ida Jean Orlando d. Imogene King

14. This nurse theorist basically viewed the person as a unified biopsychosocial system that is in constant interaction with the changing environment. The adaptive system includes input control process, output, feedback: a. Sister Callista Roy b. Lydia Hall - 3 cs c. Jean Watson d. Betty Neuman stress reduction

15. The theory on man as a biopsychosocial and spiritual being conceptualizes the following EXCEPT: a. b. c. d. Man, as a biologic being is like all other men Man, as a psychologic being is like no other man Man, as a social being is like some other men Man, is a spiritual being only when he professes his belief in God.

16. The four concepts common to nursing conceptual models are: a. person, nursing, environment, medicine b. person, health, nursing, support system c. person, environment, health, nursing d. person, environment, health, nursing paradigms

17. Florence Nightingale was born in a. Germany b. Great Britain Crimea

c. Italy- florence

d.

18. She (Florence Nightingale) had her formal nursing in: a. England b. Germany c. Crimean war where she served d. Turkey 19. Florence was born on: a. May 12, 1820 1810 b. March 9, 1850 c. August 13, 1910 d. October 12,

20. The Care, Core, Cure Model was conceptualized by which nursing theorist? a. Sister Letty Kwan c. Lydia Hall b. Betty Neuman d. Madeleine Leininger 21. Trans-cultural Nursing was conceptualized by; a. Florence Nightingale b. Betty Neuman 22. Jean Watson conceptualized which Nursing theory? a. Caring theory b. Trans-cultural Nursing c. Lydia Hall d. Madeleine Leininger c. Environmental Theory -nightingale d. Adaptation Model - roy

23. A 2-year-old child (diagnosis: meningitis) is to be sedated with Phenobarbital, 18 mg PO q6h (every 6 hours). The label reads 20 mg per 5 mL. how much Phenobarbital should the nurse administer to this child? D/H x Q = a. 4 ml b. 4.3 ml c. 4.5 ml d. 4.8 ml

24. Elixir of digoxin (Lanoxin) is available with 0.05 mg of the drug in 1 mL of solution. How much of this elixir should the nurse administer if the physicians order reads 0.125 mg PO bid? a. 2 mL b. 2.25 mL c. 2.5 mL d. 2.75 mL 25. Nurse Amy is to administer 100 mg of aminophylline IV. The ampule contains 500 mg (gr 7 1/2 ) of aminophylline in 10 mL of solution. How much solution should the nurse withdraw from the ampule? a. 2 mL b. 4 mL c. 6 mL d. 8 mL 26. A 17-month-old child has retropharyngeal abscess and is to receive ampicillin four times a day. The child weighs 15 kg (33 lb). The nurses reference indicates that the correct dosage is 75mg/kg/day. Which dose should the nurse give to this client at 10 AM? a. 11 mg b. 28 mg c. 280 mg d. 1125 mg 27. The type of research design that does not manipulate independent variable is: a. Experimental design control c. Quasi-experimental design

b. Quantitative design - control design expost facto research design

d. Non-experimental

28. A nurse researcher must be aware that her respondents may deliberately change their behavior when they know that they are being studied. This is called: a. Halo effect b. Delimitation c. Hawthorne effect - awareness d. Pretest

29. Direct collection of data is advantageous because, except: a. It reduces cost of collecting data b. The source of possible bias is eliminated c. It is impossible to guarantee the study subjects that their responses will be kept anonymous d. None of the above 30. Nurse Terrys patient told her that he has called his lawyer in order to change his will. Nurse Terry is aware that a will is considered a: a. Secondary source b. Relic c. Remain d. Primary source came from the person who made it 31. Which of the following symptoms is associated with ulcerative colitis? a. Dumping syndrome. b. Rectal bleeding. c. Soft stool. d. Fistulas. 32. Surgical management of ulcerative colitis may be performed to treat which of the following complications? a. Gastritis. b. Bowel herniation c. Bowel outpouching d. Bowel perforation 33. Which of the following medication is most effective in treating the pain associated with irritable bowel disease? a. acetaminophen b. opiates c. steroids d. Stool softener. 34. During the first few days of recovery from ostomy surgery for ulcerative colitis, which of the following aspects should be the first priority of client care? a. Body image b. Ostomy care c. Sexual concerns

d. Skin care. 35. Which of the following symptoms may cause hemorrhoids? a. Diarrhea. b. Diverticulosis. c. Portal hypertension. d. Rectal bleeding. 36. Which of the following assessment is most relevant with the diagnosis of hemorrhoids? a. Abdominal assessment b. Diet history. c. Digital rectal examination d. Sexual history 37. Medical management of hemorrhoids includes which of the following treatments? a. Recommending a high-fiber diet. b. Applying cold to reduce swelling c. Using astringent lotions to reduce swelling. d. Elevating the buttocks to reduce engorgement. 38. Which of the following responses by the nurse offer to a client who asks why hes having a vagotomy to treat his ulcer? a. To repair a hole in the stomach b. To reduce the ability of the stomach to produce acid. c. To prevent the stomach from sliding into the chest. d. To remove a potentially malignant lesion in the stomach 39. Which of the following conditions is most likely to directly cause peritonitis? a. Cholelithiasis b. Gastritis. c. Perforated ulcer d. Incarcerated hernia. 40. Which of the following symptoms would a client with peritonitis exhibits? a. Abdominal distention. b. Abdominal pain and rigidity. c. Hyperactive bowel sounds. d. Right upper quadrant pain. 41. Which of the following blood tests is most indicative of cardiac damage? a. Lactate dehydrogenase b. Complete blood count (CBC) c. Troponin I d. Creatine kinase (CK) 42. For a client with a stroke, which of the following criteria must be fulfilled before the client is fed? a. The gag reflex returns.

b. Speech returns to normal. c. Cranial nerves III, IV, & VI are intact. d. The client swallows small sips of water without coughing. 43. Which of the following diets would be least likely to lead to aspiration in a client who had a stroke with residual dysphagia? a. Clear liquid b. Full liquid c. Mechanical soft d. Thickened liquid 44. A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, & projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client of which of the following circumstances? a. Vomiting continues b. Intracranial pressure (ICP) is increased. c. The client needs mechanical ventilation. d. Blood is anticipated in the cerebrospinal fluid (CSF). 45. A client with head trauma develops a urine output of 300 ml/hr, dry skin, & dry mucous membrane. Which of the following nursing interventions is the most appropriate to perform immediately? a. Evaluate urine specific gravity. b. Anticipate treatment for renal failure. c. Provide emollients to the skin to prevent breakdown. d. Slow the I.V. fluids & notify the physician. 46. Stool softeners would be given to a client after repair of a cerebral aneurysm for which of the following reasons? a. To stimulate the bowel due to loss of nerve innervation b. To prevent straining, which increases intracranial pressure (ICP) c. To prevent the Valsalva maneuver, which may lead to bradycardia d. To prevent constipation when osmotic diuretics are used 47. A client with a subdural hematoma becomes restless & confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? a. To reduce intraocular pressure b. To prevent acute tubular necrosis c. To promote osmotic diuresis to decrease intracranial pressure (ICP) d. To draw water into the vascular system to increase blood pressure 48. A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? a. Urine output increases. b. Pupils are 8mm & nonreactive. c. Systolic blood pressure remains at 150 mm Hg. d. Blood urea nitrogen (BUN) & creatinine levels return to normal.

49. Which of the following nursing intervention should be used to prevent foot drop & contractures in a client recovering from a subdural hematoma? a. High-topped sneakers b. Low-dose heparin therapy c. Physical therapy consultation d. Sequential compression device 50. After a hypophysectomy, vasopressin is given I.M. for which of the following reasons? a. To treat growth failure b. To prevent syndrome of inappropriate antidiuretic hormone (SIADH) c. To reduce cerebral edema and lower intracranial pressure d. To replace antidiuretic hormone (ADH) normally secreted from the pituitary 51. Which of the following values is considered normal for intracranial pressure (ICP)? a. 0 to 15 mm Hg b. 25 mm Hg c. 35 to 45 mm Hg d. 120/80 mm Hg
52. Which of the following symptoms commonly occur in a client with varicose veins? a. Fatigue and pressure b. Fatigue and cool feet c. Sharp pain and fatigue d. Sharp pain and cool feet 53. Which of the following activities should a client with varicose veins avoid? a. Exercise b. Leg elevations c. Prolonged lying d. Wearing tight clothing 54. Which of the following tests demonstrates the backward flow of blood through incompetent valves of superficial veins? a. Trendelenburgs test b. Manual compression test c. Perthes test d. Plethysmorgraphy 55. Which of the following treatments is recommended for postoperative management of a client who has undergone ligation and stripping? a. Sitting b. Bed rest c. Ice packs d. Elastic leg compression

56. Which of the following factors usually causes deep vein thrombosis (DVT)? a. Aerobic exercise

b. Inactivity c. Pregnancy d. Tight clothing 57. Which of the following characteristics is typical of the pain associated with deep vein thrombosis (DVT)? a. Dull ache b. No pain c. Sudden onset d. Tingling 58. Which of the following treatments can relieve pain from deep vein thrombosis (DVT)? a. Application of heat b. Bed rest c. Exercise d. Leg elevation 59. Which of the following terms is used to describe pain in the calf due to sharp dorsiflexion of the foot? a. Dyskinesia b. Eversion c. Positive Babinskis reflex d. Positive Homans sign 60. Which of the following conditions causes intermittent claudication (cramp-like pains in the calves)? a. Inadequate blood supply b. Elevated leg position c. Dependent leg position d. Inadequate muscle oxygenation 61. Which of the following medical treatments should administered to treat intermittent claudication? a. Analgesics b. Warfarin (Coumadin) c. Heparin d. Pentoxifylline (Trental) 62. Which of the following oral medications is administered to prevent further thrombus formation? a. Warfarin (Coumadin) b. Heparin c. Furosemide (Lasix) d. Metoprolol (Lopressor) 63. After a client undergoes abdominal aortic aneurysm repair, the nurse should monitor for which of the following complications? a. Arrhythmias b. Hypertension c. Acute renal failure d. Bounding peripheral pulses

64. Which of the following organisms most pneumonia in adults? a. Haemophilus influenzae b. Klebsiella pneumoniae c. Streptococcus pneumonia d. Staphylococcus aureus

commonly

causes

community-acquired

65. An elderly client with pneumonia may appear with which of the following symptoms first? a. Altered mental status and dehydration b. Fever and chills c. Hemoptysis and dyspnea d. Pleuritic chest pain and cough 66. When auscultating the chest of a client with pneumonia, the nurse would expect to hear which of the following sounds over areas of consolidation? a. Bronchial b. Bronchovesicular c. Tubular d. Vesicular 67. A diagnosis of pneumonia is typically achieved by which of the following diagnostic tests? a. Arterial blood gas (ABG) analysis b. Chest X-ray c. Blood cultures d. Sputum culture and sensitivity 68. A client with pneumonia develops dyspnea with a respiratory rate of 32 breadths/minute and difficulty expelling his secretions. The nurse auscultates his lung fields and hears bronchial sounds in the left lower lobe. The nurse determines that the client requires which of the following treatments first? a. Antibiotics b. Bed rest c. Oxygen d. Nutritional intake 69. A 20-year-old client is being treated for pneumonia. He has persistent cough and complains of severe pain on coughing. What type of instruction could be given to help the client reduce the discomfort he is having? a. Hold in your cough as much as possible. b. Place the head of you bed flat to help with coughing. c. Restrict fluids to help decrease the amount of sputum. d. Splint your chest wall with a pillow for comfort. 70. Tuberculosis (TB) is a communicable disease transmitted by which of the following methods? a. Sexual contact b. Using dirty needles c. Using an infected persons eating utensils d. Inhaling droplets exhaled from an infected person

71. An adult client is being screened in the clinic today for tuberculosis. He reports having negative purified protein derivative (PPD) test results in the past. The nurse performs a PPD test on his right forearm today. When should he return to have the test read? a. Right after performing the test b. 24 hours after performing the test c. 48 hours after performing the test d. 1 week after performing the test 72. The right forearm of a client who had a purified protein derivative (PPD) test for tuberculosis (TB) is reddened and raised about 3 mm where the test was given. This PPD would be read as having which of the following results? a. Indeterminate b. Needs to be redone c. Negative d. Positive 73. A client with primary tuberculosis (TB) infection can expect to develop which of the following conditions? a. Active TB within 2 weeks b. Active TB within 1 moth c. A fever that requires hospitalization d. A positive skin test 74. A client has active tuberculosis (TB). Which of the following symptoms will he exhibit? a. Chest and lower back pain b. Chills, fever, night sweats, and hemoptysis c. Fever of more than 104F (40 C) and nausea d. Headache and photophobia 75. Which of the following diagnostic tests is definitive for tuberculosis? a. Chest X-ray b. Mantoux test c. Sputum culture d. Tuberculin test 76. A client with a positive Mantoux test result will be sent for a chest X-ray& For which of the ollowing reasons is this done? a. To confirm the diagnosis b. To determine if a repeat skin test is needed c. To determine the extent of lesions d. To determine if this is a primary or secondary infection 77. Which of the!following assessment findings would help confirm a diagnosis of asthma in a client suspected of having the dis rder? a. Circumoral cyanosis b. Increased forced expiratory volume c. Inspiratory and expiratory wheezing d. Normal breath sounds 78. A client with acute asthma showing inspiratry and expiratory wheezes and ` decreased forced expiratory volume should be treated with which of the following classes of medication right away?

a. b. c. d.

Beta-adrenergic blockers Bronchodilators Inhaled steroids Oral steroids

79. A client is(found to be allergic to Chinese food, which causes acute asthma. Which of the following instruction sho}ld the nurwe give the client? a. nly eat Chinesu f od once per month. b. Use you inhalers before eating Chinese food. c. Avoid Chinese fomd because this is a trigger for you. d. Determine other causes because Chinese food wouldnt cause such a violent reaction. 80. The term a. b. c. d. blue bloater refers to which of the following conditions? Adult respiratory distress syndrome (ARDS) Asthma Chronic obstructive bronchitis Emphysema

81. The term pink puffer refers to the client with which of the following conditions? a. Adult respiratory distress syndrome (ARDS) c. Chronic obstructive bronchitis b. Asthma d. Emphysema

SITUATION 17: June is a 24 year old client with symptoms of dyspnea, absent breath sounds on the right lung and chest x-ray revealed pleural effusion. The physician will perform thoracentesis. 1. Thoracentesis is useful in treating all of the following pulmonary disorders except: a. hemothorax b. tuberculosis c. hydrothorax d. empyema ANSWER: B Hemothorax, Hydrothorax, Empyema, require thracentesis for treatment. Tuberculosis requires antibiotic treatment for months, depending on what category the disease is. 2. Which of the following psychological preparation is not relevant for him? a. telling him that the gauge of the needle and anesthesia to be used b. telling him to keep still during the procedure to facilitate the insertion of the needle in the correct place c. allow June to express his feelings and concerns d. physicians explanation on the purpose of the procedure and how it will be done ANSWER: A

Answers : B, C, D, will relieve clients anxiety towards the procedure, thus it will also help in acquiring the clients participation during the procedure. Choice A is wrong because telling the patient the gauge of the needle and the type of anesthesia to be use will not help the patient that much assuming that the patient does not understand these terms. 3. Before thoracentesis, the legal consideration you must check is: a. Medicine preparation is correct b. position of the client is correct c. Consent is signed by the client d. consent is signed by relative and physician ANSWER: C Although A and B is correct the question ask for the LEGAL consideration. D is not a correct option because the patient is capable to sign the consent.

4. As a nurse, you know that the position for June before thoracentesis is: a. knee-chest b. low fowlers c. orthopneic d. sidelying position on the affected side ANSWER: C 5. Which of the following anesthetic drug is used for thoracentesis? a. Demerol 75mg b. valium 250 mg c. procaine 2% d. Phenobarbital 50mg ANSWER: C TEST TAKING: only option C is an anesthetic drug.
6. Which of the following is more life threatening? A. BP = 180/100 B. BP = 160/120

C. BP = 90/60 D. BP = 80/50 ANSWER: B Although option A is threatening because of High Systolic BP, option B is more threatening because of High diastolic BP. Remember that diastolic BP, is the pressure when the ventricles are at rest. High diastolic BP, may mean that PVR is high or the vessels are constricted. 7. When removing gloves, which of the following is an inappropriate nursing action? A. Wash gloved hand first B. Peel off gloves inside out C. Use glove to glove skin to skin technique D. Remove mask and gown before removing gloves ANSWER: D * Gloves are the dirtiest protective item nurses are wearing and therefore, the first to be removed to prevent spread of microorganism as you remove the mask and gown. 8. Which of the following is TRUE in the concept of stress? A. Stress is not always present in diseases and illnesses B. Stress are only psychological and manifests psychological symptoms C. All stressors evoke common adaptive response D. Hemostasis refers to the dynamic state of equilibrium ANSWER: C * All stressors evoke common adaptive response. A psychologic fear like nightmare and a real fear or real perceive threat evokes common manifestation like tachycardia, tachypnea, sweating, increase muscle tension etc. ALL diseases and illness causes stress. Stress can be both REAL or IMAGINARY. Hemostasis refers to the ARREST of blood flowing abnormally through a damage vessel. Homeostasis is the one that refers to dynamic state of equilibrium according to Walter Cannon. 9. According to this theorist, in his modern stress theory, Stress is the non specific response of the body to any demand made upon it. A. Hans Selye B. Walter Cannon C. Claude Bernard D. Martha Rogers

ANSWER: A * Hans Selye is the only theorist who proposed an intriguing theory about stress that has been widely used and accepted by professionals today. He conceptualized two types of human response to stress, The GAS or general adaptation syndrome which is characterized by stages of ALARM, RESISTANCE and EXHAUSTION. The Local adaptation syndrome controls stress through a particular body part. Example is when you have been wounded in your finger, it will produce PAIN to let you know that you should protect that particular damaged area, it will also produce inflammation to limit and control the spread of injury and facilitate healing process. Another example is when you are frequently lifting heavy objects, eventually, you arm, back and leg muscles hypertorphies to adapt to the stress of heavy lifting. OPTION D, Is the science of unitary human being. 10. Which of the following is NOT TRUE with regards to the concept of Modern Stress Theory? A. Stress is not a nervous energy B. Man, whenever he encounters stresses, always adapts to it C. Stress is not always something to be avoided D. Stress does not always lead to distress ANSWER: B * Man, do not always adapt to stress. Sometimes, stress can lead to exhaustion and eventually, death. A,C and D are all correct. 11. Which of the following is TRUE with regards to the concept of Modern Stress Theory? A. Stress is essential B. Man does not encounter stress if he is asleep C. A single stress can cause a disease D. Stress always leads to distress ANSWER: A * Stress is ESSENTIAL. No man can live normally without stress. It is essential because it is evoked by the body's normal pattern of response and leads to a favorable adaptive mechanism that are utilized in the future when more stressors are encountered by the body. Man can encounter stress even while asleep, example is nightmare. Disease are multifactorial, No diseases are caused by a single stressors. Stress are sometimes favorable and are not always a cause for distress. An example of favorable stress is when a carpenter meets the demand and stress of everyday work. He then develops calluses on the hand to lessen the pressure of the hammer against the tissues of his hand. He also develop larger muscle and more dense bones in the arm, thus, a stress will lead to adaptations to decrease that particular stress.

12. While assessing the newborn, the nurse checks the umbilical cord and counts the vessels present. The nurse notes one artery and one vein. Which of the following actions would be most appropriate for the nurse to take in response to this finding? a. Chart the assessment along with any other normal findings b. Inform the physician or RN that the baby only has one vein c. Inform the physician or RN that the baby only has one artery d. Chart the assessment as a normal variation in the newborn Rationale: The correct answer is (C). The newborn should have two arteries and one vein, and the absence of an artery can indicate other congenital problems, especially with the kidneys. This is not a normal finding and should be reported to the RN or physician. 13. The nurse offers the pregnant patient an HIV test. The patient acts offended, but the nurse explains that all prenatal patients are offered this test because a. it gives the medical team an idea of her lifestyle choices. b. they will then be able to notify her partner if she is positive. c. if she is positive, the baby is likely to present with HIV syndrome, which needs prompt treatment. d. if the mother is positive, she and the baby can be treated with zidovudine, which greatly reduces the chance of the baby becoming infected. Rationale: The correct answer is (D). Many states are urging prenatal patients to be tested for HIV now that there is a treatment, zidovudine, which greatly reduces the possibility of transmission of the virus to the baby, if given to the mother antepartum and intrapartum, and to the baby after delivery. Transmission to the baby is reduced from up to 33 percent to approximately 8 percent. 14. The 34-year-old patient is pregnant with her third child. She complains to the nurse that her varicose veins are worse than in her other pregnancies and asks if there is anything she can do to help relieve her discomfort. The nurse would be correct in suggesting that the patient do all of the following EXCEPT a. Elevate her legs when sitting b. Stand for long periods c. Exercise the calf muscles d. Wear support stockings Rationale: The correct answer is (B). Elevating the legs (A), exercising the calf muscles (C), and wearing support stockings (D) may all help relieve the discomfort of varicose veins. Standing for long periods tends to make them ache more. 15. The nurse weighs the newborn, a baby boy, whose weight is 4200 grams. The most appropriate nursing intervention for this large-for-gestational-age baby would be to a. monitor blood glucose levels frequently. b. delay feeding longer than usual to allow the infants glucose level to decrease. c. bottle feed instead of allowing infant to breastfeed until glucose levels are normal. d. provide respiratory support to the newborn. Rationale: The correct answer is (A). A large-for-gestational age baby is at risk for hypoglycemia, because increased size is often due to high maternal blood glucose, which the baby adjusts to by producing more than the usual amount of insulin. After the baby is born, the insulin levels are still high, but the maternal glucose source is absent, so the baby often becomes hypoglycemic. 16. The nurse is taking the vital signs of a new labor patient. She notes that her blood pressure is 146/94, her face is edematous, and she is complaining of a headache. Her urine is 2+ protein. The physician comes and orders an infusion of MgSO4 (magnesium sulfate) to be given. The nurse will monitor the patient by assessing the patients vital signs as well as e. urine for glucose.

deep tendon reflexes. calf tenderness. abdominal distention . Rationale: The correct answer is (B). MgSO4, magnesium sulfate, is often given to preeclamptic women to prevent seizures. Some of its side effects are respiratory depression and decreased deep tendon reflexes. Respiratory rate and reflexes should be assessed regularly while it is being infused. Urine glucose levels (A) are not affected, nor is the likelihood of calf tenderness (C), or phlebitis. Abdominal distention (D) does not result from this treatment. 17. A woman has returned from surgery after a right mastectomy with an IV of 0.9% NaCl infusing at 100 cc/hour into her left forearm. Several hours later, the IV infiltrates. The nurse is supervising a student nurse preparing to insert a new peripheral intravenous catheter. The nurse would intervene in which of the following situations? a. The student nurse selects a site where the veins are soft and elastic. b. The student nurse selects a site on the distal portion of the left arm. c. The student nurse selects a site close to the joint to provide for stability. d. The student nurse holds the skin taut to stabilize the vein. Strategy: "Nurse would intervene" indicates an incorrect action. (a) acceptable site selection (b) acceptable site selection (c) correctinappropriate; movement in area could cause displacement (d) acceptable procedure 18. When assisting with a bone marrow aspiration, the nurse should a. drop additional sterile supplies onto a sterile tray. b. have all sterile packs unwrapped for the procedure in case they are needed. c. reach over the tray and remove contaminated supplies. d. place the bottle of sterile liquid on the sterile field so it does not splash. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (a) correctsterile articles should be dropped at a reasonable distance from the edge of the sterile area (b) sterile packs should be opened only as needed (c) never reach an unsterile arm over a sterile field (d) outside of a bottle containing sterile liquid is not considered to be sterile 19. The client has been receiving a blood transfusion for approximately 30 minutes. Which of these assessments, if made by the nurse, would indicate an allergic reaction? a. Hypotension. b. Chills. c. Respiratory wheezing. d. Lower back discomfort. Strategy: Think about each answer. (a) indicative of a hemolytic transfusion reaction (b) indicative of a hemolytic transfusion reaction (c) correctallergic reaction is characterized by wheezing, urticaria (hives), facial flushing, and epiglottal edema (d) indicative of a hemolytic transfusion reaction

f. g. h.