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Test # 61:

Alice has a two-month-old baby who just died of SIDS. Alice was crying loudly and saying, Its my fault, I should have given you more extra attention. The husband is out of town. 1. What is the best emotional support the nurse can provide to the mother? a. Reassure the and say, Its not your fault. b. Reassure the mother and say, It is okay to cry. c. Ask the mother if she wants to be alone. d. Take the mother to the quiet room. Three months after Alices baby died of SIDS, she is still in the grieving process. Which of the following nursing action is best for the patient? a. Refer the mother to the grieving support groups. b. Involve the mother to the community social activities. c. Encourage the mother to get involved and participate with mothers of the same problems. d. Refer the mother to the psychologist.

2.

Melissa is 5 years old with asthma. She was brought to the ER in respiratory distress, has cyanosis and with shortness of breath: 3. Which of the following action taken by the nurse is appropriate to a child with respiratory distress, cyanosis, and shortness of breath? a. Start O2. b. High-Fowlers position. c. Bronchodilator. d. Steroids. Following the ventolin nebulization, what will the nurse do next? a. Document findings. b. Auscultate the lungs. c. Record breathing pattern. d. Observe the child. Which of the following laboratory findings would you see in the patient with asthma? a. Decrease pO2, increase pCO2. b. Increase pO2, increase pCO2. c. Decrease pO2, decrease pCO2. d. Increase pO2, decrease pCO2.

4.

5.

6.

Which sequence should be followed when taking the childs vital signs? a. Temperature, pulse, respiration, weight. b. Pulse, temperature, weight, respiration. c. Weight, temperature, pulse, respiration. d. Respiration, pulse, temperature, weight. A nine-month-old baby died in the ER of shaken baby syndrome. What would be the expected autopsy report that confirms the diagnosis of shake baby syndrome? a. The child has cerebral hemorrhage. b. Brain has presence of blood clots and petechiae. c. Brain shifted or herniated. d. Undetected decrease level of consciousness.

7.

Mr. Fung, 53 years old, was diagnosed with abdominal aortic aneurysm (AAA). He had a 5.7 cm mass that was seen in the abdominal CT scan. The doctor scheduled him for surgery the next day. 8. The nurse carries out the appropriate abdominal assessment on a patient with AAA by which of the following? a. Inspection and gentle palpation of abdominal mass. b. The patient complains of back pain. c. The patient assumes a side lying position. d. The nurse inspects and auscultates the patient abdomen. Linda, 52 yr old was admitted with AAA. She has a history of peripheral vascular disease a year ago. She smokes one pack of cigarette per day but tried to stop smoking after she had a complaint of pain in the abdomen. Which of the following findings may indicate aortic abdominal aneurysm? a. Bulging neck veins. b. Pulsating abdominal mass. c. Bruit on auscultation over abdominal mass. d. Abdominal pain.

9.

10. A COPD patient verbalizes to the nurse I cant breath. What would be the best nursing action? a. Give 2 L/min O2 by nasal prong. b. Suction to the patient. c. Give O2 @ 6-10 L/min via venturi mask. d. Place the patient in high Fowlers position. 11. Jesse, 55 years old was admitted with COPD. He has shortness of breath. What is the most appropriate O2 therapy for the patient? a. Simple mask. b. Nasal prong. c. Venturi mask. d. Heated nebulizer. 12. Mr. Ho has COPD and needs O2 therapy at home. The patient is not familiar with the O2 administration technique. The initial step taken by the nurse would be a. What do you know about O2 therapy? b. Ask the patient to perform return demonstration in operating the O2 tank. c. Ask if he has somebody staying with him. d. Explain the importance of O2 therapy. 13. Mr. Ho is anxious about having O2 at home. Best way of helping the patient decrease his anxiety a. Let him hold the appliance first. b. Explain to the patient the need for O2. c. Reassure the patient that it will not cause any harm if he follows the guidelines. d. Reassure the patient that it will help him a lot. 14. Sergio, 62 years old, has COPD. As Nurse Sheila increases the patient O2 to 5 L/min via facemask, he complains of shortness of breath. O2sat decreases to 93%. What is the complication of high O2 level in COPD clients? a. Can cause respiratory distress. b. Can cause CO2 narcosis. c. Can cause retrolental fibroplasias. d. Can cause respiratory depression. Benjamin, 58 years old was admitted to the hospital for TURP. He is for discharge home after 3 days following surgery.

15. The nurse who is giving the discharge teaching to the patient will provide which of the following important information? a. Inform MD if dribbling of urine occurs b. Expect hematuria within 2-3 days following discharge. c. Dont hold your urine. d. Notify the physician for frequent urination. 16. Which of the following is an expected outcome few days after TURP? a. Dribbling urine. b. Constipation. c. Bright red urine. d. Flank pain. 17. A patient just came from recovery room, the nurse noted that the CBI drainage is bright red. What is the best nursing action? a. Continue to assess the CBI flow. b. Increase the IV flow rate. c. Refer to the doctor immediately. d. Increase the rate of the CBI. 18. A post TURP patient complains of urinary incontinence. Appropriate action taken by the nurse would be, have the patient performs a. keagels exercise. b. deep breathing and coughing exercise. c. valsalvas maneuver. d. yoga exercise. 19. A burn patient has autograft taken from the left arm and she is for discharge to home. Discharge teaching to the patient would include? a. ROM exercise. b. Covering with occlusive dressing. c. Keeping the site clean and dry. d. Wrapping the extremity with elastic bandage. 20. A burn patient was admitted in the emergency room. What is the first thing that the nurse will do? a. Initiate IV and give analgesic. b. Assess the percentage and give microbacterial cream. c. Do blood extraction. d. Do dressing on the burn areas. 21. A community health nurse is giving a lecture to a group of teenagers regarding smoking cessation program. Who is the best resource person to provide motivation to a group of teenagers to stop smoking and to provide an active role in the smoking cessation? a. Actor who is a role model. b. Former smoker sharing his past experience. c. Video showing the effects of smoking cessation program. d. Magazines and pamphlets about smoking. 22. A group of aboriginal students is attending the smoking cessation program conducted by the community health nurse. How will you assess the learning needs of the aboriginal students? a. Give them a quiz. b. Encourage them to ask questions. c. Provide a questionnaire survey forms. d. Form a small group and discuss the topic.

23. Charlie, 42 years old, a heavy smoker was admitted to the hospital with incarcerated ventral hernia. He was grossly obese, weighing 400 lbs. He had a ventral hernia repair and end-to-end anastomosis for small bowel obstruction. Charlie desire to stop smoking. What will be your best nursing response? a. Involve patient in smoking cessation group. b. Refer to the community social worker. c. Inform the family member. d. Acknowledge the decision-making. 24. A group of students who smoke approach the community health nurse that they want to quit smoking. What will you do as a nurse? a. Allow the smoking students to discuss on how to stop smoking. b. Refer to the smoking support group. c. Inform the principal of the school about the plan. d. Praise and acknowledge the students for a job well done. 25. A group of aboriginal people wanted to quit smoking. Who will be the reliable person to give pertinent and reliable information that will encourage the aboriginal people to quit smoking? a. Speak with elderly people. b. Aboriginal former smoker. c. Clergy. d. Family doctor. 26. A community health nurse is giving a lecture to a group of teenagers regarding smoking. Who is the best person to motivate the teens to quit smoking? a. Ex-smoker-peer to share about health reason for quitting. b. Student president of the school. c. Medical doctor. d. Parents. The following questions pertaining to AIDS: 27. As a nurse caring for Cielo in the medical floor, what is your best practice to follow in regards to the diagnosis of HIV? a. Universal precaution. b. Body substance precautions c. Reverse isolation. d. Handwashing technique. 28. A mother of HIV patient is very much worried about spreading of virus to the rest of the family members. She is looking for help to get some information on the prevention and to prevent contamination of the disease process. What is the best nursing action? a. Discuss with her the possible ways of spreading the virus. b. Provide pamphlets and reading materials about AIDS/HIV c. Inform her use of universal precaution in the home. d. Educate the mother regarding AIDS/HIV signs and symptoms. 29. Sheila becomes depressed upon knowing her diagnosis. She seems not to accept it for now and verbalizes to the nurse, I have nothing worth living for now. What is your best nursing response? a. There is so much good in life that you need to enjoy more. b. Tell me more of what you are feeling right now. c. You shouldnt be depressed about your diagnosis. d. We are here to help, dont be too frustrated about it.

30. Eddie, 42 years old, diagnosed with AIDS was admitted to the hospital with pneumonia. He has a temperature of 38.7C, productive cough with purulent sputum. What would be the best nursing action? a. Practice the universal precaution. b. Body substance precaution. c. Reverse isolation techniques. d. Wear mask for respiratory isolation only. 31. A long-term goal is being planned for Sheila, with the involvement of the health care team. She emphasized that in her own advantage and great wishes, she wants to be with her children at home when she dies. What is the best advice to give in terms of palliative treatment? a. send her to the nursing home b. make an arrangement to the hospice care c. home care d. allow the children to visit 32. When providing home care to a group of clients, which of the following would be required referral to the MD? a. A 65-year-old diabetic complaining of constipation. b. A 47 year old with an abdominal wound that is dry with yellow crusting. c. A 72 year old with Alzheimers disease complaining of disliking his home attendant. d. A 32 year old with a brain tumor complaining of vomiting upon waking in the morning. 33. Patient teaching for the client receiving FeSO4 (iron sulfate) for ironwould include: a. The medication should be taken at bedtime. b. The medication should be taken with milk or water. c. The medication should be taken with orange juice. d. The medication should be taken after meals. deficiency anemia

34. A patient calls the MD office and states she has a severe sore throat and headache. The nurse should give the following instructions: a. Make an appointment with the MD. b. You probably have strep throat, take a pain reliever and call back if you do not improve. c. I will have the MD call in a prescription to the pharmacy for antibiotics for you to start taking. d. Take only clear fluids and call back if you develop a fever. 35. A client who was involved in a motor vehicle accident was dead on arrival (DOA). The nurse can best show respect to the clients family by which of the following? a. Come with me, theres a room for you to stay. b. Did you want me to call your Pastor for his soul? c. Would you like me to inform the other members of your family? d. Have you arranged yet for his funeral. 36. When making an assignment as the charge nurse on a medical/surgical unit, which of the following staff members should be assigned to a 65 year old with COPD, oxygen saturation of 65%, respiratory rate of 32 and blood pH of 7.32 on IV antibiotics? a. The RN who has just passed the boards. b. The RPN with 15 years experience. c. The nursing assistant with 25 years experience. d. The charge nurse, and put the RPN in charge.

37. As the triage nurse in the ER which of the following patients should be seen first? a. A 17-year-old with psychogenic amnesia. b. An 18-year-old with bloody nose for 10 minutes. c. A 27-year-old with BP 70/30, HR 152, RR 40. d. A 49-year-old with deformity to the left knee. 38. An 8-year-old is scheduled for a spinal tap. Prior to the procedure he is kicking and yelling. What would be the most appropriate response by the nurse. We will take very good care of you, this will not hurt. a. I will let you talk with your parents. b. I will give you a lollipop afterwards. c. I will sit and read with you after the procedure. 39. While caring for a child sexual abuse is suspected. The nurse understands that sexual. Abuse is most often committed by: a. A neighbor. b. A teacher. c. A relative d. A babysitter. 40. Which of the following patients can be placed in a room together? a. A patient with ulcerative colitis and patient with colostomy. b. A patient with diarrhea and a patient with HIV. c. A patient 1 day S/P cholecystectomy and a patient and a patient receiving and a patient chemotherapy. d. A patient with R/O tuberculosis and a patient newly diagnosed with tuberculosis. 41. A nurse assigned to the pediatric unit has the following patients. Which one should be given priority? a. A 2-month-old with a sunken anterior fontanel. b. A 4-month-old with altered consciousness c. A 6-month-old crying inconsolably. d. A 7-month-old who cannot hold his own bottle. 42. A first year nursing student is caring for a child with Non Organic Failure to Thrive. She asks the nurse to explain the most common cause of this problem. The nurse should respond by saying: a. It is malabsorption syndrome. b. It is due to a parents limited knowledge of infant nutrition. c. It is disruption in the parent-infant attachment d. It is usually secondary to a chronic physical illness 43. What is the most important nursing goal when caring for a child with croup? a. Administering antibiotics b. Keeping the child in the mist tent continuously c. Preventing airway obstruction d. Assessing for hypoxia 44. When caring for a child in a mist tent, the priority intervention would be to: a. Wipe the inside of tent as it gets moist b. Change the childs wet clothing and bedding c. Vent the tent each shift to let out the extra moist d. Remove all objects from the tent to prevent interference with function.

45. While caring for a child with Cystic Fibrosis the nurse is preparing a discharge plan. When discussing bronchial drainage the nurse should instruct the parents to perform the treatment. a. Immediately before aerosol treatment b. Immediately upon rising and at bedtime c. Thirty minutes after meals d. Shortly after rising, I hour before meals and at bedtime 46. Megan asked the nurse regarding nutrition as she plans to have breastfeeding. What is your best response? a. Increase fluid intake 6-8 glasses /day. b. You should follow balanced diet. c. Increase calorie to 500 kcal/day. d. Regular meals with caffeine at all times. 47. Nena, a teenage girl came to see a school nurse and asked if she can have a pregnancy test. She had sex with her boyfriend. Which of the following initial response made by the nurse is appropriate? a. Do the pregnancy test. b. Ask about her last menstrual period and intercourse. c. Perform a strip test. d. Teach her about safe sex. 48. Gina is in active labor. The nurse checked the fetal heart sound and is slow. What is the best nursing action? a. Left lateral position. b. Right lateral position. c. Knee chest position. d. Supine position. 49. George, 67 years old, is admitted with left femoral bypass graft. He is a smoker and quitted smoking a year ago. He drinks one beer per day. He lives with his wife and had 2 married children. Postoperatively, the nurse checked the electrolytes, CBC and the serum K is 3.1, Na 132, hemoglobin 110. The doctor ordered IV KCl 20 mmol in 1 liter of Normal saline to run @ 75 cc/hr, the stock of KCl is 20 mmol/10 ml. The nurse just took 500 ml of normal saline as theres no available 1 liter N/S in the unit at present. How much will you incorporate in the IV fluids? a. 5 ml b. 10 ml c. 2.5 ml d. 7.5 ml 50. The doctor ordered IV KCl 5 mmol in NS 500 ml @ 75 cc/hr. The available stock is 20 mmol/10 ml. How much are you going to incorporate in the IV fluids? a. 5 ml b. 10 ml c. 2.5 ml d. 7.5 ml 51. The doctor ordered 40 mmoL of IV KCl in 1 L of Normal saline to run @ 100 cc/hr. The stock is 20 mmoL/10 ml. How much are you going to incorporate in the IV? a. 5 ml b. 10 ml c. 15 ml d. 20 ml

52. Lulu, 57 years old has a AAA repair. On the 3rd day post op, she had a myocardial infarction. The doctor ordered Heparin infusion as per protocol. According to the heparin protocol, give 5,000 units IV then start Heparin drip @ 1000 units/hr. Take PT/PTT every six hours and adjust heparin according to PTT results. At 2400 hours, the PTT is 35 and the nurse increases the heparin to 1300 units/hour = 13 cc/hr. as per heparin protocol, the heparin infusion should be increased to 200 units and the nurse should make it 1200 unit/hr. What is the best nursing action? a. Notify the doctor. b. Inform the charge nurse. c. Tell the primary nurse to adjust according to protocol d. Write an incident report. 53. A new nurse is assigned to the patient for BT. She is supervised by her senior nurse in starting the BT. What is the first thing that she will do when theres an order for BT? a. Flush the blood set with NS. b. Piggy back the blood in the present IVF. c. Use D5W in flushing the blood-line. d. Hook the blood without flushing the line. 54. The BT is almost finished. As a new nurse, what is the best nursing responsibility as soon finished? a. Flush the line with NS. b. Hook the previous IV fluids. c. Document in the chart. 55. A newly-hired nurse in the community got a call from the remote area saying 2 men are fighting and needs a first aid. As a new nurse, how will you deal with this case? a. Carry first aid kit. b. Identify the location. c. Call the ambulance. d. Ensure that it is safe for the nurse to go to the scene. 56. A community nurse visited the patient. She is old and living alone. She has no energy for anything but she doesnt want to bother anybody. What is the best nursing action of the nurse? a. Arrange for homemaker for help. b. Refer to community nurse. c. Refer to the social worker. d. Ask the help to the neighbor. 57. An elderly client came to the community clinic saying her daughter-in-law twisted her hand. You want to connect her to helping resources in the community. Before connecting her to the good resources, what is your best nursing action? a. Obtain patients consent. b. Inform the family about the plan. c. Call the daughter-in law to confirm the incident. d. Inform the social worker. 58. A nurse is having a problem in the unit among her colleagues regarding the workload. The nurse had informed the supervisor. What will the supervisor do? a. Ask the nurse to write in paper about her suggestions and submit to her. b. Call each nurse personally and inquire their problem. c. Call for a staff meeting immediately. d. Do nothing as it is a usual problem. 59. A patient with HTN came to the clinic with history of bleeding from the nose. Patient claimed he had bleeding twice, first lasted for 10 minutes and controlled with cold compress. No more bleeding for now. How will the nurse as the BT is

document this accurately? a. Patient claimed had epistaxis 2x, first lasted for 20 minutes with bleeding from L nostril, 2nd time for 10 minutes , now asymptomatic. b. Came with hx of epistaxis 2x, controlled with cold compress, asymptomatic now. c. Patient claimed with hx of epistaxis, had bleeding 2x, 1st bleeding last for 10 minutes, controlled with cold compress, asymptomatic now. d. Hypertensive patient with hx of epistaxis, nose bleeding 2x, first lasted for 10 minutes, controlled with cold compress, now asymptomatic. 60. Mr. & Mrs. Lee, a Chinese couple came for admission in downtown hospital. They came to Canada as landed immigrants 5 years ago. They could hardly speak and understand English. The husband doesnt want to look at the nurse and not too receptive in the nursing care given to him. How would the nurse view the care of clients with different cultures? a. Culture should be preserved in a society. b. Each culture has a different view in health care approach. c. It is difficult to adapt to the new culture here in Canada. d. They should learn to adapt to the Canadian health care system. 61. Diego, 92 years old died of pneumonia. The relatives came and view the body. How will you provide respect to the family? a. Arrange a pastor for them. b. Tell them theres a private room ready for them. c. Tell them to collect the clients clothing. d. Ask them if they need help with anything. 62. Roger, 35 years old, had bronchoscopy done. What is the preoperative teaching of the nurse? a. The procedure will take 4 hours. b. You will only get ice chips after the procedure. c. You can eat only after the gag reflex comes back. d. You can drive a car home. 63. The doctor is doing a rectal examination of the patient to check for prostate tumor. He needs to lie in L Sims position. What should the nurse instruct the client? a. L leg extended and R leg flexed, hand on backside of the body. b. L leg extended and R leg extended. c. L leg extended, R leg flexed and hand in front of the body. d. Fetal position. 64. A child with cystic fibrosis. What is the characteristic finding that you will recognize in the child? a. Steatorrhea b. Yellowish pastry stools c. Bloody stools d. Foul smelling stools. 65. Betty, 6-yr-old has cystic fibrosis, The doctor ordered pancreatic enzymes. When are you going to administer the pancreatic enzymes? a. With meals b. Before meals c. After meals d. Every night 66. Janice, 5 years old, was admitted to the ER with flare ups for cystic fibrosis. The child becomes dyspneic, with shortness of breath. What is your first nursing intervention? a. Give 2-3 L/min O2 by nasal prong. b. Give her nebulization.

c. d.

Perform postural drainage. Call the MD.

67. Christine, 4 year old was diagnosed with cystic fibrosis , is admitted into the pediatric ward. What is your best nursing action when giving chest physiotherapy? a. 30 to 60 minutes before meals. b. Before giving O2. c. When patient shows signs of respiratory disorder. d. After meals. 68. Which of the following is a good source of information that you will refer the mother of the child with cystic fibrosis? a. Manuals b. Cystic fibrosis society. c. Physician d. Cystic fibrosis patient 69. Diego, 44 years old, was admitted with ulcerative colitis . The nurse taking care of Diego, will assess the patient for which of the following manifestation? a. Fever, abdominal pain, bloody diarrhea. b. Weight loss, currant jelly stools, fever. c. Constipation, abdominal pain, n/v d. Fever, rebound tenderness on abdomen, vomiting. 70. A patient diagnosed with ulcerative colitis. Which of the following clinical manifestations that the nurse will be most concerned? a. Diarrhea 15x a day. b. Currant jelly stools c. Nausea & vomiting d. Weight loss. 71. Lucy, 33 years old, was diagnosed with ulcerative colitis. What diet will you encourage to the patient? a. High CHON, high calorie, low roughage, vitamins and minerals. b. Low CHON, low calorie, high fats, vitamins. c. High roughage, vitamin ADEK, high CHON. d. High CHON, high fats, high roughage. 72. Lucy is diagnosed with ulcerative colitis. The dietitian came to see her and advised a low residue diet. What is the purpose of low residue diet? a. To promote healing. b. To reduce gastric motility. c. To reduce irritation of the colon. d. To increase bulk in the stools. 73. Jeffery, 42 years old, has been discharged from the hospital but readmitted in 2 days because of abdominal pain. He said, he had eaten fatty foods and had an alcohol drink. He is concerned about the abdominal pain and wants to know if it is due to the fatty foods and alcohol. What is your best nursing response? a. The reason for your pain is fatty foods and alcohol. b. The reason for your pain is fatty foods then alcohol. c. Theres no correlation between fatty foods and alcohol in your pain. d. Theres another reason for your pain, lets find it out. 74. George has pancreatitis and pain. What is the best position of patient that will help alleviate the pain? a. Side-lying position. b. Semi-Fowlers position.

c. d.

Side lying with knees bent. Supine position

75. A patient has pancreatitis. Which statement needs further assessment? a. Start IV fluids. b. NPO c. Give IV morphine 10 mgs. d. Proper positioning. 76. Nancy, 76 years old, has osteoporosis. She has been seen by the nurse lying in the floor near the side of the bed with her legs internally rotated and pain on the hip. What should you do? a. Call the physician. b. Place a blanket on her, instruct not to move and call the physician. c. Reposition the leg. d. Put her back to the bed. 77. Oscar had right hip surgery done. He is a smoker and drink alcohol 3 cans/day. On the second day post-op he was so aggressive and not responding to any question. What will the nurse do? a. Leave her alone. b. Give him a call bell and tell him if you need call me later. c. Stay with the patient. d. Ask the patient whats wrong with her. 78. The nurse heard a screaming sound and knocking on the wall from an aggressive patients room. What is the best nursing action? a. Come to the room and ask whats going on. b. Tell the patient to calm down. c. Nurse goes inside the room and call security for help. d. Call security and go to the room when security leaves. 79. Henry, 58 year old fell from his house and was admitted to the hospital with R hip fracture. Moores arthroplasty of the R hip was done. As a nurse taking care of the patient, how will you reposition the patient so he wont develop pressure sores? a. R side with abductor pillow in between legs. b. L side with abductor pillow in between legs. c. Log roll to the side without abductor pillow. d. High fowlers position with abductor pillow in between legs. 80. Diana, 65 years old, with diabetes mellitus and has a wound on her big toes. What is the best heath teaching of the nurse to the patient as she gets ready for discharge home? a. Call diabetic clinic and make an appointment b. Send her to a special nurse on foot care. c. Call for home care nurse. 81. Mr. Wong, a patient with diabetes mellitus is already discharged but the wife doesnt understand the health teachings. What is the best nursing action? a. Discuss with the wife and husband about it. b. Ask the wife first what she wants to know. c. Discuss the whole disease process. d. Advise her to see the MD for advice. 82. Aisha, 64 years old, was having CHF. Which of the following patients assessment indicates that the patient has CHF? a. Edema b. Bulging JVP

c. d.

Decreased urine output Tachycardia

83. Kelly, 62 years old, has angina. Her medication includes Metoprolol 25 mg tablet twice a day. Which of the following is an expected effect of beta-blocker? a. Reduces myocardial oxygen use. b. Increase myocardial contractility. c. Increase blood pressure. d. Increase heart rate. 84. The doctor ordered cardiac evolution test for Kelly. This test is a. Cardiac catheterization b. Angioplasty c. Echocardiogram d. 12 Lead ECG 85. Sheila is scheduled for echocardiography. Which of the following best describe this procedure? a. Non-invasive procedure, which gives information about heart valves and arteries. b. Invasive procedure, which causes dilation of the coronary arteries. c. It records the electrical activity of the heart. d. Invasive procedure to monitor coronary circulation.