Board Exam Compilation Book 1 With Rationale

7/26/2019 Board Exam Compilation Book 1 With Rationale

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NURSING PRACTICE I

1. A nurse calls the physician of a client scheduled for a cardiac catheterization because the client has

numerous questions regarding the procedure and has requested to speak to the physician. The physician

is very upset and arrives at the unit to visit the client after prompting by the nurse. The nurse is outside of

the clients room and hears the physician tell the client in a derogatory manner that the nurse doesnt

know anything. hich legal tort has the physician violates!

a. "ibel

b. #lander

c. Assault

d. $egligence

Answer: B

%efamation takes place when something untrue is said &slander' or written &libel' about a person(

resulting in in)ury to that persons good name and reputation. An assault occurs when a person puts

another person in fear of a harmful or an offensive contact. $egligence involves the actions ofprofessionals that fall below the standard of care for a specific professional group.

#ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2nd edition( page 32.

2. A nurse is assessing a client who has )ust been measured and fitted for crutches. The nurse

determines that the clients crutches are fitted correctly if*

a. The elbow is at a 45 degrees angle when the hand is on the handgrip

b. The elbow is straight when the hand is on the handgrip

c. The clients a6illa is resting on the crutches pad during ambulation

d. The top of the crutch is even with the a6illa

Answer: A

7or optional upper e6tremity leverage( the elbow should be at appro6imately 45 degrees of fle6ion when

the hand is resting on the handgrip. The top of the crutch need to be two to three fingerwidths lower than

the a6illa. hen crutch walking( all weight needs to be on the hands to prevent nerve palsy from pressure

on the a6illa.


4. The first attempt to elevate nursing as a profession by enriching and broadening the preparation of

nurses and by educating them in 9niversity setting is an idea conceived by*

a. -osario %elgado

b. :ulita ;. #ote)o

c. 7lorence $ightingale

d. 7aye Abdellah

Answer: B

:ulita ;. #ote)o is a nurse and lawyer who became the first dean of the 9niversity of the . A nurse is instructing a client how to safely use crutches for ambulating at home. hich measure

would the nurse recommend to minimize the risk of falls while ambulating with the crutches!

a. 9se grab bars in the bathtub or shower

b. -emove scatter rugs in the home

c. ?eep all pets out of the house

d. 9se softsoled slippers when walking with the crutches

Answer: B

To reduce the risk of falls( all obstacles should be removed from the home. $ot all pets are trip hazards

&fish( birds( guinea pigs'. @rab bars in the bathtub or shower will not necessarily assist the client while

walking with crutches. #hoes with nonslip soles should be worn.


. A client is being discharged and will receive o6ygen therapy at home. The nurse is teaching the client

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and family about o6ygen safety measures. hich of the following statements by the client indicates the

need for further teaching!

a. BC realize that C should check the o6ygen level of the portable tank on a consistent basis.

b. BC will keep my scented candles within feet of my o6ygen tank.

c. BC will not sit in front of my woodburning fireplace with my o6ygen on.

d. BC will call the physician if C e6perience any shortness of breath.

Answer: B

D6ygen is a highly combustible gas( although it will not spontaneously burn or cause an e6plosion. Ct can

easily cause fire to ignite in a clients room if it contacts a spark from a cigarette( burning candle or

electrical equipment. Dptions A( ( and % are appropriate o6ygen safety measures.


3. The four main concepts common to nursing that appear in each of the current conceptual models are*

a.


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a. -ecaps the needle

b. -emoves the gloves

c. ashes the hands

d. .

11. A client who is scheduled for gallbladder surgery is mentally impaired and is unable to communicate.

Cn regard to obtaining permission for the surgical procedure( which nursing intervention would be most

appropriate!

a. /nsure that the family has signed the informed consent

b. /nsure that the client has signed the informed consent

c. Cnform the family about the advance directive process

d. Cnform the family about the process of a living will

Answer* A

A client must be alert( able to communicate( and competent to sign the informed consent. Cf the client is

unable to( then the family can sign the consent. A living will lists the medical treatment a person chooses

to omit or refuse if the person becomes unable to make decisions and is terminally ill. Advanced

directives are forms of communication in which persons can give direction on how they would like to be

treated when they cannot speak for themselves.

#ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2nd edition( page G2.

12. A client diagnosed with tuberculosis &TI' is scheduled to go to the radiology department for a chest

6ray

evaluation. hich nursing intervention would be appropriate when preparing to transport the client!

a. Apply a mask to the client

b. Apply a mask and gown to the client

c. Apply a mask( gown( and gloves to the client

d. $otify the 6ray department that the personnel can be sure to wear a mask when the client arrives.

Answer* A

lients known or suspected of having TI should wear a mask when out of the room to prevent the spread

of the infection to others. A gown or gloves are not necessary.

#ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2nd edition( page G2.

14. A nurse is observing a client using a walker. The nurse determines that the client is using the walker

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correctly if the client*

a. hour specimen!a. Fave the client void at the start time( and place this specimen in the container.

b. %iscard the first voidingH save all subsequent voiding during the 2>hour time period.

c. 38.

pg. 4


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18. A nurse has an order to obtain a urinalysis from a client with an indwelling urinary catheter. The nurse

avoids which of the following( which could contaminate the specimen!

a. Dbtaining the specimen from the urinary drainage bag

b. lamping the tubing of the drainage bag

c. Aspirating a sample from the port on the drainage bag

d. iping the port with an alcohol swab before inserting the syringe

Answer* A

A urine specimen is not taken from the urinary drainage bag. 9rine undergoes chemical changes while

sitting in the bag and does not necessarily reflect the current client status. Cn addition( it may become

contaminated with bacteria from opening the system.

#ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2nd edition( page G3

1=. A nursing assistant is caring for an elderly client with cystitis who has an indwelling urinary catheter.

The registered nurse provides directions regarding care and ensures that the nursing assistant*

a. 9ses soap and water to cleanse the perineal areab. ?eeps the drainage bag above the level of the bladder

c. "oops the tubing under the clients leg

d. "ets the drainage tubing rest under the leg

Answer* A

43

pg. 5


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21. hich of the following signs and symptoms would the nurse e6pect to find when assessing an Asian

patient for postoperative pain following abdominal surgery!

a. %ecreased blood pressure and heart rate and shallow respirations

b. +uiet crying

c. Cmmobility( diaphoresis( and avoidance of deep breathing or coughing

d. hanging position q 2 hours

A$#/-*

An Asian patient is likely to hide his pain. onsequently the nurse must observe for ob)ective signs. Cn

an abdominal surgery patient( these might include immobility( diaphoresis and avoidance of deep

breathing or coughing( as well as increased heart rate( shallow respirations &stemming from pain upon

moving the diaphragm and respiratory muscles'( and guarding or rigidity of the abdominal wall. #uch a

patient is unlikely to display emotion such as crying.

#ource* $urse Test* a review series( 7undamentals of $ursing.


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state. The physician tells the nurse that the request was made by the clients spouse and children. The

nurse understands the legal basis for carrying out the order and first checks the clients record for

documentation of*

a. A court approval to discontinue the treatment.

b. A written order by the physician to remove the tube.

c. Authorization by the family to discontinue the treatment.

d. Approval by the institutional /thics ommittee.

A$#/-*

The family or a legal guardian can make treatment decisions for the client who is unable to do so. Dnce

the decision is made( the physician writes the order. @enerally( the family makes decisions in

collaboration with the physicians( other health care workers( and other trusted advisors.

#ource* G2

28. A client is admitted to the hospital for a bowel resection following a diagnosis of a bowel tumor.

%uring the admission assessment( the client tells the nurse that a living will was prepared three years

ago. The client asks the nurse if this document is still effective. The most appropriate nursing response is

which of the following!

a. BJes it is.

b. BJou will have to ask your lawyer.

c. BCt should be reviewed yearly with your physician.

d. BC have no idea.

Answer*

The client should discuss the living will with the physician and it should be reviewed annually to ensure

that it contains the clients present wishes and desires. Dption A is incorrect. Dption % is not at all helpful

to the client and is in fact a communication block. Although a lawyer would need to be consulted if the

living will needed to be changed( the most appropriate and accurate nursing response would be to inform

the client that the living will should be reviewed annually.


2=. A nurses note that a postoperative client has not been obtaining relief of pain with prescribed

narcotics( but only while a particular licensed practical nurse &"


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#tate and federal labor and narcotic regulations( as well as institutional policies and procedures( must be

followed. Ct is therefore most appropriate that the nurse discuss the situation with the nursing supervisor

before taking further action. The client does not need an increase in narcotics. To avoid assigning the

"


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mechanism in maintaining blood volume and conserving water. #upplemental potassium usually is given

to a patient with a low serum potassium level or one who is receiving a diuretic or other medication &such

as digo6in' that has a mild diuretic effect. A low sodium diet is usually prescribed for a patient with a high

serum sodium level( as in F7( F


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of 5.12 mg. hich nursing action is most appropriate!

a. Administer the additional 5.12 mg

b. Tell the client that the dose administered was not the total amount and administer the additional dose

c. Tell the client that too much medication was administered and an error was made

d. omplete an incident report

Answer* %

Cn accord with the agencys policy( nurses are required to file incident reports when a situation arises that

could or did cause client harm. The nurse also contacts the physician. Cf a dose of 5.12 mg was

prescribed( and a dose of 5.2 mg was administered( then the client received too much medication.

Additional medication is not required and in fact should be detrimental. The client should be informed

when an error has occurred( but in a professional manner so as to cause great fear and concern. Cn many

situations( the physician will discuss this with the client.


4=. A registered nurse &-$' is orienting a nursing assistant to the clinical nursing unit. The -$ wouldintervene if the nursing assistant did which of the following during a routine handwashing procedure!

a. ?ept hands lower than elbows

b. 9sed 4 to ml of soap from the dispenser

c. ashed continuously for 15 to 1 seconds

d. %ried from forearm down to fingers

Answer* %

degrees

d' -ight sidelying with the head of the bed elevated > degrees

Answer* A

7or administration of an enema( the client is placed in a leftlateral #ims positions so that the enema

solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the

#ims position.

pg. 10


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#ource* >. hich assessment is most important for the nurse to make before advancing a client from liquid to

solid!

a. 7ood preferences.

b. Appetite.

c.


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b. 8. A client tells the home health care nurse of the decision to refuse e6ternal cardiac massage. hich of

the following is the most appropriate initial nursing actions!

a. $otify the physician of the clients request

b. %ocument the clients request in the home health nursing care plan

c. onduct a client conference with the home health care staff to share the clients request

d. %iscuss the clients request with the family

Answer* A

/6ternal cardiac massage is one type of treatment that a client can refuse. The most appropriate nursing

action is to notify a physician because a written B %o not resuscitate B &%$-' order from the physician

must be present. The %$- order must be renewed on a regular basis per agency policy.

#ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2nd edition( page 14>.

>=. A nurse manager employs a leadership style in which decisions regarding the management of the

nursing unit are made without input from the staff. Type of leadership style that is implemented by this

nurse manager is*

a. Autocratic

b. #ituational

c. %emocratic

d. "aissezfaire

Answer* A

The autocratic style of leadership is task oriented and directive. The leader uses his or her power and

position in an authoritarian manner to set and implement organizational goals. %ecisions are made

without inputs from the staff. %emocratic styles best empower staff toward e6cellence because this style

of leadership allows nurses an opportunity to grow professionally. #ituational leadership style utilizes a

style depending on the situation and events. "aissezfaire allows staff to work without assistance(

direction( or supervision.

#ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2nd edition ( page 148.

>G. A registered nurse &-$' in charge is preparing the assignments for the day. The -$ assigns a

pg. 12


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nursing assistant to make beds and bathe one of the clients on the unit and assigns another nursing

assistant to fill the water pitchers and to serve )uice to all the clients. Another -$ is assigned to

administer all medications. Iased on the assignments designed by the -$ in charge( which type of

nursing care is being implemented!

a. 7unctional nursing

b. team nursing

c. /6emplary model of nursing

d. 5 in both eyes(

this means*

a. The patient can see twice as well as normal

b. The patient has double vision

c. The patient has less than normal vision

d. the patient has normal vision

Answer* .

$ormal vision is 25L25. A finding of 25L>5 would mean that a patient has les than normal vision.

#ource* 7undamentals of $ursing by Taylor( "illis and "emone( th /d.( p.315

1. The nurse in a well baby clinic is providing safety instructions to a mother of a 1monthold infant.

hich of the following safety instructions is most appropriate at this age!

a. over electrical outlets

b. -emove hazardous ob)ects from low places

c. "ock all poisons

d. $ever shake the infants head.

Answer* %.

The ageappropriate instruction that is most important is to instruct the mother not to shake or vigorously

)iggle the babys head. Dptions A(. I , are most important instructions to provide to the mother as the

child reaches the age of 3 months and begins to e6plore the environment.

#ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2nd edition( page 1>>

2. A nurse is receiving a client in transfer from the post anesthesia care unit following an abovetheknee

amputation. The nurse should take which of the following most important actions when positioning

the client at this time!

a. hours( the stump is placed flat on the bed to prevent hip contracture. /dema is also

controlled by stump wrapping techniques.

pg. 13


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#ource* #aunders +,A -eview for $"/0-$ by "inda Anne #ilvestri( 2nd edition( page 14G

4. A nurse manager is planning to implement a change in the method of the documentation system in

the nursing unit. Eany problems have occurred as a result of the present documentation system and the

nurse manager determines that a change is required. The initial step in the process of change for the

nurse manager is which of the following!

a. 5

>. A nurse has received the client assignment for the day and is organizing the required tasks. hich of

the following will not be a component of the plan for time management!

a.


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8. a patient has intravenous fluids infusing in the right arm. hen taking a blood pressure on this

patient( the nurse would*

a. Take the blood pressure in the right arm.

b. Take the blood pressure in the left arm.

c. 9se the smallest possible cuff

d. report inability to take the blood pressure

Answer* I.

The blood pressure should be taken in the arm opposite the one with the infusion. Ilood pressure should

not be taken in the arm with an C; infusion because the pressure of inflating the cuff may allow the artery

to clot.

#ource* 7undamentals of $ursing by Taylor( "illis and "emone( th /d.( p.=

=. A client is 2 days post operative. The vital signs are* I< 125L85( F- 115( -- 23( and

Temperature 155.> degrees 7ahrenheit &4= degrees elsius'. The client suddenly becomes profoundlyshort of breath( skin color is gray. hich assessment would have alerted the nurse first to the clientMs

change in condition!

a. Feart rate

b. -espiratory rate

c. Ilood pressure

d. Temperature

Answer I*

Tachypnea is one of the first clues that the client is not o6ygenating appropriately. The compensatory

mechanism for decreased o6ygenation is increased respiratory rate.

"ewis( #.E.( Feitkemper( E.E.( , %irksen( #. -. &255>'. Eedical#urgical $ursing* Assessment ,

management of clinical problems. #t. "ouis* Eosby.

G. onstipation is one of the most frequent complaints of elders. hen assessing this problem( which

action should be the nurseMs priority!

a. Add a thickening agent to the fluids

b. Dbtain a health and dietary history

c. -efer to a provider for a physical e6amination

d. Eeasure height and weight

Answer* I

Cnitially( the nurse should obtain information about the chronicity of and details about constipation( recent

changes in bowel habits( physical and emotional health( edications( activity pattern( and food and fluid

history. This information may suggest causes as well as an appropriate( safe treatment plan.

#ource* /delman( .". and Eandle( .E.&2552'. Fealth promotion throughout the lifespan.

35. hile caring for a client( the nurse notes a pulsating mass in the clientMs periumbilical area. hich of

the following assessments is appropriate for the nurse to perform!

a. Eeasure the length of the mass

b. Auscultate the mass

c.


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31. A client being treated for hypertension returns to the community clinic for follow up. The client says( NC

know these pills are important( but C )ust canMt take these water pills anymore. C drive a truck for a living(

and C canMt be stopping every 25 minutes to go to the bathroom.N hich of these is the best nursing

diagnosis!

a. $oncompliance related to medication side effects

b. ?nowledge deficit related to misunderstanding of disease state

c. %efensive coping related to chronic illness

d. Altered health maintenance related to occupation

Answer* A

The client kept his appointment( and stated he knew the pills were important. Fe is unable to comply with

the regimen from side effects( not a lack of knowledge about the disease process.

#ource* ?ey( :.". and Fayes( /.-. &2554'. th edition'.

'. Eedical surgical nursing. &15th edition'. . A client has altered renal function and is being treated at home. The nurse recognizes that the most

accurate indicator of fluid balance during the weekly visits is

a. difference in the intake and output

b. changes in the mucous membranes

c. skin turgor

d. weekly weight

Answer* %

The most accurate indicator of fluid balance in an acutely ill individual is the daily weight. A onekilogram

or 2.2 pounds of weight gain is equal to appro6imately 1(555 mls of retained fluid. Dther options are

considered as part of data collection( but they are not the most accurate indicator for Ofluid balance.

#ource* Altman( @. &255>'. %elmars 7undamental and Advanced $ursing #kills( 2nd ed. Albany( $J*

%elmar.

3. Dne of the ethical obligations of nursing is accountability. Accountability means that the staff nurse is

responsible for*

pg. 16


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a. The behavior of clients who are noncompliant

b. The consequences of his or her actions( even mistakes in )udgment

c. The behavior of other staff members who are negligent in their nursing care

d. The consequences of an administrative decision to decrease nursing staff

Answer* I

Accountability means responsibility for nursing actions and the consequences of those actions( even if an

honest mistake in )udgment is made.

#ource* Tutor %aviss $"/0-$ #uccess( 2nd edition

33. An -$ has been assigned for si6 clients for the 12hour shift. The -$ is responsible for every aspect

of planning( giving( and evaluating their care during the shift. hen leaving at 8*55 am( the nurse will

pass this same responsibility to the incoming nurse. This illustrates nursing care delivered via the*

a. ase method

b. 7unctional method

c. Team methodd.


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85. To monitor a clients fluid volume more closely( a central venous pressure &;


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Cn selecting the correct needle to administer an CE in)ection to a preschool child( the nurse should always

ook at the child and use )udgment in evaluating muscle mass and amount of subcutaneous fat. Cn this

case( in the absence of further data( the nurse would be most correct in selecting a needle gauge and

length appropriate for the Baverage preschool child. A medium gauge needle 21@ that is 1 inch long

would be asppropriate.

#ource* Tutor K %avis $"/0 -$( #uccess( 2nd /dition

8. Er. ". is homeless and has gangrene on his foot. The physician has recommended hospitalization

and

surgery. Er. ". has refused. The nurse knows which of the following is true! The client

a. annot be hospitalized against his will.

b. an be restrained if one physician declares him incompetent

c. annot choose which treatment to refuse.

d. Eay sign against medical advice &AEA'.

Answer* %.Against Eedical Advice( or AEA is a term used with a patient who checks him or herself out of a hospital

against the advice of his or her doctor. hile it may not be medically wise for the person to leave early( in

most cases the wishes of the patient are considered first. The patient is usually asked to sign a form

stating that he or she is aware that he or she is leaving the facility against medical advice( and the AEA

term is used on reports concerning the patient. This is for legal reasons in case there are complications to

limit liability on the part of the medical facility.

Cn a mental hospital setting( a patient is typically allowed to check out of the hospital by giving at least a

dayMs notice &though in some )urisdictions the time may vary depending on whether the patient is under

NinformalN or NformalN voluntary commitment'. This is so that if the doctor feels that the patient would be a

danger to self or others( the doctor has time to begin commitment proceedings against the patient to

compel the patient to remain in the hospital for treatment.

#ource* http*LLen.wikipedia.orgLwikiLAgainstQmedicalQadvice

83. Es. -. has been medicated for her surgery. The operating room &D-' nurse( when

going through the clientMs chart( realizes that the consent form has not been signed.

hich of the following is the best action

for the nurse to take!

a. Tell the physician that the consent form is not signed.

b. Assume it is emergency surgery and the consent is implied.

c. @et the consent form and have the client sign it.

d. Fave a family member sign the consent form.

Answer* A.

Cnformed consent is an agreement by a client to accept a course of treatment or a

procedure after complete information( including the risks of treatment and facts relating to it( has been

provided by the physician. Ct is therefore( the e6change between a client and a physician. Dbtaining

informed consent for specific medical and surgical treatments is the responsibility of the physician. Dften(

the nurses responsibility is too witness the giving of informed consent. This involves the ff*

1. itnessing the e6change between the client and the physician

2. /stablishing that the client really did understand

4. itnessing the clients signature

#ource* 7undamentals of $ursing by ?ozier( /rb( Ilais and ilkinson( th /d.( pp.22=

22G

88. Er. T. is a client on your medicalsurgical unit. Fis cousin is a physician and wants to see the chart.

hich of the following is the best response for the nurse to take!

a. Tell the cousin that the request cannot be granted.

b. Fand the cousin the clientMs chart to review.

c. all the attending physician and have the doctor speak with the cousin.

pg. 19


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d. Ask Er. T. to sign an authorization( and have someone review the chart with the cousin.

Answer* %.

-ationale*

The clients record is protected legally as a private record of the clients care. Thus( access to the record

is restricted to health professionals involved in giving care to the client. Cnsurance companies( for

e6ample( have no legal right to demand access to medical records( eventhough they may be determining

compensation to the client. Fowever a client who is making acclaim for compensation may ask to have

the medical history used as evidence. Cn this instance( the client must sign an authorization for review(

copying or release of information form the record. This form clearly indicates what information is to be

released and to whom. Cn no instance may a nurse allow access to the clients record by significant others

or any person other than a caregiver.

#ource* 7undamentals of $ursing by ?ozier( /rb( Ilais and ilkinson( th /d.( p. 183

8=. Es. ". is admitted to the floor. #he is in the terminal stages of AC%#. %uring

the admission assessment( the nurse would ask her if she had which of the following e6cept!a. An organ donation card.

b. Fealthcare pro6y.

c. "iving will

d. %urable power of attorney for health care

Answer * A

-ationale*

An advanced medical directive is a statement the client makes prior to receiving heath

care( specifyingthe clients wishes regarding heath care decisions. There are three types of advance

medical directives(the living will( the health care pro6y and the %urable power of attorney for health care.

The living will states what medical treatment the client chooses to omit or refuse in the event that the

client is unable to make those

decisions and is terminally ill. ith a health care pro6y( the client appoints a pro6y(

usually a relative or a trusted friend( to make medical decisions on the clients behalf(

in the event that the client is unable to do so. A durable power of attorney is a

notarized statement appointing someone else to manage health care treatment decisions when the client

is unable to do so.

#ource* 7undamentals of $ursing by ?ozier( /rb( Ilais and ilkinson( th /d.( p. 245

8G. The nurse enters a room and finds a fire. hich is the best initial action!

a. Activate the fire alarm or call the operator( depending on the institutionMs system.

b. @et a fire e6tinguisher and put out the fire.

c. /vacuate any people in the room( beginning with the most ambulatory and ending

with the least mobile.

d. lose all the windows and doors( and turn off any o6ygen or electrical appliances.

Answer * .

-ationale*

9pon the detection of smoke andLor fire( follow the -A/ plan described below.

-escue -escueL-emove person&s' from the immediate fire sceneLroom.

Alert Alert personnel by activating the nearest fire alarm pull station then call the

ontrol enter to report the e6act location of the fire.

onfine onfine fire and smoke by closing all doors in the area.

/6tinguish /6tinguish a small fire by using a portable fire e6tinguisher or use to

escape from a large fire. /vacuate the building immediately and( once outside(

report to your supervisor.

#ource* http*LLwww.bu.eduLehsmcLflipchartLfirepro.htm

=5. Es. -. has had both wrists restrained because she is agitated and pulls out her

C; lines. hich of the following would the nurse observe if Es. -. is not suffering

pg. 20


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any ill effects from the restraints! That

a. Es. -.Ms capillary refill is less than two seconds.

b. #he has difficulty moving her fingers and making a fist.

c. Fer skin is reddened where the mitts were tied around her wrist.

d. The client complains of numbness and tingling in her hand.

Answer* A.

-ationale* The client &in restraints' must periodically be evaluated for integrity of

distal circulation( motor movement( and sensory level of the restrained e6tremities.

&p.2234' apillary refill time is an evaluation of peripheral perfusion and cardiac

output. apillaries usually refill in a fraction of a second but normal times range

up to 4 seconds for color to return. ith diminished blood flow( the return to the

baseline color is delayed and a refill time of 4 seconds is sometimes called

sluggish. &p. 1481'

#ource* Eedical #urgical $ursing Ilack( Fawks( ?eene=1. hen a patient you are admitting to the unit asks you why you are doing a history

and e6am since the doctor )ust did one( your best reply is*

a. Cn addition to providing us with valuable information about your health status(

the nursing assessment will allow us to plan and deliver individualized( holistic nursing

care that draws on your strengths.

b. BCts hospital policy. C know it must be tiresome( but C will try to make this quickR

c. BC am a student nurse and need to develop the skill of assessing your health status

and need for nursing care. This information will help me develop a plan of care

individualized to your unique needs.

d. e want to make sure that your responses are consistent and that all our data are

accurate.

Answer* A.

Though it may be true that you need to develop assessment skills &c' ( the chief reason you are doing a

nursing history and e6am is because there needs to be a

documented nursing admission assessment to serve as a basis for nursing care.


=2. Er. C. is supine. hich of the following can the nurse do to prevent e6ternal rotation

of the legs!

a.


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and e6erts a more even force on the client during the move. Cn addition( it prevents

in)ury on the clients skin.

#ource* Eedical #urgical $ursing Ilack( Fawks( ?eene p.G18

=>. Jou are surprised to detect an elevated temperature &152 7' in a patient

scheduled for surgery. The patient has been afebrile and shows no other signs

of being febrile.. The first thing you do is to*

a. inform the charge nurse.

b. Cnform the surgeon

c. ;alidate your finding

d. %ocument your finding

Answer* .

Jou should first validate your finding if it is unusual( deviates from normal and is

unsupported by other data. #hould your initial recoding prove to be in error(

it would have been prematurity to notify the charge nurse.#ource* 7undamentals of $ursing by Taylor( "illis and "emone( th /d.( p.25

=. The nurse knows the difference between the left lateral and the #ims position is

that the

a. "ateral position places the clientMs weight on the anterior upper chest and the left

shoulder.

b. #ims position is semiprone( halfway between lateral and prone.

c. "ateral position places the weight on the right hip and shoulder.

d. #ims position places the weight on the right shoulder and hip.

Answer* I.

-ationale* Cn &left' lateral position( the person lies on one side of the body &left'.

The top hip and knee are fle6ed and placed in front of the body to create a wider(

triangular base of support. Cn #ims position( the patient assumes a posture halfway

between the lateral and prone positions. The patient assumes a side lying position

with lowermost arm behind the body and uppermost leg fle6ed.

#ource* Eedical #urgical $ursing Ilack( Fawks( ?eene &p. >3=( G1>'

=3. a professional nurse committed to the principle of autonomy would be careful to*

a.


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#ource* Eedical #urgical $ursing Ilack( Fawks( ?eene p.G1G

==. Es. 7. suffered a stroke and has rightsided hemiparesis. The nurse is going to

transfer her from bed to wheelchair. hich of the following is the best method!

a.


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-ationale* To open a &sterile' wrapped package on a surface( place the package in

the center of the work area so that the top flap of the wrapper opens away from

you. This position prevents the nurse from subsequently reaching over the e6posed

sterile contents( which could contaminate them.

#ource* 7undamentals of $ursing by ?ozier( /rb( Ilais and ilkinson( p.3G>

G2. hich of the following statements or questions would be appropriate in establishing a discharge plan

for a patient who has had ma)or abdominal surgery!

a. BC will bet you will be so glad to be home in your own bed.

b. Bhat are your e6pectations for recovery from your surgery!

c. BIe sure and take your pain medications and change your dressing.

d. BJou will )ust be fineR


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#tage CC 88

G8. The nurse takes an =am medication to the patient and properly identifies her. The

patient asks the nurse to leave the medication on the bedside table and stats that she

will take it when with breakfast when it comes. hat is the best response to this request!

a. "eave the medication and return later to make sure that it was taken.

b. Tell her that it is against the rules( and take the medication with you.

c. Tell her that you cannot leave the medication but will return with it when breakfast arrives.

d. Take the drug from the room and record it as refused.

Answer* .

#afe nursing practice requires that a medication never be left at the patients bedside.

Ct is not correct to say that the patient has refused medication in this situation.


G=. hy is the intravenous method of medication administration is called the Bmost

dangerous route of administration!

a. The vein can take only a small amount of fluid at a time.

b. The vein may harden and become nonfunctional.

c. Ilood clots may become a serious problem.

%s. The drug is placed directly into the bloodstream and its action is immediate.

Answer* %.

The intravenous route is a direct access to the bloodstream( and medications act

quickly when given intravenously. The condition of the veins is not a s important as the

rapid effect of the medication administered intravenously.


GG. Er. A. is going home from the emergency room with directions to apply a cold pack

to his ankle sprain. Fe asks how he will know if the cold pack has worked. The nurse

tells him

a. there should be less pain after applying the cold pack.

b. that the skin will be blanched and numb afterward.

c. he will notice the redblue bruises will turn purple.

d. after the first application( the swelling will be decreased.

Answer* A.

-ationale* old compresses should be applied for 25 minutes at a temperature of 1S

to relieve inflammation and swelling. hen using cold compresses( the nurse observes

pg. 25


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for adverse reactions such as burning or numbness( mottling of the skin( redness(

e6treme paleness( and a bluish skin discoloration.

#ource* 7undamentals of $ursing by


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NURSING PRACTICE II

1. The dynamic care of this nursing tool provides measurement of progress. hat is the scientific

process for quality care!

a. $ursing policies

b. $ursing standard

c. $ursing procedures

d. $ursing process

Answer* %

The nursing process is a systematic( scientific( dynamic( on going interpersonal process in which the

nurses and the clients are viewed as a system with each affecting the other and both being affected by

the factors within the behavior. The process is a series of actions that lead toward a particular result.

This process of decision making results in optimal health care for the clients to whom the nurse applies

the process

#ource* %DF &@reen and Jellow' pp. >42. hich of the following serves as basis for evaluating nursing care plan for the patient and or family!

a. Activities undertaken

b. $ursing diagnosis

c. Iaseline information

d. #et ob)ectives of the plan

Answer* %

Db)ectives refer to more specific statements of the desired results or outcomes of care. They specify the

criteria by which the degree of effectiveness of care is to be measured.

#ource* $ursing th /d( pp. G=

4. The %ental Fealth


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c. ommunity organizer

d. hange agent

Answer* %

A change agent is the one who motivates changes in health behavior of individuals( families( group and

community including lifestyle in order to promote and maintain health.

#ource* ommunity Fealth $ursing #ervices in the .

3. A nurse that develops the familys capability to take care of the sick( disabled( or dependent

members*

a.


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b. . These are essential characteristics you must consider most in providing primary health care e6cept*

a. Accessibility of health service

b. Fealth


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c. Eultisectoral approach to health care

d. Appropriate technology

Answer* I

A( and % together with the support mechanism made available characterized the primary health care.

#ource* %DF & @reen and Jellow ' pp. 3G

#ituation 2* The following 2553 data are available in your health center. Jou analyze these for planning

purposes.

$o. of population 2>(555

555

2L1555

#ource* %DF & @reen and Jellow ' pp. 445

13. The maternal mortality rate is*

a. 15L1555

b. 25L1555

c. 12L1555

d. 1L1555

Answer* A

EE- Total U of deaths from maternal causes registered for a given year 0 1555

Total U of livebirths registered of same year

3Q 0 1555

355

3555

355

15L1555


18. The infant mortality rate is*

a. L1555

b. >L1555

c. 4L1555

d. 2L1555

Answer* A

CE-Total U of deaths under 1yr of age registered in a given calendar year 0 1555

pg. 30


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Total U of registered live births of same calendar year

4 0 1555

355

4555

355


1=. The case fatality rate for 5V

b. 45V

c. 22V

d. 4V

Answer*

7-$o. of registered deaths from a specific disease for a given year 0 155$o of registered cases from same specific disease in same year

155 0 155

>5

15555

>5

22V


1G. The crude death rate is*

a. >1L1555

b. 4=L1555

c. 41L1555

d. 2L1555

Answer. A

rude %eath -ate Total U of deaths registered in a given calendar year 0 1555

Eid Jear 555

G55555

2>555

48.L1555

4=L1555


25. hat is believed to be a guarantee of effective delivery of health services!

a. Cntegration

b. -eorganization

c. %evolution

d.


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b. To empower local politicians

c. To become self reliant

d. To stop funding from national funds

Answer*

Dne of the most significant laws that radically changed the landscape of health care delivery system in

the country is -A 8135 or more commonly known as the "ocal @overnment ode. The ode aims to

transform local government units into self reliant communities and active partners in the attainment of

national goals through a more responsive and accountable local government structure instituted through

a system of decentralization.

#ource* $ursing th /d( pp. 2

22. 7or a group of children where interaction with causative agents of disease has not taken place( the

nurse concern is to provide*

a. %iagnostic and curative type

b. All this type of carec.


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"evel CC

Kon site toilet facilities of the water carriage type with water sealed and flush type with septic

vaultLtank disposal facilities.

"evel CCC

water carriage types of toilet facilities connected to septic tanks andL or to sewerage system to

treatment plant.

#ource* ommunity Fealth $ursing #ervices in the (

pg. 33


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>8=

#ituation 4* These are laws related to devolution.

28. hich one of the following is the local government code!

a. -A >584

b. -A 484

c. /D 11G

d. -A 8135

Answer* %

-A 8135 or commonly known as "ocal @overnement ode.

-A >584 liberalizes the treatment of leprosy

-A 484 declares that all communicable diseases should be reported to the nearest health station.

2=. hich laws cover /thical onduct of G K "egal basis for


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d. hlamydia trachomatis

Answer* I

A Trichomoniasis

#yphilis

% hlamydia


42. hat is the mode of transmission in the case of "uzviminda with FC;LAC%#!

a. ontaminated syringes

b. %irect contact with contaminated fluids

c. Ilood transfusion

d. #e6ual contact

Answer* %

"uzviminda is a commercial se6 worker so she must have acquired it through se6ual contact.

#ource* %DF & @reen and Jellow ' pp. 45544. hat is the confirmatory test for AC%#LFC;!

a. estern Ilot

b. #putum e6am

c. /"C#A &W'

d. %/0A

Answer* A

I confirmatory test for TI

presumptive test

% diagnostic test for Dsteoporosis

#ource* %DF & @reen and Jellow ' pp. 2G>

4>. Ct is a chronic parasitic infection which greatly reduces human productivity and quality of life. Ct is

frequently encountered in communities where eating of fresh or inadequately cooked crabs is a practice.

a. #TF

b.


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h. imminent deliveries

i. in case of imminent deliveries by risk mothers( they should still be referred to the appropriate level of

health facility if the risk remains after delivery but if the risk condition has disappeared then no referral

is needed.

). $o premature rupture of membranes

k. Adequate pelvis

l. Abdominal enlargement is appropriate for age of gestation

#ource* ommunity Fealth $ursing #ervices in the d. 1

Answer* A.

Cnstruct member of the family to watch mother for hemorrhage for at least two hours )ust after the nurse or

midwife has left the house after delivery. The first two hors after delivery are dangerous due to atony of

the uterus.

#ource* ommunity Fealth $ursing #ervices in the


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b. >55 555 C9

c. 155 555 C9

d. 5 555 C9

Answer* .

7or ;it. A deficiency( 155( 555 C9 of ;it. A is given. %osing is give today( give tomorrow( give after 2

weeks.

#ource* F$ #ervices in the 5. Eicronutrient supplementation is included in what program of the %DF!

a. /6panded


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#ource* ommunity Fealth $ursing #ervice in the 4. /. hich of the following is a primary element of /


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like open dug wells( unimproved springs and surface water.

#ource* ommunity Fealth $ursing #ervices in the 8. The following are principles of ommunity Fealth $ursing e6cept*

a. Fealth teaching is the primary responsibility of the community health nurse

b. The community health nurse utilizes the already e6isting active organized groups in the community

c. The community health nurse participate in the development of an overall health plan for the

communities and in its implementation and evaluation

d. The community health nurse must understand fully the ob)ectives and policies of the agency she

represents

Answer*

To participate in the development of an overall health plan for the community and in its implementation

and evaluation( is one the ob)ectives of ommunity Fealth $ursing. Dption A( I( and % are principles of

ommunity Fealth $ursing

#ource* ommunity Fealth $ursing #ervices in the =. All of the following are complications of gonorrhea e6cept one*

a.


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;itamin % help in the mineralization of bones by enhancing absorption of calcium

;itamin ? involves in the synthesis of blood clotting proteins and a bone protein that regulates calcium

level.

#ource* ommunity Fealth $ursing #ervices in the . 7ollowing are initial steps to gain entry in Drganizing a ommunity for Fealth Action

1. @ather initial information about the community from other members of the -F9 or from

records and reports

pg. 40


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2. Eake your courtesy calls

4. . Arrange meeting with identified leaders( request barangay officials to sign for a meeting

a. 1( 2( 4( >

b. 2( >( 1( 4

c. 4( 1( >( 2

d. 1( 2( >( 4

Answer* %

The following are initial steps to be done*

1. @ather initial information about the community from other members of the -F9 or from records and

reports.

2. "ist down names of persons to contact for a courtesy call

4. Arrange first meeting with identified key leaders( request barangay officials to sign invitation for a

meeting>.


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and research. hoices I( ( and % are incomplete

#ource* F$ by %DF Gth /d

G. hich one is not a function of calcium!

a. Ione and teeth mineralization

b. Absorption of iron in the formation of Fgb

c. Ilood clotting

d. muscle rela6ation and contraction

Answer* I

hoice describes function of copper and Lor ;itamin

#ource* %DF & @reen and Jellow ' ( pp. 143

35. A deficiency in protein leads to*

a. ?washiorkor

b. -icketts

c. Ieriberid. Femorrhage

Answer* A

-icketts results from ;itamin % deficiency. Ieriberi from ;iamin I deficiency. Femorrhage may result

from ;itamin k deficiency.

31. hat is the characteristic rashL eruptions in chicken po6!

a. Eacular

b. 4

32. hat is the period of communicability of chicken po6!

a. 2 days before to 8 days after the appearance of vesicle

b. 1 day before to 3 days after the appearance of vesicles

c. 1 day before to 8 days after the appearance of vesicles

d. 2 days before to 3 days after the appearance of vesicle

Answer* I

#ource* %DF & @reen and Jellow ' ( pp. 2>4

34. hat is the primary source of infection of chicken po6!

a. respiratory secretions of infected persons

b. skin lesions

c. scabs

d. vesicular skin eruptions

Answer* A

#ecretions from respiratory tract of the persons is the source of infectionH lesions of skin are of little

consequence. #cabs themselves are not infective.

#ource* F$ by %DF Gth /d page 2>2

3>. hat are the 2 most common complications of chicken po6!

a. Eeningitis and TI

b.


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d. /ncephalitis and endocarditis

Answer* I

months

d. 3 months

Answer* A

2 months. hoice % is the total length of treatment for ategory C patients. 2 months intensive and >

months maintenance.

#ource* %DF & @reen and Jellow ' ( pp. 25=

38. e have three levels of assessment. Cn the first level assessment( which among these problems is

not a health threat!

a. broken stairs

b. strained marital relationship

c. self medication

d. illegitimacy

Answer* %

Cllegitimacy is listed under foreseeable crisis. A( I and are all health threats.

#ource* $ursing th /d.( by Eaglaya( pp. 3=85

3=. Cn the B7amily service and


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A is categorized into health threat( health deficit and foreseeable crisis. I refers to the probability of

minimizing or totally eradicating the problem. % refers to the nature or magnitude of the future problems

that can be minimized or totally prevented if intervention is done on the problem.

#ource* $ursing th /d.( by Eaglaya( pp. =3

85. hat is the minimum interval between doses of hepatitis vaccine!

a. 4 weeks

b. 2 weeks

c. 3 weeks

d. > weeks

A$#/-* %

#ource* F$ by %DF( Gth /d.

81. At what age and route of administration is measles given!

a. G months( CE

b. 15 months( CEc. G months( C%

d. G months( #+

A$#/-* %

#ource* F$ by %DF( Gth /d

82. hen is the 2nd dose of I@ vaccine given!

a. 1 month after the first dose

b. 9pon school entry

c. 4 months after the first dose

d. 12 years old

A$#/-* I

I@ immunization is given to school entrants both in public and private schools regardless of the

presence or absence of a I@ scar.

#ource* F$ by %DF( Gth /d

#CT9ATCD$ 2* The 2555 $utritional guidelines is formulated to improve the nutritional status of 7ilipinos.

The following questions are concerned with nutrition.

84. 0eropthalmia is characterized by*

a. Tunnel vision

b. 7loaters

c. $ight blindness

d. indow ;ision

A$#/-*

0erpthalmia or night blindness results due to destruction of rods and cones. Tunnel vision is related to

open angle glaucoma. 7loaters occur in retinal detachment because of intraocular hemorrhage.

Situation: The public health nurse participate in activities aimed towards the

achievement of the goals of each and every program.

8>. Fospital waste management program is a new requirement before construction of a facility. The

hospital personnel required to train in waste management to prevent

which of the following!

a. ommunicable diseases

b. $osocomial infection

c. ross infection

d. Transmission of diseases

Answer* I


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8. Approved type of toilet facilities may need water or not depending on receiving

space. hat type of toilet is without need of water!

a.


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a.


47/123

infection from individuals to families to the community.

#ource* %DF & @reen and Jellow' ( pp. >

=>. onsidering the steps and procedures in bag technique which side of the linen or

paper lining of the


48/123

Answer* %

A( I and are the priorities of ##E.

#ource* %DF & @reen and Jellow' ( pp. 12=

=G. All of the following are the standard requirements of #entrong #igla Eovement

e6cept*

a. Cnfrastructure

b. /quipment

c.


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#ource* %DF & @reen and Jellow' ( pp. =3

G>. Cn the


50/123

Answer* %

#ource* %DF & @reen and Jellow '( pp. 244

155. All of these are health deficits e6cept*

a. Ilindness form measles

b. "ameness from polio

c. -esettlement in a new community

d. Aphasia after a ;A

Answer*

-esettlement in a new community belongs to your foreseeable crisis.

#ource* $ursing th /d. Iy Eaglaya( pp. 85

pg. 50


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NURSING PRACTICE III

1. hich of the following would the nurse identify as an advantage to using a cervical cap for

contraception!

a. = hours

b. Cs disposable and available over the counter

c. Allows #permicide application 2 hours before intercourse

d. Einimizes risk for allergic reactions to plastic

Answer. A

The cervical cap is a small rubber or plastic dome that fits snugly over the cervi6. Ct provides continuous

protection for >= hours( no matter how many times intercourse occurs. Additional #permicide is not

necessary for repeated acts of intercourse. The cervical cap is not disposable or available over the

counter( as is the female condom. A cervical cap must be fitted to the individual by a health care provider.

There is risk for allergic reaction if the woman develops allergies to plastic( rubber or #permicide.

#ource* "ippincotts -eview #eries Eaternal and $ewborn $ursing by #tright(4rd edition p.=5.2. hich of the following statements by a male client would indicate that he understands the instructions

for use of a condom!

a. BC should lubricate the condom with an oilbased product to avoid friction that could rupture the

condom.

b. BC should unroll the condom and check it for holes before applying it.

c. BC should hold the rim of the condom while withdrawing my penis from the vagina to avoid leakage.

d. BC should begin se6ual intercourse without the condom and don the condom )ust before e)aculation.

Answer.

Dilbased lubricants can break down late6 condoms. The condom should be unrolled onto the penis(

starting at the tip of the penis. Folding the rim keeps the condom from slipping off the leaking semen into

the vagina. #mall amounts of semen are released before e)aculation and can result in pregnancy.

#ource*

4. A woman using a diaphragm for contraception should be instructed to leave it in place for at least how

long after intercourse!

a. 1 hour

b. 3 hours

c. 12 hours

d. 2= hours

Answer. I

The diaphragm should remain in place for at least 3 hours after intercourse but not longer than 12 hours

to avoid the possibility of to6ic shock syndrome.

#ource* "ippincotts -eview #eries Eaternal and $ewborn $ursing by #tright(4rd edition p.8G.

>. The client has completed an athome pregnancy test with positive results. hich of the following

indicates that the client understands the meaning of the test results!

a. BC understand that this means C have ovulated in the past 2> hours.

b. BC understand that this means C am not pregnant.

c. BC understand that this means C might be pregnant.

d. BC understand that this means C am pregnant.

Answer.

A positive athome pregnancy test indicates the presence of growing trophoblastic tissue and not

necessarily a uterine pregnancy.

#ource*


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c. 7ollicle#timulating hormone

d. year old woman comes to the physicians office for a routine checkup at 4> weeks gestation.

Abdominal palpation reveals the fetal position as right occipital anterior &-DA'. To which of the following

sites would the nurse e6pects to find the fetal heart tones.

a. Ielow the umbilicus( on mothers left side.

b. Ielow the umbilicus( on mothers right side.

pg. 52


53/123

c. Above the umbilicus( on mothers left side.

d. Above the umbilicus( on mothers right side.

Answer. I

Dcciput and back are pressing against right side of mothers abdomenH 7FT would be heard below

umbilicus on the right side. and % found in breech presentation. A is found on "DA.

#ource* $"/0-$ Cnternational /dition by ?aplan( page 228

15. The client has come to the clinic because she suspects that she is pregnant. hich of the following

would be the most definitive way to confirm the diagnosis!

a. lients report of amenorrhea for 4 months

b.


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a. "ower blood pressure

b.


55/123

1G. hen hours before the onset of labor.

b. T1


56/123

a. The large size of the newborn

b.


57/123

umbilicus and deviated to the right of midline. hich of the following would be the nurses priority action

at this time!

a. Assist the mother to void

b. ;igorously massage the fundus

c. Administer additional o6ytocin to contract the uterus

d. @ive a tocolytic drug intravenously

Answer. A

A distended bladder will elevate and displace the uterus to the right. Therefore the nurse should assist the

mother to void. A displaced uterus is usually caused by a full bladder. ;igorous massage of the fundus

will not correct this and may cause unnecessary discomfort. D6ytocin would be used if the uterus was not

contracting. There is no data to suggest a need for that at this time. A tocolytic would be used if the uterus

required rela6ation( such as in premature labor.

#ource* "ippincotts -eview #eries( Eaternal $ewborn $ursing( by Iarbara -. #tright( 4rd edition( p 411.

2=. The nurse is assessing the fundal height of a client at 23 weeks gestation. The nurse should e6pectthe fundus to be*

a. "evel with the umbilicus

b. Falfway between symphysis and umbilicus

c. #lightly below ensiform cartilage

d. At 23cm.

Answer. %

7undal height in centimeters correlates well with weeks of gestation between 222> weeks and 4> weeks.

Thus( at 23 weeks gestation( fundal height is probably about 23 cm.

#ource* www.


58/123

d. The membranes have ruptured.

Answer. A

The change in the cervi6 is the only indicator of true labor

#ource* .

41. After > hours of active labor( the nurse notes that the contractions of a primigravid client are not

strong enough to dilate the cervi6. hich of the following would the nurse anticipate!

a. Dbtaining an order to begin C; o6ytocin

b. Administering a light sedative to allow the patient to rest for several hours

c.


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umbilicus at appro6imately 25 weeks gestation and reaches the 6iphoid at term or >5 weeks.


4. hich of the following danger signs should be reported promptly during the antepartum period!

a. onstipation

b. Ireast tenderness

c. $asal stuffiness

d. "eaking amniotic fluid

Answer. %

%anger signs that require prompt reporting are leaking of amniotic fluid( vaginal bleeding( blurred vision(

rapid weight gain( elevated blood pressure. onstipation( breast tenderness( and nasal stuffiness are

common discomforts associated with pregnancy.


43. 7F- can be auscultated with a fetoscope as early as which of the following!

a. weeks gestationb. 15 weeks gestation

c. 1 weeks gestation

d. 25 weeks gestation

Answer. %

The 7F- can be auscultated with the fetoscope at about 25 weeks gestation. 7F- usually is auscultated

at the midline suprapubic region with a %oppler ultrasound transducer at 15 to 12 weeks gestation. 7F-

cannot be heard any earlier than 15 weeks gestation.


48. A client at = weeks gestation calls complaining of slight nausea in the morning hours. hich of the

following client interventions should the nurse question!

a. Taking 1 teaspoon of bicarbonate of soda in an =ounce glass of water

b. /ating a few lowsodium crackers before getting out of bed

c. Avoiding the intake of liquids in the morning hours

d. /ating si6 small meals a day instead of three large meals

Answer. A

9sing bicarbonate would increase the amount of sodium ingested( which can cause complications. /ating

lowsodium crackers would be appropriate. #ince liquids can increase nausea( avoiding them in the

morning hours when nausea is usually the strongest is appropriate. /ating si6 small meals a day would

keep the stomach full( which often decreases nausea.

#ource* "ippincotts -eview #eries( Eaternal $ewborn $ursing( by Iarbara -. #tright( 4rd edition( p 45G.

4=. A client with severe preeclampsia is admitted with a I< 135L115( proteinuria( and severe pitting

edema. hich of the following would be mot important to include in the clients plan of care!

a. %aily weights

b. #eizure precautions

c. -ight lateral positioning

d. #tress reduction

Answer. I

omen hospitalized with severe preeclampsia need decreased $# stimulation to prevent a seizure.

#eizure precautions provide environmental safety should a seizure occur. Iecause of edema( daily

weight is important but not the priority.


60/123

important nursing assessments of this client include*

a. Cntake and output( level of consciousness( and blood pressure.

b. Ilood pressure( pulse( and uterine activity

c. %eep tendon refle6( hourly urine output( and respiratory rate

d. Cntake and output( blood pressure( and refle6es.

Answer.

/arly signs of magnesium to6icity that may lead to respiratory arrest are loss of patellar refle6es and

decreased respiratory rate &X12Lmin'. #ince magnesium is e6creted from the body through the renal

system( hourly urine output should be assessed. Although blood pressure is a standard assessment for

most antepartum clients( there is minimal blood pressure change( if any( associated with administration of

magnesium sulfate.

#ource* 5. A clients amniotic fluid is greenishtinged. The fetal presentation is verte6. 7etal heart rate &7F-' and

uterine activity have remained within normal limits. At the time of delivery( the nurse should anticipate theneed for*

a. An infant laryngoscope and suction catheters

b. 7orceps

c. A transport isolette

d. /mergency cesarean setup

Answer. A

Eeconium released by the fetus causes amniotic fluid to be greenishtinged. Although the presence of

meconium is associated with fetal distress( there is no evidence of immediate danger to the fetus during

labor in this case. Fowever( the infant is at risk for aspirating meconium at the time of delivery. #teps to

prevent aspiration include thorough suctioning of the nasopharyn6 including visualization of the vocal

cords to remove cords to remove meconium particles before the first breath.

#ource* 1. 7ollowing amniotomy( the most important nursing action is to*

a. -eposition the mother on her left side

b.


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b. . A nurse is caring for four postpartum clients who each have an order for Eethergine &methylgonovine

maleate'. Iased on the data collected during the nurses initial shift assessment( which client would not

receive the medication!

a. The client with a blood pressure of 13LG>

b. The client with a hematocrit of 44V

c. The client with a white blood cell count of 22(555d. The client with a temperature of 151S7

Answer. A

Fypertension is a side effect of this medicationH therefore( Eethergine is contraindicated for women with

high pressure. /levated temperature and elevated blood count are not contraindications for administering

Eethergine. Iecause Eethergine is given to prevent or reverse postpartum hemorrhage( it may also help

prevent a decrease in hematocrit levels.

#ource* www. . A 22year old woman is admitted to the hospital and delivers a healthy 8lbs 2 oz girl. The mother

decides to bottlefeed her infant. hich of the following statements( if made by the mother after a

teaching session( indicates to the nurse that the patient needs further teaching!

a. BCll pump my breast and use warm packs to relieve breast pain.

b. BCll use a tight bra and ice packs to relieve engorgement discomfort.

c. BCll take the medication prescribed by the doctor for pain.

d. BCll take the pills ordered by my doctor to help stop the production of milk.

Answer. A

This stimulates hormonal responses thereby increasing production of milk causing engorgement. Dptions

I( ( and d are all correct management for engorgement in mothers not breastfeeding. Cce packs relieve

discomfort. 8. Ct is most important for the nurse to have which drug readily available when the client is being treated

with heparin therapy for thrombophlebitis!

a. alcium gluconate

b. Aquamephyton

c.


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d. 7errous sulfate

Answer.


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a. -eport the temperature to the physician

b. -echeck the blood pressure with another cuff

c. Assess the uterus for firmness and position

d. %etermine the amount of lochia

Answer. %

A weak( thready pulse elevated to 155I=7 in the first 2> hours after birth

are related to the dehydrating effects of labor and are considered normal. Although rechecking the blood

pressure may be a correct choice of action( it is not the first action that should be implemented in light of

the other data. The data indicate a potential impending hemorrhage. Assessing the uterus for firmness

and position in relation to the umbilicus and midline is important( but the nurse should check the e6tent of

vaginal bleeding first. Then it would be appropriate to check the uterus( which may be a possible cause of

the hemorrhage.#ource* "ippincotts -eview #eries( Eaternal $ewborn $ursing( by Iarbara -. #tright( 4rd edition( p 454.

2. hen preparing to listen to the fetal heart rate at 12 weeks gestation( the nurse would use which of

the following!

b. #tethoscope placed midline at the umbilicus

c. %oppler placed midline at the suprapubic region

d. 7etoscope placed midway between the umbilicus and the 6iphoid process

e. /6ternal electronic fetal monitor placed at the umbilicus

Answer. I

At 12 weeks gestation( the uterus rises out of the pelvis and is palpable above the symphysis pubis. The

%oppler intensifies the sound of the fetal pulse rate so it is audible. The uterus has merely risen out of the

pelvis into the abdominal cavity and is not at the level of umbilicus. The fetal heart rate at this age is not

audible with a stethoscope. The uterus at 12 week is )ust above the symphysis pubis in the abdominal

cavity( not midway between the umbilicus and 6iphoid process. At 12weeks the 7F- would be difficult to

auscultate with a fetoscope. Although the e6ternal electronic fetal monitor would pro)ect the 7F-( the

uterus has not risen to the umbilicus at 12 weeks.


4. hich of the following additional assessment findings would be most suspicious and lead the nurse to

suspect postpartum Bblues in a client who is an6ious and crying!

a. "oss of appetite( constipation( abdominal pain

b. %espondency( loss of appetite( difficulty sleeping

c. Cncreased appetite( urinary retention( diarrhea

d.


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findings for this time period include lochia rubraH a fundus that is firm( located midline and at the level of

the umbilicus or slightly lowerH and transient bradycardia.

#ource* "ippincotts -eview #eries Eaternal and $ewborn $ursing by #tright(4rd edition p.13=.

. hich of the following intervention results in convection heat loss in the newborn!

a. -emoval from an incubator for procedures

b.


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$eonates generally arent able to effectively coordinate sucking( swallowing( and breathing until 4> to 43

weeks gestation. Cf fed orally before that time( they are at greater risk of aspiration. Typically they will be

fed through a gavage tube until they are able to drink from a bottle or breastfeed. Cntake can be

accurately assessed with oral and gavage feedings. The stomach of a preterm infant can digest small

amounts of formula or breast milk. Thrush is an oral yeast infection commonly caused during passage

through the birth canal( and gavage feeding will not prevent it from occurring.

#ource*


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monthold children can be so different in height and weight! hat is the appropriate response!

a. This is an abnormality that should be referred to the physician.

b. Dne of the children is displaying a Ngrowth spurt.

c. -ates of growth vary and individual differences occur for each child.

d. The sequence of growth and development is unpredictable for each child.

Answer* . -ates of growth vary and individual differences occur for each child.

Although there are general norms for growth and development rates( each child is an individual who will

progress at his or her own individual pace.

#ource* -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and

:udy /. hite( p. 4 , >

3. hildren are usually brought to the clinic for health care by a parent. At what age is it appropriate for

the nurse to question the child about presenting symptoms!

a. 4 years

b. yearsc. 8 years

d. G years

Answer* 8 years

Iy age 8( most children are able to clearly and in chronological order describe symptoms. Their

vocabulary is e6tensive enough to have words to describe what they are feeling( time of onset( changes

from the norm( etc.


:udy /. hite( p. 1G( 25 ,48

33. hen sharing the purpose of the %enver %evelopment #creening Test &%enver CC' with parents of an

1=monthold( the nurse should e6plain that*

a. The %enver CC is a test that will predict future intellectual ability.

b. The %enver CC is a screening test used to detect children who may be slow in development.

c. The %enver CC is used for early detection of speech disorders.

d. The %enver CC measures psychological( cognitive( and social development.

Answer* I The %enver CC is a screening test used to detect children who may be slow in development.

The %enver CC is used to screen children for possible developmental delays in the areas of grossmotor

skills( language( finemotor skills( and personalsocial development.


:udy /. hite( p. >G5

38. >yearold scores two failures on the %enver CC. hich of the following statements is most accurate!

a. The child is not as intelligent as e6pected for age and should be referred to a learning specialist.

b. The child has a speech problem and should be referred to a speech therapist.

c. The child is at risk for school problems and should be retested.

d. The failures are to be e6pected in preschoolers who may not be cooperative with testing.

Answer* The child is at risk for school problems and should be retested.

The %enver CC is a screening test( not a diagnostic testH therefore children who score a failure should be

retested. The child is considered atrisk until other diagnostic indicators can determine a specific problem.


:udy /. hite( p. 2

3=. hat is the most important sign of readiness to watch for when toilet training the child!

a. ability to walk

b. able to indicate that the diaper is wet

c. physical and psychological readiness

d. e6hibits willingness to please parents

Answer* physical and psychological readiness

Ct is the childs welfare that should be the paramount consideration in toilet training. The physical and

pg. 66


67/123

psychological readiness of the child will make the activity successful.

#ource* ongs /ssentials of


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:udy /. hite( p. 11

84. The nurse provides anticipatory guidance to parents of a 4yearold child. Cnstructions should include*

a. To restrain the child in the car seat facing rear in the back seat of the car.

b. The use of syrup of ipecac for accidental poisonings.

c. %rug and alcohol education.

d. The proper use of sports equipment.

Answer* I The use of syrup of ipecac for accidental poisonings.

$urses are instrumental in teaching parents how to make the toddlerMs environment safe by providing

instructions about keeping syrup of ipecac available( having the . A teenager refuses to wear the clothes his mother bought for him. Fe states he wants to look like theother kids at school and wear clothes like they wear. The nurse e6plains this behavior is an e6ample of

teenage rebellion related to internal conflicts of*

a. Autonomy vs. shame and doubt.

b. Trust vs. mistrust.

c. Cdentity vs. role confusion.

d. Cnitiative vs. inferiority.

Answer* Cdentity vs. role confusion.

/riksonMs theory of psychosocial development states that the child is faced with conflicts that need to be

resolved. /rikson identifies stages of personality development. Cdentity vs. role confusion &12 to 1G years'

is a period when adolescents search for answers regarding their future. %uring this time( the child re)ects

the identity presented by his parents and attempts to create his own identity. Cdentity is often based on

peers.


:udy /. hite( p. 18,1=

8. Fospitalization of a child results in disturbance of the dynamics in family life. The most appropriate

nursing diagnosis is*

a. %iversional activity deficit related to separations from siblings and peers.

b. #leep patterns disturbance related to unfamiliar surroundings.

c. Altered family processes related to hospitalization.

d. Cneffective individual coping related to procedures.

Answer* Altered family processes related to hospitalization.

Cdentification of nursing diagnoses that apply to the specific problem&s' of the child and family is an

essential step of the nursing process. 7amilycentered care addresses the needs of the family members(

including the childMs siblings. The primary goals are to maintain the relationship with the child and siblings

during the period of separation while hospitalized and avoid boredom and distress for the hospitalized

child.


:udy /. hite( p. 23

83. The charge nurse is developing plans to reduce the stress of hospitalized( chronically ill children.

oping for these children will be improved if*

a. They are allowed 2>hour open visitation with their peers.

b. They are assigned a primary nurse.

c. They avoid making all decisions while hospitalized.

d. All tutoring is postponed until discharge

Answer* I They are assigned a primary nurse.


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the same nurse&s'( with whom the child develops trust and rapport.

#ource* ongs /ssentials of


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=1. The pediatric nurse practitioner is working with a group developing school playgrounds. The

playground designers must identify the ma)or causes of potential in)ury for the schoolaged child. The

nurse e6plains that the most frequent accidents in schoolage children involve*

a. Eotor vehicles( diving( and drugs and alcohol.

b. #wing sets( drowning( and poisonings.

c. Iicycles( skateboards( and inline skates.

d. Aspiration of food( plastic bags( and stairways.

Answer* Iicycles( skateboards( and inline skates.

#choolage children en)oy activities like skateboarding and biking that may cause in)uries.


:udy /. hite( p. 1>

=2. A father brings his yearold to the doctorMs office for a wellchild visit. The father is embarrassed by

his childMs behavior during the visit. The father states that every time the child comes for an immunization

she begins to cry and scream. An appropriate response to this father is*a. NAll children have a ma)or fear of needlesH preschoolers often believe pain is a punishment.B

b. NJour child most likely had a traumatic e6perience at an early age.B

c. N$e6t time the mother should accompany the child for an immunization.B

d. NCt is best to ignore this type of behavior as the child is seeking attention

Answer* A NAll children have a ma)or fear of needles( preschoolers often believe pain is a punishment.B

. The mother of a yearold e6presses concern about her child who believes that N@randma is still

aliveN 4 months after the grandmotherMs death. The nurse e6plains that*

a. Eagical thinking often accounts for a preschooler who believes that dead people will come back.

b. There is a need for psychological counseling for this child and family.

c. This is a form of regression e6hibited by the preschooler.

d. The child is in denial regarding @randmaMs death.

Answer* A Eagical thinking often accounts for a preschooler who believes that dead people will come

back.

The preschooler believes that death is reversible. Their magical thinking and egocentricity often results in

their belief that the deceased will come back to life.


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c. 7ormula is the only source of nutrition given for the first year.

d. 7ruits and vegetables are good sources of iron.

Answer* I -ice cereal is the first solid introduced that is least allergenic of the cereals.

-ice cereal is the first solid food because it is a rich source of iron and rarely induces allergic reactions.


:udy /. hite( p. 8

=3. The nurse would assess for which of the following as the most frequent cause of decreased

hemoglobin and hematocrit levels in children

a. %ietary deficiency

b. /6cess fluid intake

c. hronic blood loss

d. 7requent cuts and bruises

Answer* A %ietary deficiency

The ma)or reason for low hemoglobin and hematocrit in infants and children is deficiency of iron intakethrough diet. Cronfortified rice cereal is the first solid food recommended for infants beginning about >

months of age as fetal iron stores are depleted.

#ource: -eviews and -ationales #eries for $ursingH $ursing and hild are by Eary Ann Fogan and

:udy /. hite( p. 485

=8. A recently hospitalized 2yearold client screams and shouts that he wants a Nbottle.N Fis parents are

puzzled( and state that he has drank from a cup for the past year. The nurse e6plains that*

a. Crritability is e6hibited in all age groups.

b. Temper tantrums often represent the childMs need for parental attention.

c. ;arious forms of punishment are necessary when such behaviors occur.

d. -egression to an earlier behavior often helps the child cope with stress and an6iety.

Answer* % -egression to an earlier behavior often helps the child cope with stress and an6iety.

-egression is common in toddlersH it lessens the threat of illness( hospitalization( or separation. A need to

revert to use of the bottle( refusal to use the potty( or temper tantrums represent forms of behaviors

e6hibited as regression.


:udy /. hite( p. 1=

==. The nurse discusses dental care with the parents of a 4yearold. The nurse e6plains that by the age

of 4( their child should have*

a. NtemporaryN teeth.

b. 15 NtemporaryN teeth.

c. 1 NtemporaryN teeth.

d. 25 NtemporaryN teeth.

Answer* % 25 NtemporaryN teeth.

hildren have 25 deciduous teeth that erupt between 3 months and 45 months of age.


:udy /. hite( p. 12

=G. hen observing an 1=monthold child( the nurse notes a rounded belly( sway back( bowlegs( and

slightly large head. The nursing conclusion is that*

a. The child appears to be a normal toddler.

b. The child is li

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