practice exam 1 Flashcards
(102 cards)
1
Q
- The graduates from the colleges of Nursing are being prepared to take the Nursing Licensure Examination (NLE) with the main goal to
● Provide opportunity for overseas employment.
● Determine the standards of nursing practice.
● Protect the public from incompetent nurse practioner
● Limit the practice of the profession
A
Determine the standards of nursing practice.
2
Q
- Ms. Bright Sunshine is a professional nurse who was approached by her cousin to be in a Television show where she has to wear the nurse’s uniform and advertise a commercially prepared beauty product for use in their work setting. Her mother is presently having dialysis so she accepted the offer. Ms. Bright Sunshine is violating the
Nursing Law
Nursing Code of Ethics
Nursing Jurisprudence
Consumers Fraud Law
A
Nursing Code of Ethics
3
Q
- Mr. Dark Night is scheduled for Coronary Artery Bypass Graft (CABG) surgery. He has to sign an informed consent prior to operation. The validity of this consent is how long?
36 hours after surgery
24 hours after surgery
After the surgical procedure
12 hours after surgery
A
After the surgical procedure
4
Q
- Nurse Bright Sunshine is assigned to a patient in ICU who is dying due to cardia arrest. After two hours, the patient was pronounced dead. Which of the following health status should guide the nurse if the patient is declared dead?
• All body systems are no longer functioning.
• Flat sign of electrocardiogram.
• Has no more pain sensation.
A
All body systems are no longer functioning.
5
Q
- The nursing process offers a framework for thinking through problems and provides some organization to a nurse’s critical thinking skills. It is important to point out that this process is flexible and not rigid. Which of the following statements about the nursing process is most accurate?
• Beginning in Florence Nightingale’s days, nursing students learned and practiced the nursing process.
• Use of the nursing process is optional for nurses, since there are many ways to accomplish the work of nursing.
• It ensures quality care for patients.
A
It ensures quality care for patients.
6
Q
- Nurse Morning Star is revising a client’s care plan. During which step of the nursing process does such a revision take place?
Assessment
Planning
Implementation
Evaluation
A
Evaluation
7
Q
- Nurse Morning Star noticed that there were two nursing diagnoses appear closely related, what should the nurse Morning Star do first to determine which diagnosis most accurately reflects the needs of a patient?
Reassess the patient
Examine the related to factors
Analyze the secondary to factors
Review the defining characteristics
A
Review the defining characteristics
8
Q
- Nurse Midnight Blue performs an assessment of a newly admitted patient. Midnight Blue understands that this admission assessment is conducted primarily to:
• Diagnose if the patient is at risk for falls.
• Ensure that the patient’s skin is intact.
• Establish a therapeutic relationship.
• Identify important data.
A
Identify important data.
9
Q
- Which statement by nurse Midnight Blue most accurately reflects subjective data in a nursing assessment?
• “The client’s red blood cell count is elevated.”
• “The client has a positive Babinski sign.”
• “The client’s x-ray result showed a fracture is present.”
• “The client reported that his pain is a 7 on a 1 to 10 scale.”
A
“The client reported that his pain is a 7 on a 1 to 10 scale.”
10
Q
nurses must be able to communicate with patients, other health care providers, correctional staff and outside providers.Mrs. Palakpak a client with superficial varicose veins says to the nurse,
“I hate these things. They’re so ugly. I wish I could get them to go away.” The nurse should make which therapeutic response to the
client?
• “You should try sclerotherapy. It’s great.”
• “There’s not much you can do once you get them.”
• “What have you been told about varicose veins and their
management?”
• “I understand how you feel, but you know, they really don’t look too
bad.”
A
“What have you been told about varicose veins and their
management?”
11
Q
- A structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation/inspection, palpation, percussion and auscultation are techniques used to gather information. Clinical judgment should be used to decide on
the extent of assessment required. What action should the nurse take to increase the likelihood of obtaining quality data when doing a complete physical assessment?
• Provide adequate lighting and a comfortably warm room for the
interview and physical assessment.
• Identify each piece of equipment used with the appropriate medical
term
• Ask all family members or significant others to wait outside the
room
A
12
Q
- Nurse Light Blue is providing information to a preoperative client who will be receiving relaxation therapy. The nurse tells the client
that which effects occur from this type of therapy? Select all that
apply:
Increased heart rate
Improved well-bein
Lowered blood pressure
Decreased muscle tension
Increased respiratory rate
A
Improved well-bein
Lowered blood pressure
Decreased muscle tension
13
Q
- Healthcare facilities have infection control policies and
procedures which personnel must follow in an attempt to control the spread of infection. Which of the following examples relate to medical asepsis to reduce and prevent the spread of microorganisms? Select
all that apply:
• Practicing hand hygiene
• Reapplying a sterile dressing
• Applying a sterile gown and gloves
• Routinely cleaning the hospital environment
• Wearing clean gloves to prevent direct contact with blood or body
fluids.
A
• Practicing hand hygiene
• Routinely cleaning the hospital environment
• Wearing clean gloves to prevent direct contact with blood or body fluids.
14
Q
- A structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation/inspection, palpation, percussion and auscultation are techniques used to gather information. Clinical judgment should be used to decide on the extent
of assessment required. What action should the nurse take to increase the likelihood of obtaining quality data when doing a
complete physical assessment?
• Provide adequate lighting and a comfortably warm room for the interview and physical assessment.
• Identify each piece of equipment used with the appropriate medical
term
• Ask all family members or significant others to wait outside the room
• Outline the process in detail prior to beginning the examination
A
Provide adequate lighting and a comfortably warm room for the interview and physical assessment.
15
Q
- Nurse Sweet and Spice is about to perform Romberg’s test to patient Pierro. To ensure the latter’s safety, which intervention should nurse Sweet and Spice implement?
•Allowing the client to keep his eyes open.
•Having the client hold on to furniture.
•Letting the client spread his feet apart.
•Standing close to provide support.
A
Standing close to provide support.
16
Q
- Physical assessment is being performed to Geoff by Nurse Sweet and Spice. During the abdominal examination, Sweet and Spice should perform the four physical examination techniques in which sequence?
• Auscultation immediately after inspection and then percussion and palpation
• Percussion, followed by inspection, auscultation, and palpation.
• Palpation of tender areas first and then inspection, percussion, and
auscultation.
• Inspection and then palpation, percussion, and auscultation.
A
Auscultation immediately after inspection and then percussion and palpation
17
Q
- Beginning in their 20’s, women should be told about the benefits and limitations of breast self-exam (BSE). Which scientific rationale should the nurse remember when performing a breast examination
on a female client?
• One half of all breast cancer deaths occur in women ages 35 to 45.
• The tail of Spence area must be included in self-examination.
• The position of choice for the breast examination is supine.
• A pad should be placed under the opposite scapula of the breast
being palpated.
A
The tail of Spence area must be included in self-examination.
18
Q
- A screen test for detection of human immunodeficiency virus (HIV) reveals a positive ELISA exam. Which of the following test will be used to confirm the diagnosis of HIV?
• Indirect immunofluorescence assay (IFA).
• CD4-to-CD8 ratio.
• Radioimmunoprecipitation assay (RIPA)
test.
• p24 antigen assay.
A
Indirect immunofluorescence assay (IFA).
19
Q
- A magnetic resonance imaging (MRI) scan is prescribed for a client with a suspected brain tumor. Which prescription does the nurse
prepare to administer to the client before the procedure?
An opioid
A sedative
A corticosteroid
An antihistamine
A
A sedative
20
Q
- Using crutches, a cane, or a walker can help keep your weight off your injured or weak leg, assist with balance, and enable you to perform your daily activities more safely. An adult is learning how to use a cane. Nurse Midnight Blue knows that the person can use the cane wisely when observing which of the following?
• The cane is held on the unaffected side; the cane and affected leg
are moved forward, then the unaffected leg comes forward.
• The cane is held on the affected side; the cane is moved forward then
the unaffected leg then the affected leg.
• The cane is held on the unaffected side; the cane is moved forward,
then the unaffected leg, then the affected leg.
• The cane is held on the affected side, the cane and unaffected leg are
moved forward then the affected leg comes forward.
A
The cane is held on the unaffected side; the cane and affected leg
are moved forward, then the unaffected leg comes forward.
21
Q
- The nurse is assessing a client who has just been measured and fitted for crutches. The nurse determines that the client’s crutches are
fitted correctly if:
• The elbow is at a 30-degree angle when the hand is on the handgrip
• The elbow is straight when the hand is on the handgrip.
• The client’s axilla is resting on the crutch pad during ambulation.
• The top of the crutch is even with the axilla.
A
The elbow is at a 30-degree angle when the hand is on the handgrip
22
Q
- Pepito Pilosopo asks nurse Perfecta about the difference between the cane and walker. What is the best response by the nurse Perfecta?
• A walker is a better choice than a cane.
• The cane should be used on the affected side.
• The cane should be used on the unaffected side
A
The cane should be used on the unaffected side
23
Q
- The nurse is caring for a client with a newly applied plaster leg cast. The nurse prevents the development of compartment syndrome
by:
• Elevating the affected limb and applying ice to the affected leg
• Elevating the limb and covering the limb with bath blankets
• Placing the leg in slightly dependent position and applying ice
• Keeping the leg horizontal and applying ice to the affected leg
A
Elevating the affected limb and applying ice to the affected leg
24
Q
- A client with a left arm cast complains of a foul odor. What is the appropriate action by the nurse?
• Assess further because this may be a sign of an infection.
• Teach the client proper cast care, including hygiene measures.
• This is normal, especially when a cast is in place for a few weeks.
• Assess further because this may be a sign of a neurovascular
compromise.
A
Assess further because this may be a sign of an infection.
25
24. Nurse manager Starlight is providing an educational session to the nursing staff in a skilled nursing facility on the guidelines for the safe use of physical restraints. Which of the following are safe guidelines?
• A physician's prescription is required.
• Restraints should be secured with a quick- release tie.
• Restraints are secured to side rails so that they can be easily removed
as necessary.
• Restraints are used only when other measures have failed to
prevent self-injury or injury to others.
• Restraints can be used as a usual part of treatment plans, as
indicated by the client's condition or symptoms.
• A physician's prescription is required.
• Restraints should be secured with a quick- release tie.
• Restraints are used only when other measures have failed to
prevent self-injury or injury to others.
26
25. A nurse manager is reviewing with the nursing staff the purposes for applying wrist and ankle restraints (security devices) to a client.
The nurse manager determines that further review is necessary when
a nursing staff member states that an indication for the use of a restraint is to:
• Limit movement of a limb.
• Keep the client in bed at night.
• Prevent the violent client from injuring self and others.
• Prevent the client from pulling out intravenous lines and catheters.
Keep the client in bed at night.
27
26. Nurse Bob must place a wrist restraint on a client. The client tells the nurse that he does not want to wear the restraint. The best action for Nurse Bob to do is to:
Sedate the client first.
Apply the wrist restraint.
Contact the client's family.
Consider alternative measures.
Consider alternative measures.
28
27. Emergency restraints or seclusion may be implemented without a physician's order under which of the following conditions?
• When a written order will be obtained from the primary physician
within 8 hours.
• If a voluntary client wants to leave against medical advice.
• When a minor child is out of control.
Never
When a written order will be obtained from the primary physician within 8 hours.
29
28. It is justified to use safe physical restraints as a:
• "Last resort" is necessary
• Means to ensure strict compliance with their medications.
• Way to protect the staff from being hurt by the client.
• Way to protect the client from harming himself.
"Last resort" is necessary
30
29. For any nurse working in a direct care setting, preparing medications and administering them to patients is part of the daily routine. Anticoagulant medicine reduce the ability of the blood to clot (coagulation means clotting). Mr. Stark is receiving heparin sodium and warfarin sodium (Coumadin) concurrently for a partial occlusion of the left common carotid artery. The client expresses concern about why both heparin and Coumadin are needed. The nurse's explanation is based on the knowledge that the plan:
• Allows clot dissolution and prevents new clot formation.
• Permits the administration of smaller doses of each drug.
• Immediately provides maximum protection against clot formation.
• Provides anticoagulant intravenously until the oral drug reaches its
therapeutic level.
Provides anticoagulant intravenously until the oral drug reaches its
therapeutic level.
31
30. Nitroglycerin has traditionally been the most important drug used in the symptomatic relief of angina. During the previous few months,
a 55-year-old woman felt brief twinges of chest pain while working in her garden and has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of stable angina
pectoris. Evaluation of the effectiveness of nitroglycerin SL is based
on:
Relief of anginal pain.
Improved cardiac output.
An increase in blood pressure.
Dilation of superficial blood vessels.
Relief of anginal pain.
32
31. Nurse Shine Star is caring for a female client with a history of GI bleeding, sickle cell disease, and a platelet count of 22,000/µl. The
female client is dehydrated and receiving dextrose 5% in half-normal
saline solution at 150 ml/hr. The client complains of severe bone pain and is scheduled to receive a dose of morphine sulfate. In administering the medication, Nurse Shine Star should avoid which
route?
I.V
I.M
Oral
S.C.
I.M
33
32. Doctor's Order: Cleocin Oral Susp. 600 mg p.o.; Directions for mixing: Add 100 mL of water and shake vigorously. Each 2.5 mL will
contain 100 mg of Cleocin. How many tsp of Cleocin will you administer?
3 tsp
15 tsp
1.5 tsp
6 tsp
3 tsp
34
33. Doctor's Order: Rocephin 0.5 grams in 250 mL of D5W to infuse
IVPB 45 minutes; Drop Factor: 12gtt/min. How many gtt/ min will you regulate the IVPB?
6 gtt/min
30 gtt/min
67 gtt/min
87 gtt/min
67 gtt/min
35
34. Hygiene is a highly personal matter determined by individual values and practices.
When performing oral care on a comatose client the nurse should:
• Apply lemon glycerin to the client's lips at least every 2 hours.
• Brush the teeth with the client lying supine.
• Place the client in a side-lying position, with the head of the bed
lowered.
Place the client in a side-lying position, with the head of the bed
lowered.
36
35. Nurse Param Parapa is giving a bed bath to a client who is on strict
bed rest. To increase venous return, the nurse bathes the client's
extremities by using:
• Firm circular strokes from proximal to distal areas.
• Short, patting strokes from distal to proximal areas.
• Smooth, light strokes back and forth from proximal to distal areas.
• Long, firm strokes from distal to proximal areas.
Long, firm strokes from distal to proximal areas.
37
36. After all the preoperative medications are administered,
in order to promote safety of the patient, the nurse will:
• Assess the patient for any untoward side effects of the medicines.
• Document the preoperative medications administered.
• Put the side rails up.
• Transfer the patient to the operating room.
Put the side rails up.
38
37. Maintenance of a sterile field in the operating room is
accomplished through the observance of surgical conscience by the
members of the surgical team which may mean strict adherence to
the principles of aseptic technique. Which of the following practices
observe this principle?
• The members of the sterile team face one another when they move.
• The scrub nurse places the instruments at the center of the Mayo
table and even one- inch from the edge.
• The circulating nurse touches the inner side of the wrapped sterile
instruments.
• The scrub nurse changes the whole wet sterile field.
The scrub nurse places the instruments at the center of the Mayo
table and even one- inch from the edge.
39
40
39. Nurse Pink Bloom is supervising Mr. Ong during spirometry.
Which of the following 60 actions when made by the patient would indicate that health teaching regarding correct incentive spirometer
use has been ineffective?
• immediately after taking a slow, deep inhalation, the patient exhales
slowly and steadily.
• the patient avoid brisk or quick inhalations.
• when the patient has difficulty breathing through the mouth only,
he uses a nose clip.
• Mr. Ong holds the device in an upright position.
immediately after taking a slow, deep inhalation, the patient exhales
slowly and steadily.
41
40. Nurse Free Lance is caring for a client with a closed chest drainage
system. Onoo assessment of the client, the nurse notes a rise and fall
(fluctuation) of fluid in the water seal chamber. Based on this finding,
what action should the nurse take?
Contact the physician
Add water to the water seal chamber
Add water to the suction control chamber
Document that the system is functioning accurately.
Document that the system is functioning accurately.
42
41. Dina Natutu, a client with empyema is to have thoracentesis performed at the bedside. The nurse plans to have which of the
following available in the event that the procedure is not effective?
Code cart
A small bore needles
Extra-large drainage bottle
Chest tube and drainage system
Chest tube and drainage system
43
42. Nurse Choco Laite assesses a closed chest tube drainage system of a client who had a lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. The nurse would first:
• Contact the physician
• Check the client's blood pressure and heart rate
• Check for kinks in the chest drainage system
• Connect a new drainage system to the client's chest tube.
Check for kinks in the chest drainage system
44
43. Nurse Choco Laite is providing instructions to a client being discharged from the hospital following removal of a chest tube that
was inserted after thoracic surgery. Which of the following
statements, if made by the client, indicates a need for further
instruction?
• "If I note any signs of infection, I should contact the physician"
• "If I have any difficulty in breathing, I should call the physician."
• "I should remove the chest tube site dressing as soon as I get home."
• "I should avoid heavy lifting for at least 4 to 6 weeks. "
"I should remove the chest tube site dressing as soon as I get home."
45
44. Oxygen therapy is the administration of oxygen as a therapeutic
modality. It is prescribed by the physician, who specifies the
concentration, method of delivery, and liter flow per minute.
Mr. Joey, 67 years old, was diagnosed with Chronic Bronchitis. You
were assigned to care for him. You expect to administer oxygen at:
6-8 LPM
1-2 LPM
10-15 LPM
9-10 LPM
1-2 LPM
46
45. An oxygen delivery system is prescribed for a client with Chronic
Obstructive Pulmonary Disease (COPD) to deliver a precise oxygen
concentration. Which of the following types of oxygen delivery systems would Nurse Sarah anticipate to be prescribed?
Venturi mask
Aerosol mask
Face tent
Tracheostomy collar
Venturi mask
47
46. Nurse Sun Dawn is conducting preoperative teaching with a client about the use of an incentive spirometer in the postoperative period.
Nurse Sun Dawn would include which piece of information in
discussion with the client?
• Keep a loose seal between the lips and the mouthpiece.
• Inhale as rapidly as possible.
• After maximum inspiration, hold the breath for 15 seconds and
exhale.
• The best results are achieved when the head of the bed is elevated
45 to 90 degrees.
The best results are achieved when the head of the bed is elevated
45 to 90 degrees.
48
47. Nurse Sun Dawn's client is unable to use the incentive spirometer
device. In counseling 00 the client, the first advice of nurse Sun Dawn
would be to:
• Give up and do regular deep breathing.
• Obtain another device because this one is obviously faulty.
• Be much more vigorous in increasing increments.
• Start slowly and gradually increase volume over several sessions.
Start slowly and gradually increase volume over several sessions.
49
48. The nurse is discussing breathing exercises with a postoperative client, she should indicate teaching the client to:
• Place a hand on the abdomen and feel it rise
• Take short frequent breaths.
• Exhale with the mouth open
• Plan to do the exercise twice a day
Place a hand on the abdomen and feel it rise
50
49. Chronic obstructive pulmonary disease (COPD) is a lung disease
that may either be chronic bronchitis or emphysema. The nurse is
assigned to the care of clients having these pulmonary problems.
Which diagnostic study can determine when cellular metabolism becomes anaerobic and when pH decreases?
ABG levels
CBC
OECG
Lung scan
ABG levels
51
50. The arterial blood gasses of a patient with severe chronic obstructive pulmonary 00 disease (COPD) are: pH 7.34, PaO2 80 mmHg, PaCO2 47 mmHg, HCO3 28 mEq/L. Based on these findings, what is the priority action of the nurse?
Administer oxygen 4 LPM via mask.
No action is required at this time.
Administer an IV corticosteroid.
Perform vigorous suctioning
No action is required at this time.
52
51. The nurse would anticipate which of the following ABG results in a client experiencing a prolonged, severe asthma attack?
• Decreased PaO2, increased PaO2, and decreased pH.
• Increased PaCO2, decreased PaO2, and decreased pH.
Increased PaCO2, decreased PaO2, and decreased pH.
53
52. The primary responsibility of the nurse when caring for a patient with a chest tube attached to a three-chamber underwater seal drainage system would be to:
• Maintain the closed system.
• Encourage deep breathing and coughing.
• Maintain mechanical suction to the system.
• Keep the client in the dorsal recumbent position.
Maintain the closed system.
54
53. The nurse is handling a client with a chest tube. Suddenly, the
chest drainage system is accidentally disconnected, what is the most
appropriate action for the nurse to take?
• Secure the chest tube using a tape.
• Clamp the chest tube immediately.
• Place the end of the chest tube in a container of normal sterile
saline.
Place the end of the chest tube in a container of normal sterile
saline.
55
54. Cardiovascular disease (CVD) is a class of diseases that involve the
heart or blood 00 vessels. Nurse Flora Daisy is preparing a client for cardioversion using anterolateral paddle placement. The nurse places
the conductive gel pads at which areas on the client's chest in preparation for this procedure?
• Left fourth intercostal space and left fifth intercostal space at
midaxillary line.
• Left second intercostal space and left fifth intercostal space at
midaxillary line.
• Right fourth intercostal space and left fifth intercostal space at
anterior axillary line.
• Right second intercostal space and left fifth intercostal space at
anterior axillary line.
Right second intercostal space and left fifth intercostal space at
anterior axillary line.
56
55. A client who is having an increasing number of premature ventricular contractions (PVCs) is scheduled for a 24-hour Holter monitor. The nurse instructs the client to:
• Remain NPO after midnight the night before the procedure.
• Disconnect the electrodes only to bathe.
• Keep an accurate record of activities during
Keep an accurate record of activities during
57
56. The home care nurse is caring for a client who has just been discharged from the hospital after implantation of a permanent
pacemaker. A priority nursing action to maintain a safe environment for the client would be to assess the client's home for the presence
of:
Hair dryers
Electric blankets
Electric toothbrushes
Electrical items that have strong electric currents or magnetic fields.
Electrical items that have strong electric currents or magnetic fields.
58
57. A home care nurse visits a client who just had a permanent pacemaker implanted. The nurse instructs the client about performing pulse checks. Which statement by the client indicates an understanding of this procedure? point
• I will take my pulse every day at any time, and if I notice it slowing
a little, I'll call the doctor.
• I will take my pulse at the same time every day, and if I notice any
change in the rate or rhythm, I'll call the doctor.
• It's important that I take my pulse at the same time every day and
that I count for 15 full seconds by using a watch with a second hand.
I will take my pulse at the same time every day, and if I notice any
change in the rate or rhythm, I'll call the doctor.
59
58. A client has undergone angioplasty of the iliac artery. Which of
the following techniques should the nurse perform to best detect bleeding from the angioplasty in the region of the Iliac artery?
Palpate the pedal pulses
Measure the abdominal girth
Ask the client about mild pain in the area
Auscultate over the iliac area with a Doppler device
Measure the abdominal girth
60
59. Blood Transfusions are used for various medical conditions to
replace lost components of the blood. Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit
levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.8°F. Which action should the nurse
take?
• Give an antipyretic and begin the transfusion.
• Proceed with the transfusion.
• Administer an antihistamine and begin the transfusion.
• Delay hanging the blood and inform the physician.
Delay hanging the blood and inform the physician.
61
60. After terminating the transfusion during a reaction, which action should the nurse immediately take next?
• Run a solution of 5% dextrose in water.
• Run normal saline at a keep-vein-open rate.
• Remove the IV line.
• Fast drip 200 mL normal saline.
Run normal saline at a keep-vein-open rate.
62
61. To verify the age of blood cells in a blood, the nurse will check which of the following?
Blood type.
Blood group.
Blood identification number.
Blood expiration date.
Blood expiration date.
63
62. Nurse Paulo has received a blood unit from the blood bank and has rechecked the blood bag properly with nurse Edward. Prior the facilitation of the blood transfusion, nurse Paulo priority check which of the following?
Intake and output
NPO standing order.
Vital signs.
Skin turgor.
Vital signs.
64
63. The nurse prepares a postoperative client who is ready for discharge for care at home.
The client must receive continued intravenous therapy, so the nurse
provides the client with instructions on caring for the IV site. Which is
the best method of evaluating the client's ability to care for the IV
site?
• Have the client role play an IV dressing change.
• Invite the client to change the IV dressing unaided.
• Direct the client to explain IV site care completely.
Invite the client to change the IV dressing unaided.
65
64. Nurse Steve prepares to administer an intravenous medication when he notes that the medication is incompatible with the IV solution. Which is the best intervention for the nurse to implement for safe medication administration?
• Ask the provider to prescribe a compatible IV solution.
• Start a new IV catheter for the incompatible medication.
• Collaborate with the provider for a new administration route.
• Flush tubing before and after administering the medication with
normal saline.
Flush tubing before and after administering the medication with
normal saline.
66
65. The nurse is aware that the supplemental medication most frequently ordered in conjunction with furosemide (Lasix) is:
Chloride
Digoxin
Potassium
Sodium
Potassium
67
66. The school nurse teaches an athletic coach how to prevent
dehydration among athletes practicing in the hot weather. What is
the best advice for the nurse to give to the coach?
• Drink plenty of fluids before and after practice
• Have the athletes take a salt tablet before practice.
• Reschedule for before school and after sunset.
• Provide a fluid break every 30 minutes during practice.
Provide a fluid break every 30 minutes during practice.
68
67. To stop the bleeding in aclient with esophageal varices, a Sengstaken-Blakemore tube is inserted to apply pressure against the
varices (tamponade). After insertion of the tube, the nurse
implements safety measures and:
• Elevates the head of the bed 90 degrees
• Has suction available and scissors at the bedside.
• Monitors intake and output.
• Checks level of consciousness every hour
Has suction available and scissors at the bedside.
69
68. Nurse Summer Shine is caring for a client after a colonoscopy. The
nurse monitors the client's temperature and notes that the client has
developed a sudden temperature elevation. The nurse interprets that
this finding may be associated with which potential complication of
the procedure?
A nosocomial infection
Perforation of the intestine
Severe dehydration
Internal hemorrhage
Perforation of the intestine
70
69. Nurse Summer Shine is preparing a client for a colonoscopy procedure. The nurse assist the client to assume which position for the procedure?
Knee/chest
Lithotomy
Left Sims'
Right Sims'
Left Sims'
71
70. A staff nurse is giving dietary instructions to a client who has a
new colostomy. The nurse encourages the client to eat foods representing which of the following diets for the first 4 to 6 weeks postoperatively
High protein
High carbohydrate
Low calorie
Low fiber
Low fiber
72
71. Nurse Autumn Winter is a newly hired Community Health Nurse.
In order for Nurse 00 Nona to become effective in her caregiving role
to the different types of clientele in the community, she should be equipped with the BASIC knowledge about
statistics
research
nursing process
nursing theories
nursing process
73
72. The BEST Community Health Nursing principle that will guide Nurse Autumn Winter in the effective performance of her various roles and functions is focused on the community that
• has different health needs and problems
• is considered as a primary client
• has various structures and resources
• is composed of individuals and families
has different health needs and problems
74
73. As a health monitor, which of the following should be considered by the nurse as health threats in the community? Select all that apply:
Ineffective breastfeeding
Fire hazards
Inadequate immunization
Polluted water supply
Ineffective breastfeeding
Fire hazards
Inadequate immunization
Polluted water supply
75
74. Nurse Bella Spring takes charge of handling the Mental Health
Promotion program in the midst of the ongoing health crisis due to the COVID 19 pandemic. Teaching the families on promoting mentalhealth at home in this pandemic time should focus on the following EXCEPT
Oseeking community support.
observing open communication.
engaging in social media the whole day.
reaching out to friends
engaging in social media the whole day.
76
75. During this pandemic time, which of the following roles of Nurse
Bella Spring should she significantly intensify to prevent more cases of mental problems in the community?
Case Finder
Case Manager
Researcher
Surveyor
Case Finder
77
76. There are individuals who are suffering from mental health
challenges due to the pandemic. The BEST nursing action is
• refer for admission at the mental health unit.
• help in setting up debriefing stations.
• recommend hiring of a community psychiatrist.
• set up a mental health program
set up a mental health program
78
77. Which of the following information about severity of
mental illness would be important to the mental health program in
the community setting?
• Mentally -ill patients are always dangerous..
• Mental illness is hereditary..
• Mental illness is not curable.
• Mental illness is a global concern.
Mental illness is a global concern.
79
78. After a webinar on the Mental Health Act, Nurse Bella
Spring realized that the community has to change which of the following perceptions?
Community resilience is important.
Mental illness is incurable.
psychosocial services should be available.
Mental illness is incurable.
80
79. Nurse Nancy is in charge of the Geriatric Care program of the barangay. To plan out for the activities intended for the elderly
population the nurse should begin to
• do survey of the number of the elderly population.
• get informed consent.
• ask permission from barangay officials.
• tap the help of experts
do survey of the number of the elderly population.
81
80. In assessing the health condition of the older persons, which is
the BEST measure in determining their functional status?
Financial capability of the family
Age of the patient
Activities of daily living
Activities of daily living
82
81. Which information should the nurse provide to the elderly and
their families regarding drug regimen prescribed to patients?
• Liquid medication is more convenient and safer
• Allow them to refuse to take medicines
• Give independence to take medicines
• They are more vulnerable to adverse drug reactions
They are more vulnerable to adverse drug reactions
83
82. Care giving to older persons can be burdensome to other members of family who are the caregivers. During home visit to the family, the nurse should look for symptoms of
agitation
burnout
withdrawal
suicidal tendency
burnout
84
83. Nurse Henie uses the Family coping index in assessing family health needs and problems of particularly of families who are
vulnerable to illness. Which of the following is an evidence of the poor family coping index related to healthcare attitudes?
• A parents who washes the wound of the child with running water.
• The family who observes the habit of cleaning surroundings.
• A young mother who introduced solid food to her.
• A mother who brings her child to be vaccinated for measles.
A young mother who introduced solid food to her.
85
84. Which of the following is the BEST evidence of a family whose
family coping index on therapeutic competence is rated as coping
well?
• Shows positive interpersonal relationship
• Participates in the weekly clean and green program of the community
• Maintain clean and organized household ambience.
• Visits the clinic frequently well or sick.
Maintain clean and organized household ambience.
86
85. Which of the following tools used by nurses in the community setting for assessing health needs and problems of families that is similar to family coping index
Nursing theories
Vital statistics
Case study
Nursing diagnosis
Nursing diagnosis
87
86. Ms Shine Night is a newly assigned school nurse in the elementary
school of the barangay. She planned to do physical examination of every school child. In assessing the health condition of school children, which of the following would be the findings common to this
age group?
Cancer and other malignancies.
Anemia and other blood disorders.
Lice and parasites
Fractures and injuries
Lice and parasites
88
87. In the performance of her roles and functions as a school nurse, which guiding principle should she consider very IMPORTANT?
• Health is an integral part of the education process.
• The nurse is in full authority over the children.
• The local health authority supervises the school health.
• School nursing is more focused on socialization
Health is an integral part of the education process.
89
88. Who should Nurse Shine Night consider as a priority for home visitation?
• Pedro 9 years old whose parents are both working.
• Melissa 10 years old with stunted growth for her age.
• Cindy 7 years old who has been absent due to skin lesions.
• Mike 8 years old who often sleeps during class hour.
Cindy 7 years old who has been absent due to skin lesions.
90
89. Nurse Happy Joy would like to communicate to the people the
health problems they had identified. In reaching out every household
in the community, which is the BEST strategy the nurse should employ?
Call for general assembly.
Use social media.
Send memorandum.
Write a letter to residents.
Call for general assembly.
91
90. Nurse Happy Joy received information from some community residents who suspect that neighbor is abusing his young child. Which
should be the PRIORITY nursing action?
Report to police authorities
Notify the social worker.
Ignore the information.
Validate the information.
Validate the information.
92
91. Nurse Pinky Blush is developing a plan of care for a client who is receiving parenteral nutrition (PN). The nurse identifies assessments to be made to help identify complications related to the infusion of the PN solution. The care plan will include monitoring of which of the following?
Pulse oximetry
Apical rate
Blood glucose levels
Hemoglobin and hematocrit
Blood glucose levels
93
92. A client is receiving nutrition by means of parenteral
nutrition (PN). A nurse monitors the client for complications of the therapy and assesses the client for which of the following signs of
hyperglycemia?
Fever, weak, pulse, and thirst
Nausea vomiting, and oliguria
Sweating, chills, and abdominal pain
Weakness, thirst, and increased urine output
Weakness, thirst, and increased urine output
94
93. A Registered Nurse has inserted a nasogastric (NG) tube to the
level of oropharynx has repositioned the client's head in a flexed forward position. The client has been asked to begin swallowing.The nurse starts to slowly advance the NG tube with each swallow. The client begins to cough, gag, and choke. Which nursing action would least likely result in proper tube insertion and promote client relaxation?
• Continuing to advance the tube to the desired distance.
• Pulling the tube back slightly
• Checking the back of the pharynx using a
Continuing to advance the tube to the desired distance.
95
94. Nurse Teddy Bear is preparing to initiate bolus enteral feedings via
nasogastric (NG) tube to a client. Which of the following actions
represents safe practice by the nurse?
• Checks the volume of the residual after administering the bolus
feeding.
• Aspirates gastric contents prior to initiating the feeding and assures
that pH is >9.
• Elevates the head of the bed to 25 degrees and maintains for 30
minutes after instillation of feeding.
• Measures the length of the tube from where it protrudes from the
nose to the end and compares to previously documented
measurements.
Measures the length of the tube from where it protrudes from the
nose to the end and compares to previously documented
measurements.
96
95. An appropriate intervention for a client with a nursing diagnosis
of imbalanced nutrition: more than body requirements related to uncontrolled eating is:
Make a list of food preferences.
Weigh self-daily with the same scale.
Lose 2 pounds each week
Identify the nutritional value of selected foods
Identify the nutritional value of selected foods
97
96. A client experiencing end-stage renal disease has an arteriovenous (AV) fistula placed surgically in preparation for hemodialysis. Which of the following actions is appropriate for the
nurse to document in the plan for care of the AV fistula?
• Palpate the bruit of the AV fistula weekly to assess for thrombosis.
• Use the AV fistula site for blood draws to prevent increased pain of
multiple blood draws.
• Do not carry heavy objects that would compress the AV fistula and
cause thrombosis.
√Do not carry heavy objects that would compress the AV fistula and
cause thrombosis.
98
97. A nurse is assisting a physician who is going to insert a peritoneal
dialysis catheter into a client's abdomen at the bedside. The client is
in renal failure and cannot void. To prevent complications of catheter insertion, the nurse should plan to:
• Assist the client to a standing position.
• Do a straight catheterization of the bladder before the procedure.
• Administer an opioid analgesic before peritoneal catheter placement.
• Obtain a baseline temperature for the client's record
Do a straight catheterization of the bladder before the procedure.
99
98. The client newly diagnosed with chronic renal failure recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome the nurse assesses the client during dialysis
for
• Hypertension, tachycardia, and fever.
• Hypotension, tachycardia, and hypothermia.
• Restlessness, irritability, and generalized weakness
• Headache, deteriorating level of consciousness and twitching.
√Headache, deteriorating level of consciousness and twitching.
100
99. A nurse is caring for a hospitalized client with polycystic kidney
disease who had an intravenous pyelography (IVP). The nurse monitors which specific item in the post procedure period?
Lung sounds
Groin area
Carotid pulse
√Intake and output
√Intake and output
101
100. Patient Fruity died because of Renal Failure. Nurse Angela raised
the head of bed during post-mortem care. What is the purpose of this
action by nurse Angela?
• You need to raise the head to maintain a patent airway.
• You need to raise the head for aesthetic purposes.
• You need to raise the head as a sign of respect.
• You need to raise the head for the family to see the patient better.
√ You need to raise the head for aesthetic purposes.
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