Answers and Rationale – Community Health
Nursing and Care of the Mother and Child
1. Answer: (A) Inevitable
Rationale: An inevitable abortion is termination
of pregnancy that cannot be prevented.
Moderate to severe bleeding with mild
cramping and cervical dilation would be noted
in this type of abortion.
2. Answer: (B) History of syphilis
Rationale: Maternal infections such as syphilis,
toxoplasmosis, and rubella are causes of
spontaneous abortion.
3. Answer: (C) Monitoring apical pulse
Rationale: Nursing care for the client with a
possible ectopic pregnancy is focused on
preventing or identifying hypovolemic shock
and controlling pain. An elevated pulse rate is
an indicator of shock.
4. Answer: (B) Increased caloric intake
Rationale: Glucose crosses the placenta, but
insulin does not. High fetal demands for
glucose, combined with the insulin resistance
caused by hormonal changes in the last half of
pregnancy can result in elevation of maternal
blood glucose levels. This increases the
mother’s demand for insulin and is referred to
as the diabetogenic effect of pregnancy.
5. Answer: (A) Excessive fetal activity.
Rationale: The most common signs and
symptoms of hydatidiform mole includes
elevated levels of human chorionic
gonadotropin, vaginal bleeding, larger than
normal uterus for gestational age, failure to
detect fetal heart activity even with sensitive
instruments, excessive nausea and vomiting,
and early development of pregnancy-induced
hypertension. Fetal activity would not be noted.
6. Answer: (B) Absent patellar reflexes
Rationale: Absence of patellar reflexes is an
indicator of hypermagnesemia, which requires
administration of calcium gluconate.
7. Answer: (C) Presenting part in 2 cm below the
plane of the ischial spines.
Rationale: Fetus at station plus two indicates
that the presenting part is 2 cm below the
plane of the ischial spines.
8. Answer: (A) Contractions every 1 ½ minutes
lasting 70-80 seconds.
Rationale: Contractions every 1 ½ minutes
lasting 70-80 seconds, is indicative of
hyperstimulation of the uterus, which could
result in injury to the mother and the fetus if
Pitocin is not discontinued.
9. Answer: (C) EKG tracings
Rationale: A potential side effect of calcium
gluconate administration is cardiac arrest.
Continuous monitoring of cardiac activity (EKG)
throught administration of calcium gluconate is
an essential part of care.
10. Answer: (D) First low transverse caesarean was
for breech position. Fetus in this pregnancy is in
a vertex presentation.
Rationale: This type of client has no obstetrical
indication for a caesarean section as she did
with her first caesarean delivery.
11. Answer: (A) Talk to the mother first and then to
the toddler.
Rationale: When dealing with a crying toddler,
the best approach is to talk to the mother and
ignore the toddler first. This approach helps the
toddler get used to the nurse before she
attempts any procedures. It also gives the
toddler an opportunity to see that the mother
trusts the nurse.
12. Answer: (D) Place the infant’s arms in soft
elbow restraints.
Rationale: Soft restraints from the upper arm to
the wrist prevent the infant from touching her
lip but allow him to hold a favorite item such as
a blanket. Because they could damage the
operative site, such as objects as pacifiers,
suction catheters, and small spoons shouldn’t
be placed in a baby’s mouth after cleft repair. A
baby in a prone position may rub her face on
the sheets and traumatize the operative site.
The suture line should be cleaned gently to
prevent infection, which could interfere with
healing and damage the cosmetic appearance
of the repair.
13. Answer: (B) Allow the infant to rest before
feeding.
Rationale: Because feeding requires so much
energy, an infant with heart failure should rest
before feeding.
14. Answer: (C) Iron-rich formula only.
Rationale: The infants at age 5 months should
receive iron-rich formula and that they
shouldn’t receive solid food, even baby food
until age 6 months.
15. Answer: (D) 10 months
Rationale: A 10 month old infant can sit alone
and understands object permanence, so he
would look for the hidden toy. At age 4 to 6
months, infants can’t sit securely alone. At age
8 months, infants can sit securely alone but
cannot understand the permanence of objects.
16. Answer: (D) Public health nursing focuses on
preventive, not curative, services.
Rationale: The catchments area in PHN consists
of a residential community, many of whom are
well individuals who have greater need for
preventive rather than curative services.
17. Answer: (B) Efficiency
Rationale: Efficiency is determining whether the
goals were attained at the least possible cost.
18. Answer: (D) Rural Health Unit
Rationale: R.A. 7160 devolved basic health
services to local government units (LGU’s ). The
public health nurse is an employee of the LGU.
19. Answer: (A) Mayor
Rationale: The local executive serves as the
chairman of the Municipal Health Board.
20. Answer: (A) 1
Rationale: Each rural health midwife is given a
population assignment of about 5,000.
21. Answer: (B) Health education and community
organizing are necessary in providing
community health services. Rationale: The
community health nurse develops the health
capability of people through health education
and community organizing activities.
22. Answer: (B) Measles
Rationale: Presidential Proclamation No. 4 is on
the Ligtas Tigdas Program
23. Answer: (D) Core group formation
Rationale: In core group formation, the nurse is
able to transfer the technology of community
organizing to the potential or informal
community leaders through a training program.
24. Answer: (D) To maximize the community’s
resources in dealing with health problems.
Rationale: Community organizing is a
developmental service, with the goal of
developing the people’s self-reliance in dealing
with community health problems. A, B and C
are objectives of contributory objectives to this
goal.
25. Answer: (D) Terminal
Rationale: Tertiary prevention involves
rehabilitation, prevention of permanent
disability and disability limitations appropriate
for convalescents, the disabled, complicated
cases and the terminally ill (those in the
terminal stage of a disease).
26. Answer: (A) Intrauterine fetal death.
Rationale: Intrauterine fetal death, abruptio
placentae, septic shock, and amniotic fluid
embolism may trigger normal clotting
mechanisms; if clotting factors are depleted,
DIC may occur. Placenta accreta, dysfunctional
labor, and premature rupture of the
membranes aren't associated with DIC.
27. Answer: (C) 120 to 160 beats/minute
Rationale: A rate of 120 to 160 beats/minute in
the fetal heart appropriate for filling the heart
with blood and pumping it out to the system.
28. Answer: (A) Change the diaper more often.
Rationale: Decreasing the amount of time the
skin comes contact with wet soiled diapers will
help heal the irritation.
29. Answer: (D) Endocardial cushion defect
Rationale: Endocardial cushion defects are seen
most in children with Down syndrome,
asplenia, or polysplenia.
30. Answer: (B) Decreased urine output
Rationale: Decreased urine output may occur in
clients receiving I.V. magnesium and should be
monitored closely to keep urine output at
greater than 30 ml/hour, because magnesium is
excreted through the kidneys and can easily
accumulate to toxic levels.
31. Answer: (A) Menorrhagia
Rationale: Menorrhagia is an excessive
menstrual period.
32. Answer: (C) Blood typing
Rationale: Blood type would be a critical value
to have because the risk of blood loss is always
a potential complication during the labor and
delivery process. Approximately 40% of a
woman’s cardiac output is delivered to the
uterus, therefore, blood loss can occur quite
rapidly in the event of uncontrolled bleeding.
33. Answer: (D) Physiologic anemia
Rationale: Hemoglobin values and hematocrit
decrease during pregnancy as the increase in
plasma volume exceeds the increase in red
blood cell production.
34. Answer: (D) A 2 year old infant with stridorous
breath sounds, sitting up in his mother’s arms
and drooling.
Rationale: The infant with the airway
emergency should be treated first, because of
the risk of epiglottitis.
35. Answer: (A) Placenta previa
Rationale: Placenta previa with painless vaginal
bleeding.
36. Answer: (D) Early in the morning
Rationale: Based on the nurse’s knowledge of
microbiology, the specimen should be collected
early in the morning. The rationale for this
timing is that, because the female worm lays
eggs at night around the perineal area, the first
bowel movement of the day will yield the best
results. The specific type of stool specimen
used in the diagnosis of pinworms is called the
tape test.
37. Answer: (A) Irritability and seizures
Rationale: Lead poisoning primarily affects the
CNS, causing increased intracranial pressure.
This condition results in irritability and changes
in level of consciousness, as well as seizure
disorders, hyperactivity, and learning
disabilities.
38. Answer: (D) “I really need to use the diaphragm
and jelly most during the middle of my
menstrual cycle”.
Rationale: The woman must understand that,
although the “fertile” period is approximately
mid-cycle, hormonal variations do occur and
can result in early or late ovulation. To be
effective, the diaphragm should be inserted
before every intercourse.
39. Answer: (C) Restlessness
Rationale: In a child, restlessness is the earliest
sign of hypoxia. Late signs of hypoxia in a child
are associated with a change in color, such as
pallor or cyanosis.
40. Answer: (B) Walk one step ahead, with the
child’s hand on the nurse’s elbow.
Rationale: This procedure is generally
recommended to follow in guiding a person
who is blind.
41. Answer: (A) Loud, machinery-like murmur.
Rationale: A loud, machinery-like murmur is a
characteristic finding associated with patent
ductus arteriosus.
42. Answer: (C) More oxygen, and the newborn’s
metabolic rate increases.
Rationale: When cold, the infant requires more
oxygen and there is an increase in metabolic
rate. Non-shievering thermogenesis is a
complex process that increases the metabolic
rate and rate of oxygen consumption,
therefore, the newborn increase heat
production.
43. Answer: (D) Voided
Rationale: Before administering potassium I.V.
to any client, the nurse must first check that the
client’s kidneys are functioning and that the
client is voiding. If the client is not voiding, the
nurse should withhold the potassium and notify
the physician.
44. Answer: (c) Laundry detergent
Rationale: Eczema or dermatitis is an allergic
skin reaction caused by an offending allergen.
The topical allergen that is the most common
causative factor is laundry detergent.
45. Answer: (A) 6 inches
Rationale: This distance allows for easy flow of
the formula by gravity, but the flow will be slow
enough not to overload the stomach too
rapidly.
46. Answer: (A) The older one gets, the more
susceptible he becomes to the complications of
chicken pox.
Rationale: Chicken pox is usually more severe in
adults than in children. Complications, such as
pneumonia, are higher in incidence in adults.
47. Answer: (D) Consult a physician who may give
them rubella immunoglobulin.
Rationale: Rubella vaccine is made up of
attenuated German measles viruses. This is
contraindicated in pregnancy. Immune globulin,
a specific prophylactic against German measles,
may be given to pregnant women.
48. Answer: (A) Contact tracing
Rationale: Contact tracing is the most practical
and reliable method of finding possible sources
of person-to-person transmitted infections,
such as sexually transmitted diseases.
49. Answer: (D) Leptospirosis
Rationale: Leptospirosis is transmitted through
contact with the skin or mucous membrane
with water or moist soil contaminated with
urine of infected animals, like rats.
50. Answer: (B) Cholera
Rationale: Passage of profuse watery stools is
the major symptom of cholera. Both amebic
and bacillary dysentery are characterized by the
presence of blood and/or mucus in the stools.
Giardiasis is characterized by fat malabsorption
and, therefore, steatorrhea.
51. Answer: (A) Hemophilus influenzae
Rationale: Hemophilus meningitis is unusual
over the age of 5 years. In developing countries,
the peak incidence is in children less than 6
months of age. Morbillivirus is the etiology of
measles. Streptococcus pneumonia and
Neisseria meningitidis may cause meningitis,
but age distribution is not specific in young
children.
52. Answer: (B) Buccal mucosa
Rationale: Koplik’s spot may be seen on the
mucosa of the mouth or the throat.
53. Answer: (A) 3 seconds
Rationale: Adequate blood supply to the area
allows the return of the color of the nailbed
within 3 seconds.
54. Answer: (B) Severe dehydration
Rationale: The order of priority in the
management of severe dehydration is as
follows: intravenous fluid therapy, referral to a
facility where IV fluids can be initiated within 30
minutes, Oresol or nasogastric tube. When the
foregoing measures are not possible or
effective, then urgent referral to the hospital is
done.
55. Answer: (A) 45 infants
Rationale: To estimate the number of infants,
multiply total population by 3%.
56. Answer: (A) DPT
Rationale: DPT is sensitive to freezing. The
appropriate storage temperature of DPT is 2 to
8° C only. OPV and measles vaccine are highly
sensitive to heat and require freezing. MMR is
not an immunization in the Expanded Program
on Immunization.
57. Answer: (C) Proper use of sanitary toilets
Rationale: The ova of the parasite get out of the
human body together with feces. Cutting the
cycle at this stage is the most effective way of
preventing the spread of the disease to
susceptible hosts.
58. Answer: (D) 5 skin lesions, positive slit skin
smear
Rationale: A multibacillary leprosy case is one
who has a positive slit skin smear and at least 5
skin lesions.
59. Answer: (C) Thickened painful nerves
Rationale: The lesion of leprosy is not macular.
It is characterized by a change in skin color
(either reddish or whitish) and loss of sensation,
sweating and hair growth over the lesion.
Inability to close the eyelids (lagophthalmos)
and sinking of the nosebridge are late
symptoms.
60. Answer: (B) Ask where the family resides.
Rationale: Because malaria is endemic, the first
question to determine malaria risk is where the
client’s family resides. If the area of residence is
not a known endemic area, ask if the child had
traveled within the past 6 months, where she
was brought and whether she stayed overnight
in that area.
61. Answer: (A) Inability to drink
Rationale: A sick child aged 2 months to 5 years
must be referred urgently to a hospital if
he/she has one or more of the following signs:
not able to feed or drink, vomits everything,
convulsions, abnormally sleepy or difficult to
awaken.
62. Answer: (A) Refer the child urgently to a
hospital for confinement.
Rationale: “Baggy pants” is a sign of severe
marasmus. The best management is urgent
referral to a hospital.
63. Answer: (D) Let the child rest for 10 minutes
then continue giving Oresol more slowly.
Rationale: If the child vomits persistently, that
is, he vomits everything that he takes in, he has
to be referred urgently to a hospital. Otherwise,
vomiting is managed by letting the child rest for
10 minutes and then continuing with Oresol
administration. Teach the mother to give Oresol
more slowly.
64. Answer: (B) Some dehydration
Rationale: Using the assessment guidelines of
IMCI, a child (2 months to 5 years old) with
diarrhea is classified as having SOME
DEHYDRATION if he shows 2 or more of the
following signs: restless or irritable, sunken
eyes, the skin goes back slow after a skin pinch.
65. Answer: (C) Normal
Rationale: In IMCI, a respiratory rate of
50/minute or more is fast breathing for an
infant aged 2 to 12 months.
66. Answer: (A) 1 year
Rationale: The baby will have passive natural
immunity by placental transfer of antibodies.
The mother will have active artificial immunity
lasting for about 10 years. 5 doses will give the
mother lifetime protection.
67. Answer: (B) 4 hours
Rationale: While the unused portion of other
biologicals in EPI may be given until the end of
the day, only BCG is discarded 4 hours after
reconstitution. This is why BCG immunization is
scheduled only in the morning.
68. Answer: (B) 6 months
Rationale: After 6 months, the baby’s nutrient
needs, especially the baby’s iron requirement,
can no longer be provided by mother’s milk
alone.
69. Answer: (C) 24 weeks
Rationale: At approximately 23 to 24 weeks’
gestation, the lungs are developed enough to
sometimes maintain extrauterine life. The lungs
are the most immature system during the
gestation period. Medical care for premature
labor begins much earlier (aggressively at 21
weeks’ gestation)
70. Answer: (B) Sudden infant death syndrome
(SIDS)
Rationale: Supine positioning is recommended
to reduce the risk of SIDS in infancy. The risk of
aspiration is slightly increased with the supine
position. Suffocation would be less likely with
an infant supine than prone and the position
for GER requires the head of the bed to be
elevated.
71. Answer: (C) Decreased temperature
Rationale: Temperature instability, especially
when it results in a low temperature in the
neonate, may be a sign of infection. The
neonate’s color often changes with an infection
process but generally becomes ashen or
mottled. The neonate with an infection will
usually show a decrease in activity level or
lethargy.
72. Answer: (D) Polycythemia probably due to
chronic fetal hypoxia
Rationale: The small-for-gestation neonate is at
risk for developing polycythemia during the
transitional period in an attempt to decrease
hypoxia. The neonates are also at increased risk
for developing hypoglycemia and hypothermia
due to decreased glycogen stores.
73. Answer: (C) Desquamation of the epidermis
Rationale: Postdate fetuses lose the vernix
caseosa, and the epidermis may become
desquamated. These neonates are usually very
alert. Lanugo is missing in the postdate
neonate.
74. Answer: (C) Respiratory depression
Rationale: Magnesium sulfate crosses the
placenta and adverse neonatal effects are
respiratory depression, hypotonia, and
bradycardia. The serum blood sugar isn’t
affected by magnesium sulfate. The neonate
would be floppy, not jittery.
75. Answer: (C) Respiratory rate 40 to 60
breaths/minute
Rationale: A respiratory rate 40 to 60
breaths/minute is normal for a neonate during
the transitional period. Nasal flaring,
respiratory rate more than 60 breaths/minute,
and audible grunting are signs of respiratory
distress.
76. Answer: (C) Keep the cord dry and open to air
Rationale: Keeping the cord dry and open to air
helps reduce infection and hastens drying.
Infants aren’t given tub bath but are sponged
off until the cord falls off. Petroleum jelly
prevents the cord from drying and encourages
infection. Peroxide could be painful and isn’t
recommended.
77. Answer: (B) Conjunctival hemorrhage
Rationale: Conjunctival hemorrhages are
commonly seen in neonates secondary to the
cranial pressure applied during the birth
process. Bulging fontanelles are a sign of
intracranial pressure. Simian creases are
present in 40% of the neonates with trisomy 21.
Cystic hygroma is a neck mass that can affect
the airway.
78. Answer: (B) To assess for prolapsed cord
Rationale: After a client has an amniotomy, the
nurse should assure that the cord isn't
prolapsed and that the baby tolerated the
procedure well. The most effective way to do
this is to check the fetal heart rate. Fetal wellbeing
is assessed via a nonstress test. Fetal
position is determined by vaginal examination.
Artificial rupture of membranes doesn't
indicate an imminent delivery.
79. Answer: (D) The parents’ interactions with each
other.
Rationale: Parental interaction will provide the
nurse with a good assessment of the stability of
the family's home life but it has no indication
for parental bonding. Willingness to touch and
hold the newborn, expressing interest about
the newborn's size, and indicating a desire to
see the newborn are behaviors indicating
parental bonding.
80. Answer: (B) Instructing the client to use two or
more peripads to cushion the area
Rationale: Using two or more peripads would
do little to reduce the pain or promote perineal
healing. Cold applications, sitz baths, and Kegel
exercises are important measures when the
client has a fourth-degree laceration.
81. Answer: (C) “What is your expected due date?”
Rationale: When obtaining the history of a
client who may be in labor, the nurse's highest
priority is to determine her current status,
particularly her due date, gravidity, and parity.
Gravidity and parity affect the duration of labor
and the potential for labor complications. Later,
the nurse should ask about chronic illnesses,
allergies, and support persons.
82. Answer: (D) Aspirate the neonate’s nose and
mouth with a bulb syringe.
Rationale: The nurse's first action should be to
clear the neonate's airway with a bulb syringe.
After the airway is clear and the neonate's color
improves, the nurse should comfort and calm
the neonate. If the problem recurs or the
neonate's color doesn't improve readily, the
nurse should notify the physician.
Administering oxygen when the airway isn't
clear would be ineffective.
83. Answer: (C) Conducting a bedside ultrasound
for an amniotic fluid index.
Rationale: It isn't within a nurse's scope of
practice to perform and interpret a bedside
ultrasound under these conditions and without
specialized training. Observing for pooling of
straw-colored fluid, checking vaginal discharge
with nitrazine paper, and observing for flakes of
vernix are appropriate assessments for
determining whether a client has ruptured
membranes.
84. Answer: (C) Monitor partial pressure of oxygen
(Pao2) levels.
Rationale: Monitoring PaO2 levels and reducing
the oxygen concentration to keep PaO2 within
normal limits reduces the risk of retinopathy of
prematurity in a premature infant receiving
oxygen. Covering the infant's eyes and
humidifying the oxygen don't reduce the risk of
retinopathy of prematurity. Because cooling
increases the risk of acidosis, the infant should
be kept warm so that his respiratory distress
isn't aggravated.
85. Answer: (A) 110 to 130 calories per kg.
Rationale: Calories per kg is the accepted way
of determined appropriate nutritional intake
for a newborn. The recommended calorie
requirement is 110 to 130 calories per kg of
newborn body weight. This level will maintain a
consistent blood glucose level and provide
enough calories for continued growth and
development.
86. Answer: (C) 30 to 32 weeks
Rationale: Individual twins usually grow at the
same rate as singletons until 30 to 32 weeks’
gestation, then twins don’t’ gain weight as
rapidly as singletons of the same gestational
age. The placenta can no longer keep pace with
the nutritional requirements of both fetuses
after 32 weeks, so there’s some growth
retardation in twins if they remain in utero at
38 to 40 weeks.
87. Answer: (A) conjoined twins
Rationale: The type of placenta that develops in
monozygotic twins depends on the time at
which cleavage of the ovum occurs. Cleavage in
conjoined twins occurs more than 13 days after
fertilization. Cleavage that occurs less than 3
day after fertilization results in diamniotic
dicchorionic twins. Cleavage that occurs
between days 3 and 8 results in diamniotic
monochorionic twins. Cleavage that occurs
between days 8 to 13 result in monoamniotic
monochorionic twins.
88. Answer: (D) Ultrasound
Rationale: Once the mother and the fetus are
stabilized, ultrasound evaluation of the
placenta should be done to determine the
cause of the bleeding. Amniocentesis is
contraindicated in placenta previa. A digital or
speculum examination shouldn’t be done as
this may lead to severe bleeding or
hemorrhage. External fetal monitoring won’t
detect a placenta previa, although it will detect
fetal distress, which may result from blood loss
or placenta separation.
89. Answer: (A) Increased tidal volume
Rationale: A pregnant client breathes deeper,
which increases the tidal volume of gas moved
in and out of the respiratory tract with each
breath. The expiratory volume and residual
volume decrease as the pregnancy progresses.
The inspiratory capacity increases during
pregnancy. The increased oxygen consumption
in the pregnant client is 15% to 20% greater
than in the nonpregnant state.
90. Answer: (A) Diet
Rationale: Clients with gestational diabetes are
usually managed by diet alone to control their
glucose intolerance. Oral hypoglycemic drugs
are contraindicated in pregnancy. Long-acting
insulin usually isn’t needed for blood glucose
control in the client with gestational diabetes.
91. Answer: (D) Seizure
Rationale: The anticonvulsant mechanism of
magnesium is believes to depress seizure foci in
the brain and peripheral neuromuscular
blockade. Hypomagnesemia isn’t a
complication of preeclampsia. Antihypertensive
drug other than magnesium are preferred for
sustained hypertension. Magnesium doesn’t
help prevent hemorrhage in preeclamptic
clients.
92. Answer: (C) I.V. fluids
Rationale: A sickle cell crisis during pregnancy is
usually managed by exchange transfusion
oxygen, and L.V. Fluids. The client usually needs
a stronger analgesic than acetaminophen to
control the pain of a crisis. Antihypertensive
drugs usually aren’t necessary. Diuretic
wouldn’t be used unless fluid overload resulted.
93. Answer: (A) Calcium gluconate (Kalcinate)
Rationale: Calcium gluconate is the antidote for
magnesium toxicity. Ten milliliters of 10%
calcium gluconate is given L.V. push over 3 to 5
minutes. Hydralazine is given for sustained
elevated blood pressure in preeclamptic clients.
Rho (D) immune globulin is given to women
with Rh-negative blood to prevent antibody
formation from RH-positive conceptions.
Naloxone is used to correct narcotic toxicity.
94. Answer: (B) An indurated wheal over 10 mm in
diameter appears in 48 to 72 hours.
Rationale: A positive PPD result would be an
indurated wheal over 10 mm in diameter that
appears in 48 to 72 hours. The area must be a
raised wheal, not a flat circumcised area to be
considered positive.
95. Answer: (C) Pyelonephritis
Rationale The symptoms indicate acute
pyelonephritis, a serious condition in a
pregnant client. UTI symptoms include dysuria,
urgency, frequency, and suprapubic
tenderness. Asymptomatic bacteriuria doesn’t
cause symptoms. Bacterial vaginosis causes
milky white vaginal discharge but no systemic
symptoms.
96. Answer: (B) Rh-positive fetal blood crosses into
maternal blood, stimulating maternal
antibodies.
Rationale: Rh isoimmunization occurs when Rhpositive
fetal blood cells cross into the maternal
circulation and stimulate maternal antibody
production. In subsequent pregnancies with Rhpositive
fetuses, maternal antibodies may cross
back into the fetal circulation and destroy the
fetal blood cells.
97. Answer: (C) Supine position
Rationale: The supine position causes
compression of the client's aorta and inferior
vena cava by the fetus. This, in turn, inhibits
maternal circulation, leading to maternal
hypotension and, ultimately, fetal hypoxia. The
other positions promote comfort and aid labor
progress. For instance, the lateral, or side-lying,
position improves maternal and fetal
circulation, enhances comfort, increases
maternal relaxation, reduces muscle tension,
and eliminates pressure points. The squatting
position promotes comfort by taking advantage
of gravity. The standing position also takes
advantage of gravity and aligns the fetus with
the pelvic angle.
98. Answer: (B) Irritability and poor sucking.
Rationale: Neonates of heroin-addicted
mothers are physically dependent on the drug
and experience withdrawal when the drug is no
longer supplied. Signs of heroin withdrawal
include irritability, poor sucking, and
restlessness. Lethargy isn't associated with
neonatal heroin addiction. A flattened nose,
small eyes, and thin lips are seen in infants with
fetal alcohol syndrome. Heroin use during
pregnancy hasn't been linked to specific
congenital anomalies.
99. Answer: (A) 7th to 9th day postpartum
Rationale: The normal involutional process
returns the uterus to the pelvic cavity in 7 to 9
days. A significant involutional complication is
the failure of the uterus to return to the pelvic
cavity within the prescribed time period. This is
known as subinvolution.
100. Answer: (B) Uterine atony
Rationale: Multiple fetuses, extended labor
stimulation with oxytocin, and traumatic
delivery commonly are associated with uterine
atony, which may lead to postpartum
hemorrhage. Uterine inversion may precede or
follow delivery and commonly results from
apparent excessive traction on the umbilical
cord and attempts to deliver the placenta
manually. Uterine involution and some uterine
discomfort are normal after delivery.
Thursday, November 7, 2013
TEST II - Community Health Nursing and Care of the Mother and Child
TEST II - Community Health Nursing and Care of
the Mother and Child
1. May arrives at the health care clinic and tells the
nurse that her last menstrual period was 9
weeks ago. She also tells the nurse that a home
pregnancy test was positive but she began to
have mild cramps and is now having moderate
vaginal bleeding. During the physical
examination of the client, the nurse notes that
May has a dilated cervix. The nurse determines
that May is experiencing which type of abortion?
a. Inevitable
b. Incomplete
c. Threatened
d. Septic
2. Nurse Reese is reviewing the record of a
pregnant client for her first prenatal visit. Which
of the following data, if noted on the client’s
record, would alert the nurse that the client is at
risk for a spontaneous abortion?
a. Age 36 years
b. History of syphilis
c. History of genital herpes
d. History of diabetes mellitus
3. Nurse Hazel is preparing to care for a client who
is newly admitted to the hospital with a possible
diagnosis of ectopic pregnancy. Nurse Hazel
develops a plan of care for the client and
determines that which of the following nursing
actions is the priority?
a. Monitoring weight
b. Assessing for edema
c. Monitoring apical pulse
d. Monitoring temperature
4. Nurse Oliver is teaching a diabetic pregnant
client about nutrition and insulin needs during
pregnancy. The nurse determines that the client
understands dietary and insulin needs if the
client states that the second half of pregnancy
requires:
a. Decreased caloric intake
b. Increased caloric intake
c. Decreased Insulin
d. Increase Insulin
5. Nurse Michelle is assessing a 24 year old client
with a diagnosis of hydatidiform mole. She is
aware that one of the following is unassociated
with this condition?
a. Excessive fetal activity.
b. Larger than normal uterus for
gestational age.
c. Vaginal bleeding
d. Elevated levels of human chorionic
gonadotropin.
6. A pregnant client is receiving magnesium sulfate
for severe pregnancy induced hypertension
(PIH). The clinical findings that would warrant
use of the antidote , calcium gluconate is:
a. Urinary output 90 cc in 2 hours.
b. Absent patellar reflexes.
c. Rapid respiratory rate above 40/min.
d. Rapid rise in blood pressure.
7. During vaginal examination of Janah who is in
labor, the presenting part is at station plus two.
Nurse, correctly interprets it as:
a. Presenting part is 2 cm above the plane
of the ischial spines.
b. Biparietal diameter is at the level of the
ischial spines.
c. Presenting part in 2 cm below the plane
of the ischial spines.
d. Biparietal diameter is 2 cm above the
ischial spines.
8. A pregnant client is receiving oxytocin (Pitocin)
for induction of labor. A condition that warrant
the nurse in-charge to discontinue I.V. infusion
of Pitocin is:
a. Contractions every 1 ½ minutes lasting
70-80 seconds.
b. Maternal temperature 101.2
c. Early decelerations in the fetal heart
rate.
d. Fetal heart rate baseline 140-160 bpm.
9. Calcium gluconate is being administered to a
client with pregnancy induced hypertension
(PIH). A nursing action that must be initiated as
the plan of care throughout injection of the drug
is:
a. Ventilator assistance
b. CVP readings
c. EKG tracings
d. Continuous CPR
10. A trial for vaginal delivery after an earlier
caesarean, would likely to be given to a gravida,
who had:
a. First low transverse cesarean was for
active herpes type 2 infections; vaginal
culture at 39 weeks pregnancy was
positive.
b. First and second caesareans were for
cephalopelvic disproportion.
c. First caesarean through a classic incision
as a result of severe fetal distress.
d. First low transverse caesarean was for
breech position. Fetus in this pregnancy
is in a vertex presentation.
11. Nurse Ryan is aware that the best initial
approach when trying to take a crying toddler’s
temperature is:
a. Talk to the mother first and then to the
toddler.
b. Bring extra help so it can be done
quickly.
c. Encourage the mother to hold the child.
d. Ignore the crying and screaming.
12. Baby Tina a 3 month old infant just had a cleft lip
and palate repair. What should the nurse do to
prevent trauma to operative site?
a. Avoid touching the suture line, even
when cleaning.
b. Place the baby in prone position.
c. Give the baby a pacifier.
d. Place the infant’s arms in soft elbow
restraints.
13. Which action should nurse Marian include in the
care plan for a 2 month old with heart failure?
a. Feed the infant when he cries.
b. Allow the infant to rest before feeding.
c. Bathe the infant and administer
medications before feeding.
d. Weigh and bathe the infant before
feeding.
14. Nurse Hazel is teaching a mother who plans to
discontinue breast feeding after 5 months. The
nurse should advise her to include which foods
in her infant’s diet?
a. Skim milk and baby food.
b. Whole milk and baby food.
c. Iron-rich formula only.
d. Iron-rich formula and baby food.
15. Mommy Linda is playing with her infant, who is
sitting securely alone on the floor of the clinic.
The mother hides a toy behind her back and the
infant looks for it. The nurse is aware that
estimated age of the infant would be:
a. 6 months
b. 4 months
c. 8 months
d. 10 months
16. Which of the following is the most prominent
feature of public health nursing?
a. It involves providing home care to sick
people who are not confined in the
hospital.
b. Services are provided free of charge to
people within the catchments area.
c. The public health nurse functions as part
of a team providing a public health
nursing services.
d. Public health nursing focuses on
preventive, not curative, services.
17. When the nurse determines whether resources
were maximized in implementing Ligtas Tigdas,
she is evaluating
a. Effectiveness
b. Efficiency
c. Adequacy
d. Appropriateness
18. Vangie is a new B.S.N. graduate. She wants to
become a Public Health Nurse. Where should
she apply?
a. Department of Health
b. Provincial Health Office
c. Regional Health Office
d. Rural Health Unit
19. Tony is aware the Chairman of the Municipal
Health Board is:
a. Mayor
b. Municipal Health Officer
c. Public Health Nurse
d. Any qualified physician
20. Myra is the public health nurse in a municipality
with a total population of about 20,000. There
are 3 rural health midwives among the RHU
personnel. How many more midwife items will
the RHU need?
a. 1
b. 2
c. 3
d. The RHU does not need any more
midwife item.
21. According to Freeman and Heinrich, community
health nursing is a developmental service. Which
of the following best illustrates this statement?
a. The community health nurse
continuously develops himself
personally and professionally.
b. Health education and community
organizing are necessary in providing
community health services.
c. Community health nursing is intended
primarily for health promotion and
prevention and treatment of disease.
d. The goal of community health nursing is
to provide nursing services to people in
their own places of residence.
22. Nurse Tina is aware that the disease declared
through Presidential Proclamation No. 4 as a
target for eradication in the Philippines is?
a. Poliomyelitis
b. Measles
c. Rabies
d. Neonatal tetanus
23. May knows that the step in community
organizing that involves training of potential
leaders in the community is:
a. Integration
b. Community organization
c. Community study
d. Core group formation
24. Beth a public health nurse takes an active role in
community participation. What is the primary
goal of community organizing?
a. To educate the people regarding
community health problems
b. To mobilize the people to resolve
community health problems
c. To maximize the community’s resources
in dealing with health problems.
d. To maximize the community’s resources
in dealing with health problems.
25. Tertiary prevention is needed in which stage of
the natural history of disease?
a. Pre-pathogenesis
b. Pathogenesis
c. Prodromal
d. Terminal
26. The nurse is caring for a primigravid client in the
labor and delivery area. Which condition would
place the client at risk for disseminated
intravascular coagulation (DIC)?
a. Intrauterine fetal death.
b. Placenta accreta.
c. Dysfunctional labor.
d. Premature rupture of the membranes.
27. A fullterm client is in labor. Nurse Betty is aware
that the fetal heart rate would be:
a. 80 to 100 beats/minute
b. 100 to 120 beats/minute
c. 120 to 160 beats/minute
d. 160 to 180 beats/minute
28. The skin in the diaper area of a 7 month old
infant is excoriated and red. Nurse Hazel should
instruct the mother to:
a. Change the diaper more often.
b. Apply talc powder with diaper changes.
c. Wash the area vigorously with each
diaper change.
d. Decrease the infant’s fluid intake to
decrease saturating diapers.
29. Nurse Carla knows that the common cardiac
anomalies in children with Down Syndrome (trisomy
21) is:
a. Atrial septal defect
b. Pulmonic stenosis
c. Ventricular septal defect
d. Endocardial cushion defect
30. Malou was diagnosed with severe preeclampsia
is now receiving I.V. magnesium sulfate. The
adverse effects associated with magnesium
sulfate is:
a. Anemia
b. Decreased urine output
c. Hyperreflexia
d. Increased respiratory rate
31. A 23 year old client is having her menstrual
period every 2 weeks that last for 1 week. This
type of menstrual pattern is bets defined by:
a. Menorrhagia
b. Metrorrhagia
c. Dyspareunia
d. Amenorrhea
32. Jannah is admitted to the labor and delivery
unit. The critical laboratory result for this client
would be:
a. Oxygen saturation
b. Iron binding capacity
c. Blood typing
d. Serum Calcium
33. Nurse Gina is aware that the most common
condition found during the second-trimester of
pregnancy is:
a. Metabolic alkalosis
b. Respiratory acidosis
c. Mastitis
d. Physiologic anemia
34. Nurse Lynette is working in the triage area of an
emergency department. She sees that several
pediatric clients arrive simultaneously. The client
who needs to be treated first is:
a. A crying 5 year old child with a
laceration on his scalp.
b. A 4 year old child with a barking coughs
and flushed appearance.
c. A 3 year old child with Down syndrome
who is pale and asleep in his mother’s
arms.
d. A 2 year old infant with stridorous
breath sounds, sitting up in his mother’s
arms and drooling.
35. Maureen in her third trimester arrives at the
emergency room with painless vaginal bleeding.
Which of the following conditions is suspected?
a. Placenta previa
b. Abruptio placentae
c. Premature labor
d. Sexually transmitted disease
36. A young child named Richard is suspected of
having pinworms. The community nurse collects
a stool specimen to confirm the diagnosis. The
nurse should schedule the collection of this
specimen for:
a. Just before bedtime
b. After the child has been bathe
c. Any time during the day
d. Early in the morning
37. In doing a child’s admission assessment, Nurse
Betty should be alert to note which signs or
symptoms of chronic lead poisoning?
a. Irritability and seizures
b. Dehydration and diarrhea
c. Bradycardia and hypotension
d. Petechiae and hematuria
38. To evaluate a woman’s understanding about the
use of diaphragm for family planning, Nurse
Trish asks her to explain how she will use the
appliance. Which response indicates a need for
further health teaching?
a. “I should check the diaphragm carefully
for holes every time I use it”
b. “I may need a different size of
diaphragm if I gain or lose weight more
than 20 pounds”
c. “The diaphragm must be left in place for
atleast 6 hours after intercourse”
d. “I really need to use the diaphragm and
jelly most during the middle of my
menstrual cycle”.
39. Hypoxia is a common complication of
laryngotracheobronchitis. Nurse Oliver should
frequently assess a child with
laryngotracheobronchitis for:
a. Drooling
b. Muffled voice
c. Restlessness
d. Low-grade fever
40. How should Nurse Michelle guide a child who is
blind to walk to the playroom?
a. Without touching the child, talk
continuously as the child walks down the
hall.
b. Walk one step ahead, with the child’s
hand on the nurse’s elbow.
c. Walk slightly behind, gently guiding the
child forward.
d. Walk next to the child, holding the
child’s hand.
41. When assessing a newborn diagnosed with
ductus arteriosus, Nurse Olivia should expect
that the child most likely would have an:
a. Loud, machinery-like murmur.
b. Bluish color to the lips.
c. Decreased BP reading in the upper
extremities
d. Increased BP reading in the upper
extremities.
42. The reason nurse May keeps the neonate in a
neutral thermal environment is that when a
newborn becomes too cool, the neonate
requires:
a. Less oxygen, and the newborn’s
metabolic rate increases.
b. More oxygen, and the newborn’s
metabolic rate decreases.
c. More oxygen, and the newborn’s
metabolic rate increases.
d. Less oxygen, and the newborn’s
metabolic rate decreases.
43. Before adding potassium to an infant’s I.V. line,
Nurse Ron must be sure to assess whether this
infant has:
a. Stable blood pressure
b. Patant fontanelles
c. Moro’s reflex
d. Voided
44. Nurse Carla should know that the most common
causative factor of dermatitis in infants and
younger children is:
a. Baby oil
b. Baby lotion
c. Laundry detergent
d. Powder with cornstarch
45. During tube feeding, how far above an infant’s
stomach should the nurse hold the syringe with
formula?
a. 6 inches
b. 12 inches
c. 18 inches
d. 24 inches
46. In a mothers’ class, Nurse Lhynnete discussed
childhood diseases such as chicken pox. Which
of the following statements about chicken pox is
correct?
a. The older one gets, the more susceptible
he becomes to the complications of
chicken pox.
b. A single attack of chicken pox will
prevent future episodes, including
conditions such as shingles.
c. To prevent an outbreak in the
community, quarantine may be imposed
by health authorities.
d. Chicken pox vaccine is best given when
there is an impending outbreak in the
community.
47. Barangay Pinoy had an outbreak of German
measles. To prevent congenital rubella, what is
the BEST advice that you can give to women in
the first trimester of pregnancy in the barangay
Pinoy?
a. Advise them on the signs of German
measles.
b. Avoid crowded places, such as markets
and movie houses.
c. Consult at the health center where
rubella vaccine may be given.
d. Consult a physician who may give them
rubella immunoglobulin.
48. Myrna a public health nurse knows that to
determine possible sources of sexually
transmitted infections, the BEST method that
may be undertaken is:
a. Contact tracing
b. Community survey
c. Mass screening tests
d. Interview of suspects
49. A 33-year old female client came for
consultation at the health center with the chief
complaint of fever for a week. Accompanying
symptoms were muscle pains and body malaise.
A week after the start of fever, the client noted
yellowish discoloration of his sclera. History
showed that he waded in flood waters about 2
weeks before the onset of symptoms. Based on
her history, which disease condition will you
suspect?
a. Hepatitis A
b. Hepatitis B
c. Tetanus
d. Leptospirosis
50. Mickey a 3-year old client was brought to the
health center with the chief complaint of severe
diarrhea and the passage of “rice water” stools.
The client is most probably suffering from which
condition?
a. Giardiasis
b. Cholera
c. Amebiasis
d. Dysentery
51. The most prevalent form of meningitis among
children aged 2 months to 3 years is caused by
which microorganism?
a. Hemophilus influenzae
b. Morbillivirus
c. Steptococcus pneumoniae
d. Neisseria meningitidis
52. The student nurse is aware that the
pathognomonic sign of measles is Koplik’s spot
and you may see Koplik’s spot by inspecting the:
a. Nasal mucosa
b. Buccal mucosa
c. Skin on the abdomen
d. Skin on neck
53. Angel was diagnosed as having Dengue fever.
You will say that there is slow capillary refill
when the color of the nailbed that you pressed
does not return within how many seconds?
a. 3 seconds
b. 6 seconds
c. 9 seconds
d. 10 seconds
54. In Integrated Management of Childhood Illness,
the nurse is aware that the severe conditions
generally require urgent referral to a hospital.
Which of the following severe conditions DOES
NOT always require urgent referral to a hospital?
a. Mastoiditis
b. Severe dehydration
c. Severe pneumonia
d. Severe febrile disease
55. Myrna a public health nurse will conduct
outreach immunization in a barangay Masay
with a population of about 1500. The estimated
number of infants in the barangay would be:
a. 45 infants
b. 50 infants
c. 55 infants
d. 65 infants
56. The community nurse is aware that the
biological used in Expanded Program on
Immunization (EPI) should NOT be stored in the
freezer?
a. DPT
b. Oral polio vaccine
c. Measles vaccine
d. MMR
57. It is the most effective way of controlling
schistosomiasis in an endemic area?
a. Use of molluscicides
b. Building of foot bridges
c. Proper use of sanitary toilets
d. Use of protective footwear, such as
rubber boots
58. Several clients is newly admitted and diagnosed
with leprosy. Which of the following clients
should be classified as a case of multibacillary
leprosy?
a. 3 skin lesions, negative slit skin smear
b. 3 skin lesions, positive slit skin smear
c. 5 skin lesions, negative slit skin smear
d. 5 skin lesions, positive slit skin smear
59. Nurses are aware that diagnosis of leprosy is
highly dependent on recognition of symptoms.
Which of the following is an early sign of
leprosy?
a. Macular lesions
b. Inability to close eyelids
c. Thickened painful nerves
d. Sinking of the nosebridge
60. Marie brought her 10 month old infant for
consultation because of fever, started 4 days
prior to consultation. In determining malaria
risk, what will you do?
a. Perform a tourniquet test.
b. Ask where the family resides.
c. Get a specimen for blood smear.
d. Ask if the fever is present every day.
61. Susie brought her 4 years old daughter to the
RHU because of cough and colds. Following the
IMCI assessment guide, which of the following is
a danger sign that indicates the need for urgent
referral to a hospital?
a. Inability to drink
b. High grade fever
c. Signs of severe dehydration
d. Cough for more than 30 days
62. Jimmy a 2-year old child revealed “baggy pants”.
As a nurse, using the IMCI guidelines, how will
you manage Jimmy?
a. Refer the child urgently to a hospital for
confinement.
b. Coordinate with the social worker to
enroll the child in a feeding program.
c. Make a teaching plan for the mother,
focusing on menu planning for her child.
d. Assess and treat the child for health
problems like infections and intestinal
parasitism.
63. Gina is using Oresol in the management of
diarrhea of her 3-year old child. She asked you
what to do if her child vomits. As a nurse you will
tell her to:
a. Bring the child to the nearest hospital
for further assessment.
b. Bring the child to the health center for
intravenous fluid therapy.
c. Bring the child to the health center for
assessment by the physician.
d. Let the child rest for 10 minutes then
continue giving Oresol more slowly.
64. Nikki a 5-month old infant was brought by his
mother to the health center because of diarrhea
for 4 to 5 times a day. Her skin goes back slowly
after a skin pinch and her eyes are sunken. Using
the IMCI guidelines, you will classify this infant in
which category?
a. No signs of dehydration
b. Some dehydration
c. Severe dehydration
d. The data is insufficient.
65. Chris a 4-month old infant was brought by her
mother to the health center because of cough.
His respiratory rate is 42/minute. Using the
Integrated Management of Child Illness (IMCI)
guidelines of assessment, his breathing is
considered as:
a. Fast
b. Slow
c. Normal
d. Insignificant
66. Maylene had just received her 4th dose of
tetanus toxoid. She is aware that her baby will
have protection against tetanus for
a. 1 year
b. 3 years
c. 5 years
d. Lifetime
67. Nurse Ron is aware that unused BCG should be
discarded after how many hours of
reconstitution?
a. 2 hours
b. 4 hours
c. 8 hours
d. At the end of the day
68. The nurse explains to a breastfeeding mother
that breast milk is sufficient for all of the baby’s
nutrient needs only up to:
a. 5 months
b. 6 months
c. 1 year
d. 2 years
69. Nurse Ron is aware that the gestational age of a
conceptus that is considered viable (able to live
outside the womb) is:
a. 8 weeks
b. 12 weeks
c. 24 weeks
d. 32 weeks
70. When teaching parents of a neonate the proper
position for the neonate’s sleep, the nurse
Patricia stresses the importance of placing the
neonate on his back to reduce the risk of which
of the following?
a. Aspiration
b. Sudden infant death syndrome (SIDS)
c. Suffocation
d. Gastroesophageal reflux (GER)
71. Which finding might be seen in baby James a
neonate suspected of having an infection?
a. Flushed cheeks
b. Increased temperature
c. Decreased temperature
d. Increased activity level
72. Baby Jenny who is small-for-gestation is at
increased risk during the transitional period for
which complication?
a. Anemia probably due to chronic fetal
hyposia
b. Hyperthermia due to decreased
glycogen stores
c. Hyperglycemia due to decreased
glycogen stores
d. Polycythemia probably due to chronic
fetal hypoxia
73. Marjorie has just given birth at 42 weeks’
gestation. When the nurse assessing the
neonate, which physical finding is expected?
a. A sleepy, lethargic baby
b. Lanugo covering the body
c. Desquamation of the epidermis
d. Vernix caseosa covering the body
74. After reviewing the Myrna’s maternal history of
magnesium sulfate during labor, which condition
would nurse Richard anticipate as a potential
problem in the neonate?
a. Hypoglycemia
b. Jitteriness
c. Respiratory depression
d. Tachycardia
75. Which symptom would indicate the Baby
Alexandra was adapting appropriately to extrauterine
life without difficulty?
a. Nasal flaring
b. Light audible grunting
c. Respiratory rate 40 to 60
breaths/minute
d. Respiratory rate 60 to 80
breaths/minute
76. When teaching umbilical cord care for Jennifer a
new mother, the nurse Jenny would include
which information?
a. Apply peroxide to the cord with each
diaper change
b. Cover the cord with petroleum jelly after
bathing
c. Keep the cord dry and open to air
d. Wash the cord with soap and water each
day during a tub bath.
77. Nurse John is performing an assessment on a
neonate. Which of the following findings is
considered common in the healthy neonate?
a. Simian crease
b. Conjunctival hemorrhage
c. Cystic hygroma
d. Bulging fontanelle
78. Dr. Esteves decides to artificially rupture the
membranes of a mother who is on labor.
Following this procedure, the nurse Hazel checks
the fetal heart tones for which the following
reasons?
a. To determine fetal well-being.
b. To assess for prolapsed cord
c. To assess fetal position
d. To prepare for an imminent delivery.
79. Which of the following would be least likely to
indicate anticipated bonding behaviors by new
parents?
a. The parents’ willingness to touch and
hold the new born.
b. The parent’s expression of interest
about the size of the new born.
c. The parents’ indication that they want to
see the newborn.
d. The parents’ interactions with each
other.
80. Following a precipitous delivery, examination of
the client's vagina reveals a fourth-degree
laceration. Which of the following would be
contraindicated when caring for this client?
a. Applying cold to limit edema during the
first 12 to 24 hours.
b. Instructing the client to use two or more
peripads to cushion the area.
c. Instructing the client on the use of sitz
baths if ordered.
d. Instructing the client about the
importance of perineal (kegel) exercises.
81. A pregnant woman accompanied by her
husband, seeks admission to the labor and
delivery area. She states that she's in labor and
says she attended the facility clinic for prenatal
care. Which question should the nurse Oliver ask
her first?
a. “Do you have any chronic illnesses?”
b. “Do you have any allergies?”
c. “What is your expected due date?”
d. “Who will be with you during labor?”
82. A neonate begins to gag and turns a dusky color.
What should the nurse do first?
a. Calm the neonate.
b. Notify the physician.
c. Provide oxygen via face mask as ordered
d. Aspirate the neonate’s nose and mouth
with a bulb syringe.
83. When a client states that her "water broke,"
which of the following actions would be
inappropriate for the nurse to do?
a. Observing the pooling of straw-colored
fluid.
b. Checking vaginal discharge with nitrazine
paper.
c. Conducting a bedside ultrasound for an
amniotic fluid index.
d. Observing for flakes of vernix in the
vaginal discharge.
84. A baby girl is born 8 weeks premature. At birth,
she has no spontaneous respirations but is
successfully resuscitated. Within several hours
she develops respiratory grunting, cyanosis,
tachypnea, nasal flaring, and retractions. She's
diagnosed with respiratory distress syndrome,
intubated, and placed on a ventilator. Which
nursing action should be included in the baby's
plan of care to prevent retinopathy of
prematurity?
a. Cover his eyes while receiving oxygen.
b. Keep her body temperature low.
c. Monitor partial pressure of oxygen
(Pao2) levels.
d. Humidify the oxygen.
85. Which of the following is normal newborn
calorie intake?
a. 110 to 130 calories per kg.
b. 30 to 40 calories per lb of body weight.
c. At least 2 ml per feeding
d. 90 to 100 calories per kg
86. Nurse John is knowledgeable that usually
individual twins will grow appropriately and at
the same rate as singletons until how many
weeks?
a. 16 to 18 weeks
b. 18 to 22 weeks
c. 30 to 32 weeks
d. 38 to 40 weeks
87. Which of the following classifications applies to
monozygotic twins for whom the cleavage of the
fertilized ovum occurs more than 13 days after
fertilization?
a. conjoined twins
b. diamniotic dichorionic twins
c. diamniotic monochorionic twin
d. monoamniotic monochorionic twins
88. Tyra experienced painless vaginal bleeding has
just been diagnosed as having a placenta previa.
Which of the following procedures is usually
performed to diagnose placenta previa?
a. Amniocentesis
b. Digital or speculum examination
c. External fetal monitoring
d. Ultrasound
89. Nurse Arnold knows that the following changes
in respiratory functioning during pregnancy is
considered normal:
a. Increased tidal volume
b. Increased expiratory volume
c. Decreased inspiratory capacity
d. Decreased oxygen consumption
90. Emily has gestational diabetes and it is usually
managed by which of the following therapy?
a. Diet
b. Long-acting insulin
c. Oral hypoglycemic
d. Oral hypoglycemic drug and insulin
91. Magnesium sulfate is given to Jemma with
preeclampsia to prevent which of the following
condition?
a. Hemorrhage
b. Hypertension
c. Hypomagnesemia
d. Seizure
92. Cammile with sickle cell anemia has an increased
risk for having a sickle cell crisis during
pregnancy. Aggressive management of a sickle
cell crisis includes which of the following
measures?
a. Antihypertensive agents
b. Diuretic agents
c. I.V. fluids
d. Acetaminophen (Tylenol) for pain
93. Which of the following drugs is the antidote for
magnesium toxicity?
a. Calcium gluconate (Kalcinate)
b. Hydralazine (Apresoline)
c. Naloxone (Narcan)
d. Rho (D) immune globulin (RhoGAM)
94. Marlyn is screened for tuberculosis during her
first prenatal visit. An intradermal injection of
purified protein derivative (PPD) of the
tuberculin bacilli is given. She is considered to
have a positive test for which of the following
results?
a. An indurated wheal under 10 mm in
diameter appears in 6 to 12 hours.
b. An indurated wheal over 10 mm in
diameter appears in 48 to 72 hours.
c. A flat circumcised area under 10 mm in
diameter appears in 6 to 12 hours.
d. A flat circumcised area over 10 mm in
diameter appears in 48 to 72 hours.
95. Dianne, 24 year-old is 27 weeks’ pregnant
arrives at her physician’s office with complaints
of fever, nausea, vomiting, malaise, unilateral
flank pain, and costovertebral angle tenderness.
Which of the following diagnoses is most likely?
a. Asymptomatic bacteriuria
b. Bacterial vaginosis
c. Pyelonephritis
d. Urinary tract infection (UTI)
96. Rh isoimmunization in a pregnant client
develops during which of the following
conditions?
a. Rh-positive maternal blood crosses into
fetal blood, stimulating fetal antibodies.
b. Rh-positive fetal blood crosses into
maternal blood, stimulating maternal
antibodies.
c. Rh-negative fetal blood crosses into
maternal blood, stimulating maternal
antibodies.
d. Rh-negative maternal blood crosses into
fetal blood, stimulating fetal antibodies.
97. To promote comfort during labor, the nurse John
advises a client to assume certain positions and
avoid others. Which position may cause
maternal hypotension and fetal hypoxia?
a. Lateral position
b. Squatting position
c. Supine position
98. Celeste who used heroin during her pregnancydelivers a neonate. When assessing the neonate,
the nurse Lhynnette expects to find:
a. Lethargy 2 days after birth.
b. Irritability and poor sucking.
c. A flattened nose, small eyes, and thin
lips.
d. Congenital defects such as limb
anomalies.
99. The uterus returns to the pelvic cavity in which
of the following time frames?
a. 7th to 9th day postpartum.
b. 2 weeks postpartum.
c. End of 6th week postpartum.
d. When the lochia changes to alba.
100. Maureen, a primigravida client, age 20, has
just completed a difficult, forceps-assisted
delivery of twins. Her labor was unusually
long and required oxytocin (Pitocin)
augmentation. The nurse who's caring for her
should stay alert for:
a. Uterine inversion
b. Uterine atony
c. Uterine involution
d. Uterine discomfort
the Mother and Child
1. May arrives at the health care clinic and tells the
nurse that her last menstrual period was 9
weeks ago. She also tells the nurse that a home
pregnancy test was positive but she began to
have mild cramps and is now having moderate
vaginal bleeding. During the physical
examination of the client, the nurse notes that
May has a dilated cervix. The nurse determines
that May is experiencing which type of abortion?
a. Inevitable
b. Incomplete
c. Threatened
d. Septic
2. Nurse Reese is reviewing the record of a
pregnant client for her first prenatal visit. Which
of the following data, if noted on the client’s
record, would alert the nurse that the client is at
risk for a spontaneous abortion?
a. Age 36 years
b. History of syphilis
c. History of genital herpes
d. History of diabetes mellitus
3. Nurse Hazel is preparing to care for a client who
is newly admitted to the hospital with a possible
diagnosis of ectopic pregnancy. Nurse Hazel
develops a plan of care for the client and
determines that which of the following nursing
actions is the priority?
a. Monitoring weight
b. Assessing for edema
c. Monitoring apical pulse
d. Monitoring temperature
4. Nurse Oliver is teaching a diabetic pregnant
client about nutrition and insulin needs during
pregnancy. The nurse determines that the client
understands dietary and insulin needs if the
client states that the second half of pregnancy
requires:
a. Decreased caloric intake
b. Increased caloric intake
c. Decreased Insulin
d. Increase Insulin
5. Nurse Michelle is assessing a 24 year old client
with a diagnosis of hydatidiform mole. She is
aware that one of the following is unassociated
with this condition?
a. Excessive fetal activity.
b. Larger than normal uterus for
gestational age.
c. Vaginal bleeding
d. Elevated levels of human chorionic
gonadotropin.
6. A pregnant client is receiving magnesium sulfate
for severe pregnancy induced hypertension
(PIH). The clinical findings that would warrant
use of the antidote , calcium gluconate is:
a. Urinary output 90 cc in 2 hours.
b. Absent patellar reflexes.
c. Rapid respiratory rate above 40/min.
d. Rapid rise in blood pressure.
7. During vaginal examination of Janah who is in
labor, the presenting part is at station plus two.
Nurse, correctly interprets it as:
a. Presenting part is 2 cm above the plane
of the ischial spines.
b. Biparietal diameter is at the level of the
ischial spines.
c. Presenting part in 2 cm below the plane
of the ischial spines.
d. Biparietal diameter is 2 cm above the
ischial spines.
8. A pregnant client is receiving oxytocin (Pitocin)
for induction of labor. A condition that warrant
the nurse in-charge to discontinue I.V. infusion
of Pitocin is:
a. Contractions every 1 ½ minutes lasting
70-80 seconds.
b. Maternal temperature 101.2
c. Early decelerations in the fetal heart
rate.
d. Fetal heart rate baseline 140-160 bpm.
9. Calcium gluconate is being administered to a
client with pregnancy induced hypertension
(PIH). A nursing action that must be initiated as
the plan of care throughout injection of the drug
is:
a. Ventilator assistance
b. CVP readings
c. EKG tracings
d. Continuous CPR
10. A trial for vaginal delivery after an earlier
caesarean, would likely to be given to a gravida,
who had:
a. First low transverse cesarean was for
active herpes type 2 infections; vaginal
culture at 39 weeks pregnancy was
positive.
b. First and second caesareans were for
cephalopelvic disproportion.
c. First caesarean through a classic incision
as a result of severe fetal distress.
d. First low transverse caesarean was for
breech position. Fetus in this pregnancy
is in a vertex presentation.
11. Nurse Ryan is aware that the best initial
approach when trying to take a crying toddler’s
temperature is:
a. Talk to the mother first and then to the
toddler.
b. Bring extra help so it can be done
quickly.
c. Encourage the mother to hold the child.
d. Ignore the crying and screaming.
12. Baby Tina a 3 month old infant just had a cleft lip
and palate repair. What should the nurse do to
prevent trauma to operative site?
a. Avoid touching the suture line, even
when cleaning.
b. Place the baby in prone position.
c. Give the baby a pacifier.
d. Place the infant’s arms in soft elbow
restraints.
13. Which action should nurse Marian include in the
care plan for a 2 month old with heart failure?
a. Feed the infant when he cries.
b. Allow the infant to rest before feeding.
c. Bathe the infant and administer
medications before feeding.
d. Weigh and bathe the infant before
feeding.
14. Nurse Hazel is teaching a mother who plans to
discontinue breast feeding after 5 months. The
nurse should advise her to include which foods
in her infant’s diet?
a. Skim milk and baby food.
b. Whole milk and baby food.
c. Iron-rich formula only.
d. Iron-rich formula and baby food.
15. Mommy Linda is playing with her infant, who is
sitting securely alone on the floor of the clinic.
The mother hides a toy behind her back and the
infant looks for it. The nurse is aware that
estimated age of the infant would be:
a. 6 months
b. 4 months
c. 8 months
d. 10 months
16. Which of the following is the most prominent
feature of public health nursing?
a. It involves providing home care to sick
people who are not confined in the
hospital.
b. Services are provided free of charge to
people within the catchments area.
c. The public health nurse functions as part
of a team providing a public health
nursing services.
d. Public health nursing focuses on
preventive, not curative, services.
17. When the nurse determines whether resources
were maximized in implementing Ligtas Tigdas,
she is evaluating
a. Effectiveness
b. Efficiency
c. Adequacy
d. Appropriateness
18. Vangie is a new B.S.N. graduate. She wants to
become a Public Health Nurse. Where should
she apply?
a. Department of Health
b. Provincial Health Office
c. Regional Health Office
d. Rural Health Unit
19. Tony is aware the Chairman of the Municipal
Health Board is:
a. Mayor
b. Municipal Health Officer
c. Public Health Nurse
d. Any qualified physician
20. Myra is the public health nurse in a municipality
with a total population of about 20,000. There
are 3 rural health midwives among the RHU
personnel. How many more midwife items will
the RHU need?
a. 1
b. 2
c. 3
d. The RHU does not need any more
midwife item.
21. According to Freeman and Heinrich, community
health nursing is a developmental service. Which
of the following best illustrates this statement?
a. The community health nurse
continuously develops himself
personally and professionally.
b. Health education and community
organizing are necessary in providing
community health services.
c. Community health nursing is intended
primarily for health promotion and
prevention and treatment of disease.
d. The goal of community health nursing is
to provide nursing services to people in
their own places of residence.
22. Nurse Tina is aware that the disease declared
through Presidential Proclamation No. 4 as a
target for eradication in the Philippines is?
a. Poliomyelitis
b. Measles
c. Rabies
d. Neonatal tetanus
23. May knows that the step in community
organizing that involves training of potential
leaders in the community is:
a. Integration
b. Community organization
c. Community study
d. Core group formation
24. Beth a public health nurse takes an active role in
community participation. What is the primary
goal of community organizing?
a. To educate the people regarding
community health problems
b. To mobilize the people to resolve
community health problems
c. To maximize the community’s resources
in dealing with health problems.
d. To maximize the community’s resources
in dealing with health problems.
25. Tertiary prevention is needed in which stage of
the natural history of disease?
a. Pre-pathogenesis
b. Pathogenesis
c. Prodromal
d. Terminal
26. The nurse is caring for a primigravid client in the
labor and delivery area. Which condition would
place the client at risk for disseminated
intravascular coagulation (DIC)?
a. Intrauterine fetal death.
b. Placenta accreta.
c. Dysfunctional labor.
d. Premature rupture of the membranes.
27. A fullterm client is in labor. Nurse Betty is aware
that the fetal heart rate would be:
a. 80 to 100 beats/minute
b. 100 to 120 beats/minute
c. 120 to 160 beats/minute
d. 160 to 180 beats/minute
28. The skin in the diaper area of a 7 month old
infant is excoriated and red. Nurse Hazel should
instruct the mother to:
a. Change the diaper more often.
b. Apply talc powder with diaper changes.
c. Wash the area vigorously with each
diaper change.
d. Decrease the infant’s fluid intake to
decrease saturating diapers.
29. Nurse Carla knows that the common cardiac
anomalies in children with Down Syndrome (trisomy
21) is:
a. Atrial septal defect
b. Pulmonic stenosis
c. Ventricular septal defect
d. Endocardial cushion defect
30. Malou was diagnosed with severe preeclampsia
is now receiving I.V. magnesium sulfate. The
adverse effects associated with magnesium
sulfate is:
a. Anemia
b. Decreased urine output
c. Hyperreflexia
d. Increased respiratory rate
31. A 23 year old client is having her menstrual
period every 2 weeks that last for 1 week. This
type of menstrual pattern is bets defined by:
a. Menorrhagia
b. Metrorrhagia
c. Dyspareunia
d. Amenorrhea
32. Jannah is admitted to the labor and delivery
unit. The critical laboratory result for this client
would be:
a. Oxygen saturation
b. Iron binding capacity
c. Blood typing
d. Serum Calcium
33. Nurse Gina is aware that the most common
condition found during the second-trimester of
pregnancy is:
a. Metabolic alkalosis
b. Respiratory acidosis
c. Mastitis
d. Physiologic anemia
34. Nurse Lynette is working in the triage area of an
emergency department. She sees that several
pediatric clients arrive simultaneously. The client
who needs to be treated first is:
a. A crying 5 year old child with a
laceration on his scalp.
b. A 4 year old child with a barking coughs
and flushed appearance.
c. A 3 year old child with Down syndrome
who is pale and asleep in his mother’s
arms.
d. A 2 year old infant with stridorous
breath sounds, sitting up in his mother’s
arms and drooling.
35. Maureen in her third trimester arrives at the
emergency room with painless vaginal bleeding.
Which of the following conditions is suspected?
a. Placenta previa
b. Abruptio placentae
c. Premature labor
d. Sexually transmitted disease
36. A young child named Richard is suspected of
having pinworms. The community nurse collects
a stool specimen to confirm the diagnosis. The
nurse should schedule the collection of this
specimen for:
a. Just before bedtime
b. After the child has been bathe
c. Any time during the day
d. Early in the morning
37. In doing a child’s admission assessment, Nurse
Betty should be alert to note which signs or
symptoms of chronic lead poisoning?
a. Irritability and seizures
b. Dehydration and diarrhea
c. Bradycardia and hypotension
d. Petechiae and hematuria
38. To evaluate a woman’s understanding about the
use of diaphragm for family planning, Nurse
Trish asks her to explain how she will use the
appliance. Which response indicates a need for
further health teaching?
a. “I should check the diaphragm carefully
for holes every time I use it”
b. “I may need a different size of
diaphragm if I gain or lose weight more
than 20 pounds”
c. “The diaphragm must be left in place for
atleast 6 hours after intercourse”
d. “I really need to use the diaphragm and
jelly most during the middle of my
menstrual cycle”.
39. Hypoxia is a common complication of
laryngotracheobronchitis. Nurse Oliver should
frequently assess a child with
laryngotracheobronchitis for:
a. Drooling
b. Muffled voice
c. Restlessness
d. Low-grade fever
40. How should Nurse Michelle guide a child who is
blind to walk to the playroom?
a. Without touching the child, talk
continuously as the child walks down the
hall.
b. Walk one step ahead, with the child’s
hand on the nurse’s elbow.
c. Walk slightly behind, gently guiding the
child forward.
d. Walk next to the child, holding the
child’s hand.
41. When assessing a newborn diagnosed with
ductus arteriosus, Nurse Olivia should expect
that the child most likely would have an:
a. Loud, machinery-like murmur.
b. Bluish color to the lips.
c. Decreased BP reading in the upper
extremities
d. Increased BP reading in the upper
extremities.
42. The reason nurse May keeps the neonate in a
neutral thermal environment is that when a
newborn becomes too cool, the neonate
requires:
a. Less oxygen, and the newborn’s
metabolic rate increases.
b. More oxygen, and the newborn’s
metabolic rate decreases.
c. More oxygen, and the newborn’s
metabolic rate increases.
d. Less oxygen, and the newborn’s
metabolic rate decreases.
43. Before adding potassium to an infant’s I.V. line,
Nurse Ron must be sure to assess whether this
infant has:
a. Stable blood pressure
b. Patant fontanelles
c. Moro’s reflex
d. Voided
44. Nurse Carla should know that the most common
causative factor of dermatitis in infants and
younger children is:
a. Baby oil
b. Baby lotion
c. Laundry detergent
d. Powder with cornstarch
45. During tube feeding, how far above an infant’s
stomach should the nurse hold the syringe with
formula?
a. 6 inches
b. 12 inches
c. 18 inches
d. 24 inches
46. In a mothers’ class, Nurse Lhynnete discussed
childhood diseases such as chicken pox. Which
of the following statements about chicken pox is
correct?
a. The older one gets, the more susceptible
he becomes to the complications of
chicken pox.
b. A single attack of chicken pox will
prevent future episodes, including
conditions such as shingles.
c. To prevent an outbreak in the
community, quarantine may be imposed
by health authorities.
d. Chicken pox vaccine is best given when
there is an impending outbreak in the
community.
47. Barangay Pinoy had an outbreak of German
measles. To prevent congenital rubella, what is
the BEST advice that you can give to women in
the first trimester of pregnancy in the barangay
Pinoy?
a. Advise them on the signs of German
measles.
b. Avoid crowded places, such as markets
and movie houses.
c. Consult at the health center where
rubella vaccine may be given.
d. Consult a physician who may give them
rubella immunoglobulin.
48. Myrna a public health nurse knows that to
determine possible sources of sexually
transmitted infections, the BEST method that
may be undertaken is:
a. Contact tracing
b. Community survey
c. Mass screening tests
d. Interview of suspects
49. A 33-year old female client came for
consultation at the health center with the chief
complaint of fever for a week. Accompanying
symptoms were muscle pains and body malaise.
A week after the start of fever, the client noted
yellowish discoloration of his sclera. History
showed that he waded in flood waters about 2
weeks before the onset of symptoms. Based on
her history, which disease condition will you
suspect?
a. Hepatitis A
b. Hepatitis B
c. Tetanus
d. Leptospirosis
50. Mickey a 3-year old client was brought to the
health center with the chief complaint of severe
diarrhea and the passage of “rice water” stools.
The client is most probably suffering from which
condition?
a. Giardiasis
b. Cholera
c. Amebiasis
d. Dysentery
51. The most prevalent form of meningitis among
children aged 2 months to 3 years is caused by
which microorganism?
a. Hemophilus influenzae
b. Morbillivirus
c. Steptococcus pneumoniae
d. Neisseria meningitidis
52. The student nurse is aware that the
pathognomonic sign of measles is Koplik’s spot
and you may see Koplik’s spot by inspecting the:
a. Nasal mucosa
b. Buccal mucosa
c. Skin on the abdomen
d. Skin on neck
53. Angel was diagnosed as having Dengue fever.
You will say that there is slow capillary refill
when the color of the nailbed that you pressed
does not return within how many seconds?
a. 3 seconds
b. 6 seconds
c. 9 seconds
d. 10 seconds
54. In Integrated Management of Childhood Illness,
the nurse is aware that the severe conditions
generally require urgent referral to a hospital.
Which of the following severe conditions DOES
NOT always require urgent referral to a hospital?
a. Mastoiditis
b. Severe dehydration
c. Severe pneumonia
d. Severe febrile disease
55. Myrna a public health nurse will conduct
outreach immunization in a barangay Masay
with a population of about 1500. The estimated
number of infants in the barangay would be:
a. 45 infants
b. 50 infants
c. 55 infants
d. 65 infants
56. The community nurse is aware that the
biological used in Expanded Program on
Immunization (EPI) should NOT be stored in the
freezer?
a. DPT
b. Oral polio vaccine
c. Measles vaccine
d. MMR
57. It is the most effective way of controlling
schistosomiasis in an endemic area?
a. Use of molluscicides
b. Building of foot bridges
c. Proper use of sanitary toilets
d. Use of protective footwear, such as
rubber boots
58. Several clients is newly admitted and diagnosed
with leprosy. Which of the following clients
should be classified as a case of multibacillary
leprosy?
a. 3 skin lesions, negative slit skin smear
b. 3 skin lesions, positive slit skin smear
c. 5 skin lesions, negative slit skin smear
d. 5 skin lesions, positive slit skin smear
59. Nurses are aware that diagnosis of leprosy is
highly dependent on recognition of symptoms.
Which of the following is an early sign of
leprosy?
a. Macular lesions
b. Inability to close eyelids
c. Thickened painful nerves
d. Sinking of the nosebridge
60. Marie brought her 10 month old infant for
consultation because of fever, started 4 days
prior to consultation. In determining malaria
risk, what will you do?
a. Perform a tourniquet test.
b. Ask where the family resides.
c. Get a specimen for blood smear.
d. Ask if the fever is present every day.
61. Susie brought her 4 years old daughter to the
RHU because of cough and colds. Following the
IMCI assessment guide, which of the following is
a danger sign that indicates the need for urgent
referral to a hospital?
a. Inability to drink
b. High grade fever
c. Signs of severe dehydration
d. Cough for more than 30 days
62. Jimmy a 2-year old child revealed “baggy pants”.
As a nurse, using the IMCI guidelines, how will
you manage Jimmy?
a. Refer the child urgently to a hospital for
confinement.
b. Coordinate with the social worker to
enroll the child in a feeding program.
c. Make a teaching plan for the mother,
focusing on menu planning for her child.
d. Assess and treat the child for health
problems like infections and intestinal
parasitism.
63. Gina is using Oresol in the management of
diarrhea of her 3-year old child. She asked you
what to do if her child vomits. As a nurse you will
tell her to:
a. Bring the child to the nearest hospital
for further assessment.
b. Bring the child to the health center for
intravenous fluid therapy.
c. Bring the child to the health center for
assessment by the physician.
d. Let the child rest for 10 minutes then
continue giving Oresol more slowly.
64. Nikki a 5-month old infant was brought by his
mother to the health center because of diarrhea
for 4 to 5 times a day. Her skin goes back slowly
after a skin pinch and her eyes are sunken. Using
the IMCI guidelines, you will classify this infant in
which category?
a. No signs of dehydration
b. Some dehydration
c. Severe dehydration
d. The data is insufficient.
65. Chris a 4-month old infant was brought by her
mother to the health center because of cough.
His respiratory rate is 42/minute. Using the
Integrated Management of Child Illness (IMCI)
guidelines of assessment, his breathing is
considered as:
a. Fast
b. Slow
c. Normal
d. Insignificant
66. Maylene had just received her 4th dose of
tetanus toxoid. She is aware that her baby will
have protection against tetanus for
a. 1 year
b. 3 years
c. 5 years
d. Lifetime
67. Nurse Ron is aware that unused BCG should be
discarded after how many hours of
reconstitution?
a. 2 hours
b. 4 hours
c. 8 hours
d. At the end of the day
68. The nurse explains to a breastfeeding mother
that breast milk is sufficient for all of the baby’s
nutrient needs only up to:
a. 5 months
b. 6 months
c. 1 year
d. 2 years
69. Nurse Ron is aware that the gestational age of a
conceptus that is considered viable (able to live
outside the womb) is:
a. 8 weeks
b. 12 weeks
c. 24 weeks
d. 32 weeks
70. When teaching parents of a neonate the proper
position for the neonate’s sleep, the nurse
Patricia stresses the importance of placing the
neonate on his back to reduce the risk of which
of the following?
a. Aspiration
b. Sudden infant death syndrome (SIDS)
c. Suffocation
d. Gastroesophageal reflux (GER)
71. Which finding might be seen in baby James a
neonate suspected of having an infection?
a. Flushed cheeks
b. Increased temperature
c. Decreased temperature
d. Increased activity level
72. Baby Jenny who is small-for-gestation is at
increased risk during the transitional period for
which complication?
a. Anemia probably due to chronic fetal
hyposia
b. Hyperthermia due to decreased
glycogen stores
c. Hyperglycemia due to decreased
glycogen stores
d. Polycythemia probably due to chronic
fetal hypoxia
73. Marjorie has just given birth at 42 weeks’
gestation. When the nurse assessing the
neonate, which physical finding is expected?
a. A sleepy, lethargic baby
b. Lanugo covering the body
c. Desquamation of the epidermis
d. Vernix caseosa covering the body
74. After reviewing the Myrna’s maternal history of
magnesium sulfate during labor, which condition
would nurse Richard anticipate as a potential
problem in the neonate?
a. Hypoglycemia
b. Jitteriness
c. Respiratory depression
d. Tachycardia
75. Which symptom would indicate the Baby
Alexandra was adapting appropriately to extrauterine
life without difficulty?
a. Nasal flaring
b. Light audible grunting
c. Respiratory rate 40 to 60
breaths/minute
d. Respiratory rate 60 to 80
breaths/minute
76. When teaching umbilical cord care for Jennifer a
new mother, the nurse Jenny would include
which information?
a. Apply peroxide to the cord with each
diaper change
b. Cover the cord with petroleum jelly after
bathing
c. Keep the cord dry and open to air
d. Wash the cord with soap and water each
day during a tub bath.
77. Nurse John is performing an assessment on a
neonate. Which of the following findings is
considered common in the healthy neonate?
a. Simian crease
b. Conjunctival hemorrhage
c. Cystic hygroma
d. Bulging fontanelle
78. Dr. Esteves decides to artificially rupture the
membranes of a mother who is on labor.
Following this procedure, the nurse Hazel checks
the fetal heart tones for which the following
reasons?
a. To determine fetal well-being.
b. To assess for prolapsed cord
c. To assess fetal position
d. To prepare for an imminent delivery.
79. Which of the following would be least likely to
indicate anticipated bonding behaviors by new
parents?
a. The parents’ willingness to touch and
hold the new born.
b. The parent’s expression of interest
about the size of the new born.
c. The parents’ indication that they want to
see the newborn.
d. The parents’ interactions with each
other.
80. Following a precipitous delivery, examination of
the client's vagina reveals a fourth-degree
laceration. Which of the following would be
contraindicated when caring for this client?
a. Applying cold to limit edema during the
first 12 to 24 hours.
b. Instructing the client to use two or more
peripads to cushion the area.
c. Instructing the client on the use of sitz
baths if ordered.
d. Instructing the client about the
importance of perineal (kegel) exercises.
81. A pregnant woman accompanied by her
husband, seeks admission to the labor and
delivery area. She states that she's in labor and
says she attended the facility clinic for prenatal
care. Which question should the nurse Oliver ask
her first?
a. “Do you have any chronic illnesses?”
b. “Do you have any allergies?”
c. “What is your expected due date?”
d. “Who will be with you during labor?”
82. A neonate begins to gag and turns a dusky color.
What should the nurse do first?
a. Calm the neonate.
b. Notify the physician.
c. Provide oxygen via face mask as ordered
d. Aspirate the neonate’s nose and mouth
with a bulb syringe.
83. When a client states that her "water broke,"
which of the following actions would be
inappropriate for the nurse to do?
a. Observing the pooling of straw-colored
fluid.
b. Checking vaginal discharge with nitrazine
paper.
c. Conducting a bedside ultrasound for an
amniotic fluid index.
d. Observing for flakes of vernix in the
vaginal discharge.
84. A baby girl is born 8 weeks premature. At birth,
she has no spontaneous respirations but is
successfully resuscitated. Within several hours
she develops respiratory grunting, cyanosis,
tachypnea, nasal flaring, and retractions. She's
diagnosed with respiratory distress syndrome,
intubated, and placed on a ventilator. Which
nursing action should be included in the baby's
plan of care to prevent retinopathy of
prematurity?
a. Cover his eyes while receiving oxygen.
b. Keep her body temperature low.
c. Monitor partial pressure of oxygen
(Pao2) levels.
d. Humidify the oxygen.
85. Which of the following is normal newborn
calorie intake?
a. 110 to 130 calories per kg.
b. 30 to 40 calories per lb of body weight.
c. At least 2 ml per feeding
d. 90 to 100 calories per kg
86. Nurse John is knowledgeable that usually
individual twins will grow appropriately and at
the same rate as singletons until how many
weeks?
a. 16 to 18 weeks
b. 18 to 22 weeks
c. 30 to 32 weeks
d. 38 to 40 weeks
87. Which of the following classifications applies to
monozygotic twins for whom the cleavage of the
fertilized ovum occurs more than 13 days after
fertilization?
a. conjoined twins
b. diamniotic dichorionic twins
c. diamniotic monochorionic twin
d. monoamniotic monochorionic twins
88. Tyra experienced painless vaginal bleeding has
just been diagnosed as having a placenta previa.
Which of the following procedures is usually
performed to diagnose placenta previa?
a. Amniocentesis
b. Digital or speculum examination
c. External fetal monitoring
d. Ultrasound
89. Nurse Arnold knows that the following changes
in respiratory functioning during pregnancy is
considered normal:
a. Increased tidal volume
b. Increased expiratory volume
c. Decreased inspiratory capacity
d. Decreased oxygen consumption
90. Emily has gestational diabetes and it is usually
managed by which of the following therapy?
a. Diet
b. Long-acting insulin
c. Oral hypoglycemic
d. Oral hypoglycemic drug and insulin
91. Magnesium sulfate is given to Jemma with
preeclampsia to prevent which of the following
condition?
a. Hemorrhage
b. Hypertension
c. Hypomagnesemia
d. Seizure
92. Cammile with sickle cell anemia has an increased
risk for having a sickle cell crisis during
pregnancy. Aggressive management of a sickle
cell crisis includes which of the following
measures?
a. Antihypertensive agents
b. Diuretic agents
c. I.V. fluids
d. Acetaminophen (Tylenol) for pain
93. Which of the following drugs is the antidote for
magnesium toxicity?
a. Calcium gluconate (Kalcinate)
b. Hydralazine (Apresoline)
c. Naloxone (Narcan)
d. Rho (D) immune globulin (RhoGAM)
94. Marlyn is screened for tuberculosis during her
first prenatal visit. An intradermal injection of
purified protein derivative (PPD) of the
tuberculin bacilli is given. She is considered to
have a positive test for which of the following
results?
a. An indurated wheal under 10 mm in
diameter appears in 6 to 12 hours.
b. An indurated wheal over 10 mm in
diameter appears in 48 to 72 hours.
c. A flat circumcised area under 10 mm in
diameter appears in 6 to 12 hours.
d. A flat circumcised area over 10 mm in
diameter appears in 48 to 72 hours.
95. Dianne, 24 year-old is 27 weeks’ pregnant
arrives at her physician’s office with complaints
of fever, nausea, vomiting, malaise, unilateral
flank pain, and costovertebral angle tenderness.
Which of the following diagnoses is most likely?
a. Asymptomatic bacteriuria
b. Bacterial vaginosis
c. Pyelonephritis
d. Urinary tract infection (UTI)
96. Rh isoimmunization in a pregnant client
develops during which of the following
conditions?
a. Rh-positive maternal blood crosses into
fetal blood, stimulating fetal antibodies.
b. Rh-positive fetal blood crosses into
maternal blood, stimulating maternal
antibodies.
c. Rh-negative fetal blood crosses into
maternal blood, stimulating maternal
antibodies.
d. Rh-negative maternal blood crosses into
fetal blood, stimulating fetal antibodies.
97. To promote comfort during labor, the nurse John
advises a client to assume certain positions and
avoid others. Which position may cause
maternal hypotension and fetal hypoxia?
a. Lateral position
b. Squatting position
c. Supine position
98. Celeste who used heroin during her pregnancydelivers a neonate. When assessing the neonate,
the nurse Lhynnette expects to find:
a. Lethargy 2 days after birth.
b. Irritability and poor sucking.
c. A flattened nose, small eyes, and thin
lips.
d. Congenital defects such as limb
anomalies.
99. The uterus returns to the pelvic cavity in which
of the following time frames?
a. 7th to 9th day postpartum.
b. 2 weeks postpartum.
c. End of 6th week postpartum.
d. When the lochia changes to alba.
100. Maureen, a primigravida client, age 20, has
just completed a difficult, forceps-assisted
delivery of twins. Her labor was unusually
long and required oxytocin (Pitocin)
augmentation. The nurse who's caring for her
should stay alert for:
a. Uterine inversion
b. Uterine atony
c. Uterine involution
d. Uterine discomfort
Answers and Rationale – Foundation of Professional Nursing Practice
Answers and Rationale – Foundation of
Professional Nursing Practice
1. Answer: (D) The actions of a reasonably prudent
nurse with similar education and experience.
Rationale: The standard of care is determined
by the average degree of skill, care, and
diligence by nurses in similar circumstances.
2. Answer: (B) I.M
Rationale: With a platelet count of 22,000/μl,
the clients tends to bleed easily. Therefore,
the nurse should avoid using the I.M. route
because the area is a highly vascular and can
bleed readily when penetrated by a needle.
The bleeding can be difficult to stop.
3. Answer: (C) “Digoxin 0.125 mg P.O. once daily”
Rationale: The nurse should always place a
zero before a decimal point so that no one
misreads the figure, which could result in a
dosage error. The nurse should never insert a
zero at the end of a dosage that includes a
decimal point because this could be misread,
possibly leading to a tenfold increase in the
dosage.
4. Answer: (A) Ineffective peripheral tissue
perfusion related to venous congestion.
Rationale: Ineffective peripheral tissue
perfusion related to venous congestion takes
the highest priority because venous
inflammation and clot formation impede blood
flow in a client with deep vein thrombosis.
5. Answer: (B) A 44 year-old myocardial
infarction (MI) client who is complaining of
nausea.
Rationale: Nausea is a symptom of impending
myocardial infarction (MI) and should be
assessed immediately so that treatment can
be instituted and further damage to the heart
is avoided.
6. Answer: (C) Check circulation every 15-30
minutes.
Rationale: Restraints encircle the limbs, which
place the client at risk for circulation being
restricted to the distal areas of the
extremities. Checking the client’s circulation
every 15-30 minutes will allow the nurse to
adjust the restraints before injury from
decreased blood flow occurs.
7. Answer: (A) Prevent stress ulcer
Rationale: Curling’s ulcer occurs as a
generalized stress response in burn patients.
This results in a decreased production of
mucus and increased secretion of gastric acid.
The best treatment for this prophylactic use of
antacids and H2 receptor blockers.
8. Answer: (D) Continue to monitor and record
hourly urine output
Rationale: Normal urine output for an adult is
approximately 1 ml/minute (60 ml/hour).
Therefore, this client's output is normal.
Beyond continued evaluation, no nursing
action is warranted.
9. Answer: (B) “My ankle feels warm”.
Rationale: Ice application decreases pain and
swelling. Continued or increased pain, redness,
and increased warmth are signs of
inflammation that shouldn't occur after ice
application
10. Answer: (B) Hyperkalemia
Rationale: A loop diuretic removes water and,
along with it, sodium and potassium. This may
result in hypokalemia, hypovolemia, and
hyponatremia.
11. Answer:(A) Have condescending trust and
confidence in their subordinates
Rationale: Benevolent-authoritative managers
pretentiously show their trust and confidence
to their followers.
12. Answer: (A) Provides continuous, coordinated
and comprehensive nursing services.
Rationale: Functional nursing is focused on
tasks and activities and not on the care of the
patients.
13. Answer: (B) Standard written order
Rationale: This is a standard written order.
Prescribers write a single order for
medications given only once. A stat order is
written for medications given immediately for
an urgent client problem. A standing order,
also known as a protocol, establishes
guidelines for treating a particular disease or
set of symptoms in special care areas such as
the coronary care unit. Facilities also may
institute medication protocols that specifically
designate drugs that a nurse may not give.
14. Answer: (D) Liquid or semi-liquid stools
Rationale: Passage of liquid or semi-liquid
stools results from seepage of unformed
bowel contents around the impacted stool in
the rectum. Clients with fecal impaction don't
pass hard, brown, formed stools because the
feces can't move past the impaction. These
clients typically report the urge to defecate
(although they can't pass stool) and a
decreased appetite.
15. Answer: (C) Pulling the helix up and back
Rationale: To perform an otoscopic
examination on an adult, the nurse grasps the
helix of the ear and pulls it up and back to
straighten the ear canal. For a child, the nurse
grasps the helix and pulls it down to straighten
the ear canal. Pulling the lobule in any
direction wouldn't straighten the ear canal for
visualization.
16. Answer: (A) Protect the irritated skin from
sunlight.
Rationale: Irradiated skin is very sensitive and
must be protected with clothing or sunblock.
The priority approach is the avoidance of
strong sunlight.
17. Answer: (C) Assist the client in removing
dentures and nail polish.
Rationale: Dentures, hairpins, and combs must
be removed. Nail polish must be removed so
that cyanosis can be easily monitored by
observing the nail beds.
18. Answer: (D) Sudden onset of continuous
epigastric and back pain.
Rationale: The autodigestion of tissue by the
pancreatic enzymes results in pain from
inflammation, edema, and possible
hemorrhage. Continuous, unrelieved epigastric
or back pain reflects the inflammatory process
in the pancreas.
19. Answer: (B) Provide high-protein, highcarbohydrate
diet.
Rationale: A positive nitrogen balance is
important for meeting metabolic needs, tissue
repair, and resistance to infection. Caloric
goals may be as high as 5000 calories per day.
20. Answer: (A) Blood pressure and pulse rate.
Rationale: The baseline must be established to
recognize the signs of an anaphylactic or
hemolytic reaction to the transfusion.
21. Answer: (D) Immobilize the leg before moving
the client.
Rationale: If the nurse suspects a fracture,
splinting the area before moving the client is
imperative. The nurse should call for
emergency help if the client is not hospitalized
and call for a physician for the hospitalized
client.
22. Answer: (B) Admit the client into a private
room.
Rationale: The client who has a radiation
implant is placed in a private room and has a
limited number of visitors. This reduces the
exposure of others to the radiation.
23. Answer: (C) Risk for infection
Rationale: Agranulocytosis is characterized by
a reduced number of leukocytes (leucopenia)
and neutrophils (neutropenia) in the blood.
The client is at high risk for infection because
of the decreased body defenses against
microorganisms. Deficient knowledge related
to the nature of the disorder may be
appropriate diagnosis but is not the priority.
24. Answer: (B) Place the client on the left side in
the Trendelenburg position.
Rationale: Lying on the left side may prevent
air from flowing into the pulmonary veins. The
Trendelenburg position increases intrathoracic
pressure, which decreases the amount of
blood pulled into the vena cava during
aspiration.
25. Answer: (A) Autocratic.
Rationale: The autocratic style of leadership is
a task-oriented and directive.
26. Answer: (D) 2.5 cc
Rationale: 2.5 cc is to be added, because only a
500 cc bag of solution is being medicated
instead of a 1 liter.
27. Answer: (A) 50 cc/ hour
Rationale: A rate of 50 cc/hr. The child is to
receive 400 cc over a period of 8 hours = 50
cc/hr.
28. Answer: (B) Assess the client for presence of
pain.
Rationale: Assessing the client for pain is a
very important measure. Postoperative pain is
an indication of complication. The nurse
should also assess the client for pain to
provide for the client’s comfort.
29. Answer: (A) BP – 80/60, Pulse – 110 irregular
Rationale: The classic signs of cardiogenic
shock are low blood pressure, rapid and weak
irregular pulse, cold, clammy skin, decreased
urinary output, and cerebral hypoxia.
30. Answer: (A) Take the proper equipment, place
the client in a comfortable position, and
record the appropriate information in the
client’s chart.
Rationale: It is a general or comprehensive
statement about the correct procedure, and it
includes the basic ideas which are found in the
other options
31. Answer: (B) Evaluation
Rationale: Evaluation includes observing the
person, asking questions, and comparing the
patient’s behavioral responses with the
expected outcomes.
32. Answer: (C) History of present illness
Rationale: The history of present illness is the
single most important factor in assisting the
health professional in arriving at a diagnosis or
determining the person’s needs.
33. Answer: (A) Trochanter roll extending from the
crest of the ileum to the mid-thigh.
Rationale: A trochanter roll, properly placed,
provides resistance to the external rotation of
the hip.
34. Answer: (C) Stage III
Rationale: Clinically, a deep crater or without
undermining of adjacent tissue is noted.
35. Answer: (A) Second intention healing
Rationale: When wounds dehisce, they will
allowed to heal by secondary Intention
36. Answer: (D) Tachycardia
Rationale: With an extracellular fluid or plasma
volume deficit, compensatory mechanisms
stimulate the heart, causing an increase in
heart rate.
37. Answer: (A) 0.75
Rationale: To determine the number of
milliliters the client should receive, the nurse
uses the fraction method in the following
equation.
75 mg/X ml = 100 mg/1 ml
To solve for X, cross-multiply:
75 mg x 1 ml = X ml x 100 mg
75 = 100X
75/100 = X
0.75 ml (or ¾ ml) = X
38. Answer: (D) it’s a measure of effect, not a
standard measure of weight or quantity.
Rationale: An insulin unit is a measure of
effect, not a standard measure of weight or
quantity. Different drugs measured in units
may have no relationship to one another in
quality or quantity.
39. Answer: (B) 38.9 °C
Rationale: To convert Fahrenheit degreed to
Centigrade, use this formula
°C = (°F – 32) ÷ 1.8
°C = (102 – 32) ÷ 1.8
°C = 70 ÷ 1.8
°C = 38.9
40. Answer: (C) Failing eyesight, especially close
vision.
Rationale: Failing eyesight, especially close
vision, is one of the first signs of aging in
middle life (ages 46 to 64). More frequent
aches and pains begin in the early late years
(ages 65 to 79). Increase in loss of muscle tone
occurs in later years (age 80 and older).
41. Answer: (A) Checking and taping all
connections
Rationale: Air leaks commonly occur if the
system isn’t secure. Checking all connections
and taping them will prevent air leaks. The
chest drainage system is kept lower to
promote drainage – not to prevent leaks.
42. Answer: (A) Check the client’s identification
band.
Rationale: Checking the client’s identification
band is the safest way to verify a client’s
identity because the band is assigned on
admission and isn’t be removed at any time. (If
it is removed, it must be replaced). Asking the
client’s name or having the client repeated his
name would be appropriate only for a client
who’s alert, oriented, and able to understand
what is being said, but isn’t the safe standard
of practice. Names on bed aren’t always
reliable
43. Answer: (B) 32 drops/minute
Rationale: Giving 1,000 ml over 8 hours is the
same as giving 125 ml over 1 hour (60
minutes). Find the number of milliliters per
minute as follows:
125/60 minutes = X/1 minute
60X = 125 = 2.1 ml/minute
To find the number of drops per minute:
2.1 ml/X gtt = 1 ml/ 15 gtt
X = 32 gtt/minute, or 32 drops/minute
44. Answer: (A) Clamp the catheter
Rationale: If a central venous catheter
becomes disconnected, the nurse should
immediately apply a catheter clamp, if
available. If a clamp isn’t available, the nurse
can place a sterile syringe or catheter plug in
the catheter hub. After cleaning the hub with
alcohol or povidone-iodine solution, the nurse
must replace the I.V. extension and restart the
infusion.
45. Answer: (D) Auscultation, percussion, and
palpation.
Rationale: The correct order of assessment for
examining the abdomen is inspection,
auscultation, percussion, and palpation. The
reason for this approach is that the less
intrusive techniques should be performed
before the more intrusive techniques.
Percussion and palpation can alter natural
findings during auscultation.
46. Answer: (D) Ulnar surface of the hand
Rationale: The nurse uses the ulnar surface, or
ball, of the hand to assess tactile fremitus,
thrills, and vocal vibrations through the chest
wall. The fingertips and finger pads best
distinguish texture and shape. The dorsal
surface best feels warmth.
47. Answer: (C) Formative
Rationale: Formative (or concurrent)
evaluation occurs continuously throughout the
teaching and learning process. One benefit is
that the nurse can adjust teaching strategies
as necessary to enhance learning. Summative,
or retrospective, evaluation occurs at the
conclusion of the teaching and learning
session. Informative is not a type of
evaluation.
48. Answer: (B) Once per year
Rationale: Yearly mammograms should begin
at age 40 and continue for as long as the
woman is in good health. If health risks, such
as family history, genetic tendency, or past
breast cancer, exist, more frequent
examinations may be necessary.
49. Answer: (A) Respiratory acidosis
Rationale: The client has a below-normal
(acidic) blood pH value and an above-normal
partial pressure of arterial carbon dioxide
(Paco2) value, indicating respiratory acidosis.
In respiratory alkalosis, the pH value is above
normal and in the Paco2 value is below
normal. In metabolic acidosis, the pH and
bicarbonate (Hco3) values are below normal.
In metabolic alkalosis, the pH and Hco3 values
are above normal.
50. Answer: (B) To provide support for the client
and family in coping with terminal illness.
Rationale: Hospices provide supportive care
for terminally ill clients and their families.
Hospice care doesn’t focus on counseling
regarding health care costs. Most client
referred to hospices have been treated for
their disease without success and will receive
only palliative care in the hospice.
51. Answer: (C) Using normal saline solution to
clean the ulcer and applying a protective
dressing as necessary.
Rationale: Washing the area with normal
saline solution and applying a protective
dressing are within the nurse’s realm of
interventions and will protect the area. Using a
povidone-iodine wash and an antibiotic cream
require a physician’s order. Massaging with an
astringent can further damage the skin.
52. Answer: (D) Foot
Rationale: An elastic bandage should be
applied form the distal area to the proximal
area. This method promotes venous return. In
this case, the nurse should begin applying the
bandage at the client’s foot. Beginning at the
ankle, lower thigh, or knee does not promote
venous return.
53. Answer: (B) Hypokalemia
Rationale: Insulin administration causes
glucose and potassium to move into the cells,
causing hypokalemia.
54. Answer: (A) Throbbing headache or dizziness
Rationale: Headache and dizziness often occur
when nitroglycerin is taken at the beginning of
therapy. However, the client usually develops
tolerance
55. Answer: (D) Check the client’s level of
consciousness
Rationale: Determining unresponsiveness is
the first step assessment action to take. When
a client is in ventricular tachycardia, there is a
significant decrease in cardiac output.
However, checking the unresponsiveness
ensures whether the client is affected by the
decreased cardiac output.
56. Answer: (B) On the affected side of the client.
Rationale: When walking with clients, the
nurse should stand on the affected side and
grasp the security belt in the midspine area of
the small of the back. The nurse should
position the free hand at the shoulder area so
that the client can be pulled toward the nurse
in the event that there is a forward fall. The
client is instructed to look up and outward
rather than at his or her feet.
57. Answer: (A) Urine output: 45 ml/hr
Rationale: Adequate perfusion must be
maintained to all vital organs in order for the
client to remain visible as an organ donor. A
urine output of 45 ml per hour indicates
adequate renal perfusion. Low blood pressure
and delayed capillary refill time are circulatory
system indicators of inadequate perfusion. A
serum pH of 7.32 is acidotic, which adversely
affects all body tissues.
58. Answer: (D ) Obtaining the specimen from the
urinary drainage bag.
Rationale: A urine specimen is not taken from
the urinary drainage bag. Urine undergoes
chemical changes while sitting in the bag and
does not necessarily reflect the current client
status. In addition, it may become
contaminated with bacteria from opening the
system.
59. Answer: (B) Cover the client, place the call
light within reach, and answer the phone call.
Rationale: Because telephone call is an
emergency, the nurse may need to answer it.
The other appropriate action is to ask another
nurse to accept the call. However, is not one of
the options. To maintain privacy and safety,
the nurse covers the client and places the call
light within the client’s reach. Additionally, the
client’s door should be closed or the room
curtains pulled around the bathing area.
60. Answer: (C) Use a sterile plastic container for
obtaining the specimen.
Rationale: Sputum specimens for culture and
sensitivity testing need to be obtained using
sterile techniques because the test is done to
determine the presence of organisms. If the
procedure for obtaining the specimen is not
sterile, then the specimen is not sterile, then
the specimen would be contaminated and the
results of the test would be invalid.
61. Answer: (A) Puts all the four points of the
walker flat on the floor, puts weight on the
hand pieces, and then walks into it.
Rationale: When the client uses a walker, the
nurse stands adjacent to the affected side. The
client is instructed to put all four points of the
walker 2 feet forward flat on the floor before
putting weight on hand pieces. This will ensure
client safety and prevent stress cracks in the
walker. The client is then instructed to move
the walker forward and walk into it.
62. Answer: (C) Draws one line to cross out the
incorrect information and then initials the
change.
Rationale: To correct an error documented in a
medical record, the nurse draws one line
through the incorrect information and then
initials the error. An error is never erased and
correction fluid is never used in the medical
record.
63. Answer: (C) Secures the client safety belts
after transferring to the stretcher.
Rationale: During the transfer of the client
after the surgical procedure is complete, the
nurse should avoid exposure of the client
because of the risk for potential heat loss.
Hurried movements and rapid changes in the
position should be avoided because these
predispose the client to hypotension. At the
time of the transfer from the surgery table to
the stretcher, the client is still affected by the
effects of the anesthesia; therefore, the client
should not move self. Safety belts can prevent
the client from falling off the stretcher.
64. Answer: (B) Gown and gloves
Rationale: Contact precautions require the use
of gloves and a gown if direct client contact is
anticipated. Goggles are not necessary unless
the nurse anticipates the splashes of blood,
body fluids, secretions, or excretions may
occur. Shoe protectors are not necessary.
65. Answer: (C) Quad cane
Rationale: Crutches and a walker can be
difficult to maneuver for a client with
weakness on one side. A cane is better suited
for client with weakness of the arm and leg on
one side. However, the quad cane would
provide the most stability because of the
structure of the cane and because a quad cane
has four legs.
66. Answer: (D) Left side-lying with the head of
the bed elevated 45 degrees.
Rationale: To facilitate removal of fluid from
the chest wall, the client is positioned sitting at
the edge of the bed leaning over the bedside
table with the feet supported on a stool. If the
client is unable to sit up, the client is
positioned lying in bed on the unaffected side
with the head of the bed elevated 30 to 45
degrees.
67. Answer: (D) Reliability
Rationale: Reliability is consistency of the
research instrument. It refers to the
repeatability of the instrument in extracting
the same responses upon its repeated
administration.
68. Answer: (A) Keep the identities of the subject
secret
Rationale: Keeping the identities of the
research subject secret will ensure anonymity
because this will hinder providing link between
the information given to whoever is its source.
69. Answer: (A) Descriptive- correlational
Rationale: Descriptive- correlational study is
the most appropriate for this study because it
studies the variables that could be the
antecedents of the increased incidence of
nosocomial infection.
70. Answer: (C) Use of laboratory data
Rationale: Incidence of nosocomial infection is
best collected through the use of
biophysiologic measures, particularly in vitro
measurements, hence laboratory data is
essential.
71. Answer: (B) Quasi-experiment
Rationale: Quasi-experiment is done when
randomization and control of the variables are
not possible.
72. Answer: (C) Primary source
Rationale: This refers to a primary source
which is a direct account of the investigation
done by the investigator. In contrast to this is a
secondary source, which is written by
someone other than the original researcher.
73. Answer: (A) Non-maleficence
Rationale: Non-maleficence means do not
cause harm or do any action that will cause
any harm to the patient/client. To do good is
referred as beneficence.
74. Answer: (C) Res ipsa loquitor
Rationale: Res ipsa loquitor literally means the
thing speaks for itself. This means in
operational terms that the injury caused is the
proof that there was a negligent act.
75. Answer: (B) The Board can investigate
violations of the nursing law and code of ethics
Rationale: Quasi-judicial power means that the
Board of Nursing has the authority to
investigate violations of the nursing law and
can issue summons, subpoena or subpoena
duces tecum as needed.
76. Answer: (C) May apply for re-issuance of
his/her license based on certain conditions
stipulated in RA 9173
Rationale: RA 9173 sec. 24 states that for
equity and justice, a revoked license maybe reissued
provided that the following conditions
are met: a) the cause for revocation of license
has already been corrected or removed; and,
b) at least four years has elapsed since the
license has been revoked.
77. Answer: (B) Review related literature
Rationale: After formulating and delimiting the
research problem, the researcher conducts a
review of related literature to determine the
extent of what has been done on the study by
previous researchers.
78. Answer: (B) Hawthorne effect
Rationale: Hawthorne effect is based on the
study of Elton Mayo and company about the
effect of an intervention done to improve the
working conditions of the workers on their
productivity. It resulted to an increased
productivity but not due to the intervention
but due to the psychological effects of being
observed. They performed differently because
they were under observation.
79. Answer: (B) Determines the different
nationality of patients frequently admitted and
decides to get representations samples from
each.
Rationale: Judgment sampling involves
including samples according to the knowledge
of the investigator about the participants in
the study.
80. Answer: (B) Madeleine Leininger
Rationale: Madeleine Leininger developed the
theory on transcultural theory based on her
observations on the behavior of selected
people within a culture.
81. Answer: (A) Random
Rationale: Random sampling gives equal
chance for all the elements in the population
to be picked as part of the sample.
82. Answer: (A) Degree of agreement and
disagreement
Rationale: Likert scale is a 5-point summated
scale used to determine the degree of
agreement or disagreement of the
respondents to a statement in a study
83. Answer: (B) Sr. Callista Roy
Rationale: Sr. Callista Roy developed the
Adaptation Model which involves the
physiologic mode, self-concept mode, role
function mode and dependence mode.
84. Answer: (A) Span of control
Rationale: Span of control refers to the
number of workers who report directly to a
manager.
85. Answer: (B) Autonomy
Rationale: Informed consent means that the
patient fully understands about the surgery,
including the risks involved and the alternative
solutions. In giving consent it is done with full
knowledge and is given freely. The action of
allowing the patient to decide whether a
surgery is to be done or not exemplifies the
bioethical principle of autonomy.
86. Answer: (C) Avoid wearing canvas shoes.
Rationale: The client should be instructed to
avoid wearing canvas shoes. Canvas shoes
cause the feet to perspire, which may, in turn,
cause skin irritation and breakdown. Both
cotton and cornstarch absorb perspiration.
The client should be instructed to cut toenails
straight across with nail clippers.
87. Answer: (D) Ground beef patties
Rationale: Meat is an excellent source of
complete protein, which this client needs to
repair the tissue breakdown caused by
pressure ulcers. Oranges and broccoli supply
vitamin C but not protein. Ice cream supplies
only some incomplete protein, making it less
helpful in tissue repair.
88. Answer: (D) Sims’ left lateral
Rationale: The Sims' left lateral position is the
most common position used to administer a
cleansing enema because it allows gravity to
aid the flow of fluid along the curve of the
sigmoid colon. If the client can't assume this
position nor has poor sphincter control, the
dorsal recumbent or right lateral position may
be used. The supine and prone positions are
inappropriate and uncomfortable for the
client.
89. Answer: (A) Arrange for typing and cross
matching of the client’s blood.
Rationale: The nurse first arranges for typing
and cross matching of the client's blood to
ensure compatibility with donor blood. The
other options, although appropriate when
preparing to administer a blood transfusion,
come later.
90. Answer: (A) Independent
Rationale: Nursing interventions are classified
as independent, interdependent, or
dependent. Altering the drug schedule to
coincide with the client's daily routine
represents an independent intervention,
whereas consulting with the physician and
pharmacist to change a client's medication
because of adverse reactions represents an
interdependent intervention. Administering an
already-prescribed drug on time is a
dependent intervention. An intradependent
nursing intervention doesn't exist.
91. Answer: (D) Evaluation
Rationale: The nursing actions described
constitute evaluation of the expected
outcomes. The findings show that the
expected outcomes have been achieved.
Assessment consists of the client's history,
physical examination, and laboratory studies.
Analysis consists of considering assessment
information to derive the appropriate nursing
diagnosis. Implementation is the phase of the
nursing process where the nurse puts the plan
of care into action.
92. Answer: (B) To observe the lower extremities
Rationale: Elastic stockings are used to
promote venous return. The nurse needs to
remove them once per day to observe the
condition of the skin underneath the stockings.
Applying the stockings increases blood flow to
the heart. When the stockings are in place, the
leg muscles can still stretch and relax, and the
veins can fill with blood.
93. Answer :(A) Instructing the client to report any
itching, swelling, or dyspnea.
Rationale: Because administration of blood or
blood products may cause serious adverse
effects such as allergic reactions, the nurse
must monitor the client for these effects. Signs
and symptoms of life-threatening allergic
reactions include itching, swelling, and
dyspnea. Although the nurse should inform
the client of the duration of the transfusion
and should document its administration, these
actions are less critical to the client's
immediate health. The nurse should assess
vital signs at least hourly during the
transfusion.
94. Answer: (B) Decrease the rate of feedings and
the concentration of the formula.
Rationale: Complaints of abdominal
discomfort and nausea are common in clients
receiving tube feedings. Decreasing the rate of
the feeding and the concentration of the
formula should decrease the client's
discomfort. Feedings are normally given at
room temperature to minimize abdominal
cramping. To prevent aspiration during
feeding, the head of the client's bed should be
elevated at least 30 degrees. Also, to prevent
bacterial growth, feeding containers should be
routinely changed every 8 to 12 hours.
95. Answer: (D) Roll the vial gently between the
palms.
Rationale: Rolling the vial gently between the
palms produces heat, which helps dissolve the
medication. Doing nothing or inverting the vial
wouldn't help dissolve the medication. Shaking
the vial vigorously could cause the medication
to break down, altering its action.
96. Answer: (B) Assist the client to the semi-
Fowler position if possible.
Rationale: By assisting the client to the semi-
Fowler position, the nurse promotes easier
chest expansion, breathing, and oxygen intake.
The nurse should secure the elastic band so
that the face mask fits comfortably and snugly
rather than tightly, which could lead to
irritation. The nurse should apply the face
mask from the client's nose down to the chin
— not vice versa. The nurse should check the
connectors between the oxygen equipment
and humidifier to ensure that they're airtight;
loosened connectors can cause loss of oxygen.
97. Answer: (B) 4 hours
Rationale: A unit of packed RBCs may be given
over a period of between 1 and 4 hours. It
shouldn't infuse for longer than 4 hours
because the risk of contamination and sepsis
increases after that time. Discard or return to
the blood bank any blood not given within this
time, according to facility policy.
98. Answer: (B) Immediately before administering
the next dose.
Rationale: Measuring the blood drug
concentration helps determine whether the
dosing has achieved the therapeutic goal. For
measurement of the trough, or lowest, blood
level of a drug, the nurse draws a blood
sample immediately before administering the
next dose. Depending on the drug's duration
of action and half-life, peak blood drug levels
typically are drawn after administering the
next dose.
99. Answer: (A) The nurse can implement
medication orders quickly.
Rationale: A floor stock system enables the
nurse to implement medication orders quickly.
It doesn't allow for pharmacist input, nor does
it minimize transcription errors or reinforce
accurate calculations.
100. Answer: (C) Shifting dullness over the
abdomen.
Rationale: Shifting dullness over the abdomen
indicates ascites, an abnormal finding. The
other options are normal abdominal findings.
Professional Nursing Practice
1. Answer: (D) The actions of a reasonably prudent
nurse with similar education and experience.
Rationale: The standard of care is determined
by the average degree of skill, care, and
diligence by nurses in similar circumstances.
2. Answer: (B) I.M
Rationale: With a platelet count of 22,000/μl,
the clients tends to bleed easily. Therefore,
the nurse should avoid using the I.M. route
because the area is a highly vascular and can
bleed readily when penetrated by a needle.
The bleeding can be difficult to stop.
3. Answer: (C) “Digoxin 0.125 mg P.O. once daily”
Rationale: The nurse should always place a
zero before a decimal point so that no one
misreads the figure, which could result in a
dosage error. The nurse should never insert a
zero at the end of a dosage that includes a
decimal point because this could be misread,
possibly leading to a tenfold increase in the
dosage.
4. Answer: (A) Ineffective peripheral tissue
perfusion related to venous congestion.
Rationale: Ineffective peripheral tissue
perfusion related to venous congestion takes
the highest priority because venous
inflammation and clot formation impede blood
flow in a client with deep vein thrombosis.
5. Answer: (B) A 44 year-old myocardial
infarction (MI) client who is complaining of
nausea.
Rationale: Nausea is a symptom of impending
myocardial infarction (MI) and should be
assessed immediately so that treatment can
be instituted and further damage to the heart
is avoided.
6. Answer: (C) Check circulation every 15-30
minutes.
Rationale: Restraints encircle the limbs, which
place the client at risk for circulation being
restricted to the distal areas of the
extremities. Checking the client’s circulation
every 15-30 minutes will allow the nurse to
adjust the restraints before injury from
decreased blood flow occurs.
7. Answer: (A) Prevent stress ulcer
Rationale: Curling’s ulcer occurs as a
generalized stress response in burn patients.
This results in a decreased production of
mucus and increased secretion of gastric acid.
The best treatment for this prophylactic use of
antacids and H2 receptor blockers.
8. Answer: (D) Continue to monitor and record
hourly urine output
Rationale: Normal urine output for an adult is
approximately 1 ml/minute (60 ml/hour).
Therefore, this client's output is normal.
Beyond continued evaluation, no nursing
action is warranted.
9. Answer: (B) “My ankle feels warm”.
Rationale: Ice application decreases pain and
swelling. Continued or increased pain, redness,
and increased warmth are signs of
inflammation that shouldn't occur after ice
application
10. Answer: (B) Hyperkalemia
Rationale: A loop diuretic removes water and,
along with it, sodium and potassium. This may
result in hypokalemia, hypovolemia, and
hyponatremia.
11. Answer:(A) Have condescending trust and
confidence in their subordinates
Rationale: Benevolent-authoritative managers
pretentiously show their trust and confidence
to their followers.
12. Answer: (A) Provides continuous, coordinated
and comprehensive nursing services.
Rationale: Functional nursing is focused on
tasks and activities and not on the care of the
patients.
13. Answer: (B) Standard written order
Rationale: This is a standard written order.
Prescribers write a single order for
medications given only once. A stat order is
written for medications given immediately for
an urgent client problem. A standing order,
also known as a protocol, establishes
guidelines for treating a particular disease or
set of symptoms in special care areas such as
the coronary care unit. Facilities also may
institute medication protocols that specifically
designate drugs that a nurse may not give.
14. Answer: (D) Liquid or semi-liquid stools
Rationale: Passage of liquid or semi-liquid
stools results from seepage of unformed
bowel contents around the impacted stool in
the rectum. Clients with fecal impaction don't
pass hard, brown, formed stools because the
feces can't move past the impaction. These
clients typically report the urge to defecate
(although they can't pass stool) and a
decreased appetite.
15. Answer: (C) Pulling the helix up and back
Rationale: To perform an otoscopic
examination on an adult, the nurse grasps the
helix of the ear and pulls it up and back to
straighten the ear canal. For a child, the nurse
grasps the helix and pulls it down to straighten
the ear canal. Pulling the lobule in any
direction wouldn't straighten the ear canal for
visualization.
16. Answer: (A) Protect the irritated skin from
sunlight.
Rationale: Irradiated skin is very sensitive and
must be protected with clothing or sunblock.
The priority approach is the avoidance of
strong sunlight.
17. Answer: (C) Assist the client in removing
dentures and nail polish.
Rationale: Dentures, hairpins, and combs must
be removed. Nail polish must be removed so
that cyanosis can be easily monitored by
observing the nail beds.
18. Answer: (D) Sudden onset of continuous
epigastric and back pain.
Rationale: The autodigestion of tissue by the
pancreatic enzymes results in pain from
inflammation, edema, and possible
hemorrhage. Continuous, unrelieved epigastric
or back pain reflects the inflammatory process
in the pancreas.
19. Answer: (B) Provide high-protein, highcarbohydrate
diet.
Rationale: A positive nitrogen balance is
important for meeting metabolic needs, tissue
repair, and resistance to infection. Caloric
goals may be as high as 5000 calories per day.
20. Answer: (A) Blood pressure and pulse rate.
Rationale: The baseline must be established to
recognize the signs of an anaphylactic or
hemolytic reaction to the transfusion.
21. Answer: (D) Immobilize the leg before moving
the client.
Rationale: If the nurse suspects a fracture,
splinting the area before moving the client is
imperative. The nurse should call for
emergency help if the client is not hospitalized
and call for a physician for the hospitalized
client.
22. Answer: (B) Admit the client into a private
room.
Rationale: The client who has a radiation
implant is placed in a private room and has a
limited number of visitors. This reduces the
exposure of others to the radiation.
23. Answer: (C) Risk for infection
Rationale: Agranulocytosis is characterized by
a reduced number of leukocytes (leucopenia)
and neutrophils (neutropenia) in the blood.
The client is at high risk for infection because
of the decreased body defenses against
microorganisms. Deficient knowledge related
to the nature of the disorder may be
appropriate diagnosis but is not the priority.
24. Answer: (B) Place the client on the left side in
the Trendelenburg position.
Rationale: Lying on the left side may prevent
air from flowing into the pulmonary veins. The
Trendelenburg position increases intrathoracic
pressure, which decreases the amount of
blood pulled into the vena cava during
aspiration.
25. Answer: (A) Autocratic.
Rationale: The autocratic style of leadership is
a task-oriented and directive.
26. Answer: (D) 2.5 cc
Rationale: 2.5 cc is to be added, because only a
500 cc bag of solution is being medicated
instead of a 1 liter.
27. Answer: (A) 50 cc/ hour
Rationale: A rate of 50 cc/hr. The child is to
receive 400 cc over a period of 8 hours = 50
cc/hr.
28. Answer: (B) Assess the client for presence of
pain.
Rationale: Assessing the client for pain is a
very important measure. Postoperative pain is
an indication of complication. The nurse
should also assess the client for pain to
provide for the client’s comfort.
29. Answer: (A) BP – 80/60, Pulse – 110 irregular
Rationale: The classic signs of cardiogenic
shock are low blood pressure, rapid and weak
irregular pulse, cold, clammy skin, decreased
urinary output, and cerebral hypoxia.
30. Answer: (A) Take the proper equipment, place
the client in a comfortable position, and
record the appropriate information in the
client’s chart.
Rationale: It is a general or comprehensive
statement about the correct procedure, and it
includes the basic ideas which are found in the
other options
31. Answer: (B) Evaluation
Rationale: Evaluation includes observing the
person, asking questions, and comparing the
patient’s behavioral responses with the
expected outcomes.
32. Answer: (C) History of present illness
Rationale: The history of present illness is the
single most important factor in assisting the
health professional in arriving at a diagnosis or
determining the person’s needs.
33. Answer: (A) Trochanter roll extending from the
crest of the ileum to the mid-thigh.
Rationale: A trochanter roll, properly placed,
provides resistance to the external rotation of
the hip.
34. Answer: (C) Stage III
Rationale: Clinically, a deep crater or without
undermining of adjacent tissue is noted.
35. Answer: (A) Second intention healing
Rationale: When wounds dehisce, they will
allowed to heal by secondary Intention
36. Answer: (D) Tachycardia
Rationale: With an extracellular fluid or plasma
volume deficit, compensatory mechanisms
stimulate the heart, causing an increase in
heart rate.
37. Answer: (A) 0.75
Rationale: To determine the number of
milliliters the client should receive, the nurse
uses the fraction method in the following
equation.
75 mg/X ml = 100 mg/1 ml
To solve for X, cross-multiply:
75 mg x 1 ml = X ml x 100 mg
75 = 100X
75/100 = X
0.75 ml (or ¾ ml) = X
38. Answer: (D) it’s a measure of effect, not a
standard measure of weight or quantity.
Rationale: An insulin unit is a measure of
effect, not a standard measure of weight or
quantity. Different drugs measured in units
may have no relationship to one another in
quality or quantity.
39. Answer: (B) 38.9 °C
Rationale: To convert Fahrenheit degreed to
Centigrade, use this formula
°C = (°F – 32) ÷ 1.8
°C = (102 – 32) ÷ 1.8
°C = 70 ÷ 1.8
°C = 38.9
40. Answer: (C) Failing eyesight, especially close
vision.
Rationale: Failing eyesight, especially close
vision, is one of the first signs of aging in
middle life (ages 46 to 64). More frequent
aches and pains begin in the early late years
(ages 65 to 79). Increase in loss of muscle tone
occurs in later years (age 80 and older).
41. Answer: (A) Checking and taping all
connections
Rationale: Air leaks commonly occur if the
system isn’t secure. Checking all connections
and taping them will prevent air leaks. The
chest drainage system is kept lower to
promote drainage – not to prevent leaks.
42. Answer: (A) Check the client’s identification
band.
Rationale: Checking the client’s identification
band is the safest way to verify a client’s
identity because the band is assigned on
admission and isn’t be removed at any time. (If
it is removed, it must be replaced). Asking the
client’s name or having the client repeated his
name would be appropriate only for a client
who’s alert, oriented, and able to understand
what is being said, but isn’t the safe standard
of practice. Names on bed aren’t always
reliable
43. Answer: (B) 32 drops/minute
Rationale: Giving 1,000 ml over 8 hours is the
same as giving 125 ml over 1 hour (60
minutes). Find the number of milliliters per
minute as follows:
125/60 minutes = X/1 minute
60X = 125 = 2.1 ml/minute
To find the number of drops per minute:
2.1 ml/X gtt = 1 ml/ 15 gtt
X = 32 gtt/minute, or 32 drops/minute
44. Answer: (A) Clamp the catheter
Rationale: If a central venous catheter
becomes disconnected, the nurse should
immediately apply a catheter clamp, if
available. If a clamp isn’t available, the nurse
can place a sterile syringe or catheter plug in
the catheter hub. After cleaning the hub with
alcohol or povidone-iodine solution, the nurse
must replace the I.V. extension and restart the
infusion.
45. Answer: (D) Auscultation, percussion, and
palpation.
Rationale: The correct order of assessment for
examining the abdomen is inspection,
auscultation, percussion, and palpation. The
reason for this approach is that the less
intrusive techniques should be performed
before the more intrusive techniques.
Percussion and palpation can alter natural
findings during auscultation.
46. Answer: (D) Ulnar surface of the hand
Rationale: The nurse uses the ulnar surface, or
ball, of the hand to assess tactile fremitus,
thrills, and vocal vibrations through the chest
wall. The fingertips and finger pads best
distinguish texture and shape. The dorsal
surface best feels warmth.
47. Answer: (C) Formative
Rationale: Formative (or concurrent)
evaluation occurs continuously throughout the
teaching and learning process. One benefit is
that the nurse can adjust teaching strategies
as necessary to enhance learning. Summative,
or retrospective, evaluation occurs at the
conclusion of the teaching and learning
session. Informative is not a type of
evaluation.
48. Answer: (B) Once per year
Rationale: Yearly mammograms should begin
at age 40 and continue for as long as the
woman is in good health. If health risks, such
as family history, genetic tendency, or past
breast cancer, exist, more frequent
examinations may be necessary.
49. Answer: (A) Respiratory acidosis
Rationale: The client has a below-normal
(acidic) blood pH value and an above-normal
partial pressure of arterial carbon dioxide
(Paco2) value, indicating respiratory acidosis.
In respiratory alkalosis, the pH value is above
normal and in the Paco2 value is below
normal. In metabolic acidosis, the pH and
bicarbonate (Hco3) values are below normal.
In metabolic alkalosis, the pH and Hco3 values
are above normal.
50. Answer: (B) To provide support for the client
and family in coping with terminal illness.
Rationale: Hospices provide supportive care
for terminally ill clients and their families.
Hospice care doesn’t focus on counseling
regarding health care costs. Most client
referred to hospices have been treated for
their disease without success and will receive
only palliative care in the hospice.
51. Answer: (C) Using normal saline solution to
clean the ulcer and applying a protective
dressing as necessary.
Rationale: Washing the area with normal
saline solution and applying a protective
dressing are within the nurse’s realm of
interventions and will protect the area. Using a
povidone-iodine wash and an antibiotic cream
require a physician’s order. Massaging with an
astringent can further damage the skin.
52. Answer: (D) Foot
Rationale: An elastic bandage should be
applied form the distal area to the proximal
area. This method promotes venous return. In
this case, the nurse should begin applying the
bandage at the client’s foot. Beginning at the
ankle, lower thigh, or knee does not promote
venous return.
53. Answer: (B) Hypokalemia
Rationale: Insulin administration causes
glucose and potassium to move into the cells,
causing hypokalemia.
54. Answer: (A) Throbbing headache or dizziness
Rationale: Headache and dizziness often occur
when nitroglycerin is taken at the beginning of
therapy. However, the client usually develops
tolerance
55. Answer: (D) Check the client’s level of
consciousness
Rationale: Determining unresponsiveness is
the first step assessment action to take. When
a client is in ventricular tachycardia, there is a
significant decrease in cardiac output.
However, checking the unresponsiveness
ensures whether the client is affected by the
decreased cardiac output.
56. Answer: (B) On the affected side of the client.
Rationale: When walking with clients, the
nurse should stand on the affected side and
grasp the security belt in the midspine area of
the small of the back. The nurse should
position the free hand at the shoulder area so
that the client can be pulled toward the nurse
in the event that there is a forward fall. The
client is instructed to look up and outward
rather than at his or her feet.
57. Answer: (A) Urine output: 45 ml/hr
Rationale: Adequate perfusion must be
maintained to all vital organs in order for the
client to remain visible as an organ donor. A
urine output of 45 ml per hour indicates
adequate renal perfusion. Low blood pressure
and delayed capillary refill time are circulatory
system indicators of inadequate perfusion. A
serum pH of 7.32 is acidotic, which adversely
affects all body tissues.
58. Answer: (D ) Obtaining the specimen from the
urinary drainage bag.
Rationale: A urine specimen is not taken from
the urinary drainage bag. Urine undergoes
chemical changes while sitting in the bag and
does not necessarily reflect the current client
status. In addition, it may become
contaminated with bacteria from opening the
system.
59. Answer: (B) Cover the client, place the call
light within reach, and answer the phone call.
Rationale: Because telephone call is an
emergency, the nurse may need to answer it.
The other appropriate action is to ask another
nurse to accept the call. However, is not one of
the options. To maintain privacy and safety,
the nurse covers the client and places the call
light within the client’s reach. Additionally, the
client’s door should be closed or the room
curtains pulled around the bathing area.
60. Answer: (C) Use a sterile plastic container for
obtaining the specimen.
Rationale: Sputum specimens for culture and
sensitivity testing need to be obtained using
sterile techniques because the test is done to
determine the presence of organisms. If the
procedure for obtaining the specimen is not
sterile, then the specimen is not sterile, then
the specimen would be contaminated and the
results of the test would be invalid.
61. Answer: (A) Puts all the four points of the
walker flat on the floor, puts weight on the
hand pieces, and then walks into it.
Rationale: When the client uses a walker, the
nurse stands adjacent to the affected side. The
client is instructed to put all four points of the
walker 2 feet forward flat on the floor before
putting weight on hand pieces. This will ensure
client safety and prevent stress cracks in the
walker. The client is then instructed to move
the walker forward and walk into it.
62. Answer: (C) Draws one line to cross out the
incorrect information and then initials the
change.
Rationale: To correct an error documented in a
medical record, the nurse draws one line
through the incorrect information and then
initials the error. An error is never erased and
correction fluid is never used in the medical
record.
63. Answer: (C) Secures the client safety belts
after transferring to the stretcher.
Rationale: During the transfer of the client
after the surgical procedure is complete, the
nurse should avoid exposure of the client
because of the risk for potential heat loss.
Hurried movements and rapid changes in the
position should be avoided because these
predispose the client to hypotension. At the
time of the transfer from the surgery table to
the stretcher, the client is still affected by the
effects of the anesthesia; therefore, the client
should not move self. Safety belts can prevent
the client from falling off the stretcher.
64. Answer: (B) Gown and gloves
Rationale: Contact precautions require the use
of gloves and a gown if direct client contact is
anticipated. Goggles are not necessary unless
the nurse anticipates the splashes of blood,
body fluids, secretions, or excretions may
occur. Shoe protectors are not necessary.
65. Answer: (C) Quad cane
Rationale: Crutches and a walker can be
difficult to maneuver for a client with
weakness on one side. A cane is better suited
for client with weakness of the arm and leg on
one side. However, the quad cane would
provide the most stability because of the
structure of the cane and because a quad cane
has four legs.
66. Answer: (D) Left side-lying with the head of
the bed elevated 45 degrees.
Rationale: To facilitate removal of fluid from
the chest wall, the client is positioned sitting at
the edge of the bed leaning over the bedside
table with the feet supported on a stool. If the
client is unable to sit up, the client is
positioned lying in bed on the unaffected side
with the head of the bed elevated 30 to 45
degrees.
67. Answer: (D) Reliability
Rationale: Reliability is consistency of the
research instrument. It refers to the
repeatability of the instrument in extracting
the same responses upon its repeated
administration.
68. Answer: (A) Keep the identities of the subject
secret
Rationale: Keeping the identities of the
research subject secret will ensure anonymity
because this will hinder providing link between
the information given to whoever is its source.
69. Answer: (A) Descriptive- correlational
Rationale: Descriptive- correlational study is
the most appropriate for this study because it
studies the variables that could be the
antecedents of the increased incidence of
nosocomial infection.
70. Answer: (C) Use of laboratory data
Rationale: Incidence of nosocomial infection is
best collected through the use of
biophysiologic measures, particularly in vitro
measurements, hence laboratory data is
essential.
71. Answer: (B) Quasi-experiment
Rationale: Quasi-experiment is done when
randomization and control of the variables are
not possible.
72. Answer: (C) Primary source
Rationale: This refers to a primary source
which is a direct account of the investigation
done by the investigator. In contrast to this is a
secondary source, which is written by
someone other than the original researcher.
73. Answer: (A) Non-maleficence
Rationale: Non-maleficence means do not
cause harm or do any action that will cause
any harm to the patient/client. To do good is
referred as beneficence.
74. Answer: (C) Res ipsa loquitor
Rationale: Res ipsa loquitor literally means the
thing speaks for itself. This means in
operational terms that the injury caused is the
proof that there was a negligent act.
75. Answer: (B) The Board can investigate
violations of the nursing law and code of ethics
Rationale: Quasi-judicial power means that the
Board of Nursing has the authority to
investigate violations of the nursing law and
can issue summons, subpoena or subpoena
duces tecum as needed.
76. Answer: (C) May apply for re-issuance of
his/her license based on certain conditions
stipulated in RA 9173
Rationale: RA 9173 sec. 24 states that for
equity and justice, a revoked license maybe reissued
provided that the following conditions
are met: a) the cause for revocation of license
has already been corrected or removed; and,
b) at least four years has elapsed since the
license has been revoked.
77. Answer: (B) Review related literature
Rationale: After formulating and delimiting the
research problem, the researcher conducts a
review of related literature to determine the
extent of what has been done on the study by
previous researchers.
78. Answer: (B) Hawthorne effect
Rationale: Hawthorne effect is based on the
study of Elton Mayo and company about the
effect of an intervention done to improve the
working conditions of the workers on their
productivity. It resulted to an increased
productivity but not due to the intervention
but due to the psychological effects of being
observed. They performed differently because
they were under observation.
79. Answer: (B) Determines the different
nationality of patients frequently admitted and
decides to get representations samples from
each.
Rationale: Judgment sampling involves
including samples according to the knowledge
of the investigator about the participants in
the study.
80. Answer: (B) Madeleine Leininger
Rationale: Madeleine Leininger developed the
theory on transcultural theory based on her
observations on the behavior of selected
people within a culture.
81. Answer: (A) Random
Rationale: Random sampling gives equal
chance for all the elements in the population
to be picked as part of the sample.
82. Answer: (A) Degree of agreement and
disagreement
Rationale: Likert scale is a 5-point summated
scale used to determine the degree of
agreement or disagreement of the
respondents to a statement in a study
83. Answer: (B) Sr. Callista Roy
Rationale: Sr. Callista Roy developed the
Adaptation Model which involves the
physiologic mode, self-concept mode, role
function mode and dependence mode.
84. Answer: (A) Span of control
Rationale: Span of control refers to the
number of workers who report directly to a
manager.
85. Answer: (B) Autonomy
Rationale: Informed consent means that the
patient fully understands about the surgery,
including the risks involved and the alternative
solutions. In giving consent it is done with full
knowledge and is given freely. The action of
allowing the patient to decide whether a
surgery is to be done or not exemplifies the
bioethical principle of autonomy.
86. Answer: (C) Avoid wearing canvas shoes.
Rationale: The client should be instructed to
avoid wearing canvas shoes. Canvas shoes
cause the feet to perspire, which may, in turn,
cause skin irritation and breakdown. Both
cotton and cornstarch absorb perspiration.
The client should be instructed to cut toenails
straight across with nail clippers.
87. Answer: (D) Ground beef patties
Rationale: Meat is an excellent source of
complete protein, which this client needs to
repair the tissue breakdown caused by
pressure ulcers. Oranges and broccoli supply
vitamin C but not protein. Ice cream supplies
only some incomplete protein, making it less
helpful in tissue repair.
88. Answer: (D) Sims’ left lateral
Rationale: The Sims' left lateral position is the
most common position used to administer a
cleansing enema because it allows gravity to
aid the flow of fluid along the curve of the
sigmoid colon. If the client can't assume this
position nor has poor sphincter control, the
dorsal recumbent or right lateral position may
be used. The supine and prone positions are
inappropriate and uncomfortable for the
client.
89. Answer: (A) Arrange for typing and cross
matching of the client’s blood.
Rationale: The nurse first arranges for typing
and cross matching of the client's blood to
ensure compatibility with donor blood. The
other options, although appropriate when
preparing to administer a blood transfusion,
come later.
90. Answer: (A) Independent
Rationale: Nursing interventions are classified
as independent, interdependent, or
dependent. Altering the drug schedule to
coincide with the client's daily routine
represents an independent intervention,
whereas consulting with the physician and
pharmacist to change a client's medication
because of adverse reactions represents an
interdependent intervention. Administering an
already-prescribed drug on time is a
dependent intervention. An intradependent
nursing intervention doesn't exist.
91. Answer: (D) Evaluation
Rationale: The nursing actions described
constitute evaluation of the expected
outcomes. The findings show that the
expected outcomes have been achieved.
Assessment consists of the client's history,
physical examination, and laboratory studies.
Analysis consists of considering assessment
information to derive the appropriate nursing
diagnosis. Implementation is the phase of the
nursing process where the nurse puts the plan
of care into action.
92. Answer: (B) To observe the lower extremities
Rationale: Elastic stockings are used to
promote venous return. The nurse needs to
remove them once per day to observe the
condition of the skin underneath the stockings.
Applying the stockings increases blood flow to
the heart. When the stockings are in place, the
leg muscles can still stretch and relax, and the
veins can fill with blood.
93. Answer :(A) Instructing the client to report any
itching, swelling, or dyspnea.
Rationale: Because administration of blood or
blood products may cause serious adverse
effects such as allergic reactions, the nurse
must monitor the client for these effects. Signs
and symptoms of life-threatening allergic
reactions include itching, swelling, and
dyspnea. Although the nurse should inform
the client of the duration of the transfusion
and should document its administration, these
actions are less critical to the client's
immediate health. The nurse should assess
vital signs at least hourly during the
transfusion.
94. Answer: (B) Decrease the rate of feedings and
the concentration of the formula.
Rationale: Complaints of abdominal
discomfort and nausea are common in clients
receiving tube feedings. Decreasing the rate of
the feeding and the concentration of the
formula should decrease the client's
discomfort. Feedings are normally given at
room temperature to minimize abdominal
cramping. To prevent aspiration during
feeding, the head of the client's bed should be
elevated at least 30 degrees. Also, to prevent
bacterial growth, feeding containers should be
routinely changed every 8 to 12 hours.
95. Answer: (D) Roll the vial gently between the
palms.
Rationale: Rolling the vial gently between the
palms produces heat, which helps dissolve the
medication. Doing nothing or inverting the vial
wouldn't help dissolve the medication. Shaking
the vial vigorously could cause the medication
to break down, altering its action.
96. Answer: (B) Assist the client to the semi-
Fowler position if possible.
Rationale: By assisting the client to the semi-
Fowler position, the nurse promotes easier
chest expansion, breathing, and oxygen intake.
The nurse should secure the elastic band so
that the face mask fits comfortably and snugly
rather than tightly, which could lead to
irritation. The nurse should apply the face
mask from the client's nose down to the chin
— not vice versa. The nurse should check the
connectors between the oxygen equipment
and humidifier to ensure that they're airtight;
loosened connectors can cause loss of oxygen.
97. Answer: (B) 4 hours
Rationale: A unit of packed RBCs may be given
over a period of between 1 and 4 hours. It
shouldn't infuse for longer than 4 hours
because the risk of contamination and sepsis
increases after that time. Discard or return to
the blood bank any blood not given within this
time, according to facility policy.
98. Answer: (B) Immediately before administering
the next dose.
Rationale: Measuring the blood drug
concentration helps determine whether the
dosing has achieved the therapeutic goal. For
measurement of the trough, or lowest, blood
level of a drug, the nurse draws a blood
sample immediately before administering the
next dose. Depending on the drug's duration
of action and half-life, peak blood drug levels
typically are drawn after administering the
next dose.
99. Answer: (A) The nurse can implement
medication orders quickly.
Rationale: A floor stock system enables the
nurse to implement medication orders quickly.
It doesn't allow for pharmacist input, nor does
it minimize transcription errors or reinforce
accurate calculations.
100. Answer: (C) Shifting dullness over the
abdomen.
Rationale: Shifting dullness over the abdomen
indicates ascites, an abnormal finding. The
other options are normal abdominal findings.
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