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Saturday, June 8, 2013

NURSING PRACTICE II part 2

SITUATION: The infant and child mortality rate in the low
to middle income countries is ten times higher than
industrialized countries. In response to this, the WHO
and UNICEF launched the protocol Integrated
Management of Childhood Illnesses to reduce the
morbidity and mortality against childhood illnesses.

51. If a child with diarrhea registers two signs in the
yellow row in the IMCI chart, we can classify the
patient as:
A. Moderate dehydration
B. Severe dehydration
C. Some dehydration
D. No dehydration

52. Celeste has had diarrhea for 8 days. There is no
blood in the stool, he is irritable, his eyes are
sunken, the nurse offers fluid to Celeste and he
drinks eagerly. When the nurse pinched the
abdomen it goes back slowly. How will you
classify Celeste’s illness?
A. Moderate dehydration
B. Severe dehydration
C. Some dehydration
D. No dehydration

53. A child who is 7 weeks has had diarrhea for 14
days but has no sign of dehydration is classified
as:
A. Persistent diarrhea
B. Dysentery
C. Severe dysentery
D. Severe persistent diarrhea

54. The child with no dehydration needs home
treatment. Which of the following is not
included in the rules for home treatment in this
case?
A. Forced fluids
B. When to return
C. Give vitamin A supplement
D. Feeding more

55. Fever as used in IMCI includes:
A. Axillary temperature of 37.5 or higher
B. Rectal temperature of 38 or higher
C. Feeling hot to touch
D. All of the above
E. A and C only

Situation: Prevention of Dengue is an important nursing
responsibility and controlling it’s spread is a priority once
outbreak has been observed.

56. An important role of the community health
nurse in the prevention and control of Dengue
H-fever includes:
A. Advising the elimination of vectors by
keeping water containers covered
B. Conducting strong health education
drives/campaign directed towards
proper garbage disposal
C. Explaining to the individuals, families,
groups and community the nature of
the disease and its causation
D. Practicing residual spraying with
insecticides

57. Community health nurses should be alert in
observing a Dengue suspect. The following is
NOT an indicator for hospitalization of H-fever
suspects?
A. Marked anorexia, abdominal pain and
vomiting
B. Increasing hematocrit count
C. Cough of 30 days
D. Persistent headache

58. The community health nurses’ primary concern
in the immediate control of hemorrhage among
patients with dengue is:
A. Advising low fiber and non-fat diet
B. Providing warmth through light weight
covers
C. Observing closely the patient for vital
signs leading to shock
D. Keeping the patient at rest

59. Which of these signs may NOT be REGARDED as
a truly positive signs indicative of Dengue Hfever?
A. Prolonged bleeding time
B. Appearance of at least 20 petechiae
within 1cm square
C. Steadily increasing hematocrit count
D. Fall in the platelet count

60. Which of the following is the most important
treatment of patients with Dengue H-fever?
A. Give aspirin for fever
B. Replacement of body fluids
C. Avoid unnecessary movement of patient
D. Ice cap over the abdomen in case of
melena

Situation: Health education and Health promotion is an
important part of nursing responsibility in the
community. Immunization is a form of health promotion
that aims at preventing the common childhood illnesses.

61. In correcting misconceptions and myths about
certain diseases and their management, the
health worker should first:
A. Identify the myths and misconceptions
prevailing in the community
B. Identify the source of these myths and
misconceptions
C. Explain how and why these myths came
about
D. Select the appropriate IEC strategies to
correct them

62. How many percent of measles are prevented by
immunization at 9 months of age?
A. 80%
B. 99%
C. 90%
D. 95%

63. After TT3 vaccination a mother is said to be
protected to tetanus by around:
A. 80%
B. 99%
C. 85%
D. 90%

64. If ever convulsions occur after administering
DPT, what should the nurse best suggest to the
mother?
A. Do not continue DPT vaccination
anymore
B. Advise mother to comeback after 1 week
C. Give DT instead of DPT
D. Give pertussis of the DPT and remove DT

65. These vaccines are given 3 doses at one month
intervals:
A. DPT, BCG, TT
B. OPV, HEP. B, DPT
C. DPT, TT, OPV
D. Measles, OPV, DPT
Situation – With the increasing documented cases of
CANCER the best alternative to treatment still remains to
be PREVENTION. The following conditions apply.

66. Which among the following is the primary focus
of prevention of cancer?
A. Elimination of conditions causing cancer
B. Diagnosis and treatment
C. Treatment at early stage
D. Early detection

67. In the prevention and control of cancer, which of
the following activities is the most important
function of the community health nurse?
A. Conduct community assemblies.
B. Referral to cancer specialist those clients
with symptoms of cancer.
C. Use the nine warning signs of cancer as
parameters in our process of detection,
control and treatment modalities.
D. Teach woman about proper/correct
nutrition.

68. Who among the following are recipients of the
secondary level of care for cancer cases?
A. Those under early case detection
B. Those under post case treatment
C. Those scheduled for surgery
D. Those undergoing treatment

69. Who among the following are recipients of the
tertiary level of care for cancer cases?
A. Those under early treatment
B. Those under early detection
C. Those under supportive care
D. Those scheduled for surgery

70. In Community Health Nursing, despite the
availability and use of many equipment and
devices to facilitate the job of the community
health nurse, the best tool any nurse should be
wel be prepared to apply is a scientific approach.
This approach ensures quality of care even at the
community setting. This is nursing parlance is
nothing less than the:
A. nursing diagnosis
B. nursing research
C. nursing protocol
D. nursing process

Situation – Two children were brought to you. One with
chest indrawing and the other had diarrhea. The
following questions apply:

71. Using Integrated Management and Childhood
Illness (IMCI) approach, how would you classify
the 1st child?
A. Bronchopneumonia
B. Severe pneumonia
C. No pneumonia : cough or cold
D. Pneumonia

72. The 1st child who is 13 months has fast
breathing using IMCI parameters he has:
A. 40 breaths per minute or more
B. 50 breaths per minute
C. 30 breaths per minute or more
D. 60 breaths per minute

73. Nina, the 2nd child has diarrhea for 5 days.
There is no blood in the stool. She is irritable,
and her eyes are sunken. The nurse offered
fluids and and the child drinks eagerly. How
would you classify Nina’s illness?
A. Some dehydration
B. Severe dehydration
C. Dysentery
D. No dehydration

74. Nina’s treatment should include the following
EXCEPT:
A. reassess the child and classify him for
dehydration
B. for infants under 6 months old who are
not breastfed, give 100-200 ml clean
water as well during this period
C. Give in the health center the
recommended amount of ORS for 4
hours.
D. Do not give any other foods to the child
for home treatment

75. While on treatment, Nina 18 months old
weighed 18 kgs. and her temperature registered
at 37 degrees C. Her mother says she developed
cough 3 days ago. Nina has no general danger
signs. She has 45 breaths/minute, no chest indrawing,
no stridor. How would you classify
Nina’s manifestation?
A. No pneumonia
B. Pneumonia
C. Severe pneumonia
D. Bronchopneumonia

76. Carol is 15 months old and weighs 5.5 kgs and it
is her initial visit. Her mother says that Carol is
not eating well and unable to breastfeed, he has
no vomiting, has no convulsion and not
abnormally sleepy or difficult to awaken. Her
temperature is 38.9 deg C. Using the integrated
management of childhood illness or IMCI
strategy, if you were the nurse in charge of
Carol, how will you classify her illness?
A. a child at a general danger sign
B. severe pneumonia
C. very severe febrile disease
D. severe malnutrition

77. Why are small for gestational age newborns at
risk for difficulty maintaining body temperature?
A. their skin is more susceptible to
conduction of cold
B. they are preterm so are born relatively
small in size
C. they do not have as many fat stored as
other infants
D. they are more active than usual so they
throw off comes

78. Oxytocin is administered to Rita to augment
labor. What are the first symptoms of water
intoxication to observe for during this
procedure?
A. headache and vomiting
B. a high choking voice
C. a swollen tender tongue
D. abdominal bleeding and pain

79. Which of the following treatment should NOT be
considered if the child has severe dengue
hemorrhagic fever?
A. use plan C if there is bleeding from the
nose or gums
B. give ORS if there is skin Petechiae,
persistent vomiting, and positive
tourniquet test
C. give aspirin
D. prevent low blood sugar

80. In assessing the patient’s condition using the
Integrated Management of Childhood Illness
approach strategy, the first thing that a nurse
should do is to:
A. ask what are the child’s problem
B. check for the four main symptoms
C. check the patient’s level of
consciousness
D. check for the general danger signs

81. A child with diarrhea is observed for the
following EXCEPT:
A. how long the child has diarrhea
B. presence of blood in the stool
C. skin Petechiae
D. signs of dehydration

82. The child with no dehydration needs home
treatment. Which of the following is NOT
included in the care for home management at
this case?
A. give drugs every 4 hours
B. give the child more fluids
C. continue feeding the child
D. inform when to return to the health
center

83. Ms. Jordan, RN, believes that a patient should be
treated as individual. This ethical principle that
the patient referred to:
A. beneficence
B. respect for person
C. nonmaleficence
D. autonomy

84. When patients cannot make decisions for
themselves, the nurse advocate relies on the
ethical principle of:
A. justice and beneficence
B. beneficence and nonmaleficence
C. fidelity and nonmaleficence
D. fidelity and justice

85. Being a community health nurse, you have the
responsibility of participating in protecting the
health of people. Consider this situation:
Vendors selling bread with their bare hands.
They receive money with these hands. You do
not see them washing their hands. What should
you say/do?
A. “Miss, may I get the bread myself
because you have not washed your
hands”
B. All of these
C. “Miss, it is better to use a pick up
forceps/ bread tong”
D. “Miss, your hands are dirty. Wash your
hands first before getting the bread”
Situation: The following questions refer to common
clinical encounters experienced by an entry level nurse.

86. A female client asks the nurse about the use of a
cervical cap. Which statement is correct
regarding the use of the cervical cap?
A. It may affect Pap smear results.
B. It does not need to be fitted by the
physician.
C. It does not require the use of
spermicide.
D. It must be removed within 24 hours.

87. The major components of the communication
process are:
A. Verbal, written and nonverbal
B. Speaker, listener and reply
C. Facial expression, tone of voice and
gestures
D. Message, sender, channel, receiver and
feedback

88. The extent of burns in children are normally
assessed and expressed in terms of:
A. The amount of body surface that is
unburned
B. Percentages of total body surface area
(TBSA)
C. How deep the deepest burns are
D. The severity of the burns on a 1 to 5
burn scale.

89. The school nurse notices a child who is wearing
old, dirty, poor-fitting clothes; is always hungry;
has no lunch money; and is always tired. When
the nurse asks the boy his tiredness, he talks of
playing outside until midnight. The nurse will
suspect that this child is:
A. Being raised by a parent of low
intelligence quotient (IQ)
B. An orphan
C. A victim of child neglect
D. The victim of poverty

90. Which of the following indicates the type(s) of
acute renal failure?
A. Four types: hemorrhagic with and
without clotting, and nonhemorrhagic
with and without clottings
B. One type: acute
C. Three types: prerenal, intrarenal and
postrenal
D. Two types: acute and subacute
Situation: Mike 16 y/o has been diagnosed to have AIDS;
he worked as entertainer in a cruise ship;

91. Which method of transmission is common to
contract AIDS?
A. Syringe and needles
B. Sexual contact
C. Body fluids
D. Transfusion

92. Causative organism in AIDS is one of the
following;
A. Fungus
B. retrovirus
C. Bacteria
D. Parasites

93. You are assigned in a private room of Mike.
Which procedure should be of outmost
importance;
A. Alcohol wash
B. Washing Isolation
C. Universal precaution
D. Gloving technique

94. What primary health teaching would you give to
mike;
A. Daily exercise
B. reverse isolation
C. Prevent infection
D. Proper nutrition

95. Exercise precaution must be taken to protect
health worker dealing with the AIDS patients .
which among these must be done as priority:
A. Boil used syringe and needles
B. Use gloves when handling specimen
C. Label personal belonging
D. Avoid accidental wound
Situation: Michelle is a 6 year old preschooler. She was
reported by her sister to have measles but she is at
home because of fever, upper respiratory problem and
white sports in her mouth.

96. Rubeola is an Arabic term meaning Red, the rash
appears on the skin in invasive stage prior to
eruption behind the ears. As a nurse, your
physical examination must determine
complication especially:
A. Otitis media
B. Inflammatory conjunctiva
C. Bronchial pneumonia
D. Membranous laryngitis

97. To render comfort measure is one of the
priorities, Which includes care of the skin, eyes,
ears, mouth and nose. To clean the mouth, your
antiseptic solution is in some form of which one
below?
A. Water
B. Alkaline
C. Sulfur
D. Salt

98. As a public health nurse, you teach mother and
family members the prevention of complication
of measles. Which of the following should be
closely watched?
A. Temperature fails to drop
B. Inflammation of the nasophraynx
C. Inflammation of the conjunctiva
D. Ulcerative stomatitis

99. Source of infection of measles is secretion of
nose and throat of infection person. Filterable
virus of measles is transmitted by:
A. Water supply
B. Food ingestion
C. Droplet
D. Sexual contact

100. Method of prevention is to avoid
exposure to an infection person. Nursing
responsibility for rehabilitation of patient
includes the provision of:
A. Terminal disinfection
B. Immunization
C. Injection of gamma globulin

D. Comfort measures

NURSING PRACTICE II part 1

NURSING PRACTICE II
Situation: Mariah is a 31 year old lawyer who has been
married for 6 months. She consults you for guidance in
relation with her menstrual cycle and her desire to get
pregnant.

1. She wants to know the length of her menstrual
cycle. Her previous menstrual period is October
22 to 26. Her LMB is November 21. Which of the
following number of days will be your correct
response?
A. 29
B. 28
C. 30
D. 31

2. You advised her to observe and record the signs
of Ovulation. Which of the following signs will
she likely note down?
1. A 1 degree Fahrenheit rise in basal body
temperature
2. Cervical mucus becomes copious and
clear
3. One pound increase in weight
4. Mittelschmerz
A. 1, 2, 4
B. 1, 2, 3
C. 2, 3, 4
D. 1, 3, 4

3. You instruct Mariah to keep record of her basal
temperature every day, which of the following
instructions is incorrect?
A. If coitus has occurred; this should be
reflected in the chart
B. It is best to have coitus on the evening
following a drop in BBT to become
pregnant
C. Temperature should be taken
immediately after waking and before
getting out of bed
D. BBT is lowest during the secretory
phase

4. She reports an increase in BBT on December 16.
Which hormone brings about this change in her
BBT?
A. Estrogen
B. Gonadotropine
C. Progesterone
D. Follicle stimulating hormone

5. The following month, Mariah suspects she is
pregnant. Her urine is positive for Human
chorionic gonadotrophin. Which structure
produces Hcg?
A. Pituitary gland
B. Trophoblastic cells of the embryo
C. Uterine deciduas
D. Ovarian follicles

Situation: Mariah came back and she is now pregnant.
6. At 5 month gestation, which of the following
fetal development would probably be achieve?
A. Fetal movement are felt by Mariah
B. Vernix caseosa covers the entire body
C. Viable if delivered within this period
D. Braxton hicks contractions are observed

7. The nurse palpates the abdomen of Mariah.
Now At 5 month gestation, What level of the
abdomen can the fundic height be palpated?
A. Symphysis pubis
B. Midpoint between the umbilicus and the
xiphoid process
C. Midpoint between the symphysis pubis
and the umbilicus
D. Umbilicus

8. She worries about her small breasts, thinking
that she probably will not be able to breastfeed
her baby. Which of the following responses of
the nurse is correct?
A. “The size of your breast will not affect
your lactation”
B. “You can switch to bottle feeding”
C. “You can try to have exercise to increase
the size of your breast”
D. “Manual expression of milk is possible”

9. She tells the nurse that she does not take milk
regularly. She claims that she does not want to
gain too much weight during her pregnancy.
Which of the following nursing diagnosis is a
priority?
A. Potential self-esteem disturbance
related to physiologic changes in
pregnancy
B. Ineffective individual coping related to
physiologic changes in pregnancy
C. Fear related to the effects of pregnancy
D. Knowledge deficit regarding nutritional
requirements of pregnancies related to
lack of information sources

10. Which of the following interventions will likely
ensure compliance of Mariah?
A. Incorporate her food preferences that
are adequately nutritious in her meal
plan
B. Consistently counsel toward optimum
nutritional intake
C. Respect her right to reject dietary
information if she chooses
D. Inform her of the adverse effects of
inadequate nutrition to her fetus

Situation: Susan is a patient in the clinic where you work.
She is inquiring about pregnancy.
11. Susan tells you she is worried because she
develops breasts later than most of her friends.
Breast development is termed as:
A. Adrenarche
B. Thelarche
C. Mamarche
D. Menarche

12. Kevin, Susan’s husband tells you that he is
considering vasectomy After the birth of their
new child. Vasectomy involves the incision of
which organ?
A. The testes
B. The epididymis
C. The vas deferens
D. The scrotum
13. On examination, Susan has been found of having
a cystocele. A cystocele is:
A. A sebaceous cyst arising from the vulvar fold
B. Protrusion of intestines into the vagina
C. Prolapse of the uterus into the vagina
D. Herniation of the bladder into the
vaginal wall

14. Susan typically has menstrual cycle of 34 days.
She told you she had coitus on days 8, 10, 15 and
20 of her menstrual cycle. Which is the day on
which she is most likely to conceive?
A. 8th day
B. Day 15
C. 10th day
D. Day 20

15. While talking with Susan, 2 new patients arrived
and they are covered with large towels and the
nurse noticed that there are many cameraman
and news people outside of the OPD. Upon
assessment the nurse noticed that both of them
are still nude and the male client’s penis is still
inside the female client’s vagina and the male
client said that “I can’t pull it”. Vaginismus was
your first impression. You know that The
psychological cause of Vaginismus is related to:
A. The male client inserted the penis too
deeply that it stimulates vaginal closure
B. The penis was too large that is why the
vagina triggered its defense to attempt
to close it
C. The vagina does not want to be
penetrated
D. It is due to learning patterns of the
female client where she views sex as
bad or sinful

Situation: Overpopulation is one problem in the
Philippines that causes economic drain. Most Filipinos
are against in legalizing abortion. As a nurse, Mastery of
contraception is needed to contribute to the society and
economic growth.

16. Supposed that Dana, 17 years old, tells you she
wants to use fertility awareness method of
contraception. How will she determine her
fertile days?
A. She will notice that she feels hot, as if
she has an elevated temperature.
B. She should assess whether her cervical
mucus is thin, copious, clear and
watery.
C. She should monitor her emotions for
sudden anger or crying
D. She should assess whether her breasts
feel sensitive to cool air

17. Dana chooses to use COC as her family planning
method. What is the danger sign of COC you
would ask her to report?
A. A stuffy or runny nose
B. Slight weight gain
C. Arthritis like symptoms
D. Migraine headache

18. Dana asks about subcutaneous implants and she
asks, how long will these implants be effective.
Your best answer is:
A. One month
17
B. Five years
C. Twelve months
D. 10 years

19. Dana asks about female condoms. Which of the
following is true with regards to female
condoms?
A. The hormone the condom releases
might cause mild weight gain
B. She should insert the condom before
any penile penetration
C. She should coat the condom with
spermicide before use
D. Female condoms, unlike male condoms,
are reusable

20. Dana has asked about GIFT procedure. What
makes her a good candidate for GIFT?
A. She has patent fallopian tubes, so
fertilized ova can be implanted on them
B. She is RH negative, a necessary
stipulation to rule out RH incompatibility
C. She has normal uterus, so the sperm can
be injected through the cervix into it
D. Her husband is taking sildenafil, so all
sperms will be motile
Situation: Nurse Lorena is a Family Planning and
Infertility Nurse Specialist and currently attends to
FAMILY PLANNING CLIENTS AND INFERTILE COUPLES.
The following conditions pertain to meeting the nursing
needs of this particular population group.

21. Dina, 17 years old, asks you how a tubal ligation
prevents pregnancy. Which would be the best
answer?
A. Prostaglandins released from the cut
fallopian tubes can kill sperm
B. Sperm cannot enter the uterus because
the cervical entrance is blocked.
C. Sperm can no longer reach the ova,
because the fallopian tubes are blocked
D. The ovary no longer releases ova as
there is nowhere for them to go.

22. The Dators are a couple undergoing testing for
infertility. Infertility is said to exist when:
A. A woman has no uterus
B. A woman has no children
C. A couple has been trying to conceive for 1 year
D. A couple has wanted a child for 6
months

23. Another client named Lilia is diagnosed as having
endometriosis. This condition interferes with
fertility because:
A. Endometrial implants can block the
fallopian tubes
B. The uterine cervix becomes inflamed
and swollen
C. The ovaries stop producing adequate
estrogen
D. Pressure on the pituitary leads to
decreased FSH levels

24. Lilia is scheduled to have a
hysterosalphingogram. Which of the following
instructions would you give her regarding this
procedure?
A. She will not be able to conceive for 3
months after the procedure
B. The sonogram of the uterus will reveal
any tumors present
C. Many women experience mild bleeding
as an after effect
D. She may feel some cramping when the
dye is inserted

25. Lilia’s cousin on the other hand, knowing nurse
Lorena’s specialization asks what artificial
insemination by donor entails. Which would be
your best answer if you were Nurse Lorena?
A. Donor sperm are introduced vaginally
into the uterus or cervix
B. Donor sperm are injected intraabdominally
into each ovary
C. Artificial sperm are injected vaginally to
test tubal patency
D. The husband’s sperm is administered
intravenously weekly
Situation: You are assigned to take care of a group of
patients across the lifespan.

26. Pain in the elder persons requires careful
assessment because they:
A. experienced reduce sensory perception
B. have increased sensory perception
C. are expected to experience chronic pain
D. have a decreased pain threshold

27. Administration of analgesics to the older persons
requires careful patient assessment because
older people:
A. are more sensitive to drugs
B. have increased hepatic, renal and
gastrointestinal function
C. have increased sensory perception
D. mobilize drugs more rapidly

28. The elderly patient is at higher risk for urinary
incontinence because of:
A. increased glomerular filtration
B. decreased bladder capacity
C. diuretic use
D. dilated urethra

29. Which of the following is the MOST COMMON
sign of infection among the elderly?
A. decreased breath sounds with crackles
B. pain
C. fever
D. change in mental status

30. Priorities when caring for the elderly trauma
patient:
A. circulation, airway, breathing
B. airway, breathing, disability (neurologic)
C. disability (neurologic), airway, breathing
D. airway, breathing, circulation

31. Preschoolers are able to see things from which
of the following perspectives?
A. Their peers
B. Their own and their mother’s
C. Their own and their caregivers’
D. Only their own

32. In conflict management, the win-win approach
occurs when:
A. There are two conflicts and the parties
agree to each one
B. Each party gives in on 50% of the
disagreements making up the conflict
C. Both parties involved are committed to
solving the conflict
D. The conflict is settled out of court so the
legal system and the parties win

33. According to the social-interactional perspective
of child abuse and neglect, four factors place the
family members at risk for abuse. These risk
factors are the family members at risk for abuse.
These risk factors are the family itself, the
caregiver, the child, and
A. The presence of a family crisis
B. The national emphasis on sex
C. Genetics
D. Chronic poverty

34. Which of the following signs and symptoms
would you most likely find when assessing and
infant with Arnold-Chiari malformation?
A. Weakness of the leg muscles, loss of
sensation in the legs, and restlessness
B. Difficulty swallowing, diminished or
absent gag reflex, and respiratory
distress
C. Difficulty sleeping, hypervigilant, and an
arching of the back
D. Paradoxical irritability, diarrhea, and
vomiting.

35. A parent calls you and frantically reports that her
child has gotten into her famous ferrous sulfate
pills and ingested a number of these pills. Her
child is now vomiting, has bloody diarrhea, and is
complaining of abdominal pain. You will tell the
mother to:
A. Call emergency medical services (EMS)
and get the child to the emergency room
B. Relax because these symptoms will pass
and the child will be fine
C. Administer syrup of ipecac
D. Call the poison control center

36. A client says she heard from a friend that you
stop having periods once you are on the “pill”.
The most appropriate response would be:
A. “The pill prevents the uterus from
making such endometrial lining, that is
why periods may often be scant or
skipped occasionally.”
B. “If your friend has missed her period,
she should stop taking the pills and get a
pregnancy test as soon as possible.”
C. “The pill should cause a normal
menstrual period every month. It
sounds like your friend has not been
taking the pills properly.”
D. “Missed period can be very dangerous
and may lead to the formation of
precancerous cells.”

37. The nurse assessing newborn babies and infants
during their hospital stay after birth will notice
which of the following symptoms as a primary
manifestation of Hirschsprung’s disease?
A. A fine rash over the trunk
B. Failure to pass meconium during the
first 24 to 48 hours after birth
C. The skin turns yellow and then brown
over the first 48 hours of life
D. High-grade fever

38. A client is 7 months pregnant and has just been
diagnosed as having a partial placenta previa.
She is stable and has minimal spotting and is
being sent home. Which of these instructions to
the client may indicate a need for further
teaching?
A. Maintain bed rest with bathroom
privileges
B. Avoid intercourse for three days.
C. Call if contractions occur.
D. Stay on left side as much as possible
when lying down.

39. A woman has been rushed to the hospital with
ruptured membrane. Which of the following
should the nurse check first?
A. Check for the presence of infection
B. Assess for Prolapse of the umbilical
cord
C. Check the maternal heart rate
D. Assess the color of the amniotic fluid

40. The nurse notes that the infant is wearing a
plastic-coated diaper. If a topical medication
were to be prescribed and it were to go on the
stomachs or buttocks, the nurse would teach the
caregivers to:
A. avoid covering the area of the topical
medication with the diaper
B. avoid the use of clothing on top of the
diaper
C. put the diaper on as usual
D. apply an icepack for 5 minutes to the
outside of the diaper

41. Which of the following factors is most important
in determining the success of relationships used
in delivering nursing care?
A. Type of illness of the client
B. Transference and counter transference
C. Effective communication
D. Personality of the participants

42. Grace sustained a laceration on her leg from
automobile accident. Why are lacerations of
lower extremities potentially more serious
among pregnant women than other?
A. lacerations can provoke allergic
responses due to gonadotropic hormone
release
B. a woman is less able to keep the
laceration clean because of her fatigue
C. healing is limited during pregnancy so
these will not heal until after birth
D. increased bleeding can occur from
uterine pressure on leg veins

43. In working with the caregivers of a client with an
acute or chronic illness, the nurse would:
A. Teach care daily and let the caregivers
do a return demonstration just before
discharge
B. Difficulty swallowing, diminished or
absent gag reflex, and respiratory
distress.
C. Difficulty sleeping, hypervigilant, and an
arching of the back
D. Paradoxical irritability, diarrhea, and
vomiting

44. Which of the following roles BEST exemplifies
the expanded role of the nurse?
A. Circulating nurse in surgery
B. Medication nurse
C. Obstetrical nurse
D. Pediatric nurse practitioner

45. According to DeRosa and Kochura’s (2006)
article entitled “Implement Culturally Competent
Health Care in your work place,” cultures have
different patterns of verbal and nonverbal
communication. Which difference does?
A. NOT necessarily belong?
B. Personal behavior
C. Subject matter
D. Eye contact
E. Conversational style

46. You are the nurse assigned to work with a child
with acute glomerulonephritis. By following the
prescribed treatment regimen, the child
experiences a remission. You are now checking
to make sure the child does not have a relapse.
Which finding would most lead you to the
conclusion that a relapse is happening?
A. Elevated temperature, cough, sore
throat, changing complete blood count
(CBC) with diiferential
B. A urine dipstick measurement of 2+
proteinuria or more for 3 days, or the
child found to have 3-4+ proteinutria
plus edema.
C. The urine dipstick showing glucose in the
urine for 3 days, extreme thirst, increase
in urine output, and a moon face.
D. A temperature of 37.8 degrees (100
degrees F), flank pain, burning
frequency, urgency on voiding, and
cloudy urine.

47. The nurse is working with an adolescent who
complains of being lonely and having a lack of
fulfillment in her life. This adolescent shies away
from intimate relationships at times yet at other
times she appears promiscuous. The nurse will
likely work with this adolescent in which of the
following areas?
A. Isolation
B. Lack of fulfillment
C. Loneliness
D. Identity

48. The use of interpersonal decision making,
psychomotor skills, and application of
knowledge expected in the role of a licensed
health care professional in the context of public
health welfare and safety is an example of:
A. Delegation
B. Responsibility
C. Supervision
D. Competence

49. The painful phenomenon known as “back labor”
occurs in a client whose fetus in what position?
A. Brow position
B. Breech position
C. Right Occipito-Anterior Position
D. Left Occipito-Posterior Position

50. FOCUS methodology stands for:
A. Focus, Organize, Clarify, Understand
and Solution
B. Focus, Opportunity, Continuous, Utilize,
Substantiate
C. Focus, Organize, Clarify, Understand,
Substantiate
D. Focus, Opportunity, Continuous
(process), Understand, Solution
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