Quizlet Compilation (Part 1) : Philippine Nurse Licensure Examination

QUIZLET COMPILATION
(Part 1)
PHILIPPINE NURSE LICENSURE
EXAMINATION
Compiled by: Raymundo III D. Doce

A patient has recently been diagnosed with polio and has questions
about the diagnosis. Which of the following systems is most affected by
polio?
A: PNS
B: CNS
C: Urinary system
D: Cardiac system
(B) Polio is caused by a virus that attacks the

CNS.
A nurse is reviewing a patient's medication during shift change. Which of the following medication
would be contraindicated if the patient were pregnant? Note: More than one answer may be correct.
A: Coumadin
B: Finasteride
C: Celebrex
D: Catapress
E: Habitrol
F: Clofazimine
(A) and (B) are both contraindicated with pregnancy.
A patient tells you that her urine is starting to look discolored. If you believe this
change is due to medication, which of the following patient's medication does not
cause urine discoloration?
A: Sulfasalazine
B: Levodopa
C: Phenolphthalein
D: Aspirin
(D) All of the others can cause urine

discoloration.
You are responsible for reviewing the nursing unit's refrigerator. If you found the
following drug in the refrigerator it should be removed from the refrigerator's
contents?
A: Corgard
B: Humulin (injection)

C: Urokinase
D: Epogen (injection)
(A) Corgard could be removed from the

refigerator.
A 34 year old female has recently been diagnosed with an autoimmune disease. She has
also recently discovered that she is pregnant. Which of the following is the only
immunoglobulin that will provide protection to the fetus in the womb?
A: IgA
B: IgD
C: IgE
D: IgG
(D) IgG is the only immunoglobulin that can

cross the placental barrier.
A second year nursing student has just suffered a needlestick while working with
a patient that is positive for AIDS. Which of the following is the most important
action that nursing student should take?
A: Immediately see a social worker
B: Start prophylactic AZT treatment
C: Start prophylactic Pentamide treatment
D: Seek counseling
(B) AZT treatment is the most critical

innervention.
A thirty five year old male has been an insulin-dependent diabetic for five years
and now is unable to urinate. Which of the following would you most likely
suspect?
A: Atherosclerosis
B: Diabetic nephropathy
C: Autonomic neuropathy
D: Somatic neuropath
(C) Autonomic neuropathy can cause inability

to urinate.
You are taking the history of a 14 year old girl who has a (BMI) of 18. The girl
reports inability to eat, induced vomiting and severe constipation. Which of the
following would you most likely suspect?
A: Multiple sclerosis
B: Anorexia nervosa
C: Bulimia
D: Systemic sclerosis
(B) All of the clinical signs and systems point

to a condition of anorexia nervosa
A 24 year old female is admitted to the ER for confusion. This patient has a history of a myeloma
diagnosis, constipation, intense abdominal pain, and polyuria. Which of the following would you most
likely suspect?
A: Diverticulosis
B: Hypercalcaemia
C: Hypocalcaemia
D: Irritable bowel syndrome
(B) Hypercalcaemia can cause polyuria,

severe abdominal pain, and confusion.
Rho gam is most often used to treat mothers that have
a infant.
A: RH positive, RH positive
B: RH positive, RH negative
C: RH negative, RH positive
D: RH negative, RH negative
(C) Rho gam prevents the production of anti-

RH antibodies in the mother that has a Rh
positive fetus.
A new mother has some questions about (PKU). Which of the following
statements made by a nurse is not correct regarding PKU?
A: A Guthrie test can check the necessary lab values.
B: The urine has a high concentration of phenylpyruvic acid
C: Mental deficits are often present with PKU.
D: The effects of PKU are reversible.
(D) The effects of PKU stay with the infant

throughout their life.
A patient has taken an overdose of aspirin. Which of the following should a nurse
most closely monitor for during acute management of this patient?
A: Onset of pulmonary edema
B: Metabolic alkalosis
C: Respiratory alkalosis
D: Parkinson's disease type symptom
(D) Aspirin overdose can lead to metabolic

acidosis and cause pulmonary edema
development.
A fifty-year-old blind and deaf patient has been admitted to your floor. As the charge nurse
your primary responsibility for this patient is?
A: Let others know about the patient's deficits
B: Communicate with your supervisor your concerns about the patient's deficits.
C: Continuously update the patient on the social environment.
D: Provide a secure environment for the patient.
(D) This patient's safety is your primary

concern.
A patient is getting discharged from a SNF facility. The patient has a history of severe COPD and
PVD. The patient is primarily concerned about their ability to breath easily. Which of the following
would be the best instruction for this patient?
A: Deep breathing techniques to increase O2 levels.
B: Cough regularly and deeply to clear airway passages.
C: Cough following bronchodilator utilization
D: Decrease CO2 levels by increase oxygen take output during meals.
(C) The bronchodilator will allow a more productive cough.
A nurse is caring for an infant that has recently been diagnosed with a congenital
heart defect. Which of the following clinical signs would most likely be present?
A: Slow pulse rate
B: Weight gain
C: Decreased systolic pressure
D: Irregular WBC lab values
(B) Weight gain is associated with CHF and congenital heart deficits.
A mother has recently been informed that her child has Down's syndrome. You will be assigned
to care for the child at shift change. Which of the following characteristics is not associated with
Down's syndrome?
A: Simian crease
B: Brachycephaly
C: Oily skin
D: Hypotonicity
C) The skin would be dry and not oily.

A patient has recently experienced a (MI) within the last 4 hours. Which
of the following medications would most like be administered?
A: Streptokinase
B: Atropine
C: Acetaminophen
D: Coumadin
(A) Streptokinase is a clot busting drug and the

best choice in this situation.
A patient asks a nurse, "My doctor recommended I increase my intake
of folic acid. What type of foods contain folic acids?"
A: Green vegetables and liver
B: Yellow vegetables and red meat
C: Carrots
D: Milk
(A) Green vegetables and liver are a great

source of folic acid.
A nurse is putting together a presentation on meningitis. Which of the
following microorganisms has noted been linked to meningitis in
humans?
A: S. pneumonia
B: H. influenza
C: N. meningitis
D: Cl. Difficile
(D) Cl. difficile has not been linked to

meningitis.
A nurse is administering blood to a patient who has a low hemoglobin count. The
patient asks how long to RBC's last in my body? The correct response is.
A: The life span of RBC is 45 days.
B: The life span of RBC is 60 days.
C: The life span of RBC is 90 days.
D: The life span of RBC is 120 days.
(D) RBC's last for 120 days in the body.

A 65 year old man has been admitted to the hospital for spinal stenosis surgery.
When does the discharge training and planning begin for this patient?
A: Following surgery
B: Upon admit
C: Within 48 hours of discharge
D: Preoperative discussion
(B) Discharge education begins upon admit.

A child is 5 years old and has been recently admitted into the hospital.
According to Erickson which of the following stages is the child in?
A: Trust vs. mistrust
B: Initiative vs. guilt
C: Autonomy vs. shame
D: Intimacy vs. isolation
(B) Initiative vs. guilt- 3-6 years old

A toddler is 16 months old and has been recently admitted into the
hospital. According to Erickson which of the following stages is the
toddler in?
(C) Autonomy vs Shame - 12-18 months old

A young adult is 20 years old and has been recently admitted into the hospital.
According to Erickson which of the following stages is the adult in?
(D) Intimacy vs. isolation- 18-35 years old

A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal?
A: 11 year old male - 90 b.p.m, 22 resp/min. , 100/70 mm Hg
B: 13 year old female - 105 b.p.m., 22 resp/min., 105/60 mm Hg
C: 5 year old male- 102 b.p.m, 24 resp/min., 90/65 mm Hg
D: 6 year old female- 100 b.p.m., 26 resp/min., 90/70mm Hg
(B) HR and Respirations are slightly increased. BP is down.
When you are taking a patient's history, she tells you she has been depressed
and is dealing with an anxiety disorder. Which of the following medications would
the patient most likely be taking?
A: Elavil
B: Calcitonin
C: Pergolide
D: Verapamil
(A) Elavil is a tricyclic antidepressant.

Which of the following conditions would a nurse not administer
erythromycin?
A: Campylobacterial infection
B: Legionnaire's disease
C: Pneumonia
D: Multiple Sclerosis
(D) Erythromycin is used to treat conditions A-

C.
A patient's chart indicates a history of hyperkalemia. Which of the following would
you not expect to see with this patient if this condition were acute?
A: Decreased HR
B: Paresthesias
C: Muscle weakness of the extremities
D: Migranes
(D) Answer choices A-C were symptoms of

acute hyperkalemia.
A patient's chart indicates a history of ketoacidosis. Which of the following
would you not expect to see with this patient if this condition were acute?
A: Vomiting
B: Extreme Thirst
C: Weight gain
D: Acetone breath smell
(C) Weight loss would be expected.

A patient's chart indicates a history of meningitis. Which of the following
would you not expect to see with this patient if this condition were acute?
A: Increased appetite
B: Vomiting
C: Fever
D: Poor tolerance of light
(A) Loss of appetite would be expected.

A nurse if reviewing a patient's chart and notices that the patient suffers from
conjunctivitis. Which of the following microorganisms is related to this condition?
A: Yersinia pestis
B: Helicobacter pyroli
C: Vibrio cholera
D: Hemophilus aegyptius
(D) Choice A is linked to Plague, Choice B is

linked to peptic ulcers, Choice C is linked to
Cholera.
A nurse if reviewing a patient's chart and notices that the patient suffers from
Lyme disease. Which of the following microorganisms is related to this condition?
A: Borrelia burgdorferi
B: Streptococcus pyrogens
C: Bacilus anthracis
D: Enterococcus faecalis
(A) Choice B is linked to Rheumatic fever,

Choice C is linked to Anthrax, Choice D is
linked to Endocarditis.
A fragile 87 year-old female has recently been admitted to the hospital with increased confusion
and falls over last 2 weeks. She is also noted to have a mild left hemiparesis. Which of the
following tests is most likely to be performed?
A: FBC (full blood count)
B: ECG (electrocardiogram)
C: Thyroid function tests
D: CT scan
(D) A CT scan would be performed for further

investigation of the hemiparesis.
A 84 year-old male has been loosing mobility and gaining weight over the last 2 months.
The patient also has the heater running in his house 24 hours a day, even on warm days.
Which of the following tests is most likely to be performed?
A: FBC (full blood count)
B: ECG (electrocardiogram)
C: Thyroid function tests
D: CT scan

(C) Weight gain and poor temperature
tolerance indicate something may be wrong
with the thyroid function.
A 20 year-old female attending college is found unconscious in her dorm room. She has a
fever and a noticeable rash. She has just been admitted to the hospital. Which of the
following tests is most likely to be performed first?
A: Blood sugar check
B: CT scan
C: Blood cultures
D: Arterial blood gases
(C) Blood cultures would be performed to

investigate the fever and rash symptoms.
A 28 year old male has been found wandering around in a confused pattern. The
male is sweaty and pale. Which of the following tests is most likely to be
performed first?
A: Blood sugar check
B: CT scan
C: Blood cultures
D: Arterial blood gases
A) With a history of diabetes, the first response

should be to check blood sugar levels.
A mother is inquiring about her child's ability to potty train. Which of the following
factors is the most important aspect of toilet training?
A: The age of the child
B: The child ability to understand instruction.
C: The overall mental and physical abilities of the child.
D: Frequent attempts with positive reinforcement.
(C) Age is not the greatest factor in potty training.

The overall mental and physical abilities of the
child is the most important factor.
A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid
her child drank 20 minutes. Which of the following is the most important
instruction the nurse can give the parent?
A: This too shall pass.
B: Take the child immediately to the ER
C: Contact the Poison Control Center quickly
D: Give the child syrup of ipecac
(C) The poison control center will have an

exact plan of action for this child.
A nurse is administering a shot of Vitamin K to a 30 day-old infant.
Which of the following target areas is the most appropriate?
A: Gluteus maximus
B: Gluteus minimus
C: Vastus lateralis
D: Vastus medialis
(C) Vastus lateralis is the most appropriate

location.
A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4
year-old boy who is non-verbal. This child does not have on any identification. What should the
nurse do?
A: Contact the provider
B: Ask the child to write their name on paper.
C: Ask a co-worker about the identification of the child.
D: Ask the father who is in the room the child's name.
(D) In this case you are able to determine the name of

the child by the father's statement, moreover you
should not withhold the medication from the child
following identification.
A nurse is observing a child's motor, sensory and speech development. The child
is 7 months old. Which of the following tasks would generally not be observed?
A: Child recognizes tone of voice.
B: Child exhibits fear of strangers.
C: Child pulls to stand and occasionally bounces.
D: Child plays patty-cake and imitates.
(D) These skills generally develop between 10-

15 months.
A nurse is observing a child's motor, sensory and speech development. The child
is 5 months old. Which of the following tasks would generally not be observed?
A: Child sits with support.
B: Child laughs out loud.
C: Child shifts weight side to side in prone.
D: Child transfers objects between hands.
(D) Transferring objects between hands is a 8-9 month skill.
A nurse is caring for an adult that has recently been diagnosed with renal failure.
Which of the following clinical signs would most likely not be present?
A: Hypotension
B: Heart failure
C: Dizziness
D: Memory loss
(A) Hypertension is often related renal failure.

A nurse is caring for an adult that has recently been diagnosed with hypokalemia.
Which of the following clinical signs would most likely not be present?
A: Leg cramps
B: Respiratory distress
C: Confusion
D: Flaccid paralysis
(D) Flaccid paralysis is an indication of

Hyperkalemia.
A nurse is caring for an adult that has recently been diagnosed with metabolic
acidosis. Which of the following clinical signs would most likely not be present?
A: Weakness
B: Dysrhythmias

C: Dry skin
D: Malaise
(B) Dysrhythmias are associated with metabolic
alkalosis.
A nurse is caring for an adult that has recently been diagnosed with metabolic
alkalosis. Which of the following clinical signs would most likely not be present?
A: Vomiting
B: Diarrhea
C: Agitation
D: Hyperventilation
(D) Hyperventilation occurs with metabolic

acidosis. Hypoventilation occurs with
metabolic alkalosis
A nurse is caring for an adult that has recently been diagnosed with respiratory
acidosis. Which of the following clinical signs would most likely not be present?
A: CO2 Retention
B: Dyspnea
C: Headaches
D: Tachypnea
(D) Tachypnea is associated with respiratory

alkalosis.
A nurse is caring for an adult that has recently been diagnosed with respiratory
alkalosis. Which of the following clinical signs would most likely not be present?
A: Anxiety attacks
B: Dizziness
C: Hyperventilation cyanosis
D: Blurred vision
(C) Hyperventilation cyanosis is associated with respiratory acidosis.
A nurse is reviewing a patient's medication list. The drug Pentoxifylline

is present on the list. Which of the following conditions is commonly

treated with this medication?
A: COPD (Chronic Obstructive Pulmonary Disease)
B: CAD (Coronary Artery Disease)
C: PVD (Peripheral Vascular Disease)
D: MS (Multiple Sclerosis)
(C) This drug is a hemorheological agent that helps blood viscosity.
A patient has been on long-term management for CHF. Which of the following
drugs is considered a loop dieuretic that could be used to treat CHF symptoms?
A: Ciprofloxacin
B: Lepirudin
C: Naproxen
D: Bumex
(D) Bumex is considered a loop dieuretic.

A nurse is educating a patient about right-sided heart deficits. Which of
the following clinical signs is not associated with right-sided heart
deficits?
A: Orthopnea
B: Dependent edema
C: Ascites
D: Nocturia
(A) Orthopnea is a left- sided heart failure

clinical symptom
A nurse is reviewing a patient's medication. Which of the following is
considered a potassium sparing dieuretic?
A: Esidrix
B: Lasix
C: Aldactone
D: Edecrin
(C) Aldactone (Spironolactone) is considered a

potassium sparing diuretic.
A nurse is reviewing a patient's medication. The patient is taking

Digoxin. Which of the following is not an effect of Digoxin?
A: Depressed HR
B: Increased CO
C: Increased venous pressure
D: Increased contractility of cardiac muscle
(C) Digoxin decreases venous pressure.

A patient has been instructed by the doctor to reduce their intake of
Potassium. Which types of foods should not worry about avoiding?
A: Bananas
B: Tomatoes
C: Orange juice
D: Apples
(D) All the others are high in potassium.

A patient's chart indicates the patient is suffering from Digoxin toxicity. Which of
the following clinical signs is not associated with digoxin toxicity?
A: Ventricular bigeminy
B: Anorexia
C: Normal ventricular rhythm
D: Nausea
(C) Ventricular rhythm may be premature with

Digoxin toxicity.
A fourteen year old male has just been admitted to your floor. He has a history of central
abdominal pain that has moved to the right iliac fossa region. He also has tenderness over
the region and a fever. Which of the following would you most likely suspect?
A: Appendicitis
B: Acute pancreatitis
C: Ulcerative colitis

D: Cholecystitis
(A) Appendicitis is most likely indicated in this

case.
A thirteen-year old male has a tender lump area in his left groin. His abdomen is
distended and he has been vomiting for the past 24 hours. Which of the following
would you most like suspect?
A: Ulcerative colitis
B: Biliary colic
C: Acute gastroenteritis
D: Strangulated hernia
(D) A hernia is the most likely indicated in this

case.
Which of the following is the key risk factor for development of
Parkinson's disease dementia?
A: History of strokes
B: Acute headaches history
C: Edward's syndrome
D: Use of phenothiazines
(D) Penothiazines are considered a risk factor

for Parkinson's disease dementia.
A father notifies your clinic that his son's homeroom teacher has just been diagnosed with
meningitis and his son spent the day with the teacher in detention yesterday. Which of the
following would be the most likely innervention?
A: Isolation of the son
B: Treatment of the son with Aciclovir
C: Treatment of the son with Rifampicin
D: Reassure the father
(C) Rifampicin would be used in this case.

A patient has recently been diagnosed with hyponatremia. Which of
the following is not associated with hyponatremia?
A: Muscle twitching
B: Anxiety
C: Cyanosis
D: Sticky mucous membranes
(D) Sticky mucuous membranes are associated with hypernatremia.
A patient has recently been diagnosed with hypernatremia. Which of

the following is not associated with hypernatremia?
A: Hypotension
B: Tachycardia
C: Pitting edema
D: Weight gain
(A) Hypotension would be associated with

hyponatremia.
Which of the following normal blood therapeutic concentrations
is abnormal?
A: Phenobarbital 10-40 mcg/ml
B: Lithium .6 - 1.2 mEq/L
C: Digoxin .5 - 1.6 ng/ml
D: Valproic acid 40 - 100 mcg/ml
(C) The normal ranges for Digoxin is .7 - 1.4

ng/ml.
Which of the following normal blood therapeutic concentrations
is abnormal?
A: Digitoxin 09 - 25 mcg/ml
B: Vancomycin 05 - 15 mcg/ml
C: Primidone 02 - 14 mcg/ml
D: Theophylline 10 - 20 mcg/ml
(C) The normal ranges of Primidone is 04 -12
mcg/ml.
Which of the following normal blood therapeutic concentrations is abnormal?
A: Phenytoin 10 - 20 mcg/ml
B: Quinidine 02 - 06 mcg/ml
C: Haloperidol 05 - 20 ng/ml
D: Carbamazepine 5 - 25 mcg/ml
(C) The normal ranges of Carbamazepine is 10 - 20 mcg/ml.

A nurse is providing care based on Maslow's hierarchy of basic human needs. For which
nursing activities is this approach useful?
a. Making accurate nursing diagnoses

b. Establishing priorities of care
c. Communicating concerns more concisely
d. Integrating science into nursing care
b. Maslow's hierarchy of basic human needs is useful for establishing priorities of care.
The nurse is prioritizing nursing care for a patient in a long-term care facility. Which examples of
nursing interventions help meet physiologic needs? Select all that apply.
a. Preventing falls in the facility

b. Changing a patient's oxygen tank
c. Providing materials for a patient who likes to draw
d. Helping a patient eat his dinner
e. Facilitating a visit from a spouse
f. Referring a patient to a cancer support group.
b, d. Physiologic needs—oxygen, water, food, elimination, temperature, sexuality, physical

activity, and rest—must be met at least minimally to maintain life. Providing food and
oxygen are examples of interventions to meet these needs. Preventing falls helps meet
safety and security needs, providing art supplies may help meet self-actualization needs,
facilitating visits from loved ones helps meet self-esteem needs, and referring a patient to a
support group helps meet love and belonging needs.
The nurse caring for patients postoperatively uses careful hand hygiene and sterile
techniques when handling patients. Which of Maslow's basic human needs is being met by
this nurse?
a. Physiologic
b. Safety and security
c. Self-esteem
d. Love and belonging
b. By carrying out careful hand hygiene and using sterile technique, nurses
provide safety from infection. An example of a physiologic need is clearing a
patient's airway. Self-esteem needs may be met by allowing an older adult to talk
about a past career. An example of helping meet a love and belonging need is
contacting a hospitalized patient's family to arrange a visit.
The nurse caring for patients in a long-term care facility knows that the highest level on Maslow's
hierarchy of needs is self-actualization needs. Which statements accurately describe the
achievement of self-actualization? Select all that apply.
a. Humans are born with a fully developed sense of self-actualization.

b. Self-actualization needs are met by depending on others for help.
c. The self-actualization process continues throughout life.
d. Loneliness and isolation occur when self-actualization needs are unmet.
e. A person achieves self-actualization by focusing on problems outside self.
f. Self-actualization needs may be met by creatively solving problems.
c, e, f. Self-actualization, or reaching one's full potential, is a process that continues

throughout life. A person achieves self-actualization by focusing on problems outside
oneself and using creativity as a guideline for solving problems and pursuing interests.
Humans are not born with a fully developed sense of self-actualization, and self-
actualization needs are not met specifically by depending on others for help. Loneliness and
isolation are not always the result of unmet self-actualization needs.
A nurse works with families in crisis at a community mental health care facility. What is the
best broad definition of a family?
a. A father, a mother, and children

b. A group whose members are biologically related
c. A unit that includes aunts, uncles, and cousins
d. A group of people who live together and depend on each other for support
d. Although all the responses may be true, the best definition is a group of people who
live together and depend on each other for physical, emotional, or financial support.
A nurse performs an assessment of a family consisting of a single mother, a grandmother, and two
children. Which interview questions directed to the single mother could the nurse use to assess the
affective and coping family function? Select all that apply.
a. Who is the person you depend on for emotional support?

b. Who is the breadwinner in your family?
c. Do you plan on having any more children?
d. Who keeps your family together in times of stress?

e. What family traditions do you pass on to your children?
f. Do you live in an environment that you consider safe?
a, d. The five major areas of family function are physical, economic, reproductive, affective
and coping, and socialization. Asking who provides emotional support in times of stress
assesses the affective and coping function. Assessing the breadwinner focuses on the
economic function. Inquiring about having more children assesses the reproductive
function, asking about family traditions assesses the socialization function, and checking the
environment assesses the physical function.
The nurse caring for families in a free health care clinic identifies psychosocial risk
factors for altered family health. Which example describes one of these risk factors?
a. The family does not have dental care insurance or resources to pay for it.
b. Both parents work and leave a 12-year old child to care for his younger brother.
c. Both parents and their children are considerably overweight.
d. The youngest member of the family has cerebral palsy and needs assistance from
community services.
b. Inadequate childcare resources is a psychosocial risk factor. Not having access to

dental care and obese family members are lifestyle risk factors. Having a family
member with birth defects is a biologic risk factor.
Shuba and Raul are a couple in their late seventies. According to Duvall, which
developmental task is appropriate for this older adult family?
a. Maintain a supportive home base

b. Strengthen marital relationships
c. Cope with loss of energy and privacy
d. Adjust to retirement
d. The developmental tasks of the family with older adults are to adjust to retirement
and possibly to adjust to the loss of a spouse and loss of independent living.
Maintaining a supportive home base and strengthening marital relationships are tasks of
the family with adolescents and young adults. Coping with loss of energy and privacy is
a task of the family with children.
A visiting nurse performs a community assessment in an area of the city in which the
nurse will be working. What is one element of a healthy community?
a. Meets all the needs of its inhabitants

b. Has mixed residential and industrial areas
c. Offers access to health care services
d. Has modern housing and condominiums
c. A healthy community offers access to health care services to treat illness and to
promote health. A healthy community does not usually meet all the needs of its
residents, but should be able to help with health issues such as nutrition, education,
recreation, safety, and zoning regulations to separate residential sections from industrial
ones. The age of housing is irrelevant as long as residences are maintained properly
according to code.
A nurse is practicing community-based nursing in a mobile health clinic. What would be

the central focus of this nurse's care?
a. Individual and family health care needs

b. Populations within the community
c. Local health care facilities
d. Families in crisis
a. In contrast to community health nursing, whichfocuses on populations within a

community, community-based nursing is centered on individual and family health care
needs. Community-based nurses may help families in crisis and work in health care
facilities, but these are not the focus of community-based nursing
A nurse is caring for a patient in the ICU who is being monitored for a possible cerebral
aneurysm following a loss of consciousness in the emergency room. The nurse
anticipates preparing the patient for ordered diagnostic tests. This nurse's knowledge of
the diagnostic procedures for this condition reflects which aspect of nursing?
a. The art of nursing

b. The science of nursing
c. The caring aspect of nursing
d. The holistic approach to nursing
b. The science of nursing is the knowledge base for care that is provided. In contrast,
the skilled application of that knowledge is the art of nursing. Providing holistic care to
patients based on the science of nursing is considered the art of nursing.
Which nurse who was influential in the development of nursing in North America is
regarded as the founder of American nursing?
a. Clara Barton
b. Lillian Wald
c. Lavinia Dock
d. Florence Nightingale
d. Florence Nightingale elevated the status of nursing to a respected occupation,

improved the quality of nursing care, and founded modern nursing education. Clara
Barton established the Red Cross in the United States in 1882. Lillian Wald is the
founder of public health nursing. Lavinia Dock was a nursing leader and women's rights
activist instrumental in womens' right to vote.
In early civilizations, the theory of animism attempted to explain the mysterious changes
occurring in bodily functions. Which statement describes a component of the
development of nursing that occurred in this era?
a. Women who committed crimes were recruited into nursing the sick in lieu of serving
jail sentences.
b. Nurses identified the personal needs of the patient and their role in meeting those
needs.
c. Women called deaconesses made the first visits to the sick and male religious orders
cared for the sick and buried the dead.
d. The nurse was the mother who cared for her family during sickness by using herbal
remedies.
d. The theory of animism was based on the belief that everything in nature was alive
with invisible forces and endowed with power. In this era, the nurse usually was the
mother who cared for her family during sickness by providing physical care and herbal
remedies. At the beginning of the 16th century the shortage of nurses led to the
recruitment of women who had committed crimes to provide nursing care instead of
going to jail. In the early Christian period, women called deaconesses made the first
organized visits to sick people, and members of male religious orders gave nursing care
and buried the dead. The influences of Florence Nightingale were apparent from the
middle of the 19th century to the 20th century; one of her accomplishments was
identifying the personal needs of the patient and the nurse's role in meeting those
needs.
World War II had a tremendous effect on the nursing profession. Which development
occurred during this period?
a. The role of the nurse was broadened.

b. There was a decreased emphasis on education.
c. Nursing was practiced mainly in hospital settings.
d. There was an overabundance of nurses.
a. During World War II, large numbers of women worked outside the home. They
became more independent and assertive, which led to an increased emphasis on
education. The war itself created a need for more nurses and resulted in a knowledge
explosion in medicine and technology. This trend broadened the role of nurses to
include practicing in a wide variety of health care settings.
One of the four broad aims of nursing practice is to restore health. Which examples of
nursing interventions reflect this goal? Select all that apply.
a. A nurse counsels adolescents in a drug rehabilitation program.

b. A nurse performs range-of-motion exercises for a patient on bedrest.
c. A nurse shows a diabetic patient how to inject insulin.
d. A nurse recommends a yoga class for a busy executive.
e. A nurse provides hospice care for a patient with end-stage cancer.
f. A nurse teaches a nutrition class at a local high school.
a, b, c. Activities to restore health focus on the individual with an illness and range from
early detection of a disease to rehabilitation and teaching during recovery. These
activities include drug counseling, teaching patients how to administer their medications,
and performing range-of-motion exercises for bedridden patients. Recommending a
yoga class for stress reduction is a goal of preventing illness, and teaching a nutrition
class is a goal of promoting health. A hospice care nurse helps to facilitate coping with
disability and death.
Nursing is recognized increasingly as a profession based on which defining criteria?

Select all that apply.
a. Well defined body of general knowledge

b. Interventions dependent upon the medical practice
c. Recognized authority by a professional group
d. Regulation by the medical industry
e. Code of ethics
f. Ongoing research
c, e, f. Nursing is recognized increasingly as a profession based on the following

defining criteria: well-defined body of specific and unique knowledge, strong service
orientation, recognized authority by a professional group, code of ethics, professional
organization that sets standards, ongoing research, and autonomy and self-regulation.
The National Advisory Council on Nurse Education and Practice identifies critical
challenges to nursing practice in the 21st century. What is a current health care trend
contributing to these challenges?
a. Decreased numbers of hospitalized patients

b. Older and more acutely ill patients
c. Decreasing health care costs due to managed care
d. Slowed advances in medical knowledge and technology
b. The National Advisory Council on Nurse Education and Practice identifies the
following critical challenges to nursing practice in the 21st century: A growing population
of hospitalized patients who are older and more acutely ill, increasing health care costs,
and the need to stay current with rapid advances in medical knowledge and technology.
A nurse assesses patients in a physician's office who are experiencing different levels of
health and illness. Which statements best define the concepts of health and illness?
a. Health and illness are the same for all people.

b. Health and illness are individually defined by each person.
c. People with acute illnesses are actually healthy.
d. People with chronic illnesses have poor health beliefs.
e. Health is more than the absence of illness.
f. Illness is the response of a person to a disease.
b, e, f. Each person defines health and illness individually, based on a number of

factors. Health is more than just the absence of illness; it is an active process in which a
person moves toward one's maximum potential. An illness is the response of the person
to a disease.
The student nurse learns that illnesses are classified as either acute or chronic. Which
are examples of chronic illnesses? Select all that apply.
a. Diabetes mellitus
b. Bronchial pneumonia
c. Rheumatoid arthritis
d. Cystic fibrosis
e. Fractured hip
f. Otitis media
a, c, d. Diabetes, arthritis, and cystic fibrosis are chronic diseases because they are permanent
changes caused by irreversible alterations in normal anatomy and physiology, and they require
patient education along with a long period of care or support. Pneumonia, fractures, and otitis
media are acute illnesses because they have a rapid onset of symptoms that last a relatively short
time.
Despite a national focus on health promotion, nurses working with patients in inner-city
clinics continue to see disparities in health care for vulnerable populations. Which
patients would be considered vulnerable populations? Select all that apply.
a. A White male diagnosed with HIV

b. An African American teenager who is 6 months pregnant
c. A Hispanic male who has type II diabetes
d. A low-income family living in rural America
e. A middle-class teacher living in a large city
f. A White baby who was born with cerebral palsy
b, c, d, f. National trends in the prevention of health disparities are focused on

vulnerable populations, such as racial and ethnic minorities, those living in poverty,
women, children, older adults, rural and inner-city residents, and people with disabilities
and special health care needs.
A nurse has volunteered to give influenza immunizations at a local clinic. What level of
care is the nurse demonstrating?
a. Tertiary
b. Secondary
c. Primary
d. Promotive
c. Giving influenza injections is an example of primary health promotion and illness

prevention.
A nurse's neighbor tells the nurse, "I have a high temperature, feel awful, and I am not
going to work." What stage of illness behavior is the neighbor exhibiting?
a. Experiencing symptoms
b. Assuming the sick role

c. Assuming a dependent role
d. Achieving recovery and rehabilitation
b. When people assume the sick role, they define themselves as ill, seek validation of
this experience from others, and give up normal activities. In stage 1: experiencing
symptoms, the first indication of an illness usually is recognizing one or more symptoms
that are incompatible with one's personal definition of health. The stage of assuming a
dependent role is characterized by the patient's decision to accept the diagnosis and
follow the prescribed treatment plan. In the achieving recovery and rehabilitation role,
the person gives up the dependent role and resumes normal activities and
responsibilities.
Which clinic patient is most likely to have annual breast examinations and mammograms
based on the physical human dimension?
a. Jane, whose her best friend had a benign breast lump removed
b. Sarah, who lives in a low-income neighborhood
c. Tricia, who has a family history of breast cancer
d. Nancy, whose family encourages regular physical examinations
c. The physical dimension includes genetic inheritance, age, developmental level, race,
and gender. These components strongly influence the person's health status and health
practices. A family history of breast cancer is a major risk factor.
Health promotion activities may occur on a primary, secondary, or tertiary level. Which
activities are considered tertiary health promotion? Select all that apply.
a. A nurse runs an immunization clinic in the inner city.

b. A nurse teaches a patient with an amputation how to care for the residual limb.
c. A nurse provides range-of-motion exercises for a paralyzed patient.
d. A nurse teaches parents of toddlers how to childproof their homes.
e. A school nurse provides screening for scoliosis for the students.
f. A nurse teaches new parents how to choose and use an infant car seat.
b, c. Tertiary health promotion and disease prevention begins after an illness is

diagnosed and treated to reduce disability and to help rehabilitate patients to a
maximum level of functioning. These activities include providing ROM exercises and
patient teaching for residual limb care. Providing immunizations and teaching parents
how to childproof their homes and use an appropriate car seat are primary health
promotion activities. Providing screenings is a secondary health promotion activity.
The agent-host-environment model of health and illness is based on what concept?
a. Risk factors
b. Demographic variables
c. Behaviors to promote health
d. Stages of illness
a. The interaction of the agent, host, and environment creates risk factors that increase
the probability of disease.
When providing health promotion classes, a nurse uses concepts from models of
health. What do both the health-illness continuum and the high-level wellness models
demonstrate?
a. Illness as a fixed point in time

b. The importance of family
c. Wellness as a passive state
d. Health as a constantly changing state
d. Both these models view health as a dynamic (constantly changing state).
A nurse follows accepted guidelines for a healthy lifestyle. How can this promote health
in others?
a. By being a role model for healthy behaviors

b. By not requiring sick days from work
c. By never exposing others to any type of illness
d. By spending less money on food
a. Good personal health enables the nurse to serve as a role model for patients and
families.
A nurse is providing secondary health care to patients in a health care facility. Which
patients are receiving this level of care? Select all that apply.
a. A patient enters a community clinic with signs of strep throat.

b. A patient is admitted to the hospital following a myocardial infarction.
c. A mother brings her son to the emergency department following a seizure.
d. A patient with osteogenesis imperfecta is being treated in a medical center.
e. A mother brings her son to a specialist to correct a congenital heart defect.
f. A woman has a hernia repair in an ambulatory care center.
b, c, f. Secondary health care treats problems that require specialized clinical expertise,
such as an MI, a seizure, and a hernia repair. Treating strep throat is primary health
care.Tertiary health care involves management of rare and complex disorders, such as
osteogenesis imperfecta and congenital heart malformations.
A nurse working in a physician's office prepares insurance forms in which the provider is given a
fixed amount per enrollee of the health plan. What is the term for this type of reimbursement?
a. Capitation
b. Prospective payment system
c. Bundled payment
d. Rate setting
a. Capitation plans give providers a fixed amount per enrollee in the health plan in an
effort to build a payment plan that consists of the best standards of care at the lowest
cost. The prospective payment system groups inpatient hospital services for Medicare
patients into DRGs. With bundled payments, providers receive a fixed sum of money to
provide a range of services. Rate setting means that the government could set targets
or caps for spending on health care services.
A nurse researcher keeps current on the trends to watch in healthcare delivery. What
trends are likely included? Select all that apply.
a. Globalization of economy and society

b. Slowdown in technology development
c. Decreasing diversity
d. Increasing complexity of patient care
e. Changing demographics
f. Shortages of key health care professionals and educators
a, d, e, f. Trends to watch in health care delivery include: globalization of the economy

and society, increasing complexity of patient care, changing demographics, shortages
of key health care professionals and educators, technology explosion, and increasing
diversity.
A nurse is caring for patients in a primary care center. What is the most likely role of this
nurse based on the setting?
a. Assisting with major surgery

b. Performing a health assessment
c. Maintaining patients' function and independence
d. Keeping student immunization records up to date
b. Performing patient assessments is a common role of the nurse in a primary care

center. Assisting with major surgery is a role of the nurse in the hospital setting.
Maintaining patients' function and independence is a role of the nurse in an extended-
care facility, and keeping student immunization records up to date is a role of the school
nurse.
A caregiver asks a nurse to explain respite care. How would the nurse respond?
a. "A service that allows time away for caregivers"

b. "A special service for the terminally ill and their family"
c. "Direct care provided to individuals in a long-term care facility"
d. "Living units for people without regular shelter"
a. Respite care is provided to enable a primary caregiver time away from the day-to-day
responsibilities of homebound patients.
A nurse caring for patients in a primary care setting submits paperwork for
reimbursement from managed care plans for services performed. Which purpose best
describes managed care as a framework for health care?

a. A design to control the cost of care while maintaining the quality of care
b. Care coordination to maximize positive outcomes to contain costs
c. The delivery of services from initial contact through ongoing care
d. Based on a philosophy of ensuring death in comfort and dignity
a. Managed care is a way of providing care designed to control costs while maintaining
the quality of care.
A nurse cares for dying patients by providing physical, psychological, social, and
spiritual care for the patients, their families, and other loved ones. This service is known
as:
a. Respite care
b. Palliative care
c. Hospice care
d. Extended care
c. The hospice nurse combines the skills of the home care nurse with the ability to
provide daily emotional support to dying patients and their families. Respite care is a
type of care provided for caregivers of homebound ill, disabled, or older patients.
Palliative care, which can be used inconjunction with medical treatment and in all types
of health care settings, is focused on the relief of physical, mental, and spiritual distress.
Extended-care facilities include transitional subacute care, assisted-living facilities,
intermediate and long-term care, homes for medically fragile children, retirement
centers, and residential institutions for mentally and developmentally or physically
disabled patients of all ages.
A nurse is evaluating a patient diagnosed with renal disease for treatment in a

Hospital at Home program. Which statement accurately describes a step in this
program?
a. The patient is evaluated upon hospital admission and is given daily nursing care in
the home after discharge for as long as necessary.
b. Any urgent or emergent situation requires an ambulance trip from the home to the
hospital.
c. Patients are transported to physicians' offices from the home for weekly evaluations.
d. The clinicians use care pathways, clinical outcome evaluations, and specific
discharge criteria.
d. In the Hospital at Home program, the clinicians use care pathways including illness-
specific care maps, clinical outcome evaluations, and specific discharge criteria. A
patient requiring admission for one of the target illnesses is identified in the
emergency department or ambulatory site. Staff assess whether the patient is a good
candidate for the program using validated criteria. If the patient is eligible and
consents to participate, the Hospital at Home physician evaluates the patient, who is
then transported home, usually by ambulance. Nurses are available 24 hours a day/7
days a week for any urgent or emergent situations. The patient is evaluated daily in
the home by the Hospital at Home physician, who completes an assessment and
continues to implement appropriate diagnostic and therapeutic measures.
After receiving report at the start of the evening shift, which of the following clients
should the nurse attend to first?
(a) A 34-year-old man undergoing treatment for non-Hodgkin lymphoma with a

potassium level of 7.5 mEq/L.
(b) A 21-year-old woman with sickle cell anemia with pain of 6 on a scale of 1-10.
(c) A 55-year-old woman with ovarian cancer waiting to be discharged.
(d) A 72-year-old man with chronic obstructive pulmonary disease (COPD) and a pulse
oximetry of 96% on room air.
Correct answer: (a) A 34-year-old man undergoing treatment for non-Hodgkin lymphoma
with a potassium level of 7.5 mEq/L.
Rationale: Hyperkalemia is a potentially serious condition that, in a client undergoing
treatment for non-Hodgkin lymphoma, could indicate tumour lysis syndrome. Patient (b)
should be attended to, but her condition is not as urgent. Patients (c) and (d) do not
require immediate attention.
A 34-year-old woman who developed Stevens-Johnson syndrome while undergoing

treatment with carbamazepine (Tegretol) is being transferred in stable condition from
the intensive care unit to the medical unit. There are 4 beds available. The nurse knows
the best choice of roommates for this client is which of the following?
(a) A 40-year-old man with methicillin-resistant Staphylococcus aureus (MRSA).

(b) A 28-year-old woman diagnosed with diarrhea.
(c) A 72-year-old man with fever of unknown origin.
(d) A 68-year-old woman with atrial fibrillation .
Correct answer: (d) A 68-year-old woman with atrial fibrillation.

Rationale: A client with Stevens-Johnson syndrome is likely to have severe skin integrity
issues, including blistering and skin shedding, which can place the client at high risk for
infection. Atrial fibrillation is not an infectious process. All other patients may be an
infection risk for an individual with altered skin integrity.
A 72-year-old man who had a stroke is being transferred from a medical unit to a
rehabilitation centre. The nurse case manager is assisting in the process. The nurse
knows that the goals of case management include which of the following? Select all that
apply.
(a) Improving the coordination of care

(b) Increasing referrals to local organizations
(c) Reducing the fragmentation of care
(d) Discharging clients quickly
Correct answer: (a) Improving the coordination of care; and (c) Reducing the
fragmentation of care
Rationale: Some of the primary goals of case management are to improve the
coordination of care and to reduce fragmentation of care. The other options are not
goals of case management.
A pregnant woman at 15 weeks' gestation is scheduled for an amniocentesis. As the
client is being prepped for the procedure, it becomes clear to the nurse that the client
doesn't fully understand the risks and benefits associated with the procedure. Which of
the following describe the nurse's role in obtaining informed consent? Select all that
apply.
(a) Explain the risks and benefits associated with the procedure.
(b) Describe alternatives to the procedure.
(c) Witness the client's signature on the consent form.
(d) Advocate for the client by ensuring she is making an informed decision.
Correct answer: (c) Witness the client's signature on the consent form; and
(d) Advocate for the client by ensuring she is making an informed decision.
Rationale: Some of the nurse's roles in the informed consent process are to witness the
signature on the consent form, and to advocate for the client by ensuring she has been
provided the necessary information to make an informed decision. It is the physician's
duty to provide information to the client-related risks and benefits, and to provide
alternatives.
A well-known actor has been admitted to an ambulatory surgical unit. The nurse notices
a staff member who is not involved in the client's care reading his medical record. The
nurse knows she should FIRST do which of the following?
(a) Nothing. The staff member has a hospital ID badge and is authorized to read the
medical record.
(b) Inform the staff member that without a legitimate need for the information, staff
should not be reading the medical record.
(c) Tell the client his medical records have been read by an unauthorized individual.
(d) Page the physician and ask if it's acceptable for the staff member to access the
medical records.
Correct answer: (b) Inform the staff member that without a legitimate need for the
information, staff should not be reading the medical record.
Rationale: An individual not involved in the care of the client does not have a legitimate
need to access the medical record. The nurse should protect the client's right to privacy
by ensuring only authorized individuals access medical records.
The nurse is learning how to use the hospital's new electronic medication administration
record (eMAR). The nurse knows this tool has the potential to do which of the following?
(a) Reduce medication administration errors.

(b) Improve access to information at the point of care.
(c) Eliminate the need for the nurse to document medication administration.
(d) Eliminate the need for the nurse to verify dose calculations.
Correct answer: (a) Reduce medication administration errors; and

(b) Improve access to information at the point of care.
Rationale: eMARs have the potential to reduce medication administration errors and to
improve access to client information at the point of care. It is always the nurse's
responsibility to document medication administration and to verify doses of drugs being
administered.
The nurse uses the Internet to receive electrocardiogram results from a client living in a
nursing home. The nurse knows this type of information technology is best described as
which of the following?
(a) Encryption
(b) Telecommunications
(c) Telehealth
(d) Nursing informatics
Correct answer: (c) Telehealth.

Rationale: Telehealth uses transmissions via telecommunications technology to transmit
health information remotely. Encryption refers to the conversion of information to code
during transmission to keep the information secure. Telecommunications refers to the
electronic transmission of data over phone-based lines. Nursing informatics refers to a
specialty of nursing that integrates nursing and computer science
The nurse in a maternity unit is caring for a client who has just delivered twins. The
client voices concern about her ability to manage when she gets home. Which of the
following statements best illustrates quality care delivery by the nurse? Select all that
apply.
(a) "Just focus on how lucky you are to have two healthy babies."
(b) "We can arrange for follow-up visits with a home health nurse."
(c) "Here is some information on support groups for parents of multiples."
(d) "You will find it easier to formula-feed your babies at home."
Correct answer: (b) "We can arrange for follow-up visits with a home health nurse."; and
(c) "Here is some information on support groups for parents of multiples."
Rationale: A referral to home health care provides the client with opportunities for
support and assistance during this transition; and a referral to support groups provides
the client with opportunities for support and assistance during this transition. The other
options are not appropriate for a new mother expressing concerns about her ability to
cope.
The nurse is caring for a client newly diagnosed with diabetes, and performs the
following tasks. Place the tasks the nurse would perform in the appropriate order. All
options must be used.
(a) The nurse establishes a goal with the client to be able to self-administer insulin
injections.
(b) The nurse assesses the client's level of knowledge about how to administer insulin
injections.
(c) The nurse evaluates the client while self-administering insulin injections.
(d) The nurse establishes the diagnosis of knowledge deficit.
Correct answer:
(b) The nurse assesses the client's level of knowledge about how to administer insulin
injections.
(d) The nurse establishes the diagnosis of knowledge deficit.
(a) The nurse establishes a goal with the client to be able to self-administer insulin
injections.
(c) The nurse evaluates the client while self-administering insulin injections.
Rationale: Nursing process - assessment, diagnosis, establishing outcomes/planning,
and evaluation.
A nursing team consists of an RN, an LPN/ LVN, and a nursing assistant. The nurse
should assign which of the following patients to the LPN/LVN?
(a) A 72-year-old patient with diabetes who requires a dressing change for a stasis
ulcer.
(b) A 42-year-old patient with cancer of the bone complaining of pain.
(c) A 55-year-old patient with terminal cancer being transferred to hospice home care.
(d) A 23-year-old patient with a fracture of the right leg who asks to use the urinal.
Correct answer: (a) A 72-year-old patient with diabetes who requires a dressing change
for a stasis ulcer.
Rationale: LPN/LVNs assist with implementation of care; performs procedures;
differentiates normal from abnormal; cares for stable patients with predictable
conditions; has knowledge of asepsis and dressing changes; administers medications.
Patient (a) is stable with an expected outcome. Patients (b) and (c) require assessment
and nursing judgement; and Patient (d) involves a standard unchanging procedure that
can be assigned to the nursing assistant.
A registered nurse is planning the client assignments for the day. Which of the following
is the most appropriate assignment for the nursing assistant?
(a) A client requiring colostomy irrigation

(b) A client receiving continuous tube feedings
(c) A client who requires stool specimen collections
(d) A client who has difficulty swallowing food and fluids
Correct answer: (c) A client who requires stool specimen collections

Rationale: This question addresses content related to delegation in the subcategory
Management of Care in the Client Needs category of Safe and Effective Care
Environment. Work that is delegated to others must be done consistent with the
individual's level of expertise and licensure or lack of licensure. In this situation, the
most appropriate assignment for the nursing assistant is to care for the client who
requires stool specimen collections. Colostomy irrigations and tube feedings are not
performed by unlicensed personnel. The client with difficulty swallowing food and
fluids is at risk for aspiration. Remember, the health care provider needs to be
competent and skilled to perform the assigned task or activity.
Which type of evaluation occurs continuously throughout the teaching and learning
process?
A. Formative.
B. Retrospective.
C. Summative.
D. Informative.
Correct answer: A
Formative (or concurrent) evaluation occurs continuously throughout the teaching and
learning process. It includes assessing needs, process, implementation and potential
outcomes. One benefit is that the nurse can adjust teaching strategies as necessary to
enhance learning. Retrospective or summative evaluation occurs at the conclusion of
teaching and learning sessions and often evaluates how a group has done. It includes
outcomes assessment, cost-effectiveness, and impact. Informative isn't a type of
evaluation.
A client with chest pain arrives in the emergency room and receives nitroglycerin,
morphine, oxygen, and aspirin. The client is diagnosed with acute coronary syndrome
and suspected myocardial infarction. The client arrives on the unit, and his vital signs
are stable and he has no complaints of pain. The nurse is reviewing the physician's
orders. In addition to the medications given, which other medication does the nurse
expect the physician to order?
A. A -blocker, such as carvedilol (Coreg®).
B. Digoxin (Lanoxin®).
C. Furosemide (Lasix®).
D. Nitroprusside.
Correct answer: A
A patient who is admitted with suspected myocardial infarction should receive aspirin,
nitroglycerin, morphine, and a -blocker, such as carvedilol. Digoxin in indicated for
arrhythmia rather than acute coronary syndrome. Furosemide would be used if the
client had signs of heart failure, such as peripheral or pulmonary edema, but this is not
evident. Nitroprusside is used to increase blood pressure, but the client has stable vital
signs and is not hypotensive.
The nurse is caring for a client after a lung lobectomy. The nurse notes fluctuating water
levels in the water-seal chamber of the client's chest tube. What action should the nurse
take?
A. Do nothing, but continue to monitor the client.
B. Call the physician immediately.
C. Check the chest tube for a loose connection.
D. Add more water to the water-seal chamber.
Correct answer: A
Fluctuation in the water-seal chamber is a normal finding that occurs as the client
breathes. No action is required except for continued monitoring of the client. The nurse
doesn't need to notify the physician. Continuous bubbling in the water-seal chamber
indicates an air leak in the chest tube system, such as from a loose connection in the
chest tube tubing. The water-seal chamber should be filled initially to the 2 cm line, and
no more water should be added.
A hospice program director was examining various activities related to client care with
the intent of improving quality. The director determined that many are clients were being
admitted on service without an advanced directive. The director along with a team of
individuals developed a plan including goals, objectives, and a timeline to address the
issue. This is an example of which of the following approaches?
A. Risk management project.
B. Performance improvement project.
C. Client care initiative.
D. Palliative care project.
Correct answer: B
Performance improvement projects are an approach to design, measure, assess, and
improve organizational performance. Risk management differs in that it is a planned
program of loss prevention and liability control. Although this is an initiative that involves
client care, the span of the issue extends beyond direct care providers. Advanced
directives are important in the context of palliative care, but assuring that all patients
have them relates more closely to organizational performance.
The nurse is making a teaching plan for a client with Parkinson's disease to help him
understand the implications of beginning treatment with levodopa. Which of the
following instructions should the nurse include?
A. Change positions slowly.
B. Increase intake of foods with vitamin B6.
C. Increase the dose if twitching worsens.
D. Call the physician if symptoms don't improve in 1 week.
Correct answer: A
Because levodopa can cause orthostatic hypotension, the client should be cautioned to
change positions slowly to avoid dizziness, light-headedness, or fainting. The client
should avoid foods high in vitamin B6 and vitamin B6 supplements because they can
reverse the effects of levodopa. Increased twitching may be a sign of drug overdose
and should be reported to the physician. Other signs of overdose include palpitations,
eye spasms, arrhythmias, and hypertension. When a client is started on levodopa, it
may take several weeks for symptoms to improve, so the client should not expect
immediate improvement.
The nurse is preparing to administer an I.M. injection in a client with a spinal cord injury
that has resulted in paraplegia. Which of the following muscles is best site for the
injection in this case?
A. Deltoid.
B. Dorsal gluteal.
C. Vastus lateralis.
D. Ventral gluteal.
Correct answer: A
I.M. injections should be given in the deltoid muscle in the client with a spinal cord
injury. Paraplegia involves paralysis and lack of sensation in the lower trunk and lower
extremities. Clients with spinal cord injuries exhibit reduced use of and consequently
reduced blood flow to muscles in the buttocks (dorsal gluteal and ventral gluteal) and
legs (vastus lateralis). Decreased blood flow results in impaired drug absorption and
increases the risk of local irritation and trauma, which could result in ulceration of the
tissue.
The nurse is evaluating treatment effectiveness indicators for a client who is being
discharged from the intensive outpatient drug and alcohol clinic. Which client behavior
would the nurse evaluate as a positive treatment outcome?
A. The client is following a regular sleeping routine.
B. The client is participating in scheduled group meetings.
C. The client is planning to engage in social activities.
D. The client is applying the clinic rules to others.
Correct answer: B
A client with a drug and alcohol problem who is participating in the scheduled group
sessions is making an effort to learn lifestyle changes, coping skills, and ways to
maintain a clean and sober life. Although it is healthy to follow a regular sleep pattern,
this behavior is not a specific indicator of drug and alcohol treatment effectiveness.
Plans to engage in social activities may be repeating patterns of the people, places, and
things that triggered drug use; therefore, this action could be a negative treatment
outcome. Applying the clinic rules to others is a form of distraction that prevents the
client from focusing on personal treatment goals.
The nurse is caring for a client with heart failure. Which of the following statements by
the client suggests that the client has left-sided heart failure?
A. "I sleep on three pillows each night."
B. "My feet are bigger than normal."
C. "My pants don't fit around my waist."
D. "I have to get up three times during the night to urinate."
Correct answer: A
Orthopnea is a classic sign of left-sided heart failure. The client often sleeps on several
pillows at night to help facilitate breathing because of pulmonary edema. Peripheral
edema is indicative or right-sided failure. Ascites is a late symptom of right-sided heart
failure and can increase girth. Nocturia is common with right-sided failure as peripheral
edema decreases when the feet are not dependent, increasing urinary output.
A client with type 2 diabetes has a hemoglobin A1C level of 8.8 after 6 months of oral
therapy with metformin (Glucophage®). The client tells the nurse that she often forgets
to take her medication and doesn't really follow her diet. Which of the following is the
nurse's best first response?
A. "If you don't get control of your blood sugar, you'll need to take insulin."

B. "It can be hard to get used to having a disease like diabetes. What are some of the
things you find challenging about it?"
C. "Uncontrolled diabetes can lead to eye problems and kidneys problems."
D. "Many people have diabetes."
Correct answer: B
Acknowledging that the client is going through changes and allowing her to express her
concerns will help the nurse assess her needs. Hemoglobin AIC shows the average
blood glucose levels over a 3-month period. Diabetes should maintain the AIC <7%.
Lecturing, threatening and comparing the clients to others belittles the client and
discourages discussion, but the patient must be provided adequate information in order
to make informed decisions about self-care.
The nurse is reviewing laboratory values of a client diagnosed with hyperlipidemia 6

months previously. Which results indicate that the client has been following his
therapeutic regime?
A. Total cholesterol level increases from 250 mg/dL to 275 mg/dL.
B. Low-density lipoproteins (LDL) increase from 180 mg/dL to 190 mg/dL.
C. High-density lipoproteins (HDL) increase from 25 mg/dL to 40 mg/dL.
D. Triglycerides increase from 225 mg/dL to 250 mg/dL.
Correct answer: C
HDL levels have an inverse relationship with coronary artery disease and should be
greater than 35 mg/dL. The goal of treating hyperlipidemia is to decrease total
cholesterol and LDL levels, while increasing HDL levels. Total cholesterol levels are
recommended to be below 200 mg/dL. LDL levels should be less than 160 mg/dL. In
clients with known coronary artery disease or diabetes, the LDL level should be less
than 70 mg/dL. Triglyceride level has a direct relationship a LDL level and an inverse
relationship with HDL level. Triglyceride levels should be between 100 and 200 mg/dL.
The nurse is assessing a client with aortic stenosis. Which of the following best
describes the murmur associated with aortic stenosis?
A. High-pitched and blowing.
B. Loud and rough during systole.
C. Low-pitched, rumbling during diastole.
D. Low-pitched and blowing.
Correct answer: B
An aortic murmur is loud and rough and is heard over the aortic area during systole.
Aortic insufficiency has a high-pitched and blowing murmur and is heard at the third or
fourth intercostal space at the left sternal border. Mitral stenosis has a low-pitched
rumbling murmur heard at the apex. Mitral insufficiency has a high-pitched, blowing
murmur at the apex. There is no specific condition associated with a low-pitched,
blowing murmur.
The nurse is preparing to discharge an adolescent with sickle cell disease. Which of the
following should the nurse stress during teaching? Select all that apply.
A. Infection prevention and management.
B. Pain management.
C. Fluid restriction.
D. Effective emotional coping skills.
Correct answers: A, B, and D

The goals of sickle cell management include preventing crisis and managing pain and
issues of self-esteem. This requires teaching the client how to avoid infection and follow
protocols for antibiotics as infections can trigger crisis. Pain management may include
analgesics as well as relaxation techniques and other comfort measures, such as heat
application. Sickle cell disease, as with all chronic diseases, can affect an adolescent's
feelings of self esteem, so coping skills include allowing the client as much
independence in care as possible. Dehydration poses the risk of sickle cell crisis and
blood clots, so the client must stay well hydrated.
Which type of nursing intervention does the nurse perform when she administers oral
care to a client?
A. Psychomotor.
B. Educational.
C. Maintenance.
D. Supervisory.
Correct answer: C
Oral care is an example of a maintenance nursing intervention. Other examples of
maintenance nursing interventions include skin care and hygiene. Psychomotor
interventions include positioning the client. Educational nursing interventions include the
nurse demonstrating and teaching a skill to the client. Supervisory nursing interventions
occur when the nurse supervises other health care providers performing a task.
The nurse is caring for a client with pulmonary edema. Which of the following orders
should the nurse clarify?
A. Dobutamine 5 mcg/kg/minute I.V.
B. 0.9% normal saline solution I.V. at 150 mL/hour.
C. Morphine I.V. 2 mg every 2 hours P.R.N. dyspnea.
D. Furosemide I.V. 40 mg every 6 hours.
Correct answer: B
An I.V. rate of 150 mL/hour would further increase the fluid overload and worsen the
pulmonary edema. Pulmonary edema is due to an increased blood volume in the lungs.
This blood volume causes an increased hydrostatic pressure, which forces fluid from
the pulmonary capillaries into the interstitial space and alveoli. The fluid in the alveoli
blocks the air exchange, causing impaired gas exchange. The priority treatment for
these patients is to improve their gas exchange and decrease volume overload.
Dobutamine is a positive inotrope, which helps the heart pump more effectively,
reducing the amount of blood pooling in the lungs. Morphine helps decrease venous
pressure, which helps decrease the pressure in the lungs and the movement of fluid into
the lungs, relieving dyspnea. Furosemide is a diuretic and helps remove some of the
extra fluid from the lungs.
The nurse is teaching a client newly diagnosed with type 1 diabetes how to self-
administer subcutaneous insulin injections. How does the nurse best evaluate the
effectiveness of her teaching?
A. Have the client repeat the steps back to the nurse.
B. Give the client a written test on self-administration of insulin.
C. Ask the client to write out the steps for self-administration of insulin injections.
D. Ask the client to give a return demonstration of self-administration of insulin.
Correct answer: D
Asking the client to give a return demonstration of his injection technique is the best way
to assess whether the client can perform the procedure. It also gives the nurse the
opportunity to provide feedback. Asking the client to recite the steps, pass a written test,
or write out the steps shows the nurse whether the client is able to recall the steps but
doesn't show that he has the necessary motor skills or the ability to perform the
procedure.
The nurse is assessing a female client who reports infrequent, irregular menstrual
periods. Which of the following signs and symptoms suggests to the nurse that the
client may have polycystic ovarian syndrome (POS)?
A. Muscle wasting and nervousness.
B. Hypotension.
C. Poor appetite and weight loss.
D. Obesity and hirsutism with excessive facial hair.
Correct answer: D
Polycystic ovarian syndrome (POS) is a constellation of symptoms including
amenorrhea, hirsutism on the face, chest and limbs but thinning hair on the scalp, and
obesity. Additionally, clients often exhibit insulin resistance (Type 2 diabetes mellitus).
Muscle wasting and nervousness are not characteristic of POS, but depression is
common. Hypertension may occur in some women. Increased appetite leads to weight
gain.
A nurse is caring for a client returning from an x-ray. The nursing assistant is helping
transfer the client back to bed. Which transfer technique by the nurse uses appropriate
ergonomic principles?
A. Lowering the bed for transfer and then raising the bed before leaving the room,
making sure to place the call light is within reach.
B. Maintaining a narrow base of support during transfer and encouraging the client to
hold onto her if afraid during transfer.
C. Raising the bed for transfer, maintaining a wide base of support during transfer, and
lowering the bed before leaving the room.
D. Explaining the procedure to the client and grabbing the client underneath the arms to
pull her over to the bed.
Correct answer: C
Raising the bed during transfer and maintaining a wide base of support reduces the risk
of back injury, and the bed should always be left in the low position to reduce danger
from falls. Transferring the patient with the bed in low position strains the lower back.
The client should not grab or hold onto staff members during transfers as this can
interfere with the transfer and cause the nurse injury. The nurse should not grab the
client under the arms, as this can cause the client shoulder injury or nerve damage. In
addition, pulling a client during transfers places the client at risk for skin shear injuries.
The nurse in the Emergency Department is caring for a client who has acute heart
failure. The physician is writing orders for pharmacological management, including
diuretics. Which laboratory value is most important for the nurse to check before
administering medications to treat heart failure?
A. Platelet count.
B. Potassium.
C. Calcium.
D. White blood cell count.
Correct answer: B
Diuretics, such as furosemide (Lasix®) are commonly used to treat acute heart failure.
Most diuretics increase the renal excretion of potassium. The nurse should check the
potassium level before administering diuretics and obtain an order to replace potassium
if the level is low. Other medications commonly used to treat heart failure include
angiotensin converting enzymes, digoxin, and -adrenergic blockers. While checking the
platelet count, calcium level, and white blood cell count is important, these results would
not affect the administration of medications to treat acute heart failure.
The nurse is writing the teaching plan for a client undergoing a radioactive iodine uptake
test to study thyroid function. Which of the following instructions should the nurse
include?
A. "You need to stay at least 4 feet (1.2 m) away from other people after the test
because you'll be radioactive."
B. "You need to lie very still on a stretcher that is placed in a long tube for the scan"
C. "Don't take any iodine or thyroid medication before the test."
D. "Schedule the bone scans before your radioactive iodine uptake test."
Correct answer: C
Medications such as iodine, contrast media, and antithyroid and thyroid drugs can affect
the test results and should be withheld by the client for a week or longer, as directed by
the physician. During a radioactive iodine uptake test, the client receives radioactive
iodine by mouth or I.V. in small doses and doesn't require isolation. During magnetic
resonance imaging--not radioactive iodine uptake testing--a client needs to lie still inside
a long tube. Any test, such as a bone scan, that requires iodine contrast media should
be scheduled after the radioactive iodine uptake test because the iodinated contrast
medium can decrease uptake.
The nurse is assessing a client hospitalized with type 2 diabetes mellitus. Which
assessment finding leads the nurse to suspect hyperosmolar hyperglycemic nonketotic
syndrome (HHNS) in this client?
A. Kussmaul's respirations.
B. Metabolic acidosis.
C. Serum glucose of 1,200 mg/dL.
D. Dependent edema.
Correct answer: C
Serum glucose levels in HHNS are greater than 800 mg/dL and may be as high as
2,000 mg/dL. By comparison, serum glucose levels in diabetic ketoacidosis are 300 to
800 mg/dL. In HHNS the body produces enough insulin to prevent diabetic ketoacidosis
but not enough to prevent hyperglycemia, diuresis, and dehydration. Metabolic acidosis
and Kussmaul's respirations (deep, rapid breathing) occur with diabetic ketoacidosis. In
the client with HHNS, respirations may be normal or rapid and shallow, without any
fruity odor. The osmotic diuresis that occurs in HHNS leads to profound dehydration, so
dependent edema doesn't occur.
The nurse is assessing a pregnant patient through a tocotransducer placed externally

and a spiral electrode placed internally. What information would the nurse obtain by this
arrangement? Select all that apply.
1 Lactate levels in the fetal blood
2 Strength of uterine contractions
3 Duration of uterine contractions
4 Frequency of uterine contractions
5 Accelerations of fetal heart rate
ANSWER: 3, 4, 5
A tocotransducer is an external device that is used for assessment of uterine activity
(UA). This instrument would report duration and frequency of the uterine contractions
(UCs). The spiral electrode can monitor accelerations of the fetal heart rate. These
systems do not report the intensity of UCs. Strength of UCs can be assessed using an
intrauterine pressure catheter (IUPC). Neither a tocotransducer nor a spiral electrode is
used to determine the lactate level; it is obtained by the fetal scalp sampling method.
The nurse is assessing a pregnant patient who has been given terbutaline (Brethine).
What is the desired outcome from the administration of the drug?
1- Increased fetal accelerations
2- Reduced placental abruption
3- An Apgar score less than 2
4- A cord blood ph result of 7.2
ANSWER: 4
Terbutaline (Brethine) is administered during pregnancy, especially during elective
cesarean birth. Terbutaline (Brethine) is known to improve the Apgar score of the fetus
to more than 5 and the pH value of the cord to 7.2. Terbutaline (Brethine) has no effect
on placental integrity or function. Terbutaline (Brethine) does not cause fetal heart rate
(FHR) acceleration. The fetal scalp stimulators are used to improve the accelerations.
On review of a fetal monitor tracing, the nurse notes that for several contractions the
fetal heart rate decelerates as a contraction begins and returns to baseline just before it
ends. The nurse should:
1- describe the finding in the nurse's notes.
2- reposition the woman onto her side.
3- call the physician for instructions.
4-administer oxygen at 8 to 10 L/min with a tight face mask.
ANSWER: 1
An early deceleration pattern from head compression is described. No action other than
documentation of the finding is required because this is an expected reaction to
compression of the fetal head as it passes through the cervix. Repositioning the woman
onto her side would be implemented when non-reassuring or ominous changes are
noted. Calling the physician would be implemented when non-reassuring or ominous
changes are noted. Administering oxygen would be implemented when non-reassuring
or ominous changes are noted.
After monitoring the fetal heart activity, the nurse concludes that there is impaired fetal
oxygenation. What had the nurse observed in the fetal monitor to come to this
conclusion? Select all that apply.
1 Increase in the fetal heart rate (FHR) to over 160 beats/min
2 Early decelerations
3 Moderate variability
4 Late decelerations
5 Occasional variable decelerations
ANSWER: 1, 4
Tachycardia (an increase in the FHR) is the early sign of fetal hypoxemia. Prolonged
decelerations in FHR lasting for more than 2 minutes indicates the fetus is hypoxemic.
Early decelerations, moderate variability, and occasional variable decelerations in the
FHR are common observations during labor. These are normal findings and require no
intervention.
The nurse is teaching a group of nursing students regarding fetal oxygenation. The
nurse questions a student, "What happens when oxytocin levels are elevated in the
patient?" What would be the most appropriate answer given by the nursing student
related to the patient's condition?
1 "Hemoglobin levels will decrease."
2 "Blood glucose levels will increase."
3 "Placenta lowers the blood supply."
4 "Uterine contractions (UCs) will increase."
ANSWER: 4
An elevated level of oxytocin increases UCs during labor. A reduced hemoglobin level
leads to a decreased oxygen supply to the fetus but is not a complication associated
with an elevated oxytocin level. Oxytocin has no effect on the blood glucose levels. A
family history of diabetes may increase the risk for gestational diabetes in the patient.
Conditions such as hypertension in the patient may lower the blood supply to the
placenta but are not associated with oxytocin levels.
When does the nurse use the fetal scalp stimulation technique to assess the fetal scalp
pH?
1 If the patient's contractions have increased
2 If there is maternal weight loss in the last trimester
3 If fetal bradycardia is present
4 When the fetal heart rate (FHR) is within the baseline
ANSWER: 4
Fetal scalp and vibroacoustic stimulation are two stimulating methods that are used to
determine the fetal scalp blood pH. They are performed only when the fetal baseline
heart rate is within the normal range. These techniques are not suggested if there is
fetal bradycardia. These stimulation methods are related to neither the patient's weight
nor uterine contractions.
What should be the first step taken by the nurse when assessing fetal heart activity
using an ultrasound transducer?
1 Auscultate the apical heart rate of the pregnant patient.
2 Apply some conductive gel on the maternal abdomen.
3 Apply some conductive gel on the ultrasound transducer.
4 Locate the maximal intensity area of the fetal heart rate.
ANSWER: 4
Before the ultrasonic recording, the nurse should first locate the site on the abdomen
where the maximal intensity of the fetal heart rate can be assessed. This should be
done to find where the ultrasound transducer head can be placed. The apical heart rate
of the patient need not be assessed before this procedure, because this procedure
does not interfere with the cardiac activity of the pregnant patient. After finding the site
of application, the nurse can apply conductive gel on the transducer and on the
abdomen of the patient.
Which device can be used as a noninvasive way to assess the fetal heart rate (FHR) in
a patient whose membranes are not ruptured?
1 Tocotransducer
2 Spiral electrode
3 Ultrasound transducer
4 Intrauterine pressure catheter (IUPC)
ANSWER: 3
An ultrasound transducer is used to assess the FHR by an external mode of electronic
fetal monitoring. It does not require membrane rupture and cervical dilation. A
tocotransducer can be used to assess the uterine activity (UA) in a pregnant patient
whose cervix is not sufficiently dilated, but it does not assess the FHR. Spiral electrode
is used as an internal mode of electronic fetal monitoring to assess the FHR. It can be
used only when the membranes are ruptured and the cervix is dilated during the
intrapartum period. IUPC is used to assess uterine activity in internal mode. It can be
used only when the membranes are ruptured and the cervix is dilated during the
intrapartum period.
The diagnostic test reports of a pregnant patient reveal a baseline fetal heart rate of 175 beats/min.
What does this finding indicate to the nurse?
1 Presence of fetal ischemia
2 Fetal tachycardia
3 Fetal bradycardia
4 Hypotension in the fetus
ANSWER: 2
The normal baseline fetal heart rate ranges from 110 to 160 beats/min. If the fetal heart
rate is more than 160 beats/min, then tachycardia in the fetus is indicated. Ischemia is
a condition in which there is a reduced blood supply to the fetal tissues. Baseline heart
rate below 110 beats/min indicates bradycardia in fetus. Hypotension indicates a blood
pressure level below 120/80 mm Hg, which is a life-threatening condition for the fetus.
When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that:
1 the examiner's hand should be placed over the fundus before, during, and after contractions.
2 the frequency and duration of contractions are measured in seconds for consistency.
3 contraction intensity is given a judgment number of 1 to 7 by the nurse and patient together.
4 the resting tone between contractions is described as either placid or turbulent.
ANSWER: 1
The assessment includes palpation; duration, frequency, intensity, and resting tone.
The duration of contractions is measured in seconds; the frequency is measured in
minutes. The intensity of contractions usually is described as mild, moderate, or strong.
The resting tone usually is characterized as soft or relaxed.
After observing the reports of the umbilical cord acid-base determination test, the nurse informs the
patient that the newborn's condition is normal. Which value indicates the normal condition of the
newborn?
1 Umbilical artery: pH, 7.1; Pco2, 50 mm Hg; Po2, 20 mm Hg
ANSWER: 4
In the umbilical cord acid-base stimulation method, arterial values indicate the condition
of the newborn. Arterial blood pH of 7.2 to 7.3, carbon dioxide pressure (Pco2) value of
45 to 55 mm Hg, and oxygen pressure (Po2) value of 15 to 25 mm Hg approximately
indicates the normal fetal condition. Therefore pH of 7.3, Pco2 of 45 mm Hg, and Po2
of 25 mm Hg represent the normal fetal condition. Arterial blood pH of 7.1, Pco2 of 50
mm Hg, and Po2 of 20 mm Hg indicate that the fetus may have respiratory acidosis.
Arterial blood pH of 7.4 is indicative of fetal alkalosis.
While assessing a pregnant patient using a fetoscope, the nurse also palpates the abdomen of the
patient. What is the purpose of palpating the abdomen of the patient?
1 Detection of fetal heart rate deceleration
2 Evaluation of the severity of the pain caused by active labor
3 Assessment of pain from pressure applied by the fetoscope
4 Assessment of changes in fetal heart rate during and after contraction
ANSWER: 4
While assessing the fetal heart rate (FHR) with a fetoscope, the nurse palpates the
abdomen of the fetus to evaluate uterine contractions (UCs). This is done to detect any
changes in the FHR during and after UCs. FHR decelerations are not identified by
palpating the abdomen. It is assessed using the electronic fetal monitoring system.
Pain perception is a subjective assessment. Moreover, the pressure from the fetoscope
is very minimal and does not cause pain.
The primary health care provider has administered terbutaline (Brethine) to a pregnant patient to
postpone preterm labor. What changes would the nurse observe in the fetal heart monitor after this
drug was administered?
1 Increase in fetal heart rate
2 Decrease in fetal heart rate
3 Accelerations in heart rate
4 Decelerations in heart rate

ANSWER: 1
Terbutaline (Brethine) is usually prescribed to postpone labor, because the drug
reduces the frequency of uterine contractions. Terbutaline (Brethine) can also increase
the fetal heart rate (FHR). Terbutaline (Brethine) does not decrease the heart rate, nor
does it cause any accelerations or decelerations in the FHR. Heart block or viral
infections can decrease the FHR and may result in bradycardia. There may be
accelerations in the FHR during a vaginal examination. A parasympathetic response
may cause decelerations in heart rate. Terbutaline is a sympathomimetic drug and thus
does not cause decelerations in FHR.
The charge nurse instructed a group of student nurses about the monitoring of uterine activity (UA)
during labor. Which statement by the student nurse is accurate regarding the calculation of
Montevideo units? "They can be calculated:
1 Using a spiral electrode monitoring device."
2 Using a tocotransducer monitoring system."
3 Using an ultrasound transducer machine."
4 With an intrauterine pressure catheter (IUPC)."
ANSWER: 4
Montevideo units can only be calculated using the internal monitoring of UA. An
intrauterine pressure catheter (IUPC) monitors UA internally. Therefore Montevideo
units can only be calculated using the IUPC. Spiral electrode monitoring is used for
assessing the fetal heart rate (FHR), not UA internally. The tocotransducer monitoring
system is used to monitor the UA externally. An ultrasound transducer is also used to
monitor the FHR externally.
The nurse is assisting a pregnant patient in labor. What instructions should the nurse give to the
patient to promote comfort? Select all that apply.
1 "You should cough frequently."
2 "Breathe with your mouth open."
3 "Lie down in the lateral position."
4 "Lie in the supine position in bed."
5 "Lie in the semi-Fowler position."
ANSWER: 2, 3, 5
The nurse helps the pregnant patient during labor. This includes teaching the patient
relaxation techniques. The nurse teaches the patient to keep the mouth open during
exhalation to allow air to easily leave the lungs. Placing the patient in a semi-Fowler or
lateral position is helpful during labor. Therefore the nurse should instruct the patient to
maintain a lateral or semi-Fowler position with a lateral tilt. Asking the patient to cough
frequently would increase intraabdominal pressure of the patient and would make the
patient uncomfortable. Having the patient lie down in a supine position during labor
may cause orthostatic hypotension. Therefore the nurse should instruct the patient to
lie down in a position other than supine.
The nurse administers an amnioinfusion to a pregnant patient according to the primary health care
provider's (PHP's) instructions. What is the reason behind the PHP's instructions?
1 Late decelerations
2 Early decelerations
3 Variable decelerations
4 Prolonged decelerations

ANSWER: 3
Variable decelerations in the fetal heart rate (FHR) are observed when the umbilical
cord is compressed. An amnioinfusion refers to the infusion of isotonic fluid into the
uterine cavity when the amniotic fluid levels are decreased. This intervention is usually
done for the prevention of umbilical cord compression. Late decelerations are observed
when infections or elevated uterine contractions (UCs) are seen in a patient. This
condition will be reversed by maintaining an I.V. solution, but aminoinfusion is not
administered. Early deceleration in the FHR is a normal sign that does not require any
intervention. Prolonged deceleration of the FHR occurs when there is a marked
reduction of the fetal oxygen supply.
While assessing a pregnant patient who is in labor, the nurse observes W-shaped waves on the
fetal heart rate (FHR) monitor. What would the nurse infer from this observation?
1 Placental abruption
2 Dilated cervical layers
3 Umbilical cord compression
4 Elevated uterine contractions
ANSWER: 3
W-shaped waves in the FHR monitor are indicative of variable decelerations in the
FHR. Variable decelerations are seen when the umbilical cord is compressed at the
time of labor. Placental abruption and dilated cervical layers do not cause variable
decelerations but may cause late decelerations. Similarly, increased rate of uterine
contractions may also cause late decelerations in FHR.
The nurse instructs a pregnant patient to breathe through the mouth and keep it open while pushing
during labor. What is the rationale for this nursing intervention?
1 To avoid nasal congestion in the patient
2 To decrease the efforts required for pushing
3 To facilitate increased oxygen to the fetus
4 To avoid deceleration in the fetal heart rate
ANSWER: 3
During labor, the nurse asks the patient to breathe through the mouth to keep the
mouth open to increase both maternal and fetal oxygenation. Nasal congestion is not a
complication associated with labor. Opening of the mouth does not increase the
pushing capability. Early decelerations are observed by pushing which does not require
any intervention.
While monitoring the fetal heart rate (FHR), the nurse instructs the patient to change positions and
lie in the knee-to-chest position. What is the reason for the nurse to give this instruction to the
patient?
1 Late decelerations in the FHR
2 Variable decelerations in the FHR
3 Early decelerations in the FHR
4 Prolonged decelerations in the FHR
ANSWER: 2
Variable decelerations in the FHR are usually caused by umbilical cord compression.
The knee-to-chest position is useful for relieving cord compression, and thus the nurse
should ask the patient to move into this position. Prolonged decelerations in the FHR

are not affected by the mother's position. If the nurse finds late decelerations in the
FHR, the nurse should ask the mother to lie in the lateral position. Early decelerations
in the FHR are a normal finding, and no nursing intervention is required.
A nurse caring for a woman in labor understands that increased variability of the fetal
heart rate might be caused by:
1 narcotics.
2 barbiturates.
3 methamphetamines.
4 tranquilizers.
ANSWER: 3
The use of illicit drugs (such as cocaine or methamphetamines) might cause increased
variability . Maternal ingestion of narcotics may be the cause of decreased variability.
The use of barbiturates may also result in a significant decrease in variability as these
are known to cross the placental barrier. Tranquilizer use is a possible cause of
decreased variability in the fetal heart rate.
Fetal monitoring of a pregnant patient revealed that the fetal heart rate has minimal variability.
Which prescribed drug is most likely responsible for the condition?
1 Hydroxyzine (Vistaril)
2 Terbutaline (Brethine)
3 Secobarbital (Seconal)
4 Atropine (Sal-Tropine)
ANSWER: 3
Variability in the fetal heart rate can be classified as absent, mild, or moderate
variability. This results in hypoxia and metabolic acidemia in the fetus. Central nervous
system (CNS) depressants, such as secobarbital (Seconal), cause variability in the
fetal heart rate. This medication affects the baseline heart rate in the fetus by less than
5 beats/min. Hydroxyzine (Vistaril), terbutaline (Brethine), and atropine (Sal-Tropine)
may result in tachycardia in the fetus. These drugs can increase the baseline fetal heart
rate as much as 25 beats/min.
After observing the electronic fetal monitor, a primary health care provider asks the nurse to conduct
an electrocardiogram (ECG) of the fetus. What should the nurse assess before obtaining an ECG of
the fetus? Select all that apply.
1 Fetal lactate levels
2 Placental membranes
3 Cervical dilation
4 Umbilical cord compression
5 Frequency of uterine contractions
ANSWER: 2, 3
When performing the ECG of the fetus, the nurse should insert the electrode into the
cervix to reach the fetus. Therefore the nurse should check if the cervix is dilated up to
3 cm and if the membranes are ruptured. This allows the nurse to reach the fetus's
position. Lactate levels do not affect the ECG testing and thus need not be checked
before the test. Umbilical cord compression or decreased frequency of UCs is not the
required conditions for performing an ECG on the fetus.

The primary health care provider has administered general anesthesia to a patient who is scheduled
for an elective cesarean section. What changes should the nurse observe in the fetal heart rate
(FHR) after the administration of general anesthesia?
1 Decrease
2 Increase
3 Minimal variability
4 Moderate variability
ANSWER: 3
It is necessary to monitor the FHR in the pregnant patient who is given general
anesthesia. General anesthesia usually causes minimal variability or no change in the
FHR. Tachycardia is caused by fetal hypoxemia, whereas bradycardia is caused from a
structural defect in the fetal heart. Moderate variability in the FHR indicates normal fetal
activity.
After reviewing the umbilical cord acid-base report, the nurse confirms that the fetus has respiratory
acidosis. Which reading is consistent with the nurse's conclusion?
1 A base deficit value ≥12 mmol/L
2 Blood glucose levels = 120 mg/dL
3 Arterial pH >7.20
4 Partial pressure carbon dioxide >55 mm Hg
ANSWER: 4
If pH 2 >55 mm Hg (elevated), and base deficit value respiratory acidosis. In this case,
the partial pressure carbon dioxide >55 mm Hg is indicative of respiratory acidosis. A
pH >7.20 and base deficit value ≥12 mmol/L are all considered normal. Blood glucose
level is not a part of this acid-base report.
Fetal well-being during labor is assessed by:

1 the response of the fetal heart rate (FHR) to uterine contractions (UCs).
2 maternal pain control.
3 accelerations in the FHR.
4 an FHR greater than 110 beats/min
ANSWER: 1
Fetal well-being during labor is measured by the response of the FHR to UCs . In
general, reassuring FHR patterns are characterized by an FHR baseline in the range of
110 to 160 beats/min with no periodic changes, a moderate baseline variability, and
accelerations with fetal movement. Maternal pain control is not the measure used to
determine fetal well-being in labor. Although FHR accelerations are a reassuring
pattern, they are only one component of the criteria by which fetal well-being is
assessed. Although an FHR greater than 110 beats/min may be reassuring, it is only
one component of the criteria by which fetal well-being is assessed. More information is
needed to determine fetal well-being.
Test-Taking Tip: Being emotionally prepared for an examination is key to your success.
Proper use of this text over an extended period of time ensures your understanding of
the mechanics of the examination and increases your confidence about your nursing
knowledge. Your lifelong dream of becoming a nurse is now within your reach! You are
excited, yet anxious. This feeling is normal. A little anxiety can be good because it
increases awareness of reality; but excessive anxiety has the opposite effect, acting as
a barrier and keeping you from reaching your goal. Your attitude about yourself and
your goals will help keep you focused, adding to your strength and inner conviction to
achieve success.
The nurse observes variable decelerations in fetal heart rate (FHR) while assessing a pregnant
patient with oligohydramnios. What medication should be immediately given to the patient?
1 Oxytocin (Pitocin)
2 Terbutaline (Brethine)
3 Phenylephrine (Endal)
4 Lactated Ringer's solution
ANSWER: 4
Oligohydramnios is a condition that may cause umbilical cord compression and results
in variable decelerations in the FHR. Usually lactated Ringer's or normal saline solution
can be administered into the umbilical cord to increase the amniotic fluid volume and
normalize fetal heart activity. Terbutaline (Brethine) is a uterine relaxant. It is mostly
used to reduce uterine tachysystole. The nurse can administer phenylephrine (Endal) if
other measures are unsuccessful in improving maternal hypotension. Oxytocin (Pitocin)
is a uterine stimulant to induce labor. It is not used to reduce the umbilical cord
compression.
The nurse assesses the fetal heart rate (FHR) of a pregnant patient and finds minimal FHR
variability. The nurse reassesses the patient 30 minutes later and finds moderate variability. What
should the nurse infer?
1 No acceleration
2 Late deceleration
3 Baseline heart rate is 150 beats/min
4 Baseline heart rate is 180 beats/min
ANSWER: 3
If the nurse notes minimal FHR variability, the nurse should reassess the heart rate to
determine a pattern. If in 30 minutes the nurse notices moderate variability, the fetus
may be in a sleep state. The nurse would further confirm after half an hour and report it
as moderate variability, where the heart rate baseline is confirmed as normal (110-160
beats/min). Heart rate variability is a characteristic of the baseline FHR and does not
include accelerations or decelerations of the FHR. A fetal baseline heart rate of 180
beats/min is considered severe variability.
The nurse has a prescription to obtain a blood sample from a patient to determine fetal lactate
levels. What information should the nurse provide to the patient before the procedure?
1 "There is an increased risk for postpartum hemorrhage."
2 "There may be a need to reconduct the diagnostic test."
3 "There is an increased risk for requiring a cesarean birth."
4 "There will be a small incision on the scalp of the newborn."
ANSWER: 4
The fetal blood is collected by making a small incision on the fetal scalp, which is
visible in the newborn. This might be disturbing to the patient, but the nurse should help
the patient understand the purpose of the test. Postpartum hemorrhage or increased
risk for cesarean birth is not associated with this procedure. The test has to be
conducted only once, and it does not have to be reconducted.
END OF COMPILATION PART 1

Quizlet Compilation (Part 1) : Philippine Nurse Licensure Examination

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Quizlet Compilation (Part 1) : Philippine Nurse Licensure Examination

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QUIZLET COMPILATION

Compiled by: Raymundo III D. Doce

(B) Polio is caused by a virus that attacks the

(A) and (B) are both contraindicated with pregnancy.

(D) All of the others can cause urine

Compiled by: Raymundo III D. Doce

(A) Corgard could be removed from the

(D) IgG is the only immunoglobulin that can

(B) AZT treatment is the most critical

(C) Autonomic neuropathy can cause inability

(B) All of the clinical signs and systems point

(B) Hypercalcaemia can cause polyuria,

(C) Rho gam prevents the production of anti-

(D) The effects of PKU stay with the infant

(D) Aspirin overdose can lead to metabolic

(D) This patient's safety is your primary

(C) The bronchodilator will allow a more productive cough.

C) The skin would be dry and not oily.

(A) Streptokinase is a clot busting drug and the

(A) Green vegetables and liver are a great

(D) Cl. difficile has not been linked to

(D) RBC's last for 120 days in the body.

(B) Discharge education begins upon admit.

(B) Initiative vs. guilt- 3-6 years old

(C) Autonomy vs Shame - 12-18 months old

(D) Intimacy vs. isolation- 18-35 years old

(B) HR and Respirations are slightly increased. BP is down.

(A) Elavil is a tricyclic antidepressant.

(D) Erythromycin is used to treat conditions A-

(D) Answer choices A-C were symptoms of

(C) Weight loss would be expected.

(A) Loss of appetite would be expected.

(D) Choice A is linked to Plague, Choice B is

(A) Choice B is linked to Rheumatic fever,

(D) A CT scan would be performed for further

Compiled by: Raymundo III D. Doce

(C) Blood cultures would be performed to

A) With a history of diabetes, the first response

(C) Age is not the greatest factor in potty training.

(C) The poison control center will have an

(C) Vastus lateralis is the most appropriate

(D) In this case you are able to determine the name of

(D) These skills generally develop between 10-

(A) Hypertension is often related renal failure.

(D) Flaccid paralysis is an indication of

Compiled by: Raymundo III D. Doce

(D) Hyperventilation occurs with metabolic

(D) Tachypnea is associated with respiratory

A nurse is reviewing a patient's medication list. The drug Pentoxifylline

Compiled by: Raymundo III D. Doce

(D) Bumex is considered a loop dieuretic.

(A) Orthopnea is a left- sided heart failure

(C) Aldactone (Spironolactone) is considered a

A nurse is reviewing a patient's medication. The patient is taking

(C) Digoxin decreases venous pressure.

(D) All the others are high in potassium.

(C) Ventricular rhythm may be premature with

Compiled by: Raymundo III D. Doce

(A) Appendicitis is most likely indicated in this

(D) A hernia is the most likely indicated in this

(D) Penothiazines are considered a risk factor

(C) Rifampicin would be used in this case.

A patient has recently been diagnosed with hypernatremia. Which of