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1. Bryce is a child diagnosed with coarction of aorta while assessing him, Nurse Liza
would expect to find which of the following?
a. Squatting posture
b. Absent or diminished femoral pulses
c. Severe cyanosis at birth
d. Cyanotic “Tet” episodes
Rationale: B absent or diminished femoral pulse is a classic characteristic of coarction of
aorta. C severe cyanosis at birth is seen in such defects as transposition of the great vessels.
A & D Tet episodes and squatting are characteristics of tetralogy of fallot.
2. Mr. and Mrs. Baker's only daughter is diagnosed with heart failure. Which of the
following interventions would be appropriate to promote optimal nutrition for the
infant?
a. Replacing regular nipples with easy-to-suck ones
b. Allowing the infant to feed for at least 1 hour
c. Providing large feedings evenly spaced every 4 hours
d. Offering formula that is high is sodium and calories
Rationale: A: The nurse should replace regular nipples with easy-to-suck-ones because the
infant may tire instantly with regular nipples and thus would not be able to suck sufficiently.
B, C: Also to prevent tiring, small frequent feedings lasting no more than 45 minutes, rather
than large evenly spaced feedings or ones lasting longer than 1 hour, should be given. D:
Typically, the infant receives a low-sodium, high-calorie diet.
3. Appropriate intervention is a vital for many children with heart disease in order to
go on to live active, full lives. Which of the following outlines an effective nursing
intervention to decrease cardiac demands and minimize cardiac workload?
a. Feeding the infant over long periods
b. Allowing the infant to have her way to avoid conflict
c. Scheduling care to provide uninterrupted rest periods.
d. Developing and implementing a consistent care plan.
Rationale: C organizing care to provide for uninterrupted periods of sleep reduces cardiac
demands. A, a feeding time should be restricted to a maximum of 45 minutes or discontinued
sooner if the infant tires. B, in an attempt to get her own way, the child may cry. Excessive
crying should be limited; however appropriate limit settings should be observed. D,
developing and implementing a consistent care plan can be important, but it is not related to
decreasing cardiac demands or workload.
4. A 36-year-old patient with a history of seizures and medication compliance of
phenytoin (Dilantin) and carbamazepine (tegretol) is brought to the ED by the MS
personnel for repetitive seizure activity that started 45 minutes prior to arrival. You
anticipate that the physician will order which drug for status epilepticus?
a. PO phenytoin and carbamazepine
b. IV lorazepam (Ativan)
c. IV carbamazepam
d. IV magnesium sulfate
Rationale: IV lorazepam (Ativan) is the drug of choice for status epilepticus, tegretrol is
used in the management of generalized tonic-clonic, absence or mixed type seizures, but it
does not come in an IV form. PO (per os) medications are inappropriate for this emergency
situation. Magnesium sulfate is given to control seizures in toxemia of pregnancy.
5. A 2-year-old is admitted in the pediatric unit. He is diagnosed with febrile seizures.
In preparing for his admissions, which of the following is the most important
nursing action?
a. Order a stat admission CBC
b. Place a urine collection bag and specimen cup at the bedsides
1
MISSION
“MABINI COLLEGES provides quality instruction, research and
VISION MABINI COLLEGES, INC. extension service programs at all educational levels as its
“MABINI COLLEGES shall cultivate a monumental contribution to national and global growth and
CULTURE of EXCELLENCE in education.” Governor Panotes Avenue, development.
Daet, Camarines Norte Specifically, it transforms students into:
1. God – fearing
Tel. no. (054) 721-1281 local 109 2. Nation – loving
mabinicollege@hotmail.com 3.
4. Earth caring
5. Productive, and
6. Locally and Globally competitive persons
7.
7. A male client is having a tonic-clonic seizures. What should the nurse do first?
a. Elevate the head of the bed
b. Restrain the clients arms and legs
c. Place tongue blade in the client’s mouth
d. Take measures to prevent injury
Rationale: Protecting the client from injury is the immediate priority during a seizure.
Elevating the head of the bed would have no effect on the client’s condition or safety.
Restraining the client’s arms and legs could cause injury. Placing a tongue blade or other
object in the client’s mouth could damage the teeth.
8. The emergency room nurse admits a child who experienced seizure at school. The
father comments that this is the first occurrence, and denies any family history of
epilepsy. What is the best response by the nurse?
a. “Do not worry epilepsy can be treated with medications.”
b. “The seizure may or may not mean your child has epilepsy.”
c. “Since this was the first convulsions, it may not happen again.”
d. “Long term treatment will prevent future seizures.”
Rationale: The seizure may or may not mean your child has epilepsy. There are many
possible causes of child seizures. These include fever, central nervous system conditions,
trauma, metabolic alterations and idiopathic (unknown).
9. A client is brought to the emergency department having experienced blood loss due
to a deep puncture wound. A 3-unit fresh frozen plasma (FFP) is ordered. The nurse
determines that the reason behind this order is to.
a. Provide clotting factors and volume expansion.
b. Increase hemoglobin, hematocrit, and neutrophil levels
c. Treat platelet dysfunction
d. Treat thrombocytopenia
Rationale: fresh frozen plasma may be used to provide clotting factors or volume
expansion. It is rich in clotting factors and be thawed quickly and transfused right away.
Option B is incorrect since it will not specifically increase the hemoglobin, hematocrit and
neutrophil level. Options C and D are incorrect since FFP does not contain any platelet.
2
MISSION
“MABINI COLLEGES provides quality instruction, research and
VISION MABINI COLLEGES, INC. extension service programs at all educational levels as its
“MABINI COLLEGES shall cultivate a monumental contribution to national and global growth and
CULTURE of EXCELLENCE in education.” Governor Panotes Avenue, development.
Daet, Camarines Norte Specifically, it transforms students into:
1. God – fearing
Tel. no. (054) 721-1281 local 109 2. Nation – loving
mabinicollege@hotmail.com 3.
4. Earth caring
5. Productive, and
6. Locally and Globally competitive persons
7.
10. Nurse Rochelle is caring for a client with severe blood loss who is prescribed with
multiple transfusion of blood. Nurse Rochelle obtains which most essential piece of
equipment to prevent the risk of cardiac dysrhythmias?
a. Cardiac monitor
b. Blood warmer
c. ECG machine
d. Infusion pump
Rationale: Rapid transfusion of cool blood put the client at risk for cardiac dysrhythmias. A
and C are used for any blood transfusion complication but they do not prevent the
occurrence of cardiac dysrhythmia. Option D is not beneficial in this case since the infusion
must be given rapidly.
11. Nurse liza is administering a 2 unit packed RBC’s on a client with a low hemoglobin.
The nurse will prepare which of the following in order to transfuse blood.
a. Microfusion set
b. Polyvol pro burette set.
c. Photofusion set
d. Tubing with an in-line filter
Rationale: The in-line filter helps ensure that any particles larger than the size of the filter
are caught in the filter and are not infused with the client. Option A is incorrect since the
tubing that should be used is micro drip. Option B is used for administration of IV
medication infusion. Option C is incorrect since blood does not need any protection from
light.
12. After terminating the transfusion during a reaction, which action should the nurse
immediately be taken next?
a. Run a solution of 5% dextrose in water.
b. Run normal saline at a keep-vein-open rate.
c. Remove the IV line.
d. Fast drip 200ml normal saline.
Rationale: The nurse will infuse normal saline at a KVO rate to keep the patency of the IV
line while waiting for further orders from the physician. Option A: IV solution containing
dextrose will hemolyze the red cells. Option C: The nurse will not remove the IV line
because then there would be no IV access route. Option D: Doing a fast drip will potentially
lead to congestion and is not done without the physician order.
13. To verify the age of blood cells in a blood, the nurse will check which of the
following:
a. Blood type
b. Blood group
c. Blood identification number
d. Blood expiration Date
Rationale: The safe storage of blood usually takes 35 days. Examining the expiration date
is an important responsibility of a nurse prior hanging the blood.
14. A client is receiving a platelet transfusion. The nurse determines that the client is
gaining from this therapy if the client exhibits which of the following?
a. Less frequent febrile episodes.
b. Increased level of hematocrit.
c. Less episodes of bleeding.
d. Increased level of hemoglobin.
Rationale: Platelet transfusions may be given to prevent bleeding when the platelet count
falls down. Option A: A decline in the febrile episode will happen after the transfusion of
agranulocytes. Options B and D: An increased level of hemoglobin and hematocrit will
happen after the transfusion of red blood cells.
3
MISSION
“MABINI COLLEGES provides quality instruction, research and
VISION MABINI COLLEGES, INC. extension service programs at all educational levels as its
“MABINI COLLEGES shall cultivate a monumental contribution to national and global growth and
CULTURE of EXCELLENCE in education.” Governor Panotes Avenue, development.
Daet, Camarines Norte Specifically, it transforms students into:
1. God – fearing
Tel. no. (054) 721-1281 local 109 2. Nation – loving
mabinicollege@hotmail.com 3.
4. Earth caring
5. Productive, and
6. Locally and Globally competitive persons
7.
15. The removal of entire breast, pectoralis major and minor muscles and neck lymph
nodes which is followed by skin grafting is a procedure called:
a. Simple mastectomy
b. Modified radical mastectomy
c. Radiation therapy
d. Radical mastectomy
Rationale: Halstead surgery also called radical mastectomy involves the removal of entire
breast, pectoralis major and minor muscles and neck lymph nodes. It is followed by skin
grafting. Removal of the entire breast, pectoralis major muscle and the axillary lymph
nodes is a surgical procedure called modified radical mastectomy. Simple mastectomy is
the removal of the entire breast but the pectoralis muscles and nipples remain intact.
16. The classic symptoms that define breast cancer includes the following except.
a. “pink peel’ skin
b. Solitary, irregularly shaped mass
c. Firm, nontender, nonmobile mass
d. Abnormal discharge from the nipple
Rationale: classic symptoms that define breast cancer includes: Firm, nontender,
nonmobile mass. Adherence to muscle or skin causing dimpling effect involvement of the
upper outer quadrant or central nipple portion. Asymmetry of the breast. “orange peel”
skin. Retraction of nipple. Abnormal discharge from nipple.
17. Surgical procedure to treat breast cancer involves the removal of the entire breast,
pectoralis major muscle and the axillary lymph nodes is:
a. Simple mastectomy
b. Modified radical mastectomy
c. Halstead surgery
d. Radical mastectomy
Rationale: removal of the entire breast, pectoralis major muscle and the axillary lymoh
nodes is a surgical procedure called modified radical mastectomy. Simple mastectomy is
the removal of the entire breast but the pectoralis muscles and nipples remain intact.
Halstead surgery also called radical mastectomy involves the removal of entire breast,
pectoralis major and minor muscles and neck lymph nodes. It is followed by skin grafting.
18. The nurse is caring for a patient newly diagnosed with HIV. The patient asks what
would determine the actual development of AIDS. The nurse’s response is based on
the knowledge that what is a diagnostic criterion for AIDS?
a. Presence of HIV antibodies
b. CD4⁺T cell count below 200/𝝻l
c. Presence of oral hairy leukoplakia
d. White blood cell count below 5000/𝝻l
Rationale: diagnostic criteria for AIDS include a CD4⁺T cell count below 200/𝝻l and/or the
development of specified opportunistic infections,cancers,wasting syndrome, or dementia.
The other options may be found in patients with HIV disease but do not define the
advancement of HIV infection to AIDS.
19. When teaching a patient infected with HIV regarding transmission of the virus to
others, which statement made by the patient would indicate a need for further
teaching?
a. “I will need to isolate any tissues I use as not to infect my family.”
b. “I will notify all of my sexual partners so they can get tested for HIV.”
c. “Unprotected sexual contact is the most common mode of transmission.”
d. “I do not need to worry about spreading this virus to others by sweating at the
gym.”
Rationale: HIV is not spread casually. The virus cannot be transmitted through hugging,
dry kissing, shaking hands, sharing eating utensils, using toilet sets or attending school
4
MISSION
“MABINI COLLEGES provides quality instruction, research and
VISION MABINI COLLEGES, INC. extension service programs at all educational levels as its
“MABINI COLLEGES shall cultivate a monumental contribution to national and global growth and
CULTURE of EXCELLENCE in education.” Governor Panotes Avenue, development.
Daet, Camarines Norte Specifically, it transforms students into:
1. God – fearing
Tel. no. (054) 721-1281 local 109 2. Nation – loving
mabinicollege@hotmail.com 3.
4. Earth caring
5. Productive, and
6. Locally and Globally competitive persons
7.
with an HIV-infected person. It is not transmitted through tears, saliva, urine, sputum, feces
or sweat.
20. A widely used laboratory that measures HIV-RNA test and tracks the bodys
response to HIV infection is the:
a. CD4/CD8 ratio
b. EIA test
c. Viral load test
d. Western blot
Rationale: viral load test measures plasma. A CD4/CD8 ratio measures the number of CD4
T cells in the body. EIA test identifies antibodies directed specifically against HIV. Western
Blot is used to confirm seropositivity when the EIA result is positive.
21. The nurse is instructing an unlicensed health care worker on the care of the client
with HIV who also has active genital herpes. Which statement by the health care
worker indicates effective teaching of standard precautions?
A) ''I need to know my HIV status, so I must get tested before caring for any clients."
B) ''Putting on a gown and gloves will cover up the itchy sores on my elbows.''
C) ''Washing my hands and putting on a gown and gloves is what I must do
before starting care.''
D) ''I will wash my hands before going into the room, and then put on gown and
gloves only for direct contact with the client's genitals."
Rationale: Washing my hands and putting on a gown and gloves is what I must do before
starting care.'' Standard precautions include whatever personal protective equipment
(PPE) is necessary for the prevention of transmission of HIV and genital herpes.
22. Which interventions does the home health nurse teach to family members to reduce
confusion in the client diagnosed with AIDS dementia? (Select all that apply.)
A) ''Do you think that I could post a sign on your bedroom door for everyone about
5
MISSION
“MABINI COLLEGES provides quality instruction, research and
VISION MABINI COLLEGES, INC. extension service programs at all educational levels as its
“MABINI COLLEGES shall cultivate a monumental contribution to national and global growth and
CULTURE of EXCELLENCE in education.” Governor Panotes Avenue, development.
Daet, Camarines Norte Specifically, it transforms students into:
1. God – fearing
Tel. no. (054) 721-1281 local 109 2. Nation – loving
mabinicollege@hotmail.com 3.
4. Earth caring
5. Productive, and
6. Locally and Globally competitive persons
7.
Rationale: More assessment of the patient's psychosocial status is needed before taking
any other action. The statements, "Thinking about dying will not improve the course of
AIDS" and "It is important to focus on the good things in life" discourage the patient from
sharing any further information with the nurse and decrease the nurse's ability to develop
a trusting relationship with the patient. Although antidepressants may be helpful, the initial
action should be further assessment of the patient's feelings.
25. What is the contagious period for a MERS-CoV infection?
a. The time that a sick animal or human is infectious
b. The time between infection and start of symptoms
c. The time when signs and symptoms appears.
d. unknown but may last as long as virus is being shed.
Rationale: The contagious period (the time that a sick animal or human is
infectious) for MERS-CoV is not known but may last as long as virus is being shed.
6
MISSION
“MABINI COLLEGES provides quality instruction, research and
VISION MABINI COLLEGES, INC. extension service programs at all educational levels as its
“MABINI COLLEGES shall cultivate a monumental contribution to national and global growth and
CULTURE of EXCELLENCE in education.” Governor Panotes Avenue, development.
Daet, Camarines Norte Specifically, it transforms students into:
1. God – fearing
Tel. no. (054) 721-1281 local 109 2. Nation – loving
mabinicollege@hotmail.com 3.
4. Earth caring
5. Productive, and
6. Locally and Globally competitive persons
7.
Directions. Read carefully the questions and write the correct answer before the number.
1. Bryce is a child diagnosed with coarction of aorta while assessing him, Nurse
Liza would expect to find which of the following?
a. Squatting posture
b. Absent or diminished femoral pulses
c. Severe cyanosis at birth
d. Cyanotic “Tet” episodes
2. Mr. and Mrs. Baker's only daughter is diagnosed with heart failure. Which of
the following interventions would be appropriate to promote optimal nutrition for
the infant?
a. Replacing regular nipples with easy-to-suck ones
b. Allowing the infant to feed for at least 1 hour
c. Providing large feedings evenly spaced every 4 hours
d. Offering formula that is high in sodium and calories
6.A neurological consult has been ordered for a pediatric client with suspected petit
mal seizures can be expected to have?
a. Short abrupt muscle contraction
b. Quick, bilateral severe jerking movements
c. Abrupt loss of muscle tone
d. A brief lapse in consciousness
7
MISSION
“MABINI COLLEGES provides quality instruction, research and
VISION MABINI COLLEGES, INC. extension service programs at all educational levels as its
“MABINI COLLEGES shall cultivate a monumental contribution to national and global growth and
CULTURE of EXCELLENCE in education.” Governor Panotes Avenue, development.
Daet, Camarines Norte Specifically, it transforms students into:
1. God – fearing
Tel. no. (054) 721-1281 local 109 2. Nation – loving
mabinicollege@hotmail.com 3.
4. Earth caring
5. Productive, and
6. Locally and Globally competitive persons
7.
8. The emergency room nurse admits a child who experienced seizure at school.
The father comments that this is the first occurrence, and denies any family history
of epilepsy. What is the best response by the nurse?
a. “Do not worry epilepsy can be treated with medications.”
b. “The seizure may or may not mean your child has epilepsy.”
c. “Since this was the first convulsions, it may not happen again.”
d. “Long term treatment will prevent future seizures.”
10. Nurse Rochelle is caring for a client with severe blood loss who is prescribed
with multiple transfusion of blood. Nurse Rochelle obtains which most essential
piece of equipment to prevent the risk of cardiac dysrhythmias?
a. Cardiac monitor
b. Blood warmer
c. ECG machine
d. Infusion pump
11. Nurse liza is administering a 2 unit packed RBC’s on a client with a low
hemoglobin. The nurse will prepare which of the following in order to transfuse
blood.
a. Microfusion set
b. Polyvol pro burette set.
c. Photofusion set
d. Tubing with an in-line filter
12. After terminating the transfusion during a reaction, which action should the
nurse immediately be taken next?
a. Run a solution of 5% dextrose in water.
b. Run normal saline at a keep-vein-open rate.
c. Remove the IV line.
d. Fast drip 200ml normal saline.
13. To verify the age of blood cells in a blood, the nurse will check which of the
following:
a. Blood type
b. Blood group
c. Blood identification number
d. Blood expiration Date
14. A client is receiving a platelet transfusion. The nurse determines that the
client is gaining from this therapy if the client exhibits which of the following?
a. Less frequent febrile episodes.
b. Increased level of hematocrit.
c. Less episodes of bleeding.
d. Increased level of hemoglobin.
8
MISSION
“MABINI COLLEGES provides quality instruction, research and
VISION MABINI COLLEGES, INC. extension service programs at all educational levels as its
“MABINI COLLEGES shall cultivate a monumental contribution to national and global growth and
CULTURE of EXCELLENCE in education.” Governor Panotes Avenue, development.
Daet, Camarines Norte Specifically, it transforms students into:
1. God – fearing
Tel. no. (054) 721-1281 local 109 2. Nation – loving
mabinicollege@hotmail.com 3.
4. Earth caring
5. Productive, and
6. Locally and Globally competitive persons
7.
15. The removal of entire breast, pectoralis major and minor muscles and neck
lymph nodes which is followed by skin grafting is a procedure called:
a. Simple mastectomy
b. Modified radical mastectomy
c. Radiation therapy
d. Radical mastectomy
16. The classic symptoms that define breast cancer includes the following except.
a. “pink peel’ skin
b. Solitary, irregularly shaped mass
c. Firm, nontender, nonmobile mass
d. Abnormal discharge from the nipple
17. Surgical procedure to treat breast cancer involves the removal of the entire
breast, pectoralis major muscle and the axillary lymph nodes is:
a. Simple mastectomy
b. Modified radical mastectomy
c. Halstead surgery
d. Radical mastectomy
18. The nurse is caring for a patient newly diagnosed with HIV. The patient asks
what would determine the actual development of AIDS. The nurse’s response is
based on the knowledge that what is a diagnostic criterion for AIDS?
a. Presence of HIV antibodies
b. CD4⁺T cell count below 200/𝝻l
c. Presence of oral hairy leukoplakia
d. White blood cell count below 5000/𝝻l
19. When teaching a patient infected with HIV regarding transmission of the
virus to others, which statement made by the patient would indicate a need for
further teaching?
a. “I will need to isolate any tissues I use as not to infect my family.”
b. “I will notify all of my sexual partners so they can get tested for HIV.”
c. “Unprotected sexual contact is the most common mode of transmission.”
d. “I do not need to worry about spreading this virus to others by sweating at
the gym.”
20. A widely used laboratory that measures HIV-RNA test and tracks the bodys
response to HIV infection is the:
a. CD4/CD8 ratio
b. EIA test
c. Viral load test
d. Western blot
21. The nurse is instructing an unlicensed health care worker on the care of the
client with HIV who also has active genital herpes. Which statement by the health
care worker indicates effective teaching of standard precautions?
a. ''I need to know my HIV status, so I must get tested before caring for any clients."
b. ''Putting on a gown and gloves will cover up the itchy sores on my elbows.''
c. ''Washing my hands and putting on a gown and gloves is what I must do before
starting care.''
d. ''I will wash my hands before going into the room, and then put on gown and
gloves only for direct contact with the client's genitals."
9
MISSION
“MABINI COLLEGES provides quality instruction, research and
VISION MABINI COLLEGES, INC. extension service programs at all educational levels as its
“MABINI COLLEGES shall cultivate a monumental contribution to national and global growth and
CULTURE of EXCELLENCE in education.” Governor Panotes Avenue, development.
Daet, Camarines Norte Specifically, it transforms students into:
1. God – fearing
Tel. no. (054) 721-1281 local 109 2. Nation – loving
mabinicollege@hotmail.com 3.
4. Earth caring
5. Productive, and
6. Locally and Globally competitive persons
7.
22. Which interventions does the home health nurse teach to family members to
reduce confusion in the client diagnosed with AIDS dementia? (Select all that apply.)
23. The home health nurse is making an initial home visit to the client currently
living with family members after being hospitalized with pneumonia and newly
diagnosed with AIDS. Which statement by the nurse best acknowledges the client's
fear of discovery by his family?
a. ''Do you think that I could post a sign on your bedroom door for everyone about
the need to wash their hands?''
b. ''Is there somewhere private in the home we can go and talk?''
c. ''I hope that all of your family members know about your disease and how you
need to be protected, since you have been so sick.''
d. ''It is your duty to protect your family members from getting AIDS.''
10