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Software http://www.foxitsoftware.com For evaluation only. Situation 1 - Mr. Ibarra is assigned to the triage area

Situation 1 - Mr. Ibarra is assigned to the triage area and while on duty, he assesses the condition of Mrs. Simon who came in with asthma. She has difficulty breathing and her respiratory rate is 40 per minute. Mr. Ibarra is asked to inject the client epinephrine 0.3mg subcutaneously

1. The indication for epinephrine injection for Mrs. Simon is to:

a. Reduce anaphylaxis

b. Relieve hypersensitivity to allergen

c. Relieve respiratory distress due to bronchial spasm

d. Restore client's cardiac rhythm

CORRECT ANSWER: C RATIONALE: Asthma is a chronic inflammatory disorder of the airways resulting in reversible bronchoconstriction and air hunger in response to triggers from a variety of sources. When exposed to a trigger, the hyperactivity of the medium-sized bronchi causes the release of leukotrienes, histamine and other substances from the mast cells of the lung; these agents intensify the inflammatory process and cause bronchospasm. When inhaled in small doses, epinephrine causes short-term relief from the symptoms by widening the bronchial tubes allowing air to pass through. Once again epinephrine is not the best cure, but a temporary relief when an asthma inhaler is not present. OPTIONS A & D are incorrect OPTION B: Epinephrine does have a direct effect to relieve hypersensitivity to allergen SOURCE: Hogan, Mary Ann and Hill, Karen.Prentice Hall.Reviews and Rationales series for nursing. Pathophysiology.pp.4-5;

http://www.udel.edu/chem/C465/senior/fall00/Performance1/epinephrine.htm.html

2. When preparing the epinephrine injection from an ampule, the nurse initially:

a. Taps the ampule at the top to allow fluid to flow to the base of the ampule

b. Checks expiration date of the medication ampule

c. Removes needle cap of syringe and pulls plunger to expel air

d. Breaks the neck of the ampule with a gauze wrapped around it

CORRECT ANSWER: B RATIONALE: In preparing medications in ampule or any form of medications, always check first

the expiration date and discard outdated medication. Check the label on the ampule carefully to make sure that the correct medication is being prepared.

SOURCE: Kozier & Erb. Fundamentals of Nursing. 7

th

Edition.pp. 816

3. Mrs. Simon is obese. When administering a subcutaneous injection to an obese patient. It is best

for the nurse to:

a. Inject needle at a 15 degree angle over the stretched skin of the client

b. Pinch skin at the injection site and use airlock technique

c. Pull skin of patient down to administer the drug in a Z track

d. Spread skin or pinch at the injection site and inject needle at a 45-90 degree angle

CORRECT ANSWER: D RATIONALE:To determine the angle of insertion , a general rule to follow relates to the amount of tissue that can be grasped at the site. A 45-degree angle is used when 1 inch of tissue can be grasped at the site; a 90-degree angle is used when 2 inches of tissue can be grasped. OPTION A: Skin Test

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OPTION C: IM SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 822

4. When preparing for a subcutaneous injection, the proper size of syringe and needle would be:

a.Syringe 3ml and needle gauge 21 to 23 b.Tuberculin syringe 1 ml with needle gauge 26 or 27 c. Syringe 2ml and needle gauge 22 d.Syringe l-3ml and needle gauge 25 to 27

CORRECT ANSWER: D RATIONALE: The type of syringe used for subcutaneous injections depends on the medication given. Generally a 2-ml syringe is used for most SC injections. However, if insulin is being administered, an insulin syringe is used; and if heparin is being administered, a tuberculin syringe or prefilled cartridge may be used. Needle sizes and lengths are selected based on the clients body mass,the intended angle of insertion and the planned site. Generally a #25-gauge, 5/8-inch needle is used for adults. OPTIONS A, B & C are incorrect SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 822

5. The rationale for giving medications through the subcutaneous route is; a.There are many alternative sites for subcutaneous injection b. Absorption time of the medicine is slower c. There are less pain receptors in this area d. The medication can be injected while the client is in any position

CORRECT ANSWER: B RATIONALE: Subcutaneous injections are given because there is little blood flow to fatty tissue and the injected medication is generally absorbed more slowly, sometimes over 24 hours. Some medications injected subcutaneously are growth hormone, insulin, epinephrine and other substances. OPTIONS A, C & D are all secondary reasons. SOURCE: http://www.cc.nih.gov/ccc/patient_education/pepubs/subq.pdf

Situation 2 - The use of massage and meditation to help decrease stress and pain have been strongly recommended based on documented testimonials.

6. Martha wants to do a study on the topic. "Effects of massage and meditation on stress and pain."

The type of research that best suits this topic is:

a.Applied research b.Qualitative research c. Basic research d.Quantitative research

CORRECT ANSWER: B RATIONALE: Qualitative research is the investigation of phenomena, typically in an in depth and holistic fashion, through the collection of rich narrative materials using a flexible design. Qualitative research relies on reasons behind various aspects of behavior. Simply put, it investigates the why and how of decision making, not just what, where, and when. Hence, the need is for smaller but focused samples rather than large random samples, which qualitative research categorizes data into patterns as the primary basis for organizing and reporting results. Qualitative researchers typically rely on four methods for gathering information: (1) participation in the setting, (2) direct observation, (3) in depth interviews, and (4) analysis of documents and materials OPTION A: Applied research focuses on finding solutions to existing problems. For example, a study to determine the effectiveness of a nursing intervention to ease grieving would be applied reaserch.

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OPTION C: Basic research is undertaken to extend the base of knowledge in a discipline, or to formulate or refine theory. OPTION D: Quantitative research is the investigation of phenomena that lend themselves to precise measurement and quantification, often involving rigorous and controlled design. SOURCE: Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7 th Edition.pp 18, 729; http://en.wikipedia.org/wiki/Qualitative_research

7. The type of research design that does not manipulate independent variable is:

a.Experimental design b.Quasi-experimental design c. Non-experimental design d.Quantitative design

CORRECT ANSWER: C RATIONALE: Non-experimental research- studies in which the researcher collects data without introducing an intervention. OPTION A: In experiment, the researcher controls the independent variable and randomly assigns subjects to different conditions. OPTION B: Quasi-experiment is an intervention study in which subjects are not randomly assigned to treatment conditions, but the researcher exercises certain controls to enhance the study’s internal validity. SOURCE: Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7 th Edition.pp. 718,725,729

8. This research topic has the potential to contribute to nursing because it seeks to:

a.Include new modalities of care b.Resolve a clinical problem c. Clarify an ambiguous modality of care d.Enhance client care

CORRECT ANSWER: D Rationale: Nursing research is systematic inquiry designed to develop knowledge about issues of importance to the nursing profession, including nursing practice, education administration, and informatics. Research designed to generate knowledge and to improve the health and quality of life of nurse’s clients. Nurses increasingly are expected to adopt an evidenced-based practice, which is broadly defined as the use of best clinical evidence in making patient care decisions. OPTIONS A,B and C are also correct but the best is option D SOURCE: Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7 th Edition.pp. 3-4

9. Martha does review of related literature for the purpose of:

a.Determine statistical treatment of data research b.Orientation to what is already known or unknown c. To identify if problem can be replicated d.Answering the research question

CORRECT ANSWER: D RATIONALE: All of the choices are correct except D. Answer to the research question may be found after conducting the study. The following are purposes of a literature review:

Identification of a research problem and development or refinement of research questions

or hypothesis Orientation to what is known and not known about an area of inquiry, to ascertain what

research can best make a contribution to the existing base of evidence Determination of any gaps or inconsistencies in abody of research

Determination of a need to replicate a prior study in a different setting or with a different study population

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Identification or development of new or reined clinical interventions to test through

empirical research Identification of relevant theoretical or conceptual frameworks for a research problem

Identification of suitable designs and data collection methods for a study

For those developing research proposals for finding, identification of experts in the fields

who could be used as consultants Assistance in interpreting study findings and in developing implications and recommendations

SOURCE: Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7 th Edition.pp. 5

10. Client's rights should be protected when doing research using human subjects. Martha identifies

these rights as follows EXCEPT:

a.right of self-determination

b. right

to compensation

c. right

of privacy

d. right not to be harmed

CORRECT ANSWER: B RATIONALE: All are the client’s rights for being the subject in a research except option B. The following are the basic human rights of research subjects:

Right to informed consent The right to refuse and/or withdraw from participation Right to privacy Right to confidentiality or anonymity of data Right to be protected from harm

withdraw from participation Right to privacy Right to confidentiality or anonymity of data Right to be
withdraw from participation Right to privacy Right to confidentiality or anonymity of data Right to be
withdraw from participation Right to privacy Right to confidentiality or anonymity of data Right to be
withdraw from participation Right to privacy Right to confidentiality or anonymity of data Right to be
SOURCE: Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10 t h

SOURCE: Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10 th

Edition.pp.110-111

Situation 3 - Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Mario's nursing care plan is to loosen and remove excessive secretions in the airway,

11. Mario listens to Richard's bilateral sounds and finds that congestion is in the upper lobes of the

lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does percussion would be:

a.Client lying on his back then flat on his abdomen on Trendelenburg position b.Client seated upright in bed or on a chair then leaning forward in sitting position c. Client lying flat on his back and then flat on his abdomen d.Client lying on his right then left side on Trendelenburg position

CORRECT ANSWER: B RATIONALE: Postural Drainage involves a patient assuming various positions to facilitate the flow of secretions from various parts of the lung into the bronchi, trachea and throat so that they can be cleared and expelled from the lungs more easily. The diagram below shows the correct positions to assume for draining different parts of the lung. OPTIONS A and C are inappropriate OPTION D will drain the lower lobes of the lung SOURCE: http://www.huff-n-puff.net/posturaldrainage.htm

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Software http://www.foxitsoftware.com For evaluation only. 12. When documenting outcome of Richard's treatment,

12. When documenting outcome of Richard's treatment, Mario should include the following in his

recording EXCEPT:

a.Color, amount and consistent of sputum b.Character of breath sounds and respiratory rate before and after procedure c. Amount of fluid intake of client before and after the procedure d.Significant changes in vital signs

CORRECT ANSWER: C RATIONALE: The nurse needs to evaluate the client’s tolerance of postural drainage by assessing the stability of the clients vital signs, particularly the pulse and respiratory rates and by noting signs of intolerance, such as pallor, diaphoresis, dyspnea and fatigue.Following Postural drainage, the nurse should auscultates the client’s lungs, compare the findings to the baseline data, and document the amount, color, and character of expectorated secretions. OPTION C is not part of the documentation. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 1305

13. When assessing Richard for chest percussion or chest vibration and postural drainage Mario

would focus on the following EXCEPT:

a.Amount of food and fluid taken during the last meal before treatment b.Respiratory rate, breath sounds and location of congestion c. Teaching the client's relatives to perform 'the procedure d.Doctor's order regarding position restriction and client's tolerance for lying flat

CORRECT ANSWER: C RATIONALE: Option C, though is part of nursing interventions but it is not the focus during this

time.

OPTION A is important to prevent vomiting and aspiration OPTION B will give the nurse baseline data OPTION D is important because certain position is contraindicated to the client that may further lead to dyspnea SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 1305

14. Mario prepares Richard for postural drainage and percussion. Which of the flowing is a special

consideration when doing the procedure? a.Respiratory rate of 16 to 20 per minute b.Client can tolerate sitting and lying position c. Client has no signs of infection

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d.Time of last food and fluid intake of the client

CORRECT ANSWER:D RATIONALE: Postural drainage treatments are scheduled two or three times daily, depending on the degree of lung congestion. The best times include before breakfast, before lunch, in the late afternoon and before bedtime. It is best to avoid hours shortly after meals because postural drainage at these times can be tiring and can induce vomiting. OPTION A has no special consideration since it is normal OPTIONS B & C don’t have any special considerations SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 1305

15. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference

between the

procedure is;

a.Percussion uses only one hand white vibration uses both hands

b. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently

shakes secretion loose on the exhalation cycle

c. In both percussion and vibration the hands are on top of each other and hand action is in tune

with client's breath rhythm

d. Percussion slaps the chest to loosen secretions while vibration shakes the secretions along

with the inhalation of air

CORRECT ANSWER: A RATIONALE: Percussion sometimes called clapping is forceful striking of the skin with cupped hands. Vibration is a series of vigorous quiverings produced by hands that are placed flat against the client’s chest wall. Option A is true to both percussion and vibration. OPTION B is not the correct way OPTION C: percussion can be done with one hand OPTION D: percussion is not slapping SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp.1303,1305

Situation 4 - A 61 year old man, Mr. Regalado, is admitted to the private ward for observation; after complaints of severe chest pain. You are assigned to take care of the client.

16.

When doing an initial assessment, the best way for you to identify the client's priority problem is

to:

 

a.Interview the client for chief complaints and other symptoms

b. Talk to the relatives to gather data about history of illness

c. Do auscultation to check for chest congestion

d.Do a physical examination white asking the client relevant questions

CORRECT ANSWER: A RATIONALE: An interview is a planned communication or a conversation with a purpose, for example, to get or give information, identify problems of mutual concern, evaluating change, teach, provide support or provide counseling or therapy. Initially during an assessment, the nurse first asks the complaints of the client and the associated symptoms so that initial intervention can be done. OPTION B: the client is the primary source of data OPTIONS C and D: may follow after SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp.265

17.

Upon establishing Mr. Regalado's nursing needs, the next nursing approach would be to:

a.Introduce the client to the ward staff to put the client and family at ease b.Give client and relatives a brief tour of the physical set up the unit

c. Take his vital signs for a baseline assessment

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d.Establish priority needs and implement appropriate interventions

CORRECT ANSWER: C RATIONALE: Assessment is always done first before anything else. OPTION A and B are interventions OPTION D is diagnosing, planning and interventions

18.

Mr. Regalado says he has "trouble going to sleep". In order to plan your nursing intervention you

will.

 

a.Observe his sleeping patterns in the next few days b.Ask him what he means by this statement c. Check his physical environment to decrease noise level d.Take his blood pressure before sleeping and upon waking up

CORRECT ANSWER: B RATIONALE: It is another question for prioritization. Clarifying what the patient mean of “trouble going to sleep” enable the nurse to plan for the appropriate intervention. OPTION A is inappropriate, may require some time before the intervention OPTIONS C is judgmental that the noise is the cause of trouble in sleeping OPTION D is inappropriate without further assessment

19.

Mr. Regalado's lower extremities are swollen and shiny. He has pitting pedal edema. When

taking care of Mr. Regalado, which of the following intervention would be the most appropriate immediate nursing approach. a.Moisturize lower extremities to prevent skin irritation b.Measure fluid intake and output to decrease edema

c. Elevate

d.Provide the client a list of food low in sodium

lower extremities for postural drainage

CORRECT ANSWER: A RATIONALE: All of the options are interventions for edema but option A is the immediate intervention. SOURCE: Black and Hawks. Medical Surgical Nursing.Vol. 1.7 th Edition.pp. 217-218

20. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a

client for discharge include all EXCEPT:

a.Teaching the factors that may trigger chest pain b.Giving instructions about his medication regimen c. Telling the patient to see the doctor for the final instruction d.Proper recording of pertinent data

CORRECT ANSWER: C RATIONALE: Nurse preparing to send clients home needs to assess the following parameters in their clients: personal and health data, abilities to perform the activities of daily living (ADLs), any physical, cognitive or other functional limitations, caregiver’s responses and abilities, adequacy of financial resources, community supports, hazards or barriers that the home environment presents and need for health care assistance in the home. Essential information before discharge includes information about medications, dietary, and activity restrictions, signs of complications that need to be reported to the physician, follow-up appointments an telephone numbers, and where supplies can be obtained. OPTION C is inappropriate. The nurse is giving the patient discharge instruction before leaving the hospital. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 114

Situation 5 - Accurate computation prior to drug administration is a basic skill all nurses must have.

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21. Rudolf is diagnosed with amoebiasis and is to receive metronidazole (Flagyl) tablets 1.5 gm daily in 3 divided doses for 7 consecutive days. Which of the following is the correct dose of the drug that the client will receive per

oral administration?

a.1,000 mg tid b.500 mg tid

c. 1,500 mg tid

d.250 mg tid

CORRECT ANSWER: B RATIONALE: 1gram=1,000 milligram 1.5 gm x 1,000 mg = 1,500 mg 1,500 /3doses= 500 per oral administration

22. Rhona, a 2 year old female was prescribed to receive 62.5 mg suspension three times a day.

The available dose

is 125 mg/ml. Which of the following should Nurse Paulo prepare for each oral dose?

a

b.1.25 ml

c. 2.5 ml

d.1 ml

5

ml

CORRECT ANSWER: A

RATIONALE: Q= Drug prescribed/ drug available or stock

= 62.5 mg/125mg/ml

= 0.5 ml

23. A client is ordered to take Lasix, a diuretic, to be taken orally daily. Which of the following is an

appropriate instruction by the nurse? a.Report to the physician the effects of the medication on urination

b.Take the medication early in the morning

c. Take a full glass of water with the medication

d.Measure frequency of urination in 24 hours.

CORRECT ANSWER: B RATIONALE: furosemide (Lasix) is a diuretic that will increase urination so it is important to instruct patient to take the drug early in the morning to prevent problems in sleep because when taken at night, it will produced urinary frequency. OPTION A: Effects on urination is normal since it is a diuretics OPTION C: is not that important OPTION D: measuring the total amount of output is more important than the frequency

Situation 6 - Mrs. Seva, 32 years old, asks you about possible problems regarding her elimination now that she is in the menopausal stage.

24. Instruction on health promotion regarding urinary elimination is important. Which would you

include?

a. Hold urine, as long as she can before emptying the bladder to strengthen her sphincters

muscles

b. If burning sensation is experienced while voiding, drink pineapple-juice

c. After urination, wipe from anal area up towards the pubis

d.Tell client to empty the bladder at each voiding

CORRECT ANSWER: D RATIONALE:

Promoting Urinary Elimination

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Instruct the client to respond to urge to void as soon as possible; avoid voluntary urine retention

Teach the client to empty the bladder completely at each voiding Emphasize the importance of drinking 9-10 glasses of water daily Teach female clients about Kegel’s exercises to strengthen perineal muscles

Etc.

OPTION A is incorrect OPTION B might not always be correct, pineapple juice increase the acidity of urine but burning sensation may be an indication already of an existing disease. OPTION C: wiping should be from front to back

25. Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical

changes predispose her to constipation? a.inhibition of the parasympathetic reflex b.weakness of sphincter muscles of the anus c. loss of tone of the smooth muscles of the colon d. decreased ability to absorb fluids in the lower intestines

CORRECT ANSWER: C RATIONALE: If the feces are very hard or if there is great difficulty in passing it out, then it is constipation. Causes of constipation

Peristalsis of the intestine in the elderly is usually weakened, hence they are more

prone to constipation. Aging may also affect bowel regularity because a slower metabolism results in less intestinal activity and muscle tone. Inadequate water or lack of fibre in food, leading to hard faeces.

Psychological factors, e.g. using bedpan or commode chair without privacy, a dirty

toilet, depression, etc. Drugs such as morphine group pain killers, certain diuretics, calcium tablets.

Diseases, e.g. diabetic mellitus, hypothyroidism.

SOURCE:http://healthlink.mcw.edu/article/930592170.html;http://www.info.gov.hk/elderly/english/

healthinfo/healthproblems/constipation.htm

26. The nurse understands that one of these factors contributes to constipation:

a.excessive exercise b.high fiber diet c. no regular time for defecation daily d.prolonged use of laxatives

CORRECT ANSWER: D Rationale: Laxatives contain chemicals that help increase stool motility, bulk, and frequency -- thus relieving temporary constipation. But when misused or overused, they can cause problems, including chronic constipation! A healthy diet filled with fresh fruits, vegetables, and whole-grain products; regular exercise; and drinking at least eight cups of water daily can help prevent constipation in most people. Still, 85% of doctor visits for constipation result in a prescription for a laxative. So it's important to understand how laxatives work and how to use them safely. OPTION A&B will not cause constipation OPTION C: Some people think they are constipated if they do not have a bowel movement every day. However, normal stool elimination may be three times a day or three times a week, depending on the person. SOURCE: http://www.webmd.com/digestive-disorders/laxatives-for-constipation-using-them- safely?src=RSS_PUBLIC

27. Mrs. Seva talks about her being incontinent due to a prior experience of dribbling urine when

laughing or sneezing and when she has a full bladder. Your most appropriate .instruction would be to:

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a.tell client to drink less fluids to avoid accidents b.instruct client to start wearing thin adult diapers c. ask the client to bring change of underwear "just in case" d. teach client pelvic exercise to strengthen perineal muscles

CORRECT ANSWER: D RATIONALE: It is important to remember that urinary incontinence is not part of normal aging and often treatable. Independent nursing interventions for clients with urinary incontinence include (a)a behavior-oriented continence training program that may consist of bladder training, habit training, prompted voiding, pelvic muscle exercises and positive reinforcement; (b) meticulous skin care and (c) for males, application of an external drainage device (condom-type catheter device). Pelvic muscle exercises (also known as Kegel exercises) work the muscles that you use to stop urinating. Making these muscles stronger helps you hold urine in your bladder longer. These exercises are easy to do. They can lessen or get rid of stress and urge incontinence. Kegel Exercises The muscles you want to exercise are your pelvic floor muscles. These are the ones you use to stop the flow of urine or to keep from passing gas. Often doctors suggest that you squeeze and hold these muscles for a certain count, and then relax them. Then you repeat this a number of times. You will probably do this several times a day. Your doctor will give you exact directions. OPTIONS A,B and C are inappropriate SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 1270; http://www.niapublications.org/agepages/urinary.asp

28. Mrs. Seva asked for instructions for skin care for her mother who has urinary incontinence and is

almost always in bed. Your instruction would focus on prevention of skin irritation and breakdown by

a.Using thick diapers to absorb urine well b.Drying the skin with baby powder to prevent or mask the smell of ammonia c. Thorough washing, rinsing and drying of skin area that get wet with urine d.Making sure that linen are smooth and dry at all times

CORRECT ANSWER: C RATIONALE: Skin that is continually moist becomes macerated (softened). Urine that accumulates on the skin is converted to ammonia, which is very irritating to the skin. Because both skin irritation and maceration predispose the client to skin breakdown and ulceration, the incontinent person requires meticulous skin care. To maintain skin integrity, the nurse washes the client’s perineal area with soap and water after episodes of incontinence, rinses it thoroughly, dries it gently and thoroughly and provides clean, dry clothing or bed linen. If the skin is irritated, the nurse applies barrier creams such as zinc oxide ointment to protect it from contact with urine. If it is necessary to pad the client’s clothes for protection, the nurse should use products that absorb wetness and leave a dry surface in contact with the skin. OPTION A and B: Use of diapers and other containment devices may prevent the bedding and clothing from getting soiled, however they tend to keep the urine or stool in constant contact with the skin. Within a short period of time, the skin can become damaged. Special care must be taken to prevent skin breakdown by keeping the skin clean and dry. OPTION D is also correct but the best is option C SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 1271;

http://www.healthcentral.com/ency/408/003976.html

Situation 7 - Using Maslow's need theory, Airway, Breathing and Circulation are the physiological needs vital to life. The nurse's knowledge and ability to identify and immediately intervene to meet these needs is important to save lives.

29. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues? a. Carol with a tumor in the brain b.Theresa with anemia

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c. Sonny Boy with a fracture in the femur

d.Brigette with diarrhea

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CORRECT ANSWER: B RATIONALE: Anemia is a condition characterized by abnormally low levels of healthy red blood cells or hemoglobin (the component of red blood cells that delivers oxygen to tissues throughout the body). The tissues of the human body need a regular supply of oxygen to stay healthy. Red blood cells, which contain hemoglobin that allows them to deliver oxygen throughout the body, live for only about 120 days. When they die, the iron they contain is returned to the bone marrow and used to create new red blood cells. Anemia develops when heavy bleeding causes significant iron loss or when something happens to slow down the production of red blood cells or to increase the rate at which they are destroyed. OPTIONS A, C and D has no direct effect in the oxygenation of tissues. SOURCE: http://www.answers.com/topic/anemia?cat=health

30. You noted from the lab exams in the chart of Mr. Santos that he has reduced oxygen in the

blood. This

condition is called:

a.Cyanosis

b.Hypoxia

c. Hypoxemia

d.Anemia

CORRECT ANSWER: C RATIONALE: Hypoxemia is an abnormal deficiency in the concentration of oxygen in arterial blood (Mosby's Medical Dictionary). OPTION A: Cyanosis-a bluish discoloration of the skin and mucous membranes resulting from inadequate oxygenation of the blood OPTION B: Hypoxia -a condition in which there is a decrease in the oxygen supply to a tissue. OPTION D: Anemia is having less than the normal number of red blood cells or less hemoglobin than normal in the blood.

31. You will do nasopharyngeal suctioning to Mr. Abad. Your guide for the length of insertion of the

tubing for an adult would be:

a. tip of the nose to the base of the neck

b.the distance from the tip of the nose to the middle of the cheek

c. the distance from the tip of the nose to the tip of the ear lobe

d.eight to ten inches

CORRECT ANSWER: C RATIONALE: Oropharyngeal or nasopharyngeal suctioning removes secretions from the upper

respiratory tract. Make an appropriate measure of the depth of the catheter by measuring the distance between the tip of the client’s nose and the earlobe, or about 13 cm (5 inches) for an

adult.

OPTIONS A, B and D are inappropriate SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 1318, 1320

32. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area by:

a.Applying suction for at least 20-30 seconds each time to ensure that all secretions are removed b.Using gloves to prevent introduction of pathogens to the respiratory system

c. Applying no suction while inserting the catheter

d.Rotating catheter as it is inserted with gentle suction

CORRECT ANSWER: C RATIONALE: For nasopharyngeal suctioning, without applying the suction, insert the catheter premeasured or recommended distance into either nares and advance it along the floor of the

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nasal cavity. This avoids the nasal turbinates. Never force the catheter against an obstruction. If one nostril is obstructed, try another. OPTION A: Suction is applied for 5 to 10 seconds while slowly withdrawing the catheter. A suction attempt should last only 10 to 15 seconds. OPTION B is true to prevent infection but not avoiding trauma OPTION D: The catheter is rotated during suction not during the insertion of catheter and no suction is applied during the insertion of the catheter. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 1320

33.

Myrna has difficulty breathing when on her back and must sit upright in bed to breath, effectively

and

comfortably. The nurse documents this condition as:

a.Apnea

b.Orthopnea

c. Dyspnea

d.Tachypnea

CORRECT ANSWER: B RATIONALE: Orthopnea: The inability to breathe easily unless one is sitting up straight or standing erect. OPTION A: Apnea is the temporary cessation of breathing OPTION C: Dyspnea: Difficult or labored breathing; shortness of breath. OPTION D: Abnormally fast breathing. A respiratory rate that is too rapid. SOURCE: http://www.medterms.com/script/main/art.asp?articlekey=5702

Situation 8 - You are assigned to screen for hypertension: Your task is to take blood pressure readings and you are informed about avoiding the common mistakes in BP taking that lead to 'false or inaccurate blood pressure readings.

34.

When taking blood pressure reading the cuff should be:

a.deflated fully then immediately start second reading for same client b.deflated quickly after inflating up to 180 mmHg c. large enough to wrap around upper arm of the adult client 1 cm above brachial artery d.inflated to 30 mmHg above the estimated systolic BP based on palpation of radial or brachial artery

CORRECT ANSWER: D RATIONALE: Pump up the cuff until the sphygmomanometer reads 30 mmHg above the point where the brachial pulse disappeared. OPTION A: Wait 1 to 2 minutes before making further measurements. A waiting period gives the blood trapped in the veins time to be released. Otherwise, false high systolic readings will occur. OPTION C: Wrap the deflated cuff evenly around the upper arm. Locate the brachial artery. Apply the center of the bladder directly over the artery. The bladder inside the cuff must be directly over the artery to be compressed if the reading is to be accurate. For an adult, place the lower border of the cuff approximately 2.5 cm or 1 inch above the antecubital space. OPTION D is inappropriate SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 515-516

35.

Chronic Obstructive Pulmonary Disease (COPD) in one of the leading causes of death worldwide

and

is a preventable disease. The primary cause of COPD is:

a.tobacco hack b.bronchitis c. asthma d.cigarette smoking

CORRECT ANSWER: D

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RATIONALE: COPD is a chronic lung disease. It has its own symptoms. The most common cause of COPD is known. And it's preventable. Smoking is the primary cause of COPD. It is 10 times more likely that a smoker will get COPD than a nonsmoker. Exposure to secondhand tobacco Cigarette smoke causes COPD by irritating the airways and creating inflammation that narrows the airways, making it more difficult to breathe. Cigarette smoke also causes the cilia to stop working properly so mucus and trapped particles are not cleaned from the airways. As a result, chronic cough and excess mucus production develop, leading to chronic bronchitis. OPTION B: is one of the diseases in COPD OPTION A and C:incorrect SOURCE: http://www.clevelandclinic.org/health/health-info/docs/2400/2416.asp?index=8709 http://www.copdguide.com/copd-is-different.jsp

36. In your health education class for clients with diabetes you teach, them the areas for control

Diabetes which include all EXCEPT:

a.regular physical activity b.thorough knowledge of foot care c. prevention of infection d.proper nutrition

CORRECT ANSWER: B RATIONALE: Option D: In order to maintain a constant blood sugar level, diabetics should ideally eat approximately the same amount of food per day, with a set number of calories at around the same time of day so that blood sugar levels don’t fluctuate too much. In addition, healthy snacks should be enjoyed to stop the blood glucose levels from dropping too much in between meals. Meals should never be skipped and the day’s food should contain a mixture of whole grains, fruits, lean meat or meat substitutes i.e. corn, vegetables and low fat dairy products. OPTION A: In conjunction with a healthy low fat diet, moderate exercise should be taken at least five times a week for around 30 minutes each session. How a diabetic person chooses to exercise will depend to some extent on their initial level of fitness i.e. obese people will not go jogging or cycling for miles at a time, and any exercise routine should only be performed after consulting a doctor. As an individual starts to lose weight then the level of physical activity can be increased accordingly but overdoing it to begin will undoubtedly lead to even bigger problems. OPTION C: Infection may result to hyperglycemia because the body requires more glucose for energy. Thus preventing infection also control diabetes OPTION B: A knowledge on foot care prevents complication of diabetic foot but does not control diabetes itself. SOURCE: http://www.diabeticlive.com/articles/17/1/Controlling-Diabetes-With-Diet-And-

Exercise/Page1.html

37. You teach your clients the difference between, Type I (IDDM) and Type II (NDDM) Diabetes. Which of the following is true? a. both types of diabetes mellitus clients are all prone to develop ketosis b. Type II (NIDDM) is more common and is also preventable compared to Type I (IDDM) diabetes which is genetic in etiology c. Type I (IDDM) is characterized by fasting hyperglycemia d.Type II (IDDM) is characterized by abnormal immune response

CORRECT ANSWER: B RATIONALE: While it is said that type 2 diabetes occurs mostly in individuals over 30 years old and the incidence increases with age, we are seeing an alarming number patients with type 2

diabetes who are barely in their teen years. In fact, for the first time in the history of humans, type

2 diabetes is now more common than type 1 diabetes in childhood. Most of these cases are a

direct result of poor eating habits, higher body weight, and lack of exercise.Type 1 diabetes was

also called insulin dependent diabetes mellitus (IDDM), or juvenile onset diabetes mellitus. In type

1 diabetes, the pancreas undergoes an autoimmune attack by the body itself, and is rendered

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incapable of making insulin. Abnormal antibodies have been found in the majority of patients with type 1 diabetes. Antibodies are proteins in the blood that are part of the body's immune system. The patient with type 1 diabetes must rely on insulin medication for survival. In autoimmune diseases, such as type 1 diabetes, the immune system mistakenly manufactures antibodies and inflammatory cells that are directed against and cause damage to patients' own body tissues. In persons with type 1 diabetes, the beta cells of the pancreas, which are responsible for insulin production, are attacked by the misdirected immune system. It is believed that the tendency to develop abnormal antibodies in type 1 diabetes is, in part, genetically inherited, though the details are not fully understood. OPTION A: ketoacidosis -- mostly in people with type 1 diabetes -- and hyperglycemic hyperosmolar nonketotic syndrome (HHNS) in people with type 2 diabetes or in people at risk for type 2 diabetes. OPTION C:There is no such thing as fasting hyperglycemia OPTION D: Type I is characterized by abnormal immune response SOURCE: http://www.medicinenet.com/diabetes_mellitus/page3.htm

38. Lifestyle-related diseases in general share common risk factors. These are the following except a.physical activity

b.smoking

c. genetics

d.nutrition

CORRECT ANSWER: C RATIONALE: A way of life or style of living that reflects the attitudes and values of a person or

group. Lifestyle assessment focuses on the personal lifestyle and habits of the client as they affect health. Categories of lifestyle generally assessed are physical activity, nutritional practices, stress management and such habits as smoking, alcohol consumption and drug use. OPTION C genetics is the scientific study of heredity. Genetics pertains to humans and all other

organisms. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 128

Situation 9 - Nurse Rivera witnesses a vehicular accident near the hospital where she works. She decides to get involved and help the victims of the accident.

39. Her priority nursing action would be to:

a. Assess damage to property

b.Assist in the police investigation since she is a witness

c. Report the incident immediately to the local police authorities

d.Assess the extent of injuries incurred by the victims, of the accident

CORRECT ANSWER: D RATIONALE: The first priority whenever an accident occurs is to deal with the emergency and ensure that any injuries or illnesses receive prompt medical attention. SOURCE: http://web.princeton.edu/sites/ehs/healthsafetyguide/A2.htm

40. Priority attention should be given to which of these clients?

a. Linda who shows severe anxiety due to trauma of the accident

b.Ryan who has chest injury, is pale and with difficulty of breathing

c. Noel who has lacerations on the arms with mild-bleeding

d.Andy whose left ankle swelled and has some abrasions

CORRECT ANSWER: B RATIONALE: Respiratory problems and problem with the oxygenation should always be the

priority. OPTION A is least priority because it is a psychological need OPTION C is the second OPTION D is the third

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41. In the emergency room, Nurse Rivera is assigned to attend to the client with lacerations on the

arms, while assessing the extent of the wound the nurse observes that the wound is now starting to bleed profusely. The most immediate nursing action would be to:

a.Apply antiseptic to prevent infection b.Clean the wound vigorously of contaminants c. Control and reduce bleeding of the wound d.Bandage the wound and elevate the arm

CORRECT ANSWER: D RATIONALE: Bleeding from any external wound sites on the victim's body should be controlled to prevent the victim from going into shock which could lead to death if not treated immediately. Elevation - Keeping the wound above the level of the heart will decrease the pressure at the point of injury, and will reduce the bleeding. Direct Pressure - Placing pressure on the wound will constrict the blood vessels manually. After applying pressure for sometime, you can make a pressure bandage around the injury site. The key is to not make this too tight to cut all circulation because this could have direct consequences later on. The bandage should be tight enough to maintain pressure on the wound but not too tight to impede any blood flow. If the skin turns purple-blue or if there is no pulse present at the major pressure pints then the pressure bandage is on too tight. OPTION A does not address the immediate need of the patient OPTION B is incorrect because it may induce more bleeding OPTION C is correct but option D is more specific SOURCE: http://en.wikipedia.org/wiki/Emergency_bleeding_control

42. The nurse applies pressure dressing on the bleeding site. This intervention is done to:

a.Reduce the need to change dressing frequently b.Allow the pus to surface faster c. Protect the wound from micro organisms in the air d.Promote hemostasis

CORRECT ANSWER: D RATIONALE: Hemostasis is the stoppage of bleeding or hemorrhage. Also, the stoppage of blood flow through a blood vessel or organ of the body Pressure dressing is a nonadherent bandage applied over the incision that is covered by an absorbent layer and a stretchable adhesive. This application is intended to compress dead space and prevent hematoma and seroma formation. SOURCE: http://www.woundsresearch.com/Pressure-dressing

43. After the treatment, the client is sent home and asked to come back for follow-up care. Your

responsibilities when the client is to be discharged include the following EXCEPT:

a. Encouraging the client to go to the, outpatient clinic for follow up care b.Accurate recording, of treatment done and instructions given to client c. Instructing the client to see you after discharge for further assistance d.Providing instructions regarding wound care

CORRECT ANSWER: C RATIONALE: Nurse preparing to send clients home needs to assess the following parameters in their clients: personal and health data, abilities to perform the activities of daily living (ADLs), any physical, cognitive or other functional limitations, caregiver’s responses and abilities, adequacy of financial resources, community supports, hazards or barriers that the home environment presents and need for health care assistance in the home. Essential information before discharge includes information about medications, dietary, and activity restrictions, signs of complications that need to be reported to the physician, follow-up appointments an telephone numbers, and where supplies can be obtained. OPTION C: The client does not have the direct appointment with the nurse after the discharge.

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SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 114

Situation 10 - While working in the clinic, a new client, Geline, 35 years old, arrives for her doctor's appointment. As the clinic nurse, you are to assist the client fill up forms, gather data and make an assessment.

44. The nurse purpose of your initial nursing interview is to:

a. Record pertinent information in the client chart for health team to read

b.Assist the client find solutions to her health concerns

c. Understand her lifestyle, health needs and possible problems to develop a plan of care

d.Make nursing diagnoses for identified health problems

CORRECT ANSWER: C RATIONALE: An interview is a planned communication or a conversation with a purpose, for example, to get or give information, identify problems of mutual concern, evaluating change, teach, provide support or provide counseling or therapy. Initially during an assessment, the nurse

first ask the complaints of the client and the associated symptoms so that initial intervention can be done. It is an umbrella effect. Option C encompasses options A, B and D.

SOURCE: Kozier & Erb. Fundamentals of Nursing. 7

th

Edition.pp.265

45. While interviewing Geline, she starts to moan and doubles up in pain, She tells you that this pain

occurs about an hour after taking black coffee without breakfast for a few weeks now. You will record this as follows:

a.Claims to have abdominal pains after intake of coffee unrelieved by analgesics b.After drinking coffee, the client experienced severe abdominal pain

c. Client complained of intermittent abdominal pain an hour after drinking coffee

d.Client reported abdominal pain an hour after drinking black coffee for few weeks now

CORRECT ANSWER: D RATIONALE: To complete the assessment phase, the nurse records client data. Accurate documentation is essential and should include all data collected about the client’s health status. Data are recorded in a factual manner and not interpreted by the nurse. OPTION D is more complete recording of the patient’s complaints.

SOURCE: Kozier & Erb. Fundamentals of Nursing. 7

th

Edition.pp.274

46. Geline tells you that she drinks black coffee frequently within the day to "have energy and be

wide awake"

and she eats nothing for breakfast and eats strictly vegetable salads for lunch and dinner to lose weight. She has lost weight during the past two weeks, in planning a healthy balanced diet with Geline, you will:

a. Start her off with a cleansing diet to free her body of toxins then change to a vegetarian, diet

and drink

plenty of fluids b.Plan a high protein, diet; low carbohydrate diet for her considering her favorite food

c. Instruct her to attend classes in nutrition to find food rich in complex carbohydrates to maintain

daily high energy level d.Discuss with her the importance of eating a variety of food from the major food groups with plenty of fluids

CORRECT ANSWER: D

RATIONALE: Diet planning principles (ABCNMV)

1. Adequacy -Provides sufficient energy and nutrients

2. Balance

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- Consume a number of different foods in appropriate proportion to each other

3. kCalorie control -Energy balance

4. Nutrient density -Large amount of nutrients in a food with a small amount of calories

5. Moderation -In consuming foods that are not nutrient dense

6. Variety

-Consume a variety of foods within and among the food groups OPTION A is inappropriate because the patient is already in vegetable diet OPTION B is limited only in protein and carbohydrates OPTION C is limited to carbohydrates only SOURCE: http://www.usm.edu/~nfs362/chap2.out.PDF

47.

Geline tells you that she drinks 4-5 cups of black coffee and diet cola drinks. She also smokes up

to a

pack of cigarettes daily. She confesses that she is in her 2nd month of pregnancy but she does not want to become fat that is why she limits her food intake. You warn or caution her about which of the following? a.Caffeine products affect the central nervous system and may cause the mother to have a "nervous breakdown" b. Malnutrition and its possible effects on growth and development problems in the unborn fetus c. Caffeine causes a stimulant effect on both the mother and the baby d.Studies show conclusively that caffeine causes mental retardation

CORRECT ANSWER: B RATIONALE: Maternal malnutrition impairs pregnancy outcome, increases maternal mortality and retards early childhood development. 18 million low-birth weight babies are born to undernourished mothers each year. This is a prime cause of infant mortality in developing countries OPTION A, C and D are all limited to effects of caffeine SOURCE: http://www.iaea.org/Publications/Booklets/Malnutrition/four.html

48. Your health education plan for Geline stresses proper diet for a pregnant woman and the

prevention of non-communicable diseases that are influenced by her lifestyle these include of the following EXCEPT:

a.Cardiovascular diseases b.Cancer c. Diabetes Mellitus d.Osteoporosis

CORRECT ANSWER: D RATIONALE: Your cardiovascular system consists of your heart and all blood vessels throughout your body. Diseases ranging from aneurysms to valve disease are types of cardiovascular disease. You may be born with some types of cardiovascular disease (congenital) or acquire others later on, usually from a lifetime of unhealthy habits, such as smoking, which can damage your arteries and cause atherosclerosis Cigarette smoking causes 87 percent of lung cancer deaths (1). Lung cancer is the leading cause of cancer death in both men and women (3). Smoking is also responsible for most cancers of the larynx, oral cavity and pharynx, esophagus, and bladder. In addition, it is a cause of kidney, pancreatic, cervical, and stomach cancers (2, 4), as well as acute myeloid leukemia (2). OPTION D:Osteoporosis occurs when an imbalance occurs between new bone formation and old bone resorption. The body may fail to form enough new bone, or too much old bone may be reabsorbed, or both. Two essential minerals for normal bone formation are calcium and phosphate. Throughout youth, the body uses these minerals to produce bones. If calcium intake

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is not sufficient or if the body does not absorb enough calcium from the diet, bone production and bone tissue may suffer. SOURCE: http://www.emedicinehealth.com/osteoporosis/page2_em.htm; http://www.cancer.gov/cancertopics/factsheet/Tobacco/cancer

http://www.mayoclinic.com/health/cardiovascular-disease/HB00032/UPDATEAPP=0

Situation 11 - Management of nurse practitioners is done by qualified nursing leaders who have had clinical experience and management experience.

49. An example of a management function of a nurse is:

a.Teaching patient do breathing and coughing exercises b.Preparing for a surprise party for a client

c. Performing nursing procedures for clients

d.Directing and evaluating the staff nurses

CORRECT ANSWER: D RATIONALE: Management has a unique purpose and outcome that is needed to maintain a

healthy organization. Management functions include planning, organizing, staffing, directing and controlling. According to Kleinman,the basic components of management functions include planning, organizing, delegating, problem solving, evaluating and enforcing policies and

procedures.

Other options are not correct SOURCE: Marquis, Bessie and Huston, Carol. Leadership Roles and Management Functions in Nursing. Theory and applications. 5 th Edition.pp. 39-41

50. Your head nurse in the unit believes that the staff nurses are not capable of decision making so

she makes the decisions for everyone without consulting anybody. This type of leadership is:

a.Laissez faire leadership b.Democratic leadership

c. Autocratic leadership

d.Managerial leadership

CORRECT ANSWER: C RATIONALE: Autocratic Leadership Style This is often considered the classical approach. It is one in which the manager retains as much power and decision-making authority as possible. The manager does not consult employees, nor are they allowed to give any input. Employees are expected to obey orders without receiving any

explanations. The motivation environment is produced by creating a structured set of rewards and

punishments.

OPTION A:The laissez-faire leadership style is also known as the “hands-off¨ style. It is one in which the manager provides little or no direction and gives employees as much freedom as possible. All authority or power is given to the employees and they must determine goals, make decisions, and resolve problems on their own. OPTION B:The democratic leadership style is also called the participative style as it encourages employees to be a part of the decision making. The democratic manager keeps his or her employees informed about everything that affects their work and shares decision making and problem solving responsibilities. This style requires the leader to be a coach who has the final say, but gathers information from staff members before making a decision OPTION D:A manager’s style of managing has been a continuing cause of concern to his manager's style is one of the major contributors to the performance and effectiveness of his unit. The desire to define how a manager should conduct himself while working with others has led to investigations into those variables that may affect levels of managerial performance. This article examines, in summary form, investigations by various management authorities on the subject of managerial styles. These investigations have been developed into three theories of managerial style: trait, behavior, and situation. SOURCE: http://www.essortment.com/all/leadershipstyle_rrnq.htm

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http://www.airpower.maxwell.af.mil/airchronicles/aureview/1976/mar-apr/dean.html

51. When the head nurse in your ward plots and approves your work schedules and directs your

work, she is demonstrating:

a.Responsibility

b.Delegation

c. Accountability

d.Authority

CORRECT ANSWER: D RATIONALE: Authority is defined as the legitimate right to direct the work of others. Authority is an integral component of managing. OPTION A: Responsibility is an obligation to complete a task. OPTION B: Delegation is the assignment of authority and responsibility to another person (normally from a manager to a subordinate) to carry out specific activities. However the person who delegated the work remains accountable for the outcome of the delegate work. It allows a subordinate to make decisions, i.e. it is a shift of decision-making authority from one organizational level to a lower one. OPTION C: Accountability is the ability and willingness to assume responsibility for one’s actions and accept the consequences of one’s behavior. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 477

52. The following tasks can be safely delegated by a nurse to a non-nurse health worker EXCEPT:

a.Transfer a client from bed to chair b. Change IV infusions c. Irrigation of a nasogastric tube d.Take vital signs

CORRECT ANSWER: B RATIONALE: “Delegation” is transferring to a competent individual the authority to perform a specific nursing task in a selected situation. The nurse retains the responsibility and the accountability for the delegated tasks. The registered nurse directs care and determines the appropriate utilization of any nursing assistant/nurse aide involved in providing direct patient care. The registered nurse may delegate components of care but does not delegate the nursing process itself. The functions of assessment, planning, evaluation and nursing judgment are pervasive to nursing practice and cannot be delegated. The registered nurse delegates only those tasks for which she or he believes the other health care worker has the knowledge and skill to perform, taking into consideration training, cultural competence, experience and facility/agency policies and procedures.

Tasks that may be delegated to an unlicensed assistive personnel:

Taking of vital signs Measuring and recording intake and output Patient transfer and ambulation Postmortem care Bathing Feeding Clean Catheterization Gastrostomy feedings in established settings Attending to safety Performing simple dressing changes Suctioning of chronic tracheotomies Performing basic life support

Tasks that may not be delegated to an unlicensed assistive personnel:

§

Assessment

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§ Interpretation of data

§ Making a nursing diagnosis

§ Creation of a nursing care plan

§ Evaluation if care effectiveness

§ Care of invasive lines

§ Administering parenteral medications

§ Performing venipuncture

§ Insertion of NGT

§ Client education

§ Performing triage

§ Giving telephone advise

§ Performing sterile procedures

SOURCE: Kozier Fundamentals of Nursing. 7 th ed. p. 470

53. You made a mistake in giving the medicine to the wrong client. You notify the client's doctor and

write an

incident report. You are demonstrating:

a.Responsibility

b.Accountability

c. Authority

d.Autocracy

CORRECT ANSWER: B RATIONALE: Accountability is the ability and willingness to assume responsibility for one’s actions and accept the consequences of one’s behavior. OPTION A: Responsibility is an obligation to complete a task. OPTION C:Authority is defined as the legitimate right to direct the work of others. Authority is an integral component of managing. OPTION D:Autocracy-government by a single person having unlimited power; despotism.A country or state that is governed by a single person with unlimited power. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 477

Situation 12 - Mr. Dizon, 84 years old, is brought to the .Emergency Room for complaint of hypertension flushed face, severe headache, and nausea. You are doing the initial assessment of vital signs.

54. You are to measure the client's initial blood pressure reading by doing all of the following

EXCEPT:

a.Take the blood pressure reading on both arms for comparison

b. Listen to and identify the phases of Korotkoff's sounds

c. Pump the cuff up to around 50 mmHg above the point where the pulse is obliterated

d.Observe procedures for infection control

CORRECT ANSWER: C RATIONALE: All are correct guidelines in measuring the blood pressure except Option C. The cuff is pumped until the sphygmomanometer reads 30mmHg above the point where the brachial pulse disappeared. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 516

55. A pulse oximeter is attached to Mr. Dizon's finger to:

a. Determine if the client's hemoglobin level is low and if he needs blood transfusion

b.Check level of client's tissue perfusion

c. Measure the efficacy of the client's anti hypertensive medications

d.Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops

CORRECT ANSWER: D RATIONALE: A pulse oximeter is a noninvasive device that measures a client’s arterial blood oxygen saturation by means of a sensor attached to the client’s finger, toe, nose, earlobe or

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forehead ( or around the hand or foot of a neonate). The pulse oximeter can detect hypoxemia before clinical signs and symptoms, such as dusky skin color and dusky nailbeds develop. OPTIONS A, B and C are incorrect SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 517

56. After a few hours in the Emergency Room, Mr. Dizon is admitted to the ward with an order of

hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be:

a.Inconsistent b.low systolic and high diastolic pressure c. higher than what the reading should be d.lower than what the reading should be

CORRECT Answer: C Rationale: When the cuff is too narrow it will give the nurse an erroneously high reading. OPTION A is a result of failure to use the same arm consistently OPTION B is a result of deflating the cuff too quickly OPTION D is a result of using too wide cuff SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 514

57. Through the client's health history, you gather that Mr. Dizon smokes and drinks coffee. When

taking the blood pressure of a client who recently smoked or drank coffee, how long should be the nurse

wait before taking the client's blood pressure for accurate reading? a.15 minutes b.30 minutes

c. 1 hour

d.5 minutes

CORRECT ANSWER: B RATIONALE: Make sure that the client has not smoked or ingested caffeine within 30 minutes prior to measurement. OPTIONS A,C and D are incorrect SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 515

58. While the client has the pulse oximeter on his fingertip, you notice that the sunlight is shining on

the area where the oximeter is. Your action will be to:

a.Set and turn on the alarm of the oximeter b. Do nothing since there is no identified problem c. Cover the fingertip sensor with a towel or bedsheet d.Change the location of the sensor every four hours

CORRECT ANSWER: C RATIONALE: Cover the sensor with sheet or towel to block large amounts of light from external sources (e.g., sunlight, procedure lamps, or bilirubin lights in the nursery). Large amounts of outside light may be sensed by the photodetector and alter the oxygen saturation value. OPTION A: It signals high and low SaO2 measurements and a high and low pulse rate. It is turned on before leaving the patient. OPTION B is a form of negligence OPTION D: done as part of the monitoring to ensure client safety SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 519

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Situation 13 - The nurse's understanding of ethico-legal responsibilities will guide his/her nursing practice.

59. The principles that -govern right and proper conducts of a person regarding life, biology and the

health professions is referred to as:

a.Morality

b.Religion

c. Values

d.Bioethics

CORRECT ANSWER: D RATIONALE: Bioethics is a branch of applied ethics that studies the philosophical, social, and legal issues arising in medicine and the life sciences. It is chiefly concerned with human life and well-being, though it sometimes also treats ethical questions relating to the nonhuman biological environment. OPTION A: The quality of being in accord with standards of right or good conduct. OPTION B: Belief in and reverence for a supernatural power or powers regarded as creator and governor of the universe. OPTION C: Values are considered subjective and vary across people and cultures. Types of values include ethical/moral values, doctrinal/ideological (political, religious) values, social values, and aesthetic values.

60. The purpose of having nurses' code of ethics is:

a.Delineate the scope and areas of nursing practice b.Identify nursing action recommended for specific healthcare situations c. To help the public understand professional conduct, expected of nurses d.To define the roles and functions of the health care giver, nurses, clients

CORRECT ANSWER: C RATIONALE: The professional code of ethics for Filipino nurses provide direction for the nurses to act morally. It strongly emphasizes the four-fold responsibility of the nurse, the universality of the nursing practice, the scope of the responsibilities to the people they serve, to co-workers, to society and environment and to their profession. OPTION A is The RA 9173 of the Nursing Act of 2002 SOURCE: Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10 th Edition.pp. 128-129

61. Potassium chloride (KCL) was ordered by a physician. The nurse administered it by directive

push. The patient died instantly of ventricular fibrillation. She is liable for. a.Negligence b.Malpractice c. Battery d.Assault

CORRECT ANSWER: A

RATIONALE: Negligence is the commission or omission of an act that a reasonable and prudent person would do in a similar situation or would not have done. It is also a misconduct or practice that is below the standard expected of an ordinary, reasonable and prudent person. Such conduct places another person at risk for harm. Both medical and nonmedical professional person can be liable for negligent acts. Below are the specific examples of Negligence:

1. failure to report observations to attending physicians

2. failure to exercise the degree of diligence which the circumstances of the particular case demands.

3. Mistaken Identity

4. wrong medicine, wrong concentration, wrong route, wrong dose.

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5. Defects in the equipment such as stretchers and wheelchairs may lead to falls thus injuring the patient.

6. Errors due to family assistance

7. administration of medicines without the doctor’s prescription.

OPTION B: malpractice in the usual sense implies the idea of improper or unskillful care of a patient by a nurse. Malpractice also denotes stepping beyond one’s authority with serious consequences. Malpractice is a term for negligence or carelessness of professional personnel. An example of malpractice is giving of anesthesia of a nurse or prescribing a medicine. OPTION C: Battery is an intentional, unconsented touching of another person. It is, therefore,

procedures, he must have given consent to this effect. If consent has not been secured, the person performing the procedure may be liable for battery. OPTION D: assault is the imminent threat of harmful or offensive bodily contact. It is unjustifiable to touch another person, to threat to do so in such circumstances as to cause the other to reasonably believe that it will be carried out. SOURCE: Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10 th

Edition.pp

178, 181

62. You inform the patient about his rights which include the following EXCEPT:

a.Right to expect reasonable continuity of care

b. Right to consent to or decline to participate in research studies or experiments

c. Right to obtain information about another patient

d.Right to expect that the records about his care will be treated as confidential

CORRECT ANSWER: C RATIONALE: All are rights of the patient except option C. Other patients don’t have the right to obtain information about the other patients. SOURCE: Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10 th Edition.pp. 358-361

63. The principle states that a person has unconditional worth and has the capacity to determine his

own destiny.

a.Bioethics

b.Justice

c. Fidelity

d.Autonomy

CORRECT ANSWER: D RATIONALE: Autonomy comes from the Greek word autos meaning self and nomos meaning governance. It involves self-determination and freedom to choose and implement one’s decision,

free from deceit, duress, constraint or coercion. OPTION A:Bioethics is a branch of applied ethics that studies the philosophical, social, and legal issues arising in medicine and the life sciences. It is chiefly concerned with human life and well- being, though it sometimes also treats ethical questions relating to the nonhuman biological

environment.

OPTION B: Justice refers to the right to demand to be treated justly, fairly and equally. OPTION C:Exact correspondence with fact or with a given quality, condition, or event; accuracy.

SOURCE: Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10 Edition.pp. 99,103

th

Situation 14 - Your director of nursing wants to improve the quality of health care offered in the hospital. As a staff nurse in that hospital you know that this entails quality assurance programs.

64. A legislative enactment that serves as a defense to malpractice is the Good Samaritan statute. The following statements are correct, except:

a.

It protects health care provides from civil liability that may be incurred in stopping to render aid

at

 

the scene of an accident.

b.

It also applies to hospital care given to a client as long it is of an emergency nature

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c. Health care professionals may still be sued by an injured victim for gross negligence.

d.Health care provides should not charge the patient during an emergency if they want to be

covered by the statute.

CORRECT ANSWER B RATIONALE:All of the choices, except for B, are correct. In the United States, the Good Samaritan Law has been passed to encourage on-the-spot volunteer first aid in emergency situations by persons with knowledge and skill. A nurse therefore who renders first aid or treatment at the scene of an emergency and who does so within the standard of care, acting in good faith, is relieved of the consequences of the act (Venzon, 124). The Good Samaritan Act does not apply in the hospital, only on On-the-spot situations. SOURCE: Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10 th Edition.pp. 124

65. Standards of nursing practice serve as guide for:

a. Nursing practice in the different fields of nursing

b.Proper nursing approaches and techniques

c. Safe nursing care and management

d.Evaluation of nursing cared rendered

CORRECT ANSWER: C RATIONALE: Establishing and implementing standards of practice are major functions of a professional organization. The standards (a) reflect the values and priorities of the nursing

profession, (b) provide direction for professional nursing practice, (c) provide a framework for the evaluation of nursing practice, and (d) define the profession’s accountability to the public and the client outcomes for which nurses are responsible (Kozier, 9). OPTION A does not refer to Standards OPTION B refers to Manual of Procedure OPTION D refers to Controlling of the management process (Marquis, 28).

SOURCE: Kozier & Erb. Fundamentals of Nursing. 7

Marquis, Bessie and Huston, Carol. Leadership Roles and Management Functions in Nursing.

Theory and applications. 5 th Edition.pp. 28

th

Edition.pp. 9

66. You are taking care of critically ill client and the doctor in charge calls to order a DNR (do not

resuscitate)

for the client. Which of the following is the appropriate action when getting DNR order over the phone? a.Have the registered nurse, family spokesperson, nurse supervisor and doctor sign b.Have two nurses validate the phone order, both nurses sign the order and the doctor should sign his order within 24 hours.

c. Have the registered nurse, family and doctor sign the order

d. Have 1 nurse take the order and sign it and have the doctor sign it within 24 hours

CORRECT ANSWER: D RATIONALE: Doctors should limit orders to extreme emergency situations where there is no alternative. Only in an extreme emergency and when no other resident or intern is available should a nurse receive telephone orders. The nurse should read back such order to the physician to make certain the order has been correctly written. Such order should be signed by the physician on his/her next visit within 24 hours. The nurse should sign the name of physician per her own and note the time the order was received. All other options are incorrect SOURCE: Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10 th Edition.pp 172-173

67. To ensure the client safety before starting blood transfusion the following are needed before the

procedure

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a.take baseline vital signs

b. blood should be warmed to room temperature for 30 minutes before blood transfusion is

administered

c. have two nurses verify client identification, blood type, unit number and expiration date of blood

d.get a consent signed for blood transfusion

CORRECT ANSWER: D RATIONALE: Options A,B and C are correct. It is true that consent is signed before the blood transfusion but it’s the physician’s responsibility to let the patient’s sign the consent. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 1402

68. Part of standards of care has to do with the use of restraints. Which of the following statements is

NOT true?

a.Doctor's order for restraints should be signed within 24 hours b.Remove and reapply restraints every two hours

c. Check client's pulse, blood pressure and circulation every four hours

d.Offer food and toileting every two hours

CORRECT ANSWER: C RATIONALE: All options are correct except option C. It is correct to check client’s pulse, blood pressure and circulation but it is done simultaneously every 2 hours when you remove the

restraints.

SOURCE: Kozier & Erb. Fundamentals of Nursing. 689

Situation 15 - During the NUTRITION EDUCATION class discussion a 58 year old man, Mr. Bruno shows increased interest.

69. Mr. Bruno asks what the "normal" allowable salt intake is. Your best response to Mr. Bruno is:

a.1 tsp of salt/day with iodine and sprinkle of MSG b.5 gms per day or 1 tsp of table salt/day

c. 1 tbsp of salt/day with some patis and toyo

d.1 tsp of salt/day but not patis or toyo

CORRECT ANSWER: B RATIONALE: A minimum recommendation is proposed by the RDA in the amount of 500 mg/day for adults. SOURCE: Hogan, Mary Ann and Hill, Karen.Prentice Hall.Reviews and Rationales series for nursing. Nutrition and diet therapy.pp.

70. Your instructions to reduce or limit salt intake include all the following EXCEPT:

a.eat natural food with little or no salt added b.limit use of table salt and use condiments instead

c. use herbs and spices

d.limit intake of preserved or processed food

CORRECT ANSWER: B RATIONALE: All are correct except option B because condiments still contains more sodium along with other spices. Tips for Reducing Sodium in Your Diet Buy fresh, plain frozen, or canned "with no salt added" vegetables. Use fresh poultry, fish, and lean meat, rather than canned or processed types. Use herbs, spices, and salt-free seasoning blends in cooking and at the table. Cook rice, pasta, and hot cereals without salt. Cut back on instant or flavored rice, pasta, and cereal mixes, which usually have added salt Choose "convenience" foods that are lower in sodium. Cut back on frozen dinners, pizza, packaged mixes, canned soups or broths, and salad dressings — these often have a lot of sodium.

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Rinse canned foods, such as tuna, to remove some sodium. When available, buy low- or reduced-sodium, or no-salt-added versions of foods. Choose ready-to-eat breakfast cereals that are lower in sodium. SOURCE: http://www.nhlbi.nih.gov/hbp/prevent/sodium/tips.htm

71. Which of the following behaviors by a client indicates to the nurse that learning in cognitive

domain has taken place? a.Physically demonstrating how to cook low sodium dish b.Actively demonstrating the new skill

c. Telling the nurse that he has accepted the illness and its effects on lifestyle

d.Explaining the need to have low sodium diet

CORRECT ANSWER: D RATIONALE: Learning in the cognitive domain involves the acquisition and use of knowledge mentally or intellectually. OPTION A and B involve learning in the psychomotor domain OPTION C involves learning in the affective domain which involves changing feelings and values toward a positive health behavior. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 448

72.

The nurse determines that dietary teaching has been effective when a client states that which of

the

 

following food items has the highest sodium content?

a. milk

b. fresh fruits

c. meats

d. chocolate pudding

CORRECT Answer: D RATIONALE: Processed foods have the highest sodium content. Chocolate pudding is the only option that reflects a processed food item. The other options are of lower sodium content. SOURCE: Hogan, Mary Ann and Hill, Karen.Prentice Hall.Reviews and Rationales series for nursing. Nutrition and diet therapy.pp. 86

73.

The role of the health worker in health education is to:

a. report incidence of non-communicable disease to community health center

b.educate as many people about warning signs of non-communicable diseases

c. focus on smoking cessation projects

d.monitor clients with hypertension

CORRECT ANSWER: B

RATIONALE: Individuals and communities who seek to increase their personal health and self- care require health education. The trend toward health promotion has created the opportunity for nurses to strengthen the profession’s influence on health promotion, disseminate information that promotes an educated public and assist individuals and communities to change long-standing health behaviors. As health educator, our main function is to educate the people about illness care, the prevention of problems and the promotion of optimal wellness and well-being.

SOURCE: Kozier & Erb. Fundamentals of Nursing.

7 th

Edition.pp.125, 143

Situation 16 - You are assigned to take care of 10 patients during the morning shift. The endorsement includes the IV infusion and medications for these clients.

74. Mr- Felipe, 36 years old is to be given 2700ml of D5RL to infuse for 18 hours starting at 8am. At what rate should the IV fluid be flowing hourly? a.100 ml/hour b.210 ml/hour

c. 150 ml/hour

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CORRECT ANSWER: C

RATIONALE: Milliliters per hour= Total infusion volume/Total infusion time

= 2700ml/18hours

= 150 ml/hr

SOURCE: Kozier & Erb. Fundamentals of Nursing. 1391

75. Mr. Lagro is to receive 1 liter of D5LR to run for 12 hours. The drop factor of the IV infusion set is 10 drops per minute. Approximately, how many drops per minute should the IV is regulated? a.13-14 drops b.17-18 drops c. 10-12 drops d.15-16 drops

CORRECT ANSWER: A RATIONALE: Drops per minute= Total infusion volume x drop factor Total of infusion in minutes = 1000 ml x 10 12hr x 60min

= 13.89 drops

76. You are to apply a transdermal patch of nitroglycerin to your client. The following important

guidelines to observe EXCEPT:

a. Apply to clean hairlines of the skin that are not subject to too much wrinkling b.Patches may be applied to distal part of the extremities like forearm c. Change application and site regularly to prevent irritation of the skin d. Wear gloves to avoid any medication of your hand

CORRECT ANSWER: B RATIONALE: All of the options are correct except option B. Transdermal dosage forms can be applied to any nonhairy part of the skin except distal parts of arms and legs because absoption won’t be maximal at distal sites. SOURCE: Lippincott Williams and Wilkins. Nursing 2006 Drug handbook.26 th Edition.pp. 268

77.

You will be applying eye drops to Miss Romualdez. After checking all the necessary information

and

cleaning the affected eyelid and eyelashes you administer the ophthalmic drops by instilling the eye drops. a.directly onto the cornea b.pressing on the lacrimal duct c. into the outer third of the upper conjunctival sac d.from the inner canthus going towards the side of the eye

CORRECT ANSWER: B RATIONALE: Pressing the lacrimal duct prevents the absorption through the tear duct and drainage of the medication. OPTION A: It is not instilled directly in cornea but on the sac formed by lower lid. OPTION C: it should be outer third of lower conjunctival sac OPTION D: it is true in an eye ointment. SOURCE: Hogan, Mary Ann and Hill, Karen.Prentice Hall.Reviews and Rationales series for nursing. Pharmacology.pp. 580

78. When applying eye ointment, the following guidelines apply EXCEPT:

a.squeeze about 2 cm of ointment and gently close but not squeeze eye b.apply ointment from the inner canthus going outward of the affected eye

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c. discard the first bead of the eye ointment before application because the tube likely to expel

more than desired amount of ointment d.hold the tube above the conjunctival sac do not let tip touch the conjunctiva

CORRECT ANSWER: C Rationale: All are guidelines in administering eye ointment except C. In order not to expel more than the desired amount of the medication, hold the tube of ointment in your hand for a few moments. This will warm the medicine so it will flow easily from the tube. Do not use ointment that has dried out. Or The first bead of ointment from a tube is discarded because it is considered to be contaminated not because it will expel more than the desired amount. SOURCE: Kozier & Erb. Fundamentals of Nursing pp.841; Hogan, Mary Ann and Hill, Karen.Prentice Hall.Reviews and Rationales series for nursing. Pharmacology.pp. 580;

http://www.med.umich.edu/1libr/aha/aha_dropoint_oph.htm

Situation 17 - Nursing management is performing leadership functions of governance and decision- making within organizations employing nurses.

79. The unit manager is meeting with the director of nursing for the unit manager’s yearly

performance review. The director of nursing states that the unit manager needs to improve leadership skills. In

differentiating

leadership from management, the nurse manager recognizes that which of the following approaches will apply?

a. The manager works more one-on-one with staff

b. A leader seeks a higher position on an organizational chart

c. A good leader uses managerial principles

d. A manager is not required to use leadership principles

CORRECT ANSWER: C RATIONALE: A good leader can incorporate managerial theories into practice, whereas a manager does does not necessarily utilize leadership techniques. It is unnecessary to work on- on-one with staff unless the need arises. OPTIONS B and D are false statements SOURCE: Hogan, Mary Ann and Hill, Karen.Prentice Hall.Reviews and Rationales series for nursing. Fundamentals of nursing.pp. 90, 104

80.

When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an unlicensed staff, Mrs. Guevarra.

a.

makes the assignment to teach the staff member

b.is assigning the responsibility to the aide but not the accountability for those tasks

c.

does not have to supervise or evaluate the aide

d.most know how to perform task delegated

CORRECT ANSWER: B RATIONALE: Delegation is the transference of responsibility and authority for the performance of an activity to a competent individual. It is important to note that the nurse is not held legally responsible for the acts of the unlicensed person, but is accountable for the quality of the acts of delegation and has the ultimate responsibility to ensure that proper care is provided. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 470-471

81.

A staff nurse is responsible for the care of the assigned client from admission to discharge. When

the

 

staff nurse is not on duty, others provide care based on instructions left by the staff nurse. Which

type

of nursing assignment does this represent? a.Case management

b.Team

c. Primary

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CORRECT ANSWER: C RATIONALE: In primary nursing, one nurse is responsible for total care of a number of clients 24 hours a day, 7 days a week. Team nursing provides individualized nursing care to clients by a nursing team lead by a professional nurse. The case manager may not provide direct client care but coordinates health care among numerous healthcare workers. Functional nursing care is organized by task with specific tasks being performed by different nursing personnel rather than one nurse. SOURCE: Marquis, Bessie and Huston, Carol. Leadership Roles and Management Functions in Nursing. Theory and applications. 5 th Edition.pp.331-336

82. Process of formal negotiations of working conditions between a group of registered nurses and

employer is:

a.grievance

b.arbitration

c. collective bargaining

d.strike

CORRECT ANSWER: C RATIONALE: Collective bargaining is a legal process used by organized employees to negotiate with an employer about wages and related concerns resulting in an employment contract.

OPTION B: Arbitration includes procedures for using the services of a third party to settle labor

disputes.

OPTION A: Grievance is any complaint by an employer or union concerning an aspect of

employment OPTION D: Strike is a concerted withholding of labor supply to bring about economic pressure on employers and cause them to grant employee demands. SOURCE: Marquis, Bessie and Huston, Carol. Leadership Roles and Management Functions in Nursing. Theory and applications. 5 th Edition.pp. 556; Tomey, Ann Marriner. Guide to Nursing

Management and Leadership. 7

th

Edition. pp.138

83. You are attending a certification program on cardiopulmonary resuscitation (CPR) offered and

required by

the hospital employing you. This is; a.professional course towards credits b.in-service education

c. advance training

d.continuing education

CORRECT ANSWER: B RATIONALE: In-service education program is administered by an employer; it is designed to upgrade the knowledge or skills of employees. Some in-service programs are mandatory such as cardiopulmonary resuscitation and fire safety programs OPTION D: Continuing education refers to formalized experiences designed to enlarge the knowledge or skills of practitioners. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 26

Situation 18 - There are various developments in health education that the nurse should know about.

84. The nurse is preparing a client for a magnetic resonance imaging (MRI). Which of the following

client statements indicates to the nurse that teaching has been successful?

a. “The dye used in the test will turn my urine green for about 24 hours.”

b. “This procedure will take about 90 minutes to complete. There will be no discomfort.”

c. “I will be put to sleep for this procedure. I will return to my room in two hours.”

d. “The wires that will be attached to my head and chest will not cause me any pain.”

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CORRECT ANSWER: B RATIONALE: procedure takes approximately 90 minutes, not painful OPTION A: no dye is used for an MRI OPTION C: client is not anesthetized for this procedure OPTION D:indicates misunderstanding of MRI because no wires are used SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 774

85. In preparing a teaching plan regarding colostomy irrigations, the nurse should include which of

the following?

a. The colostomy needs to be irrigated at the same time every day

b.Irrigate the colostomy after meals to increase peristalsis

c. Insert the catheter about 10 inches into the stoma

d.The solution should be very warm to increase dilation and flow

CORRECT ANSWER: A RATIONALE:Colostomy irrigation should be done at same time each day to assist in establishing a normal pattern of elimination OPTION B: colostomy should be irrigated only once a day OPTION C:catheter should never be inserted more than 4 inches OPTION D:solution should be at body temperature; increasing the temperature does not make irrigation more efficient SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 1250

86. Part of teaching client in health promotion is responsibility for one's health, when Danica states

she need

to improve her nutritional status this means:

a. Goals and interventions to be followed by client are based on nurse's priorities

b.Goals and intervention developed by nurse and client should be approved by the doctor

c. Nurse will decide goals and, interventions needed to meet client goals

d.Client will decide the goals and interventions required to meet her goals

CORRECT ANSWER: D RATIONALE: Health promotion plans need to be developed according to the needs, desires and priorities of the client. The client decides on health promotion goals, the activities or interventions to achieve those goals, the frequency and duration of the activities, and the method of evaluation. During the process the nurse acts as a resource person rather than an advisor or counselor. The nurse provides information when asked, emphasizes the importance of small steps to behavioral change and reviews the client’s goals and plans to make sure they are realistic, measurable and acceptable to the client. OPTION A: It should be based on client’s priorities OPTION D: There is no need for the doctor to approve the goal set by the client OPTION C. The client is the one who will decide. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 133

87.

Nurse Beatrice is providing tertiary prevention to Mrs. De Villa. An example of tertiary prevention

is:

a.Marriage counseling

b.Self-examination for breast cancer

c. Teaching complications of diabetes

d.Poison control

CORRECT ANSWER: A RATIONALE: Marriage counseling is a tertiary prevention. Marriage seminar ir primary prevention and accepting the presence of a problem is a secondary prevention. OPTION B and D are secondary prevention OPTION C is a primary prevention

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88. Mrs. Ostrea has a schedule for Pap smear. She has a strong family history of cervical cancer.

This is an example of:

a.tertiary prevention b.secondary prevention

c. health screening

d.primary prevention

CORRECT ANSWER: B RATIONALE: health promotion ( health education) and illness prevention ( proper nutrition, regular exercise etc.) are primary prevention; diagnosis and treatment are secondary prevention; and rehabilitation and health restoration are tertiary prevention. SOURCE: Kozier & Erb. Fundamentals of Nursing. 89

Situation 19 - Ronnie has a vehicular accident where he sustained injury to his left ankle. In the Emergency Room, you notice how anxious he looks.

89. You establish rapport with him and to reduce his anxiety you initially a.Take him to the radiology, section for X-ray of affected extremity b.Identify yourself and state your purpose in being with the client

c. Talk to the physician for an order of Valium

d.Do inspection and palpation to check extent of his injuries

CORRECT ANSWER: B RATIONALE: Nurses carry out measures to minimize client’s anxiety and stress by providing an atmosphere of warmth and trust and convey a sense of caring and empathy. For example, explain procedures before they are implemented including sensations likely to be experienced during the procedure. OPTION A: you disregard the feeling of the patient could further aggravate anxiety level OPTION C is inappropriate OPTION D: inappropriate , further aggravate anxiety SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 1023-1024

90. While doing your assessment, Ronnie asks you "Do I have a fracture? I don't want to have a

cast."

The most appropriate nursing response would be:

a. "You have to have an X-ray first to know if you have a fracture."

b."Why do you; sound so scared? It is just a cast and it's not painful"

c. "You seem to be concerned about being in a cast."

d. "Based on my assessment, there doesn't seem to be a fracture."

CORRECT ANSWER: C RATIONALE: Option C is reflecting. It is directing ideas, feelings, questions or content back to clients to enable them to explore their own ideas and feelings about a situation. OPTION A ignores the client’s feeling OPTION B belittle the client’s feeling OPTION D is giving false reassurance

Situation 20 - You are taking care of Mrs. Leyba, 66 years old, who is terminally ill with ovarian cancer stage IV.

91. When caring for a dying client you will perform which of the following activities?

a. Encourage the client to reach optimal health

b.Assist client perform activities of daily living

c. Assist the client towards a peaceful death

d. Motivate client to gain independence

CORRECT ANSWER: C

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RATIONALE: Nurses need to ensure that the client is treated with dignity, that is with honor and respect. Dying clients often feel they have lost control over their lives and over life itself. Helping clients die with dignity involves maintaining their humanity, consistent with their values, beliefs and culture. Clients want to be able to manage the events preceding death so they can die peacefully. Nurses can help clients to determine their own physical, psychologic and social

priorities.

OPTIONS A, B and D are inappropriate SOURCE: Kozier & Erb. Fundamentals of Nursing. 1050

92. The client prepares for eventual death and discusses with the nurse and her family how she would like her funeral to look like and what dress she will use. This client is in the stage of:

a.acceptance

b.resolution

c. denial

d.bargaining

CORRECT ANSWER: A RATIONALE: The model was introduced by Elizabeth Kübler-Ross in her 1969 book "On Death and Dying". The stages have become well-known as the "Five Stages of Grief". The stages are:

1.

Denial: "It can't be happening."

2.

Anger: "Why me? It's not fair."

3.

Bargaining: "Just let me live to see my children graduate."

4.

Depression: "I'm so sad, why bother with anything?"

5.

Acceptance: "It's going to be OK."

Acceptance-there is a difference between resignation and acceptance. You have to accept the loss, not just try to bear it quietly. Realization that it takes two to make or break a marriage. Realization that the person is gone (in death) that it is not their fault, they didn't leave you on purpose. (even in cases of suicide, often the deceased person, was not in their right frame of mind) Finding the good that can come out of the pain of loss, finding comfort and healing. Our goals turn toward personal growth. Stay with fond memories of person. SOURCE: http://en.wikipedia.org/wiki/K%C3%BCbler-Ross_model

Situation 21 - You are a newly hired nurse in a tertiary hospital. You have finished your orientation program recently and you are beginning to assimilate the culture of the profession.

93. Using Benner’s stages of nursing expertise, you are a beginning nurse practitioner. You will rank yourself as a/an:

a. competent nurse

b. novice nurse

c. proficient nurse

d. advanced beginner

CORRECT ANSWER: B RATIONALE: Benner’s model describes five levels of proficiency in nursing-based on the Dreyfus general model of skill acquisition. The five stages, which have implications for teaching and learning, are novice, advanced beginner, competent, proficient, and expert. Benner's Stages of Clinical Competence Stage 1: Novice Beginners have had no experience of the situations in which they are expected to perform. Novices are taught rules to help them perform. The rules are context-free and independent of specific cases; hence the rules tend to be applied universally. The rule-governed behavior typical of the novice is extremely limited and inflexible. As such, novices have no "life experience" in the application of rules. "Just tell me what I need to do and I'll do it."

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Stage 2: Advanced Beginner Advanced beginners are those who can demonstrate marginally acceptable performance, those who have coped with enough real situations to note, or to have pointed out to them by a mentor, the recurring meaningful situational components. These components require prior experience in actual situations for recognition. Principles to guide actions begin to be formulated. The principles are based on experience.

Stage 3: Competent Competence, typified by the nurse who has been on the job in the same or similar situations two or three years, develops when the nurse begins to see his or her actions in terms of long-range goals or plans of which he or she is consciously aware. For the competent nurse, a plan establishes a perspective, and the plan is based on considerable conscious, abstract, analytic contemplation of the problem. The conscious, deliberate planning that is characteristic of this skill level helps achieve efficiency and organization. The competent nurse lacks the speed and flexibility of the proficient nurse but does have a feeling of mastery and the ability to cope with and manage the many contingencies of clinical nursing. The competent person does not yet have enough experience to recognize a situation in terms of an overall picture or in terms of which aspects are most salient, most important.

Stage 4: Proficient The proficient performer perceives situations as wholes rather than in terms of chopped up parts or aspects, and performance is guided by maxims. Proficient nurses understand a situation as a whole because they perceive its meaning in terms of long-term goals. The proficient nurse learns from experience what typical events to expect in a given situation and how plans need to be modified in response to these events. The proficient nurse can now recognize when the expected normal picture does not materialize. This holistic understanding improves the proficient nurse's decision making; it becomes less labored because the nurse now has a perspective on which of the many existing attributes and aspects in the present situation are the important ones. The proficient nurse uses maxims as guides which reflect what would appear to the competent or novice performer as unintelligible nuances of the situation; they can mean one thing at one time and quite another thing later. Once one has a deep understanding of the situation overall, however, the maxim provides direction as to what must be taken into account. Maxims reflect nuances of the situation.

Stage 5: The Expert The expert performer no longer relies on an analytic principle (rule, guideline, maxim) to connect her or his understanding of the situation to an appropriate action. The expert nurse, with an enormous background of experience, now has an intuitive grasp of each situation and zeroes in on the accurate region of the problem without wasteful consideration of a large range of unfruitful, alternative diagnoses and solutions. The expert operates from a deep understanding of the total situation. The chess master, for instance, when asked why he or she made a particularly masterful move, will just say: "Because it felt right; it looked good." The performer is no longer aware of features and rules;' his/her performance becomes fluid and flexible and highly proficient. This is not to say that the expert never uses analytic tools. Highly skilled analytic ability is necessary for those situations with which the nurse has had no previous experience. Analytic tools are also necessary for those times when the expert gets a wrong grasp of the situation and then finds that events and behaviors are not occurring as expected When alternative perspectives are not available to the clinician, the only way out of a wrong grasp of the problem is by using analytic problem solving. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 13;

http://www.sonoma.edu/users/n/nolan/n312/benner.htm

94. Benner’s proficient nurse level is different from the other levels in nursing expertise in the context of having:

a.the ability to organize and plan activities b.having attained an advanced level of education c. a holistic understanding and perception of the client d. intuitive and analytic ability in new situations

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CORRECT ANSWER: C RATIONALE: Stage 4: Proficient The proficient performer perceives situations as wholes rather than in terms of chopped up parts or aspects, and performance is guided by maxims. Proficient nurses understand a situation as a whole because they perceive its meaning in terms of long-term goals. The proficient nurse learns from experience what typical events to expect in a given situation and how plans need to be modified in response to these events. The proficient nurse can now recognize when the expected normal picture does not materialize. This holistic understanding improves the proficient nurse's decision making; it becomes less labored because the nurse now has a perspective on which of the many existing attributes and aspects in the present situation are the important ones. The proficient nurse uses maxims as guides which reflect what would appear to the competent or novice performer as unintelligible nuances of the situation; they can mean one thing at one time and quite another thing later. Once one has a deep understanding of the situation overall, however, the maxim provides direction as to what must be taken into account. Maxims reflect nuances of the situation. OPTION A : Stage 3, Competent OPTION D: Stage 5. Expert SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp. 13;

http://www.sonoma.edu/users/n/nolan/n312/benner.htm

95. The nurse checks for placement of a nasogastric (NG) tube before beginning a tube feeding for a

client. Which of the following results would indicate to the nurse that the tube feeding can begin? a.A small amount of white mucus is aspirated from the NG tube

b.The pH of the contents removed from the NG tube is 3 c. No bubbles are seen when the nurse inverts the NG tube in water d.The client says he can feel the NG tube in the back of his throat

CORRECT ANSWER: B RATIONALE: Stomach contents are acidic. Research indicates that testing pH is a realiable way to determine location of a feeding tube. OPTION A:may be from lungs OPTION C: not a safe way to check placement OPTION D: not a reliable indication SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 th Edition.pp.

96. The nurse in the outpatient clinic assists with the application of a cast to the left arm of a five-year

old girl.

After the cast is applied, the nurse should a. petal the edges of the cast to prevent irritation b.elevate the client’s left arm on two pillows

c. apply cool, humidified

d.ask the client to move her fingers to maintain mobility

air to dry the cast

CORRECT ANSWER: B RATIONALE: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? Option B is correct. It minimizes swelling, elevated for first 24-48 hours, protects from pressure and flattening of cast OPTION A: done when cast is completely dry, prevents crumbling of plaster into cast OPTION C: would delay drying of cast OPTION D: maintaining mobility of fingers not most important after application of cast

97. A nurse teaches a health class at the local library to a group of senior citizens. Which of the

following behaviors should the nurse emphasize to facilitate regular bowel elimination?

a.Avoid strenuous activity b.Eat more foods with increased bulk

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c. Decrease fluid intake to decrease urinary losses

d.Use oral laxatives so that a bowel pattern emerges

CORRECT ANSWER: B RATIONALE: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?Option B is correct. It is contained in whole grains, legumes, vegetables, fruits, seeds, nuts, bulk promotes peristalsis OPTION A: regular exercise program facilitates bowel elimination OPTION C: fluid intake of 1,500 cc/day facilitates bowel elimination OPTION D: laxatives used as last resort because they become habit-forming

98. An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should

position the client

a. in semi-Fowler’s position

b. prone, with the head turned to the side

c. with the head of the bed elevated 45° and the neck extended

d. supine, with the head in the midline position

CORRECT ANSWER: A RATIONALE: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? Option A:correct–check vital signs every 15 minutes until stable, assess for respiratory difficulty (stridor and dyspnea resulting from laryngeal edema or laryngospasm) OPTION B: would limit respiratory excursion and assessment of breathing OPTION C: extension of neck could obstruct airway because tongue falls in back of mouth OPTION D: not best position after procedure

99. The nurse is reviewing procedures with the health care team. The nurse should intervene if an RN staff member makes which of the following statements?

a.“It is my responsibility to ensure that the consent form has been signed and is attached to the patient’s chart.” b.“It is my responsibility to witness the signature of the patient before surgery is performed.”

c. “It is my responsibility to explain the surgery and ask the patient to sign the consent form.”

d.“It is my responsibility to answer questions that the patient may have before surgery.”

CORRECT ANSWER: C RATIONALE: Strategy: "Nurse would intervene" indicates that you should look for an incorrect statement.Question is unstated. Read answer choices for clues.Option C: correct–physician should provide explanation and obtain patient's signature OPTION A:describes the nurse's responsibility in obtaining consent OPTION B:signature indicates that the nurse saw the patient sign the form OPTION D:.the nurse should answer questions after the physician has obtain consent

100. For a client with a neurological disorder, which of the following nursing assessments will be

MOST helpful in determining subtle changes in the client’s level of consciousness? a.Client posturing b.Glasgow coma scale c.Client thinking pattern d.Occurrence of hallucinations

CORRECT ANSWER: B RATIONALE: Strategy: Think about each answer choice. Option B:correct–Glasgow coma scale score best evaluates changes in a client’s level of consciousness by evaluating eye-opening, motor, and verbal responses OPTION A: indicates increased intracranial pressure OPTION C: more appropriate for the psychiatric client OPTION D: more appropriate for the psychiatric client

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Software http://www.foxitsoftware.com For evaluation only. Situation 1 - Nurse Minette is an independent Nurse

Situation 1 - Nurse Minette is an independent Nurse Practitioner following-up referred clients in their respective homes. Here she handles a case of POSTPARTAL MOTHER AND FAMILY focusing on HOME CARE.

1.

Nurse Minette needs to schedule a first home visit to OB client Leah, when is a first home-care visit typically made? a.Within 4 days after discharge b.Within 24 hours after discharge c. Within 1 hour after discharge d.Within 1 week of discharge

CORRECT ANSWER: A RATIONALE: Recommended Schedule of Post partum Care visits:

1st visit – 1st week post Partum preferably 3-5 days 2nd visit- 6 weeks post partum SOURCE: DOH: Public Health Nursing in the Philippines. Pp 125

2.

Leah is developing constipation from being on bed rest, what measures would you suggest she take to help prevent this?

a. Eat more frequent small meals instead of three large one daily

b. Walk for at least half an hour daily to stimulate peristalsis

c. Drink more milk, increased calcium intake prevents constipation

d. Drink eight full glasses of fluid such as water daily

CORRECT ANSWER: B RATIONALE: Early ambulation, a good diet with adequate roughage and adequate fluid intake all aid in preventing the problem of constipation. Options A and D are possible answers but in the situation, bed rest causes the constipation. Therefore, in order to prevent this allow the postpartal woman to ambulate. SOURCE:Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 644

3.

If

you were Minette, which of the following actions, would alert you that a new mother is entering

a postpartal at taking-hold phase?

a. She urges the baby to stay awake so that she can breast-feed him in her

b. She tells you she was in a lot of pain all during labor

c. She says that she has not selected a name for the baby as yet.

d. She sleeps as if exhausted from the effort of labor

CORRECT ANSWER: A RATIONALE: Taking hold phase the second phase of the postpartal period where the woman begins to initiate action. The mother is independent and show care for her baby. OPTION B: Taking in phase- the first phase of the postpartal period experienced when the woman is usually 2-3 days postpartum, she is dependent to others and does not show interest in taking care of the baby.

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OPTION C: Taking in phase OPTION D: Taking in Phase SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 623

4.

At 6-week postpartum visit what should this postpartal mother's fundic height be?

a. Inverted and palpable at the cervix

b. Six fingerbreadths below the umbilicus

c. No longer palpable on her abdomen

d. One centimeter above the symphysis pubis

CORRECT ANSWER: C RATIONALE: On the first postpartal day, it will be palpable one fingerbreath below the umbilicus; on the second day, two fingerbreadths below the umbilicus; and so on. Because a fingerbreadth is about 1cm, this can be recorded as 1cm below the umbilicus, 2cm below it and so forth. In the average woman by the ninth or tenth day, the uterus will have contracted so much that it is withdrawn into the pelvis and can no longer be detected by abdominal palpation. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 628

4.

This postpartal mother wants to loose the weight she gained in pregnancy, so she is reluctant to increase her caloric intake for breast-feeding. By how much should a lactating mother increase her caloric intake during the first 6 months after birth? a.350 cal/day b.500 cal/day c. 200 cal/day d.1,000 cal/day

CORRECT ANSWER: B RATIONALE: A woman who is breast-feeding needs an additional 500 calories (i.e., a 2700-kcal diet) and an additional 500ml of fluid ( this may be from the same source) each day to encourage the production of high quality breast milk. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 641

Situation 2 – Nurse Lisa manages her own Reproductive and Children’s Nursing Clinic in Sorsogon and necessarily she attends to health conditions of mothers and children. The following questions pertains to the growing fetus.

5. Obstetrical client Marichu asks how much longer Nurse Lisa will refer to the baby inside her as an

embryo.

What would be your best explanation?

a. Her baby will be a fetus as soon as the placenta forms

b. From the time of implantation until 5 to 8 weeks, the baby is an embryo

c. After the 20 th week of pregnancy, the baby is called a zygote

d. This term is used during the time before fertilization

CORRECT ANSWER: B

RATIONALE: Under fetal development:

2 weeks after conception

Embryonic period- beginning of the third week through the 8 weeks after conception

Fetal period- beginning of the 9 th week after conception and ending with birth SOURCE: Saunder’s Comprehensive review for the NCLEX-RN. 3 RD Edition.pp.253

Pre embryonic period- the 1

st

6. Marichu is worried that her baby will be born with a congenital heart disease. What assessment of a fetus at birth is important to help detect congenital heart defect?

a. Determining that the color of the umbilical cord is not green

b. Assessing whether the umbilical cord has two arteries and one vein

c. Assessing whether the Wharton’s jelly of the cord has a pH higher than 7.2

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d. Measuring the length of the cord to be certain that it is longer than 3 feet

CORRECT ANSWER: B RATIONALE: A normal cord contains one vein and two arteries. The absence of the umbilical arteries is associated with congenital heart and kidney anomalies, because the insult that caused the loss of the vessel may have affected other mesoderm germ layer structures as well. SOURCE:Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 615-616

7. Additionally, Nurse Lisa would gather more information about Marichu’s worry about what may threaten the health of her baby. What would Nurse Lisa hope to find?

a. Has Marichu been overly anxious about something

b.Has Marichu suffered from any communicable/contagious disease at the time of her early stage

of pregnancy

c. Has Marichu engage in sexual activity during the fetal development state of her child

d.Has Marichu engaged in any detrimental activities during the fetal development stage (e.g.

smoking, drinking, taking drugs, a bad fall, or attempts to terminate pregnancy.)

CORRECT ANSWER: D RATIONALE: During the early time of organogenesis (organ formation) the growing structure is most vulnerable to invasion by teratogens. (any factors that affects the fertilized ovum, embryo, fetus adversely, such as alcohol). It is important to teach women how to minimize their exposure to teratogens during these times OPTION B: A number of infections are not teratogenic to a fetus during pregnancy but are harmful if they are present at the time of birth. OPTION C: Sexual intercourse does not affect fetal development. SOURCE:Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 190,290, 94

8. Marichu is scheduled to have an ultrasound examination. What instruction would you give her before her examination?

a. You can have medicine for pain for any contraction caused by the test

b. Drink at least 3 glassess of fluid before the procedure

c. The intravenous fluid infused to dilate your uterus does not hurt the fetus

d. Void immediately before the procedure to reduce your bladder size

CORRECT ANSWER: B RATIONALE: Before ultrasound, the mother needs to have a full bladder in order for the sound waves to reflect best and the uterus to be held stable. In order to ensure a full bladder, a woman should drink a full glass of water 15 minutes beginning, 90 minutes before the procedure and should not void before the procedure. SOURCE:Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 615-616

9. Marichu is scheduled to have an amniocentesis to test for fetal maturity. What instruction would you give her before this procedure?

a. The x-ray used to reveal your fetus position has no long term effects

b. The intravenous fluid infused to dilate your uterus does not hurt the fetus

c. No more amniotic fluid form afterward, which is why only a small amount is removed

d. Void immediately before the procedure to reduce your bladder size.

CORRECT ANSWER: D RATIONALE: Amniocentesis is the withdrawal of amniotic fluid through the abdominal wall for analysis at 14 th -16 th week of pregnancy. In preparation for amniocentesis, ask the woman to void (to reduce the size of the bladder, thus preventing in advertent puncture). OPTION A: X-ray is not used in amniocentesis OPTION B: Intravenous fluid is not infused to dilate the uterus SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 207

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Situation 3 - Nurse Anna is a new BSN graduate and has just passed her Licensure Examination for Nurses in the Philippines. She has likewise been hired as a new Community Health Nurse in one of the Rural Health Units in their City, which of the following conditions may be acceptable TRUTHS applied to Community Health Nursing Practice.

11. Which of the following is the primary focus of community health nursing practice? a.Cure of illnesses b.Prevention of illness c. Rehabilitation back to health d.Promotion of health

CORRECT ANSWER: D RATIONALE:The primary focus of community health nursing practice is on health promotion. The community health nurse by the nature of his/her work has the opportunity and responsibility for evaluating the health status of people and groups and relating them to practice. SOURCE: DOH CHN pp. 17

12. In community health nursing, which of the following is our unit of service as nurses? a.The Community b.The Extended Members of every family c. The individual members of the Barangay d.The Family

CORRECT ANSWER: D RATIONALE: One of the principles of the Community Health Nursing, the family is the unit of service. SOURCE: DOH CHN pp. 19

13. A very important part of the Community Health Nursing Assessment Process includes; a. The application of professional judgment in estimating importance of facts to family and community b.Evaluation structures arid qualifications of health center team c. Coordination with other sectors in relation to health concerns d.Carrying out nursing procedures as per plan of action

CORRECT ANSWER: A RATIONALE: The process of assessment in community health nursing includes; intensive fact finding, the application of professional judgment in estimating the meaning and importance of these facts to the family and the community, the availability of nursing resources that can be provided, and the degree of change which nursing intervention can be expected to effect. SOURCE:DOH CHN pp. 45

14. In community health nursing it is important to take into account the family health with an equally

important need to perform ocular inspection of the areas activities which are powerful elements of:

a.evaluation

b.assessment

c. implementation

d.planning

CORRECT ANSWER: B RATIONALE: Assessment provides an estimate of degree to which a family, group or community is achieving the level of health possible for them, identify specific deficiencies for guidance needed and estimates the possible effects of the nursing interventions. SOURCE: DOH CHN pp. 43

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15. The initial step in the PLANNING process in order to engage in any nursing project or parties at

the community

level involves:

a.goal-setting

b.monitoring

c. evaluation of data

d.provision of data

CORRECT ANSWER: A

RATIONALE: The plan for nursing action or care is based on the actual and potential problems that were Identified and prioritized. Planning nursing actions include the following steps:

1. Goal setting- a goal is declaration of purpose or intent that gives essential direction to

action.

2. Constructing a Plan of Action: the planning phase of community health nursing process

is

concerned with choosing from among the possible courses of action,

selecting

the appropriate types of nursing intervention, identifying appropriate and

available

resources for care and developing an operational plan

3. Developing an Operational Plan- to develop an operational plan, the community health

nurse

must establish priorities, phase and coordinate activities.

4. Implementation of Planned Care- In community health nursing, implementation

involves various

nursing interventions which have been previously set.

5. Evaluation of Care and Services Provided- evaluation is interwoven in every nursing

activity

and every step of the community health nurses. SOURCE: DOH CHN Page 46-48

16. Transmission of HIV from an Infected Individual to another person occurs:

a.Most frequently in nurses with needle sticks

b. Only if there is a large viral load in the blood

c. Most commonly as a result of sexual contact

d. In all infants born to women with HIV infection

CORRECT ANSWER: C RATIONALE: Human Immunodeficiency Virus Causative agent: Retrovirus- Human T-cell lymphotrophic virus 3 (HTLV-3) Mode of transmission:

Sexual contact

Blood transfusion

Contaminated syringes, needles, nipper, razor blades

Direct contact of open wound/mucous membrane with contaminated blood,

body fluids, semen and vaginal discharges. OPTION D: All neonates born to HIV positive mothers acquire maternal antibody to HIV infection,

but not all acquire the infection. SOURCE: DOH CHN Page 294; Saunders Comprehensive Review for the NCLEX-RN 3 rd edition Page 346

17. The medical record of a client reveals a condition in which the fetus cannot pass through the

maternal pelvis. The nurse interprets this as:

a.Contracted pelvis

b.Maternal disproportion

c. Cervical insufficiency

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CORRECT ANSWER: D RATIONALE: A disproportion between the size of the normal fetal head and the pelvic diameters. This results in failure to progress in labor. OPTIONS A,B & C does not exist. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 606

18. The nurse would anticipate a cesarean birth for a client who has which infection present at the

onset of labor? a.Herpes simplex virus

b.Human papilloma virus

c. Hepatitis

d.Toxoplasmosia

CORRECT ANSWER: A RATIONALE: If a woman has a primary infection, herpes can be transmitted across the placenta

to cause congenital infection in the newborn, if a woman has primary or secondary active lesions

in the vagina or on the vulva at the time of birth, herpes infection can be transmitted to the

newborn at birth.If no lesion are present vaginal birth is preferable. OPTION B: Human Papilloma Virus= the presence of vulvar lesions appears to have no effect on

the fetus during pregnancy, but if they are present in the time of birth and obstruct the birth canal

a C/S may be necessary.

OPTION C: Hepatitis A not known to be transmitted to the fetus. Hepatitis B&C are spread by exposure to contaminated blood or blood products. OPTION D: Toxoplasmosis is transmitted to the mother through a raw meat or handling of cat litter of infected in the the mother; organism is transmitted to the fetus across the placenta. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 351

19. After a vaginal examination, the nurse determines that the client's fetus is in an occiput posterior

position. The nurse would anticipate that the client will have:

a. A precipitous birth

b. Intense back pain

c. Frequent leg cramps

d. Nausea and vomiting

CORRECT ANSWER: B RATIONALE: A posterior position is suggested by a dysfunctional labor pattern such as a prolonged active active phase, arrested descent, or fetal heart sounds heard best at the lateral sides of the abdomen.

A posterior head does not fit the cervix as snugly as one in an anterior portion. Because

this

increases the risk of umbilical cord prolapse, the position of the fetus is confirmed by vaginal examination or by sonogram. Because the arc of rotation is greater, it is usual for the labor to somewhat prolonged.

Because the fetal head rotates against the sacrum, a woman may experience pressure

and pain in her lower back due to sacral nerve compression. This sensations may be so intense that she

asks for

medication for relief, not for her contractions but for the intense back pressure and pain. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 600-601

20. The rationales for using a prostaglandin gel for a client prior to the induction of labor is to:

a. Soften and efface the cervix

b. Numb cervical1 pain receptors

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c. Prevent cervical lacerations

d. Stimulate uterine contractions

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CORRECT ANSWER: A RATIONALE: Prostaglandin such as Misoprostol (cytotec) are more commonly used method of

speeding cervical ripening. Applied to the interior surface of the cervix by a catheter or

suppository.

SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 608

Situation 4 - Nurse Lorena is a Family Planning and Infertility Nurse Specialist and currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions pertain to meeting the nursing needs of this particular population group.

21. Dina, 17 years old, asks you how a tubal ligation prevents pregnancy. Which would be the best

answer?

a. Prostaglandins released from the cut fallopian tubes can kill sperm

b. Sperm cannot enter the uterus, because the cervical entrance is blocked

c. Sperm can no longer reach the ova, because the fallopian tubes are blocked

d. The ovary no longer releases ova, as there is no where for them to go

CORRECT ANSWER: C RATIONALE: Tubal ligation= the fallopian tubes are occluded by cautery, crushing, clamping or blocking and thereby preventing passage of both sperm and ova. SOURCE:Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 123

22. The Dators are a couple undergoing testing for infertility. Infertility is said to exist when:

a. a woman has no uterus

b. a woman has no children

c. a couple has been trying to conceive for 1 year

d. a couple has wanted a child for 6 months

CORRECT ANSWER: C RATIONALE: Infertility is said to exist when a pregnancy has not occurred after at least 1 year of engaging in unprotected coitus. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 136

23.

Another client names Lilia is diagnosed as having endometriosis. This condition interferes with

the

 

fertility because:

a. endometrial implants can block the fallopian tubes

b. the uterine cervix becomes inflamed and swollen

c. ovaries stop producing adequate estrogen

d. pressure on the pituitary leads to decreased FSH levels

CORRECT ANSWER: A RATIONALE: Endometriosis refers to the implantation of uterine endometrium or nodules, that have spread from the interior of the uterus to locations outside the uterus. If growths occur in the fallopian tube, tubal obstruction may result or adhesions forming from these growths may displace fallopian tubes away from the ovaries preventing the entrance of ova into the tubes. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 139

24.

Lilia is scheduled to have a hysterosalpingogram. Which of the following, instructions would you

give

her regarding this procedure?

a. She will not be able to conceive for 3 months after the procedure

b. The sonogram of the uterus will reveal any tumors present

c. Many women experience mild bleeding as an after effect

d. She may feel some cramping when the dye is inserted

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CORRECT ANSWER: D RATIONALE: Hysterosalpingogram= a radiologic examination of the fallopian tubes using a

radiopaque medium, is the most frequently used method of assessing tubal patency. Because the medium is thick, it distends the uterus and tubes slightly, causing momentary painful uterine

cramping.

SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 144

25. Lilia's cousin on the other hand, knowing nurse Lorena's specialization asks what artificial

insemination by

donor entails. Which would be your best answer if you were Nurse Lorena?

a. Donor sperm are introduced vaginally into the uterus or cervix

b. Donor sperm are injected intra-abdominally into each ovary

c. Artificial sperm are injected vaginally to test tubal patency

d. The husband's sperm is administered intravenously weekly

CORRECT ANSWER: A RATIONALE: Artificial Insemination is the installation of sperm into the female reproductive tract to aid conception. The sperm can be instilled into the cervix (intracervical insemination) or into the uterus (intrauterine insemination. Donor sperm (artificial insemination by donor or therapeutic donor insemination) can be used. These test can be used if the man has an inadequate sperm count or the woman has a vaginal or cervical factor that interferes with sperm motility. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 148

Situation 5 - There are other important basic knowledge in the performance of our task as Community Health Nurse in relation to IMMUNIZATION these include:

26. The correct temperature to store vaccines in a refrigerator is:

a. between -4 deg C and +8 deg C b.between 2 deg C and +8 deg C c. between -8 deg C and 0 deg C d. between -8 deg C and +8 deg C

CORRECT ANSWER: B RATIONALE: Vaccines are substances very sensitive to various temp. to avoid spoilage and maintain potency, vaccines need to be stored at correct temperature. Below are recommended storage temperatures of EPI vaccines.

   

Types/Form of vaccines

 

Storage Temperature

Most Sensitive to Heat

Oral Polio (live attenuated)

-15C to -25C ( at the freezer)

Measles (freeze dried)

-15C to -25C ( in the body of the refrigerator

Least sensitive to Heat

DPT/Hep B

+2C to +8C (in the body of the

“D” Toxoid which is a weakened

refrigerator)

toxin “P” Killed bacteria

 

“T” Toxoid which is a weakend toxin

 

Hep B

+2 C to + 8 C ( in the body of the refrigerator)

BCG ( freeze dried)

+2 C to + 8 C ( in the body of the refrigerator)

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Tetanus Toxoid

Tetanus Toxoid

Tetanus Toxoid

SOURCE: Public health Nursing in the Philippines, Page 151

27. Which of the following vaccines is not done by intramuscular (IM) injection? a.Measles vaccine

b.DPT

c.Hep B vaccines

d.DPT

CORRECT ANSWER: A RATIONALE: Measles vaccine give subcutaneous at the outer part of the upper arm OPTION B: DPT= intramuscular given at the upper outer portion of the thigh OPTION C: Hep B vaccine= intramuscular, given at the upper outer portion of the thigh OPTION D: DPT= intramuscular given at the upper outer portion of the thigh SOURCE: Public health Nursing in the Philippines, Page 152

28. According to the new EPI Routine Schedule of immunization, when is Hepa B vaccine first given?

a. 6 weeks

b. 9 months

c. 12 months

d. at birth

CORRECT ANSWER: D RATIONALIZATION: Hepa B vaccine is first given at birth. Six weeks interval from first dose to second dose and 8 weeks interval from second dose to third dose. An early start of Hep B

reduces the chance of being infected and becoming a carrier and prevents liver cirrhosis and liver

cancer.

SOURCE:PHN pp.149

29. This is the vaccine needed before a child reaches one (1) year in order for him/her to qualify as a

"fully immunized child".

a. DPT

b. Measles

c. Hepatitis B

d. BCG

CORRECT ANSWER: B Rationale: Because it is given when the child reaches 9 months of age and the last vaccine to be

administered.

SOURCE: DOH CHN page 111

30. Which of the following dose of tetanus toxoid is given to the mother to protect her .infant from

neonatal tetanus and likewise provide 10 years protection for the mother?

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a. Tetanus toxoid 3

b. Tetanus toxoid 2

c. Tetanus toxoid 1

d. Tetanus toxoid 4

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CORRECT ANSWER: D RATIONALE: Tetanus toxoid vaccination for women is important to prevent tetanus in both mother and the baby. TT4 gives 10 years protection for the mother. OPTION A: TT3 gives 5 years protection for the mother OPTION B: TT2 gives 3 years protection for the mother. OPTION C: TT1 gives no protection SOURCE: PHN, Page 150

Situation 6 - Records contain those comprehensive descriptions of patient's health conditions and needs and at the same serve as evidences of every nurse's accountability in the care giving process. Nursing records normally differ from institution to, institution nonetheless they follow similar patterns of .meeting needs for specifics, types of information. The following pertains to documentation/records management.

31. This special form used when the patient is admitted to the unit. The nurse completes the

information in this records particularly his/her basic personal data, current illness, previous health history, health

history of the

family, emotional profile, environmental history as well as physical assessment together with nursing diagnosis on admission, what do you call this record?

a. Nursing Kardex

b. Nursing Health History and Assessment Worksheet

c. Medicine and Treatment Record

d. Discharge Summary

CORRECT ANSWER: B RATIONALE: AKA Admission Nursing Assessment/ Initial data base/Nursing History or Nursing Assessment. This is completed when the client is admitted to the nursing unit. This forms can be organized according to body systems, functional abilities, health problems and risks. OPTION A: Kardex is a widely used, concise method of organizing and recording data about a client making information quickly accessible to all health professionals. OPTION C: Medicine and treatment record- medication flow sheets usually include designated areas for the date of the medication order, the expiration date, the medication name and dose, the frequency of administration and route and the nurses signature. OPTION D: Nursing Discharge/ Referral Summary- a discharge note and referral summary are completed when the client is being discharged and transferred to another institution or to a home setting where a visit by a community health nurse is required. SOURCE: Fundamentals of Nursing 7 th edition by Barbara Kozier, Page 339

32. These, are sheets/forms which provide an efficient and time saving way to record information that

must be

obtained repeatedly at regular and/or short intervals of time. This does not replace the progress notes; instead this record of information on vital signs, intake and output, treatment, postoperative care, postpartum care, and diabetic regimen, etc., this is used whenever specific measurements or observations are needed to-be documented repeatedly. What is this?

a. Nursing Kardex

b. Graphic Flow sheets

c. Discharge Summary

d. Medicine and Treatment Record

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CORRECT ANSWER: B RATIONALE: Graphic flow sheet- a flow sheet enables nurses to record nursing data quickly and concisely and provides an easy-to-read record of the clients condition over time. OPTION A: Kardex is a widely used, concise method of organizing and recording data about a client making information quickly accessible to all health professionals. OPTION C: Nursing Discharge/ Referral Summary- a discharge note and referral summary are completed when the client is being discharged and transferred to another institution or to a home setting where a visit by a community health nurse is required. OPTION D: Medicine and treatment record- medication flow sheets usually include designated areas for the date of the medication order, the expiration date, the medication name and dose, the frequency of administration and route and the nurses signature. SOURCE:Fundamentals of Nursing 7 th edition by Barbara Kozier, Page 339

33. These records show all medications and treatment provided on a repeated basis. What do you call this record?

a. Nursing Health History and Assessment Worksheet

b. Discharge Summary

c. Nursing Kardex

d. Medicine and Treatment Record

CORRECT ANSWER: D RATIONALE: Medicine and treatment record- medication flow sheets usually include designated areas for the date of the medication order, the expiration date, the medication name and dose, the frequency of administration and route and the nurses signature.

OPTION A: AKA Admission Nursing Assessment/ Initial data base/Nursing History or Nursing Assessment. This is completed when the client is admitted to the nursing unit. This forms can be organized according to body systems, functional abilities, health problems and risks. OPTION B: Nursing Discharge/ Referral Summary- a discharge note and referral summary are completed when the client is being discharged and transferred to another institution or to a home setting where a visit by a community health nurse is required. OPTION C: Kardex is a widely used, concise method of organizing and recording data about a client making information quickly accessible to all health professionals. SOURCE:Fundamentals of Nursing 7 th edition by Barbara Kozier, Page 339

34. This flip-over card is usually kept in a portable file at the Nurses Station. It has 2-parts: the activity and treatment section and a nursing care plan section. This carries information about basic demographic data, primary medical diagnosis, current orders of the physician to be carried out by the nurse, written nursing care plan, nursing orders, scheduled tests and procedures, safety precautions in-patient care and factors related to daily living activities/ this record is used in the charge-of-shift reports or during the beside rounds or walking rounds. What record is this?

a. Discharge Summary

b. Medicine and Treatment Record

c. Nursing Health History and Assessment Worksheet

d. Nursing Kardex

CORRECT ANSWER: D RATIONALE: Kardex is a widely used, concise method of organizing and recording data about a client making information quickly accessible to all health professionals. OPTION A: Nursing Discharge/ Referral Summary- a discharge note and referral summary are completed when the client is being discharged and transferred to another institution or to a home setting where a visit by a community health nurse is required.

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OPTION B: Medicine and treatment record- medication flow sheets usually include designated areas for the date of the medication order, the expiration date, the medication name and dose, the frequency of administration and route and the nurses signature. OPTION C: AKA Admission Nursing Assessment/ Initial data base/Nursing History or Nursing Assessment. This is completed when the client is admitted to the nursing unit. This forms can be organized according to body systems, functional abilities, health problems and risks. SOURCE: Fundamentals of Nursing 7 th edition by Barbara Kozier, Page 339

35. Most nurses regard this as conventional recording of the date, time and mode by which the patient leaves a healthcare unit but this record includes importantly, directs of planning for discharge that starts soon after the" person is admitted to a healthcare institution, it is accepted that collaboration or multidisciplinary involvement (of all members of the health team) in discharge results in comprehensive care, what

do

you call this?

a.Discharge Summary b.Nursing Kardex

c. Medicine and Treatment Record

d.Nursing Health History and Assessment Worksheet

CORRECT ANSWER: A RATIONALE: Nursing Discharge/ Referral Summary- a discharge note and referral summary are completed when the client is being discharged and transferred to another institution or to a home setting where a visit by a community health nurse is required. OPTION B: Kardex is a widely used, concise method of organizing and recording data about a client making information quickly accessible to all health professionals. OPTION C: Medicine and treatment record- medication flow sheets usually include designated areas for the date of the medication order, the expiration date, the medication name and dose, the frequency of administration and route and the nurses signature. OPTION D: AKA Admission Nursing Assessment/ Initial data base/Nursing History or Nursing Assessment. This is completed when the client is admitted to the nursing unit. This forms can be organized according to body systems, functional abilities, health problems and risks. SOURCE: Fundamentals of Nursing 7 th edition by Barbara Kozier, Page 339

Situation 7 - Health instructions are essentially given to pregnant mothers.

36. A public health nurse would instruct a pregnant woman to notify the physician immediately if

which of the following symptoms occur during pregnancy?

a. Presence of dark color in the neck

b.Increased vaginal discharge

c. Swelling of the face

d.Breast tenderness

CORRECT ANSWER: C RATIONALE: Swelling of the face is a manifestation of mild preeclampsia. Edema in mild preeclampsia begins to accumulate in the upper part of the body, rather than just the typical ankle edema of pregnancy. OPTION A: Presence of a dark color in the neck is caused by increase in pigmentation, that is caused by melanocyte stimulating hormone which secreted by the pituitary gland. OPTION B: Due to increase in the activity of the epithelial cells results in white vaginal discharge throughout pregnancy OPTION D: Breast tenderness is due to increase stimulation of breast tissue by the high estrogen level in the body. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 427,228,229

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37. A woman who is 9 weeks pregnant comes to the health center with moderate bright red vaginal bleeding. On physical examination, the physician finds the client’s cervix 2 cm dilated. Which term best describes the client’s condition? a.Missed abortion b.Incomplete abortion

c. Inevitable abortion

d.Threatened abortion

CORRECT ANSWER: C RATIONALE: Occurs if uterine contractions and cervical dilatation occurs. OPTION A: The fetus dies in utero but is not expelled OPTION B: part of the conceptus (usually the fetus) is expelled, but membrane or placenta in retained in the uterus. OPTION D: is manifested by vaginal bleeding, initially beginning as scant bleeding and usually bright red. There may be slight cramping, but no cervical dilatation is present in vaginal exam. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 417

38. In a big government hospital, Nurse Pura is taking care of a woman with a diagnosis of abruptio

placenta.

What complication of this condition is of most concern to Nurse Pura?

a.Urinary tract infection b.Pulmonary embolism

c. Hypocalcemia

d.Disseminated intravascular coagulation

CORRECT ANSWER: D RATIONALE: Abruptio placenta occur when the placenta appears to have been implanted correctly. Suddenly, however, it begins to separate and bleeding results. Conditions such as abruption placenta causes DIC. Disseminated intravascular coagulation occurs when there is such extreme bleeding and so many platelets and fibrin from the general circulation rush to the site that not enough are left in the rest of the body for further clotting. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 417

39. Which of the following findings on a newly delivered woman’s chart would indicate she is risk for developing postpartum hemorrhage? a.Post-term delivery b.Epidural anesthesia

c. Grand multiparity

d.Premature rupture of membrane

CORRECT ANSWER: C

RATIONALE: Multiple gestation distends the uterus beyond average capacity causing uterine atony. Uterine atony or relaxation of the uterus is the most frequent cause of postpartal

hemorrhage.

OPTION B: Epidural anesthesia causes hypotension because of its blocking effect on the

sympathetic nerve fibers in the epidural space. OPTION D: premature rupture of membrane will cause prolapsed of the cord and uterine

infection.

SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 456-657

40. Mrs. Hacienda Gracia 35 years old postpartum client is at risk of thrombophlebitis. Which of the following nursing interventions decreases her chance of developing postpartum thrombophlebitis? a.breastfeeding the newborn b.early ambulation

c. administration of anticoagulant postpartum

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d.immobilization and elevation of the lower extremities.

CORRECT ANSWER: B RATIONALE: Thrombophlebitis is inflammation with the formation of blood clots. Ambulation and limiting the time a woman remains in obstetric stirrups encourages circulation in the lower extremities, promotes venous return and decreases the possibility of clot formation, helping to prevent thrombophlebitis. OPTION A: will not prevent thrombophlebitis OPTION C: will increase risk of pospartal hemorrhage OPTION D: though elevation of lower extremities promotes venous return, immobilization could increase risk of thrombophlebitis SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 136

Situation 8 - Nurse Joanna works as an OB-Gyne Nurse and attends to several HIGH-RISK PREGNANCIES: Particularly women with preexisting of Newly Acquired illness. The following conditions apply.

41. Bernadette is a 22-year old woman. Which condition would make her more prone than others to developing

a Candida infection during pregnancy?

a. Her husband plays gold 6 days a week

b. She was over 35 when she became pregnant

c. She usually drinks tomato juice for breakfast

d. She has developed gestational diabetes

CORRECT ANSWER: D RATIONALE: Candidiasis a vaginal infection spread by the fungus, Candida. It results in a thick vaginal discharge that resembles creamcheese and is extremely pruritic. The vagina appears red

and irritated. Candidiasis occurs more frequently during pregnancy than normally because of the increased estrogen level present during pregnancy, which causes the vaginal ph to be less acidic.

It also occurs less frequently in women being treated with an antibiotic for another infection, in women with gestational diabetes and in women with HIV infection.

42. Bernadette develops a deep-vein thrombosis following an auto accident and is prescribed heparin sub-Q. What should Joanna educate her about in regard to this? a.Some infants will be born with allergic symptoms to heparin b.Her infant will be born with scattered petechiae on his trunk c. Heparin can cause darkened skin in newborns d.Heparin does not cross the placenta and so does not affect a fetus

CORRECT ANSWER: D RATIONALE: Heparin has large molecules that cannot pass the placental blood barrier. Therefore it will not affect the baby and is allowed for pregnant mothers.

43. The cousin of Bernadette with sickle-cell anemia alerted Joanna that she may need further instruction on prenatal care. Which statement signifies this fact?

a. I've stopped jogging so I don't risk becoming dehydrated

b. I take an iron pill every day to help grown new red blood cells

c. I am careful to drink at least eight glasses of fluid everyday

d. I understand why folic acid is important for red cell formation

CORRECT ANSWER: B RATIONALE: The majority of the red blood cells are irregular or sickle-shaped so cannot carry as much hemoglobin as normally shaped red blood cells. When oxygen tension becomes reduced, as happens at high altitudes, or blood becomes more viscid than usual (dehydration), the cells tend to clump because of the irregular shape. Thus clumping can result in vessel blockage with

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reduced blood flow of the organs. The cells then will hemolyze reducing the number available and causing a severe anemia. OPTION A: Dehydration can make the blood more viscous causing the cells to clump.

OPTION C: Increasing the fluid volume of the circulatory system to lower viscosity are important

interventions.

OPTION D: Women do need a folic acid supplement to keep the new cells produced from being megaloblastic SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 136

44. Bernadette routinely takes acetylsalicylic acid (aspirin) for arthritis, why should she limit or discontinue this toward the end of pregnancy?

a. Aspirin can lead to deep vein thrombosis following birth

b. Newborns develop a red rash from salicylates toxicity

c. Newborns develop withdrawal headaches from salicylates

d. Salicylates can lead to increased maternal bleeding at childbirth

CORRECT ANSWER: D RATIONALE: Women with juvenile rheumatoid arthritis frequently take corticosteroids and non- steroidal anti-inflammatory drug (NSAID) to prevent joint pain and loss of mobility. Although they should continue to take this medications during pregnancy to prevent joint damage, large amount of salicylates

may

lead to increase bleeding at birth or prolong pregnancy (salicylates interferes withy prostaglandin synthesis, so labor contractions are not initiated). For this reason, a women is asked to decrease her intake of salicylates approximately 2 weeks before term. OPTION A: Aspirin will not cause deep vein thrombosis after birth because it has an anticoagulant effect that inhibits platelet aggregation. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 370

45. Bernadette received a laceration on her leg from her automotive accident. Why are lacerations of lower extremities potentially more serious in pregnant women than others?

a. Lacerations can provoke allergic responses because of gonadothropic hormone

b. Increased bleeding can occur from uterine pressure on leg veins

c. A woman is less able to keep the laceration clean because o f her fatigue

d. Healing is limited during pregnancy, so these will not heal until after birth

CORRECT ANSWER: B RATIONALE: Laceration (jagged cut) may involve only the skin layer or may penetrate to deeper subcutaneous tissue or tendons. Lacerations generally bleed profusely. Halt bleeding by putting pressure on the edges of the lacerations ( this is difficult to achieve in the lower extremities because venous pressure is greatly increased in pregnancy. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 387-388

Situation 9 - Still in your self-managed Child Health Nursing Clinic, you encounter these cases pertaining to the CARE OF CHILDREN WITH PULMONARY INFECTIONS.

46. Josie brought her 3-rmonths old child to your clinic because of cough and colds. Which of the following is your primary action?

a. Give cotrimoxazole tablet or syrup

b. Assess the patient using the chart on management of children with cough

c. Refer to the doctor

d. Teach the mother how to count her child's bearing

CORRECT ANSWER: B

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RATIONALE: The first thing to do is to assess the patient using the chart on management of child

with

cough. You determine if this is an initial visit or follow-up visit for this problem. Then you check for

danger signs, and ask about the main symptoms: does the child have cough or difficulty breathing?. After assessing you then classify and identify the treatment. SOURCE: IMCI Manual page 2

47. In responding to the care concerns of children with very severe disease, referral to the hospital is of the essence especially if the child manifests which of the following?

a.Wheezing

b.Stopped bleeding

c. Fast breathing

d.Difficulty to awaken

CORRECT ANSWER: D RATIONALE: Difficulty to awaken is one of the general danger signs and should be refer URGENTLY to

hospital.

OPTION C: fast breathing is under pneumonia. SOURCE: IMCI Manual Page 2

48. Which of the following is the most important responsibility of a nurse in the prevention of necessary deaths from pneumonia and other severe diseases? a.Giving of antibiotics b.Taking of the temperature of the sick child

c. Provision of Careful Assessment

d.Weighing of the sick child

CORRECT ANSWER: C Rationale: A child with danger signs needs URGENT attention; complete the assessment and any pre-referral treatment so referral is not delayed. Proper assessment would help in classifying the child .and proper treatment could be given. SOURCE: IMCI Manual Page 2

49. A child of 2 months is considered manifesting fast breathing if:

a. 50 breaths/min

b. below 50 breaths/min

c. 50 breaths/minute or more

d. 40 breaths/minute or more

CORRECT ANSWER: C RATIONALE: If the child is 2 months up to 12 months old, fast breathing is 50 breaths/minute or more OPTION D: 12 months up, 40 breaths/minute or more All other options are incorrect SOURCE: IMCI Manual Page 2

50. Which of the following is the principal focus on the CARI program of the Department of Health?

a. Enhancement of health team capabilities

b.Teach mothers how to detect signs and where to refer

c. Mortality reduction through early detection

d.Teach other community health workers how to assess patients

CORRECT ANSWER: C

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RATIONALE: The primary focus of the CARI Program is mortality reduction through early detection

and antibiotic treatment of pneumonia cases among children between the ages of 0 to less than

5 years old.

SOURCE: DOH CHN Page 259

Situation 10 - You are working as a Pediatric Nurse in your own Child Health Nursing Clinic, the following cases pertain to ASSESSMENT AND CARE of THE NEWBORN AT RISK conditions.

50. Theresa, a mother with a 2 year old daughter asks, "at what age can I be able to take the blood pressure of my daughter as a routine procedure since hypertension is common in the family?" Your answer to this is:

a. At 2 years you may

b. As early as 1 year old

c. When she's 3- years old

d. When she's 6 years old?

CORRECT ANSWER: C Rationale: Blood pressure should be included in the routine physical assessment of all children older than

3 years of age. Offer a good explanation of the procedure, especially to young children, because

wrapping their arm and applying pressure can be frightening if they are not prepared for it. Blood pressure is difficult to measure in infants due to mechanical problem. Doppler ultrasound blood pressure recording is especially effective with infants. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 1120

52. You typically gag children to inspect the back of their throat. When is it important NOT to solicit a gag reflex? a.when a girl has a geographic tongue b.when a boy has a possible inguinal hernia

c. when a

d.when children are under 5 years of age

child has symptoms of epiglottitis

CORRECT ANSWER: C RATIONALE: Epiglottitis is the inflammation of the epiglottis. If a child’s gag reflex is stimulated with a tongue blade, the swollen and inflamed epiglottis can be seen to rise in the back of the throat as a cherry-red structure. It can be so edematous, however gagging procedure causes complete obstruction of the glottis and respiratory failure. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 1252

53. Baby John was given a drug at birth to reverse the effects of a narcotic given to his mother in

labor.

What drug is commonly used for this?

a. Naloxone (Narcan)

b. Morphine Sulfate

c. Sodium Chloride

d. Penicillin G

CORRECT ANSWER: A RATIONALE: Naloxone is a drug used to counter act the effects of opiod overdose, for example heroin or morphine overdose. Naloxone is especially used to counter act life threatening depression of CNS and respiratory system. OPTION B: Morphine is a highly potent opiate analgesic drug and is the principal active agent in opium and

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the prototypical opiod. OPTION C: Sodium chloride AKA: commom salt, table salt. Is the salt most responsible for the salinity of the ocean and of the extracellular fluid of many multicellular organisms. OPTION D: Penicillin is a group of B-lactam antibiotics used in the treatment of bacterial infections caused by susceptible, usually gram positive organisms. SOURCE: Wikipedia the free encyclopedia

54. Why are small-for-gestational-age newborns at risks for difficulty maintaining body temperature?

a. They do not have as many fat stores as other infant's

b. They are more active than usual so throw off covers

c. Their skin is more susceptible to conduction of cold

d. They are preterm so are born relatively small in size

CORRECT ANSWER: A RATIONALE: An infant is small for gestational age if the birth weight is below the 10 th percentile on an intrauterine growth curve for that age. Small for gestational age infants are less able to control body temperature than normal newborns because they lack subcutaneous fat. OPTION B: Infant may seem unusually alert and active for that weight. OPTION D: SGA infants may be born preterm (before week 38 gestation) or term ( between week 38 and 34) or post term (past 42 weeks) SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 757-758

55. Baby John develops hyperbilirubinemia, what is a method used to treat hyperbilirubinemia in a

newborn?

a. Keeping infants in a warm arid dark environment

b. Administration of a cardiovascular stimulant

c. Gentle exercise to stop muscle breakdown

d. Early feeding to speed passage of meconium

CORRECT ANSWER: D RATIONALE: Hyperbilirubinemia refers to an excessive level of accumulated bilirubin in the blood and is characterized by jaundice a yellow discoloration of the skin, sclerae and nails.Early initiation of feedings and frequent breast feeding this measures are aimed at Promoting increased intestinal motility, decreasing enterohepatic shunting, and establishing normal bacterial flora in the bowel to effectively enhance the excretion by conjugated bilirubin. OPTION A: Light promotes bilirubin excretion by photo isomerization which alters the structure of bilirubin to a soluble form (luminubin) for easier excretion. SOURCE: Hockenberry, Marilyn J. Wong’s essentials of Pediatric Nursing.7 th edition.pp.263-264

Situation 11 - You are the nurse in the Out-Patient-Department and during your shift you encountered multiple children's condition. The following questions apply.

56. You assessed a child with visible severe wasting, he has:

a.edema

b.LBM

c. kwashiorkor

d.marasmus

CORRECT ANSWER: D RATIONALE: Marasmus results from general malnutrition of both calories and protein. It is characterized by gradual wasting and atrophy of body tissues, esp. of subcutaneous fat. The child appears to be very old with flabby and wrinkled skin. OPTION A: edema is the abnormal accumulation of fluid in interstitial spaces of tissues such as in the peritoneal cavity or joint capsules. OPTION B: LBM means lean body mass OPTION C: Kwashiorkor has been defined as primarily a deficiency of protein with an adequate supply of calories. The word kwashiorkor means the sickness the older child gets when the next baby is born, and aptly describes the syndrome that develops in the first child, usually between 1

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and 4 years of age, when weaned from the breast after the second child is born. Kwashiorkor has thin, wasted extremities and a prominent abdomen from edema (ascites). The edema often

masks the severe muscular atrophy, making the child appears debilitated than he/she actually is. The skin is scaly and dry and has areas of depigmentation SOURCE:Hockenberry, Marilyn J. Wong’s essentials of Pediatric Nursing.7 th edition.pp 373;

Mosby’s pocket dictionary. 4

th

ed.

57. Which of the following conditions is NOT true about contraindication to immunization?

a. do not give DPT2 or DPT3 to a child who has convulsions within 3 days of DPT1

b. do not give BCG if the child has known hepatitis .

c. do not give OPT to a child who has recurrent convulsion or active neurologic disease

d. do not give BCG if the child has known AIDS

CORRECT ANSWER: B RATIONALE: BCG can be given in a child with hepatitis. OPTION A: Vaccines containing the whole cell pertussis component should not be given to children with an evolving neurological disease. (uncontrolled epilepsy of progressive encephalopathy) OPTION D: Live vaccines like BCG vaccine must not be given to individuals who are immunosuppressed due to malignant disease, (e.g. child with clinical AIDS), therapy with immunosuppressive agents on

radiation.

SOURCE: PHN.pp.143

58. Which of the following statements about immunization is NOT true?

a.A child with diarrhea who is due for OPV should receive the OPV and make extra dose on the next visit

b. There is no contraindication to immunization if the child is well enough to go home

c. There is no contraindication to immunization if the child is well enough to go home and a child

should be immunized in the health center before referrals are both correct

d. A child should be immunized in the center before referral

CORRECT ANSWER: A RATIONALE: False contraindications to immunizations are children with malnutrition, low grade

fever, mild respiratory infections and other minor illnesses and diarrhea should not be considered a contraindication to OPV vaccination. Bur there is no nned to make an extra dose on the next

visit.

SOURCE: PHN pp. 142

59. A child with visible severe wasting or severe palmar pallor may be classified as:

a.moderate malnutrition/anemia b.severe malnutrition/anemia

c. not very tow weight no anemia

d.anemia/very low weight

CORRECT ANSWER: B Rationale: Visible severe wasting , edema of both feet or severe palmar pallor is classified under severe Malnutrition or severe anemia. Treatment includes give Vit. A and refer URGENTLY to hospital. SOURCE: IMCI manual page 6

60. A child who has some palmar pallor can be classified as:

a.moderate anemia/normal weight b.severe malnutrition/anemia

c. anemia/very low weight

d.not very low eight to anemia

CORRECT ANSWER: C

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RATIONALE: Some palmar pallor and Very low weight for age is classified under Anemia or Very low Weight. SOURCE: IMCI manual page 6

Situation 12 - Nette, a nurse palpates the abdomen of Mrs. Medina, a primigravida. She is unsure of the date of her last menstrual period. Leopold's Maneuver is done. The obstetrician told her that she appears to be 20 weeks

61. Nette explains this because the fundus is:

a.At the level the umbilicus and the fetal heart can be heard with a fetoscope

b. 18 cm, and the baby is just about to move

c. is just over the symphysis, and fetal heart cannot be heard

d.28 cm, and fetal heart can be heard with a Doppler

CORRECT ANSWER: A RATIONALE: Fundal height is measured to evaluate the fetus gestational age. At 20-22 weeks, the fundus is at the level of umbilicus. OPTION B: 18 weeks-fetal movement can be felt by the mother and the fundus can be found below the umbilicus OPTION C: 12 weeks- at the level of the symphysis pubis OPTION D: 28 weeks- the fundus can be felt between the xyphoid process and the umbilicus SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 226

62. In doing Leopold's maneuver palpation which among the following is NOT considered a good

preparation?

a. The woman should lie in a supine position with her knees flexed slightly

b. The hands of the nurse should be cold so that abdominal muscles would contract and tighten

c. Be certain that your hands are warm (by washing them in warm water first if necessary)

d. The woman empties her bladder before palpation

CORRECT ANSWER: B RATIONALE: It should be wash hands using warm water. Handwashing prevents the spread of possible infection. Using warm water aids in client’s comfort and prevents tightening of abdominal muscle. OPTION A: Flexing the knees relaxes the abdominal muscles OPTION D: Doing so promotes comfort and allows for more productive palpation because fetal contour will not obscured by a distended bladder.

63. In her pregnancy, she experienced fatigue and drowsiness. This probably occurs because:

a. of high blood pressure

b. she is expressing pressure

c. the fetus utilizes her glucose stores and leaves her with a low blood glucose

d. of the rapid growth of the fetus

CORRECT ANSWER: D RATIONALE: Fatigue is extremely common in early pregnancy probably due to increased metabolic requirements. OPTION C: The glucose level of the fetus is about 30mg/100 ml lower than the maternal glucose level. To prevent fetal hypoglycemia, with resultant cell destruction on lack of fetal growth, the maternal glucose level is usually at a higher than normal level during pregnancy. Although, the pancreas secretes an increased level of insulin throughout pregnancy, it appears to be not as effective. With insulin that is less effective, fat stores of the woman are utilizedas well as available glucose. This maintains maternal glucose level at a fairly steady level despite long intervals between meals or days of increased activity. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 238

64. The nurse assesses the woman at 20 weeks gestation and expects the woman to report:

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For evaluation only.

a. Spotting related to fetal implantation

b. Symptoms of diabetes as human placental lactogen is released

c. Feeling fetal kicks

d. Nausea and vomiting related HCG production

CORRECT ANSWER: C RATIONALE: The fetus can be seen to move on ultrasonography as early as the 11 th week, although the mother usually does not feel this movement (quickening) until almost 20 weeks of gestation. (presumptive sign of pregnancy). SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp.222

65. If Mrs. Medina comes to you for check-up on June 2, her EDC is June 11, what do you expect

during

assessment?

a. Fundic ht 2 fingers below xyphoid process, engaged

b. Cervix close, uneffaced, FH-midway between the umbilicus and symphysis pubis

c. Cervix open, fundic ht. 2 fingers below xyphoid process, floating.

d. Fundic height at least at the level of the xyphoid process, engaged

CORRECT ANSWER: A RATIONALE: The fundic height is 2 cm below the xyphoid process. Lightening is a descent of the fetal presenting part into the pelvis, occurs approximately 10-14 days before labor begins. This changes a woman’s abdominal contour because the uterus becomes lower and more anterior. OPTION B: FH midway between umbilicus and symphysis pubis is 16 weeks gestation OPTION D: FH at the level of the xyphoid process indicates 36 weeks gestation. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 489, 226

Situation 13 - Please continue responding as a professional nurse in varied health situations through the following questions.