ANSWERS

1) B
- The nurse administering the dose should
have compared the MAR with the Kardex and
noted the discrepancy. The transcribing
nurse and pharmacist aren't void of
responsibility; however, the nurse
administering the dose is most responsible.
The facility's policy does provide for a
system of checks and balances. Therefore,
the facility isn't responsible for the error.
2) C
- The purpose of deep palpation, in which
the nurse indents the client's skin
approximately 1" (3.8 cm), is to assess
underlying organs and structures, such as
the kidneys and spleen. Skin turgor,
hydration, and temperature can be assessed
by using light touch or light palpation
3) D
Nursing Fundamentals Questions Rationale:
When giving an I.M. injection, the nurse
inserts the needle into the muscle at a 90-
degree angle, using a quick, dartlike motion.
A 15-degree angle is appropriate when
administering an intradermal injection. A 30-
degree angle isn't used for any type of
injection. A 45- or 90-degree angle can be
used when giving a subcutaneous injection
4) C
- A client age 40 to 49 with no family history
of breast cancer or other risk factors for this
disease should have a mammogram every 2
years. After age 50, the client should have a
mammogram every year
5) C
- In Maslow's hierarchy of needs, pain relief
is on the first layer. Activity (option B) is on
the second layer. Safety (option D) is on the
third layer. Love and belonging (option A)
are on the fourth layer.
6) D
- Sleeping undisturbed for a period of time
would indicate that the client feels more
relaxed, comfortable, and trusting and is less
anxious. Decreasing eye contact, asking to
see family, and joking may also indicate that
the client is more relaxed. However, these
also could be diversions.
7) A
- A living will states that no life-saving
measures are to be used in terminal
conditions. There is no indication that the
client is terminally ill. Furthermore, a living
will doesn't apply to nonterminal events such
as choking on an enteral feeding device. The
nurse should clear the client's airway.
Making the client comfortable ignores the
life-threatening event. Cardiopulmonary
resuscitation isn't indicated, and removing
the NG tube would exacerbate the situation
8) D
- Although the client should eat a balanced
diet with foods from all food groups, the diet
should emphasize foods that supply
complete protein, such as lean meats and
low-fat milk, because protein helps build and
repair body tissue, which promotes healing.
Fundamentals in nursing teaches that
legumes provide incomplete protein. Cheese
contains complete protein, but also fat,
which should be limited to 30% or less of
caloric intake. Whole grain products supply
incomplete proteins and carbohydrates.
Fruits and vegetables provide mainly
carbohydrates.
9) C
- A client with renal failure can't eliminate
sufficient fluid, increasing the risk of fluid
overload and consequent respiratory and
electrolyte problems. This client has signs of
excessive fluid volume and is acutely ill. Fear
and a toileting self-care deficit may be
problems, but they take lower priority
because they aren't life-threatening. Urinary
retention may cause renal failure but is a
less urgent concern than fluid imbalance.
10) B
- The client is at risk for infection because
the WBC count is dangerously low. Hb level
and HCT are within normal limits; therefore,
fluid balance, rest, and prevention of injury
are inappropriate.
1) C
- R.A. 7305 is the "Magna Carta for the
Public Health Workers with objectives to
promote and improve the social and
economic well-being of health workers;
develop their skills and capabilities; and
encourage those qualified and with abilities
to remain in government service.A-
Philippine Medical Act B- Midwifery Law D-
Dangerous Drug Act
2) D
- Qualifications to be a member of the Board
of Nursing are;(1) be a citizen and resident
of the Philippines; (2) be a member in good
standing of the accredited national nurses
association; (3) be a RN and holder of a
masters degree in Nursing conferred by a
college or university duly recognized by the
government; (4) have at least 10 years of
continuous practice of nursing prior to
appointment; (5) not a holder of a green
card or its equivalent; and (6) not have been
convicted of any offense involving moral
turpitude even if previously extended pardon
by the President of the Philippines.
3) A
- Incident report is a record of an accident or
incident. This report is used to make all facts
about an accident available to agency
personnel, to contribute to statistical data
about accidents and incidents, and to help
personnel prevent future accidents. All
accidents are usually reported on incident
forms. The report should be completed
within 24 hours of the incident.
4) C
- Before any medical or surgical procedure
can be performed on a patient, consent must
be obtained from the patient or his
authorized representative. It is only in
emergency cases that consent requirement
does not apply. The intentional touching or
unlawful beating of another person without
authorization to do so is a legal wrong called
battery.
5) A
- The essential elements of an informed
consent include (1) the consent must be
given voluntarily; (2) the consent must be
given by an individual with the capacity and
competence to understand; (3) the client
must be given enough information to be an
ultimate decision maker.
6) C
- Philippine Nursing Act of 1991 section 28
states "in the administration of intravenous
injections, special training shall be required
according to a protocol established. Nurses
should use the Intravenous Nursing
Standards of Practice developed by the
Association of Nursing Service Administration
of the Philippines (ANSAP).
7) C
- R.A. 2382 is the Philippine Medical Act that
defines the practice of medicine. R.A. 1612 is
the Profession Tax or Omnibus Tax that
states to pay P50.00 on or before January 31
of every year. Exempted are those working
in the government agencies. R.A. 1082 is the
Rural Health Act.
8) C
- PD 996 requires compulsory immunization
for all children below 8 years old against
communicable diseases.A- Presidential
proclamation of a Nurses Week (last week of
October of very year beginning in 1958).B-
Seniors Citizens Act D- Amended RA 679
(women and Child Labor Law) stating the
employable age shall be 16 years old. It also
provided aside from the minimum
employable age, the privileges of a working
woman.
9) D
- Principal sources of these pronouncements
are (1) the constitution; (2) the statues or
legislations; (3) regulations issued by the
Executive branch of the government; (4)
case decisions or judicial opinions, (5)
Presidential decrees; (6) Letters of
instructions
10) D
- R.A. 2382-is the Philippine Medical Act that
defines the practice of medicine. R.A. 1612 is
the Profession Tax or Omnibus Tax that
states to pay P50.00 on or before January 31
of every year. Exempted are those working
in the government agencies? R.A. 6111 is
the Philippine Medical Care Act that states
"all government employees covered by SSS
and GSIS are given hospitalization
privileges.
1) B
- Hemorrhage and shock are the most
common complications after abdominal
aortic aneurysm resection. Renal failure can
occur as a result of shock or from injury to
the renal arteries during surgery. Graft
occlusion and enteric fistula formation are
rare complications of abdominal aortic
aneurysm repair.
2) A
- Common signs and symptoms of
cardiovascular dysfunction include shortness
of breath, chest pain, dyspnea, palpitations,
fainting, fatigue, and peripheral edema.
Insomnia seldom indicates a cardiovascular
problem. Although irritability may occur if
cardiovascular dysfunction leads to cerebral
oxygen deprivation, this symptom more
commonly reflects a respiratory or
neurologic dysfunction. Lower substernal
abdominal pain occurs with some GI
disorders.
3) D
- Answer to this cardiovascular nursing
questions - Controllable risk factors include
hypertension, hypercholesterolemia, obesity,
lack of exercise, smoking, diabetes, stress,
alcohol abuse, and use of contraceptives.
Uncontrollable risk factors for coronary
artery disease include gender, age, and
heredity.
4) B
- This client's findings indicate cardiogenic
shock, which occurs when the heart fails to
pump properly, impeding blood supply and
oxygen flow to vital organs. Cardiogenic
shock also may cause cold, clammy skin and
generalized weakness, fatigue, and muscle
pain as lactic acid accumulates from poor
blood flow, preventing waste removal. Left-
sided and right-sided heart failure eventually
cause venous congestion with jugular vein
distention and edema as the heart fails to
pump blood forward. A ruptured aneurysm
causes severe hypotension and a quickly
deteriorating clinical status from blood loss
and circulatory collapse; this client has low
but not severely decreased blood pressure.
Also, in ruptured aneurysm, deterioration is
more rapid and full cardiac arrest is
common.
5) C
- Furosemide is a potassium-wasting
diuretic. The nurse must monitor the serum
potassium level and assess for signs of low
potassium. As water and sodium are lost in
the urine, blood pressure decreases, blood
volume decreases, and urine output
increases.
6) B
- Because of decreased contractility and
increased fluid volume and pressure in
clients with heart failure, fluid may be driven
from the pulmonary capillary beds into the
alveoli, causing pulmonary edema. In right-
sided heart failure, the client would exhibit
hepatomegaly, jugular vein distention, and
peripheral edema. In pneumonia, the client
would have a temperature spike and sputum
that varies in color. Cardiogenic shock would
show signs of hypotension and tachycardia.
7) D
- TIAs are considered forerunners of
cerebrovascular accident (CVA). Because
CVAs may result from clots in cerebral
vessels, aspirin is prescribed to prevent clot
formation by reducing platelet agglutination.
A 325-mg dose of aspirin is inadequate to
relieve headache pain in an adult. Aspirin
has no effect on the body's immune
response. Intracranial bleeding isn't
associated with TIAs, and the action of
aspirin probably would worsen any bleeding
present.
8) A
- For a client recovering from CABG surgery,
Decreased cardiac output is the most
important nursing diagnosis because
myocardial function may be depressed from
anesthetics or a long cardiopulmonary
bypass time, leading to decreased cardiac
output. Other possible causes of decreased
cardiac output in this client include fluid
volume deficit and impaired electrical
conduction. The nurse exam other options
may be relevant but take lower priority at
this time because maintaining cardiac output
is essential to sustaining the client's life.
9) C
- The risk factors for coronary artery disease
that can be controlled or modified include
obesity, inactivity, diet, stress, and smoking.
Gender and family history are risk factors
that can't be controlled.
10) B
- Because bleeding gums are an adverse
effect of heparin that may indicate excessive
anticoagulation, the nurse should notify the
physician, who will evaluate the client's
condition. Laboratory tests, such as partial
thromboplastin time, should be performed
before concluding that the client's bleeding is
significant. The prescribed heparin dose may
be therapeutic rather than excessive, so the
nurse shouldn't discontinue the heparin
infusion, unless the physician orders this
after evaluating the client. Protamine sulfate,
not a coumarin derivative, is given to
counteract heparin. Bleeding gums aren't a
normal effect of heparin.
1) D
- Cryptorchidism (failure of one or both
testes to descend into the scrotum) appears
to play a role in testicular cancer, even when
corrected surgically. Other significant history
findings for testicular cancer include mumps
orchitis, inguinal hernia during childhood,
and maternal use of diethylstilbestrol or
other estrogen-progestin combinations
during pregnancy. Testosterone therapy
during childhood, sexually transmitted
disease, and early onset of puberty aren't
risk factors for testicular cancer.
2) A
- The liver is one of the five most common
cancer metastasis sites. The others are the
lymph nodes, lung, bone, and brain. The
colon, reproductive tract, and WBCs are
occasional metastasis sites.
3) A
- Persistent hoarseness may signal throat
cancer, which commonly is associated with
tobacco use. To assess the client's risk for
throat cancer, the nurse should ask about
smoking habits. Although straining the voice
may cause hoarseness, it wouldn't cause
hoarseness lasting for 1 month.
Consumption of red meat or spicy foods isn't
associated with persistent hoarseness.
4) C
- Presence of Bence Jones protein in the
urine almost always confirms the disease,
but absence doesn't rule it out. Serum
calcium levels are elevated because calcium
is lost from the bone and reabsorbed in the
serum. Serum protein electrophoresis shows
elevated globulin spike. The serum creatinine
level may also be increased.
5) D
- Kaposi's sarcoma is the most common
cancer associated with AIDS. Squamous cell
carcinoma, multiple myeloma, and leukemia
may occur in anyone and aren't associated
specifically with AIDS.
6) C
- The nurse has a moral and professional
responsibility to advocate for clients who
experience decreased independence, loss of
freedom of action, and interference with
their ability to make autonomous choices.
Coordinating a meeting between the
physician and family members may give the
client an opportunity to express his wishes
and promote awareness of his feelings as
well as influence future care decisions. All
other options are inappropriate.
7) B
- The incidence of ovarian cancer increases
in women who have never been pregnant,
are over age 40, are infertile, or have
menstrual irregularities. Other risk factors
include a family history of breast, bowel, or
endometrial cancer. The risk of ovarian
cancer is reduced in women who have taken
oral contraceptives, have had multiple births,
or have had a first child at a young age.
8) D
- The correct nurse test questions answer is:
Men can develop breast cancer, although
they seldom do. The most reliable method
for detecting breast cancer is monthly self-
examination, not mammography. Lung
cancer causes more deaths than breast
cancer in women of all ages. A mastectomy
may not be required if the tumor is small,
confined, and in an early stage.
9) B
- A fixed nodular mass with dimpling of the
overlying skin is common during late stages
of breast cancer. Many women have slightly
asymmetrical breasts. Bloody nipple
discharge is a sign of intraductal papilloma, a
benign condition. Multiple firm, round, freely
movable masses that change with the
menstrual cycle indicate fibrocystic breasts,
a benign condition.
10) C
- Fine needle aspiration and biopsy provide
cells for histologic examination to confirm a
diagnosis of cancer. A breast self-
examination, if done regularly, is the most
reliable method for detecting breast lumps
early. Mammography is used to detect
tumors that are too small to palpate. Chest
X-rays can be used to pinpoint rib
metastasis.
1) B
- An acute addisonian crisis is a life-
threatening event, caused by deficiencies of
cortisol and aldosterone. Glucocorticoid
insufficiency causes a decrease in cardiac
output and vascular tone, leading to
hypovolemia. The client becomes tachycardic
and hypotensive and may develop shock and
circulatory collapse. The client with Addison's
disease is at risk for infection; however,
reducing infection isn't a priority during an
addisonian crisis. Impaired physical mobility
is also an appropriate nursing diagnosis for
the client with Addison's disease, but it isn't
a priority in a crisis. Imbalanced nutrition:
Less than body requirements is also an
important nursing diagnosis for the client
with Addison's disease but not a priority
during a crisis.
2) C
- A client with hyperthyroidism needs to be
encouraged to balance periods of activity
and rest. Many clients with hyperthyroidism
are hyperactive and complain of feeling very
warm. Consequently, it's important to keep
the environment cool and to teach the client
how to manage his physical reactions to
heat. Clients with hypothyroidism - not
hyperthyroidism - complain of being cold
and need warm clothing and blankets to
maintain a comfortable temperature. They
also receive thyroid replacement therapy,
often feel lethargic and sluggish, and are
prone to constipation. The nurse should
encourage clients with hypothyroidism to be
more active to prevent constipation.
3) B
- Endocrine System Practice Tests Answer -
Diabetic clients must exercise at least three
times a week to meet the goals of planned
exercise - lowering the blood glucose level,
reducing or maintaining the proper weight,
increasing the serum high-density lipoprotein
level, decreasing serum triglyceride levels,
reducing blood pressure, and minimizing
stress. Exercising once a week wouldn't
achieve these goals. Exercising more than
three times a week, although beneficial,
would exceed the minimum requirement.
4) D
- To control hypoglycemic episodes, the
nurse should instruct the client to consume a
low-carbohydrate, high-protein diet, avoid
fasting, and avoid simple sugars. Increasing
saturated fat intake and increasing vitamin
supplementation wouldn't help control
hypoglycemia.
5) A
- Excessive secretion of aldosterone in the
adrenal cortex is responsible for the client's
hypertension. This hormone acts on the
renal tubule, where it promotes reabsorption
of sodium and excretion of potassium and
hydrogen ions. The pancreas mainly secretes
hormones involved in fuel metabolism. The
adrenal medulla secretes the catecholamines
- epinephrine and norepinephrine. The
parathyroids secrete parathyroid hormone.
1) C
- Black, tarry stools are a sign of bleeding
high in the GI tract, as from a gastric ulcer,
and result from the action of digestive
enzymes on the blood. Vomitus associated
with upper GI tract bleeding commonly is
described as coffee-ground-like. Clay-colored
stools are associated with biliary obstruction.
Bright red stools indicate lower GI tract
bleeding.
2) C
- In ascites, accumulation of large amounts
of fluid causes extreme abdominal
distention, which may put pressure on the
diaphragm and interfere with respiration. If
uncorrected, this may lead to atelectasis or
pneumonia. Although fluid volume excess is
present, the diagnosis Ineffective breathing
pattern takes precedence because it can lead
more quickly to life-threatening
consequences. The nurse can deal with
fatigue and altered nutrition after the client
establishes and maintains an effective
breathing pattern.
3) C
- Ulcerative colitis is more common in people
who have family members with the disease.
(The same is true of some types of GI
cancers, ulcers, and Crohn's disease.)
Hepatitis, iron deficiency anemia, and
chronic peritonitis are acquired disorders
that don't run in families.
4) C
- The nurse should collect the stool specimen
using sterile technique and a sterile stool
container. The stool may be collected for 3
consecutive days; no follow-up care is
needed. Although a stool culture should be
taken to the laboratory as soon as possible,
it need not be delivered immediately (unlike
stool being examined for ova and parasites).
Applying a solution to a stool specimen
would contaminate it; this procedure is done
when testing stool for occult blood, not
organisms. The nurse shouldn't store a stool
culture on ice because the abrupt
temperature change could kill the organisms.
5) D
- The RUQ contains the liver, gallbladder,
duodenum, head of the pancreas, hepatic
flexure of the colon, portions of the
ascending and transverse colon, and a
portion of the right kidney. The sigmoid
colon is located in the left lower quadrant;
the appendix, in the right lower quadrant;
and the spleen, in the left upper quadrant.
6) A
- Any hole, no matter how small, will destroy
the odor-proof seal of a drainage bag.
Removing the bag or unclamping it is the
only appropriate method for relieving gas.
7) B
- Hepatic encephalopathy, a major
complication of advanced cirrhosis, occurs
when the liver no longer can convert
ammonia (a by-product of protein
breakdown) into glutamine. This leads to an
increased blood level of ammonia - a
central nervous system toxin - which
causes a decrease in the level of
consciousness. Fatigue, muscle weakness,
nausea, anorexia, and weight gain occur
during the early stages of cirrhosis.
8) B
- Nursing Board Exams Rationale -
Appendicitis most commonly results from
obstruction of the appendix, which may lead
to rupture. A high-fat diet or duodenal ulcer
doesn't cause appendicitis; however, a client
may require dietary restrictions after an
appendectomy.
9) B
- The large intestine normally contains
bacteria because its alkaline environment
permits growth of organisms that putrefy
and break down remaining proteins and
indigestible residue. These organisms include
Escherichia coli, Aerobacter aerogenes,
Clostridium perfringens, and Lactobacillus.
Although bowel resection with anastomosis is
considered major surgery, it poses no
greater risk of infection than any other type
of major surgery. Malnutrition seldom follows
bowel resection with anastomosis because
nutritional absorption (except for some
water, sodium, and chloride) is completed in
the small intestine. An NG tube is placed
through a natural opening, not a wound, and
therefore doesn't increase the client's risk of
infection.
10) B
- Prothrombin synthesis in the liver requires
vitamin K. In cirrhosis, vitamin K is lacking,
precluding prothrombin synthesis and, in
turn, increasing the client's PT. An increased
PT, which indicates clotting time, increases
the risk of bleeding. Therefore, the nurse
should expect to administer phytonadione
(vitamin K1) to promote prothrombin
synthesis. Spironolactone and furosemide
are diuretics and have no effect on bleeding
or clotting time. Warfarin is an anticoagulant
that prolongs PT.
1) C
- When caring for a client, the nurse must
first wash her hands. Putting on gloves,
removing the dressing, and observing the
drainage are all parts of performing a
dressing change after hand washing is
completed.
2) B
- Wrapping elastic bandages on dependent
areas limits edema formation and bleeding
and promotes graft acceptance. The nurse
should wrap the client's arms and legs from
the distal to proximal ends and use strict
sterile technique throughout the dressing
change. Maximum bandages should be
avoided because bulky dressings limit
mobility; instead, the nurse should use
enough bandages to absorb wound drainage.
Sterile gloves are required throughout all
phases of the dressing change to prevent
contamination.
3) C
- Pouring solution onto a sterile field cloth
violates surgical asepsis because moisture
penetrating the cloth can carry
microorganisms to the sterile field via
capillary action. The other options are
practices that help ensure surgical asepsis.
4) D
- To prevent eye discomfort, the client must
protect the eyes for 48 hours after taking
medication for photochemotherapy.
Protecting the eyes for a shorter period
increases the risk of eye injury.
5) B
- The scab formation is found in the
migratory phase. It is accompanied by
migration of epithelial cells, synthesis of scar
tissue by fibroblasts, and development of
new cells that grow across the wound. In the
inflammatory phase, a blood clot forms,
epidermis thickens, and an inflammatory
reaction occurs in the subcutaneous tissue.
During the proliferative phase, the actions of
the migratory phase continue and intensify,
and granulation tissue fills the wound. In the
maturation phase, cells and vessels return to
normal and the scab sloughs off.
6) B
- Applying an emollient immediately after
taking a bath or shower prevents
evaporation of water from the hydrated
epidermis, the skin's upper layer. Although
emollients make the skin feel soft, this effect
occurs whether or not the client has just
bathed or showered. An emollient minimizes
cracking of the epidermis, not the dermis
(the layer beneath the epidermis). An
emollient doesn't prevent skin inflammation.
7) B
- To prevent the spread of scabies in other
hospitalized clients, the nurse should isolate
the client's bed linens until the client is no
longer infectious - usually 24 hours after
treatment begins. Other required
precautions include using good hand-
washing technique and wearing gloves when
applying the pediculicide and during all
contact with the client. Although the nurse
should notify the nurse in the day surgery
unit of the client's condition, a scabies
epidemic is unlikely because scabies is
spread through skin or sexual contact. This
client doesn't require enteric precautions
because the mites aren't found on feces.
8) B
- Answer to nursing board exam questions -
Adults and children with gonorrhea may
develop gonococcal conjunctivitis by
touching the eyes with contaminated hands.
The client should avoid sexual intercourse
until treatment is completed, which usually
takes 4 to 7 days, and a follow-up culture
confirms that the infection has been
eradicated. A client who doesn't refrain from
intercourse before treatment is completed
should use a condom in addition to informing
sex partners of the client's health status and
instructing them to wash well after
intercourse. Meningitis and widespread CNS
damage are potential complications of
untreated syphilis, not gonorrhea.
9) C
- Sunscreen should be applied even on
overcast days, because the sun's rays are as
damaging then as on sunny days. The sun is
strongest from 10 a.m. to 2 p.m. (11 a.m. to
3 p.m. daylight saving time) - not from 1 to
4 p.m. Sun exposure should be minimized
during these hours. The nurse should
recommend sunscreen with a sun protection
factor of at least 15. Sitting in the shade
when at the beach doesn't guarantee
protection against sunburn because sand,
concrete, and water can reflect more than
half the sun's rays onto the skin.
10) B
- Answer to nursing board exam questions -
Impetigo is a contagious, superficial skin
infection caused by beta-hemolytic
streptococci. If the condition is severe, the
physician typically prescribes systemic
antibiotics for 7 to 10 days to prevent
glomerulonephritis, a dangerous
complication. The client's nails should be
kept trimmed to avoid scratching; however,
mitts aren't necessary. Topical antibiotics are
less effective than systemic antibiotics in
treating impetigo.
1) C
- In pernicious anemia, the gastric mucosa
doesn't secrete intrinsic factor, a protein
necessary for vitamin B12 absorption.
Without intrinsic factor, vitamin B12
replacements taken orally won't be
absorbed; therefore, vitamin B12 must be
administered through the I.M. or deep
subcutaneous routes. Clients must take
vitamin B12 each day for 2 weeks initially,
then weekly for several months, then once
each month for life.
2) C
- Gingival hyperplasia may occur with long-
term administration of phenytoin, an
anticonvulsant. This adverse effect
presumably is dose related. Frequent
toothbrushing removes food particles and
helps prevent infection; regular dental care
and frequent gum massage also are
recommended. Gingival hyperplasia isn't a
reported adverse effect of procainamide,
azathioprine, or allopurinol.
3) B
- Hematology Questions and Answers for
number 3 is B - Pallor, tachycardia, and a
sore tongue are all characteristic findings in
pernicious anemia. Other clinical
manifestations include anorexia; weight loss;
a smooth, beefy red tongue; a wide pulse
pressure; palpitations; angina; weakness;
fatigue; and paresthesia of the hands and
feet. Bradycardia, reduced pulse pressure,
weight gain, and double vision aren't
characteristic findings in pernicious anemia.
4) D
- In sickle cell crisis, sickle-shaped red blood
cells clump together in a blood vessel, which
causes occlusion, ischemia, and extreme
pain. Therefore, option D is the appropriate
choice. Although nutrition is important, poor
nutritional intake isn't necessarily related to
sickle cell crisis. During sickle cell crisis, pain
or another internal stimulus is more likely to
disturb the client's sleep than external
stimuli. Although clients with sickle cell
anemia can develop chronic leg ulcers
caused by small vessel blockage, they don't
typically experience pruritus.
5) A
- Vitamin B12 absorption depends on
intrinsic factor, which is secreted by parietal
cells in the stomach. The vitamin binds with
intrinsic factor and is absorbed in the ileum.
Hydrochloric acid, histamine, and liver
enzymes don't influence vitamin B12
absorption.
1) B
- The physician usually prescribes colchicine
for a client experiencing an acute gout
attack. This drug decreases leukocyte
motility, phagocytosis, and lactic acid
production, thereby reducing urate crystal
deposits and relieving inflammation.
Allopurinol is used to decrease uric acid
production in clients with chronic gout.
Although corticosteroids are prescribed to
treat gout, the nurse wouldn't give them
because they must be administered
interarticularly to this client. Propoxyphene,
a narcotic, may be used to treat
osteoarthritis.
2) B
- Kyphosis refers to an increased thoracic
curvature of the spine, or "humpback."
Lordosis is an increase in the lumbar curve
or swayback. Scoliosis is a lateral deformity
of the spine. Genus varum is a bow-legged
appearance of the legs.
3) A
- After a myelogram, answer to
musculoskeletal test questions about
positioning will depend on the dye injected.
When a water-soluble dye such as
metrizamide is injected, the head of the bed
is elevated to a 45-degree angle to slow the
upward dispersion of the dye. The other
positions are contraindicated when a water-
soluble contrast dye is used. If an air-
contrast study were performed, the client
should be positioned supine with the head
lower than the trunk.
4) B
- As untreated scoliosis progresses, the
thoracic spinal curvature can impinge on the
lungs and affect pulmonary function.
Osteoporosis, spinal cord injury, and
pituitary hyposecretion aren't directly
attributed to untreated scoliosis.
5) B
- To avoid pressure ulcers in an immobilized
client, the nurse must assess the skin
thoroughly and use such preventive
measures as regular turning, massage of
bony prominences, a low-air-loss mattress,
and a trapeze (if the client's condition
allows). The nurse should increase, not
decrease, the client's fluid intake to help
prevent renal calculi, which may result from
immobility. To prevent atelectasis, another
complication of immobility, having the client
cough, deep breathe, and use an incentive
spirometer would be more effective than
raising the head of the bed. Instead of
bathing and feeding the client, the nurse
should promote independent self-care
activities whenever possible to prepare the
client for a return to the previous health
status.
1) C
- Because of its short duration of action,
edrophonium is the drug of choice for
diagnosing myasthenia gravis. It's also used
to differentiate myasthenia gravis from
cholinergic toxicity. Ambenonium is used as
an antimyasthenic. Pyridostigmine serves
primarily as an adjunct in treating severe
anticholinergic toxicity; it's also an
antiglaucoma agent and a miotic. Carbachol
reduces intraocular pressure during
ophthalmologic procedures; topical carbachol
is used to treat open-angle and closed-angle
glaucoma.
2) A
- Phenytoin can lead to excessive gum tissue
growth. However, brushing the teeth two or
three times daily helps retard such growth.
Some clients may require excision of
excessive gum tissue every 6 to 12 months.
Phenytoin may cause central nervous system
stimulation, leading to insomnia,
nervousness, and twitching; it doesn't cause
drowsiness. Other adverse reactions to
phenytoin include hypotension, not
hypertension; and visual disturbances, not
tinnitus.
3) D
- Neurosurgical nursing answer - Levodopa-
carbidopa, used to replace insufficient
dopamine in clients with Parkinson's disease,
may cause harmless darkening of the urine.
The drug doesn't cause eye spasms,
although blurred vision is an expected
adverse effect. The client should take
levodopa-carbidopa shortly before meals, not
at bedtime, and must continue to take it for
life.
4) A
- To help confirm ALS, the physician typically
orders EMG, which detects abnormal
electrical activity of the involved muscles. To
help establish the diagnosis of ALS, EMG
must show widespread anterior horn cell
dysfunction with fibrillations, positive waves,
fasciculations, and chronic changes in the
potentials of neurogenic motor units in
multiple nerve root distribution in at least
three limbs and the paraspinal muscles.
Normal sensory responses must accompany
these findings. Doppler scanning, Doppler
ultrasonography, and quantitative spectral
phonoangiography are used to detect
vascular disorders, not muscular or
neuromuscular abnormalities.
5) D- Myasthenia gravis is characterized by a
weakness of muscles, especially in the face
and throat, caused by a lower motor neuron
lesion at the myoneural junction. It isn't a
genetic disorder. A combined upper and
lower motor neuron lesion generally occurs
as a result of spinal injuries. A lesion
involving cranial nerves and their axons in
the spinal cord would cause decreased
conduction of impulses at an upper motor
neuron.
1) C
- This is an example of a negative attitude
and passive-agressive behavior to word
demands for adequate performance. People
with this disorder won't confront or discuss
issues with others but will go to great
lengths to "get even." Obsessive-compulsive
disorder involves rituals or rules that
interfere with normal functioning. A person
with a narcissistic personality has an
exaggerated sense of self-worth. A person
with a dependent personality is submissive
and frequently apologizes and backs down
when confronted.
2) C
- Denial is the avoidance of reality by
ignoring or refusing to acknowledge
unpleasant incidents. This defense
mechanism is used to allay anxiety
immediately after a stressful event.
Introjection is an intense form of
identification in which one incorporates the
values or qualities of another person or
group into one's own ego structure.
Suppression is the conscious analog of
repression. A person intentionally uses
suppression to consciously exclude material
from awareness. Repression is the
unconscious exclusion of painful episodes
from awareness.
3) C
- Psychiatric nursing quiz answer - Children
may not have the verbal and cognitive skills
to express what they feel and may benefit
from alternative modes of expression. It is
important for the child to find a way to
express internalized feelings. The child must
also know that he is not to blame for this
situation. In the process of doing play
therapy, the child can also have fun, but that
isn't the main goal of therapy.
4) D
- The aggressor is negative and hostile and
uses sarcasm to degrade others. The role of
the blocker is to resist group efforts. The
monopolizer controls the group by
dominating conversations. The recognition
seeker talks about accomplishments to gain
attention.
5) A
- Individuals in a crisis need immediate
assistance. They are unable to solve
problems and need structure and assistance
in accessing resources. Clients in a crisis
don't need lengthy explanations or have time
to develop insight on their own. They might
need medication but, in most cases, support
and direction can be most helpful.
1) C
- The client needs to be advised to avoid
strenuous activity for 4-6 weeks and to avoid
lifting items that weigh more than 20
pounds. The client needs to consume a daily
intake of at least 6 to 8 glasses of
nonalcoholic fluids to minimize clot
formation. Straining during defecation for at
least 6 weeks after surgery is avoided to
prevent bleeding. Prune juice is satisfactory
bowel stimulant.
2) C
- Ovulation occurs 14 days before the onset
of menses.A- Midway between her cycles
would be appropriate only if the client has a
28-day cycle.B- This would mean that
ovulation would occur on approximately day
5 of the menstrual cycle.D- Variations in the
cycle occur in the preovulation period; thus
this is wrong information.
3) C
- A teaching from Nursing Test Bank said
that hydrocele is an abnormal collection of
fluid within the layers of the tunica vaginalis
that surrounds the testis. It may be
unilateral or bilateral and can occur in an
infant or adult. Hydrocelectomy is the
excision of the fluid-filled sac in the tunica
vaginalis. The client needs to be instructed
that the sutures used during the procedure
are absorbable. The other options are
correct.
4) C
- The client with genital herpes should be
instructed to avoid sexual intercourse until
lesions are completely healed. When the
client is diagnosed with genital herpes,
outbreaks may occur at any time. The
perineal area should be kept dry. Clients
should wear loose-fitting cotton underwear
to promote drying of lesions.
5 C
- Catheter blockage or occlusion by clits
following prostatectomy can result in urine
back-up and leakage around the urethral
meatus. This would be accompanied by a
stoppage of outflow through the catheter
into the drainage bag. Drainage that is bright
red indicates that the irrigant is running too
slowly; drainage that is pale pink indicates
sufficient flow. A true urine output of 50
mL/hr indicates catheter patency.
6) A
- Testicular cancer is highly curable
particularly when it is treated in its early
stage. Self-examinations allow early
detection and facilitate the early initiation of
treatment. The highest mortality rates from
cancer among men are in men with lung
cancer. Testicular cancer is found more
commonly in younger men ages 20-40 years
old.
7) B
- The client who suddenly becomes
disoriented and confused following TURP
could be experiencing early signs of
hyponatremia. This may occur because of
the flushing solution used during the
operative procedure is hypotonic. If enough
solution is absorbed through the prostate
veins during surgery, the client experiences
increased circulating volume and dilutional
hyponatremia. The nurse needs to report
these symptoms.
8) D
- Based on some nursing review, sperm
motility is increased at pH values near
neutral or slightly alkaline; a sodium
bicarbonate douche will reduce the acidity of
fluids in the vagina and help optimize the
pH.
A- Estrogen does not alter pH.B- Sulfur does
not change pH in any way.C- This would
increase the acid content and kill the sperm.
9) A
- Women with condylomata acuminata are at
risk for cancer of the cervix and vulva. Yearly
Pap smears are very important for early
detection. Because condylomata acuminata
is a virus, there is no permanent cure.
Because it can occur on the vulva, a condom
wont protect sexual partners. HPV can be
transmitted to her parts of the body, such as
the mouth, oropharynx, and larynx.
10) C
- nurse should avoid removing the traction
tape applied by the surgeon in the operating
room. The purpose of the tape is to place
pressure on the prostate to reduce bleeding
Suppositories ordered on a PRN basis for
bladder spasm should be warmed to a room
temperature before administration. The
nurse routinely monitors hourly urine output
since the client has a three-way bladder
irrigation running. The nurse also assesses
for confusion which could result from
hyponatremia secondary to the hypotonic
solution irrigation during the surgical
procedure.
1) D
- Sitting or holding a child upright for
formula feedings help prevents pooling of
formula in the pharyngeal area. When the
vaccum in the middle ear opens in the
pharyngeal area, formula (along with
bacteria) is drawn into the middle ear. A-
Cleansing the ear does not reduce the
incidence of otitis media because the
pathogenic bacteria are in the nasopharynx,
not the external area of the ears. B-
Continuous low-dose antibiotic therapy is
used only in cases of recurrent otitis media,
when the child finishes a course of antibiotics
but then develops another ear infection a
few days later. C- Although accumulation of
cerumen makes it difficult to visualize the
tympanic membrane, it does not promote
inner ear infection.
2) A
- Placing ear plugs in the ears will prevent
contaminated bathwater from entering the
middle ear through the tympanostomy tube
and causing an infection. B- Blowing the
nose forcibly during a cold causes organisms
to ascend through the Eustachian tube,
possibly causing otitis media. C- It is not
necessary to administer antibiotics
continuously to a child with tympanostomy
tube. Antibiotics are appropriate only when
an ear infection is present.D- Drainage from
the ear may be a sign of middle ear infection
and should be reported to the health care
provider.
3) D
- According to Pediatric Nurse Education
Books, a myringotomy relieves pressure and
prevents spontaneous rupture of the
eardrum by allowing pus and fluid to escape
from the middle ear into the external
auditory canal, from which the exudates
drain.A, B & C-The CNS, lacrimal glands, and
the urinary sytem are not involved in
myringotomy.
4) A
- Conjunctivitis is very contagious, so using a
siblings towel is not recommended because
the danger of spreading the infection.
Careful and frequent handwashing is
necessary to reduce risk of transmission.
Typically, the child can return to school 24
hours after starting treatment. Medication
for conjunctivitis is used for approximately 5
days. Teaching for the parents and the child
with conjunctivitis should also include
instructions to wash hands after touching the
eyes, dispose of tissue used to clean the
eyes after use, and launder washcloths and
towels in hot water.
5) C
- Prolonged oxygen administration at
relatively high concentrations in a premature
infant whose retina is incompletely
differentiated and/or vascularized may result
in retinopathy of prematurity (retrolental
fibroplasias); when oxygen therapy is
discontinued, capillary overgrowth in the
retina and vitreous body may result and
include capillary hemorrhage, fibrosis, and
retinal detachment
A- Though true, temperature and humidity
not factors in the development of
retinopathy of prematurity.
B- Phototherapy is used to decrease
hyperbilirubinemia; it is unrelated to
retrolental fibroplasias; however eyes are
covered to prevent injury for all infants
receiving phototherapy.
D- High oxygen concentration is dangerous
and a factor in the development of
retinopathy of prematurity.
6) B
- Respiratory distress syndrome is
predominately seen in premature infants;
the more premature the infant, the more
severe the disease - according to Pediatric
Nursing Education Books.
A & C- Intrauterine growth retardation and
prolonged rupture of membrane are unlikely
associated with development of respiratory
distress syndrome.
D - A 38- week gestation neonate usually
has more mature lungs and isnt at risk for
respiratory distress syndrome.
7) D
- Tertbutaline, a beta2- receptor agonist, is
used to inhibit preterm uterine contractions.
A- Magnesium sulfate is used to treat
pregnancy-induced hypertension.
B- Dinoprosterone is used to induce fetal
expulsion and promotes cervical dilatation
and softening.
C- It is used to stop uterine blood flow, for
example, in hemorrhage.
8) C
- Pediatric Nursing Education teaches that
much of a full-term infants birth weight is
gained during the last month of pregnancy
(almost a third), and most of this final spurt
is subcutaneous fat, which serves as
insulation; the preterm infant has not has
the time to grow in the uterus and has little
of this insulating layer.
A- There is relatively larger surface area per
body weight.
B- There is an extremely limited shivering
and sweating response in the preterm infant.
D- This is unrelated to the maintenance of
body temperature.
9) D
- The assessment findings are indicative of a
preterm infant; therefore the nurse should
closely monitor the infant for signs of
respiratory distress syndrome; this occurs
commonly in preterm infants because their
lungs are immature.
A- Preterm AGA infants do not develop
polycythemia; preterm LGA infants may
develop polycythemia, but there are no data
to indicate the infant is LGA.
B- Preterm AGA infants may become
hypoglycemic.
C- The neonate is preterm, not post-term.
10) A
- Before 32 weeks gestation, the majority of
neonates have difficulty coordinating sucking
and swallowing reflexes along with
breathing. Increased respiratory distress
may occur with bottle feeding. Bottle feeding
can be given once the neonate shows
sucking and swallowing behaviors.
B- high-caloric formulas can be given by
bottle or by gavage feeding.
C- Although frequent feeding prevents
hypoglycemia, it does not have to be given
via gavage tube.
D- Although neonates can be stressed by
cold, they can be kept warm with blankets
while bottle feeding or fed while in the warm
Isolette environment.
A
- The Gynecoid is considered the normal
pelvis type. This is transversely rounded or
blunt. Option B is the Android. Wedge
shaped or angulated. Seen in males. Not
favorable for labor. Its narrow pelvic planes
can cause slow descent and mid pelvis
arrest. Option C is the Anthropoid type. This
is oval shaped. The outlet is adequate, with
a normal or moderately narrow pubic arch.
Option D is what we call the platypelloid.
This is flat in shape with an oval inlet.
Transverse diameter is wide but
anteroposterior diameter is short making the
outlet inadequate.
2 D
- Human chorionic gonadotropin is produced
by the trophoblastic tissue of the placenta
and secreted into the urine and serum of a
pregnant woman shortly after the onset of
pregnancy. Leutinizing hormone (option a)
and follicle stimulating hormone (option b)
are anterior pituitary hormones necessary
for developing and releasing the mature
ovum and for synthesizing estrogen and
progesterone. Human chorionic
somatomammotropin (option c) is a
placental hormone that acts similarly to the
pituitary growth hormone. It produces a
diabetogenic effect in pregnant women and
isnt diagnostic of pregnancy.
3 C
- The chorionic villi and desidua basalis fuse
to become the placenta. The deciduas vera is
also a layer of the deciduas, but neither it or
nor the deciduas capsularis is in direct
contact with the ovum. The chorionic
frondosum is part of the chorionic villi that
fuses with deciduas basalis. The chorionic
laeve is the part of the chorionic villi that
does not fuse with the deciduas basalis; it
degenerates and finally almost disappears.
4 C
- Amniotic fluid does not provide the fetus
with immune bodies but it does help dilate
the cervix, protect the fetus from injury and
keep the fetus at an even tenperature.
5 C
- The umbilical cord normally consists of two
arteries and one vein. Oxygen and other
nutrients are carried to the fetal circulation
by one umbilical vein. The oxygen-poor
blood is pumped back to the placenta by the
fetal heart through the two umbilical
arteries. A single umbilical artery is
sometimes associated with congenital
anomalies.
n3
AN3wER KEY:
1. C
2. C
3. 8
1. A
5. 0
. A
Z. C
8. 0
9. 0
10. A
11. A
12. 0
13. 0
11. 0
15. A
1. 0
1Z. C
18. 8
19.
20.
21.
22.
23.
21.
25. A
2. A
2Z. A
28. 8
29. C
30. C
31. A
32. A
33. A
31. 0
35. 0
3. C
3Z. 0
38. 8
39. A
10. A
11. 8
12. C
13. A
11. 8
15. C
1.
1Z.
18.
19.
50.
51. 0
52. 8
53. 8
51. A
55. A
5. A
5Z. C
58. 0
59. A
0. 8
1. A
2. 8
3. 0
1. 0
5. 0
. 8
Z. 0
8. C
9. C
Z0. C
Z1. C
Z2. 8
Z3. 8
Z1. A
Z5. 8
Z. 8
ZZ. 8
Z8. C
Z9. 8
80. C
81. 8
82. 8
83. 0
81. 0
85. 0
8. 8
8Z. A
88. 8
89. 0
90. 8
91. C
92.
93. 0
91. 8
95. C
9. 0
9Z. A
98. 8
99. A
100. A
NP1-5
uA8uC888u8
C8Au88u8u8
88AuCuCCA8
CCuCA88AuC

Answer u 8eLurn of S1 segmenL Lo basellne on LCC
lmproved perfuslon should resulL from Lhls medlcaLlon along
wlLh Lhe reducLlon of S1 segmenL elevaLlon
Answer C Clnglval hyperplasla
Swollen and Lender gums occur ofLen wlLh use of phenyLoln
Cood oral hyglene and regular vlslLs Lo Lhe denLlsL should be
emphaslzed
Answer C 1he nurse racLlce AcLs requlres reporLlng Lhe
susplclon of Lhe lmpalred
nurses 1he 8oard of nurslng has [urlsdlcLlon over Lhe
pracLlce of nurslng and may
develop plans for LreaLmenL and supervlslon 1hls susplclon
needs Lo be reporLed Lo Lhe nurslng supervlsor who wlll Lhen
reporL Lo Lhe 8oard of nurslng ConfronLlng Lhe colleague
may cause confllcL Asklng Lhe colleague Lo go Lo Lhe nurses'
lounge Lo sleep for a whlle does noL safeguard cllenLs
Answer 8 LxLernal Cardlac Massage ls a llfesavlng LreaLmenL
LhaL a cllenL can
refuse 1he mosL approprlaLe lnlLlal nurslng acLlon ls Lo noLlfy
Lhe physlclan because
wrlLLen do noL 8esusclLaLe (un8) order from Lhe physlclan ls
needed 1he un8 order
musL be revlewed or renewed on a regular basls per agency
pollcy

Answer u ConfronLaLlon ls an lmporLanL sLraLegy Lo meeL
reslsLance headon laceLo
face meeLlngs Lo confronL Lhe lssue aL hand wlll allow
verballzaLlon of feellngs
ldenLlflcaLlons of problems and lssues
Answer 8
Answer u
Answer C
Answer A