1
Q
SITUATION - Zion, 11-year-old, is admitted due to bronchitis. Upon production of mucus (sputum), yellowish’ in color, fatigue, shortness of breath, slight fever and chills and chest discomfort. The physician orders 41/min oxygenation.
- The first standards step in oxygen therapy that the nurse should do is
A. assess client’s condition
B. gather all the equipment and supplies
C. prepare the client for the oxygen treatment
D. check the chart for ordered flow rate and oxygen delivery method
A
D
2
Q
- In planning for Zion’s oxygen therapy the nurse should consider which of the following EXCEPT
A. Need for a humidifier v
B. length of tubing
C. determine the age of Excel
D. manner of administering oxygen, continuous or intermittent
A
B
3
Q
- Which of the following is the PRIORITY action for the Rurse for Zion who is on oxygen therapy?
A. Check the flow
B. Connect the flow mater to the pipe oxygen outlet
C. turn on the oxygen
D. attach the humidifier and connecting tubing to the 2 oxygen delivery
A
B
4
Q
- What PRIORITY precautionary measure should be done by the nurse during the oxygen therapy?
A. Humidifier’s water should be checked regularly
B. No smoking sign
C. Oxygen tank should have belt
D. Limit visitors
A
B
5
Q
5 One evening, Zion complained of dyspnea despite continuous oxygen therapy. What should be the first action of the nurse?
A. Reassess the client
B. Give PRN medication
C. Assess the patency of the tubing
D. Refer client to the physician
A
C
6
Q
SITUATION - The senior nurse Reese; is planning to revisit and implement a change in the management system for the obstetric Unit. This would be a pilot unit as planned by the administration. Many problems have occurred one of which is the present documentation system, and the charge nurse determines that a change is required.
What should be the INITIAL STEP in the process of change for the senior nurse.
A. Set goals and priorities regarding the change process
B. Plan strategies and implement the change.
C. Identify potential solutions and strategies for the change.
D. Identify the inefficiency that needs improvement or correction.
A
D
7
Q
Nurse Reese is preparing the patient assignment for the day and need to assign patient to midwife and nursing assistant. Which patient should the nurse assign to the midwife because of patient needs that cannot be met by the nursing assistant? A patient requiring
A. dressing change of post caesarian surgery
B, collecting of urine specimen for urinalysis testing X
C. performing range-of-motion exercise twice a day
D. taking of vital signs measurement every 4 hours
A
A
8
Q
Because of the scarcity of nurses in the hospital settings, different service delivery models were proposed.
Which situation represents the primary nursing care delivery model?
A. The nursing aide is assigned to make beds and other errands.
B. The nurse develops a plan of care for patients and collaborates with other team members.
C. The nurse performs all task needed by the individual patient to optimize health.
D. The nurse provides care to 4 patients while the nursing aide is to care for 2 patients.
A
B
9
Q
One of the post-caesarian patients has a private duty nurse and is responsible for providing holistic care to her patient during the shift. What modality of nursing care is implemented?
A. Primary
B. Team
C. Total care
D. Functional
A
C
10
Q
Lillian complains of unbearable plain. Which of the following characteristics are EMPHASIZED in a culturally sensitive nursing care?
(Select all that apply)
I. The expression of pain is affected by learned behavior
II. physiologically, all individuals experience pain in a similar manner.
III. Some Asian people has high response to pain medications.
IV. Patients should be assessed for plain regardless of overt symptomatology.
A.Ill and IV
B. I and II
C. I and III
D. II and Ill
A
A
11
Q
At which stage of Lewin’s planned change indicate the nurse identifying, planning and implementing appropriate strategies ensuring that driving forces exceed restraining forces?
A. refreezing
B. unfreezing
C. movement
D. in activism
A
C
12
Q
SITUATION - Olivia, a 25-year-old, high school student Visited the health center for prenatal check-up. Per nurse’s initial assessment, the patient drink alcohol and smokes cigarettes about 5 sticks a day for 2 years now.
Her last menstrual period (LMP) was October 10, 2020
- Base on the nurse’s computation utilizing Naegele’s rule, the patient’s excepted date of birth (EDB) Will be on
A. September 17, 2021
B. June 17, 2021
C. July 17, 2021
D. August 17, 2021
A
C
13
Q
- Which of the following is the MOST common emotional response among women during the first trimester of pregnancy?
A. Ambivalence
B. Depression
C. Acceptance
D. Jealousy
A
A
14
Q
Olivia mentioned that she can experience uttering squeezing. Which of the following signs of normal pregnancy should the nurse consider?
A. Braxton-Hicks contractions
B. Hegar’s sign
C. Ballottement
D. Goodell’s sign
A
A
15
Q
Nurse Emma advised the patient to quit smoking because nicotine will contribute to
A. low birth weight infant
B. ectopic tubal pregnancy
C. congenital anomalies
D. large for gestation age infants
A
A
16
Q
Emotional lability is common to pregnant women.
Identify which of the following reaction is accepted as part of a normal pregnancy?
A. Feelings are easily hurt by remarks
B. Mood swing
C. Amusing or even charming situation
D. Narcissism
A
B
17
Q
SITUATION - Nurse Lingling is in the process of evaluating the effectiveness of her teaching which is the critical part of the process.
- Which of the following would BEST help Nurse Lingling in conducting her evaluation?
A. Written examination knowledge
B. Change in behavior
C. Return demonstration
D. obtain feedback from the client
A
C
18
Q
12 Which of the following aspects nurses continually teach patients to do? (Select all that apply)
1. Disease or disorder
2. Diet medication
3. Treatments
4. Self-care
A. 1 only
B. 1, 2, 3
C. 1, 2, 3, &4
D. 283
A
C
19
Q
- The first step in teaching is assessing which of the following? (Select all that apply).
major - Learning needs
- knowledge deficit
- Education background
- Social status
A. 1, 2, 3
B. 38 4
C. 1 only
D, 1, 2, 3, 4
A
D
20
Q
- Which of the following environmental factors affect _earning? (Select all that apply)
- Client comfort
- Lighting
- Noise level
- Room temperature
A. 2 & 4
B. 3 & 4
C. 1 only
D. 1,2, 3, 4
A
D
21
Q
- Which of the following environmental factors affect learning? (Select all that apply).
- Nursing specialist
- Videotapes
- Demonstration equipment
- Books
A. 2 & 4
B. 2 & 3
C. 1, 2,3, & 4
D. 1, 2 & 3
A
234
22
Q
SITUATION - Ramon, 6-year-old, has been recently diagnosed to have acute Lymphocytic Leukemia. The child has undergone chemotherapy. However, the father is witnessing before his very eyes his first child dying. The father is very much depressed.
- In what way will the nurse handle the situation?
A. Tell her to trust on god’s love and mercy
B. Tell her that death is a reality
C. Encourage her to keep calm because the health care team is doing their best to help Ramon recover.
D. Encourage the mother to express more about her thought and feelings
A
D
23
Q
22 The APPROPRIATE nursing diagnosis to protect the patient from further injury is, which of the following?
A. Altered mucous membrane related to chemotherapy.
B. Interrupted family processes related to life threatening illness of a family member.
C. Fatique related to disease process.
D. Risk for injury related to thrombocytopenia.
A
D
24
Q
- Mouth sores have developed in the child’s mouth.
The father asked the nurse the reasons for this. The MOST APPROPRIATE response of the nurse os
A. “The child’s oral hygiene needs to be improved.” V
B. “There is no need to have them/” X
C. “He is allergic to the drug so I will report this to the doctor and suggest a change of during.”
D.” Mouth sores result because the cells of the mouth are sensitive to chemotherapy
A
D
25
24-Ramon died at 10:00 PM. His father cried much and
refused to move Ramon's body. What is the APPROPRIATE approach of the nurse?
A. Talk about the reality of death
B. Leave the mother and the child for the last time
C. Silence to allow the mother to grieve
D. Cry with the mother as you remember your own experience of death in family.
C
26
25. The nurse's MAIN responsibility in preparing Ramon's discharge is, which of the following?
A. Assist the mother to pay the hospital bill.
B. Prepare Ramon's cadaver
C. Prepare the death certificate.
D. Extend condolences to the bereaved family
C
27
SITUATION - Asst Chief for education & Training, Nurse Mendoza, is planning to conduct an inservice training program on intravenous therapy for the staff nurses.
26. To be able to justify the conduct of any inservice training program in a hospital, which of the following should be the bases for the implementation of the program?
1. Needs assessment
2. Needs analysis
3 Per recommendation by the chief Nurse
4. Incident Reports
A. 1, 2, & 4
B. 1, 2, & 3
C. 1 only
D. 1, 2, 3, & 4
A
28
The BEST rationale for the conduct of the program is mich of the following?
A. Ensure safe practice in the hospital
B. Provide knowledge and skills to all nursing staff in IV therapy
C. Improve nursing practice in general
D. Deliver safe and quality nursing to all care patients on intravenous therapy
D
29
28. One of the lecturers discussed the complications that patients may have while on IV therapy. Which of the following is the most common complication that IV patient may contract while on IV therapy?
A. Embolism.
B. Cardiac overload
C. Phlebitis
D. Aneurysm
C
30
29. The participants may avail of continuing professional Development (CPD) units if Nurse Mendoza had filed the program to be CPD accredited to which of the following?
A. Professional Regulatory Board of Nursing
B. Professional Regulation Commission
C. Continuing Professional Development Council for
Nursing
D. Commission on Higher Education
A
31
30. The participants should know the way by which they may obtain CPD units aside from attending inservice training programs, which are EXCEPT
A. professional seminars and conference
B. graduate studies
C. short course training for specialization
D. joining nursing service committees
D
32
SITUATION - The concept of reproductive health is introduced as early as primary and secondary levels with different degrees of concentration. Students, interested to continue health courses were asking questions on human sexuality.
31. Nurse Hailey discusses the 2020 National Health
Goals. Which of the following statements is an EXCEPTION in planning sexual health programs.
A. Make sexual education program voluntary
B. Increase the proportion of adolescents who have never engaged in sexual intercourse.
C. Reduce deaths from cancer resulting from uterine cervix.
D. Reduce deaths from cancer of the uterine cervix.
B
33
32. Maternal and child Nursing is a concept under the national Goals. Which objective should nurse Hailey emphasize to support the program?
A. Avoid having misdirected children and become street children.
B. Promote the well-being of the mother's family life and family planning.
C. Consider that every child has love, security, and a better future.
D. Avoid complications of pregnancy and promote vaginal deliveries.
B
34
33. Which of the following topics should the patient feel
MORE comfortable when reproductive anatomy and physiology is discussed with the nurse?
A. Sexual health education
B. Gender reassignment
C. Varied sexual positions
D. Gender identify
A
35
34. When can the patient tell all information to the
nurse?
A. All diagnostic laboratory test performed had been competed
B. Once the feeling of security is established in the nurse-patient relationship
C. A change in physical appearance occurs
D. The nurse knows the genogram of the patient
B
36
35. Which nursing diagnosis is NOT RELEVANT to sexual health?
A. Anxiety-related inability to conceive after six months.
B. Health-seeking behaviors relayed to reproductive functioning.
C. Sexual dysfunction related to high-risk sexual behaviors.
D. Risk for infection related to high-risk sexual behaviors.
A
37
SITUATION - Ruby, a pregnant patient 37-week gestation is admitted due to who has a diagnosis of sickle cell anemia.
36. Nurse Sophia administer oxygen to patient Ruby and Implements additional measures to prevent a sickling crisis from occurring?
A. Maintain strict asepsis.
B. Maintains adequate hydration.
C. Monitors the temperature.
D. Reassures the patient.
B
38
37. Nurse Sophie hooks a 1000 mL intravenous (IV)
solution of D5water as ordered by the physician at 9 am to infuse 80 mL/hr. via macro drop infusion at what would be the level of the remaining amount in the IV bag at 2 pm?
A. 500
B. 200
C.400
D. 300
C
39
38. The patient began receiving an intravenous (IV) infusion of packed red blood cells 30 minutes ago. The patients complain of difficultly of breathing, itching and a tight sensation the chest. Which is the IMMEDIATE action of the nurse?
A. Recheck the unit of blood for compatibility.
B. Call the physician.
C. Check the patient's temperature
D. Stop the infusion.
D
40
39. Nurse Sophie checks the gauge of the patient's intravenous catheter. Which is the smallest gauge catheter that the nurse can use to administer blood?
A. 22-gauge
B. 18-gauge
C. 20-guage
D. 12-guage
A
41
40. The nurse reviews the patient's plan of care. Which of the following nursing diagnoses will be the PRIORITY?
A. Fluid volume, deficit
B. Risk for pain, acute
C. Coping, ineffective
D. Body image, disturbed
A
42
Lillian asks the nurse the cause of this ailments. Which the following would the nurse explain as predisposing factors of mastitis? (Select all that apply)
1. Milk stasis
TI. Nipple trauma
III. Using alcohol in cleaning nipples
IV. Baby's sitting position
A. Il and IV
B. I and IV
C. 1 and II
D. Il and III
D
43
SITUATION - Nurse Nilda is a beginning nurse assigned in the pediatrics Unit in a government hospital. The unit has pediatric patients of different ages. Since she will be dealing with patients of varied ages, she thought it best to review her notes on human growth and development, specifically Erikson's psychosocial theory.
41, The BEST reason why the nurse Nilda opted to review Erikson's psychosocial theory is, which of the following statements?
A. Completion of task results in a sense of competence and a healthy personality.
B. Failure to master these task leads to feelings of inadequacy.
C. Helps children grow into successful, contributing members of society.
D. We are motivated by the need to achieve competence in certain areas of our lives.
A
44
42. Nurse Nilda immediately responds to an cry from her pediatric patients because it is, which of the following reasons?
A. To attend to her patient who cannot communicate verbally
B. To check if the child is hungry or wet
C. To lessen the noise overload in the unit
D. A powerful influence over that individual's interactions with others for the remainder of his/her life
D
45
43. Nurse Linda is attending to a two-year-old Neneng who was admitted due to chronic bronchitis. Neneng sports a long hair that extends after to her shoulder. As part of the morning care, Nurse Linda decided to style neneng's hair into pony tail. However, Neneng vehemently resisted her hair being tied by a rubber band.
The BEST thing that Nurse Linda should do is, which of the following?
A. Assert her authority
B. Denny Neneng's preference
C. Explain that a pony tail would make Neneng's more beautiful.
D. Allow Neneng's preference
D
46
44, Joll, 17 years old is admitted in a private room due to nfluenza. In one of Nurse Linda's conversation with Joji, the patients expressed is unhappiness with the program he is taking up in the college. This is not his choice but rather the choice of his parents. In which of erikson's stage of development does this case fall?
A. Autonomy versus shame/doubt Y
B. Integrity versus despair
C. identify versus role confusion
D. Trust versus distrust
C
47
45. When a 3-year-old patient of nurse Nilds asserts to choose the pants and shirt to wear to indude food preference. Based on Erikson's development task, the child's such behavior is attributed to their which of the following?
1. struggling to acquire a sense of autonomy
2. discovering they have a will of their own
3 awareness that they cannot control others
4. leaming which behavior gains approval
A 1.2.3
B.2. 3. 4
C. 1 2 3.4
D. 1, 2, 4
C
48
SITUATION - Gwen a unit manager is assigned to evaluate applicants for the position in the 0B Unit. During the interview, the applicant was asked 5 questions.
46 when a patient is admitted to the OB ward with complains of dizziness and body weakness, this is an example of
A secondary source
B. primary source
C. objective data -
D. subjective data
D
49
47 What are the possible cases that need informed consent?
A. Administering skin testing
B. Subjective the patients to an invasive procedure
C. Hair shampooing the patients *
D. Performing a laboratory procedure
B
50
48. The applicant was further asked about an incident report. Which of the following is a PRIORITY case for an incident report to be accomplished?
A. Patient fell from the bed.
B. A visitor encourage a patient on bed rest to ambulate. Y
C. Refusal to go to the physical therapy session.
D. Nurse left before his duty ends
A
51
49. On which occasion would a nurse can be charge with negligence?
A. Giving the patient the wrong medication
B. Giving competent care.
C. Following standards of care.
D. Communicating with another health team.
A
52
50. What can be delegated to his nursing assistant during his tour of duty?
A. Changing wound dressings.
B. Administering analgesic drug.
C. performing a physical drug. arsesSmat
D. Taking vital sign.
D
53
SITUATION - Nurse Trining has been assigned to the pediatric ward for two years. She wants to join the team of nurses who will be conducting a study on sleep. The team leader wants to be assured that the nurse Trining is equipped with the basic knowledge of nursing research.
51. The team leader decided to ask Nurse Trining the meaning of informed consent. After being able to define what the term means, she was further asked the reasons for it use. Nurse Trining's answer should be, which of the following?
1. To fully understand what the research is all about and what will happen should the participants opt to involve themselves in the research study.
2. To get assurance that participants have the right to withdraw from the participating in the research at any given time.
3. To get a complete and full information as to the objective of the study, procedures to be implemented, data collection, benefits and harm and options in the method of treatment.
4. To get assurance how anonymity and confidentiality will be maintained.
A. 1,2 & 3
B. 2 only
C. 1, 2, 3 & 4
D. 3 only
C
54
52. As to the observance of respecting privacy, Nurse Trining explained about.
A. breach of contract
B. anonymity
C. ethical dilemma
D. confidentiality
B
55
53. In nursing, Nurse Trining explained that the main GOAL of conducting a research is to.
A, justify the role of nurses as health care provider X
B. establish a credible body of evidence to support and Improve the delivery of care.
C. identify research priorities that will justify the oversupply of nurses.
D. develop a body of knowledge to address non-nursing problems
B
56
55. Should a 24-hour period clinical observation and activities be considered in conducting the research on sleep, the type of study that training will be conducting iS
A. Quantitative
B. Descriptive
C. Ethnological
D. Exploratory
B
57
SITUATION - Presley enters the labor and delivery unit in probable preterm labor at 36 weeks" gestation. The patient was informed that the fetus is in breech presentation. She has a catheterized urine specimen ordered.
56. Patient Presley asks the nurse why such a diagnostic procedure is required. What is the MOST APPROPRIATE answer can the nurse give?
A. Urinary tract infections are strongly associated with the occurrence of preterm labor.
B. Reduced sensation to urinate usually occur during preterm labor.
C. Preterm labor treatment usually causes women bladder infection because of restricted fluid intake.
D. Catheterized urine is usually ordered for any woman admitted to the labor and delivery unit.
B
58
In conducting a study on sleep, Nurse Trining was sked which of the types of research will be used should involve collecting numerical data which is the most often under considerable control. Her answer should be.
A. Ethnographic
B. Phenomenological
C. Qualitative
D. Quantitative
D
59
57. Betamethasone (Celestone) is prescribed to be administered and the patient asks nurse Hope about the purpose of this medication?
A. Promote fetal lung maturity.
B. Prevent the premature closure of the ductus arteriosus.
C. Delay delivery for at least 48 hours,
D. Stop the premature uterine contractions.
A
60
58. Patient Presley who is ordered for diagnostic pelvic. ultrasounds ask what preparation she'll take. Appropriate preparations for this procedure include
A explanation of the procedure
B. NPO 6 hours before
C. Informed consent
D. voiding
A
61
59. Pelvic ultrasound can detect, which of the following?
A. Congenital defects in the structure, fetal gender, H-mole
B. Fetal sex, number, and lung maturity
C. Fetal DM, multiple pregnancies, fetal age of gestation
D. Fetal congenital defects, placenta previa, fetal lung. maturity
A
62
60. The labor progress and the physician performed Amniotomy the nurse should First asses for.
A. Bladder distention
B. maternal blood pressure
C. cervical dilatation
D. fetal heart rate (FHR) pattern
D
63
SITUATION - Sienna, a patient with severe preecampsia is admitted to the hospital. She is the student from one of the local universities and insist on continuing studies while in the hospital, despite being instructed to rest. The patient studies approximately 10 hours a day and has numerous visit from fellow students, family and friends.
61, Which intervention should the nurse use to promote rest?
A. Develop a routine with the patient to balance her studies and her rest needs.
B. Include a significant other in helping the patients understand the need for rest.
C. Instruct the patients that the baby's health is more important than her studies at this time.
D. Ask complying with her why she is not complying with the prescription of bed rest.
A
64
62, Patients Sienna who seems to be irritated with the nurse said "I don't want to talk with you because you're only a nurse. I will wait for my doctor." Which of the following should the nurse say in response to the patient?
A. Your doctor prescribed this for us to do nursing care.
B. I understand. I should call your doctor.
C. I'm angry with the way you dismiss me.
D. So then you would prefer to speak with your doctor?
D
65
63. Nurse Mauve is now ethical dilemma. This occurs
when
A. a decision had to be made quickly under stressful * situation
B. choices are unclear
C. there is a conflict between the nurse's decision and that of his/her superior193
D. there is a a conflict of two or more ethical principles
D
66
64. Despite the reaction of the patient. Which of the ethical principles that the nurse is responsible of providing all patients with caring attention and information?
A, Beneficence
B. Nonmaleficence
C. Veracity
D. Advocacy
A
67
65. Nurse Mauve should plan to initiate which action to provide a safe environment?
A. Take the patient's vital signs every 4 hours.
B. Encourage visits from family and friends for psychosocial support
C. Maintain fluid and sodium restrictions.
D. Take off the room lights and draw the window shades.
D
68
Nurse Namie is aware that history taking and physical exam are critical to the diagnostic process and often provide more information than can be gained by broad testing strategies. History taking indudes the following,
EXCEPT
A. History of present illness
B. Religious affiliation
G. Social &Family history
D. Past medical history
B
69
67. The objective of taking the history of present illness is to illicit the chronologic description of the chief complaint. Which of the following questions would try to answer what Nurse Nanie wishes to illicit?
1, History of immunizations
2. Aggravating and alleviating factors
3. Duration of disease onset
4. Any treatment and response to treatment
A. 1, 2, & 3
B. 2, 3 & 4
C, 1, 2, 3, & 4
D. 1, 2, &3
B
70
68. Past medical history section of Krini contains the following, but NOT
A. Prenatal history
B. Child hood illness
C. Current history
D. Birth history
C
71
SITUATION - Lillian 2-week postparturn mother is seen in the health center. Redness on the left breast, and the mother is diagnosed with mastitis.
81. Which additional finding confirms the diagnosis that the patient has has mastitis?
A. Enlarged glands in the axilla
B. Normal temperature
C. Engorged both breasts
D. Hard mass and reddened area
D
72
69. Which of the following statements is TRUE?
A. History must taking must be long regardless if the child appears to be well.
B. No proper history can be obtained without observation of the child and the mother.
C. Nurse Nanie should refrain from asking about the illness of other members of the family.
D. An example of what can be elicited from asocial history is how the disease started.
B
73
70, In order not to frighten small children, it is best to examine things that are uncomfortable or frightening to them last so as not to lose their cooperation. This means the LAST thing to do in a child is, which of the following,
EXCEPT
A. Inspections of the throat with a throat stick
B. Inspection of the ears with an otoscope
C. Auscultation of the heart
D. Undressing the child
D
74
SITUATION - Ximena a Christian 29-year-old pregnant woman was admitted to the hospital with a complaint of moderate hypogastric pain. She intends to visit the clinic for her first prenatal check-up and informs nurse parker that she did not realize she's pregnant until a week ago.
As a result, she has been on a diet, weightlifting at the health gym.
71. Patient Ximena was seen by the physician and was ordered for a medication that is larger than the standard dose. What should the nurse medication that is larger than the standard dose. What should the nurse do?
A. Give a drug as prescribed.
B. Inform the supervisor
C. Give the average dose of the medication
D. Discuss the prescription with the physician
D
75
72. The patient refuses to take the medication because it causes diarrhea. Nurse Parker explains the action of the drug but the patient vehemently refuses the medication.
What should be the INITIAL action of the nurse?
A. Discuss with a family member the need for the patient to take the medication.
B. Document the patient's refusal to take the medication
C. Notify the physician of the patient's refusal to take the medication
D. Explain again to the patient the consequences of refusing to take the medication
D
76
As a strong believer of her faith and the need for spiritual guidance, patient Ximena request that she wants that clengy (priest) will visit her. How did nurse parker function when she initiated the visit?
A. Dependently
B. collegially
C. Interdependently
D. Independently
C
77
7A. Patient Ximena sought referral to an abortion clinic from the nurse. Reasons out that her pregnancy a burden to her work and daily routines. What should be the BEST RESPONSE of the nurse?
A. It will cause discrimination from friends and relatives. *
B. Inform her that abortion is morally and legally wrong by virtue of the law
C. It will cause infection
D. It is against any religion
B
78
While administering a medication, the patient says, "This looks different from the one I had taken before." What the APPROPRIATE action of the nurse?
A. Explain the purpose of the medication
B. Encourage the patients to take the medication
C. Check the original medication prescription
D. Ask what the other pill looked like
C
79
76. She asked by the nurse supervisor about her concern and what are the considered ideal fetal positions for a healthy delivery?
A. Right occipito posterior with no flexion
B. Right occipito posterior with full flexion
C. Left transverse anterior in moderate flexion
D. Left sacroanterior with füll flexion
B
80
The physician ordered sonography. The nurse informs the ultrasounds unit in charge and prepares the patients for the procedure. The patients asked the importance of the procedure, the nurse's CORRECT response is
A. to determine diameters of the fetal skull
B. increase sensitivity for common bile duct of the fetus /
C. useful to a visualized cystic duct of the fetus
D. to assess fetus' well-being
D
81
The supervisors noticed that the newly hired nurse felt uneasy upon learning that the fetus is on breech presentation. Which of the following is the BEST RESPONSE by the supervisors?
A. "I understand how you feel. Tell me more."
B. "Is this your first time to witness a breech presentation"
C. "Are you afraid to assist the case"
D. "Don't worry. There's always a first time".
A
82
79, After the successful vaginal delivery, medication was ordered to be given immediately. The supervisors reassured the newly hired nurse that everything will be fine because the medication will
A. Promote vasoconstriction of uterine muscles
B. hasten uterine contractility and control and control bleeding
C. facilitate the return of pregnancy vital signs
D. promote vasodilation of uterine muscle
B
83
80. The newly - hired nurse oriented the caregiver hired by the couple. Which of the following should be nurse encourage the parents to do?
A. Relate to each twin individually to enhance the attachment process.
B. Avoid assistance from other family members and support groups
C. Bottle-feed the twins to prevent maternal exhaustion Y
D. plan for each parent to spend equal amounts of time with each twin
A
84
Nurse Addison provides instructions about measures to prevent postpartum mastitis who is breastfeeding her newborn. Which of the following would indicate that the mother needs further instruction?
A. wash my hands well before breastfeeding
B. breastfeed every 2- 3 hours
C. change the breast pads frequently
D. wash my nipples with soap and water prior to feeding
D
85
85. Considering her level of knowledge and the anxiety of her condition, patient Lillian raised questions on possible ways of relieving her breast discomfort. Which of the statements NEEDS further instructions?
A. I have to stop breastfeeding until this condition resolves."
B. "I can take antibiotics, and should begin to feel better in 24 to 48 hours."
C. "I can use analgesic to assist in alleviating some of these discomforts."
D. "I have to wear a supportive bra to relieve the discomfort."
A
86
SITUATION - Nurse Lyca is assigned in the Nursery. She is performing newborn assessment on a baby Boy Pratts born at 40 weeks gestation.
86. Using APCAR Score, Nurse Lyca should bear in mind that is method of evaluating a newborn's condition is used at how many minutes after birth?
A. 1 to 10
B. 1 to 3
C. 1 to 7
D. 1 to 5
D
87
87. Nurse Lyca is aware that testing of vision in infants and children has been treated separately from the testing adult. Which of the statement is not true?
A. Infants and children often cannot be tested with the same materials and techniques as adults.
B. Special techniques often must be used, especially to standards that apply to test for adults.
C Some infants who appear visually impaired early in ife will not show normal visual responses several weeks or months later.
D. Course of visual and cognitive develop must be taken into account in evaluating infants' and children's visual abilities.
C
88
88. The false statement about physiologic jaundice in the statement below is
A. Caused by impairment in the removal of bilirubin deficiency in the production of glucoronide transferase.
B. Begins to decrease by 6th or 7" day.
C. Is visible in skin and sclera
D. Begins after 48 hours of life
A
89
89. Neonatal jaundice FIRST becomes visible in which of the following parts?
(Select all that apply)
1. Face
2. Forehead
3. Trunk
4. Extremities
A. 3 & 4
B. 1 82
C.184
D. 283
B
90
90. When caring for patients with hyperbilirubinemia, the nursing care plan should focus on the following,
A. informing appropriately the significant others =no abnormality
B. preventing injury
C. maintaining physiological homeostasis with bilirubin levels increasing
D. preventing complications
A
91
SITUATIONS - Lily, 23-year-old pregnant woman, 37th week's gestation, is admitted in the intensive care unit due paroxysmal ventricular tachycardia. The patients is conscious; cervix is open so they decided to induce or labor.
91 When the patient was informed about induction, she asks Nurse Aurora what is it all about. Which of the following statement by the nurse is correct? Inductions is a
A. local anesthesia used for blocking pain during episiotomy stimulate labor
B. deliberate initiation of uterine contractions that stimulates labor
C. medication injected into the subarachnoid space and has a rapid onset of action
D. procedure performed by artificial rupture of the membranes
B
92
92. Which of the following statement is NOT an indication for any uterine stimulants (Oxytocin)?
A. preinducting cervical ripening
B. Controlling postpartum bleeding
C. Inducing or augmenting labor
D. Manages an incomplete abortion
A
93
93. Oxytocin drip was started to induce labor. Which assessment findings should cause the nurse to IMMEDIATELY discontinue the oxtocin infusion?
(SELECT ALL THAT APPLY)
I. Fatigue and drowsiness
II. Early decelerations of the petal heart rate
III. Uterine hyper stimulation
IV. Late deceleration of fetal heart rate
A. III and IV
B. Il and III
C. I and III
p. I and II
A
94
94. Simultaneous with the oxytocin drip (left arm) is the prescribed intravenous (IV) lidocaine (Xylocaine). Nurse Aurora should dilute the concentrated solution of lidocaine (right arm) with which solution?
A. 5 percent Dextrose in water
B. Normal saline 0.99 percent
C. Normal saline 0.45 percent
D. Lactated Ringer's
A
95
95. Take home medications given to patient Lily includes digitalis therapy which was given to patient since she was pregnant. Which of the following would the nurse anticipate with patient's drug therapy?
A. Switching to a more potent drug gravido cardiac
B. Continuation of the same dosage
C. Need for change in medication
D. Addition of diuretic to the regimen
D
96
SITUATION - The indication of tracheostomy in children has changed care of patient Irma, an eight-year-old female child, who was admitted to the pediatric ward due to pneumonia. The child is taking care of this patient being her first day of duty in the pediatric Ward.
96. When preparing the patient for suctioning, what is the FIRST step?
A. Perform hand hygiene
B. Gather equipment
C. Asses lung sounds, heart rate and care plan
D. Check physician's order and patient care plan
D
97
97. Patient Irma will be placed in which of the following position? Select all that apply.
1. Fowler
2. Semi-fowler
3. Supine
4. Sim
A. 1, 2 and 3
B. 2 only
C 1 and 2
D. 1 only
C
98
98. Usually the common indication (s) for the tracheostomy in patients Irma's condition is which of the following? (SELECT ALL THAT APPLY)
1. Prolonged intubation
2. Sepsis
3. Hypoventilation associated with neurologic disorders
4. Severe sleep Obstructive Apnea Syndrome (SOAS)
A. 2 only
B. 1 & 2
C. 1, 2, 3 & 4
D.1 only
D
99
99. The PRIORITY nursing objective when caring a patient with a tracheostomy is.
A. To increase tissue oxygenation
B. To provide patient airway
C. To decrease tissue oxygenation
D. TO improve ventilation
B
100
100. The Top nursing expected outcome performing suctioning is,
A. Lessened amount of secretions leading to decreased frequency of suctioning
B. Secretions removed without complication
C. Tube-fed patient does not aspirate feeding
D. Prevention of occurrence of hypoxemia and bradycardia.
B
