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Sample Nursing Examinations - Answer & Rationale

Steven, an athletic 20-year-old college student, suffered a fractured shoulder and sprained wrist in a fall at a ski resort. 1. In developing Steven's care plan following surgery, which of the following typical problems would you anticipate? A. He will undergo an alteration in self-concept. B. He will experience anxiety as a result of flashbacks about the skiing accident. C. He will have impaired mobility caused by immobilization of upper extremity. D. There will be abnormal tissue perfusion caused by swelling. If you use both the information provided and your understanding of surgical needs following reduction of a fracture, the only problem that would normally occur is impaired mobility. In analyzing data you would first attempt to recall and understand typical scenarios or patterns of needs that commonly occur. Validate your problem definition by incorporating specialized data or individualized signs and symptoms presented by your client. These specialized data should be accompanied by a statement of cause. For example, if you note that Steven's fingertips are cold and pitting edema is forming on the back of the hand, your analytic statement might be option D, abnormal tissue perfusion caused by swelling. An accurate analysis of data provides a valid and useful framework for planning patient care. Jean Thomas is a 25-year-old secretary admitted to the emergency room with diaphoresis, hyperventilation, palpitations, and trembling. Jean tells the nurse that she has been "very upset and nervous" over a poor employment evaluation. A tentative diagnosis of acute anxiety episode is made. 1. Which of the following acid-base imbalances would likely occur as a result of Jean's hyperventilation? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

The intended response is B, since hyperventilation will cause an increased loss of CO2, Mrs. Durham is recovering from a colon resection for removal of a malignant mass in the large bowel. Following breakfast one morning, she told the nurse, "I'm tired of waiting, I want my bath now. You're never here when I need you." 1. Which of the following responses by the nurse is most appropriate? A. What do you mean, I'm never here? I spent all three hours with you yesterday, Mrs. Durham. B. I'm sorry you've been waiting Mrs. Durham. Let's get you comfortable now and I'll be back in twenty minutes to give you a bath. C. I'm doing my best, Mrs. Durham. You know I have three other patients to take care of today, besides you. D. I must see Mrs. Jones right now, Mrs. Durham. She's really sick today. I'll be back as soon as I can. The only appropriate response is option B. Acknowledge her feelings and give her a clear, factual response to her concern. Never challenge a patient's statements and don't be defensive (option C). Do not reprimand the patient unnecessarily or talk about the needs of the other patients ( options C and D). In this case you did not need to know a lot about colon resections to answer this question. You did need to have skill in basic communication and human interaction. Brian, aged 4 years, is sitting in the pediatric day room with Michael, another patient. He suddenly realizes that he has wet his pants and runs to the nurse, crying. 1. The most appropriate initial response by the nurse is: A. Why, Brian, what happened? Why did you wet your pants? B. You know better than this, Brian; next time you'll get a good spanking. C. Let's take off those wet pants, Brian, and put on something dry so you'll be more comfortable. D. Wait until I tell Michael what you did. Aren't you ashamed of yourself? Several relevant principles come into play in this item in selecting the correct answer. A very basic principle is, "The nurse shows respect for the individual in

treating human responses to actual or potential health problems." In other words, focus on treating the patient with respect first and then attempt to modify wrong behavior. This principle shows an acceptable standard of nursing action. The intended response is C. Margaret O'Hara, a 30-year-old known diabetic, is brought to the emergency department by ambulance. The paramedic team reports symptoms of apparent hyperglycemia. Stat blood glucose is 640. 1. The nurse is aware that excess serum glucose acts to draw fluids osmotically with resultant polyuria. In addition to increased urinary output, the nurse should expect to observe which of the following sets of symptoms in Margaret? A. Polydipsia, diaphoresis, bradycardia B. Thirst, dry mucous membranes, hot dry skin C. Hypotension, bounding pulse, headache D. Nervousness, rapid respirations, diarrhea The intended response is B, because these are all symptoms associated with the dehydration that occurs in hyperglycemia. Although polydypsia is expected (response A), diaphoresis does not occur in the body's effort to compensate by holding back fluid. The patient would experience tachycardia as a cardiac compensatory mechanism, causing a rapid, thready pulse. Headache and nervousness (responses C and D) are symptoms associated with hypoglycemia. Molly Flannery is a 67-year-old female with chronic congestive heart failure and hypertension. She is being evaluated for complaints of muscular weakness and general fatigue. 1. Molly's serum electrolyte studies reveal a K+ level of 2.9. Which of the following medications taken by the patient at home contributed most to her hypokalemic state? A. Digoxin, .125 mg, PO, daily B. Lasix, 80 mg, PO, daily C. Aldomet, 250 mg, PO, tid D. Aspirin, 10 grains, bid The intended response is B, since Lasix, in addition to its diuretic action, also wastes K+ by increasing urinary excretion. Digoxin, response A, contributes to

K+ loss by enhancing urinary output, but Lasix is much more directly related to the development of hypokalemia. Response C is an anti-hypertensive that is not related to K+ loss. Response D, aspirin, may have been prescribed as myocardial infarction prophylaxis, and is not related to K+ loss. Mr. Robert Bacchus is a 63-year-old retired business executive who comes to the emergency room with complaints of dyspnea, shortness of breath, and chest pain radiating to the left arm. 1. The nurse caring for Mr. Bacchus should implement which of the following actions FIRST? A. Administer prescribed pain medication B.. Apply oxygen per nasal cannula as ordered C. Assess vital signs D. Apply electrocardiogram electrodes to the patient's chest The intended response is C, since vital sign assessment will provide baseline data of vital cardiac and respiratory function, which will then serve as a guideline for diagnosis and therapy measures. Loberta Jackson, a 21-year-old college student, is admitted to a medical unit with diagnosis of uncontrolled diabetes, acute hypoglycemic reaction. 1. Loberta explains to the admitting nurse that she had been feeling "sick to my stomach, like I was coming down with the flu" for the past 48 hours. She has continued to take her usual daily dosage of insulin. Noting that Loberta has been admitted with a blood-glucose value of 46, which of the following assessment questions would provide the most valuable information about Loberta's status? A.. "Have you been under a great deal of stress lately, Loberta?" B. "Were you having difficulty sleeping after this illness started?" C. "Have you eaten anything in the past 48 hours?" D. "Did you take any medications for this illness other than your insulin?" The intended response is C, because it is highly probable that Loberta, feeling "sick to her stomach," has not taken in adequate foods and fluids, and coupled with taking her usual dosage of daily insulin, has brought about an acute hypoglycemic reaction. (Higher than normal circulating levels of insulin with insufficient food intake of essential nutrients will result in acute decreased blood-

glucose levels). Response A, focusing on increased stress, would more than likely stimulate a hyperglycemic reaction, since stress causes elevations of blood glucose. Response D, focusing on other medications the patient has taken, would probably not trigger a hypoglycemic reaction. Response B is unrelated to her present status. Jerry is a 32-year-old white male. He has been married for 10 months, and he and his wife, Sue, are expecting their first child in 6 months. Prior to marrying Sue, Jerry was sexually active and nonmonogamous. He has been sexually active since the age of 18. Recently Jerry has complained of persistent dry cough, night sweats, and a temperature over 100?F. Although Jerry is concerned about his weight and watches his diet, he has lost 15 pounds without even trying. Upon assessing Jerry, he admits to having had sexual intercourse with prostitutes, both male and female, during the last 10 years. 1. Jerry's symptoms of elevated temperature, chills, and dry cough are probably related to which undiagnosed condition? A. Alteration in tissue perfusion B. An infection, etiology unknown C. Indigestion from too frequent traveling D. Lack of knowledge related to frequent travel The intended response is B. Classic signs and symptoms of infection are fever, chills, loss of appetite, generalized myalgias, or localized pain and discomfort. The dry cough that Jerry experiences can be associated with the system of involvement. Pulmonary etiology should be assessed and evaluated. Mrs. Brown's husband was admitted to the emergency room in delirium tremens (DTs). This admission is his third visit in 2 weeks. While waiting to see her husband, Mrs. Brown said to the nurse, "What in the world can I do to help Joe get over this drinking problem?" 1. The best initial response for the nurse is: A. Don't feel guilty, Mrs. Brown; I know this must be difficult for you. B. Let's go into the lounge so we can talk more about your concern, Mrs. Brown. C. You need to convince Joe to seek professional help, Mrs. Brown. D. How long has your husband been drinking, Mrs. Brown?

If you chose Option A, you are reading into the question and adding a factor that was not provided-- that Mrs. Brown is feeling guilty. Perhaps you know of someone who did feel guilty in a situation like this, or perhaps you thought she should feel guilty. Because this background statement does not tell you how Mrs. Brown feels, you can't make this assumption (option A). Option C is incorrect because you don't have enough information about the situation to offer this advice. You should be in the assessment or data collection phase of the nursing process. Option D is not the best choice because it focuses on Mr. Brown's problem and channels the interaction specifically, rather than encouraging Mrs. Brown to express her concerns. Since Mrs. Brown is concerned about what she can do to help her husband, the correct response is one that first encourages her to verbalize how she is feeling (option B). Amy Stevens is a 17-year-old student admitted for evaluation of lower abdominal pain. She tells the nurse, "I wish my friends would come to visit me. I don't like being here alone." 1. Which of the following would be the most appropriate response of the nurse? A. "You sound very lonely. Shall I stay with your for awhile?" B. "I'm sure your friends will come to see you soon." C. "It's a little too early for visiting hours. You'll have to wait until this afternoon." D. "It's hard to be alone. Would you like me to stay with you?" The intended response is D, since this response acknowledges the patient's feelings and offers support. Response A tends to catastrophize the patient's situation by saying "you must be very lonely." Response B provides false reassurance because the nurse has no real way of knowing if in fact friends will come to visit Amy. Finally, C is incorrect because it provides only a factual response and does not attend to the feeling tone of Amy's remarks. Patty Daniels is a 25-year-old white female, pregnant with her first child. She is being seen in the obstetrical clinic for her first prenatal visit. 1. Patty tells the nurse, "I drank a glass of wine at a party before I found out that I was pregnant. I'm worried that I might have hurt the baby." Based on an understanding of alcohol use in pregnancy, which of the following responses is the most appropriate? A. "We don't really know how much alcohol is too much during pregnancy. Don't drink anymore and try not to worry about it."

B. "As long as your drinking is moderate, I wouldn't worry about it. There were plenty of healthy babies born to drinking mothers before they ever discovered fetal alcohol syndrome." C. "An occasional drink shouldn't hurt the baby. Research has shown that the risk to the fetus increases as the amount and frequency of alcohol consumption increases." D. "I can understand why you're so upset, but an occasional drink shouldn't hurt the baby." The correct response is C. This patient needs two things from the nurse: information about alcohol use in pregnancy and reassurance about the potential risk to her own baby. Alcohol is a known teratogenic substance, but it is unclear how much alcohol it takes and at what point in development to adversely affect the fetus. Research has shown that the incidence of fetal alcohol syndrome and related disorders increases as the amount and frequency of alcohol consumption increase. An occasional drink should not harm the fetus. C is the correct response because it is the only answer that offers reassurance and accurate information without catastrophizing the situation. Kelly Jones, aged 3 years, is brought to the emergency room by her mother following an accidental ingestion of acetaminophen. When questioned, Mrs. Jones states that she believes that Kelly ingested approximately 20 tablets. She further states that she believes that the ingestion occurred within the last hour. 1. Immediately upon arrival in the emergency room the nurse should: A. Assess vital signs B. Administer O2 C. Start IV fluids D. Perform an arterial puncture for blood gases A is the correct response. The establishment of baseline vital signs should always be done first. Although hyperventilation and resultant respiratory alkalosis is the most obvious clinical manifestation, acetaminophen does not exert its peak effect until 2 to 4 hours following ingestion. Performing an arterial puncture for blood-gas analysis will be important, but it is not the first thing that the nurse should do. There is no indication at this time for the administration of O2 or IV fluids. Posted by Earn-On-Line on Tuesday, August 14, 2007 at 1:16 PM |

15 Item ACLS Drill Answers and Rationale

1. To confirm proper placement of tracheal tube through 5-point auscultation, which of the following observations are appropriate? Check all that apply. __ __ __ __ check breath sounds in the left and right lateral chest and lung bases auscultate breath sounds in the left and right anterior sides of the chest listen for gastric bubbling noises front the epigastrium ensure equal and adequate chest expansion bilaterally

The correct answer is all choices. The rescuer should perform 5 point auscultation during hand ventilation as follows: as the bag is squeezed, listen over the epigastrium and observe the chest wall for movement. If you hear stomach gurgling and see no chest wall expansion, you have intubated the esophagus. Deliver no further ventilations. Remove the tracheal tube at once. Reattempt intubation. If the chest wall rises appropriately and stomach gurgling is not heard, listen to the lung fields: left and right anterior, left and right midaxillary, and once again over the stomach. 2. Which of the following is true about an oropharyngeal airway? a. it eliminates the need to position the head of the unconscious patient b. it eliminates the possibility of an upper airway obstruction c. it is of no value once a tracheal tube is inserted d. it may stimulate vomiting or laryngospasm if inserted in the semiconscious patient The correct answer is D. An oropharyngeal airway may stimulate vomiting or laryngospasm in the semiconscious patient. A semiconscious patient may maintain an intact gag reflex, so insertion of the airway can cause vomiting or laryngospasm. Use of an oropharyngeal airway is recommended to help hold the tongue from the back of the pharynx in an unconscious victim. Answer A is incorrect because you must still maintain proper head positioning in an unconscious patient even when an oropharyngeal airway is in place. Answer B is incorrect because incomplete upper airway obstruction can occur despite an oropharyngeal airway. Monitor the victim closely. Answer C is incorrect because oropharyngeal airway help prevent intubated patients from biting down on the tracheal tube. 3. Which of the following is an indication for tracheal intubation? a. difficulty encountered by qualified rescuers in ventilating an apneic patient with a bagmask device b. a respiratory rate of less than 20 breaths per minute in a patient with severe chest pain c. presence of premature ventricular contractions d. to provide airway protection in a responsive patient with an adequate gag reflex The correct answer is A. If adequate chest expansion and breath sounds cannot be achieved, tracheal intubation should be performed to ensure adequate ventilation. Indications for tracheal intubation include: (1) inability of the rescuer to ventilate the unconscious patient with less invasive methods and (2) absence of protective reflexes (coma or cardiac arrest). Answer B is incorrect because a respiratory rate less than 20 in a patient with severe chest pain in not in itself an indication of the need for intubation. Tracheal intubation secures an unprotected airway and facilitates adequate ventilation. There is no indication that this patient with chest pain has an unprotected airway or inadequate ventilation. Answer C is incorrect because the presence of premature ventricular contractions does not indicate the need for control of the airway. Answer D is incorrect because it describes a conscious patient with an adequate airway.

4. Which of the following is the most important step to restore oxygenation and ventilation for the unresponsive, breathless submersion (near drowning) victim? a. attempt to drain water from breathing passages by performing the Heimlich maneuver b. begin chest compressions c. provide cervical spine stabilization because a diving accident may have occurred d. open the airway and begin rescue breathing as soon as possible even in the water The correct answer is D. The first and most important treatment of the near-drowning victim is provision of immediate mouth to mouth ventilation. Prompt initiation of rescue breathing has a positive association with survival. Answer A is incorrect because the drainage of water is unnecesary and will delay provision of rescue breathing. The ACLS guidelines state there is no need to clear the airway of aspirated water. Some victims aspirate nothing At most only a modest amount of water is aspirated by the majority of drowning victims, and it is rapidly absorbed. In addition the abdominal thrusts can cause injuries. Answer B is incorrect because chest compressions should be performed only if there are no signs of circulation after delivery of 2 breaths if the victim is unresponsive and not breathing. Answer C is incorrect because providing cervical spine stabilization will not restore oxygenation and ventilation. 5. You respond with 2 other rescuers to a 50 year old man who is unresponsive, pulseless, and not breathing. What tasks would you assign the other rescuers while you set up the AED? a. one rescuer should call rescue assistance and the others rescuer should begin CPR b. both rescuers should help set up the AED and provide CPR c. one rescuer should open the airway and begin rescue breathing, and the second rescuer should begin chest compressions d. recruit additional first responders to help The correct answer is A. The rescuers should act simultaneously to ensure rapid EMS activation and immediate initiation of CPR. Answers B and C are incorrect because if both rescuers assist with setting up the AED or performing CPR, no one is activating the EMS system. Answer D is incorrect because 2 rescuers are already available to help. 6. An AED hangs on the wall suddenly a code is called, you grab the AED and run to the room where the resuscitation is ongoing. A colleague has begun CPR and confirms that the patient is in pulseless arrest. As you begin to attach the AED, you see a transdermal medication patch on the victims upper right chest, precisely where you were going to place an AED electrode pad. What is your most appropriate action? a. ignore the medication patch and place the electrode pad in the usual position b. avoid the medication patch and place the second electrode pad on the victims back c. remove the medication patch, wipe the area dry, and place the electrode pad in the correct position d. place the electrode pad on the victims right abdomen The correct answer is C. Answer A is incorrect because if you place the electrode pad over the medication patch, it may result in reduced current delivery to the heart and reduced effectiveness of the shock. Answers B and D are incorrect because it does not recommended to suggest alternative sites for placement of AED pads to avoid a medication patch. Instead, it is recommend that the medication patch be removed, the area wiped dry, and the

electode pad placed in the correct location. 7. A patient who has Ventricular Fibrillation has failed to respond to 3 shocks. Paramedics started an IV and inserted a tracheal tube, confirming proper placement. Which of the following drugs should this patient receive first? a. Amiodarone 300 mg IV push b. Lidocaine 1 to 1.5 mg/kg IV push c. Procainamide 30 mg/min up to a total dose of 17 mg/kg d. Epinephrine 1 mg IV push The correct answer is D. If VF persists after 3 shocks, epinephrine should be administered. This drug produces vasoconstriction, elevating end diastolic pressure, and may improve coronary artery perfusion pressure. Answers A and B are incorrect because antiarrhythmics should be considered only after administration of 1 mg epinephrine IV plus a fourth shock. Answer C is incorrect because procainamide is not indicated for refractory VF. 8. After giving epinephrine 1 mg IV and a fourth shock, a patient remains in VF. You want to continue to administer epinephrine at appropriate doses and intervals if the patient remains in VF. Which epinephrine dose is recommended under these conditions? a. give the following epinephrine dose sequence, each 3 minutes apart: 1 mg, 3 mg, and 5 mg b. give a single high dose of epinephrine: 0.1 to 0.2 mg/kg c. give epinephrine 1 mg IV, then in 5 minutes start vasopressin 40 U IV every 3 to 5 minutes d. give epinephrine 1 mg IV; repeat 1 mg every 3 to 5 minutes The correct answer is D. Epinephrine should be administered every 3 to 5 minutes during cardiac arrest. If the initial standard dose fails, administration of a single higher dose, eg 5 mg or 0.1 mg/kg, is left to the discretion of the clinician. Answers A and B are incorrect because it is not recommended for high-dose or escalating-dose epinephrine because of lack of demonstrated benefit and because of potential for harm. Answer C is incorrect because vasopressin is administered in a single dose. Epinephrine should be administered every 3 to 5 minutes during cardiac arrest. 9. Which of the following therapies is the most important intervention for VF/pulseless VT with the greatest effect on survival to hospital discharge? a. Epinephrine b. Defibrillation c. Oxygen d. Amiodarone The correct answer is B. Treatment of VF/pulseless VT requires defibrillation. CPR prolongs the duration of VF and therefore the time the heart will be responsive to a shock. Answers A and D are incorrect because their effects on survival are minor compared with defibrillation. Vasopressors (epinephrine) and antiarrhythmics (amiodarone) come into play only when a patient with a VF fails to respond in 3 stacked shocks. The vast majority of VF patients who are successfully resuscitated respond with the first 3 shocks. Answer C is incorrect because, although oxygen is important, patients can be successfully ventilated with room air. The key to succesful resuscitation is time from collapse to defibrillation.

10. A 60 yr old man persists in VF arrest despite 3 stacked shocks at appropriate energy levels. Your code team, however, has been unable to start an IV or insert a tracheal tube. Therefore administration of IV or tracheal medications will be delayed. What is the most appropriate immediate next step? a. deliver additional shocks in an attempt to defibrillate b. deliver a precordial thump c. perform a venous cut-down to gain IV access d. administer intramuscular epinephrine 2 mg The correct answer is A. Repeated shocks for VF/VT should continue regardless of inability to deliver epinephrine, antiarhythmics, or other medications. The most important treatment for VF is always prompt defibrillation. Answer B is incorrect because a precordial thump would be very unlikely to achieve a defibrillation in a patient who continues in VF after 3 shocks. Answer C is incorrect because it would be inappropriate to delay additional shocks to perform a surgical procedure. Answer D is incorrect because there is no human evidence regarding the use of intramuscular epinephrine in cardiac arrest. 11. A 75 year old homeless man is in cardiac arrest with pulseless VT at a rate of 220 bpm. After CPR, 3 shocks in rapid succession, 1mg IV epinephrine, plus 3 more shocks, the man continues to be in polymorphic pulseless VT. He appears wasted and malnourished. The paramedics recognize him as a chronic alcoholic known in the neighborhood. Because he remains in VT after 6 shocks, you are considering an antiarryhthymic. Which of the following agents would be most appropriate for this patient at this time? a. Amiodarone b. Procainamide c. Magnesium d. Diltiazem The correct answer is C. Low levels of magnesium sulfate are very common in chronic malnourished people and alcoholics, and this man combined both risk factors. At certain levels of low magnesium, patients with refractory VF/pulseless VT will simply not convert without emergency replacement of magnesium. No other antiarrhythmic will be effective, and magnesium alone may be sufficient to render the fibrillating myocardium responsive to the next shock. In addition, magnesium is the agent of choice for treating torsades de pointes even when the torsades is not associated with hypomagnesemia. This mans VT, described as polymorphic VT, may well be Torsades. 12. You are called to assist in the attempted resuscitation of a patient who is demonstrating PEA. As you hurry to the patients room, you review the information you learned in the ACLS course about management of PEA. Which one of the following about PEA is true? a. chest compressions should be administered only if the patient with PEA develops a ventricular rate of less than 50 bpm b. successful treatment of PEA requires identification and treatment of reversible causes c. atropine is the drug of choice for treatment of PEA, whether the ventricular rate is slow or fast d. PEA is rarely caused by hypovolemia, so fluid administration is contraindicated and should not be attempted The correct answer is B. Successful treatment requires identification and treatment of reversible causes, such as 5 Hs and 5 Ts. PEA is the absence of a pulse in the presence of

organized cardiac electrical activity other than VT or VF. PEA, which can cause cardiac arrest, is often caused by reversible conditions that begin with either an H (hypovolemia, hypoxia, hydrogen ions or acidosis, hyperkalemia/hypokalemia, or hypothermia) or a T (tablets causing intentional or unintentional overdose, tamponade, tension pneumothorax, thrombosis of a coronary artery, or thrombosis in pulmonary artery). Answer A is incorrect because chest compressions should be provided to the patient in PEA regardless of the ventricular complexes. Answer C is incorrect because atropine is recommended if the PEA rate is slow or relatively slow. Atropine is not recommended for PEA with a rapid ventricular rate. Answer D is incorrect because hypovolemia is one of the most common causes. 13. For which of the following patients with PEA is sodium bicarbonate therapy (1 mEq/kg) most likely to be most effective? a. the patient with hypercarbic acidosis and tension pneumothorax treated with decompression b. the patient with a brief arrest interval c. the patient with documented severe hyperkalemia d. the patient with documented severe hypokalemia The correct answer is C. The patient with severe hyperkalemia should be treated with the hyperkalemia sequence that begins with administration of calcium chloride and includes sodium bicarbonate and glucose plus insulin. Answer A is incorrect because sodium bicarbonate is contraindicated for patient with hypercarbic acidosis and inadequate ventilation. Administration of sodium bicarbonate to the patient with inadequate ventilation or ventilation compromised by a tension pneumothorax will result in greater hypercarbia and worsening of the respiratory acidosis. Answer B is incorrect because most patients with a brief arrest interval will not require sodium bicarbonate because the best way to correct any mild acidosis from a brief arrest interval is to restore a perfusing rhythm with effective ventilation. Answer D is incorrect because hypokalemia will be worsened by administration of sodium bicarbonate. Sodium bicarbonate alkalinizes the serum, which produces an intracellular shift of potassium so that serum potassium falls. 14. Which of the following is the correct initial drug and dose for treatment of asystole? a. epinephrine 2mg IV b. atropine 0.5 mg IV c. lidocaine 1mg/kg IV d. epinephrine 1mg IV The correct answer is D. Epinephrine 1mg IV is traditionally recommended for the treatment of asystole. Answer A is incorrect because this dose of epinephrine is noted as may be used but is not recommended and should be considered only if patient fails to respond to the conventional dose. It should not be administered as single dose of epinephrine. Answer B is incorrect because atropine 1mg IV should be administered after a dose of epinephrine. Answer C is incorrect because lidocaine is not included in the asystole algorithm. 15. You are considering transcutaneous pacing for a patient in asystole. Which of the following candidates would be most likely to respond to such a pacing attempt? a. the patient in asystole who has failed to respond to 20 minutes of BLS and ACLS therapy b. the patient in asystole following blunt trauma c. the patient in asystole following a defibrillatory shock d. the patient who has just arrived in the emergency department following transport and

CPR in the field for persistent asystole after submersion The correct answer is C. Transcutaneous pacing is most likely to be effective in the patient in asystole following a defibrillatory shock if performed immediately. If the patient developed asystole immediately after defibrillation, that asystole would be short-lived. Answers A and D are incorrect because both characterize patients who have been in cardiac arrest for a prolonged time. Answer B is incorrect because reversible causes of cardiac arrest associated with blunt trauma include conditions such as hypovolemia, neurologic injury, tension pneumothorax, or major organ damage. It is unlikely that any of these causes would respond to transcutaneous pacing.

Source: American Heart Association ACLS Provider Manual

Posted by chum on Friday, January 05, 2007 at 6:30 PM | Per

60 Item Medical Surgical Nursing : Musculoskeletal Examination Answers


60 Item Medical Surgical Nursing : Musculoskeletal Examination Answers 1. A client is 1 day postoperative after a total hip replacement. The client should be placed in which of the following position? a. Supine b. Semi Fowler's c. Orthopneic d. Trendelenburg 2. A client who has had a plaster of Paris cast applied to his forearm is receiving pain medication. To detect early manifestations of compartment syndrome, which of these assessments should the nurse make? a. Observe the color of the fingers b. Palpate the radial pulse under the cast c. Check the cast for odor and drainage d. Evaluate the response to analgesics 3. After a computer tomography scan with intravenous contrast medium, a client returns to the unit complaining of shortness of breath and itching. The nurse should be prepared to treat the client for: a. An anaphylactic reaction to the dye b. Inflammation from the extravasation of fluid during injection. c. Fluid overload from the volume of the infusions d. A normal reaction to the stress of the diagnostic procedure. 4. While caring for a client with a newly applied plaster of Paris cast, the nurse makes note of all the following conditions. Which assessment finding requires immedite notification of the physician? a. Moderate pain, as reported by the client b. Report, by client, the heat is being felt under the cast

c. Presence of slight edema of the toes of the casted foot d. Onset of paralysis in the toes of the casted foot 5. Which of these nursing actions will best promote independence for the client in skeletal traction? a. Instruct the client to call for an analgesic before pain becomes severe. b. Provide an overhead trapeze for client use c. Encourage leg exercise within the limits of traction d. Provide skin care to prevent skin breakdown. 6. A client presents in the emergency department after falling from a roof. A fracture of the femoral neck is suspected. Which of these assessments best support this diagnosis. a. b. c. d. The client reports pain in the affected leg A large hematoma is visible in the affected extremity The affected extremity is shortenend, adducted, and extremely rotated The affected extremity is edematous.

7. The nurse is caring for a client with compound fracture of the tibia and fibula. Skeletal traction is applied. Which of these priorities should the nurse include in the care plan? a. b. c. d. Order a trapeze to increase the client's ambulation Maintain the client in a flat, supine position at all times. Provide pin care at least every hour Remove traction weights for 20 minutes every two hours.

8. To prevent foot drop in a client with Buck's traction, the nurse should: a. Place pillows under the client's heels. b. Tuck the sheets into the foot of the bed c. Teach the client isometric exercises d. Ensure proper body positioning. 9. Which nursing intervention is appropriate for a client with skeletal traction? a. Pin care b. Prone positioning c. Intermittent weights d. 5lb weight limit 10. In order for Buck's traction applied to the right leg to be effective, the client should be placed in which position? a. Supine c. Sim's b. Prone d. Lithotomy 11. An elderly client has sustained intertrochanteric fracture of the hip and has just returned from surgery where a nail plate was inserted for internal fixation. The client has been instructed that she should not flex her hip. The best explanation of why this movement would be harmful is: a. It will be very painful for the client

b. The soft tissue around the site will be damaged c. Displacement can occur with flexion d. It will pull the hip out of alignment 12. When the client is lying supine, the nurse will prevent external rotation of the lower extremity by using a: a. b. c. d. Trochanter roll by the knee Sandbag to the lateral calf Trochanter roll to the thigh Footboard

13. A client has just returned from surgery after having his left leg amputated below the knee. Physician's orders include elevation of the foot of the bed for 24 hours. The nurse observes that the nursing assistant has placed a pillow under the client's amputated limb. The nursing action is to: a. Leave the pillow as his stump is elevated b. Remove the pillow and elevate the foot of the bed c. Leave the pillow and elevate the foot of the bed d. Check with the physician and clarify the orders 14. A client has sustained a fracture of the femur and balanced skeletal traction with a Thomas splint has been applied. To prevent pressure points from occurring around the top of the splint, the most important intervention is to: a. b. c. d. Protect the skin with lotion Keep the client pulled up in bed Pad the top of the splint with washcloths Provide a footplate in the bed

15. The major rationale for the use of acetylsalicylic acid (aspirin) in the treatment of rheumatoid arthritis is to: a. Reduce fever b. Reduce the inflammation of the joints c. Assist the client's range of motion activities without pain d. Prevent extension of the disease process 16. Following an amputation, the advantage to the client for an immediate prosthesis fitting is: a. Ability to ambulate sooner b. Less change of phantom limb sensation c. Dressing changes are not necessary d. Better fit of the prosthesis 17. One method of assessing for sign of circulatory impairment in a client with a fractured femur is to ask the client to: a. Cough and deep breathe b. Turn himself in bed c. Perform biceps exercise

d. Wiggle his toes 18. The morning of the second postoperative day following hip surgery for a fractured right hip, the nurse will ambulate the client. The first intervention is to: a. Get the client up in a chair after dangling at the bedside. b. Use a walker for balance when getting the client out of bed c. Have the client put minimal weight on the affected side when getting up d. Practice getting the client out of bed by having her slightly flex her hips 19. A young client is in the hospital with his left leg in Buck's traction. The team leader asks the nurse to place a footplate on the affected side at the bottom of the bed. The purpose of this action is to: a. Anchor the traction b. Prevent footdrop c. Keep the client from sliding down in bed d. Prevent pressure areas on the foot 20. When evaluating all forms of traction, the nurse knows the direction of pull is controlled by the: a. Client's position b. Rope/pulley system c. Amount of weight d. Point of friction 21. When a client has cervical halter traction to immobilize the cervical spine counteraction is provided by: a. Elevating the foot of the bed b. Elevating the head of the bed c. Application of the pelvic girdle d. Lowering the head of the bed 22. After falling down the basement steps in his house, a client is brought to the emergency room. His physician confirms that his leg is fractured. Following application of a leg cast, the nurse will first check the client's toes for: a. Increase in the temperature b. Change in color c. Edema d. Movement 23. A 23 year old female client was in an automobile accident and is now a paraplegic. She is on an intermittent urinary catheterization program and diet as tolerated. The nurse's priority assessment should be to observe for: a. Urinary retention b. Bladder distention c. Weight gain d. Bower evacuation

24. A female client with rheumatoid arthritis has been on aspirin grain TID and prednisone 10mg BID for the last two years. The most important assessment question for the nurse to ask related to the client's drug therapy is whether she has a. Headaches b. Tarry stools c. Blurred vision d. Decreased appetite 25. A 7 year old boy with a fractured leg tells the nurse that he is bored. An appropriate intervention would be to a. b. c. d. Read a story and act out the part Watch a puppet show Watch television Listen to the radio

26. On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. Which of the following would be the nurse most likely to asses: a. b. c. d. Limited motion of joints Deformed joints of the hands Early morning stiffness Rheumatoid nodules

27. After teaching the client about risk factors for rheumatoid arthritis, which of the following, if stated by the client as a risk factor, would indicate to the nurse that the client needs additional teaching? a. b. c. d. History of Epstein-Barr virus infection Female gender Adults between the ages 60 to 75 years Positive testing for human leukocyte antigen (HLA) DR4 allele

28. When developing the teaching plan for the client with rheumatoid arthritis to promote rest, which of the following would the nurse expect to instruct the client to avoid during the rest periods? a. Proper body alignment b. Elevating the part c. Prone lying positions d. Positions of flexion 29. After teaching the client with severe rheumatoid arthritis about the newly prescribed medication methothrexate (Rheumatrex 0), which of the following statements indicates the need for further teaching? a. "I will take my vitamins while I am on this drug" b. "I must not drink any alcohol while I'm taking this drug" c. I should brush my teeth after every meal" d. "I will continue taking my birth control pills" 30. When completing the history and physical examination of a client diagnosed with

osteoarthritis, which of the following would the nurse assess? a. Anemia c. Weight loss b. Osteoporosis d. Local joint pain 31. At which of the following times would the nurse instruct the client to take ibuprofen (Motrin), prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation? a. At bedtime c. Immediately after meal b. On arising d. On an empty stomach 32. When preparing a teaching plan for the client with osteoarthritis who is taking celecoxib (Celebrex), the nurse expects to explain that the major advantage of celecoxib over diclofenac (Voltaren), is that the celecoxib is likely to produce which of the following? a. b. c. d. Hepatotoxicity Renal toxicity Gastrointestinal bleeding Nausea and vomiting

33. After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse interprets these findings as indicating which of the following? a. b. c. d. A developing infection Bleeding in the operative site Joint dislocation Glue seepage into soft tissue

34. Which of the following would the nurse assess in a client with an intracapsular hip fracture? a. Internal rotation c. Shortening of the affected leg b. Muscle flaccidity d. Absence of pain the fracture area 35. Which of the following would be inappropriate to include when preparing a client for magnetic resonance imaging (MRI) to evaluate a rupture disc? a. Informing the client that the procedure is painless b. Taking a thorough history of past surgeries c. Checking for previous complaints of claustrophobia d. Starting an intravenous line at keep-open rate 36. Which of the following actions would be a priority for a client who has been in the postanesthesia care unit (PACU) for 45 minutes after an above the knee amputation and develops a dime size bright red spot on the ace bondage above the amputation site? a. Elevate the stump b. Reinforcing the dressing c. Calling the surgeon d. Drawing a mark around the site

37. A client in the PACU with a left below the knee amputation complains of pain in her left big toe. Which of the following would the nurse do first? a. Tell the client it is impossible to feel the pain b. Show the client that the toes are not there c. Explain to the client that the pain is real d. Give the client the prescribed narcotic analgesic 38. The client with an above the knee amputation is to use crutches until the prosthesis is being adjusted. In which of the following exercises would the nurse instruct the client to best prepare him for using crutches? a. Abdominal exercises b. Isometric shoulder exercises c. Quadriceps setting exercises d. Triceps stretching exercises 39. The client with an above the knee amputation is to use crutches until the prosthesis is properly lifted. When teaching the client about using the crutches, the nurse instructs the client to support her weight primarily on which of the following body areas? a. Axillae b. Elbows c. Upper arms d. Hands 40. Three hours ago a client was thrown from a car into a ditch, and he is now admitted to the ED in a stable condition with vital signs within normal limits, alert and oriented with good coloring and an open fracture of the right tibia. When assessing the client, the nurse would be especially alert for signs and symptoms of which of the following? a. Hemorrhage b. Infection c. Deformity d. Shock 41. The client with a fractured tibia has been taking methocarbamol (Robaxin), when teaching the client about this drug, which of the following would the nurse include as the drug's primary effect? a. b. c. d. Killing of microorganisms Reduction in itching Relief of muscle spasms Decrease in nervousness

42. A client who has been taking carisoprodol (Soma) at home for a fractured arm is admitted with a blood pressure of 80/50 mmHg, a pulse rate of 115bpm, and respirations of 8 breaths/minute and shallow, the nurse interprets these finding as indicating which of the following? a. Expected common side effects b. Hypersensitivity reactions c. Possible habituating effects

d. Hemorrhage from GI irritation 43. When admitting a client with a fractured extremity, the nurse would focus the assessment on which of the following first? a. b. c. d. The area proximal to the fracture The actual fracture site The area distal to the fracture The opposite extremity for baseline comparison

44. A client with fracture develops compartment syndrome. When caring for the client, the nurse would be alert for which of the following signs of possible organ failure? a. Rales c. Generalized edema b. Jaundice d. Dark, scanty urine 45. Which of the following would lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus? a. Acute respiratory distress syndrome b. Migraine like headaches c. Numbness in the right leg d. Muscle spasms in the right thigh 46. The client who had an open femoral fracture was discharged to her home, where she developed, fever, night sweats, chills, restlessness and restrictive movement of the fractured leg. The nurse interprets these finding as indicating which of the following? a. Pulmonary emboli b. Osteomyelitis c. Fat emboli d. Urinary tract infection 47. When antibiotics are not producing the desired outcome for a client with osteomyelitis, the nurse interprets this as suggesting the occurrence of which of the following as most likely? a. b. c. d. Formation of scar tissue interfering with absorption Development of pus leading to ischemia Production of bacterial growth by avascular tissue Antibiotics not being instilled directly into the bone

48. Which of the following would the nurse use as the best method to assess for the development of deep vein thrombosis in a client with a spinal cord injury? a. Homan's sign c. Tenderness b. Pain d. Leg girth 49. The nurse is caring for the client who is going to have an arthogram using a contrast medium. Which of the following assessments by the nurse are of highest priority? a. Allergy to iodine or shellfish b. Ability of the client to remain still during the procedure

c. Whether the client has any remaining questions about the procedure d. Whether the client wishes to void before the procedure 50. The client immobilized skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse formulates which of the following nursing diagnoses for this client? a. Divertional activity deficit b. Powerlessness c. Self care deficit d. Impaired physical mobility 51. The nurse is teaching the client who is to have a gallium scan about the procedure. The nurse includes which of the following items as part of the instructions? a. The gallium will be injected intravenously 2 to 3 hours before the procedure b. The procedure takes about 15 minutes to perform c. The client must stand erect during the filming d. The client should remain on bed rest for the remainder of the day after the scan 52. The nurse is assessing the casted extremity of a client. The nurse assesses for which of the following signs and symptoms indicative of infection? a. Coolness and pallor of the extremity b. Presence of a "hot spot" on the cast c. Diminished distal pulse d. Dependent edema 53. The client has Buck's extension applied to the right leg. The nurse plans which of the following interventions to prevent complications of the device? a. b. c. d. Massage the skin of the right leg with lotion every 8 hours Give pin care once a shift Inspect the skin on the right leg at least once every 8 hours Release the weights on the right leg for range of motion exercises daily

54. The nurse is giving the client with a left cast crutch walking instructions using the three point gait. The client is allowed touchdown of the affected leg. The nurse tells the client to advance the: a. Left leg and right crutch then right leg and left crutch b. Crutches and then both legs simultaneously c. Crutches and the right leg then advance the left leg d. Crutches and the left leg then advance the right leg 55. The client with right sided weakness needs to learn how to use a cane. The nurse plans to teach the client to position the cane by holding it with the: a. b. c. d. Left hand and placing the cane in front of the left foot Right hand and placing the cane in front of the right foot Left hand and 6 inches lateral to the left foot Right hand and 6 inches lateral to the left foot

56. The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. The nurse uses a: a. Pillow to keep the right leg abducted during turning b. Pillow to keep the right leg adducted during turning c. Trochanter roll to prevent external rotation while turning d. Trochanter roll to prevent abduction while turning 57. The nurse has an order to get the client out of bed to a chair on the first postoperative day after a total knee replacement. The nurse plans to do which of the following to protect the knee joint: a. Apply a knee immobilizer before getting the client up and elevate the client's surgical leg while sitting b. Apply an Ace wrap around the dressing and put ice on the knee while sitting c. Lift the client to the bedside change leaving the CPM machine in place d. Obtain a walker to minimize weight bearing by the client on the affected leg 58. The nurse is caring for the client who had an above the knee amputation 2days ago. The residual limb was wrapped with an elastic compression bandage which has come off. The nurse immediately: a. Calls the physician b. Rewrap the stump with an elastic compression bandage c. Applies ice to the site d. Applies a dry sterile dressing and elevates it on a pillow 59. The nurse has taught the client with a below the knee amputation about prosthesis and stump care. The nurse evaluates that the client states to: a. Wear a clean nylon stump sock daily b. Toughen the skin of the stump by rubbing it with alcohol c. Prevent cracking of the skin of the stump by applying lotion daily d. Using a mirror to inspect all areas of the stump each day 60. The nurse is caring for a client with a gout. Which of the following laboratory values does the nurse expect to note in the client? a. Uric acid level of 8 mg/dl b. Calcium level of 9 mg/dl c. Phosphorus level of 3 mg/dl d. Uric acid level of 5 mg/dl

Posted by Budek on Monday, December 25, 2006 at 3:44 PM |

40 items Comprehensive NCLEX review answer key


1. Which individual is at greatest risk for developing hypertension? A) 45 year-old African American attorney B) 60 year-old Asian American shop owner C) 40 year-old Caucasian nurse D)55 year-old Hispanic teacher

The correct answer is A: 45 year-old African American attorney The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising. 2. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first? A) Gastric lavage PRN B) Acetylcysteine (mucomyst) for age per pharmacy C) Start an IV Dextrose 5% with 0.33% normal saline to keep vein open D) Activated charcoal per pharmacy The correct answer is A: Gastric lavage PRN Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next drug to give would be activated charcoal, then mucomyst and lastly the IV fluids. 3. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? A) angina at rest B) thrombus formation C) dizziness D) falling blood pressure The correct answer is B: thrombus formation Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure. 4. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The clients temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is A) Maintain fluid and electrolyte balance B) Control nausea C) Manage pain D) Prevent urinary tract infection The correct answer is C: Manage pain The immediate goal of therapy is to alleviate the clients pain. 5. What would the nurse expect to see while assessing the growth of children during their school age years? A) Decreasing amounts of body fat and muscle mass B) Little change in body appearance from year to year C) Progressive height increase of 4 inches each year D) Yearly weight gain of about 5.5 pounds per year The correct answer is D: Yearly weight gain of about 5.5 pounds per year School age children gain about 5.5 pounds each year and increase about 2 inches in height. 6. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states My blood pressure is usually much lower. The nurse should tell the client to A) go get a blood pressure check within the next 48 to 72 hours B) check blood pressure again in 2 months

C) see the health care provider immediately D) visit the health care provider within 1 week for a BP check The correct answer is A: go get a blood pressure check within the next 48 to 72 hours The blood pressure reading is moderately high with the need to have it rechecked in a few days. The client states it is usually much lower. Thus a concern exists for complications such as stroke. However immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long. 7. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission? A) A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago B) A young adult with diabetes mellitus Type 2 for over 10 years and admitted with antibiotic induced diarrhea 24 hours ago C) An elderly client with a history of hypertension, hypercholesterolemia and lupus, and was admitted with Stevens-Johnson syndrome that morning D) An adolescent with a positive HIV test and admitted for acute cellulitus of the lower leg 48 hours ago The correct answer is A: A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home. 8. A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication: A) Should be taken in the morning B) May decrease the client's energy level C) Must be stored in a dark container D) Will decrease the client's heart rate The correct answer is A: Should be taken in the morning Thyroid supplement should be taken in the morning to minimize the side effects of insomnia 9. A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first? A) Prepare the child for x-ray of upper airways B) Examine the child's throat C) Collect a sputum specimen D) Notify the healthcare provider of the child's status The correct answer is D: Notify the health care provider of the child''s status These findings suggest a medical emergency and may be due to epiglottises. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction. 10. In children suspected to have a diagnosis of diabetes, which one of the following

complaints would be most likely to prompt parents to take their school age child for evaluation? A) Polyphagia B) Dehydration C) Bed wetting D) Weight loss The correct answer is C: Bed wetting In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by the parents 11. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection? A) Trichomoniasis B) Chlamydia C) Staphylococcus D) Streptococcus The correct answer is B: Chlamydia Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease. 12. An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? A) A middle-aged client who says "I took too many diet pills" and "my heart feels like it is racing out of my chest." B) A young adult who says "I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?" C) An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 D) An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking into the emergency room The correct answer is c: An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opoid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future. 13. When teaching a client with coronary artery disease about nutrition, the nurse should emphasize A) Eating 3 balanced meals a day B) Adding complex carbohydrates C) Avoiding very heavy meals D) Limiting sodium to 7 gms per day The correct answer is C: Avoiding very heavy meals Eating large, heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease. 14. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working? A) The client complains of discomfort at the IV insertion site

B) The client states "I just can't get relief from my pain." C) The level of drug is 100 ml at 8 AM and is 80 ml at noon D) The level of the drug is 100 ml at 8 AM and is 50 ml at noon The correct answer is C: The level of drug is 100 ml at 8 AM and is 80 ml at noon The minimal dose of 10 ml per hour which would be 40 ml given in a 4 hour period. Only 60 ml should be left at noon. The pump is not functioning when more than expected medicine is left in the container. 15. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurses response? A) Electrical energy fields B) Spinal column manipulation C) Mind-body balance D) Exercise of joints The correct answer is B: Spinal column manipulation The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation. 16. The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention? A) Decrease in level of consciousness B) Loss of bladder control C) Altered sensation to stimuli D) Emotional lability The correct answer is A: Decrease in level of consciousness A further decrease in the level of consciousness would be indicative of a further progression of the CVA. 17. A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time? A) Positive sweat test B) Bulky greasy stools C) Moist, productive cough D) Meconium ileus The correct answer is C: Moist, productive cough Option c is a later sign. Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF. 18. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should A) Place a call to the client's health care provider for instructions B) Send him to the emergency room for evaluation C) Reassure the client's wife that the symptoms are transient

D) Instruct the client's wife to call the doctor if his symptoms become worse The correct answer is B: Send him to the emergency room for evaluation This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client''s best interest. 19. Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test? A) Client must be NPO before the examination B) Enema to be administered prior to the examination C) Medicate client with Lasix 20 mg IV 30 minutes prior to the examination D) No special orders are necessary for this examination The correct answer is D: No special orders are necessary for this examination No special preparation is necessary for this examination. 20. The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question? A) "You need to regain your strength before attempting such exertion." B) "When you can climb 2 flights of stairs without problems, it is generally safe." C) "Have a glass of wine to relax you, then you can try to have sex." D) "If you can maintain an active walking program, you will have less risk." The correct answer is B: "When you can climb 2 flights of stairs without problems, it is generally safe." There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.

21. A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first? A) A 2 month old infant with a history of rolling off the bed and has buldging fontanels with crying B) A teenager who got a singed beard while camping C) An elderly client with complaints of frequent liquid brown colored stools D) A middle aged client with intermittent pain behind the right scapula The correct answer is B: A teenager who got singed a singed beard while camping This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling. 22. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs? A) "I want to protect my child from any falls."

B) "I will set limits on exploring the house." C) "I understand the need to use those new skills." D) "I intend to keep control over our child." The correct answer is C: "I understand the need to use those new skills." Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment. 23. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is A) Verify correct placement of the tube B) Check that the feeding solution matches the dietary order C) Aspirate abdominal contents to determine the amount of last feeding remaining in stomach D) Ensure that feeding solution is at room temperature The correct answer is A: Verify correct placement of the tube Proper placement of the tube prevents aspiration. 24. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued? A) Narrowed QRS complex B) Shortened "PR" interval C) Tall peaked T waves D) Prominent "U" waves The correct answer is C: Tall peaked T waves A tall peaked T wave is a sign of hyperkalemia. The health care provider should be notified regarding discontinuing the medication. 25. A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body? A) All striated muscles B) The cerebellum C) The kidneys D) The leg bones The correct answer is A: All striated muscles Rhabdomyosarcoma is the most common children''s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word and is myo which typically means muscle. 26. The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to A) Achieve harmony B) Maintain a balance of energy C) Respect life
D) Restore yin and yang

The correct answer is D: Restore yin and yang For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang. 27. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to A) Increase fluids that are high in protein B) Restrict fluids C) Force fluids and reassess blood pressure D) Limit fluids to non-caffeine beverages The correct answer is C: Force fluids and reassess blood pressure Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency. 28. A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure A) Right heart function B) Left heart function C) Renal tubule function D) Carotid artery function The correct answer is B: Left heart function The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. The pressure readings are inferred from pressure measurements obtained on the right side of the circulation. Right-sided heart function is assessed through the evaluation of the central venous pressures (CVP). 29. A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is A) Start a peripheral IV B) Initiate closed-chest massage C) Establish an airway D) Obtain the crash cart The correct answer is C: Establish an airway Establishing an airway is always the primary objective in a cardiopulmonary arrest. 30. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider? A) Blood pressure 94/60 B) Heart rate 76 C) Urine output 50 ml/hour D) Respiratory rate 16 The correct answer is A: Blood pressure 94/60 Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100; systolic B/P over 100) in order to safely administer both medications.

31. While assessing a 1 month-old infant, which finding should the nurse report immediately? A) Abdominal respirations B) Irregular breathing rate C) Inspiratory grunt D) Increased heart rate with crying The correct answer is C: Inspiratory grunt Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant. 32. The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to A) Excessive fetal weight B) Low blood sugar levels C) Depletion of subcutaneous fat D) Progressive placental insufficiency The correct answer is D: Progressive placental insufficiency The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may be related to hypoxia. 33. The nurse is caring for a client who had a total hip replacement 4 days ago. Which assessment requires the nurses immediate attention? A) I have bad muscle spasms in my lower leg of the affected extremity. B) "I just can't 'catch my breath' over the past few minutes and I think I am in grave danger." C) "I have to use the bedpan to pass my water at least every 1 to 2 hours." D) "It seems that the pain medication is not working as well today." The correct answer is B: "I just can''t ''catch my breath'' over the past few minutes and I think I am in grave danger." The nurse would be concerned about all of these comments. However the most life threatening is option B. Clients who have had hip or knee surgery are at greatest risk for development of post operative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Option C may indicate a urinary tract infection. And option D requires further investigation and is not life threatening. 34. A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication? A) Weight gain of 5 pounds B) Edema of the ankles C) Gastric irritability D) Decreased appetite The correct answer is D: Decreased appetite Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias. 35. A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this

information? A) Gravida 4 para 2 B) Gravida 2 para 1 C) Gravida 3 para 1 D) Gravida 3 para 2 The correct answer is C: Gravida 3 para 1 Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins). 36. The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing? A) Apply dressing using sterile technique B) Improve the client's nutrition status C) Initiate limb compression therapy D) Begin proteolytic debridement The correct answer is B: Improve the client''s nutrition status The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other answers are correct, but without proper nutrition, the other interventions would be of little help. 37. A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a preoperative client. Which action should the nurse take first? A) Raise the side rails on the bed B) Place the call bell within reach C) Instruct the client to remain in bed D) Have the client empty bladder The correct answer is D: Have the client empty bladder The first step in the process is to have the client void prior to administering the pre-operative medication. The other actions follow this initial step in this sequence: 4 3 1 2 38. Which of these statements best describes the characteristic of an effective rewardfeedback system? A) Specific feedback is given as close to the event as possible B) Staff are given feedback in equal amounts over time C) Positive statements are to precede a negative statement D) Performance goals should be higher than what is attainable The correct answer is A: Specific feedback is given as close to the event as possible Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if the standards are clearly understood. 39. A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which A) Increase the heart rate B) Lead to dehydration C) Are considered aerobic D) May be competitive

The correct answer is B: Lead to dehydration The client must take in adequate fluids before and during exercise periods. 40. During the evaluation of the quality of home care for a client with Alzheimer's disease, the priority for the nurse is to reinforce which statement by a family member? A) At least 2 full meals a day is eaten. B) We go to a group discussion every week at our community center. C) We have safety bars installed in the bathroom and have 24 hour alarms on the doors. D) The medication is not a problem to have it taken 3 times a day. The correct answer is C: We have safety bars installed in the bathroom and have 24 hour alarms on the doors. Ensuring safety of the client with increasing memory loss is a priority of home care. Note all options are correct statements. However, safety is most important to reinforce.

Posted by Jeddah on Wednesday, December 27, 2006 at 10:28 PM |

40 items Comprehensive NCLEX review answer key


1. Which individual is at greatest risk for developing hypertension? A) 45 year-old African American attorney B) 60 year-old Asian American shop owner C) 40 year-old Caucasian nurse D)55 year-old Hispanic teacher The correct answer is A: 45 year-old African American attorney The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising. 2. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first? A) Gastric lavage PRN B) Acetylcysteine (mucomyst) for age per pharmacy C) Start an IV Dextrose 5% with 0.33% normal saline to keep vein open D) Activated charcoal per pharmacy The correct answer is A: Gastric lavage PRN Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next drug to give would be activated charcoal, then mucomyst and lastly the IV fluids. 3. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? A) angina at rest B) thrombus formation C) dizziness D) falling blood pressure The correct answer is B: thrombus formation Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is associated with the first 12 hours after

the procedure. 4. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The clients temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is A) Maintain fluid and electrolyte balance B) Control nausea C) Manage pain D) Prevent urinary tract infection The correct answer is C: Manage pain The immediate goal of therapy is to alleviate the clients pain. 5. What would the nurse expect to see while assessing the growth of children during their school age years? A) Decreasing amounts of body fat and muscle mass B) Little change in body appearance from year to year C) Progressive height increase of 4 inches each year D) Yearly weight gain of about 5.5 pounds per year The correct answer is D: Yearly weight gain of about 5.5 pounds per year School age children gain about 5.5 pounds each year and increase about 2 inches in height. 6. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states My blood pressure is usually much lower. The nurse should tell the client to A) go get a blood pressure check within the next 48 to 72 hours B) check blood pressure again in 2 months C) see the health care provider immediately D) visit the health care provider within 1 week for a BP check The correct answer is A: go get a blood pressure check within the next 48 to 72 hours The blood pressure reading is moderately high with the need to have it rechecked in a few days. The client states it is usually much lower. Thus a concern exists for complications such as stroke. However immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long. 7. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission? A) A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago B) A young adult with diabetes mellitus Type 2 for over 10 years and admitted with antibiotic induced diarrhea 24 hours ago C) An elderly client with a history of hypertension, hypercholesterolemia and lupus, and was admitted with Stevens-Johnson syndrome that morning D) An adolescent with a positive HIV test and admitted for acute cellulitus of the lower leg 48 hours ago The correct answer is A: A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home.

8. A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication: A) Should be taken in the morning B) May decrease the client's energy level C) Must be stored in a dark container D) Will decrease the client's heart rate The correct answer is A: Should be taken in the morning Thyroid supplement should be taken in the morning to minimize the side effects of insomnia 9. A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first? A) Prepare the child for x-ray of upper airways B) Examine the child's throat C) Collect a sputum specimen D) Notify the healthcare provider of the child's status The correct answer is D: Notify the health care provider of the child''s status These findings suggest a medical emergency and may be due to epiglottises. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction. 10. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation? A) Polyphagia B) Dehydration C) Bed wetting D) Weight loss The correct answer is C: Bed wetting In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by the parents 11. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection? A) Trichomoniasis B) Chlamydia C) Staphylococcus D) Streptococcus The correct answer is B: Chlamydia Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease. 12. An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? A) A middle-aged client who says "I took too many diet pills" and "my heart feels like it is racing out of my chest." B) A young adult who says "I hear songs from heaven. I need money for beer. I quit

drinking 2 days ago for my family. Why are my arms and legs jerking?" C) An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 D) An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking into the emergency room The correct answer is c: An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opoid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future. 13. When teaching a client with coronary artery disease about nutrition, the nurse should emphasize A) Eating 3 balanced meals a day B) Adding complex carbohydrates C) Avoiding very heavy meals D) Limiting sodium to 7 gms per day The correct answer is C: Avoiding very heavy meals Eating large, heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease. 14. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working? A) The client complains of discomfort at the IV insertion site B) The client states "I just can't get relief from my pain." C) The level of drug is 100 ml at 8 AM and is 80 ml at noon D) The level of the drug is 100 ml at 8 AM and is 50 ml at noon The correct answer is C: The level of drug is 100 ml at 8 AM and is 80 ml at noon The minimal dose of 10 ml per hour which would be 40 ml given in a 4 hour period. Only 60 ml should be left at noon. The pump is not functioning when more than expected medicine is left in the container. 15. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurses response? A) Electrical energy fields B) Spinal column manipulation C) Mind-body balance D) Exercise of joints The correct answer is B: Spinal column manipulation The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation. 16. The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention? A) Decrease in level of consciousness B) Loss of bladder control C) Altered sensation to stimuli

D) Emotional lability The correct answer is A: Decrease in level of consciousness A further decrease in the level of consciousness would be indicative of a further progression of the CVA. 17. A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time? A) Positive sweat test B) Bulky greasy stools C) Moist, productive cough D) Meconium ileus The correct answer is C: Moist, productive cough Option c is a later sign. Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF. 18. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should A) Place a call to the client's health care provider for instructions B) Send him to the emergency room for evaluation C) Reassure the client's wife that the symptoms are transient D) Instruct the client's wife to call the doctor if his symptoms become worse The correct answer is B: Send him to the emergency room for evaluation This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client''s best interest. 19. Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test? A) Client must be NPO before the examination B) Enema to be administered prior to the examination C) Medicate client with Lasix 20 mg IV 30 minutes prior to the examination D) No special orders are necessary for this examination The correct answer is D: No special orders are necessary for this examination No special preparation is necessary for this examination. 20. The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question? A) "You need to regain your strength before attempting such exertion." B) "When you can climb 2 flights of stairs without problems, it is generally safe." C) "Have a glass of wine to relax you, then you can try to have sex." D) "If you can maintain an active walking program, you will have less risk."

The correct answer is B: "When you can climb 2 flights of stairs without problems, it is generally safe." There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.

21. A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first? A) A 2 month old infant with a history of rolling off the bed and has buldging fontanels with crying B) A teenager who got a singed beard while camping C) An elderly client with complaints of frequent liquid brown colored stools D) A middle aged client with intermittent pain behind the right scapula The correct answer is B: A teenager who got singed a singed beard while camping This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling. 22. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs? A) "I want to protect my child from any falls." B) "I will set limits on exploring the house." C) "I understand the need to use those new skills." D) "I intend to keep control over our child." The correct answer is C: "I understand the need to use those new skills." Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment. 23. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is A) Verify correct placement of the tube B) Check that the feeding solution matches the dietary order C) Aspirate abdominal contents to determine the amount of last feeding remaining in stomach D) Ensure that feeding solution is at room temperature The correct answer is A: Verify correct placement of the tube Proper placement of the tube prevents aspiration. 24. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued? A) Narrowed QRS complex

B) Shortened "PR" interval C) Tall peaked T waves D) Prominent "U" waves The correct answer is C: Tall peaked T waves A tall peaked T wave is a sign of hyperkalemia. The health care provider should be notified regarding discontinuing the medication. 25. A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body? A) All striated muscles B) The cerebellum C) The kidneys D) The leg bones The correct answer is A: All striated muscles Rhabdomyosarcoma is the most common children''s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word and is myo which typically means muscle. 26. The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to A) Achieve harmony B) Maintain a balance of energy C) Respect life
D) Restore yin and yang The correct answer is D: Restore yin and yang For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang. 27. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to A) Increase fluids that are high in protein B) Restrict fluids C) Force fluids and reassess blood pressure D) Limit fluids to non-caffeine beverages The correct answer is C: Force fluids and reassess blood pressure Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency. 28. A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure A) Right heart function B) Left heart function C) Renal tubule function D) Carotid artery function The correct answer is B: Left heart function The Swan-Ganz catheter is placed in the

pulmonary artery to obtain information about the left side of the heart. The pressure readings are inferred from pressure measurements obtained on the right side of the circulation. Right-sided heart function is assessed through the evaluation of the central venous pressures (CVP). 29. A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is A) Start a peripheral IV B) Initiate closed-chest massage C) Establish an airway D) Obtain the crash cart The correct answer is C: Establish an airway Establishing an airway is always the primary objective in a cardiopulmonary arrest. 30. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider? A) Blood pressure 94/60 B) Heart rate 76 C) Urine output 50 ml/hour D) Respiratory rate 16 The correct answer is A: Blood pressure 94/60 Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100; systolic B/P over 100) in order to safely administer both medications. 31. While assessing a 1 month-old infant, which finding should the nurse report immediately? A) Abdominal respirations B) Irregular breathing rate C) Inspiratory grunt D) Increased heart rate with crying The correct answer is C: Inspiratory grunt Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant. 32. The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to A) Excessive fetal weight B) Low blood sugar levels C) Depletion of subcutaneous fat D) Progressive placental insufficiency The correct answer is D: Progressive placental insufficiency The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may be related to hypoxia. 33. The nurse is caring for a client who had a total hip replacement 4 days ago. Which assessment requires the nurses immediate attention? A) I have bad muscle spasms in my lower leg of the affected extremity.

B) "I just can't 'catch my breath' over the past few minutes and I think I am in grave danger." C) "I have to use the bedpan to pass my water at least every 1 to 2 hours." D) "It seems that the pain medication is not working as well today." The correct answer is B: "I just can''t ''catch my breath'' over the past few minutes and I think I am in grave danger." The nurse would be concerned about all of these comments. However the most life threatening is option B. Clients who have had hip or knee surgery are at greatest risk for development of post operative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Option C may indicate a urinary tract infection. And option D requires further investigation and is not life threatening. 34. A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication? A) Weight gain of 5 pounds B) Edema of the ankles C) Gastric irritability D) Decreased appetite The correct answer is D: Decreased appetite Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias. 35. A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information? A) Gravida 4 para 2 B) Gravida 2 para 1 C) Gravida 3 para 1 D) Gravida 3 para 2 The correct answer is C: Gravida 3 para 1 Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins). 36. The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing? A) Apply dressing using sterile technique B) Improve the client's nutrition status C) Initiate limb compression therapy D) Begin proteolytic debridement The correct answer is B: Improve the client''s nutrition status The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other answers are correct, but without proper nutrition, the other interventions would be of little help. 37. A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a preoperative client. Which action should the nurse take first?

A) Raise the side rails on the bed B) Place the call bell within reach C) Instruct the client to remain in bed D) Have the client empty bladder The correct answer is D: Have the client empty bladder The first step in the process is to have the client void prior to administering the pre-operative medication. The other actions follow this initial step in this sequence: 4 3 1 2 38. Which of these statements best describes the characteristic of an effective rewardfeedback system? A) Specific feedback is given as close to the event as possible B) Staff are given feedback in equal amounts over time C) Positive statements are to precede a negative statement D) Performance goals should be higher than what is attainable The correct answer is A: Specific feedback is given as close to the event as possible Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if the standards are clearly understood. 39. A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which A) Increase the heart rate B) Lead to dehydration C) Are considered aerobic D) May be competitive The correct answer is B: Lead to dehydration The client must take in adequate fluids before and during exercise periods. 40. During the evaluation of the quality of home care for a client with Alzheimer's disease, the priority for the nurse is to reinforce which statement by a family member? A) At least 2 full meals a day is eaten. B) We go to a group discussion every week at our community center. C) We have safety bars installed in the bathroom and have 24 hour alarms on the doors. D) The medication is not a problem to have it taken 3 times a day. The correct answer is C: We have safety bars installed in the bathroom and have 24 hour alarms on the doors. Ensuring safety of the client with increasing memory loss is a priority of home care. Note all options are correct statements. However, safety is most important to reinforce.

Posted by Jeddah on Wednesday, December 27, 2006 at 10:28 PM |

COMMUNITY HEALTH NURSING EXAMINATION PART I Answer Key


COMMUNITY HEALTH NURSING EXAMINATION PART I By : Budek http://pinoybsn.blogspot.com

Outline : I. Epidemiology II. Vital Statistics III. FHSIS IV. COPAR V. Health Education SITUATION : Epidemiology and Vital statistics is a very important tool that a nurse could use in controlling the spread of disease in the community and at the same time, surveying the impact of the disease on the population and prevent its future occurrence. 1. It is concerned with the study of factors that influence the occurrence and distribution of diseases, defects, disability or death which occurs in groups or aggregation of individuals. A. Epidemiology B. Demographics C. Vital Statistics D. Health Statistics 2. Which of the following is the backbone in disease prevention? A. Epidemiology B. Demographics C. Vital Statistics D. Health Statistics 3. Which of the following type of research could show how community expectations can result in the actual provision of services? A. Basic Research B. Operational Research C. Action Research D. Applied Research 4. An outbreak of measles has been reported in Community A. As a nurse, which of the following is your first action for an Epidemiological investigation? A. Classify if the outbreak of measles is epidemic or just sporadic B. Report the incidence into the RHU C. Determine the first day when the outbreak occurred D. Identify if it is the disease which it is reported to be 5. After the epidemiological investigation produced final conclusions, which of the following is your initial step in your operational procedure during disease outbreak? A. Coordinate personnel from Municipal to the National level B. Collect pertinent laboratory specimen to confirm disease causation C. Immunize nearby communities with Measles D. Educate the community in future prevention of similar outbreaks 6. The main concern of a public health nurse is the prevention of disease, prolonging of life

and promoting physical health and efficiency through which of the following? A. Use of epidemiological tools and vital health statistics B. Determine the spread and occurrence of the disease C. Political empowerment and Socio Economic Assistance D. Organized Community Efforts 7. In order to control a disease effectively, which of the following must first be known? 1. 2. 3. 4. The conditions surrounding its occurrence Factors that do not favor its development The condition that do not surround its occurrence Factors that favors its development

A. 1 and 3 B. 1 and 4 C. 2 and 3 D. 2 and 4 8. All of the following are uses of epidemiology except: A. To study the history of health population and the rise and fall of disease B. To diagnose the health of the community and the condition of the people C. To provide summary data on health service delivery D. To identify groups needing special attention 9. Before reporting the fact of presence of an epidemic, which of the following is of most importance to determine? A. Are the facts complete? B. Is the disease real? C. Is the disease tangible? D. Is it epidemic or endemic? 10. An unknown epidemic has just been reported in Barangay Dekbudekbu. People said that affected person demonstrates hemorrhagic type of fever. You are designated now to plan for epidemiological investigation. Arrange the sequence of events in accordance with the correct outline plan for epidemiological investigation. 1. Report the presence of dengue 2. Summarize data and conclude the final picture of epidemic 3. Relate the occurrence to the population group, facilities, food supply and carriers 4. Determine if the disease is factual or real 5. Determine any unusual prevalence of the disease and its nature; is it epidemic, sporadic, endemic or pandemic? 6. Determine onset and the geographical limitation of the disease. A. 4,1,3,5,2,6 B. 4,1,5,6,3,2 C. 5,4,6,2,1,3 D. 5,4,6,1,2,3 E. 1,2,3,4,5,6

11. In the occurrence of SARS and other pandemics, which of the following is the most vital role of a nurse in epidemiology? A. Health promotion B. Disease prevention C. Surveillance D. Casefinding 12. Measles outbreak has been reported in Barangay Bahay Toro, After conducting an epidemiological investigation you have confirmed that the outbreak is factual. You are tasked to lead a team of medical workers for operational procedure in disease outbreak. Arrange the correct sequence of events that you must do to effectively contain the disease 1. 2. 3. 4. 5. 6. Create a final report and recommendation Perform nasopharyngeal swabbing to infected individuals Perform mass measles immunization to vulnerable groups Perform an environmental sanitation survey on the immediate environment Organize your team and Coordinate the personnels Educate the community on disease transmission

A. 1,2,3,4,5,6 B. 6,5,4,3,2,1 C. 5,6,4,2,3,1 D. 5,2,3,4,6,1 13. All of the following are function of Nurse Budek in epidemiology except A. Laboratory Diagnosis B. Surveillance of disease occurrence C. Follow up cases and contacts D. Refer cases to hospitals if necessary E. Isolate cases of communicable disease 14. All of the following are performed in team organization except A. Orientation and demonstration of methodology to be employed B. Area assignments of team members C. Check teams equipments and paraphernalia D. Active case finding and Surveillance 15. Which of the following is the final output of data reporting in epidemiological operational procedure? A. Recommendation B. Evaluation C. Final Report D. Preliminary report 16. The office in charge with registering vital facts in the Philippines is none other than the A. PCSO B PAGCOR C. DOH

D. NSO 17. The following are possible sources of Data except: A. Experience B. Census C. Surveys D. Research 18. This refers to systematic study of vital events such as births, illnesses, marriages, divorces and deaths A. Epidemiology B. Demographics C. Vital Statistics D. Health Statistics 19. In case of clerical errors in your birth certificate, Where should you go to have it corrected? A. NSO B. Court of Appeals C. Municipal Trial Court D. Local Civil Registrar 20. Acasia just gave birth to Lestat, A healthy baby boy. Who are going to report the birth of Baby Lestat? A. Nurse B. Midwife C. OB Gyne D. Birth Attendant 21. In reporting the birth of Baby Lestat, where will he be registered? A. At the Local Civil Registrar B. In the National Statistics Office C. In the City Health Department D. In the Field Health Services and Information System Main Office 22. Deejay, The birth attendant noticed that Lestat has low set of ears, Micrognathia, Microcephaly and a typical cat like cry. What should Deejay do? A. Bring Lestat immediately to the nearest hospital B. Ask his assistant to call the nearby pediatrician C. Bring Lestat to the nearest pediatric clinic D. Call a Taxi and together with Acasia, Bring Lestat to the nearest hospital 23. Deejay would suspect which disorder? A. Trisomy 21 B. Turners Syndrome C. Cri Du Chat

D. Klinefelters Syndrome 24. Deejay could expect which of the following congenital anomaly that would accompany this disorder? A. AVSD B. PDA C. TOF D. TOGV 26. Which presidential decree orders reporting of births within 30 days after its occurrence? A. 651 B. 541 C. 996 D. 825 25. These rates are referred to the total living population, It must be presumed that the total population was exposed to the risk of occurrence of the event. A. Rate B. Ratio C. Crude/General Rates D. Specific Rate 26. These are used to describe the relationship between two numerical quantities or measures of events without taking particular considerations to the time or place. A. Rate B. Ratios C. Crude/General Rate D. Specific Rate 27. This is the most sensitive index in determining the general health condition of a community since it reflects the changes in the environment and medical conditions of a community A. Crude death rate B. Infant mortality rate C. Maternal mortality rate D. Fetal death rate 28. According to the WHO, which of the following is the most frequent cause of death in children underfive worldwide in the 2003 WHO Survey? A. Neonatal B. Pneumonia C. Diarrhea D. HIV/AIDS 29. In the Philippines, what is the most common cause of death of infants according to the latest survey?

A. Pneumonia B. Diarrhea C. Other perinatal condition D. Respiratory condition of fetus and newborn 30. The major cause of mortality from 1999 up to 2002 in the Philippines are A. Diseases of the heart B. Diseases of the vascular system C. Pneumonias D. Tuberculosis 31. Alicia, a 9 year old child asked you What is the common cause of death in my age group here in the Philippines? The nurse is correct if he will answer A. Pneumonia is the top leading cause of death in children age 5 to 9 B. Malignant neoplasm if common in your age group C. Probability wise, You might die due to accidents D. Diseases of the respiratory system is the most common cause of death in children 32. In children 1 to 4 years old, which is the most common cause of death? A. Diarrhea B. Accidents C. Pneumonia D. Diseases of the heart 33. Working in the community as a PHN for almost 10 years, Aida knew the fluctuation in vital statistics. She knew that the most common cause of morbidity among the Filipinos is A. Diseases of the heart B. Diarrhea C. Pneumonia D. Vascular system diseases 34. Nurse Aida also knew that most maternal deaths are caused by A. Hemorrhage B. Other Complications related to pregnancy occurring in the course of labor, delivery and puerperium C. Hypertension complicating pregnancy, childbirth and puerperium D. Abortion SITUATION : Barangay PinoyBSN has the following data in year 2006 1. 2. 3. 4. 5. 6. 7. 8. July 1 population : 254,316 Livebirths : 2,289 Deaths from maternal cause : 15 Death from CVD : 3,029 Deaths under 1 year of age : 23 Fetal deaths : 8 Deaths under 28 days : 8 Death due to rabies : 45

9. Registered cases of rabies : 45 10. People with pneumonia : 79 11. People exposed with pneumonia : 2,593 12. Total number of deaths from all causes : 10,998 The following questions refer to these data 35. What is the crude birth rate of Barangay PinoyBSN? A. 90/100,000 B. 9/100 C. 90/1000 D. 9/1000 36. What is the cause specific death rate from cardiovascular diseases? A. 27/100 B. 1191/100,000 C. 27/100,000 D. 1.1/1000 37. What is the Maternal Mortality rate of this barangay? A. 6.55/1000 B. 5.89/1000 C. 1.36/1000 D. 3.67/1000 38. What is the fetal death rate? A. 3.49/1000 B. 10.04/1000 C. 3.14/1000 D. 3.14/100,000 39. What is the attack rate of pneumonia? A. 3.04/1000 B. 7.18/1000 C. 32.82/100 D. 3.04/100 40. Determine the Case fatality ratio of rabies in this Barangay A. 1/100 B. 100% C. 1% D. 100/1000 41. The following are all functions of the nurse in vital statistics, which of the following is not? A. Consolidate Data

B. Collects Data C. Analyze Data D. Tabulate Data 42. The following are Notifiable diseases that needs to have a tally sheet in data reporting, Which one is not? A. Hypertension B. Bronchiolitis C. Chemical Poisoning D. Accidents 43. Which of the following requires reporting within 24 hours? A. Neonatal tetanus B. Measles C. Hypertension D. Tetanus 44. Which Act declared that all communicable disease be reported to the nearest health station? A. 1082 B. 1891 C. 3573 D. 6675 45. In the RHU Team, Which professional is directly responsible in caring a sick person who is homebound? A. Midwife B. Nurse C. BHW D. Physician 46. During epidemics, which of the following epidemiological function will you have to perform first? A. Teaching the community on disease prevention B. Assessment on suspected cases C. Monitor the condition of people affected D. Determining the source and nature of the epidemic 47. Which of the following is a POINT SOURCE epidemic? A. Dengue H.F B. Malaria C. Contaminated Water Source D. Tuberculosis 48. All but one is a characteristic of a point source epidemic, which one is not? A. The spread of the disease is caused by a common vehicle

B. The disease is usually caused by contaminated food C. There is a gradual increase of cases D. Epidemic is usually sudden 49. The only Microorganism monitored in cases of contaminated water is A. Vibrio Cholera B. Escherichia Coli C. Entamoeba Histolytica D. Coliform Test 50. Dengue increase in number during June, July and August. This pattern is called A. Epidemic B. Endemic C. Cyclical D. Secular SITUATION : Field health services and information system provides summary data on health service delivery and selected program from the barangay level up to the national level. As a nurse, you should know the process on how these information became processed and consolidated. 51. All of the following are objectives of FHSIS Except A. To complete the clinical picture of chronic disease and describe their natural history B. To provide standardized, facility level data base which can be accessed for more in depth studies C. To minimize recording and reporting burden allowing more time for patient care and promotive activities D. To ensure that data reported are useful and accurate and are disseminated in a timely and easy to use fashion 52. What is the fundamental block or foundation of the field health service information system? A. Family treatment record B. Target Client list C. Reporting forms D. Output record 53. What is the primary advantage of having a target client list? A. Nurses need not to go back to FTR to monitor treatment and services to beneficiaries thus saving time and effort B. Help monitor service rendered to clients in general C. Facilitate monitoring and supervision of services D. Facilitates easier reporting 54. Which of the following is used to monitor particular groups that are qualified as eligible to a certain program of the DOH?

A. Family treatment record B. Target Client list C. Reporting forms D. Output record 55. In using the tally sheet, what is the recommended frequency in tallying activities and services? A. Daily B. Weekly C. Monthly D. Quarterly 56. When is the counting of the tally sheet done? A. At the end of the day B. At the end of the week C. At the end of the month D. At the end of the year 57. Target client list will be transmitted to the next facility in the form of A. Family treatment record B. Target Client list C. Reporting forms D. Output record 58. All but one of the following are eligible target client list A. Leprosy cases B. TB cases C. Prenatal care D. Diarrhea cases 59. This is the only mechanism through which data are routinely transmitted from once facility to another A. Family treatment record B. Target Client list C. Reporting forms D. Output record 60. FHSIS/Q-3 Or the report for environmental health activities is prepared how frequently? A. Daily B. Weekly C. Quarterly D. Yearly 61. Nurse Budek is preparing the reporting form for weekly notifiable diseases. He knew that he will code the report form as A. FHSIS/E-1

B. FHSIS/E-2 C. FHSIS/E-3 D. FHSIS/M-1 62. In preparing the maternal death report, which of the following correctly codes this occurrence? A. FHSIS/E-1 B. FHSIS/E-2 C. FHSIS/E-3 D. FHSIS/M-1 63. Where should Nurse Budek bring the reporting forms if he is in the BHU Facility? A. Rural health office B. FHSIS Main office C. Provincial health office D. Regional health office 64. After bringing the reporting forms in the right facility for processing, Nurse Budek knew that the output reports are solely produced by what office? A. Rural health office B. FHSIS Main office C. Provincial health office D. Regional health office 65. Mang Raul entered the health center complaining of fatigue and frequent syncope. You assessed Mang Raul and found out that he is severely malnourished and anemic. What record should you get first to document these findings? A. Family treatment record B. Target Client list C. Reporting forms D. Output record 66. The information about Mang Rauls address, full name, age, symptoms and diagnosis is recorded in A. Family treatment record B. Target Client list C. Reporting forms D. Output record 67. Another entry is to be made for Mang Raul because he is in the target clients list, In what TCL should Mang Rauls entry be documented? A. TCL Eligible Population B. TCL Family Planning C. TCL Nutrition D. TCL Pre Natal 68. The nurse uses the FHSIS Record system incorrectly when she found out that

A. She go to the individual or FTR for entry confirmation in the Tally/Report Summary B. She refer to other sources for completing monthly and quarterly reports C. She records diarrhea in the Tally sheet/Report form with a code FHSIS/M-1 D. She records a Child who have frequent diarrhea in TCL : Under Five 69. The BHS Is the lowest level of reporting unit in FHSIS. A BHS can be considered a reporting unit if all of the following are met except A. It renders service to 3 barangays B. There is a midwife the regularly renders service to the area C. The BHS Have no mother BHS D. It should be a satellite BHS 70. Data submitted to the PHO is processed using what type of technology? A. Internet B. Microcomputer C. Supercomputer D. Server Interlink Connections SITUATION : Community organizing is a process by which people, health services and agencies of the community are brought together to act and solve their own problems. 71. Mang ambo approaches you for counseling. You are an effective counselor if you A. Give good advice to Mang Ambo B. Identify Mang Ambos problems C. Convince Mang Ambo to follow your advice D. Help Mang Ambo identify his problems 72. As a newly appointed PHN instructed to organize Barangay Baritan, Which of the following is your initial step in organizing the community for initial action? A. Study the Barangay Health statistics and records B. Make a courtesy call to the Barangay Captain C. Meet with the Barangay Captain to make plans D. Make a courtesy call to the Municipal Mayor 73. Preparatory phase is the first phase in organizing the community. Which of the following is the initial step in the preparatory phase? A. Area selection B. Community profiling C. Entry in the community D. Integration with the people 74. the most important factor in determining the proper area for community organizing is that this area should A. Be already adopted by another organization B. Be able to finance the projects C. Have problems and needs assistance

D. Have people with expertise to be developed as leaders 75. Which of the following dwelling place should the Nurse choose when integrating with the people? A. A simple house in the border of Barangay Baritan and San Pablo B. A simple house with fencing and gate located in the center of Barangay Baritan C. A modest dwelling place where people will not hesitate to enter D. A modest dwelling place where people will not hesitate to enter located in the center of the community 76. In choosing a leader in the community during the Organizational phase, Which among these people will you choose? A. Miguel Zobel, 50 years old, Rich and Famous B. Rustom, 27 years old, Actor C. Mang Ambo, 70, Willing to work for the desired change D. Ricky, 30 years old, Influential and Willing to work for the desired change 77. Which type of leadership style should the leaders of the community practice? A. Autocratic B. Democratic C. Laissez Faire D. Consultative 78. Setting up Committee on Education and Training is in what phase of COPAR? A. Preparatory B. Organizational C. Education and Training D. Intersectoral Collaboration E. Phase out 79. Community diagnosis is done to come up with a profile of local health situation that will serve as basis of health programs and services. This is done in what phase of COPAR? A. Preparatory B. Organizational C. Education and Training D. Intersectoral Collaboration E. Phase out 80. The people named the community health workers based on the collective decision in accordance with the set criteria. Before they can be trained by the Nurse, The Nurse must first A. Make a lesson plan B. Set learning goals and objective C. Assess their learning needs D. Review materials needed for training 81. Nurse Budek wrote a letter to PCSO asking them for assistance in their feeding

programs for the communitys nutrition and health projects. PCSO then approved the request and gave Budek 50,000 Pesos and a truckload of rice, fruits and vegetables. Which phase of COPAR did Budek utilized? A. Preparatory B. Organizational C. Education and Training D. Intersectoral Collaboration E. Phase out 82. Ideally, How many years should the Nurse stay in the community before he can phase out and be assured of a Self Reliant community? A. 5 years B. 10 years C. 1 year D. 6 months 83. Major discussion in community organization are made by A. The nurse B. The leaders of each committee C. The entire group D. Collaborating Agencies 84. The nurse should know that Organizational plan best succeeds when 1. 2. 3. 4. People sees its values People think its antagonistic professionally It is incompatible with their personal beliefs It is compatible with their personal beliefs

A. 1 and 3 B. 2 and 4 C. 1 and 2 D. 1 and 4 85. Nurse Budek made a proposal that people should turn their backyard into small farming lots to plant vegetables and fruits. He specified that the objective is to save money in buying vegetables and fruits that tend to have a fluctuating and cyclical price. Which step in Community organizing process did he utilized? A. Fact finding B. Determination of needs C. Program formation D. Education and Interpretation 86. One of the critical steps in COPAR is becoming one with the people and understanding their culture and lifestyle. Which critical step in COPAR will the Nurse try to immerse himself in the community? A. Integration B. Social Mobilization

C. Ground Work D. Mobilization 87. The Actual exercise of people power occurs during when? A. Integration B. Social Mobilization C. Ground Work D. Mobilization 88. Which steps in COPAR trains indigenous and informal leaders? A. Ground Work B. Mobilization C. Core Group formation D. Integration 89. As a PHN, One of your role is to organize the community. Nurse Budek knows that the purposes of community organizing are 1. 2. 3. 4. Move the community to act on their own problems Make people aware of their own problems Enable the nurse to solve the community problems Offer people means of solving their own problems

A. 1,2,3 B. 1,2,3,4 C. 1,2 D. 1,2,4 90. This is considered the first act of integrating with the people. This gives an in depth participation in community health problems and needs. A. Residing in the area of assignment B. Listing down the name of person to contact for courtesy call C. Gathering initial information about the community D. Preparing Agenda for the first meeting SITUATION : Health education is the process whereby knowledge, attitude and practice of people are changed to improve individual, family and community health. 91. Which of the following is the correct sequence in health education? 1. Information 2. Communication 3. Education A. 1,2,3 B. 3,2,1 C. 1,3,2 D. 3,1,2 92. The health status of the people is greatly affected and determined by which of the

following? A. Behavioral factors B. Socioeconomic factors C. Political factors D. Psychological factors 93. Nurse Budek is conducting a health teaching to Agnesia, 50 year old breast cancer survivor needing rehabilitative measures. He knows that health education is effective when A. Agnesia recites the procedure and instructions perfectly B. Agnesias behavior and outlook in life was changed positively C. Agnesia gave feedback to Budek saying that she understood the instruction D. Agnesia requested a written instruction from Budek 94. Which of the following is true about health education? A. It helps people attain their health through the nurses sole efforts B. It should not be flexible C. It is a fast and mushroom like process D. It is a slow and continuous process 95. Which of the following factors least influence the learning readiness of an adult learner? A. The individuals stage of development B. Ability to concentrate on information to be learned C. The individuals psychosocial adaptation to his illness D. The internal impulses that drive the person to take action 96. Which of the following is the most important condition for diabetic patients to learn how to control their diet? A. Use of pamphlets and other materials during instructions B. Motivation to be symptom free C. Ability of the patient to understand teaching instruction D. Language used by the nurse 97. An important skill that a primigravida has to acquire is the ability to bathe her newborn baby and clean her breast if she decides to breastfeed her baby, Which of the following learning domain will you classify the above goals? A. Psychomotor B. Cognitive C. Affective D. Attitudinal 98. When you prepare your teaching plan for a group of hypertensive patients, you first formulate your learning objectives. Which of the following steps in the nursing process corresponds to the writing of the learning objectives? A. Planning B. Implementing C. Evaluation

C. Assessment 99. Rose, 50 years old and newly diagnosed diabetic patient must learn how to inject insulin. Which of the following physical attribute is not in anyway related to her ability to administer insulin? A. Strength B. Coordination C. Dexterity D. Muscle Built 100. Appearance and disposition of clients are best observed initially during which of the following situation? A. Taking V/S B. Interview C. Implementation of the initial care D. Actual Physical examination 95-100 are taken from actual board questions, However the answer key given in the compilation are incorrect. Comments, Question, Suggestion or Reactions? YM or MAIL me @ pinoybsn@yahoo.com

Posted by Budek on Monday, November 06, 2006 at 10:44 AM |