PNLE I for Foundation of Professional Nursing Practice B.

A 44 year-old myocardial infarction (MI) client

who is complaining of nausea.
1. The nurse In-charge in labor and delivery unit
administered a dose of terbutaline to a client without C. A 26 year-old client admitted for dehydration
checking the client’s pulse. The standard that would be whose intravenous (IV) has infiltrated.
used to determine if the nurse was negligent is: D. A 63 year-old post operative’s abdominal
A. The physician’s orders. hysterectomy client of three days whose
incisional dressing is saturated
B. The action of a clinical nurse specialist who is with serosanguinous fluid.
recognized expert in the field.
6. Nurse Gail places a client in a four-point restraint
C. The statement in the drug literature about following orders from the physician. The client care plan
administration of terbutaline. should include:
D. The actions of a reasonably prudent nurse with A. Assess temperature frequently.
similar education and experience.
B. Provide diversional activities.
2. Nurse Trish is caring for a female client with a history
of GI bleeding, sickle cell disease, and a platelet count of C. Check circulation every 15-30 minutes.
22,000/μl. The female client is dehydrated and receiving D. Socialize with other patients once a shift.
dextrose 5% in half-normal saline solution at 150 ml/hr.
The client complains of severe bone pain and is 7. A male client who has severe burns is receiving H2
scheduled to receive a dose of morphine sulfate. In receptor antagonist therapy. The nurse In-charge knows
administering the medication, Nurse Trish should avoid the purpose of this therapy is to:
which route? A. Prevent stress ulcer
A. I.V B. Block prostaglandin synthesis
B. I.M C. Facilitate protein synthesis.
C. Oral D. Enhance gas exchange
D. S.C 8. The doctor orders hourly urine output measurement
3. Dr. Garcia writes the following order for the client for a postoperative male client. The nurse Trish records
who has been recently admitted “Digoxin .125 mg P.O. the following amounts of output for 2 consecutive
once daily.” To prevent a dosage error, how should the hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these
nurse document this order onto the medication amounts, which action should the nurse take?
administration record? A. Increase the I.V. fluid infusion rate
A. “Digoxin .1250 mg P.O. once daily” B. Irrigate the indwelling urinary catheter
B. “Digoxin 0.1250 mg P.O. once daily” C. Notify the physician
C. “Digoxin 0.125 mg P.O. once daily” D. Continue to monitor and record hourly urine
D. “Digoxin .125 mg P.O. once daily” output

4. A newly admitted female client was diagnosed with 9. Tony, a basketball player twist his right ankle while
deep vein thrombosis. Which nursing diagnosis should playing on the court and seeks care for ankle pain and
receive the highest priority? swelling. After the nurse applies ice to the ankle for 30
minutes, which statement by Tony suggests that ice
A. Ineffective peripheral tissue perfusion related application has been effective?
to venous congestion.
A. “My ankle looks less swollen now”.
B. Risk for injury related to edema.
B. “My ankle feels warm”.
C. Excess fluid volume related to peripheral
vascular disease. C. “My ankle appears redder now”.

D. Impaired gas exchange related to increased D. “I need something stronger for pain relief”
blood flow. 10.The physician prescribes a loop diuretic for a client.
5. Nurse Betty is assigned to the following clients. The When administering this drug, the nurse anticipates
client that the nurse would see first after endorsement? that the client may develop which electrolyte
imbalance?
A. A 34 year-old post operative appendectomy
client of five hours who is complaining of pain. A. Hypernatremia
 B. Hyperkalemia D. Apply lotion or oil to the radiated area when it
is red or sore.
C. Hypokalemia
17.In assisting a female client for immediate surgery,
D. Hypervolemia
the nurse In-charge is aware that she should:
11.She finds out that some managers have benevolent-
A. Encourage the client to void following
authoritative style of management. Which of the
preoperative medication.
following behaviors will she exhibit most likely?
B. Explore the client’s fears and anxieties about
A. Have condescending trust and confidence in
the surgery.
their subordinates.
C. Assist the client in removing dentures and nail
B. Gives economic and ego awards.
polish.
C. Communicates downward to staffs.
D. Encourage the client to drink water prior to
D. Allows decision making among subordinates. surgery.

12. Nurse Amy is aware that the following is true about 18. A male client is admitted and diagnosed with acute
functional nursing pancreatitis after a holiday celebration of excessive
food and alcohol. Which assessment finding reflects this
A. Provides continuous, coordinated and diagnosis?
comprehensive nursing services.
A. Blood pressure above normal range.
B. One-to-one nurse patient ratio.
B. Presence of crackles in both lung fields.
C. Emphasize the use of group collaboration.
C. Hyperactive bowel sounds
D. Concentrates on tasks and activities.
D. Sudden onset of continuous epigastric and back
13.Which type of medication order might read “Vitamin pain.
K 10 mg I.M. daily × 3 days?”
19. Which dietary guidelines are important for nurse
A. Single order Oliver to implement in caring for the client with burns?
B. Standard written order A. Provide high-fiber, high-fat diet
C. Standing order B. Provide high-protein, high-carbohydrate diet.
D. Stat order C. Monitor intake to prevent weight gain.
14.A female client with a fecal impaction frequently D. Provide ice chips or water intake.
exhibits which clinical manifestation?
20.Nurse Hazel will administer a unit of whole blood,
A. Increased appetite which priority information should the nurse have about
B. Loss of urge to defecate the client?

C. Hard, brown, formed stools A. Blood pressure and pulse rate.

D. Liquid or semi-liquid stools B. Height and weight.

15.Nurse Linda prepares to perform an otoscopic C. Calcium and potassium levels

examination on a female client. For proper visualization, D. Hgb and Hct levels.
the nurse should position the client’s ear by:
21. Nurse Michelle witnesses a female client sustain a
A. Pulling the lobule down and back fall and suspects that the leg may be broken. The nurse
B. Pulling the helix up and forward takes which priority action?

C. Pulling the helix up and back A. Takes a set of vital signs.

D. Pulling the lobule down and forward B. Call the radiology department for X-ray.

16. Which instruction should nurse Tom give to a male C. Reassure the client that everything will be
client who is having external radiation therapy: alright.

A. Protect the irritated skin from sunlight. D. Immobilize the leg before moving the client.

B. Eat 3 to 4 hours before treatment. 22.A male client is being transferred to the nursing unit
for admission after receiving a radium implant for
C. Wash the skin over regularly.
bladder cancer. The nurse in-charge would take which B. 55 cc/ hour
priority action in the care of this client?
C. 24 cc/ hour
A. Place client on reverse isolation.
D. 66 cc/ hour
B. Admit the client into a private room.
28.The nurse is aware that the most important nursing
C. Encourage the client to take frequent rest action when a client returns from surgery is:
periods.
A. Assess the IV for type of fluid and rate of flow.
D. Encourage family and friends to visit.
B. Assess the client for presence of pain.
23.A newly admitted female client was diagnosed with
C. Assess the Foley catheter for patency and urine
agranulocytosis. The nurse formulates which priority
output
nursing diagnosis?
D. Assess the dressing for drainage.
A. Constipation
29. Which of the following vital sign assessments that
B. Diarrhea
may indicate cardiogenic shock after myocardial
C. Risk for infection infarction?

D. Deficient knowledge A. BP – 80/60, Pulse – 110 irregular

24.A male client is receiving total parenteral nutrition B. BP – 90/50, Pulse – 50 regular
suddenly demonstrates signs and symptoms of an air
C. BP – 130/80, Pulse – 100 regular
embolism. What is the priority action by the nurse?
D. BP – 180/100, Pulse – 90 irregular
A. Notify the physician.
30.Which is the most appropriate nursing action in
B. Place the client on the left side in the
obtaining a blood pressure measurement?
Trendelenburg position.
A. Take the proper equipment, place the client in a
C. Place the client in high-Fowlers position.
comfortable position, and record the
D. Stop the total parenteral nutrition. appropriate information in the client’s chart.

25.Nurse May attends an educational conference on B. Measure the client’s arm, if you are not sure of
leadership styles. The nurse is sitting with a nurse the size of cuff to use.
employed at a large trauma center who states that the
C. Have the client recline or sit comfortably in a
leadership style at the trauma center is task-oriented
chair with the forearm at the level of the heart.
and directive. The nurse determines that the leadership
style used at the trauma center is: D. Document the measurement, which extremity
was used, and the position that the client was in
A. Autocratic.
during the measurement.
B. Laissez-faire.
31.Asking the questions to determine if the person
C. Democratic. understands the health teaching provided by the nurse
would be included during which step of the nursing
D. Situational
process?
26.The physician orders DS 500 cc with KCl 10 mEq/liter
A. Assessment
at 30 cc/hr. The nurse in-charge is going to hang a 500
cc bag. KCl is supplied 20 mEq/10 cc. How many cc’s of B. Evaluation
KCl will be added to the IV solution?
C. Implementation
A. .5 cc
D. Planning and goals
B. 5 cc
32.Which of the following item is considered the single
C. 1.5 cc most important factor in assisting the health
professional in arriving at a diagnosis or determining the
D. 2.5 cc
person’s needs?
27.A child of 10 years old is to receive 400 cc of IV fluid
A. Diagnostic test results
in an 8 hour shift. The IV drip factor is 60. The IV rate
that will deliver this amount is: B. Biographical date

A. 50 cc/ hour C. History of present illness

 D. Physical examination 38. A male client with diabetes mellitus is receiving
insulin. Which statement correctly describes an insulin
33.In preventing the development of an external
unit?
rotation deformity of the hip in a client who must
remain in bed for any period of time, the most A. It’s a common measurement in the metric
appropriate nursing action would be to use: system.

A. Trochanter roll extending from the crest of the B. It’s the basis for solids in the avoirdupois
ileum to the midthigh. system.

B. Pillows under the lower legs. C. It’s the smallest measurement in the
apothecary system.
C. Footboard
D. It’s a measure of effect, not a standard measure
D. Hip-abductor pillow
of weight or quantity.
34.Which stage of pressure ulcer development does the
39.Nurse Oliver measures a client’s temperature at 102°
ulcer extend into the subcutaneous tissue?
F. What is the equivalent Centigrade temperature?
A. Stage I
A. 40.1 °C
B. Stage II
B. 38.9 °C
C. Stage III
C. 48 °C
D. Stage IV
D. 38 °C
35.When the method of wound healing is one in which
40.The nurse is assessing a 48-year-old client who has
wound edges are not surgically approximated and
come to the physician’s office for his annual physical
integumentary continuity is restored by granulations,
exam. One of the first physical signs of aging is:
the wound healing is termed
A. Accepting limitations while developing assets.
A. Second intention healing
B. Increasing loss of muscle tone.
B. Primary intention healing
C. Failing eyesight, especially close vision.
C. Third intention healing
D. Having more frequent aches and pains.
D. First intention healing
41.The physician inserts a chest tube into a female
36.An 80-year-old male client is admitted to the hospital
client to treat a pneumothorax. The tube is connected
with a diagnosis of pneumonia. Nurse Oliver learns that
to water-seal drainage. The nurse in-charge can prevent
the client lives alone and hasn’t been eating or drinking.
chest tube air leaks by:
When assessing him for dehydration, nurse Oliver
would expect to find: A. Checking and taping all connections.

A. Hypothermia B. Checking patency of the chest tube.

B. Hypertension C. Keeping the head of the bed slightly elevated.

C. Distended neck veins D. Keeping the chest drainage system below the
level of the chest.
D. Tachycardia
42.Nurse Trish must verify the client’s identity before
37.The physician prescribes meperidine (Demerol), 75
administering medication. She is aware that the safest
mg I.M. every 4 hours as needed, to control a client’s
way to verify identity is to:
postoperative pain. The package insert is “Meperidine,
100 mg/ml.” How many milliliters of meperidine should A. Check the client’s identification band.
the
B. Ask the client to state his name.
client receive?
C. State the client’s name out loud and wait a
A. 0.75
client to repeat it.
B. 0.6
D. Check the room number and the client’s name
C. 0.5 on the bed.

D. 0.25 43.The physician orders dextrose 5 % in water, 1,000 ml

to be infused over 8 hours. The I.V. tubing delivers 15
drops/ml. Nurse John should run the I.V. infusion at a 49.A male client has the following arterial blood gas
rate of: values: pH 7.30; Pao2 89 mmHg; Paco2 50 mmHg; and
HCO3 26mEq/L. Based on these values, Nurse Patricia
A. 30 drops/minute
should expect which condition?
B. 32 drops/minute
A. Respiratory acidosis
C. 20 drops/minute
B. Respiratory alkalosis
D. 18 drops/minute
C. Metabolic acidosis
44.If a central venous catheter becomes disconnected
D. Metabolic alkalosis
accidentally, what should the nurse in-charge do
immediately? 50.Nurse Len refers a female client with terminal cancer
to a local hospice. What is the goal of this referral?
A. Clamp the catheter
A. To help the client find appropriate treatment
B. Call another nurse
options.
C. Call the physician
B. To provide support for the client and family in
D. Apply a dry sterile dressing to the site. coping with terminal illness.

45.A female client was recently admitted. She has fever, C. To ensure that the client gets counseling
weight loss, and watery diarrhea is being admitted to regarding health care costs.
the facility. While assessing the client, Nurse Hazel
D. To teach the client and family about cancer and
inspects the client’s abdomen and notice that it is
its treatment.
slightly concave. Additional assessment should proceed
in which order: 51.When caring for a male client with a 3-cm stage I
pressure ulcer on the coccyx, which of the following
A. Palpation, auscultation, and percussion.
actions can the nurse institute independently?
B. Percussion, palpation, and auscultation.
A. Massaging the area with an astringent every 2
C. Palpation, percussion, and auscultation. hours.

D. Auscultation, percussion, and palpation. B. Applying an antibiotic cream to the area three
times per day.
46. Nurse Betty is assessing tactile fremitus in a client
with pneumonia. For this examination, nurse Betty C. Using normal saline solution to clean the ulcer
should use the: and applying a protective dressing as necessary.

A. Fingertips D. Using a povidone-iodine wash on the ulceration

three times per day.
B. Finger pads
52.Nurse Oliver must apply an elastic bandage to a
C. Dorsal surface of the hand client’s ankle and calf. He should apply the bandage
D. Ulnar surface of the hand beginning at the client’s:

47. Which type of evaluation occurs continuously A. Knee

throughout the teaching and learning process? B. Ankle
A. Summative C. Lower thigh
B. Informative D. Foot
C. Formative 53.A 10 year old child with type 1 diabetes develops
D. Retrospective diabetic ketoacidosis and receives a continuous insulin
infusion. Which condition represents the greatest risk to
48.A 45 year old client, has no family history of breast this child?
cancer or other risk factors for this disease. Nurse John
should instruct her to have mammogram how often? A. Hypernatremia

A. Twice per year B. Hypokalemia

B. Once per year C. Hyperphosphatemia

C. Every 2 years D. Hypercalcemia

D. Once, to establish baseline

54.Nurse Len is administering sublingual nitrglycerin 59.Nurse Meredith is in the process of giving a client a
(Nitrostat) to the newly admitted client. Immediately bed bath. In the middle of the procedure, the unit
afterward, the client may experience: secretary calls the nurse on the intercom to tell the
nurse that there is an emergency phone call. The
A. Throbbing headache or dizziness
appropriate nursing action is to:
B. Nervousness or paresthesia.
A. Immediately walk out of the client’s room and
C. Drowsiness or blurred vision. answer the phone call.

D. Tinnitus or diplopia. B. Cover the client, place the call light within
reach, and answer the phone call.
55.Nurse Michelle hears the alarm sound on the
telemetry monitor. The nurse quickly looks at the C. Finish the bed bath before answering the phone
monitor and notes that a client is in a ventricular call.
tachycardia. The nurse rushes to the client’s room.
D. Leave the client’s door open so the client can be
Upon reaching the client’s bedside, the nurse would
monitored and the nurse can answer the phone
take which action first?
call.
A. Prepare for cardioversion
60. Nurse Janah is collecting a sputum specimen for
B. Prepare to defibrillate the client culture and sensitivity testing from a client who has a
productive cough. Nurse Janah plans to implement
C. Call a code which intervention to obtain the specimen?
D. Check the client’s level of consciousness A. Ask the client to expectorate a small amount of
56.Nurse Hazel is preparing to ambulate a female client. sputum into the emesis basin.
The best and the safest position for the nurse in B. Ask the client to obtain the specimen after
assisting the client is to stand: breakfast.
A. On the unaffected side of the client. C. Use a sterile plastic container for obtaining the
B. On the affected side of the client. specimen.

C. In front of the client. D. Provide tissues for expectoration and obtaining

the specimen.
D. Behind the client.
61. Nurse Ron is observing a male client using a walker.
57.Nurse Janah is monitoring the ongoing care given to The nurse determines that the client is using the walker
the potential organ donor who has been diagnosed with correctly if the client:
brain death. The nurse determines that the standard of
care had been maintained if which of the following data A. Puts all the four points of the walker flat on the
is observed? floor, puts weight on the hand pieces, and then
walks into it.
A. Urine output: 45 ml/hr
B. Puts weight on the hand pieces, moves the
B. Capillary refill: 5 seconds walker forward, and then walks into it.
C. Serum pH: 7.32 C. Puts weight on the hand pieces, slides the
D. Blood pressure: 90/48 mmHg walker forward, and then walks into it.

58. Nurse Amy has an order to obtain a urinalysis from a D. Walks into the walker, puts weight on the hand
male client with an indwelling urinary catheter. The pieces, and then puts all four points of the
nurse avoids which of the following, which contaminate walker flat on the floor.
the specimen? 62.Nurse Amy has documented an entry regarding
A. Wiping the port with an alcohol swab before client care in the client’s medical record. When checking
inserting the syringe. the entry, the nurse realizes that incorrect information
was documented. How does the nurse correct this
B. Aspirating a sample from the port on the error?
drainage bag.
A. Erases the error and writes in the correct
C. Clamping the tubing of the drainage bag. information.
D. Obtaining the specimen from the urinary B. Uses correction fluid to cover up the incorrect
drainage bag. information and writes in the correct
information.
 C. Draws one line to cross out the incorrect 67.Nurse John develops methods for data gathering.
information and then initials the change. Which of the following criteria of a good instrument
refers to the ability of the instrument to yield the same
D. Covers up the incorrect information completely
results upon its repeated administration?
using a black pen and writes in the correct
information A. Validity

63.Nurse Ron is assisting with transferring a client from B. Specificity

the operating room table to a stretcher. To provide
C. Sensitivity
safety to the client, the nurse should:
D. Reliability
A. Moves the client rapidly from the table to the
stretcher. 68.Harry knows that he has to protect the rights of
human research subjects. Which of the following
B. Uncovers the client completely before
actions of Harry ensures anonymity?
transferring to the stretcher.
A. Keep the identities of the subject secret
C. Secures the client safety belts after transferring
to the stretcher. B. Obtain informed consent
D. Instructs the client to move self from the table C. Provide equal treatment to all the subjects of
to the stretcher. the study.
64.Nurse Myrna is providing instructions to a nursing D. Release findings only to the participants of the
assistant assigned to give a bed bath to a client who is study
on contact precautions. Nurse Myrna instructs the
nursing assistant to use which of the following 69.Patient’s refusal to divulge information is a limitation
protective items when giving bed bath? because it is beyond the control of Tifanny”. What type
of research is appropriate for this study?
A. Gown and goggles
A. Descriptive- correlational
B. Gown and gloves
B. Experiment
C. Gloves and shoe protectors
C. Quasi-experiment
D. Gloves and goggles
D. Historical
65. Nurse Oliver is caring for a client with impaired
mobility that occurred as a result of a stroke. The client 70.Nurse Ronald is aware that the best tool for data
has right sided arm and leg weakness. The nurse would gathering is?
suggest that the client use which of the following A. Interview schedule
assistive devices that would provide the best stability
for ambulating? B. Questionnaire

A. Crutches C. Use of laboratory data

B. Single straight-legged cane D. Observation

C. Quad cane 71.Monica is aware that there are times when only
manipulation of study variables is possible and the
D. Walker elements of control or randomization are not attendant.
66.A male client with a right pleural effusion noted on a Which type of research is referred to this?
chest X-ray is being prepared for thoracentesis. The A. Field study
client experiences severe dizziness when sitting upright.
To provide a safe environment, the nurse assists the B. Quasi-experiment
client to which position for the procedure? C. Solomon-Four group design
A. Prone with head turned toward the side D. Post-test only design
supported by a pillow.
72.Cherry notes down ideas that were derived from the
B. Sims’ position with the head of the bed flat. description of an investigation written by the person
C. Right side-lying with the head of the bed who conducted it. Which type of reference source
elevated 45 degrees. refers to this?

D. Left side-lying with the head of the bed A. Footnote

elevated 45 degrees. B. Bibliography
 C. Primary source C. Formulating and delimiting the research
problem
D. Endnotes
D. Design the theoretical and conceptual
73.When Nurse Trish is providing care to his patient, she
framework
must remember that her duty is bound not to do doing
any action that will cause the patient harm. This is the 78. The leader of the study knows that certain patients
meaning of the bioethical principle: who are in a specialized research setting tend to
respond psychologically to the conditions of the study.
A. Non-maleficence
This referred to as :
B. Beneficence
A. Cause and effect
C. Justice
B. Hawthorne effect
D. Solidarity
C. Halo effect
74.When a nurse in-charge causes an injury to a female
D. Horns effect
patient and the injury caused becomes the proof of the
negligent act, the presence of the injury is said to 79.Mary finally decides to use judgment sampling on
exemplify the principle of: her research. Which of the following actions of is
correct?
A. Force majeure
A. Plans to include whoever is there during his
B. Respondeat superior
study.
C. Res ipsa loquitor
B. Determines the different nationality of patients
D. Holdover doctrine frequently admitted and decides to get
representations samples from each.
75.Nurse Myrna is aware that the Board of Nursing has
quasi-judicial power. An example of this power is: C. Assigns numbers for each of the patients, place
these in a fishbowl and draw 10 from it.
A. The Board can issue rules and regulations that
will govern the practice of nursing D. Decides to get 20 samples from the admitted
patients
B. The Board can investigate violations of the
nursing law and code of ethics 80. The nursing theorist who developed transcultural
nursing theory is:
C. The Board can visit a school applying for a
permit in collaboration with CHED A. Florence Nightingale

D. The Board prepares the board examinations B. Madeleine Leininger

76. When the license of nurse Krina is revoked, it means C. Albert Moore
that she:
D. Sr. Callista Roy
A. Is no longer allowed to practice the profession
81.Marion is aware that the sampling method that gives
for the rest of her life
equal chance to all units in the population to get picked
B. Will never have her/his license re-issued since it is:
has been revoked
A. Random
C. May apply for re-issuance of his/her license
B. Accidental
based on certain conditions stipulated in RA
9173 C. Quota

D. Will remain unable to practice professional D. Judgment

nursing
82.John plans to use a Likert Scale to his study to
77.Ronald plans to conduct a research on the use of a determine the:
new method of pain assessment scale. Which of the
A. Degree of agreement and disagreement
following is the second step in the conceptualizing
phase of the research process? B. Compliance to expected standards
A. Formulating the research hypothesis C. Level of satisfaction
B. Review related literature D. Degree of acceptance
83.Which of the following theory addresses the four A. Arrange for typing and cross matching of the
modes of adaptation? client’s blood.

A. Madeleine Leininger B. Compare the client’s identification wristband

with the tag on the unit of blood.
B. Sr. Callista Roy
C. Start an I.V. infusion of normal saline solution.
C. Florence Nightingale
D. Measure the client’s vital signs.
D. Jean Watson
90.A 65 years old male client requests his medication at
84.Ms. Garcia is responsible to the number of personnel
9 p.m. instead of 10 p.m. so that he can go to sleep
reporting to her. This principle refers to:
earlier. Which type of nursing intervention is required?
A. Span of control
A. Independent
B. Unity of command
B. Dependent
C. Downward communication
C. Interdependent
D. Leader
D. Intradependent
85.Ensuring that there is an informed consent on the
91.A female client is to be discharged from an acute
part of the patient before a surgery is done, illustrates
care facility after treatment for right leg
the bioethical principle of:
thrombophlebitis. The Nurse Betty notes that
A. Beneficence the client’s leg is pain-free, without redness or edema.
The nurse’s actions reflect which step of the nursing
B. Autonomy process?
C. Veracity A. Assessment
D. Non-maleficence B. Diagnosis
86.Nurse Reese is teaching a female client with C. Implementation
peripheral vascular disease about foot care; Nurse
Reese should include which instruction? D. Evaluation

A. Avoid wearing cotton socks. 92.Nursing care for a female client includes removing
elastic stockings once per day. The Nurse Betty is aware
B. Avoid using a nail clipper to cut toenails. that the rationale for this intervention?
C. Avoid wearing canvas shoes. A. To increase blood flow to the heart
D. Avoid using cornstarch on feet. B. To observe the lower extremities
87.A client is admitted with multiple pressure ulcers. C. To allow the leg muscles to stretch and relax
When developing the client’s diet plan, the nurse should
include: D. To permit veins in the legs to fill with blood.

A. Fresh orange slices 93.Which nursing intervention takes highest priority

when caring for a newly admitted client who’s receiving
B. Steamed broccoli a blood transfusion?
C. Ice cream A. Instructing the client to report any itching,
D. Ground beef patties swelling, or dyspnea.

88.The nurse prepares to administer a cleansing enema. B. Informing the client that the transfusion usually
What is the most common client position used for this take 1 ½ to 2 hours.
procedure? C. Documenting blood administration in the client
A. Lithotomy care record.

B. Supine D. Assessing the client’s vital signs when the

transfusion ends.
C. Prone
94.A male client complains of abdominal discomfort and
D. Sims’ left lateral nausea while receiving tube feedings. Which
89.Nurse Marian is preparing to administer a blood intervention is most appropriate for this problem?
transfusion. Which action should the nurse take first? A. Give the feedings at room temperature.
 B. Decrease the rate of feedings and the D. The system reinforces accurate calculations.
concentration of the formula.
100. Nurse Oliver is assessing a client’s abdomen. Which
C. Place the client in semi-Fowler’s position while finding should the nurse report as abnormal?
feeding.
A. Dullness over the liver.
D. Change the feeding container every 12 hours.
B. Bowel sounds occurring every 10 seconds.
95.Nurse Patricia is reconstituting a powdered
C. Shifting dullness over the abdomen.
medication in a vial. After adding the solution to the
powder, she nurse should: D. Vascular sounds heard over the renal arteries.
A. Do nothing.

B. Invert the vial and let it stand for 3 to 5

minutes.

C. Shake the vial vigorously.

D. Roll the vial gently between the palms.

96.Which intervention should the nurse Trish use when

administering oxygen by face mask to a female client?

A. Secure the elastic band tightly around the

client’s head.

B. Assist the client to the semi-Fowler position if

possible.

C. Apply the face mask from the client’s chin up

over the nose.

D. Loosen the connectors between the oxygen

equipment and humidifier.

97.The maximum transfusion time for a unit of packed

red blood cells (RBCs) is:

A. 6 hours

B. 4 hours

C. 3 hours

D. 2 hours

98.Nurse Monique is monitoring the effectiveness of a

client’s drug therapy. When should the nurse Monique
obtain a blood sample to measure the trough drug
level?

A. 1 hour before administering the next dose.

B. Immediately before administering the next

dose.

C. Immediately after administering the next dose.

D. 30 minutes after administering the next dose.

99.Nurse May is aware that the main advantage of using

a floor stock system is:

A. The nurse can implement medication orders

quickly.

B. The nurse receives input from the pharmacist.

C. The system minimizes transcription errors.

PNLE II for Community Health Nursing and Care of the C. Vaginal bleeding
Mother and Child
D. Elevated levels of human chorionic
1. May arrives at the health care clinic and tells the gonadotropin.
nurse that her last menstrual period was 9 weeks ago.
6. A pregnant client is receiving magnesium sulfate for
She also tells the nurse that a home pregnancy test was
severe pregnancy induced hypertension (PIH). The
positive but she began to have mild cramps and is now
clinical findings that would warrant use of the antidote ,
having moderate vaginal bleeding. During the physical
calcium gluconate is:
examination of the client, the nurse notes that May has
a dilated cervix. The nurse determines that May is A. Urinary output 90 cc in 2 hours.
experiencing which type of abortion?
B. Absent patellar reflexes.
A. Inevitable
C. Rapid respiratory rate above 40/min.
B. Incomplete
D. Rapid rise in blood pressure.
C. Threatened
7. During vaginal examination of Janah who is in labor,
D. Septic the presenting part is at station plus two. Nurse,
correctly interprets it as:
2. Nurse Reese is reviewing the record of a pregnant
client for her first prenatal visit. Which of the following A. Presenting part is 2 cm above the plane of the
data, if noted on the client’s record, would alert the ischial spines.
nurse that the client is at risk for a spontaneous
abortion? B. Biparietal diameter is at the level of the ischial
spines.
A. Age 36 years
C. Presenting part in 2 cm below the plane of the
B. History of syphilis ischial spines.
C. History of genital herpes D. Biparietal diameter is 2 cm above the ischial
spines.
D. History of diabetes mellitus
8. A pregnant client is receiving oxytocin (Pitocin) for
3. Nurse Hazel is preparing to care for a client who is
induction of labor. A condition that warrant the nurse
newly admitted to the hospital with a possible diagnosis
in-charge to discontinue I.V. infusion of Pitocin is:
of ectopic pregnancy. Nurse Hazel develops a plan of
care for the client and determines that which of the A. Contractions every 1 ½ minutes lasting 70-80
following nursing actions is the priority? seconds.
A. Monitoring weight B. Maternal temperature 101.2
B. Assessing for edema C. Early decelerations in the fetal heart rate.
C. Monitoring apical pulse D. Fetal heart rate baseline 140-160 bpm.
D. Monitoring temperature 9. Calcium gluconate is being administered to a client
with pregnancy induced hypertension (PIH). A nursing
4. Nurse Oliver is teaching a diabetic pregnant client
action that must be initiated as the plan of care
about nutrition and insulin needs during pregnancy. The
throughout injection of the drug is:
nurse determines that the client understands dietary
and insulin needs if the client states that the second half A. Ventilator assistance
of pregnancy require:
B. CVP readings
A. Decreased caloric intake
C. EKG tracings
B. Increased caloric intake
D. Continuous CPR
C. Decreased Insulin
10. A trial for vaginal delivery after an earlier
D. Increase Insulin caesareans, would likely to be given to a gravida, who
had:
5. Nurse Michelle is assessing a 24 year old client with a
diagnosis of hydatidiform mole. She is aware that one of A. First low transverse cesarean was for active
the following is unassociated with this condition? herpes type 2 infections; vaginal culture at 39
weeks pregnancy was positive.
A. Excessive fetal activity.
B. First and second caesareans were for
B. Larger than normal uterus for gestational age.
cephalopelvic disproportion.
 C. First caesarean through a classic incision as a 16.Which of the following is the most prominent
result of severe fetal distress. feature of public health nursing?

D. First low transverse caesarean was for breech A. It involves providing home care to sick people
position. Fetus in this pregnancy is in a vertex who are not confined in the hospital.
presentation.
B. Services are provided free of charge to people
11.Nurse Ryan is aware that the best initial approach within the catchments area.
when trying to take a crying toddler’s temperature is:
C. The public health nurse functions as part of a
A. Talk to the mother first and then to the toddler. team providing a public health nursing services.

B. Bring extra help so it can be done quickly. D. Public health nursing focuses on preventive, not
curative, services.
C. Encourage the mother to hold the child.
17.When the nurse determines whether resources were
D. Ignore the crying and screaming.
maximized in implementing Ligtas Tigdas, she is
12.Baby Tina a 3 month old infant just had a cleft lip and evaluating
palate repair. What should the nurse do to prevent
A. Effectiveness
trauma to operative site?
B. Efficiency
A. Avoid touching the suture line, even when
cleaning. C. Adequacy

B. Place the baby in prone position. D. Appropriateness

C. Give the baby a pacifier. 18.Vangie is a new B.S.N. graduate. She wants to
become a Public Health Nurse. Where should she apply?
D. Place the infant’s arms in soft elbow restraints.
A. Department of Health
13. Which action should nurse Marian include in the
care plan for a 2 month old with heart failure? B. Provincial Health Office

A. Feed the infant when he cries. C. Regional Health Office

B. Allow the infant to rest before feeding. D. Rural Health Unit

C. Bathe the infant and administer medications 19.Tony is aware the Chairman of the Municipal Health
before feeding. Board is:

D. Weigh and bathe the infant before feeding. A. Mayor

14.Nurse Hazel is teaching a mother who plans to B. Municipal Health Officer

discontinue breast feeding after 5 months. The nurse
C. Public Health Nurse
should advise her to include which foods in her infant’s
diet? D. Any qualified physician
A. Skim milk and baby food. 20.Myra is the public health nurse in a municipality with
a total population of about 20,000. There are 3 rural
B. Whole milk and baby food.
health midwives among the RHU personnel. How many
C. Iron-rich formula only. more midwife items will the RHU need?

D. Iron-rich formula and baby food. A. 1

15.Mommy Linda is playing with her infant, who is B. 2

sitting securely alone on the floor of the clinic. The
C. 3
mother hides a toy behind her back and the infant looks
for it. The nurse is aware that estimated age of the D. The RHU does not need any more midwife item.
infant would be:
21.According to Freeman and Heinrich, community
A. 6 months health nursing is a developmental service. Which of the
following best illustrates this statement?
B. 4 months
A. The community health nurse continuously
C. 8 months
develops himself personally and professionally.
D. 10 months
 B. Health education and community organizing are B. Placenta accreta.
necessary in providing community health
C. Dysfunctional labor.
services.
D. Premature rupture of the membranes.
C. Community health nursing is intended primarily
for health promotion and prevention and 27.A fullterm client is in labor. Nurse Betty is aware that
treatment of disease. the fetal heart rate would be:
D. The goal of community health nursing is to A. 80 to 100 beats/minute
provide nursing services to people in their own
places of residence. B. 100 to 120 beats/minute

22.Nurse Tina is aware that the disease declared C. 120 to 160 beats/minute
through Presidential Proclamation No. 4 as a target for D. 160 to 180 beats/minute
eradication in the Philippines is?
28.The skin in the diaper area of a 7 month old infant is
A. Poliomyelitis excoriated and red. Nurse Hazel should instruct the
B. Measles mother to:

C. Rabies A. Change the diaper more often.

D. Neonatal tetanus B. Apply talc powder with diaper changes.

23.May knows that the step in community organizing C. Wash the area vigorously with each diaper
that involves training of potential leaders in the change.
community is: D. Decrease the infant’s fluid intake to decrease
A. Integration saturating diapers.

B. Community organization 29.Nurse Carla knows that the common cardiac

anomalies in children with Down Syndrome (tri-somy
C. Community study 21) is:
D. Core group formation A. Atrial septal defect
24.Beth a public health nurse takes an active role in B. Pulmonic stenosis
community participation. What is the primary goal of
community organizing? C. Ventricular septal defect

A. To educate the people regarding community D. Endocardial cushion defect

health problems 30.Malou was diagnosed with severe preeclampsia is
B. To mobilize the people to resolve community now receiving I.V. magnesium sulfate. The adverse
health problems effects associated with magnesium sulfate is:

C. To maximize the community’s resources in A. Anemia

dealing with health problems. B. Decreased urine output
D. To maximize the community’s resources in C. Hyperreflexia
dealing with health problems.
D. Increased respiratory rate
25.Tertiary prevention is needed in which stage of the
natural history of disease? 31.A 23 year old client is having her menstrual period
every 2 weeks that last for 1 week. This type of
A. Pre-pathogenesis menstrual pattern is bets defined by:
B. Pathogenesis A. Menorrhagia
C. Prodromal B. Metrorrhagia
D. Terminal C. Dyspareunia
26.The nurse is caring for a primigravid client in the D. Amenorrhea
labor and delivery area. Which condition would place
the client at risk for disseminated intravascular 32. Jannah is admitted to the labor and delivery unit.
coagulation (DIC)? The critical laboratory result for this client would be:

A. Intrauterine fetal death. A. Oxygen saturation

B. Iron binding capacity

 C. Blood typing 38.To evaluate a woman’s understanding about the use
of diaphragm for family planning, Nurse Trish asks her
D. Serum Calcium
to explain how she will use the appliance. Which
33.Nurse Gina is aware that the most common response indicates a need for further health teaching?
condition found during the second-trimester of
A. “I should check the diaphragm carefully for
pregnancy is:
holes every time I use it”
A. Metabolic alkalosis
B. “I may need a different size of diaphragm if I
B. Respiratory acidosis gain or lose weight more than 20 pounds”

C. Mastitis C. “The diaphragm must be left in place for atleast

6 hours after intercourse”
D. Physiologic anemia
D. “I really need to use the diaphragm and jelly
34.Nurse Lynette is working in the triage area of an most during the middle of my menstrual cycle”.
emergency department. She sees that several pediatric
clients arrive simultaneously. The client who needs to 39.Hypoxia is a common complication of
be treated first is: laryngotracheobronchitis. Nurse Oliver should
frequently assess a child with laryngotracheobronchitis
A. A crying 5 year old child with a laceration on his for:
scalp.
A. Drooling
B. A 4 year old child with a barking coughs and
flushed appearance. B. Muffled voice

C. A 3 year old child with Down syndrome who is C. Restlessness

pale and asleep in his mother’s arms.
D. Low-grade fever
D. A 2 year old infant with stridorous breath
40.How should Nurse Michelle guide a child who is blind
sounds, sitting up in his mother’s arms and
to walk to the playroom?
drooling.
A. Without touching the child, talk continuously as
35.Maureen in her third trimester arrives at the
the child walks down the hall.
emergency room with painless vaginal bleeding. Which
of the following conditions is suspected? B. Walk one step ahead, with the child’s hand on
the nurse’s elbow.
A. Placenta previa
C. Walk slightly behind, gently guiding the child
B. Abruptio placentae
forward.
C. Premature labor
D. Walk next to the child, holding the child’s hand.
D. Sexually transmitted disease
41.When assessing a newborn diagnosed with ductus
36.A young child named Richard is suspected of having arteriosus, Nurse Olivia should expect that the child
pinworms. The community nurse collects a stool most likely would have an:
specimen to confirm the diagnosis. The nurse should
A. Loud, machinery-like murmur.
schedule the collection of this specimen for:
B. Bluish color to the lips.
A. Just before bedtime
C. Decreased BP reading in the upper extremities
B. After the child has been bathe
D. Increased BP reading in the upper extremities.
C. Any time during the day
42.The reason nurse May keeps the neonate in a
D. Early in the morning
neutral thermal environment is that when a newborn
37.In doing a child’s admission assessment, Nurse Betty becomes too cool, the neonate requires:
should be alert to note which signs or symptoms of
A. Less oxygen, and the newborn’s metabolic rate
chronic lead poisoning?
increases.
A. Irritability and seizures
B. More oxygen, and the newborn’s metabolic rate
B. Dehydration and diarrhea decreases.

C. Bradycardia and hypotension C. More oxygen, and the newborn’s metabolic rate
increases.
D. Petechiae and hematuria
 D. Less oxygen, and the newborn’s metabolic rate D. Consult a physician who may give them rubella
decreases. immunoglobulin.

43.Before adding potassium to an infant’s I.V. line, 48.Myrna a public health nurse knows that to
Nurse Ron must be sure to assess whether this infant determine possible sources of sexually transmitted
has: infections, the BEST method that may be undertaken is:

A. Stable blood pressure A. Contact tracing

B. Patant fontanelles B. Community survey

C. Moro’s reflex C. Mass screening tests

D. Voided D. Interview of suspects

44.Nurse Carla should know that the most common 49.A 33-year old female client came for consultation at
causative factor of dermatitis in infants and younger the health center with the chief complaint of fever for a
children is: week. Accompanying symptoms were muscle pains and
body malaise. A week after the start of fever, the client
A. Baby oil
noted yellowish discoloration of his sclera. History
B. Baby lotion showed that he waded in flood waters about 2 weeks
before the onset of symptoms. Based on her history,
C. Laundry detergent which disease condition will you suspect?
D. Powder with cornstarch A. Hepatitis A
45.During tube feeding, how far above an infant’s B. Hepatitis B
stomach should the nurse hold the syringe with
formula? C. Tetanus

A. 6 inches D. Leptospirosis

B. 12 inches 50.Mickey a 3-year old client was brought to the health

center with the chief complaint of severe diarrhea and
C. 18 inches the passage of “rice water” stools. The client is most
D. 24 inches probably suffering from which condition?

46. In a mothers’ class, Nurse Lhynnete discussed A. Giardiasis

childhood diseases such as chicken pox. Which of the B. Cholera
following statements about chicken pox is correct?
C. Amebiasis
A. The older one gets, the more susceptible he
becomes to the complications of chicken pox. D. Dysentery

B. A single attack of chicken pox will prevent 51.The most prevalent form of meningitis among
future episodes, including conditions such as children aged 2 months to 3 years is caused by which
shingles. microorganism?

C. To prevent an outbreak in the community, A. Hemophilus influenzae

quarantine may be imposed by health
B. Morbillivirus
authorities.
C. Steptococcus pneumoniae
D. Chicken pox vaccine is best given when there is
an impending outbreak in the community. D. Neisseria meningitidis

47.Barangay Pinoy had an outbreak of German measles. 52.The student nurse is aware that the pathognomonic
To prevent congenital rubella, what is the BEST advice sign of measles is Koplik’s spot and you may see Koplik’s
that you can give to women in the first trimester of spot by inspecting the:
pregnancy in the barangay Pinoy?
A. Nasal mucosa
A. Advice them on the signs of German measles.
B. Buccal mucosa
B. Avoid crowded places, such as markets and
C. Skin on the abdomen
movie houses.
D. Skin on neck
C. Consult at the health center where rubella
vaccine may be given. 53.Angel was diagnosed as having Dengue fever. You
will say that there is slow capillary refill when the color
of the nailbed that you pressed does not return within D. 5 skin lesions, positive slit skin smear
how many seconds?
59.Nurses are aware that diagnosis of leprosy is highly
A. 3 seconds dependent on recognition of symptoms. Which of the
following is an early sign of leprosy?
B. 6 seconds
A. Macular lesions
C. 9 seconds
B. Inability to close eyelids
D. 10 seconds
C. Thickened painful nerves
54.In Integrated Management of Childhood Illness, the
nurse is aware that the severe conditions generally D. Sinking of the nosebridge
require urgent referral to a hospital. Which of the
60.Marie brought her 10 month old infant for
following severe conditions DOES NOT always require
consultation because of fever, started 4 days prior to
urgent referral to a hospital?
consultation. In determining malaria risk, what will you
A. Mastoiditis do?

B. Severe dehydration A. Perform a tourniquet test.

C. Severe pneumonia B. Ask where the family resides.

D. Severe febrile disease C. Get a specimen for blood smear.

55.Myrna a public health nurse will conduct outreach D. Ask if the fever is present everyday.
immunization in a barangay Masay with a population of
61.Susie brought her 4 years old daughter to the RHU
about 1500. The estimated number of infants in the
because of cough and colds. Following the IMCI
barangay would be:
assessment guide, which of the following is a danger
A. 45 infants sign that indicates the need for urgent referral to a
hospital?
B. 50 infants
A. Inability to drink
C. 55 infants
B. High grade fever
D. 65 infants
C. Signs of severe dehydration
56.The community nurse is aware that the biological
used in Expanded Program on Immunization (EPI) D. Cough for more than 30 days
should NOT be stored in the freezer?
62.Jimmy a 2-year old child revealed “baggy pants”. As a
A. DPT nurse, using the IMCI guidelines, how will you manage
Jimmy?
B. Oral polio vaccine
A. Refer the child urgently to a hospital for
C. Measles vaccine
confinement.
D. MMR
B. Coordinate with the social worker to enroll the
57.It is the most effective way of controlling child in a feeding program.
schistosomiasis in an endemic area?
C. Make a teaching plan for the mother, focusing
A. Use of molluscicides on menu planning for her child.

B. Building of foot bridges D. Assess and treat the child for health problems
like infections and intestinal parasitism.
C. Proper use of sanitary toilets
63.Gina is using Oresol in the management of diarrhea
D. Use of protective footwear, such as rubber of her 3-year old child. She asked you what to do if her
boots child vomits. As a nurse you will tell her to:
58.Several clients is newly admitted and diagnosed with A. Bring the child to the nearest hospital for
leprosy. Which of the following clients should be further assessment.
classified as a case of multibacillary leprosy?
B. Bring the child to the health center for
A. 3 skin lesions, negative slit skin smear intravenous fluid therapy.
B. 3 skin lesions, positive slit skin smear C. Bring the child to the health center for
C. 5 skin lesions, negative slit skin smear assessment by the physician.
 D. Let the child rest for 10 minutes then continue A. 8 weeks
giving Oresol more slowly.
B. 12 weeks
64.Nikki a 5-month old infant was brought by his
C. 24 weeks
mother to the health center because of diarrhea for 4 to
5 times a day. Her skin goes back slowly after a skin D. 32 weeks
pinch and her eyes are sunken. Using the IMCI
guidelines, you will classify this infant in which 70.When teaching parents of a neonate the proper
category? position for the neonate’s sleep, the nurse Patricia
stresses the importance of placing the neonate on his
A. No signs of dehydration back to reduce the risk of which of the following?
B. Some dehydration A. Aspiration
C. Severe dehydration B. Sudden infant death syndrome (SIDS)
D. The data is insufficient. C. Suffocation
65.Chris a 4-month old infant was brought by her D. Gastroesophageal reflux (GER)
mother to the health center because of cough. His
respiratory rate is 42/minute. Using the Integrated 71.Which finding might be seen in baby James a
Management of Child Illness (IMCI) guidelines of neonate suspected of having an infection?
assessment, his breathing is considered as: A. Flushed cheeks
A. Fast B. Increased temperature
B. Slow C. Decreased temperature
C. Normal D. Increased activity level
D. Insignificant 72.Baby Jenny who is small-for-gestation is at increased
66.Maylene had just received her 4th dose of tetanus risk during the transitional period for which
toxoid. She is aware that her baby will have protection complication?
against tetanus for A. Anemia probably due to chronic fetal hyposia
A. 1 year B. Hyperthermia due to decreased glycogen stores
B. 3 years C. Hyperglycemia due to decreased glycogen
C. 5 years stores

D. Lifetime D. Polycythemia probably due to chronic fetal

hypoxia
67.Nurse Ron is aware that unused BCG should be
discarded after how many hours of reconstitution? 73.Marjorie has just given birth at 42 weeks’ gestation.
When the nurse assessing the neonate, which physical
A. 2 hours finding is expected?
B. 4 hours A. A sleepy, lethargic baby
C. 8 hours B. Lanugo covering the body
D. At the end of the day C. Desquamation of the epidermis
68.The nurse explains to a breastfeeding mother that D. Vernix caseosa covering the body
breast milk is sufficient for all of the baby’s nutrient
needs only up to: 74.After reviewing the Myrna’s maternal history of
magnesium sulfate during labor, which condition would
A. 5 months nurse Richard anticipate as a potential problem in the
neonate?
B. 6 months
A. Hypoglycemia
C. 1 year
B. Jitteriness
D. 2 years
C. Respiratory depression
69.Nurse Ron is aware that the gestational age of a
conceptus that is considered viable (able to live outside D. Tachycardia
the womb) is:
75.Which symptom would indicate the Baby Alexandra A. Applying cold to limit edema during the first 12
was adapting appropriately to extra-uterine life without to 24 hours.
difficulty?
B. Instructing the client to use two or more
A. Nasal flaring peripads to cushion the area.

B. Light audible grunting C. Instructing the client on the use of sitz baths if
ordered.
C. Respiratory rate 40 to 60 breaths/minute
D. Instructing the client about the importance of
D. Respiratory rate 60 to 80 breaths/minute
perineal (kegel) exercises.
76. When teaching umbilical cord care for Jennifer a
81. A pregnant woman accompanied by her husband,
new mother, the nurse Jenny would include which
seeks admission to the labor and delivery area. She
information?
states that she’s in labor and says she attended the
A. Apply peroxide to the cord with each diaper facility clinic for prenatal care. Which question should
change the nurse Oliver ask her first?

B. Cover the cord with petroleum jelly after A. “Do you have any chronic illnesses?”
bathing
B. “Do you have any allergies?”
C. Keep the cord dry and open to air
C. “What is your expected due date?”
D. Wash the cord with soap and water each day
D. “Who will be with you during labor?”
during a tub bath.
82.A neonate begins to gag and turns a dusky color.
77.Nurse John is performing an assessment on a
What should the nurse do first?
neonate. Which of the following findings is considered
common in the healthy neonate? A. Calm the neonate.

A. Simian crease B. Notify the physician.

B. Conjunctival hemorrhage C. Provide oxygen via face mask as ordered

C. Cystic hygroma D. Aspirate the neonate’s nose and mouth with a

bulb syringe.
D. Bulging fontanelle
83. When a client states that her “water broke,” which
78.Dr. Esteves decides to artificially rupture the
of the following actions would be inappropriate for the
membranes of a mother who is on labor. Following this
nurse to do?
procedure, the nurse Hazel checks the fetal heart tones
for which the following reasons? A. Observing the pooling of straw-colored fluid.

A. To determine fetal well-being. B. Checking vaginal discharge with nitrazine paper.

B. To assess for prolapsed cord C. Conducting a bedside ultrasound for an

amniotic fluid index.
C. To assess fetal position
D. Observing for flakes of vernix in the vaginal
D. To prepare for an imminent delivery.
discharge.
79.Which of the following would be least likely to
84. A baby girl is born 8 weeks premature. At birth, she
indicate anticipated bonding behaviors by new parents?
has no spontaneous respirations but is successfully
A. The parents’ willingness to touch and hold the resuscitated. Within several hours she develops
new born. respiratory grunting, cyanosis, tachypnea, nasal flaring,
and retractions. She’s diagnosed with respiratory
B. The parent’s expression of interest about the distress syndrome, intubated, and placed on a
size of the new born. ventilator. Which nursing action should be included in
C. The parents’ indication that they want to see the baby’s plan of care to prevent retinopathy of
the newborn. prematurity?

D. The parents’ interactions with each other. A. Cover his eyes while receiving oxygen.

80.Following a precipitous delivery, examination of the B. Keep her body temperature low.
client’s vagina reveals C. Monitor partial pressure of oxygen (Pao2)
a fourth-degree laceration. Which of the following levels.
would be contraindicated when caring for this client?
 D. Humidify the oxygen. 91. Magnesium sulfate is given to Jemma with
preeclampsia to prevent which of the following
85. Which of the following is normal newborn calorie
condition?
intake?
A. Hemorrhage
A. 110 to 130 calories per kg.
B. Hypertension
B. 30 to 40 calories per lb of body weight.
C. Hypomagnesemia
C. At least 2 ml per feeding
D. Seizure
D. 90 to 100 calories per kg
92. Cammile with sickle cell anemia has an increased
86. Nurse John is knowledgeable that usually individual
risk for having a sickle cell crisis during pregnancy.
twins will grow appropriately and at the same rate as
Aggressive management of a sickle cell crisis includes
singletons until how many weeks?
which of the following measures?
A. 16 to 18 weeks
A. Antihypertensive agents
B. 18 to 22 weeks
B. Diuretic agents
C. 30 to 32 weeks
C. I.V. fluids
D. 38 to 40 weeks
D. Acetaminophen (Tylenol) for pain
87. Which of the following classifications applies to
93. Which of the following drugs is the antidote for
monozygotic twins for whom the cleavage of the
magnesium toxicity?
fertilized ovum occurs more than 13 days after
fertilization? A. Calcium gluconate (Kalcinate)

A. conjoined twins B. Hydralazine (Apresoline)

B. diamniotic dichorionic twins C. Naloxone (Narcan)

C. diamniotic monochorionic twin D. Rho (D) immune globulin (RhoGAM)

D. monoamniotic monochorionic twins 94. Marlyn is screened for tuberculosis during her first
prenatal visit. An intradermal injection of purified
88. Tyra experienced painless vaginal bleeding has just
protein derivative (PPD) of the tuberculin bacilli is given.
been diagnosed as having a placenta previa. Which of
She is considered to have a positive test for which of the
the following procedures is usually performed to
following results?
diagnose placenta previa?
A. An indurated wheal under 10 mm in diameter
A. Amniocentesis
appears in 6 to 12 hours.
B. Digital or speculum examination
B. An indurated wheal over 10 mm in diameter
C. External fetal monitoring appears in 48 to 72 hours.

D. Ultrasound C. A flat circumcised area under 10 mm in

diameter appears in 6 to 12 hours.
89. Nurse Arnold knows that the following changes in
respiratory functioning during pregnancy is considered D. A flat circumcised area over 10 mm in diameter
normal: appears in 48 to 72 hours.

A. Increased tidal volume 95. Dianne, 24 year-old is 27 weeks’ pregnant arrives at

her physician’s office with complaints of fever, nausea,
B. Increased expiratory volume vomiting, malaise, unilateral flank pain, and
C. Decreased inspiratory capacity costovertebral angle tenderness. Which of the following
diagnoses is most likely?
D. Decreased oxygen consumption
A. Asymptomatic bacteriuria
90. Emily has gestational diabetes and it is usually
managed by which of the following therapy? B. Bacterial vaginosis

A. Diet C. Pyelonephritis

B. Long-acting insulin D. Urinary tract infection (UTI)

C. Oral hypoglycemic 96. Rh isoimmunization in a pregnant client develops

during which of the following conditions?
D. Oral hypoglycemic drug and insulin
 A. Rh-positive maternal blood crosses into fetal
blood, stimulating fetal antibodies.

B. Rh-positive fetal blood crosses into maternal

blood, stimulating maternal antibodies.

C. Rh-negative fetal blood crosses into maternal

blood, stimulating maternal antibodies.

D. Rh-negative maternal blood crosses into fetal

blood, stimulating fetal antibodies.

97. To promote comfort during labor, the nurse John

advises a client to assume certain positions and avoid
others. Which position may cause maternal hypotension
and fetal hypoxia?

A. Lateral position

B. Squatting position

C. Supine position

D. Standing position

98. Celeste who used heroin during her pregnancy

delivers a neonate. When assessing the neonate, the
nurse Lhynnette expects to find:

A. Lethargy 2 days after birth.

B. Irritability and poor sucking.

C. A flattened nose, small eyes, and thin lips.

D. Congenital defects such as limb anomalies.

99. The uterus returns to the pelvic cavity in which of

the following time frames?

A. 7th to 9th day postpartum.

B. 2 weeks postpartum.

C. End of 6th week postpartum.

D. When the lochia changes to alba.

100. Maureen, a primigravida client, age 20, has just

completed a difficult, forceps-assisted delivery of twins.
Her labor was unusually long and required oxytocin
(Pitocin) augmentation. The nurse who’s caring for her
should stay alert for:

A. Uterine inversion

B. Uterine atony

C. Uterine involution

D. Uterine discomfort