PNLE I for Foundation of Nursing
1. Which element in the circular chain of infection can be eliminated by preserving skin integrity?
A. Host
B. Reservoir
C. Mode of transmission
D. Portal of entry
Answer: D. In the circular chain of infection, pathogens must be able to leave their reservoir and be transmitted to a susceptible host through a portal of entry, such as broken skin.
2. Which of the following will probably result in a break in sterile technique for respiratory isolation?
A. Opening the patient’s window to the outside environment
B. Turning on the patient’s room ventilator
C. Opening the door of the patient’s room leading into the hospital corridor
D. Failing to wear gloves when administering a bed bath
Answer: C. Respiratory isolation, like strict isolation, requires that the door to the door patient’s room remain closed. However, the patient’s room should be well ventilated, so opening the window or turning on the ventricular is desirable. The nurse does not need to wear gloves for respiratory isolation, but good hand washing is important for all types of isolation
3. Which of the following patients is at greater risk for contracting an infection?
A. A patient with leukopenia
B. A patient receiving broad-spectrum antibiotics
C. A postoperative patient who has undergone orthopedic surgery
D. A newly diagnosed diabetic patient
Answer: A. Leukopenia is a decreased number of leukocytes (white blood cells), which are important in resisting infection. None of the other situations would put the patient at risk for contracting an infection; taking broadspectrum antibiotics might actually reduce the infection risk.
4. Effective hand washing requires the use of:
A. Soap or detergent to promote emulsification
B. Hot water to destroy bacteria
C. A disinfectant to increase surface tension
D. All of the above
Answer: A. Soaps and detergents are used to help remove bacteria because of their ability to lower the surface tension of water and act as emulsifying agents. Hot water may lead to skin irritation or burns
5. After routine patient contact, hand washing should last at least:
A. 30 seconds
B. 1 minute C. 2 minute D. 3 minutes
Answer: A. Depending on the degree of exposure to pathogens, hand washing may last from 10 seconds to 4 minutes. After routine patient contact, hand washing for 30 seconds effectively minimizes the risk of
pathogen transmission.
6. Which of the following procedures always requires surgical asepsis?
A. Vaginal instillation of conjugated estrogen
B. Urinary catheterization
C. Nasogastric tube insertion
D. Colostomy irrigation
Answer: B. The urinary system is normally free of microorganisms except at the urinary meatus. Any procedure that involves entering this system must use surgically aseptic measures to maintain a bacteria-free state
7. Sterile technique is used whenever: A. Strict isolation is required
B. Terminal disinfection is performed C. Invasive procedures are performed D. Protective isolation is necessary
Answer: C. All invasive procedures, including surgery, catheter insertion, and administration of parenteral therapy, require sterile technique to maintain a sterile environment. All equipment must be sterile, and the nurse and
the physician must wear sterile gloves and maintain surgical asepsis. In the operating room, the nurse and physician are required to wear sterile gowns, gloves, masks, hair covers, and shoe covers for all invasive procedures. Strict isolation requires the use of clean gloves, masks, gowns and equipment to prevent the transmission of highly communicable diseases by contact or by airborne routes. Terminal disinfection is the disinfection of all contaminated supplies and equipment after a patient has been discharged to prepare them for reuse by another patient. The purpose of protective (reverse) isolation is to prevent a person
with seriously impaired resistance from coming into contact who potentially pathogenic organisms.
8. Which of the following constitutes a break in sterile technique while preparing a sterile field for a dressing change?
A. Using sterile forceps, rather than sterile gloves, to handle a sterile item
B. Touching the outside wrapper of sterilized material without sterile gloves
C. Placing a sterile object on the edge of the sterile field
D. Pouring out a small amount of solution (15 to 30 ml)
before pouring the solution into a sterile container
Answer: C. The edges of a sterile field are considered contaminated. When sterile items are allowed to come in contact with the edges of the field, the sterile items also become contaminated
9. A natural body defense that plays an active role in preventing infection is:
A. Yawning B. Body hair C. Hiccupping
D. Rapid eye movements
Answer: B. Hair on or within body areas, such as the nose, traps and holds particles that contain microorganisms. Yawning and hiccupping do not prevent microorganisms from entering or leaving the body. Rapid eye movement marks the stage of sleep during which dreaming occurs.
10. All of the following statement are true about donning sterile gloves except:
A. The first glove should be picked up by grasping the inside of the cuff.
B. The second glove should be picked up by inserting the
gloved fingers under the cuff outside the glove.
C. The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wrist
D. The inside of the glove is considered sterile
Answer: D. The inside of the glove is always considered to be clean, but not sterile.
11.When removing a contaminated gown, the nurse should be careful that the first thing she touches is the:
A. Waist tie and neck tie at the back of the gown
B. Waist tie in front of the gown
C. Cuffs of the gown
D. Inside of the gown
Answer: A. The back of the gown is considered clean, the front is contaminated. So, after removing gloves and
washing hands, the nurse should untie the back of the gown;
slowly move backward away from the gown, holding
the inside of the gown and keeping the edges off the floor;
turn and fold the gown inside out; discard it in a contaminated linen container; then wash her hands again.
12.Which of the following nursing interventions is considered the most effective form or universal precautions?
A. Cap all used needles before removing them from their syringes
B. Discard all used uncapped needles and syringes in an impenetrable protective container
C. Wear gloves when administering IM injections
D. Follow enteric precautions
Answer: B. According to the Centers for Disease Control (CDC), blood-to-blood contact occurs most commonly when a health care worker attempts to cap a used needle. Therefore, used needles should never be recapped; instead they should be inserted in a specially designed puncture resistant, labeled container. Wearing gloves is not always necessary when administering an I.M. injection. Enteric precautions prevent the transfer of pathogens via feces.
13.All of the following measures are recommended to prevent pressure ulcers except:
A. Massaging the reddened are with lotion
B. Using a water or air mattress
C. Adhering to a schedule for positioning and turning
D. Providing meticulous skin care
Answer: A. Nurses and other health care professionals previously believed that massaging a reddened area with lotion would promote venous return and reduce edema to the area. However, research has shown that massage only increases the likelihood of cellular ischemia and necrosis to the area
14.Which of the following blood tests should be performed before a blood transfusion?
A. Prothrombin and coagulation time B. Blood typing and cross-matching C. Bleeding and clotting time
D. Complete blood count (CBC) and electrolyte levels.
Answer: B. Before a blood transfusion is performed, the blood of the donor and recipient must be checked for
compatibility. This is done by blood typing (a test that determines a person’s blood type) and cross-matching (a procedure that determines the compatibility of the
donor’s and recipient’s blood after the blood types has been matched). If the blood specimens are incompatible, hemolysis and antigen-antibody reactions will occur
15.The primary purpose of a platelet count is to evaluate the:
A. Potential for clot formation
B. Potential for bleeding
C. Presence of an antigen-antibody response
D. Presence of cardiac enzymes
Answer: A. Platelets are disk-shaped cells that are essential for blood coagulation. A platelet count determines the number of thrombocytes in blood available for promoting hemostasis and assisting with blood coagulation after injury. It also is used to evaluate the patient’s potential for bleeding; however, this is not its primary purpose. The
normal count ranges from 150,000 to 350,000/mm3. A count
of 100,000/mm3 or less indicates a potential for bleeding; count of less than 20,000/mm3 is associated with spontaneous bleeding.
16.Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?
A. 4,500/mm³ B. 7,000/mm³ C. 10,000/mm³
D. 25,000/mm³
Answer: D. Leukocytosis is any transient increase in the number of white blood cells (leukocytes) in the blood. Normal WBC counts range from 5,000 to 100,000/mm3. Thus, a count of 25,000/mm3 indicates leukocytosis
17. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping and muscle weakness. These symptoms probably indicate that the patient is experiencing:
A. Hypokalemia B. Hyperkalemia C. Anorexia
D. Dysphagia
Answer: A. Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an inadequate potassium level), which is a potential side effect of diuretic therapy. The physician usually orders supplemental potassium to prevent hypokalemia in patients receiving diuretics. Anorexia is another symptom of hypokalemia. Dysphagia means
difficulty swallowing.
18.Which of the following statements about chest X-ray is false?
A. No contradictions exist for this test
B. Before the procedure, the patient should remove all
jewelry, metallic objects, and buttons above the waist
C. A signed consent is not required
D. Eating, drinking, and medications are allowed before
this test
Answer: A. Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray. However, if a chest X-ray is necessary, the patient can wear a lead apron to protect the pelvic region from radiation. Jewelry, metallic objects, and buttons would interfere with the X-ray and thus should not
be worn above the waist. A signed consent is not required
because a chest X-ray is not an invasive examination. Eating, drinking and medications are allowed because the X-ray is of the chest, not the abdominal region.
19.The most appropriate time for the nurse to obtain a sputum specimen for culture is:
A. Early in the morning
B. After the patient eats a light breakfast
C. After aerosol therapy
D. After chest physiotherapy
Answer: A. Obtaining a sputum specimen early in this morning ensures an adequate supply of bacteria for culturing and decreases the risk of contamination from food or medication.
20.A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the
patient’s skin. The most appropriate nursing action would be
to:
A. Withhold the moderation and notify the physician B. Administer the medication and notify the physician C. Administer the medication with an antihistamine
D. Apply corn starch soaks to the rash
Answer: A. Initial sensitivity to penicillin is commonly manifested by a skin rash, even in individuals who have not been allergic to it previously. Because of the danger of anaphylactic shock, he nurse should withhold the drug
and notify the physician, who may choose to substitute another drug. Administering an antihistamine is a dependent nursing intervention that requires a written physician’s order. Although applying corn starch to the rash may relieve discomfort, it is not the nurse’s top priority in such
a potentially life-threatening situation.
21.All of the following nursing interventions are correct when using the Ztrack method of drug injection except:
A. Prepare the injection site with alcohol
B. Use a needle that’s a least 1” long
C. Aspirate for blood before injection
D. Rub the site vigorously after the injection to promote absorption
Answer: D. The Z-track method is an I.M. injection technique in which the patient’s skin is pulled in such a way that the needle track is sealed off after the injection. This procedure seals medication deep into the muscle, thereby minimizing skin staining and irritation. Rubbing the injection site
is contraindicated because it may cause the medication to extravasate into the skin
22.The correct method for determining the vastus lateralis site for I.M. injection is to:
A. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac crest
B. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm
C. Palpate a 1” circular area anterior to the umbilicus
D. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds, and select the middle third on the anterior of the thigh
Answer: D. The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is viewed by many clinicians as the site of choice for I.M. injections because it
has relatively few major nerves and blood vessels. The middle third of the muscle is recommended as the injection site.
The patient can be in a supine or sitting position for an
injection into this site.
23.The mid-deltoid injection site is seldom used for I.M. injections because it:
A. Can accommodate only 1 ml or less of medication
B. Bruises too easily
C. Can be used only when the patient is lying down
D. Does not readily parenteral medication
Answer: A. The mid-deltoid injection site can accommodate only 1 ml or less of medication because of its size and location (on the deltoid muscle of the arm, close to the brachial artery and radial nerve
24.The appropriate needle size for insulin injection is: A. 18G, 1 ½” long
B. 22G, 1” long
C. 22G, 1 ½” long
D. 25G, 5/8” long
Answer: D. A 25G, 5/8” needle is the recommended size for insulin injection because insulin is administered by the subcutaneous route. An 18G, 1 ½” needle is usually used for I.M. injections in children, typically in the vastus lateralis. A
22G, 1 ½” needle is usually used for adult I.M. injections, which are typically administered in the vastus lateralis or ventrogluteal site.
25.The appropriate needle gauge for intradermal injection is: A. 20G
B. 22G C. 25G D. 26G
Answer: D. Because an intradermal injection does not penetrate deeply into the skin, a small-bore 25G needle is recommended. This type of injection is used primarily to administer antigens to evaluate reactions for allergy
or sensitivity studies. A 20G needle is usually used for I.M. injections of oilbased medications; a 22G needle for I.M. injections; and a 25G needle, for I.M. injections; and a 25G needle, for subcutaneous insulin injections.
26.Parenteral penicillin can be administered as an:
A. IM injection or an IV solution
B. IV or an intradermal injection
C. Intradermal or subcutaneous injection
D. IM or a subcutaneous injection
Answer: A. Parenteral penicillin can be administered I.M. or added to a solution and given I.V. It cannot be administered subcutaneously or intradermally.
27.The physician orders gr 10 of aspirin for a patient. The equivalent dose in milligrams is:
A. 0.6 mg B. 10 mg C. 60 mg D. 600 mg
Answer: D. gr 10 x 60mg/gr 1 = 600 mg
28.The physician orders an IV solution of dextrose 5% in
water at 100ml/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml?
A. 5 gtt/minute B. 13 gtt/minute C. 25 gtt/minute D. 50 gtt/minute
Answer: C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute
29.Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion?
A. Hemoglobinuria
B. Chest pain
C. Urticaria
D. Distended neck veins
Answer: A. Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a hemolytic reaction (incompatibility of the donor’s and recipient’s blood). In this reaction, antibodies in the recipient’s plasma combine rapidly with donor RBC’s; the cells are hemolyzed in
either circulatory or reticuloendothelial system. Hemolysis
occurs more rapidly in ABO incompatibilities than in Rh incompatibilities. Chest pain and urticaria may be symptoms of impending anaphylaxis. Distended neck veins are
an indication of hypervolemia.
30.Which of the following conditions may require fluid restriction?
A. Fever
B. Chronic Obstructive Pulmonary Disease
C. Renal Failure
D. Dehydration
Answer: C. In real failure, the kidney loses their ability to effectively eliminate wastes and fluids. Because of this, limiting the patient’s intake of oral and I.V. fluids may be necessary. Fever, chronic obstructive pulmonary disease, and dehydration are conditions for which fluids should
be encouraged.
31.All of the following are common signs and symptoms of phlebitis except:
A. Pain or discomfort at the IV insertion site B. Edema and warmth at the IV insertion site C. A red streak exiting the IV insertion site
D. Frank bleeding at the insertion site
Answer: D. Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V. solutions or medications), mechanical irritants (the needle or catheter used during venipuncture or cannulation), or a localized allergic reaction to the needle or catheter. Signs and symptoms of
phlebitis include pain or discomfort, edema and heat at the I.V. insertion site, and a red streak going up the arm or leg from the I.V. insertion site.
32.The best way of determining whether a patient has learned to instill ear medication properly is for the nurse to:
A. Ask the patient if he/she has used ear drops before
B. Have the patient repeat the nurse’s instructions using
her own words
C. Demonstrate the procedure to the patient and encourage to ask questions
D. Ask the patient to demonstrate the procedure
Answer: D. Return demonstration provides the most certain evidence for evaluating the effectiveness of patient teaching.
33.Which of the following types of medications can be administered via gastrostomy tube?
A. Any oral medications
B. Capsules whole contents are dissolve in water
C. Enteric-coated tablets that are thoroughly dissolved in water
D. Most tablets designed for oral use, except for extended-duration compounds
Answer: D. Capsules, enteric-coated tablets, and most extended duration or sustained release products should not be dissolved for use in a gastrostomy tube. They are pharmaceutically manufactured in these forms for valid reasons, and altering them destroys their purpose. The nurse should seek an alternate physician’s order when an ordered medication is inappropriate for delivery by tube.
34.A patient who develops hives after receiving an antibiotic is exhibiting drug:
A. Tolerance
B. Idiosyncrasy
C. Synergism
D. Allergy
Answer: D. A drug-allergy is an adverse reaction resulting from an immunologic response following a previous sensitizing exposure to the drug. The reaction can range from a rash or hives to anaphylactic shock. Tolerance to a drug means that the patient experiences a decreasing
physiologic response to repeated administration of the drug in the same dosage. Idiosyncrasy is an individual’s unique hypersensitivity to a drug, food, or other substance; it appears to be genetically determined. Synergism, is a drug
interaction in which the sum of the drug’s combined effects is
greater than that of their separate effects.
35.A patient has returned to his room after femoral arteriography. All of the following are appropriate nursing interventions except:
A. Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours
B. Check the pressure dressing for sanguineous drainage
C. Assess a vital signs every 15 minutes for 2 hours
D. Order a hemoglobin and hematocrit count 1 hour after
the arteriography
Answer: D. A hemoglobin and hematocrit count would be ordered by the physician if bleeding were suspected. The other answers are appropriate nursing interventions for a patient who has undergone femoral arteriography.
36.The nurse explains to a patient that a cough:
A. Is a protective response to clear the respiratory tract of irritants
B. Is primarily a voluntary action
C. Is induced by the administration of an antitussive drug
D. Can be inhibited by “splinting” the abdomen
Answer: A. Coughing, a protective response that clears the respiratory tract of irritants, usually is involuntary; however it can be voluntary, as when a patient is taught to perform coughing exercises. An antitussive drug inhibits coughing. Splinting the abdomen supports the abdominal
muscles when a patient coughs
37.An infected patient has chills and begins shivering. The best nursing intervention is to:
41.In which step of the nursing process would the nurse ask a patient if the medication she administered relieved his pain?
|
A. |
Apply iced alcohol sponges |
A. |
Assessment |
|
B. C. |
Provide increased cool liquids Provide additional bedclothes |
B. C. |
Analysis Planning |
|
D. |
Provide increased ventilation |
D. |
Evaluation |
Answer: C. In an infected patient, shivering results from the body’s attempt to increase heat production and the production of neutrophils and phagocytotic action through increased skeletal muscle tension and contractions. Initial vasoconstriction may cause skin to feel cold to the touch. Applying additional bed clothes helps to equalize the
body temperature and stop the chills. Attempts to cool the body result in further shivering, increased metabloism, and thus increased heat production.
38.A clinical nurse specialist is a nurse who has:
A. Been certified by the National League for Nursing
B. Received credentials from the Philippine Nurses’
Association
C. Graduated from an associate degree program and is a
registered professional nurse
D. Completed a master’s degree in the prescribed clinical
area and is a registered professional nurse.
Answer: D. A clinical nurse specialist must have completed a master’s degree in a clinical specialty and be a registered professional nurse. The National League of Nursing accredits educational programs in nursing and provides a testing service to evaluate student nursing competence but it does
not certify nurses. The American Nurses Association identifies requirements for certification and offers examinations for certification in many areas of nursing., such as medical
surgical nursing. These certification (credentialing)
demonstrates that the nurse has the knowledge and
the ability to provide high quality nursing care in the area of her certification. A graduate of an associate degree program is not a clinical nurse specialist: however, she is prepared to provide bed side nursing with a high degree of knowledge and skill. She must successfully complete the
licensing examination to become a registered professional nurse.
39.The purpose of increasing urine acidity through dietary means is to:
A. Decrease burning sensations
B. Change the urine’s color
C. Change the urine’s concentration
D. Inhibit the growth of microorganisms
Answer: D. Microorganisms usually do not grow in an acidic environment.
40.Clay colored stools indicate: A. Upper GI bleeding
B. Impending constipation C. An effect of medication D. Bile obstruction
Answer: D. Bile colors the stool brown. Any inflammation or obstruction that impairs bile flow will affect the stool pigment, yielding light, clay-colored stool. Upper GI bleeding results in black or tarry stool. Constipation is characterized by small,
hard masses. Many medications and foods will discolor stool
– for example, drugs containing iron turn stool black.;
beets turn stool red.
Answer: D. In the evaluation step of the nursing process, the nurse must decide whether the patient has achieved the expected outcome that was identified in the planning phase.
42.All of the following are good sources of vitamin A except:
A. White potatoes
B. Carrots
C. Apricots
D. Egg yolks
Answer: A. The main sources of vitamin A are yellow and green vegetables (such as carrots, sweet potatoes, squash, spinach, collard greens, broccoli, and cabbage) and yellow fruits (such as apricots, and cantaloupe). Animal sources include liver, kidneys, cream, butter, and egg yolks.
43.Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in place?
A. Maintain the drainage tubing and collection bag level with the patient’s bladder
B. Irrigate the patient with 1% Neosporin solution three
times a daily
C. Clamp the catheter for 1 hour every 4 hours to maintain the bladder’s elasticity
D. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity
Answer: D. Maintaing the drainage tubing and collection bag level with the patient’s bladder could result in reflux of urine into the kidney. Irrigating the bladder with Neosporin and clamping the catheter for 1 hour every 4 hours must be prescribed by a physician
44.The ELISA test is used to:
A. Screen blood donors for antibodies to human immunodeficiency virus (HIV)
B. Test blood to be used for transfusion for HIV antibodies
C. Aid in diagnosing a patient with AIDS
D. All of the above
Answer: D. The ELISA test of venous blood is used to assess blood and potential blood donors to human immunodeficiency virus (HIV). A positive ELISA test combined with various signs and symptoms helps to diagnose acquired immunodeficiency syndrome (AIDS)
45.The two blood vessels most commonly used for TPN
infusion are the:
A. Subclavian and jugular veins B. Brachial and subclavian veins C. Femoral and subclavian veins D. Brachial and femoral veins
Answer: D. Tachypnea (an abnormally rapid rate of breathing) would indicate that the patient was still hypoxic (deficient in oxygen).The partial pressures of arterial oxygen and carbon dioxide listed are within the normal range. Eupnea refers to normal respiration.
46.Effective skin disinfection before a surgical procedure includes which of the following methods?
A. Shaving the site on the day before surgery
B. Applying a topical antiseptic to the skin on the evening before surgery
C. Having the patient take a tub bath on the morning of
surgery
D. Having the patient shower with an antiseptic soap on the evening v=before and the morning of surgery
Answer: D. Studies have shown that showering with an antiseptic soap before surgery is the most effective method
of removing microorganisms from the skin. Shaving the site of
the intended surgery might cause breaks in the skin, thereby increasing the risk of infection; however, if indicated, shaving, should be done immediately before surgery, not the day before. A topical antiseptic would not remove
microorganisms and would be beneficial only after proper cleaning and rinsing. Tub bathing might transfer organisms to another body site rather than rinse them away.
47.When transferring a patient from a bed to a chair, the nurse should use which muscles to avoid back injury?
A. Abdominal muscles
B. Back muscles
C. Leg muscles
D. Upper arm muscles
Answer: C. The leg muscles are the strongest muscles in the body and should bear the greatest stress when lifting.
Muscles of the abdomen, back, and upper arms may be easily injured.
48.Thrombophlebitis typically develops in patients with which of the following conditions?
A. Increases partial thromboplastin time
B. Acute pulsus paradoxus
C. An impaired or traumatized blood vessel wall
D. Chronic Obstructive Pulmonary Disease (COPD)
Answer: C. The factors, known as Virchow’s triad, collectively predispose a patient to thromboplebitis; impaired venous return to the heart, blood hypercoagulability, and injury to a blood vessel wall. Increased partial thromboplastin time indicates a prolonged bleeding time during fibrin
clot formation, commonly the result of anticoagulant (heparin) therapy. Arterial blood disorders (such as pulsus paradoxus) and lung diseases (such as COPD) do not necessarily impede venous return of injure vessel walls.
49.In a recumbent, immobilized patient, lung ventilation can become altered, leading to such respiratory complications as:
A. Respiratory acidosis, ateclectasis, and hypostatic pneumonia
B. Appneustic breathing, atypical pneumonia and respiratory alkalosis
C. Cheyne-Strokes respirations and spontaneous
pneumothorax
D. Kussmail’s respirations and hypoventilation
Answer: A. Because of restricted respiratory movement, a recumbent, immobilize patient is at particular risk for respiratory acidosis from poor gas exchange; atelectasis from reduced surfactant and accumulated mucus in the bronchioles, and hypostatic pneumonia from bacterial growth caused by stasis of mucus secretions
50.Immobility impairs bladder elimination, resulting in such disorders as
A. Increased urine acidity and relaxation of the perineal muscles, causing incontinence
B. Urine retention, bladder distention, and infection
C. Diuresis, natriuresis, and decreased urine specific
gravity
D. Decreased calcium and phosphate levels in the urine
Answer: B. The immobilized patient commonly suffers from urine retention caused by decreased muscle tone in the perineum. This leads to bladder distention and urine stagnation, which provide an excellent medium for bacterial growth leading to infection. Immobility also results in
more alkaline urine with excessive amounts of calcium, sodium and phosphate, a gradual decrease in urine production, and an increased specific gravity.
PNLE II for Community Health Nursing and Care of the
Mother and Child
1. May arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. She also tells the nurse that a home pregnancy test was positive but she began to have mild cramps and is now having moderate vaginal bleeding. During the physical examination of the client, the nurse notes that May has a dilated cervix. The nurse determines that May is experiencing which type of abortion? A. Inevitable
B. Incomplete C. Threatened D. Septic
Answer: Answer: (A) Inevitable. An inevitable abortion is termination of pregnancy that cannot be prevented. Moderate to severe bleeding with mild cramping
and cervical dilation would be noted in this type of abortion
2. Nurse Reese is reviewing the record of a pregnant client for her first prenatal visit. Which of the following data, if noted
on the client’s record, would alert the nurse that the client is
at risk for a spontaneous abortion? A. Age 36 years
B. History of syphilis
C. History of genital herpes
D. History of diabetes mellitus
Answer: Answer: (B) History of syphilis. Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion.
3. Nurse Hazel is preparing to care for a client who is newly admitted to the hospital with a possible diagnosis of ectopic pregnancy. Nurse Hazel develops a plan of care for the client and determines that which of the following nursing actions is the priority?
A. Monitoring weight
B. Assessing for edema
C. Monitoring apical pulse
D. Monitoring temperature
Answer: Answer: (C) Monitoring apical pulse. Nursing care
for the client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and
controlling pain. An elevated pulse rate is an indicator of
shock
4. Nurse Oliver is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin
needs if the client states that the second half of pregnancy require:
A. Decreased caloric intake
B. Increased caloric intake
C. Decreased Insulin
D. Increase Insulin
Answer: (B) Increased caloric intake. Glucose crosses the placenta, but insulin does not. High fetal demands for glucose, combined with the insulin resistance caused by hormonal changes in the last half of pregnancy can result in elevation
of maternal blood glucose levels. This increases the mother’s demand for insulin and is referred to as the diabetogenic effect of pregnancy.
5. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware that one of the following is unassociated with this condition?
A. Excessive fetal activity.
B. Larger than normal uterus for gestational age. C. Vaginal bleeding
D. Elevated levels of human chorionic gonadotropin.
Answer: Answer: (A) Excessive fetal activity. The most common signs and symptoms of hydatidiform mole includes elevated levels of human chorionic gonadotropin,
vaginal bleeding, larger than normal uterus for gestational age, failure to detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting, and early development of pregnancy-induced hypertension. Fetal activity would not be noted.
6. A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is: A. Urinary output 90 cc in 2 hours.
B. Absent patellar reflexes.
C. Rapid respiratory rate above 40/min. D. Rapid rise in blood pressure.
Answer: Answer: (B) Absent patellar reflexes. Absence of patellar reflexes is an indicator of hypermagnesemia, which requires administration of calcium gluconate
7. During vaginal examination of Janah who is in labor, the presenting part is at station plus two. Nurse, correctly interprets it as:
A. Presenting part is 2 cm above the plane of the ischial spines.
B. Biparietal diameter is at the level of the ischial spines.
C. Presenting part in 2 cm below the plane of the ischial
spines.
D. Biparietal diameter is 2 cm above the ischial spines.
Answer: Answer: (C) Presenting part in 2 cm below the plane of the ischial spines. Fetus at station plus two indicates that the presenting part is 2 cm below the plane of the ischial spines.
8. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the nurse in- charge to discontinue I.V. infusion of Pitocin is:
A. Contractions every 1 ½ minutes lasting 70-80 seconds.
B. Maternal temperature 101.2
C. Early decelerations in the fetal heart rate.
D. Fetal heart rate baseline 140-160 bpm.
Answer: Answer: (A) Contractions every 1 ½ minutes lasting
70-80 seconds. Contractions every 1 ½ minutes lasting 70-80
seconds, is indicative of hyperstimulation of the uterus, which
could result in injury to the mother and the fetus if Pitocin is not discontinued.
9. Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). A nursing action that must be initiated as the plan of care throughout injection of the drug is:
A. Ventilator assistance
B. CVP readings
C. EKG tracings
D. Continuous CPR
Answer: Answer: (C) EKG tracings. A potential side effect of calcium gluconate administration is cardiac arrest. Continuous monitoring of cardiac activity (EKG) throught administration of calcium gluconate is an essential part of care.
10. A trial for vaginal delivery after an earlier caesareans, would likely to be given to a gravida, who had:
A. First low transverse cesarean was for active herpes type
2 infections; vaginal culture at 39 weeks pregnancy was
positive.
B. First and second caesareans were for cephalopelvic disproportion.
C. First caesarean through a classic incision as a result of severe fetal distress.
D. First low transverse caesarean was for breech position.
Fetus in this pregnancy is in a vertex presentation.
Answer: Answer: (D) First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation. This type of client has no obstetrical indication for a caesarean section as she did with her first caesarean delivery.
11.Nurse Ryan is aware that the best initial approach when
trying to take a crying toddler’s temperature is:
A. Talk to the mother first and then to the toddler.
B. Bring extra help so it can be done quickly.
C. Encourage the mother to hold the child. D. Ignore the crying and screaming.
Answer: Answer: (A) Talk to the mother first and then to the toddler. When dealing with a crying toddler, the best approach is to talk to the mother and ignore the toddler first. This approach helps the toddler get used to the nurse before she attempts any procedures. It also gives the toddler an opportunity to see that the mother trusts the nurse.
12.Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the nurse do to prevent trauma to operative site?
A. Avoid touching the suture line, even when cleaning.
B. Place the baby in prone position. C. Give the baby a pacifier.
D. Place the infant’s arms in soft elbow restraints.
Answer: Answer: (D) Place the infant’s arms in soft elbow restraints. Soft restraints from the upper arm to the wrist prevent the infant from touching her lip but allow him to hold a favorite item such as a blanket. Because they could damage the operative site, such as objects as pacifiers, suction catheters, and small spoons shouldn’t be placed in a baby’s mouth after cleft repair. A baby in a prone position may rub her face on the sheets and traumatize the operative site. The suture line should be cleaned gently to prevent infection, which could interfere with healing and damage the cosmetic appearance of the repair.
13. Which action should nurse Marian include in the care plan for a 2 month old with heart failure?
A. Feed the infant when he cries.
B. Allow the infant to rest before feeding.
C. Bathe the infant and administer medications before feeding.
D. Weigh and bathe the infant before feeding.
Answer: Answer: (B) Allow the infant to rest before
feeding. Because feeding requires so much energy, an infant with heart failure should rest before feeding
14.Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5 months. The nurse should advise her to include which foods in her infant’s diet?
A. Skim milk and baby food.
B. Whole milk and baby food. C. Iron-rich formula only.
D. Iron-rich formula and baby food.
Answer: Answer: (C) Iron-rich formula only. The infants at age 5 months should receive iron-rich formula and that they shouldn’t receive solid food, even baby food until age 6 months.
15.Mommy Linda is playing with her infant, who is sitting securely alone on the floor of the clinic. The mother hides a toy behind her back and the infant looks for it. The nurse is aware that estimated age of the infant would be:
A. 6 months B. 4 months C. 8 months D. 10 months
Answer: Answer: (D) 10 months. A 10 month old infant can sit alone and understands object permanence, so he would look for the hidden toy. At age 4 to 6 months, infants can’t sit securely alone. At age 8 months, infants can sit securely alone but cannot understand the permanence of objects.
16.Which of the following is the most prominent feature of public health nursing?
A. It involves providing home care to sick people who are
not confined in the hospital.
B. Services are provided free of charge to people within the catchments area.
C. The public health nurse functions as part of a team
providing a public health nursing services.
D. Public health nursing focuses on preventive, not curative, services.
Answer: Answer: (D) Public health nursing focuses on preventive, not curative, services. The catchments area in PHN consists of a residential community, many of whom are well individuals who have greater need for preventive rather than curative services.
17.When the nurse determines whether resources were maximized in implementing Ligtas Tigdas, she is evaluating A. Effectiveness
B. Efficiency
C. Adequacy
D. Appropriateness
Answer: Answer: (B) Efficiency. Efficiency is determining whether the goals were attained at the least possible cost.
18.Vangie is a new B.S.N. graduate. She wants to become a
Public Health Nurse. Where should she apply?
A. Department of Health
B. Provincial Health Office C. Regional Health Office D. Rural Health Unit
Answer: Answer: (D) Rural Health Unit. R.A. 7160 devolved basic health services to local government units (LGU’s ). The public health nurse is an employee of the LGU.
19.Tony is aware the Chairman of the Municipal Health Board is:
A. Mayor
B. Municipal Health Officer
C. Public Health Nurse
D. Any qualified physician
Answer: Answer: (A) Mayor. The local executive serves as the chairman of the Municipal Health Board
20.Myra is the public health nurse in a municipality with a total population of about 20,000. There are 3 rural health midwives among the RHU personnel. How many more midwife items will the RHU need?
A. 1
B. 2
C. 3
D. The RHU does not need any more midwife item.
Answer: Answer: (A) 1. Each rural health midwife is given a population assignment of about 5,000.
21.According to Freeman and Heinrich, community health nursing is a developmental service. Which of the following best illustrates this statement?
A. The community health nurse continuously develops himself personally and professionally.
B. Health education and community organizing are
necessary in providing community health services. C. Community health nursing is intended primarily for health promotion and prevention and treatment of
disease.
D. The goal of community health nursing is to provide nursing services to people in their own places of residence.
Answer: Answer: (B) Health education and community organizing are necessary in providing community health services. The community health nurse develops the health capability of people through health education and community organizing activities
22.Nurse Tina is aware that the disease declared through Presidential Proclamation No. 4 as a target for eradication in the Philippines is?
A. Poliomyelitis
B. Measles
C. Rabies
D. Neonatal tetanus
Answer: Answer: (B) Measles. Presidential Proclamation No.
4 is on the Ligtas Tigdas Program.
23.May knows that the step in community organizing that involves training of potential leaders in the community is: A. Integration
B. Community organization
C. Community study
D. Core group formation
Answer: Answer: (D) Core group formation. In core group formation, the nurse is able to transfer the technology of
community organizing to the potential or informal community leaders through a training program.
24.Beth a public health nurse takes an active role in community participation. What is the primary goal of community organizing?
A. To educate the people regarding community health
problems
B. To mobilize the people to resolve community health problems
C. To maximize the community’s resources in dealing
with health problems.
D. To maximize the community’s resources in dealing
with health problems.
Answer: (D) To maximize the community’s resources in dealing with health problems. Community organizing is a developmental service, with the goal of developing the people’s self-reliance in dealing with community health problems. A, B and C are objectives of contributory objectives to this goal.
25.Tertiary prevention is needed in which stage of the natural history of disease?
A. Pre-pathogenesis
B. Pathogenesis
C. Prodromal
D. Terminal
Answeer: Answer: Answer: (D) Terminal. Tertiary prevention involves rehabilitation, prevention of permanent disability and disability limitation appropriate for convalescents, the disabled, complicated cases and the terminally ill (those in the terminal stage of a disease
26.The nurse is caring for a primigravid client in the labor and delivery area. Which condition would place the client at risk for disseminated intravascular coagulation (DIC)?
A. Intrauterine fetal death.
B. Placenta accreta.
C. Dysfunctional labor.
D. Premature rupture of the membranes.
Answer: Answer: (A) Intrauterine fetal death. Intrauterine fetal death, abruptio placentae, septic shock, and amniotic fluid embolism may trigger normal clotting mechanisms; if clotting factors are depleted, DIC may occur. Placenta accreta, dysfunctional labor, and premature rupture of the
membranes aren’t associated with DIC.
27.A fullterm client is in labor. Nurse Betty is aware that the fetal heart rate would be:
A. 80 to 100 beats/minute B. 100 to 120 beats/minute C. 120 to 160 beats/minute D. 160 to 180 beats/minute
Answer: Answer: (C) 120 to 160 beats/minute. A rate of 120 to 160 beats/minute in the fetal heart appropriate for filling the heart with b
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