PNLE I Nursing Practice

Text Mode – Text version of the exam

Scope of this Nursing Test I is parallel to the NP1 NLE Coverage:
 Foundation of Nursing
 Nursing Research
 Professional Adjustment
 Leadership and Management
1. The registered nurse is planning to delegate tasks to unlicensed assistive personnel (UAP). Which
of the following task could the registered nurse safely assigned to a UAP?

A. Monitor the I&O of a comatose toddler client with salicylate poisoning

B. Perform a complete bed bath on a 2-year-old with multiple injuries from a serious fall
C. Check the IV of a preschooler with Kawasaki disease
D. Give an outmeal bath to an infant with eczema
2. A nurse manager assigned a registered nurse from telemetry unit to the pediatrics unit. There
were three patients assigned to the RN. Which of the following patients should not be assigned to the
floated nurse?

A. A 9-year-old child diagnosed with rheumatic fever

B. A young infant after pyloromyotomy
C. A 4-year-old with VSD following cardiac catheterization
D. A 5-month-old with Kawasaki disease
3. A nurse in charge in the pediatric unit is absent. The nurse manager decided to assign the nurse in
the obstetrics unit to the pediatrics unit. Which of the following patients could the nurse manager
safely assign to the float nurse?

A. A child who had multiple injuries from a serious vehicle accident

B. A child diagnosed with Kawasaki disease and with cardiac complications
C. A child who has had a nephrectomy for Wilm’s tumor
D. A child receiving an IV chelating therapy for lead poisoning
4. The registered nurse is planning to delegate task to a certified nursing assistant. Which of the
following clients should not be assigned to a CAN?

A. A client diagnosed with diabetes and who has an infected toe

B. A client who had a CVA in the past two months
C. A client with Chronic renal failure
D. A client with chronic venous insufficiency
5. The nurse in the medication unit passes the medications for all the clients on the nursing unit. The
head nurse is making rounds with the physician and coordinates clients’ activities with other
departments. The nurse assistant changes the bed lines and answers call lights. A second nurse is
assigned for changing wound dressings; a licensed practitioner nurse takes vital signs and bathes
theclients. This illustrates of what method of nursing care?

A. Case management method

B. Primary nursing method
C. Team method
 D. Functional method
6. A registered nurse has been assigned to six clients on the 12-hour shift. The RN is responsible for
every aspect of care such as formulating the care of plan, intervention and evaluating the care during
her shift. At the end of her shift, the RN will pass this same task to the next RN in charge. This
nursing care illustrates of what kind of method?

A. primary nursing method

B. case method
C. team method
D. functional method
7. A newly hired nurse on an adult medicine unit with 3 months experience was asked to float to
pediatrics. The nurse hesitates to perform pediatric skills and receive an interesting assignment that
feels overwhelming. The nurse should:

A. resign on the spot from the nursing position and apply for a position that does not require
floating
B. Inform the nursing supervisor and the charge nurse on the pediatric floor about the nurse’s
lack of skill and feelings of hesitations and request assistance
C. Ask several other nurses how they feel about pediatrics and find someone else who is willing
to accept the assignment
D. Refuse the assignment and leave the unit requesting a vacation a day
8. An experienced nurse who voluntarily trained a less experienced nurse with the intention of
enhancing the skills and knowledge and promoting professional advancement to the nurse is called a:

A. mentor
B. team leader
C. case manager
D. change agent
9. The pediatrics unit is understaffed and the nurse manager informs the nurses in the obstetrics unit
that she is going to assign one nurse to float in the pediatric units. Which statement by the
designated float nurse may put her job at risk?

A. “I do not get along with one of the nurses on the pediatrics unit”
B. “I have a vacation day coming and would like to take that now”
C. “I do not feel competent to go and work on that area”
D. “ I am afraid I will get the most serious clients in the unit”
10. The newly hired staff nurse has been working on a medical unit for 3 weeks. The nurse manager
has posted the team leader assignments for the following week. The new staff knows that a major
responsibility of the team leader is to:

A. Provide care to the most acutely ill client on the team

B. Know the condition and needs of all the patients on the team
C. Document the assessments completed by the team members
D. Supervise direct care by nursing assistants
11. A 15-year-old girl just gave birth to a baby boy who needs emergency surgery. The nurse
prepared the consent form and it should be signed by:

A. The Physician
B. The Registered Nurse caring for the client
 C. The 15-year-old mother of the baby boy
D. The mother of the girl
12. A nurse caring to a client with Alzheimer’s disease overheard a family member say to the client,
“if you pee one more time, I won’t give you any more food and drinks”. What initial action is best for
the nurse to take?

A. Take no action because it is the family member saying that to the client
B. Talk to the family member and explain that what she/he has said is not appropriate for the
client
C. Give the family member the number for an Elder Abuse Hot line
D. Document what the family member has said
13. Which is true about informed consent?

A. A nurse may accept responsibility signing a consent form if the client is unable
B. Obtaining consent is not the responsibility of the physician
C. A physician will not subject himself to liability if he withholds any facts that are necessary to
form the basis of an intelligent consent
D. If the nurse witnesses a consent for surgery, the nurse is, in effect, indicating that the
signature is that of the purported person and that the person’s condition is as indicated at the
time of signing
14. A mother in labor told the nurse that she was expecting that her baby has no chance to survive
and expects that the baby will be born dead. The mother accepts the fate of the baby and informs
the nurse that when the baby is born and requires resuscitation, the mother refuses any treatment to
her baby and expresses hostility toward the nurse while the pediatric team is taking care of the baby.
The nurse is legally obligated to:

A. Notify the pediatric team that the mother has refused resuscitation and any treatment for the
baby and take the baby to the mother
B. Get a court order making the baby a ward of the court
C. Record the statement of the mother, notify the pediatric team, and observe carefully for signs
of impaired bonding and neglect as a reasonable suspicion of child abuse
D. Do nothing except record the mother’s statement in the medical record
15. The hospitalized client with a chronic cough is scheduled for bronchoscopy. The nurse is tasks to
bring the informed consent document into the client’s room for a signature. The client asks the nurse
for details of the procedure and demands an explanation why the process of informed consent is
necessary. The nurse responds that informed consent means:

A. The patient releases the physician from all responsibility for the procedure.
B. The immediate family may make decision against the patient’s will.
C. The physician must give the client or surrogates enough information to make health care
judgments consistent with their values and goals.
D. The patient agrees to a procedure ordered by the physician even if the client does not
understand what the outcome will be.
16. A hospitalized client with severe necrotizing ulcer of the lower leg is schedule for an amputation.
The client tells the nurse that he will not sign the consent form and he does not want any surgery or
treatment because of religious beliefs about reincarnation. What is the role of the RN?

A. call a family meeting

B. discuss the religious beliefs with the physician
 C. encourage the client to have the surgery
D. inform the client of other options
17. While in the hospital lobby, the RN overhears the three staff discussing the health condition of
her client. What would be the appropriate nursing action for the RN to take?

A. Tell them it is not appropriate to discuss the condition of the client

B. Ignore them, because it is their right to discuss anything they want to
C. Join in the conversation, giving them supportive input about the case of the client
D. Report this incident to the nursing supervisor
18. A staff nurse has had a serious issue with her colleague. In this situation, it is best to:

A. Discuss this with the supervisor

B. Not discuss the issue with anyone. It will probably resolve itself
C. Try to discuss with the colleague about the issue and resolve it when both are calmer
D. Tell other members of the network what the team member did
19. The nurse is caring to a client who just gave birth to a healthy baby boy. The nurse may not
disclose confidential information when:

A. The nurse discusses the condition of the client in a clinical conference with other nurses
B. The client asks the nurse to discuss the her condition with the family
C. The father of a woman who just delivered a baby is on the phone to find out the sex of the
baby
D. A researcher from an institutionally approved research study reviews the medical record of a
patient
20. A 17-year-old married client is scheduled for surgery. The nurse taking care of the client realizes
that consent has not been signed after preoperative medications were given. What should the nurse
do?

A. Call the surgeon

B. Ask the spouse to sign the consent
C. Obtain a consent from the client as soon as possible
D. Get a verbal consent from the parents of the client
21. A 12-year-old client is admitted to the hospital. The physician ordered Dilantin to the client. In
administering IV phenytoin (Dilantin) to a child, the nurse would be most correct in mixing it with:

A. Normal Saline
B. Heparinized normal saline
C. 5% dextrose in water
D. Lactated Ringer’s solution
22. The nurse is caring to a client who is hypotensive. Following a large hematemesis, how should
the nurse position the client?

A. Feet and legs elevated 20 degrees, trunk horizontal, head on small pillow
B. Low Fowler’s with knees gatched at 30 degrees
C. Supine with the head turned to the left
D. Bed sloped at a 45 degree angle with the head lowest and the legs highest
23. The client is brought to the emergency department after a serious accident. What would be the
initial nursing action of the nurse to the client?
 A. assess the level of consciousness and circulation
B. check respirations, circulation, neurological response
C. align the spine, check pupils, check for hemorrhage
D. check respiration, stabilize spine, check circulation
24. A nurse is assigned to care to a client with Parkinson’s disease. What interventions are important
if the nurse wants to improve nutrition and promote effective swallowing of the client?

A. Eat solid food

B. Give liquids with meals
C. Feed the client
D. Sit in an upright position to eat
25. During tracheal suctioning, the nurse should implement safety measures. Which of the following
should the nurse implements?

A. limit suction pressure to 150-180 mmHg

B. suction for 15-20 seconds
C. wear eye goggles
D. remove the inner cannula
26. The nurse is conducting a discharge instructions to a client diagnosed with diabetes. What sign of
hypoglycemia should be taught to a client?

A. warm, flushed skin

B. hunger and thirst
C. increase urinary output
D. palpitation and weakness
27. A client admitted to the hospital and diagnosed with Addison’s disease. What would be the
appropriate nursing action to the client?

A. administering insulin-replacement therapy

B. providing a low-sodium diet
C. restricting fluids to 1500 ml/day
D. reducing physical and emotional stress
28. The nurse is to perform tracheal suctioning. During tracheal suctioning, which nursing action is
essential to prevent hypoxemia?

A. aucultating the lungs to determine the baseline data to assess the effectiveness of suctioning
B. removing oral and nasal secretions
C. encouraging the patient to deep breathe and cough to facilitate removal of upper-airway
secretions
D. administering 100% oxygen to reduce the effects of airway obstruction during suctioning.
29. An infant is admitted and diagnosed with pneumonia and suspicious-looking red marks on the
swollen face resembling a handprint. The nurse does further assessment to the client. How would the
nurse document the finding?

A. Facial edema with ecchymosis and handprint mark: crackles and wheezes
B. Facial edema, with red marks; crackles in the lung
C. Facial edema with ecchymosis that looks like a handprint
D. Red bruise mark and ecchymosis on face
30. On the evening shift, the triage nurse evaluates several clients who were brought to the
emergency department. Which in the following clients should receive highest priority?

A. an elderly woman complaining of a loss of appetite and fatigue for the past week
B. A football player limping and complaining of pain and swelling in the right ankle
C. A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his jaw
D. A mother with a 5-year-old boy who says her son has been complaining of nausea and
vomited once since noon
31. A 80-year-old female client is brought to the emergency department by her caregiver, on the
nurse’s assessment; the following are the manifestations of the client: anorexia, cachexia and
multiple bruises. What would be the best nursing intervention?

A. check the laboratory data for serum albumin, hematocrit, and hemoglobin
B. talk to the client about the caregiver and support system
C. complete a police report on elder abuse
D. complete a gastrointestinal and neurological assessment
32. The night shift nurse is making rounds. When the nurse enters a client’s room, the client is on the
floor next to the bed. What would be the initial action of the nurse?

A. chart that the patient fell

B. call the physician
C. chart that the client was found on the floor next to the bed
D. fill out an incident report
33. The nurse on the night shift is about to administer medication to a preschooler client and notes
that the child has no ID bracelet. The best way for the nurse to identify the client is to ask:

A. The adult visiting, “The child’s name is ____________________?”

B. The child, “Is your name____________?”
C. Another staff nurse to identify this child
D. The other children in the room what the child’s name is
34. The nurse caring to a client has completed the assessment. Which of the following will be
considered to be the most accurate charting of a lump felt in the right breast?

A. “abnormally felt area in the right breast, drainage noted”

B. “hard nodular mass in right breast nipple”
C. “firm mass at five ‘ clock, outer quadrant, 1cm from right nipple’
D. “mass in the right breast 4cmx1cm
35. The physician instructed the nurse that intravenous pyelogram will be done to the client. The
client asks the nurse what is the purpose of the procedure. The appropriate nursing response is to:

A. outline the kidney vasculature

B. determine the size, shape, and placement of the kidneys
C. test renal tubular function and the patency of the urinary tract
D. measure renal blood flow
36. A client visits the clinic for screening of scoliosis. The nurse should ask the client to:

A. bend all the way over and touch the toes

B. stand up as straight and tall as possible
C. bend over at a 90-degree angle from the waist
 D. bend over at a 45-degree angle from the waist
37. A client with tuberculosis is admitted in the hospital for 2 weeks. When a client’s family members
come to visit, they would be adhering to respiratory isolation precautions when they:

A. wash their hands when leaving

B. put on gowns, gloves and masks
C. avoid contact with the client’s roommate
D. keep the client’s room door open
38. An infant is brought to the emergency department and diagnosed with pyloric stenosis. The
parents of the client ask the nurse, “Why does my baby continue to vomit?” Which of the following
would be the best nursing response of the nurse?

A. “Your baby eats too rapidly and overfills the stomach, which causes vomiting
B. “Your baby can’t empty the formula that is in the stomach into the bowel”
C. “The vomiting is due to the nausea that accompanies pyloric stenosis”
D. “Your baby needs to be burped more thoroughly after feeding”
39. A 70-year-old client with suspected tuberculosis is brought to the geriatric care facilities. An
intradermal tuberculosis test is schedule to be done. The client asks the nurse what is the purpose of
the test. Which of the following would be the best rationale for this?

A. reactivation of an old tuberculosis infection

B. increased incidence of new cases of tuberculosis in persons over 65 years old
C. greater exposure to diverse health care workers
D. respiratory problems are characteristic in this population
40. The nurse is making a health teaching to the parents of the client. In teaching parents how to
measure the area of induration in response to a PPD test, the nurse would be most accurate in
advising the parents to measure:

A. both the areas that look red and feel raised

B. The entire area that feels itchy to the child
C. Only the area that looks reddened
D. Only the area that feels raised
41. A community health nurse is schedule to do home visit. She visits to an elderly person living
alone. Which of the following observation would be a concern?

A. Picture windows
B. Unwashed dishes in the sink
C. Clear and shiny floors
D. Brightly lit rooms
42. After a birth, the physician cut the cord of the baby, and before the baby is given to the mother,
what would be the initial nursing action of the nurse?

A. examine the infant for any observable abnormalities

B. confirm identification of the infant and apply bracelet to mother and infant
C. instill prophylactic medication in the infant’s eyes
D. wrap the infant in a prewarmed blanket and cover the head
43. A 2-year-old client is admitted to the hospital with severe eczema lesions on the scalp, face, neck
and arms. The client is scratching the affected areas. What would be the best nursing intervention to
prevent the client from scratching the affected areas?
 A. elbow restraints to the arms
B. Mittens to the hands
C. Clove-hitch restraints to the hands
D. A posey jacket to the torso
44. The parents of the hospitalized client ask the nurse how their baby might have gotten pyloric
stenosis. The appropriate nursing response would be:

A. There is no way to determine this preoperatively

B. Their baby was born with this condition
C. Their baby developed this condition during the first few weeks of life
D. Their baby acquired it due to a formula allergy
45. A male client comes to the clinic for check-up. In doing a physical assessment, the nurse should
report to the physician the most common symptom of gonorrhea, which is:

A. pruritus
B. pus in the urine
C. WBC in the urine
D. Dysuria
46. Which of the following would be the most important goal in the nursing care of an infant client
with eczema?

A. preventing infection
B. maintaining the comfort level
C. providing for adequate nutrition
D. decreasing the itching
47. The nurse is making a discharge instruction to a client receiving chemotherapy. The client is at
risk for bone marrow depression. The nurse gives instructions to the client about how to prevent
infection at home. Which of the following health teaching would be included?

A. “Get a weekly WBC count”

B. “Do not share a bathroom with children or pregnant woman”
C. “Avoid contact with others while receiving chemotherapy”
D. “Do frequent hand washing and maintain good hygiene”
48. The nurse is assigned to care the client with infectious disease. The best antimicrobial agent for
the nurse to use in handwashing is:

A. Isopropyl alcohol
B. Hexachlorophene (Phisohex)
C. Soap and water
D. Chlorhexidine gluconate (CHG) (Hibiclens)
49. The mother of the client tells the nurse, “ I’m not going to have my baby get any immunization”.
What would be the best nursing response to the mother?

A. “You and I need to review your rationale for this decision”

B. “Your baby will not be able to attend day care without immunizations”
C. “Your decision can be viewed as a form of child abuse and neglect”
D. “You are needlessly placing other people at risk for communicable diseases”
50. The nurse is teaching the client about breast self-examination. Which observation should the
client be taught to recognize when doing the examination for detection of breast cancer?
 A. tender, movable lump
B. pain on breast self-examination
C. round, well-defined lump
D. dimpling of the breast tissue
Answers and Rationales
1. D. Bathing an infant with eczema can be safely delegated to an aide; this task is basic and can
competently performed by an aid.
2. B. The RN floated from the telemetry unit would be least prepared to care for a young infant
who has just had GI surgery and requires a specific feeding regimen.
3. C. RN floated from the obstetrics unit should be able to care for a client with major abdominal
surgery, because this nurse has experienced caring for clients with cesarean births.
4. A. The patient is experiencing a potentially serious complication related to diabetes and needs
ongoing assessment by an RN
5. D. It describes functional nursing. Staff is assigned to specific task rather than specific clients.
6. B. Case management. The nurse assumes total responsibility for meeting the needs of the
client during her entire duty.
7. B. The nurse is ethically obligated to inform the person responsible for the assignment and the
person responsible for the unit about the nurse’s skill level. The nurse therefore avoids a
situation of abandoningclients and exposing them to greater risks
8. A. This describes a mentor
9. B. This action demonstrates a lack of responsibility and the nurse should attempt negotiation
with the nurse manager.
10. B. The team leader is responsible for the overall management of all clients and staff on the
team, and this information is essential in order to accomplish this
11. C. Even though the mother is a minor, she is legally able to sign consent for her own child.
12. B.  This response is the most direct and immediate. This is a case of potential need for
advocacy and patient’s rights.
13. D.  The nurse who witness a consent for treatment or surgery is witnessing only that the client
signed the form and that the client’s condition is as indicated at the time of signing. The nurse is
not witnessing that the client is “informed”.
14. C. Although the statements by the mother may not create a suspicion of neglect, when they
are coupled with observations about impaired bonding and maternal attachment, they may
impose the obligation to report child neglect. The nurse is further obligated to notify caregivers
of refusal to consent to treatment
15. C. It best explains what informed consent is and provides for legal rights of the patient
16. B. The physician may not be aware of the role that religious beliefs play in making a decision
about surgery.
17. A. The behavior should be stopped. The first step is to remind the staff that confidentiality
may be violated
18. C. Waiting for emotions to dissipate and sitting down with the colleague is the first rule of
conflict resolution.
19. C. The nurse has no idea who the person is on the phone and therefore may not share the
information even if the patient gives permission
20. A. The priority is to let the surgeon know, who in turn may ask the husband to sign the
consent.
21. A. Phenytoin (Dilantin) can cause venous irritation due to its alkalinity, therefore it should be
mixed with normal saline.
22. A. This position increases venous return, improves cardiac volume, and promotes adequate
ventilation and cerebral perfusion
23. D. Checking the airway would be a priority, and a neck injury should be suspected
24. D. Client with Parkinson’s disease are at a high risk for aspiration and undernutrition. Sitting
upright promotes more effective swallowing.
25. C.  It is important to protect the RN’s eyes from the possible contamination of coughed-up
secretions
26. D. There has been too little food or too much insulin. Glucose levels can be markedly
decreased (less than 50 mg/dl). Severe hypoglycemia may be fatal if not detected
27. D. Because the client’s ability to react to stress is decreased, maintaining a quiet environment
becomes a nursing priority. Dehydration is a common problem in Addison’s disease, so close
observation of the client’s hydration level is crucial.
28. D.  Presuctioning and postsuctioning ventilation with 100% oxygen is important in reducing
hypoxemia which occurs when the flow of gases in the airway is obstructed by the suctioning
catheter.
29. B. This is an example of objective data of both pulmonary status and direct observation on the
skin by the nurse.
30. C.  These are likely signs of an acute myocardial infarction (MI). An acute MI is a
cardiovascular emergency requiring immediate attention. Acute MI is potentially fatal if not
treated immediately.
31. D. Assessment and more data collection are needed. The client may have gastrointestinal or
neurological problems that account for the symptoms. The anorexia could result from
medications, poor dentition, or indigestion, and the bruises may be attributed to ataxia, frequent
falls, vertigo or medication.
32. B. This is closest to suggesting action-assessment, rather than paperwork- and is therefore the
best of the four.
33. C. The only acceptable way to identify a preschooler client is to have a parent or another staff
member identify the client.
34. C. It describes the mass in the greatest detail.
35. C. Intravenous pyelogram tests both the function and patency of the kidneys. After the
intravenous injection of a radiopaque contrast medium, the size, location, and patency of the
kidneys can be observed by roentgenogram, as well as the patency of the urethra and bladder as
the kidneys function to excrete the contrast medium.
36. C. This is the recommended position for screening for scoliosis. It allows the nurse to inspect
the alignment of the spine, as well as to compare both shoulders and both hips.
37. A.  Handwashing is the best method for reducing cross-contamination. Gowns and gloves are
not always required when entering a client’s room.
38. B. Pyloric stenosis is an anomaly of the upper gastrointestinal tract. The condition involves a
thickening, or hypertrophy, of the pyloric sphincter located at the distal end of the stomach. This
causes a mechanical intestinal obstruction, which leads to vomiting after feeding the infant. The
vomiting associated with pyloric stenosis is described as being projectile in nature. This is due to
the increasing amounts of formula the infant begins to consume coupled with the increasing
thickening of the pyloric sphincter.
39. B. Increased incidence of TB has been seen in the general population with a high incidence
reported in hospitalized elderly clients. Immunosuppression and lack of classic manifestations
because of the aging process are just two of the contributing factors of tuberculosis in the
elderly.
40. D. Parents should be taught to feel the area that is raised and measure only that.
41. C. It is a safety hazard to have shiny floors because they can cause falls.
42. D. The first priority, beside maintaining a newborn’s patent airway, is body temperature.
43. B.  The purpose of restraints for this child is to keep the child from scratching the affected
areas. Mittens restraint would prevent scratching, while allowing the most movement
permissible.
44. C. Pyloric stenosis is not a congenital anatomical defect, but the precise etiology is unknown.
It develops during the first few weeks of life.
45. B. Pus is usually the first symptom, because the bacteria reproduce in the bladder.
46. A. Preventing infection in the infant with eczema is the nurse’s most important goal. The infant
with eczema is at high risk for infection due to numerous breaks in the skin’s integrity. Intact skin
is always the infant’s first line of defense against infection.
47. D. Frequent hand washing and good hygiene are the best means of preventing infection.
48. D. CHG is a highly effective antimicrobial ingredient, especially when it is used consistently
over time.
49. A.  The mother may have many reasons for such a decision. It is the nurse’s responsibility to
review this decision with the mother and clarify any misconceptions regarding immunizations that
may exist.
50. D. The tumor infiltrates nearby tissue, it can cause retraction of the overlying skin and create a
dimpling appearance.
PNLE II Nursing Practice

Text Mode – Text version of the exam

The scope of  this Nursing Test II is parallel to the NP2 NLE Coverage:
 Maternal and Child Health
 Community Health Nursing
 Communicable Diseases
 Integrated Management of Childhood Illness
1. The student nurse is assigned to take the vital signs of the clients in the pediatric ward. The
student nurse reports to the staff nurse that the parent of a toddler who is 2 days postoperative after
a cleft palate repair has given the toddler a pacifier. What would be the best immediate action of the
nurse?

A. Notify the pediatrician of this finding

B. Reassure the student that this is an acceptable action on the parent’s part
C. Discuss this action with the parents
D. Ask the student nurse to remove the pacifier from the toddler’s mouth
2. The nurse is providing a health teaching to the mother of an 8-year-old child with cystic fibrosis.
Which of the following statement if made by the mother would indicate to the nurse the need for
further teaching about the medication regimen of the child?

A. “My child might need an extra capsule if the meal is high in fat”
B. “I’ll give the enzyme capsule before every snack”
C. “I’ll give the enzyme capsule before every meal”
D. “My child hates to take pills, so I’ll mix the capsule into a cup of hot chocolate
3. The mother brought her child to the clinic for follow-up check up. The mother tells the nurse that
14 days after starting an oral iron supplement, her child’s stools are black. Which of the following is
the best nursing response to the mother?

A. “I will notify the physician, who will probably decrease the dosage slightly”
B. “This is a normal side effect and means the medication is working”
C. “You sound quite concerned. Would you like to talk about this further?”
D. “I will need a specimen to check the stool for possible bleeding”
4. An 8-year-old boy with asthma is brought to the clinic for check up. The mother asks the nurse if
the treatment given to her son is effective. What would be the appropriate response of the nurse?

A. I will review first the child’s height on a growth chart to know if the treatment is working
B. I will review first the child’s weight on a growth chart to know if the treatment is working
C. I will review first the number of prescriptions refills the child has required over the last 6
months to give you an accurate answer
D. I will review first the number of times the child has seen the pediatrician during the last 6
months to give you an accurate answer
5. The nurse is caring to a child client who is receiving tetracycline. The nurse is aware that in taking
this medication, it is very important to:

A. Administer the drug between meals

B. Monitor the child’s hearing
 C. Give the drug through a straw
D. Keep the child out of the sunlight
6. A 14 day-old infant with a cyanotic heart defects and mild congestive heart failure is brought to
the emergency department. During assessment, the nurse checks the apical pulse rate of the infant.
The apical pulse rate is 130 beats per minute. Which of the following is the appropriate nursing
action?

A. Retake the apical pulse in 15 minutes

B. Retake the apical pulse in 30 minutes
C. Notify the pediatrician immediately
D. Administer the medication as scheduled
7. The physician prescribed gentamicin (Garamycin) to a child who is also receiving chemotherapy.
Before administering the drug, the nurse should check the results of the child’s:

A. CBC and platelet count

B. Auditory tests
C. Renal Function tests
D. Abdominal and chest x-rays
8. Which of the following is the suited size of the needle would the nurse select to administer the IM
injection to a preschool child?

A. 18 G, 1-1/2 inch
B. 25 G, 5/8 inch
C. 21 G, 1 inch
D. 18 G, 1inch
9. A 9-year-old boy is admitted to the hospital. The boy is being treated with salicylates for the
migratory polyarthritis accompanying the diagnosis of rheumatic fever. Which of the following
activities performed by the child would give a best sign that the medication is effective?

A. Listening to story of his mother

B. Listening to the music in the radio
C. Playing mini piano
D. Watching movie in the dvd mini player
10. The physician decided to schedule the 4-year-old client for repair of left undescended testicle.
The Injection of a hormone, HCG finds it less successful for treatment. To administer a pentobarbital
sodium (Nembutal) suppository preoperatively to this client, in which position should the nurse place
him?

A. Supine with foot of bed elevated

B. Prone with legs abducted
C. Sitting with foot of bed elevated
D. Side-lying with upper leg flexed
11. The nurse is caring to a 24-month-old child diagnosed with congenital heart defect. The physician
prescribed digoxin (Lanoxin) to the client. Before the administration of the drug, the nurse checks the
apical pulse rate to be 110 beats per minute and regular. What would be the next nursing action?

A. Check the other vital signs and level of consciousness

B. Withhold the digoxin and notify the physician
C. Give the digoxin as prescribed
 D. Check the apical and radial simultaneously, and if they are the same, give the digoxin.
12. An 8-year-old client with cystic fibrosis is admitted to the hospital and will undergo a chest
physiotherapy treatment. The therapy should be properly coordinated by the nurse with the
respiratory therapy department so that treatments occur during:

A. After meals
B. Between meals
C. After medication
D. Around the child’s play schedule
13. The nurse is providing health teaching about the breastfeeding and family planning to the client
who gave birth to a healthy baby girl. Which of the following statement would alert the nurse that
the client needs further teaching?

A. “I understand that the hormones for breastfeeding may affect when my periods come”
B. “Breastfeeding causes my womb to tighten and bleed less after birth”
C. “I may not have periods while I am breastfeeding, so I don’t need family planning”
D. “I can get pregnant as early as one month after my baby was born”
14. A toddler is brought to the hospital because of severe diarrhea and vomiting. The nurse assigned
to the client enters the client’s room and finds out that the client is using a soiled blanket brought in
from home. The nurse attempts to remove the blanket and replace it with a new and clean blanket.
The toddler refuses to give the soiled blanket. The nurse realizes that the best explanation for the
toddler’s behavior is:

A. The toddler did not bond well with the maternal figure
B. The blanket is an important transitional object
C. The toddler is anxious about the hospital experience
D. The toddler is resistive to nursing interventions
15. The nurse has knowledge about the developmental task of the child. In caring a 3-year-old-client,
the nurse knows that the suited developmental task of this child is to:

A. Learn to play with other children

B. Able to trust others
C. Express all needs through speaking
D. Explore and manipulate the environment
16. A mother who gave birth to her second daughter is so concerned about her 2-year old daughter.
She tells the nurse, “I am afraid that my 2-year-old daughter may not accept her newly born sister”.
It is appropriate to the nurse to response that:

A. The older daughter be given more responsibility and assure her “that she is a big girl now, and
doesn’t need Mommy as much”
B. The older daughter not have interaction with the baby at the hospital, because she may harm
her new sibling
C. The older daughter stay with her grandmother for a few days until the parents and new baby
are settled at home
D. The mother spend time alone with her older daughter when the baby is sleeping
17. A 2-year-old client with cystic fibrosis is confined to bed and is not allowed to go to the playroom.
Which of the following is an appropriate toy would the nurse select for the child:

A. Puzzle
 B. Musical automobile
C. Arranging stickers in the album
D. Pounding board and hammer
18. Which of the following clients is at high risk for developmental problem?

A. A toddler with acute Glomerulonephritis on antihypertensive and antibiotics

B. A 5-year-old with asthma on cromolyn sodium
C. A preschooler with tonsillitis
D. A 2 1/2 –year old boy with cystic fibrosis
19. Which of the following would be the best divesionary activity for the nurse to select for a 2 weeks
hospitalized 3-year-old girl?

A. Crayons and coloring books

B. doll
C. xylophone toy
D. puzzles
20. A nurse is providing safety instructions to the parents of the 11-month-old child. Which of the
following will the nurse includes in the instructions?

A. Plugging all electrical outlets in the house

B. Installing a gate at the top and bottom of any stairs in the home
C. Purchasing an infant car seat as soon as possible
D. Begin to teach the child not to place small objects in the mouth
21. An 8-year-old girl is in second grade and the parents decided to enroll her to a new school. While
the child is focusing on adjusting to new environment and peers, her grades suffer. The child’s father
severely punishes the child and forces her daughter to study after school. The father does not allow
also her daughter to play with other children. These data indicate to the nurse that this child is
deprived of forming which normal phase of development?

A. Heterosexual relationships
B. A love relationship with the father
C. A dependency relationship with the father
D. Close relationship with peers
22. A 5-year-old boy client is scheduled for hernia surgery. The nurse is preparing to do preoperative
teaching with the child. The nurse should knows that the 5-year-old would:

A. Expect a simple yet logical explanation regarding the surgery

B. Asks many questions regarding the condition and the procedure
C. Worry over the impending surgery
D. Be uninterested in the upcoming surgery
23. The nine-year-old client is admitted in the hospital for almost 1 week and is on bed rest. The
child complains of being bored and it seems tiresome to stay on bed and doing nothing. What activity
selected by the nurse would the child most likely find stimulating?

A. Watching a video
B. Putting together a puzzle
C. Assembling handouts with the nurse for an upcoming staff development meeting
D. Listening to a compact disc
24. The parent of a 16-year-old boy tells the nurse that his son is driving a motorbike very fast and
with one hand. “It is making me crazy!” What would be the best explanation of the nurse to the
behavior of the boy?

A. The adolescent might have an unconscious death wish

B. The adolescent feels indestructible
C. The adolescent lacks life experience to realize how dangerous the behavior is
D. The adolescent has found a way to act out hostility toward the parent
25. An 8-month-old infant is admitted to the hospital due to diarrhea. The nurse caring for the client
tells the mother to stay beside the infant while making assessment. Which of the following
developmental milestones the infant has reached?

A. Has a three-word vocabulary

B. Interacts with other infants
C. Stands alone
D. Recognizes but is fearful of strangers
26. The community nurse is conducting a health teaching in the group of married women. When
teaching a woman about fertility awareness, the nurse should emphasize that the basal body
temperature:

A. Should be recorded each morning before any activity

B. Is the average temperature taken each morning
C. Can be done with a mercury thermometer but not a digital one
D. Has a lower degree of accuracy in predicting ovulation than the cervical mucus test
27. The community nurse is providing an instruction to the clients in the health center about the use
of diaphragm for family planning. To evaluate the understanding of the woman, the nurse asks her to
demonstrate the use of the diaphragm. Which of following statement indicates a need for further
health teaching?

A. “I should check the diaphragm carefully for holes every time I use it.”
B. “The diaphragm must be left in place for at least 6 hours after intercourse.”
C. “I really need to use the diaphragm and jelly most during the middle of my menstrual cycle
D. “I may need a different size diaphragm if I gain or lose more than 20 pounds”
28. The client visits the clinic for prenatal check-up. While waiting for the physician, the nurse
decided to conduct health teaching to the client. The nurse informed the client that primigravida
mother should go to the hospital when which patter is evident?

A. Contractions are 2-3 minutes apart, lasting 90 seconds, and membranes have ruptured
B. Contractions are 5-10 minutes apart, lasting 30 seconds, and are felt as strong menstrual
cramps
C. Contractions are 3-5 minutes apart, accompanied by rectal pressure and bloody show
D. Contractions are 5 minutes apart, lasting 60 seconds, and increasing in intensity
29. A nurse is planning a home visit program to a new mother who is 2 weeks postpartum and
breastfeeding, the nurse includes in her health teaching about the resumption of fertility,
contraception and sexual activity. Which of the following statement indicates that the mother has
understood the teaching?

A. “Because breastfeeding speeds the healing process after birth, I can have sex right away and
not worry about infection”
B. “Because I am breastfeeding and my hormones are decreased, I may need to use a vaginal
lubricant when I have sex”
C. “After birth, you have to have a period before you can get pregnant again’
D. “Breastfeeding protects me from pregnancy because it keeps my hormones down, so I don’t
need any contraception until I stop breastfeeding”
30. A community nurse enters the home of the client for follow-up visit. Which of the following is the
most appropriate area to place the nursing bag of the nurse when conducting a home visit?

A. cushioned footstool
B. bedside wood table
C. kitchen countertop
D. living room sofa
31. The nurse in the health center is making an assessment to the infant client. The nurse notes
some rashes and small fluid-filled bumps in the skin. The nurse suspects that the infant has eczema.
Which of the following is the most important nursing goal:

A. Preventing infection
B. Providing for adequate nutrition
C. Decreasing the itching
D. Maintaining the comfort level
32. The nurse in the health center is providing immunization to the children. The nurse is carefully
assessing the condition of the children before giving the vaccines. Which of the following would the
nurse note to withhold the infant’s scheduled immunizations?

A. a dry cough
B. a skin rash
C. a low-grade fever
D. a runny nose
33. A mother brought her child in the health center for hepatitis B vaccination in a series. The mother
informs the nurse that the child missed an appointment last month to have the third hepatitis B
vaccination. Which of the following statements is the appropriate nursing response to the mother?

A. “I will examine the child for symptoms of hepatitis B”

B. “Your child will start the series again”
C. “Your child will get the next dose as soon as possible”
D. “Your child will have a hepatitis titer done to determine if immunization has taken place.”
34. The community health nurse implemented a new program about effective breast cancer
screening technique for the female personnel of the health department of Valenzuela. Which of the
following technique should the nurse consider to be of the lowest priority?

A. Yearly breast exam by a trained professional

B. Detailed health history to identify women at risk
C. Screening mammogram every year for women over age 50
D. Screening mammogram every 1-2 years for women over age of 40.
35. Which of the following technique is considered an aseptic practice during the home visit of the
community health nurse?

A. Wrapping used dressing in a plastic bag before placing them in the nursing bag
B. Washing hands before removing equipment from the nursing bag
 C. Using the client’s soap and cloth towel for hand washing
D. Placing the contaminated needles and syringes in a labeled container inside the nursing bag
36. The nurse is planning to conduct a home visit in a small community. Which of the following is the
most important factor when planning the best time for a home care visit?

A. Purpose of the home visit

B. Preference of the patient’s family
C. Location of the patient’s home
D. Length of time of the visit will take
37. The nurse assigned in the health center is counseling a 30-year-old client requesting oral
contraceptives. The client tells the nurse that she has an active yeast infection that has recurred
several times in the past year. Which statement by the nurse is inaccurate concerning health
promotion actions to prevent recurring yeast infection?

A. “During treatment for yeast, avoid vaginal intercourse for one week”
B. “Wear loose-fitting cotton underwear”
C. “Avoid eating large amounts of sugar or sugar-bingeing”
D. “Douche once a day with a mild vinegar and water solution”
38. During immunization week in the health center, the parent of a 6-month-old infant asks the
health nurse, “Why is our baby going to receive so many immunizations over a long time period?”
The best nursing response would be:

A. “The number of immunizations your baby will receive shows how many pediatric
communicable and infectious diseases can now be prevented.”
B. “You need to ask the physician”
C. “The number of immunizations your baby will receive is determined by your baby’s health
history and age”
D. “It is easier on your baby to receive several immunizations rather than one at a time”
39. The community health nurse is conducting a health teaching about nutrition to a group of
pregnant women who are anemic and are lactose intolerant. Which of the following foods should the
nurse especially encourage during the third trimester?

A. Cheese, yogurt, and fish for protein and calcium needs plus prenatal vitamins and iron
supplements
B. Prenatal iron and calcium supplements plus a regular adult diet
C. Red beans, green leafy vegetables, and fish for iron and calcium needs plus prenatal vitamins
and iron supplements
D. Red meat, milk and eggs for iron and calcium needs plus prenatal vitamins and iron
supplements
40. A woman with active tuberculosis (TB) and has visited the health center for regular therapy for
five months wants to become pregnant. The nurse knows that further information is necessary when
the woman states:

A. “Spontaneous abortion may occur in one out of five women who are infected”
B. “Pulmonary TB may jeopardize my pregnancy”
C. “I know that I may not be able to have close contact with my baby until contagious is no
longer a problem
D. “I can get pregnant after I have been free of TB for 6 months”
41. The Department of Health is alarmed that almost 33 million people suffer from food poisoning
every year. Salmonella enteritis is responsible for almost 4 million cases of food poisoning. One of the
major goals is to promote proper food preparation. The community health nurse is tasks to conduct
health teaching about the prevention of food poisoning to a group of mother everyday. The nurse
can help identify signs and symptoms of specific organisms to help patients get appropriate
treatment. Typical symptoms of salmonella include:

A. Nausea, vomiting and paralysis

B. Bloody diarrhea
C. Diarrhea and abdominal cramps
D. Nausea, vomiting and headache
42. A community health nurse makes a home visit to an elderly person living alone in a small house.
Which of the following observation would be a great concern?

A. Big mirror in a wall

B. Scattered and unwashed dishes in the sink
C. Shiny floors with scattered rugs
D. Brightly lit rooms
43. The health nurse is conducting health teaching about “safe” sex to a group of high school
students. Which of the following statement about the use of condoms should the nurse avoid
making?

A. “Condoms should be used because they can prevent infection and because they may prevent
pregnancy”
B. “Condoms should be used even if you have recently tested negative for HIV”
C. “Condoms should be used every time you have sex because condoms prevent all forms of
sexually transmitted diseases”
D. “Condoms should be used every time you have sex even if you are taking the pill because
condoms can prevent the spread of HIV and gonorrhea”
44. The department of health is promoting the breastfeeding program to all newly mothers. The
nurse is formulating a plan of care to a woman who gave birth to a baby girl. The nursing care plan
for a breast-feeding mother takes into account that breast-feeding is contraindicated when the
woman:

A. Is pregnant
B. Has genital herpes infection
C. Develops mastitis
D. Has inverted nipples
45. The City health department conducted a medical mission in Barangay Marulas. Majority of the
children in the Barangay Marulas were diagnosed with pinworms. The community health nurse should
anticipate that the children’s chief complaint would be:

A. Lack of appetite
B. Severe itching of the scalp
C. Perianal itching
D. Severe abdominal pain
46. The mother brought her daughter to the health center. The child has head lice. The nurse
anticipates that the nursing diagnosis most closely correlated with this is:
 A. Fluid volume deficit related to vomiting
B. Altered body image related to alopecia
C. Altered comfort related to itching
D. Diversional activity deficit related to hospitalization
47. The mother brings a child to the health care clinic because of severe headache and vomiting.
During the assessment of the health care nurse, the temperature of the child is 40 degree Celsius,
and the nurse notes the presence of nuchal rigidity. The nurse is suspecting that the child might be
suffering from bacterial meningitis. The nurse continues to assess the child for the presence of
Kernig’s sign. Which finding would indicate the presence of this sign?

A. Flexion of the hips when the neck is flexed from a lying position
B. Calf pain when the foot is dorsiflexed
C. Inability of the child to extend the legs fully when lying supine
D. Pain when the chin is pulled down to the chest
48. A community health nurse makes a home visit to a child with an infectious and communicable
disease. In planning care for the child, the nurse must determine that the primary goal is that the:

A. Child will experience mild discomfort

B. Child will experience only minor complications
C. Child will not spread the infection to others
D. Public health department will be notified
49. The mother brings her daughter to the health care clinic. The child was diagnosed with
conjunctivitis. The nurse provides health teaching to the mother about the proper care of her
daughter while at home. Which statement by the mother indicates a need for additional information?

A. “I do not need to be concerned about the spreading of this infection to others in my family”
B. “I should apply warm compresses before instilling antibiotic drops if purulent discharge is
present in my daughter’s eye”
C. “I can use an ophthalmic analgesic ointment at nighttime if I have eye discomfort”
D. “I should perform a saline eye irrigation before instilling, the antibiotic drops into my
daughter’s eye if purulent discharge is present”
50. A community health nurse is caring for a group of flood victims in Marikina area. In planning for
the potential needs of this group, which is the most immediate concern?

A. Finding affordable housing for the group

B. Peer support through structured groups
C. Setting up a 24-hour crisis center and hotline
D. Meeting the basic needs to ensure that adequate food, shelter and clothing are available
Answers and Rationales
1. C. Nothing must be placed in the mouth of a toddler who just undergone a cleft palate repair
until the suture line has completely healed. It is the nurse’s responsibility to inform the parent of
the client. Spoon, forks, straws, and tongue blades are other unacceptable items to place in the
mouth of a toddler who just undergone cleft palate repair. The general principle of care is that
nothing should enter the mouth until the suture line has completely healed.
2. D. The pancreatic capsules contain pancreatic enzyme that should be administered in a cold,
not a hot, medium (example: chilled applesauce versus hot chocolate) to maintain the
medication’s integrity.
3. B. When oral iron preparations are given correctly, the stools normally turn dark green or
black. Parents of children receiving this medication should be advised that this side effect
indicates the medication is being absorbed and is working well.
4. C. Reviewing the number of prescription refills the child has required over the last 6 months
would be the best indicator of how well controlled and thus how effective the child’s asthma
treatment is. Breakthrough wheezing, shortness of breath, and upper respiratory infections
would require that the child take additional medication. This would be reflected in the number of
prescription refills.
5. D. Tetracycline may cause a phototoxic reaction.
6. D. The normal heart rate of an infant is 120-160 beats per minute.
7. C. Both gentamicin and chemotherapeutic agents can cause renal impairment and acute renal
failure; thus baseline renal function must be evaluated before initiating either medication.
8. C. In selecting the correct needle to administer an IM injection to a preschooler, the nurse
should always look at the child and use judgment in evaluating muscle mass and amount of
subcutaneous fat. In this case, in the absence of further data, the nurse would be most correct
in selecting a needle gauge and length appropriate for the “average’ preschool child. A medium-
gauge needle (21G) that is 1 inch long would be most appropriate.
9. C. The purpose of the salicylate therapy is to relieve the pain associated with the migratory
polyarthritis accompanying the rheumatic fever. Playing mini piano would require movement of
the child’s joints and would provide the nurse with a means of evaluating the child’s level of pain.
10. D. The recommended position to administer rectal medications to children is side-lying with
the upper leg flexed. This position allows the nurse to safely and effectively administer the
medication while promoting comfort for the child.
11. C. For a 12month-old child, 110 apical pulse rate is normal and therefore it is safe to give the
digoxin. A toddler’s normal pulse rate is slightly lower than an infant’s (120).
12. B. Chest physiotherapy treatments are scheduled between meals to prevent aspiration of
stomach contents, because the child is placed in a variety of positions during the treatment
process.
13. C. It is common misconception that breastfeeding may prevent pregnancy.
14. B. The “security blanket” is an important transitional object for the toddler. It provides a
feeling of comfort and safety when the maternal figure is not present or when in a new situation
for which the toddler was not prepared. Virtually any object (stuffed animal, doll, book etc) can
become a security blanket for the toddler.
15. D. Toddlers need to meet the developmental milestone of autonomy versus shame and doubt.
In order to accomplish this, the toddler must be able to explore and manipulate the environment.
16. D. The introduction of a baby into a family with one or more children challenges parent to
promote acceptance of the baby by siblings. The parent’s attitudes toward the arrival of the baby
can set the stage for the other children’s reaction. Spending time with the older siblings alone
will also reassure them of their place in the family, even though the older children will have to
eventually assume new positions within the family hierarchy.
17. D. The autonomous toddler would be frustrated by being confined to be. The pounding board
and hammer is developmentally appropriate and an excellent way for the toddler to release
frustration.
18. D.  It is the developmental task of an 18-month-old toddler to explore and learn about the
environment. The respiratory complications associated with cystic fibrosis (which are present in
almost all children with cystic fibrosis) could prevent this development task from occurring.
19. C. The best diversion for a hospitalized child aged 2-3 years old would be anything that makes
noise or makes a mess; xylophone which certainly makes noise or music would be the best
choice.
20. B. An 11-month-old child stands alone and can walk holding onto people or objects. Therefore
the installation of a gate at the top and bottom of any stairs in the house is crucial for the child’s
safety.
21. D. In second grade a child needs to form a close relationships with peers.
22. B.  A 5-year-old is highly concerned with body integrity. The preschool-age child normally asks
many questions and in a situation such as this, could be expected to ask even more.
23. C. A 9-year-old enjoys working and feeling a sense of accomplishment. The school-age child
also enjoys “showing off,” and doing something with the nurse on the pediatric unit would allow
this. This activity also provides the school-age child a needed opportunity to interact with others
in the absence of school and personal friends.
24. B. Adolescents do feel indestructible, and this is reflected in many risk-taking behaviors.
25. D. An 8-month-old infant both recognizes and is fearful of strangers. This developmental
milestone is known as “stranger anxiety”.
26. A. The basal body temperature (BBT) is the lowest body temperature of a healthy person that
is taken immediately after waking and before getting out of bed. The BBT usually varies from
36.2 – 36.3 degree Celsius during menses and for about 5-7 days afterward. About the time of
ovulation, a slight drop approximately 0.05 degree Celsius in temperature may be seen; after
ovulation, in concert with the increasing progesterone levels of the early luteal phase, the BBT
rises 0.2-0.4 degree Celsius. This elevation remains until 2-3 days before menstruation, or if
pregnancy has occurred.
27. C.  The woman must understand that, although the “fertile” period is approximately midcycle,
hormonal variations do occur and can result in early or late ovulations. To be effective, the
diaphragm should be inserted before every intercourse.
28. D. Although instructions vary among birth centers, primigravidas should seek care when
regular contractions are felt about 5 minutes apart, becoming longer and stronger.
29. B.  Prolactin suppresses estrogen, which is needed to stimulate vaginal lubrication during
arousal.
30. B. A wood surface provides the least chance for organisms to be present.
31. A. Preventing infection in the infant with eczema is the nurse’s most important goal. The infant
with eczema is at high risk for infection due to numerous breaks in the skin’s integrity. Intact skin
is always the infant’s first line of defense against infection.
32. B.  A skin rash could indicate a concurrent infectious disease process in the infant. The
scheduled immunizations should be withheld until the status of the infant’s health can be
determined. Fevers above 38.5 degrees Celsius, alteration in skin integrity, and infectious-
appearing secretions are indications to withhold immunizations.
33. C. Continuity is essential to promote active immunity and give hepatitis B lifelong prophylaxis.
Optimally, the third vaccination is given 6 months after the first.
34. B. Because of the high incidence of breast cancer, all women are considered to be at risk
regardless of health history.
35. B. Handwashing is the best way to prevent the spread of infection.
36. A. The purpose of the visit takes priority.
37. D. Frequent douching interferes with the natural protective barriers in the vagina that resist
yeast infection and should be avoided.
38. A. Completion for the recommended schedule of infant immunizations does not require a large
number of immunizations, but it also provides protection against multiple pediatric communicable
and infectious diseases.
39. C. This is appropriate foods that are high in iron and calcium but would not affect lactose
intolerance.
40. D. Intervention is needed when the woman thinks that she needs to wait only 6 months after
being free of TB before she can get pregnant. She needs to wait 1.5-2years after she is declared
to be free of TB before she should attempt pregnancy.
41. C. Salmonella organisms cause lower GI symptoms
42. C. It is a safety hazard to have shiny floors and scattered rugs because they can cause falls
and rugs should be removed.
43. C. Condoms do not prevent ALL forms of sexually transmitted diseases.
44. A.  Pregnancy is one contraindication to breast-feeding. Milk secretion is inhibited and the
baby’s sucking may stimulate uterine contractions.
45. C.  Perianal itching is the child’s chief complaint associated with the diagnosis of pinworms.
The itching, in this instance, is often described as being “intense” in nature. Pinworms infestation
usually occurs because the child is in the anus-to-mouth stage of development (child uses the
toilet, does not wash hands, places hands and pinworm eggs in mouth). Teaching the child hand
washing before eating and after using the toilet can assist in breaking the cycle.
46. C.  Severe itching of the scalp is the classic sign and symptom of head lice in a child. In turn,
this would lead to the nursing diagnosis of “altered comfort”.
47. C. Kernig’s sign is the inability of the child to extend the legs fully when lying supine. This sign
is frequently present in bacterial meningitis. Nuchal rigidity is also present in bacterial meningitis
and occurs when pain prevents the child from touching the chin to the chest.
48. C. The primary goal is to prevent the spread of the disease to others. The child should
experience no complication. Although the health department may need to be notified at some
point, it is no the primary goal. It is also important to prevent discomfort as much as possible.
49. A. Conjunctivitis is highly contagious. Antibiotic drops are usually administered four times a
day. When purulent discharge is present, saline eye irrigations or eye applications of warm
compresses may be necessary before instilling the medication. Ophthalmic analgesic ointment or
drops may be instilled, especially at bedtime, because discomfort becomes more noticeable when
the eyelids are closed.
50. D.  The question asks about the immediate concern. The ABCs of community health care are
always attending to people’s basic needs of food, shelter, and clothing
PNLE III Nursing Practice

Text Mode – Text version of the exam

The scope of this Nursing Test III is parallel to the NP3 NLE Coverage:
 Medical Surgical Nursing
1. The nurse is going to replace the Pleur-O-Vac attached to the client with a small, persistent left
upper lobe pneumothorax with a Heimlich Flutter Valve. Which of the following is the best rationale
for this?

A. Promote air and pleural drainage

B. Prevent kinking of the tube
C. Eliminate the need for a dressing
D. Eliminate the need for a water-seal drainage
2. The client with acute pancreatitis and fluid volume deficit is transferred from the ward to the ICU.
Which of the following will alert the nurse?

A. Decreased pain in the fetal position

B. Urine output of 35mL/hr
C. CVP of 12 mmHg
D. Cardiac output of 5L/min
3. The nurse in the morning shift is making rounds in the ward. The nurse enters the client’s room
and found the client in discomfort condition. The client complains of stiffness in the joints. To reduce
the early morning stiffness of the joints of the client,the nurse can encourage the client to:

A. Sleep with a hot pad

B. Take to aspirins before arising, and wait 15 minutes before attempting locomotion
C. Take a hot tub bath or shower in the morning
D. Put joints through passive ROM before trying to move them actively
4. The nurse is planning of care to a client with peptic ulcer disease. To avoid the worsening
condition of the client, the nurse should carefully plan the diet of the client. Which of the following
will be included in the diet regime of the client?

A. Eating mainly bland food and milk or dairy products

B. Reducing intake of high-fiber foods
C. Eating small, frequent meals and a bedtime snack
D. Eliminating intake of alcohol and coffee
5. The physician has given instruction to the nurse that the client can be ambulated on crutches, with
no weight bearing on the affected limb. The nurse is aware that the appropriate crutch gait for the
nurse to teach the client would be:

A. Tripod gait
B. Two-point gait
C. Four-point gait
D. Three-point gait
6. The client is transferred to the nursing care unit from the operating room after a transurethral
resection of the prostate. The client is complaining of pain in the abdomen area. The nurse suspects
of bladder spasms, which of the following is the best nursing action to minimize the pain felt by the
client?

A. Advising the client not to urinate around catheter

B. Intermittent catheter irrigation with saline
C. Giving prescribed narcotics every 4 hour
D. Repositioning catheter to relieve pressure
7. A client is diagnosed with peptic ulcer. The nurse caring for the client expects the physician to
order which diet?

A. NPO
B. Small feedings of bland food
C. A regular diet given frequently in small amounts
D. Frequent feedings of clear liquids
8. The nurse is going to insert a Miller-Abbott tube to the client. Before insertion of the tube, the
balloon is tested for patency and capacity and then deflated. Which of the following nursing measure
will ease the insertion to the tube?

A. Positioning the client in Semi-Fowler’s position

B. Administering a sedative to reduce anxiety
C. Chilling the tube before insertion
D. Warming the tube before insertion
9. The physician ordered a low-sodium diet to the client. Which of the following food will the nurse
avoid to give to the client?

A. Orange juice.
B. Whole milk.
C. Ginger ale.
D. Black coffee.
10. Mr. Bean, a 70-year-old client is admitted in the hospital for almost one month. The nurse
understands that prolonged immobilization could lead to decubitus ulcers. Which of the following
would be the least appropriate nursing intervention in the prevention of decubitus?

A. Giving backrubs with alcohol

B. Use of a bed cradle
C. Frequent assessment of the skin
D. Encouraging a high-protein diet
11. The physician prescribed digoxin 0.125 mg PO qd to a client and instructed the nurse that the
client is on high-potassium diet. High potassium foods are recommended in the diet of a client taking
digitalis preparations because a low serum potassium has which of the following effects?

A. Potentiates the action of digoxin

B. Promotes calcium retention
C. Promotes sodium excretion
D. Puts the client at risk for digitalis toxicity
12. The nurse is caring for a client who is transferred from the operating room for pneumonectomy.
The nurse knows that immediately following pneumonectomy; the client should be in what position?
 A. Supine on the unaffected side
B. Low-Fowler’s on the back
C. Semi-Fowler’s on the affected side
D. Semi-Fowler’s on the unaffected side
13. A client is placed on digoxin, high potassium foods are recommended in the diet of the client.
Which of the following foods willthe nurse give to the client?

A. Whole grain cereal, orange juice, and apricots

B. Turkey, green bean, and Italian bread
C. Cottage cheese, cooked broccoli, and roast beef
D. Fish, green beans and cherry pie
14. The nurse is assigned to care to a client who undergone thyroidectomy. What nursing
intervention is important during the immediate postoperative period following a thyroidectomy?

A. Assess extremities for weakness and flaccidity

B. Support the head and neck during position changes
C. Position the client in high Fowler’s
D. Medicate for restlessness and anxiety
15. What would be the recommended diet the nurse will implement to a client with burns of the
head, face, neck and anterior chest?

A. Serve a high-protein, high-carbohydrate diet

B. Encourage full liquid diet
C. Serve a high-fat diet, high-fiber diet
D. Monitor intake to prevent weight gain
16. A client with multiple fractures of both lower extremities is admitted for 3 days ago and is on
skeletal traction. The client is complaining of having difficulty in bowel movement. Which of the
following would be the most appropriate nursing intervention?

A. Administer an enema
B. Perform range-of-motion exercise to all extremities
C. Ensure maximum fluid intake (3000ml/day)
D. Put the client on the bedpan every 2 hours
17. John is diagnosed with Addison’s disease and admitted in the hospital. What would be the
appropriate nursing care for John?

A. Reducing physical and emotional stress

B. Providing a low-sodium diet
C. Restricting fluids to 1500ml/day
D. Administering insulin-replacement therapy
18. Mr. Smith is scheduled for an above-the-knee amputation. After the surgery he was transferred
to the nursing care unit. The nurse assigned to him knows that 72 hours after the procedure the
client should be positioned properly to prevent contractures. Which of the following is the best
position to the client?

A. Side-lying, alternating left and right sides

B. Sitting in a reclining chair twice a day
C. Lying on abdomen several times daily
D. Supine with stump elevated at least 30 degrees
19. A client is scheduled to have an inguinal herniorraphy in the outpatient surgical department. The
nurse is providing health teaching about post surgical care to the client. Which of the following
statement if made by the client would reflect the need for more teaching?

A. “I should call the physician if I have a cough or cold before surgery”

B. “I will be able to drive soon after surgery”
C. “I will not be able to do any heavy lifting for 3-6 weeks after surgery”
D. “I should support my incision if I have to cough or turn”
20. Ms Jones is brought to the emergency room and is complaining of muscle spasms, numbness,
tremors and weakness in the arms and legs. The client was diagnosed with multiple sclerosis. The
nurse assigned to Ms. Jones is aware that she has to prevent fatigue to the client to alleviate the
discomfort. Which of the following teaching is necessary to prevent fatigue?

A. Avoid extremes in temperature

B. Install safety devices in the home
C. Attend support group meetings
D. Avoid physical exercise
21. Mr. Stewart is in sickle cell crisis and complaining pain in the joints and difficulty of breathing. On
the assessment of the nurse, his temperature is 38.1 ºC. The physician ordered Morphine sulfate via
patient-controlled analgesia (PCA), and oxygen at 4L/min. A priority nursing diagnosis to Mr. Stewart
is risk for infection. A nursing intervention to assist in preventing infection is:

A. Using standard precautions and medical asepsis

B. Enforcing a “no visitors” rule
C. Using moist heat on painful joints
D. Monitoring a vital signs every 2 hour
22. Mrs. Maupin is a professor in a prestigious university for 30 years. After lecture, she experience
blurring of vision and tiredness. Mrs. Maupin is brought to the emergency department. On
assessment, the nurse notes that the blood pressure of the client is 139/90. Mrs. Maupin has been
diagnosed with essential hypertension and placed on medication to control her BP. Which potential
nursing diagnosis will be a priority for discharge teaching?

A. Sleep Pattern disturbance

B. Impaired physical mobility
C. Noncompliance
D. Fluid volume excess
23. Following a needle biopsy of the kidney, which assessment is an indication that the client is
bleeding?

A. Slow, irregular pulse

B. Dull, abdominal discomfort
C. Urinary frequency
D. Throbbing headache
24. A client with acute bronchitis is admitted in the hospital. The nurse assigned to the client is
making a plan of care regarding expectoration of thick sputum. Which nursing action is most
effective?

A. Place the client in a lateral position every 2 hour

B. Splint the patient’s chest with pillows when coughing
 C. Use humified oxygen
D. Offer fluids at regular intervals
25. The nurse is going to assess the bowel sound of the client. For accurate assessment of the bowel
sound, the nurse should listen for at least:

A. 5 minutes
B. 60 seconds
C. 30 seconds
D. 2 minutes
26. The nurse encourages the client to wear compression stockings. What is the rationale behind in
using compression stockings?

A. Compression stockings promote venous return

B. Compression stockings divert blood to major vessels
C. Compression stockings decreases workload on the heart
D. Compression stockings improve arterial circulation
27. Mr. Whitman is a stroke client and is having difficulty in swallowing. Which is the best nursing
intervention is most likely to assist the client?

A. Placing food in the unaffected side of the mouth

B. Increasing fiber in the diet
C. Asking the patient to speak slowly
D. Increasing fluid intake
28. Following nephrectomy, the nurse closely monitors the urinary output of the client. Which
assessment finding is an early indicator of fluid retention in the postoperative period?

A. Periorbital edema
B. Increased specific gravity of urine
C. A urinary output of 50mL/hr
D. Daily weight gain of 2 lb or more
29. A nurse is completing an assessment to a client with cirrhosis. Which of the following nursing
assessment is important to notify the physician?

A. Expanding ecchymosis
B. Ascites and serum albumin of 3.2 g/dl
C. Slurred speech
D. Hematocrit of 37% and hemoglobin of 12g/dl
30. Mr. Park is 32-year-old, a badminton player and has a type 1 diabetes mellitus. After the game,
the client complains of becoming diaphoretic and light-headedness. The client asks the nurse how to
avoid this reaction. The nurse will recommend to:

A. Allow plenty of time after the insulin injection and before beginning the match
B. Eat a carbohydrate snack before and during the badminton match
C. Drink plenty of fluids before, during, and after bed time
D. Take insulin just before starting the badminton match
31. A client is rushed to the emergency room due to serious vehicle accident. The nurse is suspecting
of head injury. Which of the following assessment findings would the nurse report to the physician?

A. CVP of 5mmHa
 B. Glasgow Coma Scale score of 13
C. Polyuria and dilute urinary output
D. Insomnia
32. Mrs. Moore, 62-year-old, with diabetes is in the emergency department. She stepped on a sharp
sea shells while walking barefoot along the beach. Mrs. Moore did not notice that the object pierced
the skin until later that evening. What problem does the client most probably have?

A. Nephropathy
B. Macroangiopathy
C. Carpal tunnel syndrome
D. Peripheral neuropathy
33. A client with gangrenous foot has undergone a below-knee amputation. The nurse in the nursing
care unit knows that the priority nursing intervention in the immediate post operative care of this
client is:

A. Elevate the stump on a pillow for the first 24 hours

B. Encourage use of trapeze
C. Position the client prone periodically
D. Apply a cone-shaped dressing
34. A client with a diagnosis of gastric ulcer is complaining of syncope and vertigo. What would be
the initial nursing intervention by the nurse?

A. Monitor the client’s vital signs

B. Keep the client on bed rest
C. Keep the patient on bed rest
D. Give a stat dose of Sucralfate (Carafate)
35. After a right lower lobectomy on a 55-year-old client, which action should the nurse initiate when
the client is transferred from the post anesthesia care unit?

A. Notify the family to report the client’s condition

B. Immediately administer the narcotic as ordered
C. Keep client on right side supported by pillows
D. Encourage coughing and deep breathing every 2 hours
36. The nurse is providing a discharge instruction about the prevention of urinary stasis to a client
with frequent bladder infection. Which of the following will the nurse include in the instruction?

A. Drink 3-4 quarts of fluid every day

B. Empty the bladder every 2-4 hours while awake
C. Encourage the use of coffee, tea, and colas for their diuretic effect
D. Teach Kegel exercises to control bladder flow
37. A male client visits the clinic for check-up. The client tells the nurse that there is a yellow
discharge from his penis. He also experiences a burning sensation when urinating. The nurse is
suspecting of gonorrhea. What teaching is necessary for this client?

A. Sex partner of 3 months ago must be treated

B. Women with gonorrhea are symptomatic
C. Use a condom for sexual activity
D. Sex partner needs to be evaluated
38. A client with AIDS is admitted in the hospital. He is receiving intravenous therapy. While the
nurse is assessing the IV site, the client becomes confused and restless and the intravenous catheter
becomes disconnected and minimal amount of the client’s blood spills onto the floor. Which action
will the nurse take to remove the blood spill?

A. Promptly clean with a 1:10 solution of household bleach and water

B. Promptly clean up the blood spill with full-strength antimicrobial cleaning solution
C. Immediately mop the floor with boiling water
D. Allow the blood to dry before cleaning to decrease the possibility of cross-contamination
39. Before surgery, the physician ordered pentobarbital sodium (Nembutal) for the client to sleep.
The night before the scheduled surgery, the nurse gave the pre-medication. One hour later the client
is still unable to sleep. The nurse review the client’s chart and note the physician’s prescription with
an order to repeat. What should the nurse do next?

A. Rub the client’s back until relaxed

B. Prepare a glass of warm milk
C. Give the second dose of pentobarbital sodium
D. Explore the client’s feelings about surgery
40. The nurse on the night shift is making rounds in the nursing care unit. The nurse is about to
enter to the client’s room when a ventilator alarm sounds, what is the first action the nurse should
do?

A. Assess the lung sounds

B. Suction the client right away
C. Look at the client
D. Turn and position the client
41. What effective precautions should the nurse use to control the transmission of methicillin-
resistant Staphylococcus aureus (MRSA)?

A. Use gloves and handwashing before and after client contact

B. Do nasal cultures on healthcare providers
C. Place the client on total isolation
D. Use mask and gown during care of the MRSA client
42. The postoperative gastrectomy client is scheduled for discharge. The client asks the nurse,
“When I will be allowed to eat three meals a day like the rest of my family?”. The appropriate nursing
response is:

A. “You will probably have to eat six meals a day for the rest of your life.”
B. “Eating six meals a day can be a bother, can’t it?”
C. “Some clients can tolerate three meals a day by the time they leave the hospital. Maybe it will
be a little longer for you.”
D. “ It varies from client to client, but generally in 6-12 months most clients can return to their
previous meal patterns”
43. A male client with cirrhosis is complaining of belly pain, itchiness and his breasts are getting
larger and also the abdomen. The client is so upset because of the discomfort and asks the nurse
why his breast and abdomen are getting larger. Which of the following is the appropriate nursing
response?

A. “How much of a difference have you noticed”

 B. “It’s part of the swelling your body is experiencing”
C. “It’s probably because you have been less physically active”
D. “Your liver is not destroying estrogen hormones that all men produce”
44. A client is diagnosed with detached retina and scheduled for surgery. Preoperative teaching of
the nurse to the client includes:

A. No eye pain is expected postoperatively

B. Semi-fowler’s position will be used to reduce pressure in the eye.
C. Eye patches may be used postoperatively
D. Return of normal vision is expected following surgery
45. A 70-year-old client is brought to the emergency department with a caregiver. The client has
manifestations of anorexia, wasting of muscles and multiple bruises. What nursing interventions
would the nurse implement?

A. Talk to the client about the caregiver and support system

B. Complete a gastrointestinal and neurological assessment
C. Check the lab data for serum albumin, hematocrit and hemoglobin
D. Complete a police report on elder abuse
46. A nurse is providing a discharge instruction to the client about the self-catheterization at home.
Which of the following instructions would the nurse include?

A. Wash the catheter with soap and water after each use
B. Lubricate the catheter with Vaseline
C. Perform the Valsalva maneuver to promote insertion
D. Replace the catheter with a new one every 24 hour
47. The nurse in the nursing care unit is assigned to care to a client who is Immunocompromised.
The client tells the nurse that his chest is painful and the blisters are itchy. What would be the
nursing intervention to this client?

A. Call the physician

B. Give a prn pain medication
C. Clarify if the client is on a new medication
D. Use gown and gloves while assessing the lesions
48. A client is admitted and has been diagnosed with bacterial (meningococcal) meningitis. The
infection control registered nurse visits the staff nurse caring to the client. What statement made by
the nurse reflects an understanding of the management of this client?

A. speech pattern may be altered

B. Respiratory isolation is necessary for 24 hours after antibiotics are started
C. Perform skin culture on the macular popular rash
D. Expect abnormal general muscle contractions
49. A 18-year-old male client had sustained a head injury from a motorbike accident. It is uncertain
whether the client may have minimal but permanent disability. The family is concerned regarding the
client’s difficulty accepting the possibility of long term effects. Which nursing diagnosis is best for this
situation?

A. Nutrition, less than body requirements

B. Injury, potential for sensory-perceptual alterations
C. Impaired mobility, related to muscle weakness
 D. Anticipatory grieving, due to the loss of independence
50. A client with AIDS is scheduled for discharge. The client tells the nurse that one of his hobbies at
home is gardening. What will be the discharge instruction of the nurse to the client knowing that the
client is prone to toxoplasmosis?

A. Wash all vegetables before cooking

B. Wear gloves when gardening
C. Wear a mask when travelling to foreign countries
D. Avoid contact with cats and birds
Answers and Rationales
1. D. The Heimlich flutter valve has a one-way valve that allows air and fluid to drain.
Underwater seal drainage is not necessary. This can be connected to a drainage bag for the
patient’s mobility. The absence of a long drainage tubing and the presence of a one-way valve
promote effective therapy
2. C. C = the normal CVP is 0-8 mmHg. This value reflects hypervolemia. The right ventricular
function of this client reflects fluid volume overload, and the physician should be notified.
3. C. A hot tub bath or shower in the morning helps many patients limber up and reduces the
symptoms of early morning stiffness. Cold and ice packs are used to a lesser degree, though
some clients state that cold decreases localized pain, particularly during acute attacks.
4. D. These substances stimulate the production of hydrochloric acid, which is detrimental in
peptic ulcer disease.
5. D. The three-point gait is appropriate when weight bearing is not allowed on the affected limb.
The swing-to and swing-through crutch gaits may also be used when only one leg can be used
for weight bearing
6. A. The client needs to be told before surgery that the catheter causes the urge to void.
Attempts to void around the catheter cause the bladder muscles to contract and result in painful
spasms.
7. B. Bland feedings should be given in small amounts on a frequent basis to neutralize the
hydrochloric acid and to prevent overload
8. C. Chilling the tube before insertion assists in relieving some of the nasal discomfort. Water-
soluble lubricants along with viscous lidocaine (Xylocaine) may also be used. It is usually only
lightly lubricated before insertion
9. B. Whole milk should be avoided to include in the client’s diet because it has 120 mg of
sodium in 8 0z of milk.
10. A. Alcohol is extremely drying and contributes to skin break down. An emollient lotion should
be used.
11. D.  Potassium influences the excitability of nerves and muscles. When potassium is low and
the client is on digoxin, the risk of digoxin toxicity is increased.
12. C. This position allows maximum expansion, ventilation, and perfusion of the remaining lung.
13. A. These foods are high in potassium
14. B. Stress on the suture line should be avoided. Prevent flexion or hyperextension of the neck,
and provide a small pillow under thehead and neck. Neck muscles have been affected during a
thyroidectomy, support essential for comfort and incisional support.
15. A. A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and
resistance to infection. Caloric goals may be as high as 5000 calories per day.
16. C. The best early intervention would be to increase fluid intake, because constipation is
common when activity is decreased or usual routines have been interrupted.
17. A. Because the client’s ability is to react to stress is decreased, maintaining a quiet
environment becomes A nursing priority. Dehydration is a common problem in Addison’s disease,
 so close observation of the client’s hydration level is crucial. To promote optimal hydration and
sodium intake, fluid intake is increased, particularly fluid containing electrolytes, such as broths,
carbonated beverages, and juices.
18. C. At about 48-72 hours, the client must be turned onto the abdomen to prevent flexion
contractures.
19. B. The client should not drive for 2 weeks after surgery to avoid stress on the incision. This
reflects a need for additional teaching.
20. A. Extremes in heat and cold will exacerbate symptoms. Heat delays transmission of impulses
and increases fatigue.
21. A. Vigilant implementation of standard precautions and medical asepsis is an effective means
of preventing infection
22. C. Noncompliance is a major problem in the management of chronic disease. In hypertension,
the client often does not feel ill and thus does not see a need to follow a treatment regimen.
23. B. An accumulation of blood from the kidney into the abdomen would manifest itself with
these symptoms
24. D. Fluids liquefy secretions and therefore make it easier to expectorate
25. D. Physical assessment guidelines recommend listening for atleast 2 minutes in each quadrant
(and up to 5 minutes, not at least 5 minutes).
26. A. Compression stockings promote venous return and prevent peripheral pooling.
27. A. Placing food in the unaffected side of the mouth assists in the swallowing process because
the client has sensation on that side and will have more control over the swallowing process.
28. D. Daily weights are taken following nephrectomy. Daily increases of 2 lb or more are
indicative of fluid retention and should be reported to the physician. Intake and output records
may also reflect this imbalance.
29. A. Clients with cirrhosis have already coagulation due to thrombocytopenia and vitamin K
deficiency. This could be a sign of bleeding
30. B. Exercise enhances glucose uptake, and the client is at risk for an insulin reaction. Snacks
with carbohydrates will help.
31. C. These are symptoms of diabetes insipidus. The patient can become hypovolemic and
vasopressin may reverse the Polyuria.
32. D. Peripheral neuropathy refers to nerve damage of the hands and feet. The client did not
notice that the object pierced the skin.
33. A. The elevation of the stump on a pillow for the first 24 hours decreases edema and increases
venous return.
34. B. The priority is to maintain client’s safety. With syncope and vertigo, the client is at high risk
for falling.
35. D. Coughing and deep breathing are essential for re-expansion of the lung
36. B. Avoiding stasis of urine by emptying the bladder every 2-4 hours will prevent overdistention
of the bladder and future urinary tract infections.
37. D. If infected, the sex partner must be evaluated and treated
38. A. A 1:10 solution of household bleach and water is recommended by the Centers for Disease
Control and Prevention to kill the human immunodeficiency virus (HIV).
39. D. Given the data, presurgical anxiety is suspected. The client needs an opportunity to talk
about concerns related to surgery before further actions (which may mask the anxiety).
40. C. A quick look at the client can help identify the type and cause of the ventilator alarm.
Disconnection of the tube from the ventilator, bronchospasm, and anxiety are some of the
obvious reasons that could trigger an alarm.
41. A. Contact isolation has been advised by the Centers for Disease Control and Prevention (CDC)
to control transmission of MRSA, which includes gloves and handwashing.
42. D. In response to the question of the client, the nurse needs to provide brief, accurate
information. Some clients who have had gastrectomies are able to tolerate three meals a day
before discharge from the hospital. However, for the majority of clients, it takes 6-12 months
before their surgically reduced stomach has stretched enough to accommodate a larger meal.
43. A. This allows the client to elaborate his concern and provides the nurse a baseline of
assessment
44. C. Use of eye patches may be continued postoperatively, depending on surgeon preference.
This is done to achieve >90% success rate of the surgery.
45. B. Assessment and more data collection are needed. The client may have gastrointestinal or
neurological problems that account for the symptoms. The anorexia could result from
medications, poor dentition, or indigestion, the bruises may be attributed to ataxia, frequent
falls, vertigo, or medication.
46. A. The catheter should be washed with soap and water after withdrawal and placed in a clean
container. It can be reused until it is too hard or too soft for insertion. Self-care, prevention of
complications, and cost-effectiveness are important in home management.
47. D. The client may have herpes zoster (shingles), a viral infection. The nurse should use
standard precautions in assessing the lesions. Immunocompromised clients are at risk for
infection.
48. B. After a minimum of 24 hours of IV antibiotics, the client is no longer considered
communicable. Evaluation of the nurse’s knowledge is needed for safe care and continuity of
care.
49. D. Stem of the question supports this choice by stating that the client has difficulty accepting
the potential disability.
50. B. Toxoplasmosis is an opportunistic infection and a parasite of birds and mammals. The
oocysts remain infectious in moist soil for about 1 year.
PNLE IV Nursing Practice

Text Mode – Text version of the exam

The scope of this Nursing Test IV is parallel to the NP4 NLE Coverage:
 Medical Surgical Nursing
1. Following spinal injury, the nurse should encourage the client to drink fluids to avoid:

A. Urinary tract infection.

B. Fluid and electrolyte imbalance.
C. Dehydration.
D. Skin breakdown.
2. The client is transferred from the operating room to recovery room after an open-heart surgery.
The nurse assigned is taking the vital signs of the client. The nurse notified the physician when the
temperature of the client rises to 38.8 ºC or 102 ºF because elevated temperatures:

A. May be a forerunner of hemorrhage.

B. Are related to diaphoresis and possible chilling.
C. May indicate cerebral edema.
D. Increase the cardiac output.
3. After radiation therapy for cancer of the prostate, the client experienced irritation in the bladder.
Which of the following sign of bladder irritability is correct?

A. Hematuria
B. Dysuria
C. Polyuria
D. Dribbling
4. A client is diagnosed with a brain tumor in the occipital lobe. Which of the following will the client
most likely experience?

A. Visual hallucinations.
B. Receptive aphasia.
C. Hemiparesis.
D. Personality changes.
5. A client with Addison’s disease has a blood pressure of 65/60. The nurse understands that
decreased blood pressure of the client with Addison’s disease involves a disturbance in the production
of:

A. Androgens
B. Glucocorticoids
C. Mineralocorticoids
D. Estrogen
6. The nurse is planning to teach the client about a spontaneous pneumothorax. The nurse would
base the teaching on the understanding that:

A. Inspired air will move from the lung into the pleural space.
 B. There is greater negative pressure within the chest cavity.
C. The heart and great vessels shift to the affected side.
D. The other lung will collapse if not treated immediately.
7. During an assessment, the nurse recognizes that the client has an increased risk for developing
cancer of the tongue. Which of the following health history will be a concern?

A. Heavy consumption of alcohol.

B. Frequent gum chewing.
C. Nail biting.
D. Poor dental habits.
8. The client in the orthopedic unit asks the nurse the reason behind why compact bone is stronger
than cancellous bone. Which of the following is the correct response of the nurse?

A. Compact bone is stronger than cancellous bone because of its greater size.
B. Compact bone is stronger than cancellous bone because of its greater weight.
C. Compact bone is stronger than cancellous bone because of its greater volume.
D. Compact bone is stronger than cancellous bone because of its greater density.
9. The nurse is reviewing the laboratory results of the client. In reviewing the results of the RBC
count, the nurse understands that the higher the red blood cell count, the :

A. Greater the blood viscosity.

B. Higher the blood pH.
C. Less it contributes to immunity.
D. Lower the hematocrit.
10. The physician advised the client with Hemiparesis to use a cane. The client asks the nurse why
cane will be needed. The nurse explains to the client that cane is advised specifically to:

A. Aid in controlling involuntary muscle movements.

B. Relieve pressure on weight-bearing joints.
C. Maintain balance and improve stability.
D. Prevent further injury to weakened muscles.
11. The nurse is conducting a discharge teaching regarding the prevention of further problems to a
client who undergone surgery for carpal tunnel syndrome of the right hand. Which of the following
instruction will the nurse includes?

A. Learn to type using your left hand only.

B. Avoid typing in a long period of time.
C. Avoid carrying heavy things using the right hand.
D. Do manual stretching exercise during breaks.
12. A female client is admitted because of recurrent urinary tract infections. The client asks the nurse
why she is prone to this disease. The nurse states that the client is most susceptible because of:

A. Continuity of the mucous membrane.

B. Inadequate fluid intake.
C. The length of the urethra.
D. Poor hygienic practices.
13. A 55-year-old client is admitted with chest pain that radiates to the neck, jaw and shoulders that
occurs at rest, with high body temperature, weak with generalized sweating and with decreased
blood pressure. A myocardial infarction is diagnosed. The nurse knows that the most accurate
explanation for one of these presenting adaptations is:

A. Catecholamines released at the site of the infarction causes intermittent localized pain.
B. Parasympathetic reflexes from the infarcted myocardium causes diaphoresis.
C. Constriction of central and peripheral blood vessels causes a decrease in blood pressure.
D. Inflammation in the myocardium causes a rise in the systemic body temperature.
14. Following an amputation of a lower limb to a male client, the nurse provides an instruction on
how to prevent a hip flexion contracture. The nurse should instruct the client to:.

A. Perform quadriceps muscle setting exercises twice a day.

B. Sit in a chair for 30 minutes three times a day.
C. Lie on the abdomen 30 minutes every four hours.
D. Turn from side to side every 2 hours.
15. The physician scheduled the client with rheumatoid arthritis for the injection of hydrocortisone
into the knee joint. The client asks the nurse why there is a need for this injection. The nurse
explains that the most important reason for doing this is to:

A. Lubricate the joint.

B. Prevent ankylosis of the joint.
C. Reduce inflammation.
D. Provide physiotherapy.
16. The nurse is assigned to care for a 57-year-old female client who had a cataract surgery an hour
ago. The nurse should:

A. Advise the client to refrain from vigorous brushing of teeth and hair.
B. Instruct the client to avoid driving for 2 weeks.
C. Encourage eye exercises to strengthen the ocular musculature.
D. Teach the client coughing and deep-breathing techniques.
17. A client with AIDS develops bacterial pneumonia is admitted in the emergency department. The
client’s arterial blood gases is drawn and the result is PaO2 80mmHg. then arterial blood gases are
drawn again and the level is reduced from 80 mmHg to 65 mmHg. The nurse should;

A. Have arterial blood gases performed again to check for accuracy.

B. Increase the oxygen flow rate.
C. Notify the physician.
D. Decrease the tension of oxygen in the plasma.
18. An 18-year-old college student is brought to the emergency department due to serious motor
vehicle accident. Right above-knee-amputation is done. Upon awakening from surgery the client tells
the nurse, “What happened to me? I cannot remember anything?” Which of the following would be
the appropriate initial nursing response?

A. “You sound concerned; You’ll probably remember more as you wake up.”
B. “Tell me what you think happened.”
C. “You were in a car accident this morning.”
D. “An amputation of your right leg was necessary because of an accident.”
19. A 38-year-old client with severe hypertension is hospitalized. The physician prescribed a Captopril
(Capoten) and Alprazolam (Xanax) for treatment. The client tells the nurse that there is something
wrong with the medication and nursing care. The nurse recognizes this behavior is probably a
manifestation of the client’s:

A. Reaction to hypertensive medications.

B. Denial of illness.
C. Response to cerebral anoxia.
D. Fear of the health problem.
20. Before discharge, the nurse scheduled the client who had a colostomy for colorectal cancer for
discharge instruction about resuming activities. The nurse should plan to help the client understands
that:

A. After surgery, changes in activities must be made to accommodate for the physiologic changes
caused by the operation.
B. Most sports activities, except for swimming, can be resumed based on the client’s overall
physical condition.
C. With counseling and medical guidance, a near normal lifestyle, including complete sexual
function is possible.
D. Activities of daily living should be resumed as quickly as possible to avoid depression and
further dependency.
21. A client is scheduled for bariatric surgery. Preoperative teaching is done. Which of the following
statement would alert the nurse that further teaching to the client is necessary?

A. “I will be limiting my intake to 600 to 800 calories a day once I start eating again.”
B. “I’m going to have a figure like a model in about a year.”
C. “I need to eat more high-protein foods.”
D. “I will be going to be out of bed and sitting in a chair the first day after surgery.”.
22. The client who had transverse colostomy asks the nurse about the possible effect of the surgery
on future sexual relationship. What would be the best nursing response?

A. The surgery will temporarily decrease the client’s sexual impulses.

B. Sexual relationships must be curtailed for several weeks.
C. The partner should be told about the surgery before any sexual activity.
D. The client will be able to resume normal sexual relationships.
23. A 75-year-old male client tells the nurse that his wife has osteoporosis and asks what chances he
had of getting also osteoporosis like his wife. Which of the following is the correct response of the
nurse?

A. “This is only a problem for women.”

B. “You are not at risk because of your small frame.”
C. “You might think about having a bone density test,”
D. “Exercise is a good way to prevent this problem.”
24. An older adult client with acute pain is admitted in the hospital. The nurse understands that in
managing acute pain of the client during the first 24 hours, the nurse should ensure that:

A. Ordered PRN analgesics are administered on a scheduled basis.

B. Patient controlled analgesia is avoided in this population.
C. Pain medication is ordered via the intramuscular route.
D. An order for meperidine (Demerol) is secured for pain relief.
25. A nurse is caring to an older adult with presbycusis. In formulating nursing care plan for this
client, the nurse should expect that hearing loss of the client that is caused by aging to have:

A. Overgrowth of the epithelial auditory lining.

B. Copious, moist cerumen.
C. Difficulty hearing women’s voices.
D. Tears in the tympanic membrane.
26. The nurse is reviewing the client’s chart about the ordered medication. The nurse must observe
for signs of hyperkalemia when administering:

A. Furosemide (Lasix)
B. Hydrochlorothiazide (HydroDIURIL)
C. Metolazone (Zaroxolyn)
D. Spironolactone (Aldactone)
27. The physician prescribed Albuterol (Proventil) to the client with severe asthma. After the
administration of the medication the nurse should monitor the client for:

A. Palpitation
B. Visual disturbance
C. Decreased pulse rate
D. Lethargy
28. A client is receiving diltiazem (Cardizem). What should the nurse include in a teaching plan aimed
at reducing the side effects of this medication?

A. Take the drug with an antacid.

B. Lie down after meals.
C. Avoid dairy products in diet.
D. Change positions slowly.
29. A client is receiving simvastatin (Zocor). The nurse is aware that this medication is effective when
there is decrease in:

A. The triglycerides
B. The INR
C. Chest pain
D. Blood pressure
30. A client is taking nitroglycerine tablets, the nurse should teach the client the importance of:

A. Increasing the number of tablets if dizziness or hypertension occurs.

B. Limiting the number of tablets to 4 per day.
C. Making certain the medication is stored in a dark container.
D. Discontinuing the medication if a headache develops.
31. The physician prescribes Ibuprofen (Motrin) and hydroxychloroquine sulfate (Plaquenil) for a 58-
year-old male client with arthritis. The nurse provides information about toxicity of the
hydroxychloroquine. The nurse can determine if the information is clearly understood if the client
states:

A. “I will contact the physician immediately if I develop blurred vision.”

B. “I will contact the physician immediately if I develop urinary retention.”
C. “I will contact the physician immediately if I develop swallowing difficulty.”
 D. “I will contact the physician immediately if I develop feelings of irritability.”
32. The client with an acute myocardial infarction is hospitalized for almost one week. The client
experiences nausea and loss of appetite. The nurse caring for the client recognizes that these
symptoms may indicate the:

A. Adverse effects of spironolactone (Aldactone)

B. Adverse effects of digoxin (Lanoxin)
C. Therapeutic effects of propranolol (Indiral)
D. Therapeutic effects of furosemide (Lasix)
33. A client with a partial occlusion of the left common carotid artery is scheduled for discharge. The
client is still receiving Coumadin. The nurse provided a discharge instruction to the client regarding
adverse effects of Coumadin. The nurse should tell the client to consult with the physician if:

A. Swelling of the ankles increases.

B. Blood appears in the urine.
C. Increased transient Ischemic attacks occur.
D. The ability to concentrate diminishes.
34. Levodopa is ordered for a client with Parkinson’s disease. Before starting the medication, the
nurse should know that:

A. Levodopa is inadequately absorbed if given with meals.

B. Levodopa may cause the side effects of orthostatic hypotension.
C. Levodopa must be monitored by weekly laboratory tests.
D. Levodopa causes an initial euphoria followed by depression.
35. In making a diagnosis of myasthenia gravis Edrophonium HCI (Tensilon) is used. The nurse
knows that this drug will cause a temporary increase in:

A. Muscle strength
B. Symptoms
C. Blood pressure
D. Consciousness
36. The nurse can determine the effectiveness of carbamazepine (Tegretol) in the management of
trigeminal neuralgia by monitoring the client’s:

A. Seizure activity
B. Liver function
C. Cardiac output
D. Pain relief
37. Administration of potassium iodide solution is ordered to the client who will undergo a subtotal
thyroidectomy. The nurse understands that this medication is given to:

A. Ablate the cells of the thyroid gland that produce T4.

B. Decrease the total basal metabolic rate.
C. Decrease the size and vascularity of the thyroid.
D. Maintain function of the parathyroid gland.
38. A client with Addison’s disease is scheduled for discharge. Before the discharge, the physician
prescribes hydrocortisone and fludrocortisone. The nurse expects the hydrocortisone to:

A. Increase amounts of angiotensin II to raise the client’s blood pressure.

 B. Control excessive loss of potassium salts.
C. Prevent hypoglycemia and permit the client to respond to stress.
D. Decrease cardiac dysrhythmias and dyspnea.
39. A client with diabetes insipidus is taking Desmopressin acetate (DDAVP). To determine if the drug
is effective, the nurse should monitor the client’s:

A. Arterial blood pH
B. Pulse rate
C. Serum glucose
D. Intake and output
40. A client with recurrent urinary tract infections is to be discharged. The client will be taking
nitrofurantoin (Macrobid) 50 mg po every evening at home. The nurse provides discharge instructions
to the client. Which of the following instructions will be correct?

A. Strain urine for crystals and stones

B. Increase fluid intake.
C. Stop the drug if the urinary output increases
D. Maintain the exact time schedule for drug taking.
41. A client with cancer of the lung is receiving chemotherapy. The physician orders antibiotic
therapy for the client. The nurse understands that chemotherapy destroys rapidly growing leukocytes
in the:

A. Bone marrow
B. Liver
C. Lymph nodes
D. Blood
42. The physician reduced the client’s Dexamethasone (Decadron) dosage gradually and to continue
a lower maintenance dosage. The client asks the nurse about the change of dosage. The nurse
explains to the client that the purpose of gradual dosage reduction is to allow:

A. Return of cortisone production by the adrenal glands.

B. Production of antibodies by the immune system
C. Building of glycogen and protein stores in liver and muscle
D. Time to observe for return of increases intracranial pressure
43. The nurse is assigned to care for a client with diarrhea. Excessive fluid loss is expected. The
nurse is aware that fluid deficit can most accurately be assessed by:

A. The presence of dry skin

B. A change in body weight
C. An altered general appearance
D. A decrease in blood pressure
44. Which of the following is the most important electrolyte of intracellular fluid?

A. Potassium
B. Sodium
C. Chloride
D. Calcium
45. Which of the following client has a high risk for developing hyperkalemia?
 A. Crohn’s disease
B. End-Stage renal disease
C. Cushing’s syndrome
D. Chronic heart failure
46. The nurse is reviewing the laboratory result of the client. The client’s serum potassium level is 5.8
mEq/L. Which of the following is the initial nursing action?

A. Call the cardiac arrest team to alert them

B. Call the laboratory and repeat the test
C. Take the client’s vital signs and notify the physician
D. Obtain an ECG strip and have lidocaine available
47. Potassium chloride, 20 mEq, is ordered and to be added in the IV solution of a client in a diabetic
ketoacidosis. The primary reason for administering this drug is:

A. Replacement of excessive losses

B. Treatment of hyperpnea
C. Prevention of flaccid paralysis
D. Treatment of cardiac dysrhythmias
48. A female client is brought to the emergency unit. The client is complaining of abdominal cramps.
On assessment, client is experiencing anorexia and weight is reduced. The physician’s diagnosis is
colitis. Which of the following symptoms of fluid and electrolyte imbalance should the nurse report
immediately?

A. Skin rash, diarrhea, and diplopia

B. Development of tetaniy with muscles spasms
C. Extreme muscle weakness and tachycardia
D. Nausea, vomiting, and leg and stomach cramps.
49. The client is to receive an IV piggyback medication. When preparing the medication the nurse
should be aware that it is very important to:

A. Use strict sterile technique

B. Use exactly 100mL of fluid to mix the medication
C. Change the needle just before adding the medication
D. Rotate the bag after adding the medication
50. The nurse is reviewing the laboratory result of the client. An arterial blood gas report indicates
the client’s pH is 7.20, PCO2 35 mmHg and HCO3 is 19 mEq/L. The results are consistent with:

A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Answers and Rationales
1. A. Clients in the early stage of spinal cord damage experience an atonic bladder, which is
characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort with
distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid
intake limits urinary stasis and infection by diluting the urine and increasing urinary output.
2. D. The temperature of 102 ºF (38.8ºC) or greater lead to an increased metabolism and cardiac
workload.
3. B. Dysuria, nocturia, and urgency are all signs an irritable bladder after radiation therapy.
4. A. The occipital lobe is involve with visual interpretation.
5. C. Mineralocorticoids such as aldosterone cause the kidneys to retain sodium ions. With
sodium, water is also retained, elevating blood pressure. Absence of this hormone thus causes
hypotension.
6. B. As a person with a tear in the lung inhales, air moves through that opening into the
intrapleural and causes partial or complete collapse of the lungs.
7. A. Heavy alcohol ingestion predisposes an individual to the development of oral cancer.
8. D. The greater the density of compact bone makes it stronger than the cancellous bone.
Compact bone forms from cancellous bone by the addition of concentric rings of bones
substances to the marrow spaces of cancellous bone. The large marrow spaces are reduced to
haversian canals.
9. A. Viscosity, a measure of a fluid’s internal resistance to flow, is increased as the number of
red cells suspended in plasma.
10. C. Hemiparesis creates instability. Using a cane provides a wider base of support and,
therefore greater stability.
11. D. Manual stretching exercises will assist in keeping the muscles and tendons supple and
pliable, reducing the traumatic consequences of repetitive activity.
12. C. The length of the urethra is shorter in females than in males; therefore microorganisms
have a shorter distance to travel to reach the bladder. The proximity of the meatus to the anus
in females also increases this incidence.
13. D. Temperature may increase within the first 24 hours and persist as long as a week.
14. C. The hips are in extension when the client is prone; this keeps the hips from flexing.
15. C. Steroids have an anti-inflammatory effect that can reduce arthritic pannus formation.
16. A. Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure
and may lead to hemorrhage in the anterior chamber.
17. C. This decrease in PaO2 indicates respiratory failure; it warrants immediate medical
evaluation.
18. C. This is truthful and provides basic information that may prompt recollection of what
happened; it is a starting point.
19. D. Clients adapting to illness frequently feel afraid and helpless and strike out at health team
members as a way of maintaining control or denying their fear.
20. C. There are few physical restraints on activity postoperatively, but the client may have
emotional problems resulting from the body image changes.
21. B. Clients need to be prepared emotionally for the body image changes that occur after
bariatric surgery. Clients generally experience excessive abdominal skin folds after weight
stabilizes, which may require a panniculectomy. Body image disturbance often occurs in response
to incorrectly estimating one’s size; it is not uncommon for the client to still feel fat no matter
how much weight is lost.
22. D. Surgery on the bowel has no direct anatomic or physiologic effect on sexual performance.
However, the nurse should encourage verbalization.
23. C. Osteoporosis is not restricted to women; it is a potential major health problem of all older
adults; estimates indicate that half of all women have at least one osteoporitic fracture and the
risk in men is estimated between 13% and 25%; a bone mineral density measurement assesses
the mass of bone per unit volume or how tightly the bone is packed.
24. A. Around-the-clock administration of analgesics is recommended for acute pain in the older
adult population; this help to maintain a therapeutic blood level of pain medication.
25. C. Generally, female voices have a higher pitch than male voices; older adults with presbycusis
(hearing loss caused by the aging process) have more difficulty hearing higher-pitched sounds.
26. D. Aldactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect.
27. A. Albuterol’s sympathomimetic effect causes cardiac stimulation that may cause tachycardia
and palpitation.
28. D. Changing positions slowly will help prevent the side effect of orthostatic hypotension.
29. A. Therapeutic effects of simvastatin include decreased serum triglyceries, LDL and
cholesterol.
30. C. Nitroglycerine is sensitive to light and moisture ad must be stored in a dark, airtight
container.
31. A. Visual disturbance are a sign of toxicity because retinopathy can occur with this drug.
32. B. Toxic levels of Lanoxin stimulate the medullary chemoreceptor trigger zone, resulting in
nausea and subsequent anorexia.
33. B. Warfarin derivatives cause an increase in the prothrombin time and INR, leading to an
increased risk for bleeding. Any abnormal or excessive bleeding must be reported, because it
may indicate toxic levels of the drug.
34. B. Levodopa is the metabolic precursor of dopamine. It reduces sympathetic outflow by
limiting vasoconstriction, which may result in orthostatic hypotension.
35. A. Tensilon, an anticholinesterase drug, causes temporary relief of symptoms of myasthenia
gravis in client who have the disease and is therefore an effective diagnostic aid.
36. D. Carbamazepine ( Tegretol) is administered to control pain by reducing the transmission of
nerve impulses in clients with trigeminal neuralgia.
37. C. Potassium iodide, which aids in decreasing the vascularity of the thyroid gland, decreases
the risk for hemorrhage.
38. C. Hydrocortisone is a glucocorticoid that has anti-inflammatory action and aids in metabolism
of carbohydrate, fat, and protein, causing elevation of blood glucose. Thus it enables the body to
adapt to stress.
39. D. DDAVP replaces the ADH, facilitating reabsorption of water and consequent return of
normal urine output and thirst.
40. B. To prevent crystal formation, the client should have sufficient intake to produce 1000 to
1500 mL of urine daily while taking this drug.
41. A. Prolonged chemotherapy may slow the production of leukocytes in bone marrow, thus
suppressing the activity of the immune system. Antibiotics may be required to help counter
infections that the body can no longer handle easily.
42. A. Any hormone normally produced by the body must be withdrawn slowly to allow the
appropriate organ to adjust and resume production.
43. B. Dehydration is most readily and accurately measured by serial assessment of body weight;
1 L of fluid weighs 2.2 pounds.
44. A. The concentration of potassium is greater inside the cell and is important in establishing a
membrane potential, a critical factor in the cell’s ability to function.
45. B. The kidneys normally eliminate potassium from the body; hyperkalemia may necessitate
dialysis.
46. C. Vital signs monitor cardiorespiratory status; hyperkalemia causes serious cardiac
dysrhythmias.
47. A. Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the
cell, causing hypokalemia; therefore potassium, along with the replacement fluid, is generally
supplied.
48. C. Potassium, the major intracellular cation, functions with sodium and calcium to regulate
neuromuscular activity and contraction of muscle fibers, particularly the heart muscle. In
hypokalemia these symptoms develop.
49. A. Because IV solutions enter the body’s internal environment, all solutions and medications
utilizing this route must be sterile to prevent the introduction of microbes.
50. A. A low pH and bicarbonate level are consistent with metabolic acidosis.
PNLE V Nursing Practice

Text Mode – Text version of the exam

The scope of this Nursing Test V is parallel to the NP5 NLE Coverage:
 Psychiatric Nursing
1. A 17-year-old client has a record of being absent in the class without permission, and “borrowing”
other people’s things without asking permission. The client denies stealing; rationalizing instead that
as long as no one was using the items, there is no problem to use it by other people. It is important
for the nurse to understand that psychodynamically, the behavior of the client may be largely
attributed to a development defect related to the:

A. Oedipal complex
B. Superego
C. Id
D. Ego
2. A client tells the nurse, “Yesterday, I was planning to kill myself.” What is the best nursing
response to this cient?

A. “What are you going to do this time?”

B. Say nothing. Wait for the client’s next comment
C. “You seem upset. I am going to be here with you; perhaps you will want to talk about it”
D. “Have you felt this way before?”
3. In crisis intervention therapy, which of the following principle that the nurse will use to plan
her/his goals?

A. Crises are related to deep, underlying problems

B. Crises seldom occur in normal people’s lives
C. Crises may go on indefinitely.
D. Crises usually resolved in 4-6 weeks.
4. The nurse enters the room of the male client and found out that the client urinates on the floor.
The client hides when the nurse is about to talk to him. Which of the following is the best nursing
intervention?

A. Place restriction on the client’s activities when his behavior occurs.

B. Ask the client to clean the soiled floor.
C. Take the client to the bathroom at regular intervals.
D. Limit fluid intake.
5. A young lady with a diagnosis of schizophrenic reaction is admitted to the psychiatric unit. In the
past two months, the client has poor appetite, experienced difficulty in sleeping, was mute for long
periods of time, just stayed in her room, grinning and pointing at things. What would be the initial
nursing action on admitting the client to the unit?

A. Assure the client that “ You will be well cared for.”

B. Introduce the client to some of the other clients.
C. Ask “Do you know where you are?”
 D. Take the client to the assigned room.
6. A 16-year-old girl was diagnosed with anorexia. What would be the first assessment of the nurse?

A. What food she likes.

B. Her desired weight.
C. Her body image.
D. What causes her behavior.
7. On an adolescent unit, a nurse caring to a client was informed that her client’s closest roommate
dies at night. What would be the most appropriate nursing action?

A. Do not bring it up unless the client asks.

B. Tell the client that her roommate went home.
C. Tell the client, if asked, “You should ask the doctor.”
D. Tell the client that her closest roommate died.
8. A woman gave birth to an unhealthy infant, and with some body defects. The nurse should expect
the woman’s initial reactions to include:

A. Depression
B. Withdrawal
C. Apathy
D. Anger
9. A client in the psychiatric unit is shouting out loud and tells the nurse, “Please, help me. They are
coming to get me.” What would be the appropriate nursing response?

A. “ I won’t let anyone get you.”

B. “Who are they?”
C. “I don’t see anyone coming.”
D. “You look frightened.”
10. A client who is severely obese tells the nurse, “My therapist told me that I eat a lot because I
didn’t get any attention and love from my mother. What does the therapist mean?” What is the best
nursing response?

A. “What do you think is the connection between your not getting enough love and overeating?”
B. “Tell me what you think the therapist means.”
C. “You need to ask your therapist.”
D. “ We are here to deal with your diet, not with your psychological problems.”
11. After the discussion about the procedure the physician scheduled the client for mastectomy. The
client tells the nurse, “If my breasts will be removed, I’m afraid my husband will not love me
anymore and maybe he will never touch me.” What should the nurse’s response?

A. “I doubt that he feels that way.”

B. “What makes you feel that way?”
C. “Have you discussed your feelings with your husband?”
D. Ask the husband, in front of the wife, how he feels about this.
12. The child is brought to the hospital by the parents. During assessment of the nurse, what
parental behavior toward a child should alert the nurse to suspect child abuse?

A. Ignoring the child.

B. Flat affect.
 C. Expressions of guilt.
D. Acting overly solicitous toward the child
13. A nurse is caring to a client with manic disorder in the psychiatric ward. On the morning shift, the
nurse is talking with the client who is now exhibiting a manic episode with flight of ideas. The nurse
primarily needs to:

A. Focus on the feelings conveyed rather than the thoughts expressed.

B. Speak loudly and rapidly to keep the client’s attention, because the client is easily distracted.
C. Allow the client to talk freely.
D. Encourage the client to complete one thought at a time.
14. The nurse is caring to an autistic child. Which of the following play behavior would the nurse
expect to see in a child?

A. competitive play
B. nonverbal play
C. cooperative play
D. solitary play
15. The client is telling the nurse in the psychiatric ward, “I hate them.” Which of the following is the
most appropriate nursing response to the client?

A. “Tell me about your hate.”

B. “I will stay with you as long as you feel this way.”
C. “For whom do you have these feelings?”
D. “I understand how you can feel this way.”
16. The mother visits her son with major depression in the psychiatric unit. After the conversation of
the client and the mother, the nurse asks the mother how it is talking to her son. The mother tells
the nurse that it was a stressful time. During an interview with the client, the client says, “we had a
marvelous visit.” Which of the following coping mechanism can be described to thestatement of the
client?

A. Identification.
B. Rationalization.
C. Denial.
D. Compensation.
17. A male client is quiet when the physician told him that he has stage IV cancer and has 4 months
to live. The nurse determines that this reaction may be an example of:

A. Indifference
B. Denial
C. Resignation
D. Anger
18. A nurse is caring to a female client with five young children. The family member told the client
that her ex-husband has died 2 days ago. The reaction of the client is stunned silence, followed by
anger that the ex-husband left no insurance money for their young children. The nurse should
understand that:

A. The children and the injustice done to them by their father’s death are the woman’s main
concern.
B. To explain the woman’s reaction, the nurse needs more information about the relationship and
breakup.
C. The woman is not reacting normally to the news.
D. The woman is experiencing a normal bereavement reaction.
19. A client who is manic comes to the outpatient department. The nurse is assigning an activity for
the client. What activity is best for the nurse to encourage for a client in a manic phase?

A. Solitary activity, such as walking with the nurse, to decrease stimulation.

B. Competitive activity, such as bingo, to increase the client’s self-esteem.
C. Group activity, such as basketball, to decrease isolation.
D. Intellectual activity, such as scrabble, to increase concentration.
20. The nurse is about to administer Imipramine HCI (Tofranil) to the client, the client says, “Why
should I take this?” The doctor started me on this 10days ago; it didn’t help me at all.” Which of the
following is the best nursing response:

A. “What were you expecting to happen?”

B. “It usually takes 2-3 weeks to be effective.”
C. “Do you want to refuse this medication? You have the right.”
D. “That’s a long time wait when you feel so depressed.”
21. Which of the following drugs the nurse should choose to administer to a client to prevent
pseudoparkinsonism?

A. Isocarboxazid (Marplan)
B. Chlorpromazine HCI (Thorazine)
C. Trihexyphenidyl HCI (Artane)
D. Trifluoperazine HCI (Stelazine)
22. The nurse is caring to an 80-year-old client with dementia? What is the most important
psychosocial need for this client?

A. Focus on the there-and-then rather the here-and-now.

B. Limit in the number of visitors, to minimize confusion.
C. Variety in their daily life, to decrease depression.
D. A structured environment, to minimize regressive behaviors.
23. A client tells the nurse, “I don’t want to eat any meals offered in this hospital because the food is
poisoned.” The nurse is aware that the client is expressing an example of:

A. Delusion.
B. Hallucination.
C. Negativism.
D. Illusion.
24. A client is admitted in the hospital. On assessment, the nurse found out that the client had
several suicidal attempts. Which of the following is the most important nursing action?

A. Ignore the client as long as he or she is talking about suicide, because suicide attempt is
unlikely.
B. Administer medication.
C. Relax vigilance when the client seems to be recovering from depression.
D. Maintain constant awareness of the client’s whereabouts.
25. The nurse suspects that the client is suffering from depression. During assessment, what are the
most characteristic signs and symptoms of depression the nurse would note?

A. Constipation, increased appetite.

B. Anorexia, insomnia.
C. Diarrhea, anger.
D. Verbosity, increased social interaction.
26. The client in the psychiatric unit states that, “The goodas are coming! I must be ready.” In
response to this neologism, the nurse’s initial response is to:

A. Acknowledge that the word has some special meaning for the client.
B. Try to interpret what the client means.
C. Divert the client’s attention to an aspect of reality.
D. State that what the client is saying has not been understood and then divert attention to
something that is really bound.
27. A male client diagnosed with depression tells the nurse, “I don’t want to look weak and I don’t
even cry because my wife and my kids can’t bear it.” The nurse understands that this is an example
of:

A. Repression.
B. Suppression.
C. Undoing.
D. Rationalization.
28. A female client tells the nurse that she is afraid to go out from her room because she thinks that
the other client might kill her. The nurse is aware that this behavior is related to:

A. Hallucination.
B. Ideas of reference.
C. Delusion of persecution.
D. Illusion.
29. A female client is taking Imipramine HCI (Tofranil) for almost 1 week and shows less awareness
of the physical body. What problem would the nurse be most concerned?

A. Nausea.
B. Gait disturbances.
C. Bowel movements.
D. Voiding.
30. A 6-year-old client dies in the nursing unit. The parents want to see the child. What is the most
appropriate nursing action?

A. Give the parents time alone with the body.

B. Ask the physician for permission.
C. Complete the postmortem care and quietly accompany the family to the child’s room.
D. Suggest the parents to wait until the funeral service to say “good-bye.”
31. A 20-year-old female client is diagnosed with anxiety disorder. The physician prescribed
Flouxetine (Prozac). What is the most important side effects should a nurse be concerned?

A. Tremor, drowsiness.
B. Seizures, suicidal tendencies.
 C. Visual disturbance, headache.
D. Excessive diaphoresis, diarrhea.
32. A nurse is assigned to activate a client who is withdrawn, hears voices and negativistic. What
would be the best nursing approach?

A. Mention that the “voices” would want the client to participate.

B. Demand that the client must join a group activity.
C. Give the client a long explanation of the benefits of activity.
D. Tell the client that the nurse needs a partner for an activity.
33. A nurse is going to give a rectal suppository as a preoperative medication to a 4-year-old boy.
The boy is very anxious and frightened. Which of the following statement by the nurse would be
most appropriate to gain the child’s cooperation?

A. “Be a big kid! Everyone’s waiting for you.”

B. “Lie still now and I’ll let you have one of your presents before you even have your operation.”
C. “Take a nice, big, deep breath and then let me hear you count to five.”
D. “You look so scared. Want to know a secret? This won’t hurt a bit!”
34. A depressed client is on an MAO inhibitor? What should the nurse watch out for?

A. Hypertensive crisis.
B. Diet restrictions.
C. Taking medication with meals.
D. Exposure to sunlight.
35. A 16-year-old girl is admitted for treatment of a fracture. The client shares to the nurse caring to
her that her step-father has made sexual advances to her. She got the chance to tell it to her mother
but refuses to believe. What is the most therapeutic action of the nurse would be:

A. Tell the client to work it out with her father.

B. Tell the client to discuss it with her mother.
C. Ask the father about it.
D. Ask the mother what she thinks.
36. A client with a diagnosis of paranoid disorder is admitted in the psychiatric hospital. The client
tells the nurse, “the FBI is following me. These people are plotting against me.” With this statement
the nurse will need to:

A. Acknowledge that this is the client’s belief but not the nurse’s belief.
B. Ask how that makes the client feel.
C. Show the client that no one is behind.
D. Use logic to help the client doubt this belief.
37. A nurse is completing the routine physical examination to a healthy 16-year-old male client. The
client shares to the nurse that he feels like killing his girlfriend because he found out that her
girlfriend had another boyfriend. He then laughs, and asks the nurse to keep this a secret just
between the two of them. The nurse reviews his chart and notes that there is no previously history of
violence or psychiatric illness. Which of the following would be the best action of the nurse to take at
this time?

A. Suggest the teen meet with a counselor to discuss his feelings about his girlfriend.
B. Tell the teen that his feelings are normal, and recommend that he find another girlfriend to
take his mind off the problem.
 C. Recall the teenage boys often say things they really do not mean and ignore the comment.
D. Regard the comment seriously and notify the teen’s primary health care provider and parents
38. Which of the following person will be at highest risk for suicide?

A. A student at exam time

B. A married woman, age 40, with 6 children.
C. A person who is an alcoholic.
D. A person who made a previous suicide attempt.
39. A male client is repetitively doing the handwashing every time he touches things. It is important
for a nurse to understand that the client’s behavior is probably an attempt to:

A. Seek attention from the staff.

B. Control unacceptable impulses or feelings.
C. Do what the voices the patient hears tell him or her to do.
D. Punish himself or herself for guilt feeling.
40. In a mental health settings, the basic goal of nursing is to:

A. Advance the science of psychiatry by initiating research and gathering data for current
statistics on emotional illness.
B. Plan activity programs for clients.
C. Understand various types of family therapy and psychological tests and how to interpret them.
D. Maintain a therapeutic environment.
41. A 3-year-old boy is brought to the emergency department. After an hour, the boy dies of
respiratory failure. The mother of the boy becomes upset, shouting and abusive, saying to the nurse,
“If it had been your son, they would have done more to save it. “What should the nurse say or do?

A. Touch her and tell her exactly what was done for her baby.
B. Allow the mother to continue her present behavior while sitting quietly with her.
C. “No, all clients are given the same good care.”
D. “Yes, you’re probably right. Your son did not get better care.”
42. The nurse is interacting to a client with an antisocial personality disorder. What would be the
most therapeutic approach of the nurse to an antisocial behavior?

A. Gratify the client’s inner needs.

B. Give the client opportunities to test reality.
C. Provide external controls.
D. Reinforce the client’s self-concept.
43. A 55-year-old male client tells the nurse that he needs his glasses and hearing aid with him in the
recovery room after the surgery, or he will be upset for not granting his request. What is the
appropriate nursing response?

A. “Do you get upset and confused often?”

B. “You won’t need your glasses or hearing aid. The nurses will take care of you.”
C. “I understand. You will be able to cooperate best if you know what is going on, so I will find
out how I can arrange to have your glasses and hearing aid available to you in the recovery
room.”
D. I understand you might be more cooperative if you have your aid and glasses, but that is just
not possible. Rules, you know.”
44. The male client had fight with his roommates in the psychiatric unit. The client agitated client is
placed in isolation for seclusion. The nurse knows it is essential that:

A. A staff member has frequent contacts with the client.

B. Restraints are applied.
C. The client is allowed to come out after 4 hours.
D. All the furniture is removed form the isolation room.
45. A medical representative comes to the hospital unit for the promotion of a new product. A female
client, admitted for hysterical behavior, is found embracing him. What should the nurse say?

A. “Have you considered birth control?”

B. “This isn’t the purpose of either of you being here.”
C. “I see you’ve made a new friend.”
D. “Think about what you are doing.”
46. A client with dementia is for discharge. The nurse is providing a discharge instruction to the
family member regarding safety measures at home. What suggestion can the nurse make to the
family members?

A. Avoid stairs without banisters.

B. Use restraints while the client is in bed to keep him or her from wandering off during the
night.
C. Use restraints while the client is sitting in a chair to keep him or her from wandering off during
the day.
D. Provide a night-light and a big clock.
47. A 30-year-old married woman comes to the hospital for treatment of fractures. The woman tells
the nurse that she was physically abused by her husband. The woman receives a call from her
husband telling her to get home and things will be different. He felt sorry of what he did. What can
the nurse advise her?

A. “Do you think so?”

B. “It’s not likely.”
C. “What will be different?”
D. “I hope so, for your sake.”
48. A female client was diagnosed with breast cancer. It is found to be stage IV, and a modified
mastectomy is performed. After the procedure, what behaviors could the nurse expects the client to
display?

A. Denial of the possibility of carcinoma.

B. Signs of grief reaction.
C. Relief that the operation is over.
D. Signs of deep depression.
49. A client is withdrawn and does not want to interact to anybody even to the nurse. What is the
best initial nursing approach to encourage communication with this client?

A. Use simple questions that call for a response.

B. Encourage discussion of feelings.
C. Look through a photo album together.
D. Bring up neutral topics.
50. Which of the following nursing approach is most important in a client with depression?
 A. Deemphasizing preoccupation with elimination, nourishment, and sleep.
B. Protecting against harm to others.
C. Providing motor outlets for aggressive, hostile feelings.
D. Reducing interpersonal contacts.
Answers and Rationales
1. B. This shows a weak sense of moral consciousness. According to Freudian theory, personality
disorders stem from a weak superego.
2. C. The client needs to have his or her feelings acknowledged, with encouragement to discuss
feelings, and be reassured about the nurse’s presence.
3. D. Part of the definition of a crisis is a time span of 4-6 weeks.
4. C. The client is most likely confused, rather than exhibiting acting-out, hostile behavior.
Frequent toileting will allow urination in an appropriate place.
5. D. The client needs basic, simple orientation that directly relates to the here-and-now, and
does not require verbal interaction.
6. A. Although all options may appear correct. A is the best because it focuses on a range of
possible positive reinforcers, a basis for an effective behavior modification program. It can lead
to concrete, specific nursing interventions right away and provides a therapeutic use of “control”
for the 16-year-old.
7. A. The nurse needs to wait and see: do not “jump the gun”; do not assume that the client
wants to know now.
8. D. The woman is experiencing an actual loss and will probably exhibit many of the same
symptoms as a person who has lost someone to death.
9. C. This option is an example of pointing out reality- the nurse’s perception.
10. B. This response asks information that the nurse can use. If the client understands the
statement, the nurse can support the therapist when focusing on connection between food, love,
and mother. If the client does not understand thestatement, the nurse can help get clarification
from the therapist.
11. C. This option redirects the client to talk to her husband.
12. D. This is an example of reaction formation, a coping mechanism.
13. A. Often the verbalized ideas are jumbled, but the underlying feelings are discernible and must
be acknowledged.
14. D. Autistic children do best with solitary play because they typically do not interact with others
in a socially comprehensible and acceptable way.
15. A. The nurse is asking the client to clarify and further discuss feelings.
16. C. Denial is the act of avoiding disagreeable realities by ignoring them.
17. B. Reactions when told of a life-threatening illness stem from Kübler-Ross’ ideas on death and
dying. Denial is a typical grief response, and usually is a first reaction.
18. D. Shock and anger are commonly the primary initial reactions.
19. A. This option avoids external stimuli, yet channels the excess motor activity that is often part
of the manic phase.
20. B. The patient needs a brief, factual answer.
21. C. Trihexyphenidyl HCI (Artane) is often used to counteract side effect of pseudoparkinsonism,
which often accompanies the use of phenothiazine, such as chlorpromazine HCI (Thorazine or
Trifluoperazine HCI (Stelazine).
22. D. Persons with dementia needs sameness, consistency, structure, routine, and predictability.
23. A. This is a false belief developed in response to an emotional need.
24. D. The client must be constantly observed.
25. B. The appetite is diminished and sleeping is affected to a client with depression.
26. A. It is important to acknowledge a statement, even if it is not understood.
27. D. Rationalization is the process of constructing plausible reasons for one’s responses.
28. C. The client has ideas that someone is out to kill her.
29. D. A serious side effect of Imipramine HCI (Tofranil) is urinary retention (voiding problems)
30. A. This allows the parents/family to grieve over the loss of the child, by going through the
steps of leave taking.
31. B. Assess for suicidal tendencies, especially during early therapy. There is an increased risk of
seizures in debilitated client and those with a history of seizures.
32. D. The nurse helps to activate by doing something with the client.
33. C. Preschool children commonly experience fears and fantasies regarding invasive procedures.
The nurse should attempts to momentarily distract the child with a simple task that can be easily
accomplished while the child remains in the side-lying position. The suppository can be slipped
into place while the child is counting, and then the nurse can praise the child for cooperating,
while holding the buttocks together to prevent expulsion of the suppository.
34. A. This is the more inclusive answer, although diet restrictions (answer1) are important, their
purpose is to prevent hypertensive crisis (answer 2).
35. D. This comes closest to beginning to focus on family-centered approach to intervene in the
“conspiracy of silence”. This is therefore the best among the options.
36. A. The nurse should neither challenge nor use logic to dispel an irrational belief.
37. D. Any threat to the safety of oneself or other should always be taken seriously and never
disregarded by the nurse.
38. C. The likelihood of multiple contributing factors may make this person at higher risk for
suicide. Some factors that may exist are physical illness related to alcoholism, emotional factors (
anxiety, guilt, remorse), social isolation due to impaired relationships and economic problems
related to employment.
39. B. A ritual, such as compulsive handwashing, is an attempt to allay anxiety caused by
unconscious impulses that are frightening.
40. D. This is the most neutral answer by process of elimination.
41. B. This option allows a normal grief response (anger).
42. C. Personality disorders stem from a weak superego, implying a lack of adequate controls.
43. C. The client will be easier to care for if he has his hearing aid and glasses.
44. A. Frequent contacts at times of stress are important, especially when a client is isolated.
45. B. This response is aimed at redirecting the inappropriate behavior.
46. D. This option is best to decrease confusion and disorientation to place and time.
47. C. This option helps the woman to think through and elaborate on her own thoughts and
prognosis.
48. B. It is mostly likely that grief would be expressed because of object loss.
49. D. Neutral, nonthreatening topics are best in attempting to encourage a response.
50. C. It is important to externalize the anger away from self.