PREBOARDS 2_NP2

Question 1

1. Blood loss of _________ would lead to Nurse Barbie to suspect that the patient is experiencing postpartum hemorrhage.
   *
   1 punto
   A. More than 300ml/24 hours
   B. More than 400ml/ 24 hours
   C. More than 500ml/ 24 hours
   D. Less than 200ml/ 24 hours

Answer 1

C. More than 500ml/ 24 hours

Question 2

2. This is a condition caused by a markedly distended uterus and intermittent uterine contractions within 2 to 3 days after birth?
   *
   1 punto
   A. Retained placenta
   B. Afterpains
   C. Uterine atony
   D. Boggy uterus

Answer 2

B. Afterpains

Question 3

3. Nurse Barbie observes that her patient is still adjusting to being a mother. In line with Ramona Mercer’s Maternal Role Attainment Theory, which statement best describes the process of becoming a mother?
   *
   1 punto
   A. A woman learns mothering behavior as early as a teenager.
   B. The woman learns to become comfortable with her role as a married individual.
   C. It reflects the transitional process from being single to raising a family.
   D. It involves the dynamic transformation of a women’s persona.

Answer 3

D. It involves the dynamic transformation of a women’s persona.

Question 4

4. The mother suddenly becomes worried when a gush of blood comes out of her vagina when she first arises from her bed. She asks Nurse Barbie why this has occurred. Nurse Barbie is correct when she says _________.
   *
   1 punto
   A. “Blood pools at the top of the uterus and passes upon rising or sitting on the bed”
   B. “This is due to the normal pooling of blood in the vagina when the woman lies down to rest or sleep.”
   C. “Physical activity stimulates bleeding in the vagina”
   D. “This is a normal physiologic occurrence where the body attempts to eliminate excess fluids.”

Answer 4

B. “This is due to the normal pooling of blood in the vagina when the woman lies down to rest or sleep.”

Question 5

5. The mother is currently having difficulty with voiding due to her perineal edema. What can Nurse Barbie do to stimulate the sensation of voiding?
   *
   1 punto
   A. Reminding her to void every hour
   B. Helping the mother into the shower.
   C. Insertion of a catheter
   D. Running water in the sink or shower.

Answer 5

D. Running water in the sink or shower.

Question 6

Situation
A postpartum mother who underwent a normal spontaneous vaginal delivery asks the nurse when and how her body will return to its prepregnancy state.
6. The uterus is known to return to its prepregnancy state in ____.
*
1 punto
A. 6 weeks
B. 6 days
C. 4 weeks
D. 35 days

Answer 6

A. 6 weeks

Question 7

7. The nurse knows that the process where the uterus changes after childbirth to return to its previous, prepregnancy state is called __________.
   *
   1 punto
   A. Involution
   B. Evolution
   C. Subinvolution
   D. Inversion

Answer 7

A. Involution

Question 8

8. Among the following factors experienced by the patient during her pregnancy and subsequent delivery, which would most likely contribute to a slow uterine involution?
   *
   1 punto
   A. Full bladder during labor
   B. Difficult Birth
   C. Perineal Laceration
   D. Gestational Hypertension

Answer 8

B. Difficult Birth - birth of multiple fetus, etc.

Question 9

9. To assess the progression of involution, the nurse plans to assess the uterine fundus of the mother. Which part of the abdomen should the nurse begin with her assessment?
   *
   1 punto
   A. Symphysis pubis
   B. Umbilicus
   C. 5 cm below the xiphoid process
   D. 5 cm below the umbilicus

Answer 9

B. Umbilicus - fundus can be found at the umbilicus

Question 10

10. The priority nursing intervention during the immediate postpartum period is focused on ____.
    *
    1 punto
    A. Monitoring for signs of infection
    B. Watching out for postpartum hemorrhage
    C. Taking the vital signs every 2 hours
    D. Assessing level of consciousness

Answer 10

B. Watching out for postpartum hemorrhage

Question 11

Situation
Liza, a multigravida currently at 20th weeks of gestation visited your clinic with complaints of dizziness, vertigo, and heartburn. Upon assessment, it was determined that she was malnourished.
11. Liza, a multigravida currently at 20th weeks of gestation visited your clinic with complaints of dizziness, vertigo, and heartburn. Upon assessment, it was determined that she was malnourished.
*
1 punto
A. “I don’t need to take these as our bodies have iron stores.”
B. “Iron supplements may cause my stool to become blackish green in color”
C. “The iron is best absorbed if taken on an empty stomach.”
D. “Meat should be avoided as to ensure iron is absorbed”

Answer 11

C. “The iron is best absorbed if taken on an empty stomach.”

Question 12

12. Liza was concerned with taking her iron supplements as she has been taking vitamin C regularly. What will be the most appropriate response to this?
    *
    1 punto
    A. “This is okay as long as you take the two supplements 1 hour apart”
    B. “Stop taking Vitamin C supplements”
    C. “This is okay as absorption of iron is enhanced with Vitamin C.”
    D. “This is not okay as absorption of iron is decreased by Vitamin C.”

Answer 12

C. “This is okay as absorption of iron is enhanced with Vitamin C.”

Question 13

13. Calcium supplements were also prescribed to Liza to be taken during the 2nd and 3rd trimesters. To help facilitate absorption of calcium, which of the following should you advise her to take with this?
    *
    1 punto
    A. Fat-soluble vitamins
    B. Water-soluble vitamins
    C. Iron
    D. Milk

Answer 13

A. Fat-soluble vitamins - Vitamin D

Question 14

14. Liza asks you what the main source of nutrition for her baby is. You answer correctly by stating that it is the ______.
    *
    1 punto
    A. Amniotic Fluid
    B. Placenta
    C. Fetal Circulation
    D. Small Intestines

Answer 14

B. Placenta

Question 15

15. You performed a health teaching session for Liza to manage her heartburn. Which statement by Liza indicates a need for further teaching?
    *
    1 punto
    A. I will lie down after eating
    B. I will drink milk between meals
    C. I will eat small, frequent meals
    D. I will avoid fatty or spicy foods

Answer 15

A. I will lie down after eating

Question 16

Situation
Nurse Young was recently transferred to the pediatric ward and was assigned to give medications for the shift
16. When giving medicine to pediatric patients, dosage varies. Which of the following should Nurse Alicia consider?
*
1 punto
A. Height and weight
B. Size, surface area and age
C. Size and surface area
D. Size, surface area, age and weight

Answer 16

C. Size and surface area

Question 17

17.Before administering oral medications, Nurse Young is being assessed by the head nurse on her knowledge on administering medications for pediatric patients. Which of the following statements shows correct understanding by Nurse Young?
*
1 punto
A. Compared to an adult’s reaction, a child’s reaction to the medication is more predictable
B. When giving oral medication, the child as young as two years of age cannot be taught to swallow drugs.
C. The child should be told to place the tablet on top of their tongue and drink water to wash down the tablet.
D. The possibility of error is greater in the giving of medication to children than to adults.

Answer 17

D. The possibility of error is greater in the giving of medication to children than to adults.

Question 18

18. Nurse Young is to administer a medication via IM injection to an 10-month-old baby. What part should she use to reduce the risk of nerve damage and vascular injury?
    *
    1 punto
    A. Gluteus maximus
    B. Vastus lateralis
    C. Deltoid muscle
    D. Dorso-gluteal

Answer 18

B. Vastus lateralis

Gluteus maximus - is still underdeveloped and has sciatic nerve

Question 19

19. Intramuscular injections have been known to produce serious adverse effects according to research. Nurse Young knows that the most common complication that may arise from this is ___________.
    *
    1 punto
    A. Infection
    B. Paralysis
    C. Hematoma
    D. Muscle contracture

Answer 19

D. Muscle contracture

Question 20

20. Nurse Young is to administer the IM medication to the 10-month-old baby. To ensure that the ordered medication is given to the right patient, what will Nurse Young do first?
    *
    1 punto
    A. Check the patient’s hospital bracelet.
    B. Ask the parent/significant other to state name of patient and birth date of patient.
    C. Verify patient’s allergies with chart and with patient.
    D. Compare medication order to identification bracelet.

Answer 20

B. Ask the parent/significant other to state name of patient and birth date of patient.

Question 21

Situation
Kim, a college student, was recently admitted to the hospital due to having severe pre-eclampsia. Despite her physician advising her to rest, Kim insists on continuing her work while admitted. She currently studies around 10 hours a day and is often visited by her peers and relatives.
21. Nurse Dani is concerned about Kim’s ability to comply with the doctor’s instruction to rest. What appropriate action should she take?
*
1 punto
A. Ask her mother to explain to her why she needs to rest.
B. Develop a routine with the patient to balance her studies and her rest needs.
C. Tell her that she should prioritize her baby’s health more than her studies
D. Ask her why she is not complying with the prescription for bed rest.

Answer 21

B. Develop a routine with the patient to balance her studies and her rest needs.

Question 22

22. During the interview, Patient Kim becomes irritated with the nurse, stating “I don’t want to talk to you since you’re only a nurse. I’ll just wait for the doctor. What would be Nurse Dani’s best response?
    *
    1 punto
    A. “I do not like the way that you dismiss me.”
    B. “Noted. I should call your doctor.”
    C. “So then you would prefer to speak with your doctor?”
    D. “Your doctor prescribed this for us to do nursing care.”

Answer 22

C. “So then you would prefer to speak with your doctor?” - for clarification and restating; helps understandinf

Question 23

23. Due to the previous situation, Nurse Dani is now experiencing a dilemma. This occurs when _____.
    *
    1 punto
    A. There is a conflict between the nurse’s decision and that of their superior
    B. Choices regarding patient care are unclear
    C. There is a conflict of two or more ethical principles
    D. A decision must be made quickly under a stressful situation

Answer 23

C. There is a conflict of two or more ethical principles

Question 24

24. Nurse Dani knows that regardless of what just happened, she must still abide to the ethical principle that states the nurse is obligated to implement actions that will provide care and benefit to the patient. What specific principle is this?
    *
    1 punto
    A. Beneficence
    B. Justice
    C. Nonmaleficence
    D. Veracity

Answer 24

A. Beneficence - we are obligated to do good

Question 25

25. In providing a safe environment for the patient with preeclampsia, what can Nurse Dani do?
    *
    1 punto
    A. Maintain fluid and sodium restrictions.
    B. Encourage frequent visits from family and friends for psychosocial support
    C. Take the patient’s vital signs every 4 hours.
    D. Take off the room lights and draw the window shades.

Answer 25

D. Take off the room lights and draw the window shades. - bright lights can cause seizure

A - can activate RAAS system and cause elevation of BP
B - frequent visits (noise and crowd) can trigger seizure
C - Added stimulus

Question 26

26. In caring for patient Rosita, Head Nurse Kylie is discussing with Nurse Josie, a newly hired nurse, on how to utilize the nursing process for the pregnant patient. Nurse Josie is correct when she mentions the planning phase includes:
    *
    1 punto
    A. Reviewing the history of the patient during assessment
    B. Prioritizing the patient’s problems
    C. Identifying the nursing diagnoses
    D. Collecting information of the patient’s problem has been resolved in the evaluation phase

Answer 26

B. Prioritizing the patient’s problems

• setting priorities
• selecting nursing interventions
• identifying goals

Question 27

27. Nurse Thea, one of the assigned group leaders during the training, is reviewing the steps of the nursing process with the group. Nurse Thea identifies which of the following is/are objective data? Select all that apply.
    I. Respiratory rate is 22/min.
    II. Feels pain after a 10-minute walk
    III. Pain is rated as 3 on a scale of 10.
    IV. Skin is pinkish in color, warm, and dry.
    *
    1 punto
    A. II and III
    B. I and IV
    C. III and IV
    D. I and II

Answer 27

B. I and IV

Question 28

28. The very next day, Patient Rosita delivered an alive baby girl. After delivery, she complained of leg pains. Nurse Josie took hold of Patient Rosita’s chart. In the chart, an order was provided to give PONSTAN 500 mg every 4 hours PRN for pain. After 40 minutes, the patient felt relieved. Nurse Josie should have conducted what step of nursing process?
    *
    1 punto
    A. Assessment
    B. Planning
    C. Evaluation
    D. Intervention

Answer 28

B. Planning

Assessment: taking of chief complaint
Evaluation: Patient felt relief
Intervention: Medication was given

Question 29

29. If Patient Rosita’s pain was not satisfactorily relieved after administration of the medication, Nurse Josie should perform which of the following actions upholding the nursing process?
    *
    1 punto
    A. Wait for more time for the pain reliever to take effect
    B. Collect additional data as to why the patient has not been relieved of pain.
    C. Teach the patient relaxation breathing techniques.
    D. Refer to attending physician.

Answer 29

B. Collect additional data as to why the patient has not been relieved of pain.

Question 30

30. Head Nurse Kylie discusses in the training the different elements of documentation. In order for the document to be comprehensive and timely, it must be:
    *
    1 punto
    A. Complete and current
    B. Accurate and concise
    C. Organized
    D. Factual

Answer 30

A. Complete and current

“COMPREHENSIVE AND TIMELY”

Question 31

Situation
Mommy Oni is a 28-year-old primigravida that is admitted to Solaris Birthing Center. She confirms to have been in labor for the past 10 hours, having contractions 5 minutes apart. With astute observation from Nurse Karen, she deduced that the patient is having hypotonic contractions. Mommy Oni also complains of more pain in her back than in her abdomen. Sonogram was performed which showed her fetus to be “borderline” large for gestation and in occipito-posterior position.
31. Nurse Karen notices that Mommy Oni’s uterine contractions are short in duration and irregular in frequency. During contractions, Mommy Oni is screaming with pain. Nurse Karen knows that the BEST nursing action to perform is?
*
1 punto
A. Try to divert attention from pain.
B. Administer pain reliever as ordered.
C. Stay with the patient and offer her a back rub.
D. Document and report frequency and duration of contractions.

Answer 31

D. Document and report frequency and duration of contractions. - it is important to monitor the progression of contractions

A & B = HYPERTONIC UTERINE CONTRACTIONS

Question 32

32. Mommy Oni’s physician is considering augmenting her labor with the use of oxytocin. Nurse Karen would question the use of Oxytocin for Mommy Oni if?
    *
    1 punto
    A. She had an amniocentesis performed during pregnancy
    B. Her fetus is large for gestational age by a sonogram
    C. Her membrane ruptured after only 1 hour of labor
    D. Her blood pressure is slightly elevated above normal

Answer 32

D. Her blood pressure is slightly elevated above normal

large for gestational age = oxytocin is helpful in delivery since it causes hypotonic labor

Question 33

33. Nurse Karen observes that Mommy Oni’s contractions are 70 seconds long and occurring every 90 seconds when assessing the frequency of her contractions after oxytocin was administered. Nurse Karen’s first action should be which of the following?
    *
    1 punto
    A. Give an emergency bolus of oxytocin to relax the uterus
    B. Discontinue the administration of the oxytocin infusion.
    C. Increase the rate of client’s IV infusion
    D. Ask client to turn to her left side and take breaths deeply.

Answer 33

B. Discontinue the administration of the oxytocin infusion. - MOTHER IS EXPERIENCING HYPERTONIC CONTRACTIONS ALREADY

Contractions should not occur more than every 2 mins
Not stroger than 50 mmHg
Should not last longer than 70 seconds

STOP THE INFUSION IMMEDIATELY

Question 34

34. As Nurse Karen monitors Mommy Oni, she should know which finding shows an adequate pattern of uterine contraction?
    *
    1 punto
    A. Three to 5 contractions in a 10-minute period, with resultant cervical dilatation
    B. Four contractions every 5 minutes, without resultant cervical dilatation
    C. One contraction every 10 minutes, without resultant cervical dilatation
    D. One contraction per minute, with resultant cervical dilatation

Answer 34

A. Three to 5 contractions in a 10-minute period, with resultant cervical dilatation

Question 35

35. Nurse Karen is an effective nurse when she knows which of the nursing measures should she LEAST consider doing to Mommy Oni having oxytocin drip?
    *
    1 punto
    A. Know how to recognize potential adverse reactions.
    B. Administer oxytocin drug with caution
    C. Monitor patient closely when infusing oxytocin
    D. Inform patient about potential complication.

Answer 35

D. Inform patient about potential complication. - you are

Question 36

Situation
Madam Irene’s daughter, one-year-old Trixie, is admitted at Sta. Teresa Medical Center due to Pneumonia. Upon admission, she was given IV antibiotics, decongestant, antipyretic, and vitamins. She was also subjected to oxygen therapy.
36. As Nurse Ria gives Trixie her oral medication, she immediately refuses, making Nurse Ria worried. Nurse Ria will handle the situation by:
*
1 punto
A. Leaving the child alone
B. Seeking the help of the mother in giving the oral drug.
C. Mixing the drug with milk to cover up the unfavorable taste.
D. Getting angry with the mother and the child.

Answer 36

B. Seeking the help of the mother in giving the oral drug.

Question 37

37. Leaving the child alone Seeking the help of the mother in giving the oral drug. Mixing the drug with milk to cover up the unfavorable taste. Getting angry with the mother and the child.
    *
    1 punto
    A. has separation anxiety.
    B. internalizes the attitudes of others.
    C. utilizes magical thinking.
    D. is negativistic in all matters.

Answer 37

D. is negativistic in all matters. - assertion of self-control

Question 38

38. Nurse Ria knows that in giving Trixie oxygen effectively, the best way to administer it is through the use of _______.
    *
    1 punto
    A. hood
    B. face Mask
    C. Incentive Spirometer
    D. nasal catheters

Answer 38

D. nasal catheters - low flow device requiring low flow rate for infants; tube has soft prongs

Hood - high flow device and leads to a lot of wastage

Question 39

39. With Trixie being given IV Antibiotic therapy, Nurse Ria should give the MOST common gauge used for IV cannula for her age which is gauge ____.
    *
    1 punto
    A. 20
    B. 24
    C. 22
    D. 18

Answer 39

B. 24

Question 40

40. Nurse Ria is monitoring Trixie for improvement of her condition. An IMPORTANT evaluation parameter that she should watch out is ____.
    *
    1 punto
    A. Absence of fever.
    B. Absence of chest indrawing.
    C. Respiratory rate of 45 beats per minute,
    D. Respiratory rate of 55 beats/ minute.

Answer 40

A. Absence of fever. - pneumonia is characterized by high grade fever, afebrile is a sign that the infection is already resolving.

KEY: “IMPROVEMENT OF HER CONDITION”

Question 41

Situation
Patient Boa Hancock is a postpartum patient admitted at Marineford General Hospital where she delivered a stillborn. She is hooked to an intravenous fluid (IVF) and is currently being monitored postpartum. She tells her nurse, Nurse Luffy, that she wants to leave the hospital. However, she doesn’t have an order from Dr. Chopper to be discharged from the hospital.
41. Given that Nurse Luffy is aware of the ethico-legal concerns regarding Boa Hancock’s request, he has to avoid liabilities. Which of the following actions is APPROPRIATE for Nurse Luffy to do?
*
1 punto
A. Notify nursing supervisor of the patient’s plans to leave
B. Arrange medication prescriptions at the patient’s preferred pharmacy.
C. Notify directly the attending obstetrician.
D. Ask the patient about transportation plans from the hospital.

Answer 41

C. Notify directly the attending obstetrician.

A. Notify nursing supervisor of the patient’s plans to leave (new answer)

Question 42

42. With Patient Boa Hancock being on postpartum, Nurse Luffy reminds her on the importance and need of early ambulation. As per Nurse Luffy’s instruction, which of the following is INCORRECT in doing ambulation?
    *
    1 punto
    A. Assist the patient from sitting to standing position.
    B. Raise the head of the bed slowly to achieve sitting position of the patient.
    C. Allow the patient to rise from the bed to a standing position unassisted.
    D. Assist patient to rise from lying to sitting position.

Answer 42

C. Allow the patient to rise from the bed to a standing position unassisted. = possible for orthostatic hypotension, ambulation should be gradual

Question 43

43. As Nurse Luffy is waiting for an update from Nurse Rayleigh, his supervisor, regarding Boa Hancock’s request to go home, he proceeds to check his patient. As he entered the room, he discovers that the basket containing wastes caught on fire. In response to the emergency, Nurse Luffy calmly recalled that the correct steps to do in this situation is:
    I. Rescue the patient.
    II. Activate the fire alarm.
    III. Close the door to confine the fire.
    IV. Put off the fire with fire extinguisher.
    *
    1 punto
    A. IV, II and I
    B. I, II, III and IV
    C. I, II and IV
    D. II, IV and I

Answer 43

B. I, II, III and IV

III - can cut off air circulation

Question 44

44. After Nurse Luffy put out the fire, he noticed that Boa Hancock has absconded. What is the ethico-legal responsibility of Nurse Luffy?
    *
    1 punto
    A. Autonomy
    B. Nonmaleficence
    C. Beneficence
    D. Justice

Answer 44

B. Nonmaleficence - prevents the pt from getting harmed

1. Nnot stable to leave the hospitak
2. Facility just recovered from fire
3. Important to find patient

Question 45

45. Nurse Rayleigh told Nurse Luffy that absconding is inevitable in any health care facility. If the patient suddenly absconded, Nurse Luffy should IMMEDIATELY inform which of the following?
    *
    1 punto
    A. Attending physician
    B. Security guard on duty
    C. Resident on duty
    D. Nursing staff

Answer 45

B. Security guard on duty

Abscond - patient has been absent from a clinical area without noticing the staff

Question 46

46. Nurse Fiona performs her initial assessment on Anya. She notices that Patient Anya keeps crying and constantly pulling her right ear. Being Patient Anya’s nurse, she knows that the MOST APPROPRIATE action to do is:
    *
    1 punto
    A. Request parent to carry the child
    B. Take Catherine’s vital signs.
    C. Refer to the attending physician.
    D. Assess the description and frequency of pain.

Answer 46

C. Refer to the attending physician.

Question 47

47. Patient Anya’s physician gives a doctor’s order to administer Ofloxacin eardrop on Patient Anya. As Nurse Fiona prepares to administer the order, she needs to hold the bottle with her hands to warm up the solution to prevent dizziness for ______.
    *
    1 punto
    A. 5-6 minutes
    B. 1 to 2 minutes
    C. 3-4 minutes
    D. 6-7 minutes

Answer 47

B. 1 to 2 minutes

Question 48

48. Nurse Fiona washed her hands and gently started cleaning any discharges that can be removed easily from the outer ear. As Nurse Fiona positions Patient Anya, she vividly remembers that the next step in the procedure is to:
    *
    1 punto
    A. Gently press the tragus of the ear four times in a pumping motion.
    B. Gently pull the outer ear
    C. Drop the medicine into the ear canal.
    D. Keep the ear up for five minutes.

Answer 48

B. Gently pull the outer ear - straighten auditory canal, pull upward and backward; straighten auditory canal allows flow of medication to entire length of canal.

Question 49

49. Based on her previous knowledge on otitis media, Nurse Selma remembers that children like Patient Anya are predisposed to Acute otitis media due to the following risk factors, EXCEPT _____.
    *
    1 punto
    A. absence of breastfeeding
    B. Swimming
    C. exposure to cigarette smoke
    D. poor hygiene

Answer 49

B. Swimming - acute otitis externa; swimmers ear

A-Immunologic factors that protect infants against respiratory viruses and allergy

Question 50

50. Nurse Fiona’s nursing interventions to promote drainage and reduce pressure from fluid from is to have Patient Anya assume any of the following positions, EXCEPT?
    *
    1 punto
    A. tilt head to side if sitting up
    B. lie on the affected area
    C. put the pillows behind the head
    D. lie on the non-affected ear

Answer 50

D. lie on the non-affected ear - does not promote drainage

Question 51

Situation
Nurse May is a nurse that is currently rotated in the Pediatrics Ward of Kawayan Medical Center. To better appreciate her role as a professional nurse in the area, she needs to review the principles and concepts of human growth development.
51. As she was assigned to provide care to pediatric patients, Nurse May should recall which of the following correct information?
*
1 punto
A. Toddler period ranges from 12 to 36 months.
B. An infant’s tongue is smaller than the adult.
C. Early childhood period ranges from 3 to 7 years.
D. Breast milk provides complete infant nutrition.

Answer 51

A. Toddler period ranges from 12 to 36 months.

Young child has relatively larger tongue than the adult

Question 52

52. Nurse May is checking Baby Janjan’s temperature when her mother asks about what age does growth and development become more rapid. Nurse May knows that rapid growth and development occurs during which time?
    *
    1 punto
    A. Ten
    B. Nine
    C. Twelve
    D. Eleven

Answer 52

B. Nine

Question 53

53. The mother of Baby Janjan further asked Nurse May how to determine if her baby is at the right age of her development. Nurse May explained that one of the key determinants of the baby’s development is her gross and fine motor development. She emphasized further that there are actions that can stimulate and growth and fine motor movement, such as which of the following?
54. Push/pull
55. Use of scissors and pencil appropriately
56. Poking straws into holes
57. Stand on tiptoes if shown first
    *
    1 punto
    A. 1 and 2
    B. 2 and 3
    C. 3 and 4
    D. 1, 2, 3 and 4

Answer 53

D. 1, 2, 3 and 4

Gross motor skills: development involves large muscles
FIne motor skills: use of small muscles

Question 54

54. According to the World Health Organization (WHO), suicide has become a global phenomenon. As a pediatric nurse that deals with different children from toddler to adolescent, Nurse May is bound to take care of adolescents who are emotionally disturbed. As such, it is vital for Nurse May to have prior knowledge of warning signs of suicide which occur for at least a month before an attempt. Which of the following warning signs should NOT alert Nurse May?
    *
    1 punto
    A. increase in initiative
    B. verbalization of suicidal thoughts.
    C. Crying
    D. Sleep disturbances

Answer 54

A. increase in initiative

Question 55

55. Head Nurse Jona regularly performs rounds in the Pediatric Ward. In one of her nursing rounds, she asked Nurse Ester about the age inclusivity where a person transitions from childhood to adulthood or graduation. Nurse Ester knows that the CORRECT age range is from ________.
    *
    1 punto
    A. 15 to 18
    B. 12 to 16
    C. 11 to 18
    D. 13 to 18

Answer 55

C. 11 to 18

Question 56

Situation
Nurse Elle is working in the Birthing station of Maayo General Hospital, where five postpartum mothers delivered 2 hours, 4 hours, and 6 hours ago, respectively. Upon their obstetric history, she discovered that all of them have had past pregnancies. Nurse Elle, being a nurse educator, opted to conduct health education about postpartum hemorrhage which would deem vital to all postpartum mothers present.
56. Nurse Elle explains to the mothers about early indications for hypovolemia caused by postpartum hemorrhage. She is CORRECT when she states that early signs and symptoms that can be observed is:
*
1 punto
A. increasing pulse and decreasing blood pressure
B. altered mental status and level of consciousness
C. dizziness and increasing respiratory rate
D. cool, clammy skin, and pale mucous membranes

Answer 56

B. altered mental status and level of consciousness

Question 57

57. Nurse Elle further discussed with the mothers that there are risk factors that can lead to postpartum hemorrhage. Nurse Elle correctly explains that the following are risk factors EXCEPT:
    *
    1 punto
    A. ruptured uterus
    B. uterine atony
    C. overdistended uterus
    D. retroversion of the uterus

Answer 57

D. retroversion of the uterus = UTERINE DEVIATION > more on fertility

Question 58

58. Nurse Elle reviews the normal postpartum course and expects to note sexual activity during:
    *
    1 punto
    A. After weeks from the delivery
    B. 4 days after the delivery
    C. When the client’s bladder is full
    D. The day after the delivery

Answer 58

A. After weeks from the delivery

Question 59

59. During the health education session, one mother asked Nurse Elle if sexual activity will return if no complications develop. Nurse Elle explains that through a normal postpartum course, they would expect the return of sexual activity during what time?
    *
    1 punto
    A. In 4 to 6 weeks
    B. At any time
    C. After the 6-week physician check-up
    D. When her normal menstrual period has resumed

Answer 59

A. In 4 to 6 weeks

Question 60

60. Nurse Elle instructs the postpartum mothers that there may be possibilities of them experiencing postpartum hemorrhage in the future. Nurse Elle emphasizes that proper nutrition and diet may prevent or lessen the occurrence of hemorrhage. An example would be the inclusion of Vitamin K intake to lessen the bleeding itself. Nurse Elle knows that the patient should take Vitamin K with _______ for easier absorption.
    *
    1 punto
    A. Proteins
    B. Carbohydrates
    C. Minerals
    D. Fats

Answer 60

D. Fats

Question 61

Situation
Nurse Sherry is the head nurse of the OB/GYN ward of Marianas General Hospital. In one of her nursing rounds, she noticed that there is a lack of data filled up in the Intake & Output sheets of various patients of the ward.
61. Based on the discovered findings, what would be the most appropriate action for Head Nurse Sherry to do?
*
1 punto
A. Ask the staff nurses the reasons for the failure to properly fill up the Intake & Output flow sheet.
B. Give the staff nurses first warning.
C. Conduct a needs assessment.
D. Review the Orientation Program.

Answer 61

A. Ask the staff nurses the reasons for the failure to properly fill up the Intake & Output flow sheet.

Question 62

62. With the presenting issue in the ward, Head Nurse Sherry decided to coach her staff nurses. One of the questions she asked was what fluids should not be included in documenting the Intake/Output flowsheet. The staff nurse is correct if she said:
    *
    1 punto
    A. Intravenous Fluids
    B. Gelatin
    C. Solid Foods
    D. Beverages

Answer 62

C. Solid Foods

Question 63

63. Head Nurse Sherry also emphasized to the staff nurses that which of the following should be EXCLUDED in documenting the Output list?
    *
    1 punto
    A. Drainage from tubes
    B. Solid/hard feces
    C. Urine
    D. Vomitus

Answer 63

B. Solid/hard feces

Question 64

64. Another question asked by Head Nurse Sherry is about the time to record the Intake and Output. The staff nurse is correct when she said that the BEST TIME to record the intake and output is:
    *
    1 punto
    A. During endorsement
    B. After endorsement
    C. Right before endorsement
    D. Any time before duty

Answer 64

C. Right before endorsement. - end of shift

Question 65

65. Mommy Mathilda, a pregnant patient in the ward, is also diagnosed with Chronic Heart Failure. In patients with chronic heart failure, monitoring intake and output is considered vital. The MAIN purpose of recording accurate data on intake and output of these patients is to _____________.
    *
    1 punto
    A. determine if client is improving or not
    B. find out if there is still water retention in the interstitial cells
    C. detect cardiac overload
    D. determine weight gain/loss

Answer 65

B. find out if there is still water retention in the interstitial cells = third spacing cells; if there id fluid shifting d/t third spacing, fluids retain in the body but no available for use = isotonic fluid volume deficit

Question 66

Situation
Nurse Melanie and her fellow staff nurses assigned in the delivery room of Pandacan Medical Center, is interested in conducting a research study on the experiences of pregnant women in labor. They are planning on making it qualitative research to yield accurate results, with Nurse Melanie as the lead researcher.
66. In the presentation of results and discussion portion of the qualitative study, Nurse Melanie should use as a reference in the write-up the ______ person.
*
1 punto
A. First
B. Second
C. Fourth
D. Third

Answer 66

D. Third = its avoid subjectivity and it removes direct reference to researcher but there are few who use first person depends on association.

Question 67

67. Nursing is always regarded as both an art and a science. In the field of human science, nursing deals with the critical and fundamental differences in attitude towards their respective phenomena. Which of the following is an aim of human sciences?
    *
    1 punto
    A. Construct prediction
    B. Seek causal explanation
    C. Sets control
    D. makes meaningful interpretation

Answer 67

D. makes meaningful interpretation = phenomenological

Question 68

68. Nurse Melanie’s research group is observing the activities occurring in the delivery room. One of the activities happening involves social processes, which can be further explored. To explore this, which of the following qualitative research method should be used?
    *
    1 punto
    A. Grounded theory
    B. Historical research
    C. Descriptive Phenomenology
    D. Case study

Answer 68

A. Grounded theory = social structures, social interactions, social processes

Question 69

69. After the research group is done analyzing the data of their study about experiences of pregnant women in labor, they proceed to return to the participants in order to determine the accuracy of the emerged themes. The research group is doing which criteria of trustworthiness?
    *
    1 punto
    A. Confirmability
    B. Credibility
    C. Transferability
    D. Dependability

Answer 69

B. Credibility = confidence in the truth of data, accurate

A. = objectivity
C.= in quanti
D. = stability

Question 70

70. While conducting the interview as their method of data collection in the study, the research group utilized audio recording devices to capture what transpired in the interview session. After transcribing the data, the research group is aware that the APPROPRIATE action to do with the audio tape is:
    *
    1 punto
    A. Keep the audiotape in a vault and dispose of it a year after.
    B. Submit the audiotape to their research adviser.
    C. Throw it in the trash bin immediately after it was used
    D. Post the recording on their university research website for others to listen.

Answer 70

A. Keep the audiotape in a vault and dispose of it a year after.

Question 71

Situation
Nurse Christine is the head nurse of the OB/GYN area at Santa Monica General Hospital. To increase better performance in the area, she conducted an in-service program on staff development.
71. Head Nurse Christine discussed with the nurses in the area that the MOST frequently neglected area in management is __________.
*
1 punto
A. Managerial knowledge
B. Professional development
C. Clinical skills
D. Successful communication

Answer 71

D. Successful communicationm

Most common conflict is break comm.

Question 72

72. Being the head nurse in the area, Nurse Christine knows that a vital component in the process of supervising is delegation of tasks. She knows that the delegation is MOST empowering to the staff because:
    *
    1 punto
    A. Effective delegation does not require nurses to know the abilities and weaknesses of their staff
    B. Delegation frees the manager to do other task while empowering staff.
    C. Delegation fosters the responsibility of staff while increasing professional growth.
    D. Delegation starts at top management down to subordinates

Answer 72

C. Delegation fosters the responsibility of staff while increasing professional growth.

Question 73

73. During the in-service program, Head Nurse Christine discussed one of the common conflict resolution methods which is negotiation. She asked one staff what the focus of negotiation is. The staff answered correctly if she said negotiation creates a ________.
    *
    1 punto
    A. Soothing situation
    B. Third party consultation
    C. Trade-off
    D. Win-win situation

Answer 73

D. Win-win situation

Question 74

74. Head Nurse Christine emphasized that after delegation of duty comes supervision. She stated that the PRIMARY purpose of supervision is it:
    *
    1 punto
    A. Influences the organization’s approach in recruitment, promotion and personnel evaluation.
    B. Improves staff compliance with policy and procedures.
    C. Assigns appropriate work tasks to the best-qualified
    D. Enhances the delivery of quality nursing care.

Answer 74

D. Enhances the delivery of quality nursing care. = provision of guidance

Question 75

75. Head Nurse Christine reinforced that Delegation involves transferring of nursing care to an individual. She stated that when delegating care to the staff, there are various criteria to observe. What is considered the BEST criterion when delegating staff?
    *
    1 punto
    A. Responsibility
    B. Adaptability
    C. Flexibility
    D. Competence

Answer 75

D. Competence

Question 76

Situation
Therapeutic Communication is an important aspect in providing better rapport as it promotes understanding between the sender and receiver. Nurse Dan, a staff nurse in the Medical-Surgical ward of Taginting Medical Center, should be abreast with common therapeutic communication techniques if he wants to have an effective and achievable nursing care.
76. Karylle, a patient with gastrointestinal problems explicitly says, “I am not sure if I should undergo colonoscopy or not as I am scared.” To give a proper response, which of the following therapeutic communication technique is the MOST appropriate for Nurse Dan to use?
*
1 punto
A. Touch
B. Clarifying
C. Restating
D. Silence

Answer 76

C. Restating

Question 77

77. When Karylle said, “Whenever I see my husband visit me, I feel depressed,” Nurse Dan replied, “Your husband depresses you?” Nurse Dan responded with which therapeutic communication technique?
    *
    1 punto
    A. Restatement
    B. Focusing
    C. Focusing
    D. Seeking clarification

Answer 77

A. Restatement

Question 78

78. As Nurse Dan continued to converse with Patient Karylle, he said, “Tell me more about your experience when you had the colonoscopy” Which therapeutic communication technique is Nurse Dan utilizing?
    *
    1 punto
    A. Focusing
    B. Clarifying
    C. Encouraging elaboration
    D. Restating

Answer 78

C. Encouraging elaboration

Question 79

79. When Nurse Dan says, “Tell me more about about your experience. I wish to hear about…” He is displaying which therapeutic communication technique?
    *
    1 punto
    A. Restating
    B. Seeking clarification
    C. Open-ended questions
    D. Summarizing

Answer 79

B. Seeking clarification = better answer is FOCUSING.

Question 80

80. Nurse Dan tells the patient, “You will be wheeled in to the OR and will be hooked to an IVF where the anesthesia will be given intravenously.” The therapeutic communication technique that Nurse Dan used is ____________.
    *
    1 punto
    A. Clarification
    B. Summarizing
    C. Giving information
    D. Reflection

Answer 80

C. Giving information

Question 81

Situation
Patient Sheena is a 12-year-old pediatric patient admitted at Calantag Hospital Private Room, where she was equipped with a tracheostomy tube. Nurse Kenny is the person assigned to care of Sheena.
81. Nurse Kenny is a newly registered nurse, so he does not have the experience and skill caring for Patient Sheena who has a tracheostomy tube. As an inexperienced nurse, he can ask for anyone of the following to perform the care, EXCEPT:
*
1 punto
A. Medical Resident
B. Medical Intern
C. Charge Nurse
D. Mother of child with care of tracheostomy tube experience

Answer 81

D. Mother of child with care of tracheostomy tube experience

Question 82

82. Dr. Dizon, the otolaryngologist, arrived at the room to perform the changing of tracheostomy tube. He asked Nurse Kenny to prepare for the appropriate equipment and supplies needed for the procedure. Nurse Kenny is aware that the CORRECT department to collaborate with is:
    *
    1 punto
    A. Emergency Department
    B. Central Supply Unit
    C. Anesthesia Department
    D. Operating Room Department

Answer 82

B. Central Supply Unit

Question 83

83. Nurse Kenny informed his head nurse, Jane, that he still does not have the skill and experience to perform this procedure. To assure that Nurse Kenny learns the proper way of caring for patients with tracheostomy tube, Head Nurse Jane knows to collaborate with who among the following personnel?
    *
    1 punto
    A. Asst. Chief Nurse for Clinical
    B. Chief of Unit
    C. Asst. Chief Nurse to Education & Training
    D. Chief of Clinics

Answer 83

C. Asst. Chief Nurse to Education & Training

Question 84

84. Dr. Dizon ordered a change of the tracheostomy tube ties for Patient Sheena. Among the following, which should Dr. Dizon collaborate with in performing this task?
    *
    1 punto
    A. Medical Intern
    B. Medical Resident
    C. Nursing Aide
    D. Staff Nurse

Answer 84

D. Staff Nurse

Question 85

85. Dr. Dizon is going to perform suctioning on patient Sheena using a single-used catheter for tracheostomy. To perform the skill of suctioning using a single-used catheter for tracheostomy safely, he needs how many assistants?
    *
    1 punto
    A. Four
    B. Two
    C. Three
    D. One

Answer 85

D. One

Question 86

Situation
Madellaine, a multipara patient is admitted at Nicanor Buenavente General Hospital due to having labor pain that started an hour ago. Upon performing the vaginal examination, Nurse Patricia noted that the cervix is completely dilated and 100% effaced. With this assessment, Patient Madellaine is experiencing true labor pains.
86. During the shift, Nurse Patricia is keeping watch of Patient Madellaine’s labor. She is aware that one of the problems that can occur with labor is that the labor and delivery can be completed in less than 3 hours. This is usually termed as ________ labor.
*
1 punto
A. Precipitous
B. Preterm
C. Induced
D. Prolonged

Answer 86

A. Precipitous

B before 36 weeks of gestation
C administraion of oxcytoxin

Question 87

87. Patient Madellaine is referred to the physician, Dr. Matthew. Upon doctor’s recommendation, routine blood examinations were taken. After reviewing the serum electrolyte levels, Dr. Matthew ordered IV infusion of Isotonic fluid as prescribed. With Nurse Patricia’s knowledge on IV fluids, which IV solution should she prepare?
    *
    1 punto
    A. 5 percent dextrose in water
    B. 0.45 percent sodium chloride solution
    C. 10 percent dextrose in water
    D. 3 percent sodium chloride solution

Answer 87

A. 5 percent dextrose in water = ISOTONIC

B hypo
C hyper
D hyper

Question 88

88. Patient Madellaine, having been in labor, would anticipate some emotional support. To keep Patient Madellaine calm during labor, Nurse Patricia should perform which of the following nursing intervention?
    *
    1 punto
    A. Giving praise for her the sense of satisfaction regarding quick labor.
    B. Support in maintaining a sense of alcohol
    C. Explanation of the effect of labor on the newborn.
    D. Allowing the patient to express pain and anxiety.

Answer 88

D. Allowing the patient to express pain and anxiety. = Relieve strong emotions….

Question 89

Situation
Jonah, a multiparous patient experiencing true labor pains, is noted to have complete dilatation of the cervix and effacement of 100 percent.
89. A nursing student asks the nurse why Patient Jonah’s labor now is much shorter compared to her previous deliveries. Which of the following is the BEST RESPONSE?
*
1 punto
A. Onset of contraction was gradual.
B. Multigravida patient has shorter labor.
C. Cervical lengthening was longer.
D. Induction of labor was done.

Answer 89

B. Multigravida patient has shorter labor.

Question 90

90. Methylergonovine maleate (Methergin) is prescribed by the physician and was administered intramuscularly after delivery. What is the primary action of this medication?
    *
    1 punto
    A. Reduces the amount of lochia drainage.
    B. Prevents postpartum hemorrhage
    C. Decreases uterine contractions.
    D. Maintains normal blood pressure.

Answer 90

B. Prevents postpartum hemorrhage

Question 91

Situation
A doctor ordered oxygenation of 4 liters per minute for Joseph, a 10-year-old child with bronchitis.
91. What is the first standard step in oxygen therapy?
*
1 punto
A. Prepare the patient for the oxygen treatment
B. Check the chart for ordered flow rate and oxygen delivery method.
C. Gather all the equipment and supplies.
D. Assess patient’s condition.

Answer 91

B. Check the chart for ordered flow rate and oxygen delivery method.

Question 92

92. All of the following needs to be considered when administering oxygen therapy, EXCEPT _____.
    *
    1 punto
    A. need for a humidifier.
    B. length of tubing.
    C. determine the age of Joseph.
    D. manner of administering oxygen, continuous or intermittent.

Answer 92

B. length of tubing.

A: devices that add water vapor to inspired air
C: Developmental factors have important influences on respiratory actions
D..

Question 93

93. The nurse knows that the PRIORITY nursing action when administering oxygen therapy is to ______.
    *
    1 punto
    A. attach the humidifier and connect tubing to the oxygen delivery device.
    B. connect the flow meter to the pipe in oxygen outlet
    C. turn on the oxygen
    D. check the flow.

Answer 93

C. turn on the oxygen

Question 94

94. Which precautionary measure done by the nurse is PRIORITY during oxygen therapy?
    *
    1 punto
    A. Limit visitors.
    B. Attach “No Smoking” signage
    C. Check humidifier’s water regularly
    D. Connect belt to oxygen tank.

Answer 94

B. Attach “No Smoking” signage = highly combustible

Question 95

95. Joseph, while on continuous oxygen therapy, still complains of having difficulty breathing. The nurse’s INITIAL intervention is to ______.
    *
    1 punto
    A. Give PRN medication.
    B. Refer patient to the physician
    C. Assess the patency of the tubing.
    D. Re-assess the patient.

Answer 95

C. Assess the patency of the tubing.

Question 96

96. Due to an increasing number of errors in regard to documentation and record management, Head nurse Levi is conducting a lecture on proper nursing documentation and management of records in her ward.
    *
    1 punto
    A. Reduce the number of forms of the chart
    B. List the patients’ health problems.
    C. Record the patient’s progress.
    D. Provide confidentiality of the chart.

Answer 96

C. Record the patient’s progress. = systematic, assessment

Question 97

97. When charting patient’s progress accurately, which of the following principles should be followed?
    *
    1 punto
    A. Statements are qualified by the use of “seems’ and “appears”
    B. Assumptions and conclusions are reported
    C. Specific and definite words or phrases are used.
    D. General statements and measurement are used.

Answer 97

C. Specific and definite words or phrases are used.

Question 98

98. All of the following are characteristics of a chart, EXCEPT?
    *
    1 punto
    A. Complete
    B. Subjective
    C. Objective
    D. Accurate

Answer 98

B. Subjective

Question 99

99. Kardex is used during nursing endorsements. Which of the following is NOT true about Kardex?
    *
    1 punto
    A. kept up to date
    B. a quick reference for current information about the client.
    C. consists of folded card for each patient.
    D. part of the medical record.

Answer 99

D. Part of the medical record = faster endorsement

Question 100

100. When an error is made during charting, what should the nurse do?
     *
     1 punto
     A. Recopy the sheet and destroy the original sheet
     B. Use a single line to cross out the error, the write the date, time and sign the correction made.
     C. Use correction fluid to erase the error
     D. Use eraser to remove the wrong entry

Answer 100

B. Use a single line to cross out the error, the write the date, time and sign the correction made.