Recalls 4 - NP2 Flashcards
Patient Natalie, 15 years old, G0P1, AOG 39 weeks, has been admitted at 6:30 in the morning for lumbo-sacral pains and strong uterine contractions every 10 minutes. Nurse Gracie was there to admit her. She uses Focus, Data, Action and Response (FDAR) as the form of charting.
- In any type of charting or documentation, which of the following should the nurse refer to and use to generate and describe the status of patient Fe? Nursing __________.
A. Assessment
B. Process
C. Actions
D. Diagnosis
A. Assessment
- Which of the following are the purposes of documentation? To ________.
I. Ensure the development of organized comprehensive care plan
II. Have a clear and accurate record of what was done to the patient.
III. Have an evidence of the health care member’s accountability in giving care
IV. Detect patients who are clinically deteriorating
A. II, III, IV
B. I, II, III, IV
C. I, II, III
D. I, III, IV
C. I, II, III
- Which of the following is the CORRECT definition of focus charting?
A. It is an electronically form of documentation of nursing care done to a patient by a registered nurse.
B. It is a note, written or electronically generated, to provide documentation related to a specific focus.
C. It is a nurse-centered way of documentation that describes the patient status and nursing care rendered.
D. It is a nurse-centered approach to documentation.
B. It is a note, written or electronically generated, to provide documentation related to a specific focus.
- In the given situation, which is the FOCUS?
A. Patient Natalie as the admitting nurse
B. Lumbo-sacral pains and strong uterine contractions
C. 15 years old, G0P1, AOG of 36 weeks
D Admission at 6:30 in the morning
B. Lumbo-sacral pains and strong uterine contractions
- What is the term used to describe the patient’s data or assessment, the action done based on
A. Progress Note
B. Flow sheets
C. Standard of Care
D. Focus Format
D. Focus Format
Situation
This is the first postoperative day for patient Shiela who delivered by caesarean section
(CS). Nurse Gemma a newly hired staff was assigned to her
- Patient Shiela asks the nurse why she has to get up and walk the day after surgery. Which of the following is the BEST response of the nurse? Walking hastens _________.
A. Hastens lactation
B. Relieves pain
C. Heals wounds
D. Fast recovery from anesthesia
C. Heals wounds
- Which laboratory finding should the nurse assess on the patient 24 hours after caesarian section delivery upon doctor’s request?
A. Trace 1+ proteinuria
B. Hematocrit 35%
C. White blood cell count 20,000/cu.mm
D. Hemoglobin 7.0 g/dL
D. Hemoglobin 7.0 g/dL
- Patient Shiela complains of “afterpains”. What should be the nurse IMMEDIATE action?
A. Advise her to stop breast-feeding for a day
B. Encourage her to drink more water
C. Assess vital signs and pain level
D. Administer an analgesic STAT
C. Assess vital signs and pain level
- Patient Shiela is to be discharge 3 days after CS delivery. Which of the following observations of the nurse would cause the delay of her discharge and would warrant notification to the physician?
A. Moderate amount of lochia rubra
B. Fundus is firm at umbilicus
C. Pulse rate of 61 beats/minute taken in 24 hours
D. Five voidings totaling 240 cc in 12 hours
D. Five voidings totaling 240 cc in 12 hours
10.On the third postpartum day, Patient Shiela reports that she has voided five times that morning. What should the nurse INITIALLY do?
A. Insert a Foley catheter
B. Collect the next voiding and measure the urine amount
C. Catheterize the client to check for residual urine
D. Call the physician
A. Insert a Foley catheter
Situation
Patient Apple, 19 years old, is in her first trimester of pregnancy. Because it is her first
pregnancy, she went for her prenatal check-up with her mother. She asked a lot of questions which
she expects the nurse to answer her.
- The nurse asked for the personal data of the patient which, to some, Patient Apple did not like to answer. And so she asked: “Why do you need to know if I am married?” what should be a good response of the nurse? “I asked your marital status because _________.
A. If you do not have a husband, then that can pose a big problem for you.”
B. If you are married then your husband will also suffer from discomforts like you.”
C. You need your husband to accompany you every prenatal check-up.”
D. Your husband is your best support system during your pregnancy.”
D. Your husband is your best support system during your pregnancy.”
- The patient asked what is the term for signs such as breast changes, urinary frequency, fatigue, morning sickness and amenorrhea?
A. Probable signs
B. Presumptive signs
C. Possible signs
D. Positive signs
B. Presumptive signs
- The patient asked what causes newborn babies with total absence of extremities. The nurse answered that the cause for Amelia is intake of which of the following medications during pregnancy ___________.
A. Anti-emetics
B. Antibiotics
C. analgesics
D. anti-bacterials
A. Anti-emetics
- The patient complained that every morning, she becomes nauseated and oftentimes, she would vomit excessively. “What could be the cause of this,” she asked? The nurse’s answer is: “It is due to increase level of ________.”
A. Heart burn
B. Estrogen
C. heart rate
D. Progesterone
B. Estrogen
- The nurse advised patient Patient Apple to report to her physician which of the following MOST important sign, if ever she will suffer from it?
A. Cough
B. Vaginal bleeding
C. Headache
D. strong fetal movement
B. Vaginal bleeding
As a newly-hired staff nurse of the hospital, Jubilee learned that the hospitals have an
in-service training for its staff. The in-service trainings conducted are based on hospital and staff’s
needs. One of the identified needs was on knowledge deficit of Mother and Baby Friendly Hospital
Initiative (MBFHI).
- What is the FIRST step among the ten steps for successful breastfeeding?
A. Have a written breastfeeding policy that is routinely communicated to all staff.
B. Inform all pregnant women about the benefits and management of breastfeeding.
C. Foster the establishment of breastfeeding support groups.
D. Train all health care staff in skills necessary to implement the policy.
A. Have a written breastfeeding policy that is routinely communicated to all staff.
- When practicing rooming-in, how long should the baby stay with the mother? ______ hours.
A. 8
B. 24
C. 12
D. 10
B. 24
- What is the CORRECT time for which the mother should initiate breastfeeding? It should be _______ hours after birth.
A. ½
B. 1
C. 3
D. 2
A. ½
- Jubilee learned that newborn infants should ONLY be given, which of the following?
A. Fruit juice
B. Breastmilk
C. water
D. cow’s milk
B. Breastmilk
- Which is the LAST part of the initiative, as recommended by WHO and UNICEF, for the MBFHI external team to do before its final designation as MBFHI Hospital?
A. Assess business facilities if they follow the 10 steps for successful breastfeeding.
B. Develop a research on the benefits of breastfeeding within the institution.
C. Disseminate the benefits of breastfeeding to communities.
D. Follow up mothers if they are exclusively breastfeeding.
A. Assess business facilities if they follow the 10 steps for successful breastfeeding.
Situation
Heather is 23 years old. She and her boyfriend, Patrick, are planning to get married in a
couple of months. Thereafter, they plan to have three babies. For this reason they sought
reproductive health counseling for their benefit and the proper growth and development of their
future children. Nurse Susane was there to help them.
- Heather asks what she must do in order to be healthy in case she becomes pregnant. Which among the answers of Nurse Susane should NOT be followed by Heather?
A. Get support from husband and family.
B. May have a massage from a lay midwife.
C. To readily accept her pregnancy.
D. Early prenatal check-up
B. May have a massage from a lay midwife.
- Patrick asks what possible contribution he could give for the normal development of the baby. Nurse Susane agreed that his BEST contribution would be the following EXCEPT __________.
A. Stroke Heather’s abdomen and talk to baby
B. Provide Heather nutritious food and drinks
C. Join wife during prenatal check-up
D. May smoke once in a while
D. May smoke once in a while
- For the normal developmental of the fetus, Nurse Susane taught the couple that Heather should prevent Folic Acid Deficiency anemia by good diet, correct way of cooking vegetables and taking Folic Acid supplements. Which of the following is NOT included among the outcomes of folic acid deficiency to the baby?
A. Cleft lip
B. Cleft palate
C. Neural tube defect
D. Fractures of all types
D. Fractures of all types
- Heather asks the nurse what possible diseases should she avoid that would guarantee health for the baby? These are:
- Rubella
- Rheumatic fever
- Anemia
- Chronic hypertension
A. 1, 2, 3
B. 1, 2, 3, 4
C. 1, 2, 4
D. 2, 3, 4
B. 1, 2, 3, 4
- Nurse Susane advised the couple that the BEST way to check the condition of the mother and the baby is to have _________.
A. Regular well-selected exercise
B. Regular prenatal check-up
C. Music therapy
D. Good food
B. Regular prenatal check-up
Situation
A hospitalized adolescent Scottie suddenly has a seizure while his family is visiting. Nurse
Nisha notes whole body rigidity followed by general jerking movements. Scottie vomits immediately
after seizure.
- Which of the following would be the PRIORITY nursing diagnosis for Scottie?
A. Fluid volume deficit related to vomiting.
B. Altered family processes related to chronic illness.
C. High risk for infection related to vomiting.
D. Risk for aspiration related to loss of consciousness
D. Risk for aspiration related to loss of consciousness
- Scottie will be taking phenytoin (Dilantin) regularly for seizure control. Which of the following will be the MOST important teaching to Scottie’s family?
A. Administer acetaminophen to promote sleep.
B. Serve a diet that is high in iron
C. Maintain good oral hygiene and dental care
D. Omit medication if the child is seizure free.
C. Maintain good oral hygiene and dental care
- Which of the following would be the LEAST PRIORITY nursing care for a child with seizure disorder?
A. Observation and recording all seizures.
B. Ensuring safety and protection from injury.
C. Teaching the family about anticonvulsant drug therapy: indication, dosage, route and effects.
D. Assessing for signs and symptoms of Increased Intracranial Pressure.
D. Assessing for signs and symptoms of Increased Intracranial Pressure.
- After teaching the parents about their child’s unique psychological needs related to a seizures disorder and possible stressors, which of the following concerns voiced by them would indicate the need for additional teaching? The child’s ___________.
A. Feeling different from peers
B. Cognitive delays
C. Poor self-image
D. Dependency
B. Cognitive delays
- Which of the following is NOT a focus for teaching plan for an adolescent with a seizure disorder?
A. Obtaining a driver’s license
B. Increase risk for infections
C. Peer pressure
D. Drug and alcohol use
B. Increase risk for infections
- A woman 2 ½ months pregnant calls you by telephone because she passed out some “berry-like” blood clots and now has continued dark brown vaginal bleeding. Which of the following is the BEST instruction you should give her?
A. “Continue normal activity but take your pulse and respiratory rate every 4 hours.”
B. “Come to the health facility if uterine contractions start.”
C. “Come to the health facility with any vaginal material passed out.”
D. “Maintain bedrest and count the number of perineal pads used every hour.”
C. “Come to the health facility with any vaginal material passed out.”
Situation
Any pregnancy may pose a risk. A pregnant woman must therefore submit herself for
regular pre-natal consultation in any health facility near her place of abode. A nurse can play an
important role in making these pregnant women aware of these risks in all stages of pregnancy.
- What CHIEF ingredient of the prenatal vitamin for pregnancy nutrition that the patient should look for?
A. Vitamin B12
A. Potassium
C. Vitamin C
D. Folic Acid
D. Folic Acid
- A woman in labor is at risk for abruptio placenta. Which of the following assessments would MOST convince you and the pregnant woman to believe that this has happened?
A. Painless vaginal bleeding and downward trend of BP.
B. And increased blood pressure and scanty urination.
C. Pain at the lower quadrant and increased pulse rate.
D. Sharp fundal pain and discomfort between contractions.
D. Sharp fundal pain and discomfort between contractions.
- A woman, 33 weeks pregnant, with preterm rupture of membranes had blood work ordered daily. Which laboratory report would be MOST important to read daily?
A. Serum creatinine
B. Red blood cell count
C. Sodium and potassium levels
D. White blood cell count
D. White blood cell count
- An 18 –year –old delivers to an 8 –pound – baby after 10 hours of labor. In the post-partal period, which of the following would be a PRIORITY concern to assess for by the nurse?
A. Endometritis
B. Thrombophlebitis
C. Bleeding
D. Amniotic embolus
C. Bleeding
Situation
Head nurse Eva supervises Nurse Hannah who is assigned to take care of a newborn baby
boy named Edwin with a cleft palate.
36.The mother asks the head nurse why the pediatrician recommended that closure of the palate should be done before he is 6 months old. She asked Nurse Hannah to answer her. Which of the following is Nurse Hannah’s APPROPRIATE response?
A. “After age 2, surgery is very frightening and should be avoided if possible.”
B. “The eruption of the 2-year molars often complicates the surgical procedure.”
C. “Surgery should be performed before the child starts to use faulty speech patterns.”
D. “As he gets older the palate gets wider and more difficult to repair.”
C. “Surgery should be performed before the child starts to use faulty speech patterns.”
- The head nurse continued to ask Nurse Hannah, “A cleft lip predispose an infant to infections PRIMARILY because of which of the following reasons?”
A. Waste products that accumulate along the defect.
B. Inadequate circulation in the defective area.
C. Deficient nutrition from ineffective feeding.
D. Mouth breathing that dries the oropharyngeal mucous membranes.
D. Mouth breathing that dries the oropharyngeal mucous membranes.
38.Which SIGNIFICANT statement of the mother predisposes her son to cleft lip or palate?
A. “On my 6 months of pregnancy, I saw a rabbit with the same case of my son.”
B. “I am asthmatic and I usually take steroids.”
C. “My mother- in- law doesn’t like me, that’s why she cursed me.”
D. “I believe my enemy did some forms of witchcraft on me.”
B. “I am asthmatic and I usually take steroids.”
39.For an infant born with a unilateral cleft lip and palate, which of the following type of feeding will be BEST to use?
A. Rubber-tipped syringe or medicine dropper.
B. Full breast feeding.
C. IV fluids on limited number of ounces.
D. Cross-cut rubber nipple.
D. Cross-cut rubber nipple.
40.Which of the following is the number ONE consideration in the care of an infant after the surgical repair of a cleft lip?
A. Preventing the infant from crying
B. Feeding the infant with a spoon for 2 days after surgery
C. Placing the infant in a semi-sitting position
D. Keeping the infant NPO for 1 say after surgery.
C. Placing the infant in a semi-sitting position