Nurse Betty is assigned to the following clients. The client that the nurse would see first after endorsement?

A 44 year-old myocardial infarction (MI) client who is complaining of nausea.

A 34 year-old post operative appendectomy client of five hours who is complaining of pain.

A 44 year-old myocardial infarction (MI) client who is complaining of nausea.

A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated.

A 63 year-old post operative’s abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid.

Nurse Gail places a client in a four-point restraint following orders from the physician. The client care plan should include:

Check circulation every 15-30 minutes.

Provide diversional activities.

Check circulation every 15-30 minutes.

Socialize with other patients once a shift.

The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take?

Continue to monitor and record hourly urine output

Increase the I.V. fluid infusion rate

Irrigate the indwelling urinary catheter

Continue to monitor and record hourly urine output

Tony, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by Tony suggests that ice application has been effective?

“My ankle looks less swollen now”.

“My ankle appears redder now”.

“I need something stronger for pain relief”

She finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors will she exhibit most likely?

Have condescending trust and confidence in their subordinates.

Communicates downward to staffs.

Allows decision making among subordinates.

Nurse Amy is aware that the following is true about functional nursing

Concentrates on tasks and activities.

Provides continuous, coordinated and comprehensive nursing services.

One-to-one nurse patient ratio.

Emphasize the use of group collaboration.

Concentrates on tasks and activities.

Nurse Linda prepares to perform an otoscopic examination on a female client. For proper visualization, the nurse should position the client's ear by:

Pulling the lobule down and back

Pulling the helix up and forward

Pulling the lobule down and forward

Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware that one of the following is unassociated with this condition?

Larger than normal uterus for gestational age.

Elevated levels of human chorionic gonadotropin.

A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is:

Urinary output 90 cc in 2 hours.

Rapid respiratory rate above 40/min.

During vaginal examination of Janah who is in labor, the presenting part is at station plus two. Nurse, correctly interprets it as:

Presenting part in 2 cm below the plane of the ischial spines.

Presenting part is 2 cm above the plane of the ischial spines.

Biparietal diameter is at the level of the ischial spines.

Presenting part in 2 cm below the plane of the ischial spines.

Biparietal diameter is 2 cm above the ischial spines.

A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is:

Contractions every 1 ½ minutes lasting 70-80 seconds.

Early decelerations in the fetal heart rate.

Fetal heart rate baseline 140-160 bpm.

A trial for vaginal delivery after an earlier caesareans, would likely to be given to a gravida, who had:

First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation.

First low transverse cesarean was for active herpes type 2 infections; vaginal culture at 39 weeks pregnancy was positive.

First and second caesareans were for cephalopelvic disproportion.

First caesarean through a classic incision as a result of severe fetal distress.

First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation.

Nurse Ryan is aware that the best initial approach when trying to take a crying toddler’s temperature is:

Talk to the mother first and then to the toddler.

Bring extra help so it can be done quickly.

Encourage the mother to hold the child.

Ignore the crying and screaming.

Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the nurse do to prevent trauma to operative site?

Place the infant’s arms in soft elbow restraints.

Avoid touching the suture line, even when cleaning.

Place the baby in prone position.

Place the infant’s arms in soft elbow restraints.

Which action should nurse Marian include in the care plan for a 2 month old with heart failure?

Allow the infant to rest before feeding.

Bathe the infant and administer medications before feeding.

Weigh and bathe the infant before feeding.

Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5 months. The nurse should advise her to include which foods in her infant’s diet?

Iron-rich formula and baby food.

Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action?

Call for help and note the time.

Give two sharp thumps to the precordium, and check the pulse.

Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse should:

Make sure that the client takes food and medications at prescribed intervals.

Plan care so the client can receive 8 hours of uninterrupted sleep each night.

Monitor vital signs every 2 hours.

Make sure that the client takes food and medications at prescribed intervals.

Provide milk every 2 to 3 hours.

A male client was on warfarin (Coumadin) before admission, and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?

Stop the I.V. infusion of heparin and notify the physician.

Expect the warfarin to increase the PTT.

Increase the dosage, because the level is lower than normal.

A client undergone ileostomy, when should the drainage appliance be applied to the stoma?

24 hours later, when edema has subsided.

After the ileostomy begin to function.

When the client is able to begin self-care procedures.

July PNLE Pre-board Preparation 2011(Online Exam)

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July PNLE Pre-board Preparation 2011(Online Exam)

Nurse Betty is assigned to the following clients. The client that the nurse would see first after endorsement?

Nurse Gail places a client in a four-point restraint following orders from the physician. The client care plan should include:

A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse In-charge knows the purpose of this therapy is to:

The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take?

Tony, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by Tony suggests that ice application has been effective?

The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?

She finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors will she exhibit most likely?

Nurse Amy is aware that the following is true about functional nursing

Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"

A female client with a fecal impaction frequently exhibits which clinical manifestation?

Nurse Linda prepares to perform an otoscopic examination on a female client. For proper visualization, the nurse should position the client's ear by:

Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware that one of the following is unassociated with this condition?

A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is:

During vaginal examination of Janah who is in labor, the presenting part is at station plus two. Nurse, correctly interprets it as:

A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is:

Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). A nursing action that must be initiated as the plan of care throughout injection of the drug is:

A trial for vaginal delivery after an earlier caesareans, would likely to be given to a gravida, who had:

Nurse Ryan is aware that the best initial approach when trying to take a crying toddler’s temperature is:

Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the nurse do to prevent trauma to operative site?

Which action should nurse Marian include in the care plan for a 2 month old with heart failure?

Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5 months. The nurse should advise her to include which foods in her infant’s diet?

Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action?

Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse should:

A male client was on warfarin (Coumadin) before admission, and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?

A client undergone ileostomy, when should the drainage appliance be applied to the stoma?

A client undergone spinal anesthetic, it will be important that the nurse immediately position the client in:

While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure?

Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first?

A male client has active tuberculosis (TB). Which of the following symptoms will be exhibit?

Mark, a 7-year-old client is brought to the emergency department. He’s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has a nonproductive cough. He recently had a cold. Form this history; the client may have which of the following conditions?

Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have which of the following reactions?

A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging?

Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby should monitor the client for the systemic side effect of:

Norma, with recent colostomy expresses concern about the inability to control the passage of gas. Nurse Oliver should suggest that the client plan to:

Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, “I should:

Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and electrolyte imbalances. The client is somewhat confused and complains of nausea and muscle weakness. As part of the prescribed therapy to correct this electrolyte imbalance, the nurse would expect to:

Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:

Terence suffered form burn injury. Using the rule of nines, which has the largest percent of burns?

Herbert, a 45 year old construction engineer is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:

Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?

The nurse is ware that the most relevant knowledge about oxygen administration to a male client with COPD is

What is Nurse John likely to note in a male client being admitted for alcohol withdrawal?

Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that it “doesn’t help” and refuses to take it. What should the nurse say or do?

In preparing a female client for electroconvulsive therapy (ECT), Nurse Michelle knows that succinylcoline (Anectine) will be administered for which therapeutic effect?

Nurse Gina is aware that the dietary implications for a client in manic phase of bipolar disorder is:

What parental behavior toward a child during an admission procedure should cause Nurse Ron to suspect child abuse?

Nurse Lynnette notices that a female client with obsessive-compulsive disorder washes her hands for long periods each day. How should the nurse respond to this compulsive behavior?