Pre-board Exam For November 2009 NLE (Practice Mode)
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The nurse observes the female client in the psychiatric ward that she is having a hard time sleeping at night. The nurse asks the client about it and the client says, “I can’t sleep at night because of fear of dying.” What is the best initial nursing response?
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“It must be frightening for you to feel that way. Tell me more about it.”
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“Don’t worry, you won’t die. You are just here for some test.”
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“Why are you afraid of dying?”
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“Try to sleep. You need the rest before tomorrow’s test.”
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Mark the letter of the letter of choice then click on the next button. Answer will be revealed after each question. No time limit to finish the exam. Good luck!
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- 2.
A male client tells the nurse that there is a big bug in his bed. The most therapeutic nursing response would be:
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Silence
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“Where’s the bug? I’ll kill it for you.”
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“I don’t see a bug in your bed, but you seem afraid.”
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“You must be seeing things.”
Correct Answer
A. “I don’t see a bug in your bed, but you seem afraid.”Explanation
This response does not contradict the client’s perception, is honest, and shows empathy.Rate this question:
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- 3.
The pediatric nurse in the neonatal unit was informed that the baby that is brought to the mother in the hospital room is wrong. The nurse determines that two babies were placed in the wrong cribs. The most appropriate nursing action would be to:
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Determine who is responsible for the mistake and terminate his or her employment.
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Record the event in an incident/variance report and notify the nursing supervisor.
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Reassure both mothers, report to the charge nurse, and do not record.
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Record detailed notes of the event on the mother’s medical record.
Correct Answer
A. Record the event in an incident/variance report and notify the nursing supervisor.Explanation
Every event that exposes a client to harm should be recorded in an incident report, as well as reported to the appropriate supervisors in order to resolve the current problems and permit the institution to prevent the problem from happening again.Rate this question:
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- 4.
An infant is brought to the health care clinic for three immunizations at the same time. The nurse knows that hepatitis B, DPT, and Haemophilus influenzae type B immunizations should:
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Be drawn in the same syringe and given in one injection.
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Be mixed and inject in the same sites.
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Not be mixed and the nurse must give three injections in three sites.
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Be mixed and the nurse must give the injection in three sites.
Correct Answer
A. Not be mixed and the nurse must give three injections in three sites.Explanation
Immunization should never be mixed together in a syringe, thus necessitating three separate injections in three sites. Note: some manufacturers make a premixed combination of immunization that is safe and effective.Rate this question:
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- 5.
Which of the following will best describe a management function?
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Writing a letter to the editor of a nursing journal.
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Negotiating labor contracts.
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Directing and evaluating nursing staff members.
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Explaining medication side effects to a client.
Correct Answer
A. Directing and evaluating nursing staff members.Explanation
Directing and evaluation of staff is a major responsibility of a nursing manager.Rate this question:
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- 6.
In the admission care unit, which of the following client would the nurse give immediate attention?
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A client who is 3 days postoperative with left calf pain.
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A client who is postoperative hip pinning who is complaining of pain.
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New admitted client with chest pain
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A client with diabetes who has a glucoscan reading of 180.
Correct Answer
A. New admitted client with chest painExplanation
The client with chest pain may be having a myocardial infarction, and immediate assessment and intervention is a priority.Rate this question:
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- 7.
The nurse assesses the health condition of the female client. The client tells the nurse that she discovered a lump in the breast last year and hesitated to seek medical advice. The nurse understands that, women who tend to delay seeking medical advice after discovering the disease are displaying what common defense mechanism?
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Intellectualization.
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Suppression.
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Repression.
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Denial.
Correct Answer
A. Denial.Explanation
Denial is a very strong defense mechanism used to allay the emotional effects of discovering a potential threat. Although denial has been found to be an effective mechanism for survival in some instances, such as during natural disasters, it may in greater pathology in a woman with potential breast carcinoma.Rate this question:
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- 8.
In the hospital lobby, the registered nurse overhears a two staff members discussing about the health condition of her client. What would be the appropriate action for the registered nurse to take?
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Join in the conversation, giving her input about the case.
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Ignore them, because they have the right to discuss anything they want to.
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Tell them it is not appropriate to discuss such things.
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Report this incident to the nursing supervisor.
Correct Answer
A. Tell them it is not appropriate to discuss such things.Explanation
The behavior should be stopped. The first is to remind the staff that confidentiality maybe violated.Rate this question:
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- 9.
A client with obsessive-compulsive behavior is admitted in the psychiatric unit. The nurse taking care of the client knows that the primary treatment goal is to:
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Provide distraction.
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Support but limit the behavior.
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Prohibit the behavior.
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Point out the behavior.
Correct Answer
A. Support but limit the behavior.Explanation
Support and limit setting decrease anxiety and provide external control.Rate this question:
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- 10.
A male client is brought to the emergency department due to motor vehicle accident. While monitoring the client, the nurse suspects increasing intracranial pressure when:
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Client is oriented when aroused from sleep, and goes back to sleep immediately.
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Blood pressure is decreased from 160/90 to 110/70.
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Client refuses dinner because of anorexia.
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Pulse is increased from 88-96 with occasional skipped beat.
Correct Answer
A. Client is oriented when aroused from sleep, and goes back to sleep immediately.Explanation
This suggests that the level of consciousness is decreasing.Rate this question:
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- 11.
The community nurse is teaching the group of mothers about the cervical mucus method of natural family planning. Which characteristics are typical of the cervical mucus during the “fertile” period of the menstrual cycle?
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Absence of ferning.
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Thin, clear, good spinnbarkeit.
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Thick, cloudy.
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Yellow and sticky.
Correct Answer
A. Thin, clear, good spinnbarkeit.Explanation
Under high estrogen levels, during the period surrounding ovulation, the cervical mucus becomes thin, clear, and elastic (spinnbarkeit), facilitating sperm passage.Rate this question:
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- 12.
A community health nurse is providing a health teaching to a woman infected with herpes simplex 2. Which of the following health teaching must the nurse include to reduce the chances of transmission of herpes simplex 2?
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“Abstain from intercourse until lesions heal.”
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“Therapy is curative.”
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“Penicillin is the drug of choice for treatment.”
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“The organism is associated with later development of hydatidiform mole.
Correct Answer
A. “Abstain from intercourse until lesions heal.”Explanation
Abstinence will eliminate any unnecessary pain during intercourse and will reduce the possibility of transmitting infection to one’s sexual partner.Rate this question:
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- 13.
The physician calls the nursing unit to leave an order. The senior nurse had conversation with the other staff. The newly hired nurse answers the phone so that the senior nurses may continue their conversation. The new nurse does not know the physician or the client to whom the order pertains. The nurse should:
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Ask the physician to call back after the nurse has read the hospital policy manual.
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Take the telephone order.
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Refuse to take the telephone order.
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Ask the charge nurse or one of the other senior staff nurses to take the telephone order.
Correct Answer
A. Ask the charge nurse or one of the other senior staff nurses to take the telephone order.Explanation
Get a senior nurse who know s the policies, the client, and the doctor. Generally speaking, a nurse should not accept telephone orders. However, if it is necessary to take one, follow the hospital’s policy regarding telephone orders. Failure to follow hospital policy could be considered negligence. In this case, the nurse was new and did not know the hospital’s policy concerning telephone orders. The nurse was also unfamiliar with the doctor and the client. Therefore the nurse should not take the order unless a) no one else is available and b) it is an emergency situation.Rate this question:
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- 14.
The client is brought to the emergency department because of serious vehicle accident. After an hour, the client has been declared brain dead. The nurse who has been with the client must now talk to the family about organ donation. Which of the following consideration is necessary?
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Include as many family members as possible.
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Take the family to the chapel.
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Discuss life support systems.
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Clarify the family’s understanding of brain death.
Correct Answer
A. Clarify the family’s understanding of brain death.Explanation
The family needs to understand what brain death is before talking about organ donation. They need time to accept the death of their family member. An environment conducive to discussing an emotional issue is needed.Rate this question:
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- 15.
The ambulance team calls the emergency department that they are going to bring a client who sustained burns in a house fire. While waiting for the ambulance, the nurse will anticipate emergency care to include assessment for:
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Gas exchange impairment
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Hypoglycemia.
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Hyperthermia.
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Fluid volume excess.
Correct Answer
A. Gas exchange impairmentExplanation
Smoke inhalation affects gas exchange.Rate this question:
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- 16.
A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned to care for the client must institute appropriate precautions. The nurse should:
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Place the client in a private room.
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Wear an N 95 respirator when caring for the client.
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Put on a gown every time when entering the room.
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Don a surgical mask with a face shield when entering the room.
Correct Answer
A. Wear an N 95 respirator when caring for the client.Explanation
The N 95 respirator is a high-particulate filtration mask that meets the CDC performance criteria for a tuberculosis respirator.Rate this question:
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- 17.
Which of the following complications during a breech birth the nurse needs to be alarmed?
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Abruption placenta.
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Caput succedaneum.
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Pathological hyperbilirubinemia.
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Umbilical cord prolapse
Correct Answer
A. Umbilical cord prolapseExplanation
Because umbilical cord’s insertion site is born before the fetal head, the cord may be compressed by the after-coming head in a breech birth.Rate this question:
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- 18.
A hospitalized client cannot find his handkerchief and accuses other cient in the room and the nurse of stealing them. Which is the most therapeutic approach to this client?
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Divert the client’s attention.
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Listen without reinforcing the client’s belief.
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Inject humor to defuse the intensity.
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Logically point out that the client is jumping to conclusions.
Correct Answer
A. Listen without reinforcing the client’s belief.Explanation
Listening is probably the most effective response of the four choices.Rate this question:
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- 19.
A client who undergone appendectomy 3 days ago is scheduled for discharge today. The nurse notes that the client is restless, picking at bedclothes and saying, “I am late on my appointment,” and calling the nurse by the wrong name. The nurse suspects:
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Panic reaction.
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Medication overdose.
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Toxic reaction to an antibiotic.
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Delirium tremens.
Correct Answer
A. Delirium tremens.Explanation
The behavior described is likely to be symptoms of delirium tremens, or alcohol withdrawal (often unsuspected on a surgical unit.)Rate this question:
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- 20.
The nurse in the nursing care unit checks the fluctuation in the water-seal compartment of a closed chest drainage system. The fluctuation has stopped, the nurse would:
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Vigorously strip the tube to dislodge a clot.
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Raise the apparatus above the chest to move fluid.
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Increase wall suction above 20 cm H2O pressure.
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Ask the client to cough and take a deep breath.
Correct Answer
A. Ask the client to cough and take a deep breath.Explanation
Asking the client to cough and take a deep breath will help determine if the chest tube is kinked or if the lungs has reexpanded.Rate this question:
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- 21.
Which of the following action is an accurate tracheal suctioning technique?
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25 seconds of continuous suction during catheter insertion.
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20 seconds of continuous suction during catheter insertion.
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10 seconds of intermittent suction during catheter withdrawal.
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15 seconds of intermittent suction during catheter withdrawal.
Correct Answer
A. 10 seconds of intermittent suction during catheter withdrawal.Explanation
Suctioning is only done for 10 seconds, intermittently, as the catheter is being withdrawn.Rate this question:
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- 22.
After a cystectomy and formation of an ileal conduit, the nurse provides instruction regarding prevention of leakage of the pouch and backflow of the urine. The nurse is correct to include in the instruction to empty the urine pouch:
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Every 3-4 hours.
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Every hour.
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Twice a day.
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Once before bedtime.
Correct Answer
A. Every 3-4 hours.Explanation
Urine flow is continuous. The pouch has an outlet valve for easy drainage every 3-4 hours. (the pouch should be changed every 3-5 days, or sooner if the adhesive is loose).Rate this question:
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- 23.
Which of the following nursing intervention is essential for the client who had pneumonectomy?
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Medicate for pain only when needed.
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Connect the chest tube to water-seal drainage.
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Notify the physician if the chest drainage exceeds 100mL/hr.
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Encourage deep breathing and coughing.
Correct Answer
A. Encourage deep breathing and coughing.Explanation
Surgery and anesthesia can increase mucus production. Deep breathing and coughing are essential to prevent atelectasis and pneumonia in the client’s only remaining lung.Rate this question:
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- 24.
The nurse is assigned to care to a 17-year-old male client with a history of substance abuse. The client asks the nurse, “Have you ever tried or used drugs?” The most correct response of the nurse would be:
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“Yes, once I tried grass.”
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“No, I don’t think so.”
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“Why do you want to know that?”
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“How will my answer help you?”
Correct Answer
A. “How will my answer help you?”Explanation
The client may perceive this as avoidance, but it is more important to redirect back to the client, especially in light of the manipulative behavior of drug abusers and adolescents.Rate this question:
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- 25.
The nursing applicant has given the chance to ask questions during a job interview at a local hospital. What should be the most important question to ask that can increase chances of securing a job offer?
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Begin with questions about client care assignments, advancement opportunities, and continuing education.
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Decline to ask questions, because that is the responsibility of the interviewer.
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Ask as many questions about the facility as possible.
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Clarify information regarding salary, benefits, and working hours first, because this will help in deciding whether or not to take the job.
Correct Answer
A. Begin with questions about client care assignments, advancement opportunities, and continuing education.Explanation
This choice implies concern for client care and self-improvement.Rate this question:
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- 26.
A 3-month-old client is in the pediatric unit. During assessment, the nurse is suspecting that the baby may have hypothyroidism when mother states that her baby does not:
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Sit up.
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Pick up and hold a rattle.
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Roll over.
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Hold the head up.
Correct Answer
A. Hold the head up.Explanation
Development normally proceeds cephalocaudally; so the first major developmental milestone that the infant achieves is the ability to hold the head up within the first 8-12 weeks of life. In hypothyroidism, the infant’s muscle tone would be poor and the infant would not be able to achieve this milestone.Rate this question:
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- 27.
Which of the following treatment modality is appropriate for a client with paranoid tendency?
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Activity therapy.
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Individual therapy.
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Group therapy.
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Family therapy.
Correct Answer
A. Individual therapy.Explanation
This option is least threatening.Rate this question:
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- 28.
The parents of an infant client ask the nurse to teach them how to administer Cortisporin eye drops. The nurse is correct in advising the parents to place the drops:
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In the middle of the lower conjunctival sac of the infant’s eye.
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Directly onto the infant’s sclera.
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In the outer canthus of the infant’s eye.
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In the inner canthus of the infant’s eye.
Correct Answer
A. In the middle of the lower conjunctival sac of the infant’s eye.Explanation
The recommended procedure for administering eyedrops to any client calls for the drops to be placed in the middle of the lower conjunctival sac.Rate this question:
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- 29.
Which telephone call from a student’s mother should the school nurse take care of at once?
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A telephone call notifying the school nurse that the child’ pediatrician has informed the mother that the child will need cardiac repair surgery within the next few weeks.
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A telephone call notifying the school nurse that the child’s pediatrician has informed the mother that the child has head lice.
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A telephone call notifying the school nurse that a child has a temperature of 102ºF and a rash covering the trunk and upper extremities of the body.
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A telephone call notifying the school nurse that a child underwent an emergency appendectomy during the previous night.
Correct Answer
A. A telephone call notifying the school nurse that a child has a temperature of 102ºF and a rash covering the trunk and upper extremities of the body.Explanation
A high fever accompanied by a body rash could indicate that the child has a communicable disease and would have exposed other students to the infection. The school nurse would want to investigate this telephone call immediately so that plans could be instituted to control the spread of such infection.Rate this question:
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- 30.
A client diagnosed with schizophrenia is shouting and banging on the door leading to the outside, saying, “I need to go to an appointment.” What is the appropriate nursing intervention?
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Tell the client that he cannot bang on the door.
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Ignore this behavior.
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Escort the client going back into the room.
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Ask the client to move away from the door.
Correct Answer
A. Escort the client going back into the room.Explanation
Gentle but firm guidance and nonverbal direction is needed to intervene when a client with schizophrenic symptoms is being disruptive.Rate this question:
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- 31.
After therapy with the thrombolytic alteplase (t-PA), what observation will the nurse report to the physician?
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3+ peripheral pulses.
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Change in level of consciousness and headache.
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Occasional dysrhythmias.
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Heart rate of 100/bpm.
Correct Answer
A. Change in level of consciousness and headache.Explanation
This could indicate intracranial bleeding. Alteplase is a thrombolytic enzyme that lyses thrombi and emboli. Bleeding is an adverse effect. Monitor clotting times and signs of any gastrointestinal or internal bleeding.Rate this question:
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- 32.
A client with ruptured appendix had surgery an hour ago and is transferred to the nursing care unit. The nurse placed the client in a semi-Fowler’s position primarily to:
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Facilitate movement and reduce complications from immobility.
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Fully aerate the lungs.
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Splint the wound.
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Promote drainage and prevent subdiaphragmatic abscesses.
Correct Answer
A. Promote drainage and prevent subdiaphragmatic abscesses.Explanation
After surgery for a ruptured appendix, the client should be placed in a semi-Fowler’s position to promote drainage and to prevent possible complications.Rate this question:
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- 33.
The nurse is formulating a plan of care to a client with a somatoform disorder. The nurse needs to have knowledge of which psychodynamic principle?
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The symptoms of a somatoform disorder are an attempt to adjust to painful life situations or to cope with conflicting sexual, aggressive, or dependent feelings.
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The major fundamental mechanism is regression.
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The client’s symptoms are imaginary and the suffering is faked.
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An extensive, prolonged study of the symptoms will be reassuring to the client, who seeks sympathy, attention and love.
Correct Answer
A. The symptoms of a somatoform disorder are an attempt to adjust to painful life situations or to cope with conflicting sexual, aggressive, or dependent feelings.Explanation
Somatoform disorders provide a way of coping with conflicts.Rate this question:
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- 34.
The LPN/LVN asks the registered nurse why oxytocin (Pitocin), 10 units (IV or IM) must be given to a client after birth fo the fetus. The nurse is correct to explain that oxytocin:
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Minimizes discomfort from “afterpains.”
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Suppresses lactation.
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Promotes lactation.
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Maintains uterine tone.
Correct Answer
A. Maintains uterine tone.Explanation
Oxytocin (Pitocin) is used to maintain uterine tone.Rate this question:
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- 35.
A newborn infant with Down syndrome is to be discharged today. The nurse is preparing to give the discharge teaching regarding the proper care at home. The nurse would anticipate that the mother is probably at the:
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40 years of age
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20 years of age.
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35 years of age.
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20 years of age.
Correct Answer
A. 40 years of ageExplanation
Perinatal risk factors for the development of Down syndrome include advanced maternal age, especially with the first pregnancy.Rate this question:
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- 36.
A pregnant client tells the nurse that she is worried about having urinary frequency. What will be the most appropriate nursing response?
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“Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you have frequency associated with fever, pain on voiding, or blood in the urine, call your doctor/nurse-midwife.
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“Placental progesterone causes irritability of the bladder sphincter. Your symptoms will go away after the baby comes.”
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“Pregnant women urinate frequently to get rid of fetal wastes. Limit fluids to 1L/daily.”
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“Frequency is due to bladder irritation from concentrate urine and is normal in pregnancy. Increase your daily fluid intake to 3L.”
Correct Answer
A. “Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you have frequency associated with fever, pain on voiding, or blood in the urine, call your doctor/nurse-midwife.Explanation
Progesterone also reduces smooth muscle motility in the urinary tract and predisposes the pregnant woman to urinary tract infections. Women should contact their doctors if they exhibit signs of infection. Kegel exercise will help strengthen the perineal muscles; limiting fluids at bedtime reduces the possibility of being awakened by the necessity of voiding.Rate this question:
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- 37.
The nurse is counseling a couple in their mid 30’s who have been unable to conceive for about 6 months. They are concerned that one or both of them may be infertile. What is the best advice the nurse could give to the couple?
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“it is no unusual to take 6-12 months to get pregnant, especially when the partners are in their mid-30s. Eat well, exercise, and avoid stress.”
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“Start planning adoption. Many couples get pregnant when they are trying to adopt.”
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“Consult a fertility specialist and start testing before you get any older.”
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“Have sex as often as you can, especially around the time of ovulation, to increase your chances of pregnancy.”
Correct Answer
A. “it is no unusual to take 6-12 months to get pregnant, especially when the partners are in their mid-30s. Eat well, exercise, and avoid stress.”Explanation
Infertility is not diagnosed until atleast 12months of unprotected intercourse has failed to produce a pregnancy. Older couples will experience a longer time to get pregnant.Rate this question:
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- 38.
The client with rheumatoid arthritis is for discharge. In preparing the client for discharge on prednisone therapy, the nurse should advise the client to:
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Wear sunglasses if exposed to bright light for an extended period of time.
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Take oral preparations of prednisone before meals.
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Have periodic complete blood counts while on the medication.
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Never stop or change the amount of the medication without medical advice.
Correct Answer
A. Never stop or change the amount of the medication without medical advice.Explanation
In preparing the client for discharge that is receiving prednisone, the nurse should caution the client to (a) take oral preparations after meals; (b) remember that routine checks of vital signs, weight, and lab studies are critical; (c) NEVER STOP OR CHANGE THE AMOUNT OF MEDICATION WITHOUT MEDICAL ADVICE; (d) store the medication in a light-resistant container.Rate this question:
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- 39.
The nurse is teaching a group of women about fertility awareness, the nurse should emphasize that basal body temperature:
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Can be done with a mercury thermometer but no a digital one.
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The average temperature taken each morning.
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Should be recorded each morning before any activity.
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Has a lower degree of accuracy in predicting ovulation than the cervical mucus test.
Correct Answer
A. Should be recorded each morning before any activity.Explanation
The basal body temperature 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 ºC to 36.3ºC during menses and for about 5-7 days afterward. About the time of ovulation, a slight drop 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 ºC. This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred.Rate this question:
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- 40.
The nurse advised the pregnant woman that smoking and alcohol should be avoided during pregnancy. The nurse takes into account that the developing fetus is most vulnerable to environment teratogens that cause malformation during:
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The entire pregnancy.
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The third trimester.
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The first trimester.
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The second trimester.
Correct Answer
A. The first trimester.Explanation
The first trimester is the period of organogenesis, that is, cell differentiation into the various organs, tissues, and structures.Rate this question:
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- 41.
A pregnant woman who is at term is admitted to the birthing unit in active labor. The client has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her contractions. Which of the following is the most important aspect of nursing intervention at this time?
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Timing and recording length of contractions.
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Monitoring.
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Preparing for an emergency cesarean birth.
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Checking the perineum for bulging.
Correct Answer
A. Timing and recording length of contractions.Explanation
The oxytocic effect of Pitocin increases the intensity and durations of contractions; prolonged contractions will jeopardize the safety of the fetus and necessitate discontinuing the drug.Rate this question:
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- 42.
Which of the following describes a health care team with the principles of participative leadership?
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Each member of the team can independently make decisions regarding the client’s care without necessarily consulting the other members.
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The physician makes most of the decisions regarding the client’s care.
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The team uses the expertise of its members to influence the decisions regarding the client’s care.
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Nurses decide nursing care; physicians decide medical and other treatment for the client.
Correct Answer
A. The team uses the expertise of its members to influence the decisions regarding the client’s care.Explanation
It describes a democratic process in which all members have input in the client’s care.Rate this question:
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- 43.
A female client who has a 28-day menstrual cycle asks the community health nurse when she get pregnant during her cycle. What will be the best nursing response?
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It is impossible to determine the fertile period reliably. So it is best to assume that a woman is always fertile.
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In a 28-day cycle, ovulation occurs at or about day 14. The egg lives for about 24 hours and the sperm live for about 72 hours. The fertile period would be approximately between day 11 and day 15.
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In a 28- day cycle, ovulation occurs at or about day 14. The egg lives for about 72 hours and the sperm live for about 24 hours. The fertile period would be approximately between day 13 and 17.
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In a 28-day cycle, ovulation occurs 8 days before the next period or at about day 20. The fertile period is between day 20 and the beginning of the next period.
Correct Answer
A. In a 28-day cycle, ovulation occurs at or about day 14. The egg lives for about 24 hours and the sperm live for about 72 hours. The fertile period would be approximately between day 11 and day 15.Explanation
It is the most accurate statement of physiological facts for a 28-day menstrual cycle: ovulation at day 14, egg life span 24 hours, sperm life span of 72 hours. Fertilization could occur from sperm deposited before ovulation.Rate this question:
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- 44.
The nurse is caring to a child client who has had a tonsillectomy. The child complains of having dryness of the throat. Which of the following would the nurse give to the child?
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Cola with ice
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Yellow noncitrus Jello
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Cool cherry Kool-Aid
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A glass of milk
Correct Answer
A. Yellow noncitrus JelloExplanation
After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and hot or cold liquids should be avoided because they may irritate the throat. Red liquids should be avoided because they give the appearance of blood if the child vomits. Milk and milk products including pudding are avoided because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding.Rate this question:
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- 45.
A pregnant client in late pregnancy is complaining of groin pain that seems worse on the right side. Which of the following is the most likely cause of it?
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Beginning of labor.
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Bladder infection.
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Constipation.
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Tension on the round ligament.
Correct Answer
A. Tension on the round ligament.Explanation
Tension on round ligament occurs because of the erect human posture and pressure exerted by the growing fetus.Rate this question:
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- 46.
A mother is in the third stage of labor. Which of the following signs will help the nurse determine the signs of placental separation?
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The uterus becomes globular.
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The umbilical cord is shortened.
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The fundus appears at the introitus.
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Mucoid discharge is increased.
Correct Answer
A. The uterus becomes globular.Explanation
Signs of placental separation include a change in the shape of the uterus from ovoid to globular.Rate this question:
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- 47.
While feeding a newborn with an unrepaired cardiac defect, the nurse keeps on assessing the condition of the client. The nurse notes that the newborn’s respiration is 72 breaths per minute. What would be the initial nursing action?
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Burp the newborn.
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Stop the feeding.
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Continue the feeding.
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Notify the physician.
Correct Answer
A. Stop the feeding.Explanation
A normal respiratory rate for a newborn is 30-40 breaths per minute.Rate this question:
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- 48.
A nurse is giving a health teaching to a woman who wants to breastfeed her newborn baby. Which hormone, normally secreted during the postpartum period, influences both the milk ejection reflex and uterine involution?
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Oxytocin.
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Estrogen.
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Progesterone.
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Relaxin.
Correct Answer
A. Oxytocin.Explanation
Contraction of the milk ducts and let-down reflex occur under the stimulation of oxytocin released by the posterior pituitary gland.Rate this question:
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- 49.
A female client with cancer has radium implants. The nurse wants to maintain the implants in the correct position. The nurse should position the client:
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Flat in bed.
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On the side only.
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With the foot of the bed elevated.
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With the head elevated 45-degrees (semi-Fowler’s).
Correct Answer
A. Flat in bed.Explanation
Clients with radioactive implants should be positioned flat in bed to prevent dislodgement of the vaginal packing. The client may roll to the side for meals but the upper body should not be raised more than 20 degrees.Rate this question:
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Mar 22, 2023Quiz Edited by
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May 13, 2012Quiz Created by
RNpedia.com
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