NCLEX-RN NURSING BOARD PRACTICE TEST COMPILATION (COMPLETE SOLUTIONS NURSING PRACTICE 1-5) Test Bank with Complete Questions and Solutions 547 PAGES

NCLEX-RN NURSING BOARD PRACTICE TEST COMPILATION (COMPLETE SOLUTIONS NURSING PRACTICE 1-5). Test Bank with Complete Questions and Solutions 547 PAGES. To clarify, this is the test bank, not the textbook. You get immediat ...

NCLEX-RN NURSING BOARD PRACTICE TEST COMPILATION (COMPLETE SOLUTIONS NURSING PRACTICE 1-5). Test Bank with Complete Questions and Solutions 547 PAGES. To clarify, this is the test bank, not the textbook. You get immediate access to download your test bank. You will receive a complete test bank; in other words, all chapters will be there. Test banks come in PDF format; therefore, you do not need specialized software to open them. PREVIEW..... Contents NURSING PRACTICE I: FOUNDATION OF NURSING PRACTICE .......................................................................... 4 NURSING PRACTICE II ..................................................... 15 NURSING PRACTICE III .................................................... 26 NURSING PRACTICE IV.................................................... 36 NURSING PRACTICE V..................................................... 46 TEST I - Foundation of Professional Nursing Practice .... 56 Answers and Rationale – Foundation of Professional Nursing Practice ......................................................... 66 TEST II - Community Health Nursing and Care of the Mother and Child ........................................................... 74 Answers and Rationale – Community Health Nursing and Care of the Mother and Child ............................. 84 TEST III - Care of Clients with Physiologic and Psychosocial Alterations ................................................ 91 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 102 TEST IV - Care of Clients with Physiologic and Psychosocial Alterations .............................................. 111 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 122 TEST V - Care of Clients with Physiologic and Psychosocial Alterations .................................................................... 133 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 144 PART III PRACTICE TEST I FOUNDATION OF NURSING . 153 ANSWERS AND RATIONALE – FOUNDATION OF NURSING .................................................................. 158 PRACTICE TEST II Maternal and Child Health ............... 162 ANSWERS AND RATIONALE – MATERNAL AND CHILD HEALTH ..................................................................... 167 MEDICAL SURGICAL NURSING ..................................... 173 ANSWERS AND RATIONALE – MEDICAL SURGICAL NURSING .................................................................. 178 PSYCHIATRIC NURSING ................................................ 180 ANSWERS AND RATIONALE – PSYCHIATRIC NURSING ................................................................................. 185 FOUNDATION OF PROFESSIONAL NURSING PRACTICE 188 ANSWER KEY - FOUNDATION OF PROFESSIONAL NURSING PRACTICE .................................................. 199 COMMUNITY HEALTH NURSING AND CARE OF THE MOTHER AND CHILD .................................................... 200 ANSWER KEY: COMMUNITY HEALTH NURSING AND CARE OF THE MOTHER AND CHILD .......................... 211 Comprehensive Exam 1................................................ 213 CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS ...................................... 222 ANSWER KEY: CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS ......................... 234 Nursing Practice Test V ................................................ 235 Nursing Practice Test V ................................................ 245 TEST I - Foundation of Professional Nursing Practice .. 255 Answers and Rationale – Foundation of Professional Nursing Practice ....................................................... 265 TEST II - Community Health Nursing and Care of the Mother and Child ......................................................... 273 Answers and Rationale – Community Health Nursing and Care of the Mother and Child ........................... 283 TEST III - Care of Clients with Physiologic and Psychosocial Alterations .............................................. 290 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 301 TEST IV - Care of Clients with Physiologic and Psychosocial Alterations .............................................. 310 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 321 TEST V - Care of Clients with Physiologic and Psychosocial Alterations .................................................................... 332 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 343 PART III ......................................................................... 352 PRACTICE TEST I FOUNDATION OF NURSING .............. 352 ANSWERS AND RATIONALE – FOUNDATION OF NURSING .................................................................. 357 PRACTICE TEST II Maternal and Child Health ............... 361ANSWERS AND RATIONALE – MATERNAL AND CHILD HEALTH ..................................................................... 366 MEDICAL SURGICAL NURSING ..................................... 372 ANSWERS AND RATIONALE – MEDICAL SURGICAL NURSING .................................................................. 377 PSYCHIATRIC NURSING ................................................ 379 ANSWERS AND RATIONALE – PSYCHIATRIC NURSING ................................................................................. 384 FUNDAMENTALS OF NURSING PART 1 ........................ 387 FUNDAMENTALS OF NURSING PART 2 ........................ 392 ANSWERS and RATIONALES for FUNDAMENTALS OF NURSING PART 2 ...................................................... 397 FUNDAMENTALS OF NURSING PART 3 ........................ 401 ANSWERS and RATIONALES for FUNDAMENTALS OF NURSING PART 3 ...................................................... 405 MATERNITY NURSING Part 1 ........................................ 409 ANSWERS and RATIONALES for MATERNITY NURSING Part 1 ........................................................................ 418 MATERNITY NURSING Part 2 ........................................ 428 Answer for maternity part 2 .................................... 433 PEDIATRIC NURSING .................................................... 434 ANSWERS and RATIONALES for PEDIATRIC NURSING ................................................................................. 439 COMMUNITY HEALTH NURSING Part 1........................ 444 COMMUNITY HEALTH NURSING Part 2........................ 454 MEDICAL SURGICAL NURSING Part 1 ........................... 475 ANSWERS and RATIONALES for MEDICAL SURGICAL NURSING Part 1 ........................................................ 479 MEDICAL SURGICAL NURSING Part 2 ........................... 481 MEDICAL SURGICAL NURSING Part 2 ....................... 485 ANSWERS and RATIONALES for MEDICAL SURGICAL NURSING Part 2 ........................................................ 489 MEDICAL SURGICAL NURSING Part 3 ........................... 491 ANSWERS and RATIONALES for MEDICAL SURGICAL NURSING Part 3 ........................................................ 495 PSYCHIATRIC NURSING Part 1 ...................................... 497 ANSWERS and RATIONALES for PSYCHIATRIC NURSING Part 1 ........................................................................ 502 PSYCHIATRIC NURSING Part 2 ...................................... 504 ANSWERS and RATIONALES for PSYCHIATRIC NURSING Part 2 ........................................................................ 509 PSYCHIATRIC NURSING Part 3 ...................................... 512 ANSWERS and RATIONALES for PSYCHIATRIC NURSING Part 3 ........................................................................ 516 PROFESSIONAL ADJUSTMENT ...................................... 519 LEADERSHIP and MANAGEMENT ................................. 522 NURSING RESEARCH Part 1 .......................................... 532 NURSING RESEARCH Part 2 .......................................... 542 Nursing Research Suggested Answer Key ................ 546 235. NURSING PRACTICE I: FOUNDATION OF NURSING PRACTICE SITUATION: Nursing is a profession. The nurse should have a background on the theories and foundation of nursing as it influenced what is nursing today. 1. Nursing is the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of the individuals, families, communities and the population. This is the most accepted definition of nursing as defined by the: a. PNA b. ANA c. Nightingale d. Henderson 2. Advancement in Nursing leads to the development of the Expanded Career Roles. Which of the following is NOT an expanded career role for nurses? a. Nurse practitioner b. Nurse Researcher c. Clinical nurse specialist d. Nurse anaesthesiologist 3. The Board of Nursing regulated the Nursing profession in the Philippines and is responsible for the maintenance of the quality of nursing in the country. Powers and duties of the board of nursing are the following, EXCEPT: a. Issue, suspend, revoke certificates of registration b. Issue subpoena duces tecum, ad testificandum c. Open and close colleges of nursing d. Supervise and regulate the practice of nursing 4. A nursing student or a beginning staff nurse who has not yet experienced enough real situations to make judgments about them is in what stage of Nursing Expertise? a. Novice b. Newbie c. Advanced Beginner d. Competent 4 9. Benner’s “Proficient” nurse level is different from the other levels in nursing expertise in the context of having: a. the ability to organize and plan activities b. having attained an advanced level of education c. a holistic understanding and perception of the client d. intuitive and analytic ability in new situations SITUATION: The nurse has been asked to administer an injection via Z TRACK technique. Questions 6 to 10 refer to this. 6. The nurse prepares an IM injection for an adult client using the Z track technique. 4 ml of medication is to be administered to the client. Which of the following site will you choose? a. Deltoid b. Rectus femoris c. Ventrogluteal d. Vastus lateralis 7. In infants 1 year old and below, which of the following is the site of choice for intramuscular Injection? a. Deltoid b. Rectus femoris c. Ventrogluteal d. Vastus lateralis 8. In order to decrease discomfort in Z track administration, which of the following is applicable? a. Pierce the skin quickly and smoothly at a 90 degree angle b. Inject the medication steadily at around 10 minutes per millilitre c. Pull back the plunger and aspirate for 1 minute to make sure that the needle did not hit a blood vessel d. Pierce the skin slowly and carefully at a 90 degree angle After injection using the Z track technique, the nurse should know that she needs to wait for a few seconds before withdrawing the needle and this is to allow the medication to disperse into the muscle tissue, thus decreasing the client’s discomfort. How many seconds should the nurse wait before withdrawing the needle? a. 2 seconds5 b. 5 seconds c. 10 seconds d. 15 seconds 10. The rationale in using the Z track technique in an intramuscular injection is: a. It decreases the leakage of discolouring and irritating medication into the subcutaneous tissues b. It will allow a faster absorption of the medication c. The Z track technique prevent irritation of the muscle d. It is much more convenient for the nurse SITUATION: A Client was rushed to the emergency room and you are his attending nurse. You are performing a vital sign assessment. 11. All of the following are correct methods in assessment of the blood pressure EXCEPT: a. Take the blood pressure reading on both arms for comparison b. Listen to and identify the phases of Korotkoff’s sound c. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated d. Observe procedures for infection control 12. You attached a pulse oximeter to the client. You know that the purpose is to: a. Determine if the client’s hemoglobin level is low and if he needs blood transfusion b. Check level of client’s tissue perfusion c. Measure the efficacy of the client’s anti- hypertensive medications d. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops 13. After a few hours in the Emergency Room, The client is admitted to the ward with an order of hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be: a. inconsistent b. low systolic and high diastolic c. higher than what the reading should be d. lower than what the reading should be 14. Through the client’s health history, you gather 18. 17. 16. that the patient smokes and drinks coffee. When taking the blood pressure of a client who recently smoked or drank coffee, how long should the nurse wait before taking the client’s blood pressure for accurate reading? a. 15 minutes b. 30 minutes c. 1 hour d. 5 minutes 15. While the client has pulse oximeter on his fingertip, you notice that the sunlight is shining on the area where the oximeter is. Your action will be to: a. Set and turn on the alarm of the oximeter b. Do nothing since there is no identified problem c. Cover the fingertip sensor with a towel or bedsheet d. Change the location of the sensor every four hours The nurse finds it necessary to recheck the blood pressure reading. In case of such re assessment, the nurse should wait for a period of: a. 15 seconds b. 1 to 2 minutes c. 30 minutes d. 15 minutes If the arm is said to be elevated when taking the blood pressure, it will create a: a. False high reading b. False low reading c. True false reading d. Indeterminate You are to assessed the temperature of the client the next morning and found out that he ate ice cream. How many minutes should you wait before assessing the client’s oral temperature? a. 10 minutes b. 20 minutes c. 30 minutes d. 15 minutes 19. When auscultating the client’s blood pressure the nurse hears the following: From 150 mmHg to 130 mmHg: Silence, Then: a thumping sound continuing down to 100 mmHg; muffled sound continuing down to 80 mmHg and then silence.What is the client’s blood pressure? a. 130/80 b. 150/100 c. 100/80 d. 150/100 to lungs. This can be avoided by: a. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing the buccal cavity 20. In a client with a previous blood pressure of 130/80 4 hours ago, how long will it take to release the blood pressure cuff to obtain an accurate reading? a. 10-20 seconds b. 30-45 seconds c. 1-1.5 minutes d. 3-3.5 minutes Situation: Oral care is an important part of hygienic practices and promoting client comfort. 21. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and presence of sores. Which of the following is BEST to use for oral care? a. lemon glycerine b. Mineral oil c. hydrogen peroxide d. Normal saline solution 22. When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs? a. Put the client on a sidelying position with head of bed lowered b. Keep the client dry by placing towel under the chin c. Wash hands and observes appropriate infection control d. Clean mouth with oral swabs in a careful and an orderly progression 23. The advantages of oral care for a client include all of the following, EXCEPT: a. decreases bacteria in the mouth and teeth b. reduces need to use commercial mouthwash which irritate the buccal mucosa c. improves client’s appearance and self- confidence d. improves appetite and taste of food 24. A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration 6 28. 27. b. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs c. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and ums d. suctioning as needed while cleaning the buccal cavity 25. Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened by using: a. salt solution b. petroleum jelly c. water d. mentholated ointment Situation – Ensuring safety before, during and after a diagnostic procedure is an important responsibility of the nurse. 26. To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the following prior to the procedure? a. Clenching his fist every 2 minutes b. Breathing in and out through the nose with his mouth open c. Tensing the shoulder muscles while lying on his back d. Holding his breath periodically for 30 seconds Following a bronchoscopy, which of the following complains to Fernan should be noted as a possible complication: a. Nausea and vomiting b. Shortness of breath and laryngeal stridor c. Blood tinged sputum and coughing d. Sore throat and hoarseness Immediately after bronchoscopy, you instructed Fernan to: a. Exercise the neck muscles b. Refrain from coughing and talking7 c. Breathe deeply d. Clear his throat 29. Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important function during the procedure is to: a. Keep the sterile equipment from contamination b. Assist the physician c. Open and close the three-way stopcock d. Observe the patient’s vital signs 30. Right after thoracentesis, which of the following is most appropriate intervention? a. Instruct the patient not to cough or deep breathe for two hours b. Observe for symptoms of tightness of chest or bleeding c. Place an ice pack to the puncture site d. Remove the dressing to check for bleeding Situation: Knowledge of the acid-base disturbance and the functions of the electrolytes is necessary to determine appropriate intervention and nursing actions. 31. A client with diabetes milletus has a blood glucose level of 644 mg/dL. The nurse interprets that this client is at most risk for the development of which type of acid-base imbalance? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis 32. In a client in the health care clinic, arterial blood gas analysis gives the following results: pH 7.48, PCO2 32 mmHg, PO2 94 mmHg, HCO3 24 mEq/L. The nurse interprets that the client has which acid base disturbance? a. Respiratory acidosis b. Metabolic acidosis c. Respiratory alkalosis d. Metabolic alkalosis 33. A client has an order for ABG analysis on radial artery specimens. The nurse ensures that which of the following has been performed or tested before the ABG specimens are drawn? a. Guthrie test b. Romberg’s test c. Allen’s test d. Weber’s test 34. A nurse is reviewing the arterial blood gas values of a client and notes that the ph is 7.31, Pco2 is 50 mmHg, and the bicarbonate is 27 mEq/L. The nurse concludes that which acid base disturbance is present in this client? a. Respiratory acidosis b. Metabolic acidosis c. Respiratory alkalosis d. Metabolic alkalosis 35. Allen’s test checks the patency of the: a. Ulnar artery b. Carotid artery c. Radial artery d. Brachial artery Situation 6: Eileen, 45 years old is admitted to the hospital with a diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 0C. 36. Given the above assessment data, the most immediate goal of the nurse would be which of the following? a. Prevent urinary complication b. maintains fluid and electrolytes c. Alleviate pain d. Alleviating nausea 37. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post-operative order includes “daily urine specimen to be sent to the laboratory”. Eileen has a foley catheter attached to a urinary drainage system. How will you collect the urine specimen? a. remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into the specimen container b. empty a sample urine from the collecting bag into the specimen container c. Disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter into the specimen container. d. Disconnect the drainage from the collecting bag and allow the urine to flow from the catheter into the specimen container.38. Where would the nurse tape Eileen’s indwelling catheter in order to reduce urethral irritation? a. to the patient’s inner thigh b. to the patient’ buttocks c. to the patient’s lower thigh d. to the patient lower abdomen regulation is secreted in the: a. Thyroid gland b. Parathyroid gland c. Hypothalamus d. Anterior pituitary gland 39. Which of the following menu is appropriate for one with low sodium diet? a. instant noodles, fresh fruits and ice tea b. ham and cheese sandwich, fresh fruits and vegetables c. white chicken sandwich, vegetable salad and tea d. canned soup, potato salad, and diet soda 40. How will you prevent ascending infection to Eileen who has an indwelling catheter? a. see to it that the drainage tubing touches the level of the urine b. change he catheter every eight hours c. see to it that the drainage tubing does not touch the level of the urine d. clean catheter may be used since urethral meatus is not a sterile area Situation: Hormones are secreted by the various glands in the body. Basic knowledge of the endocrine system is necessary. 41. Somatocrinin or the Growth hormone releasing hormone is secreted by the: a. Hypothalamus b. Posterior pituitary gland c. Anterior pituitary gland d. Thyroid gland 42. All of the following are secreted by the anterior pituitary gland except: a. Somatotropin/Growth hormone b. Thyroid stimulating hormone c. Follicle stimulating hormone d. Gonadotropin hormone releasing hormone 43. All of the following hormones are hormones secreted by the Posterior pituitary gland except: a. Vasopressin b. Anti-diuretic hormone c. Oxytocin d. Growth hormone 44. 8 Calcitonin, a hormone necessary for calcium 45. While Parathormone, a hormone that negates the effect of calcitonin is secreted by the: a. Thyroid gland b. Parathyroid gland c. Hypothalamus d. Anterior pituitary gland Situation: The staff nurse supervisor requests all the staff nurses to “brainstorm” and learn ways to instruct diabetic clients on self-administration of insulin. She wants to ensure that there are nurses available daily to do health education classes. 46. The plan of the nurse supervisor is an example of a. in service education process b. efficient management of human resources c. increasing human resources d. primary prevention 47. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an unlicensed staff, Mrs. Guevarra a. makes the assignment to teach the staff member b. is assigning the responsibility to the aide but not the accountability for those tasks c. does not have to supervise or evaluate the aide d. most know how to perform task delegated 48. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had six weeks ago when she started the job. The nurse supervisor should a. empathize with the nurse and listen to her b. tell her to take the day off c. discuss how she is adjusting to her new job d. ask about her family life 49. Process of formal negotiations of working conditions between a group of registered nurses and employer is9 a. grievance b. arbitration c. collective bargaining d. strike 50. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and required by the hospital employing you. This is a. professional course towards credits b. in-service education c. advance training d. continuing education Situation: As a nurse, you are aware that proper documentation in the patient chart is your responsibility. 51. Which of the following is not a legally binding document but nevertheless very important in the care of all patients in any health care setting? a. Bill of rights as provided in the Philippine constitution b. Scope of nursing practice as defined by RA 9173 c. Board of nursing resolution adopting the code of ethics d. Patient’s bill of rights 52. A nurse gives a wrong medication to the client. Another nurse employed by the same hospital as a risk manager will expect to receive which of the following communication? a. Incident report b. Nursing kardex c. Oral report d. Complain report 53. Performing a procedure on a client in the absence of an informed consent can lead to which of the following charges? a. Fraud b. Harassment c. Assault and battery d. Breach of confidentiality 54. Which of the following is the essence of informed consent? a. It should have a durable power of attorney b. It should have coverage from an insurance company c. It should respect the client’s freedom from coercion d. It should disclose previous diagnosis, prognosis and alternative treatments available for the client 55. Delegation is the process of assigning tasks that can be performed by a subordinate. The RN should always be accountable and should not lose his accountability. Which of the following is a role included in delegation? a. The RN must supervise all delegated tasks b. After a task has been delegated, it is no longer a responsibility of the RN c. The RN is responsible and accountable for the delegated task in adjunct with the delegate d. Follow up with a delegated task is necessary only if the assistive personnel is not trustworthy Situation: When creating your lesson plan for cerebrovascular disease or STROKE. It is important to include the risk factors of stroke. 56. The most important risk factor is: a. Cigarette smoking b. binge drinking c. Hypertension d. heredity 57. Part of your lesson plan is to talk about etiology or cause of stroke. The types of stroke based on cause are the following EXCEPT: a. Embolic stroke b. diabetic stroke c. Hemorrhagic stroke d. thrombotic stroke 58. Hemmorhagic stroke occurs suddenly usually when the person is active. All are causes of hemorrhage, EXCEPT: a. phlebitis b. damage to blood vessel c. trauma d. aneurysm 59. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. Which drug is closely linked to this? a. Amphetamines b. shabu c. Cocaine d. Demerold. Iron 75 mg/100 ml 60. A participant in the STROKE class asks what is a risk factor of stroke. Your best response is: a. “More red blood cells thicken blood and make clots more possible.” b. “Increased RBC count is linked to high cholesterol.” c. “More red blood cell increases hemoglobin content.” d. “High RBC count increases blood pressure.” Situation: Recognition of normal values is vital in assessment of clients with various disorders. 61. A nurse is reviewing the laboratory test results for a client with a diagnosis of severe dehydration. The nurse would expect the hematocrit level for this client to be which of the following? a. 60% b. 47% c. 45% d. 32% 62. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is 5.6 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory value? a. ST depression b. Prominent U wave c. Inverted T wave d. Tall peaked T waves 63. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory value? a. U waves b. Elevated T waves c. Absent P waves d. Elevated ST Segment 64. Dorothy underwent diagnostic test and the result of the blood examination are back. On reviewing the result the nurse notices which of the following as abnormal finding? a. Neutrophils 60% b. White blood cells (WBC) 9000/mm c. Erythrocyte sedimentation rate (ESR) is 39 mm/hr 10 65. Which of the following laboratory test result indicate presence of an infectious process? a. Erythrocyte sedimentation rate (ESR) 12 mm/hr b. White blood cells (WBC) 18,000/mm3 c. Iron 90 g/100ml d. Neutrophils 67% Situation: Pleural effusion is the accumulation of fluid in the pleural space. Questions 66 to 70 refer to this. 66. Which of the following is a finding that the nurse will be able to assess in a client with Pleural effusion? a. Reduced or absent breath sound at the base of the lungs, dyspnea, tachpynea and shortness of breath b. Hypoxemia, hypercapnea and respiratory acidosis c. Noisy respiration, crackles, stridor and wheezing d. Tracheal deviation towards the affected side, increased fremitus and loud breath sounds 67. Thoracentesis is performed to the client with effusion. The nurse knows that the removal of fluid should be slow. Rapid removal of fluid in thoracentesis might cause: a. Pneumothorax b. Cardiovascular collapse c. Pleurisy or Pleuritis d. Hypertension 68. 3 Days after thoracentesis, the client again exhibited respiratory distress. The nurse will know that pleural effusion has reoccurred when she noticed a sharp stabbing pain during inspiration. The physician ordered a closed tube thoracotomy for the client. The nurse knows that the primary function of the chest tube is to: a. Restore positive intrathoracic pressure b. Restore negative intrathoracic pressure c. To visualize the intrathoracic content d. As a method of air administration via ventilator 69. The chest tube is functioning properly if: a. There is an oscillation b. There is no bubbling in the drainage bottle11 c. There is a continuous bubbling in the waterseal d. The suction control bottle has a continuous bubbling 70. In a client with pleural effusion, the nurse is instructing appropriate breathing technique. Which of the following is included in the teaching? a. Breath normally b. Hold the breath after each inspiration for 1 full minute c. Practice abdominal breathing d. Inhale slowly and hold the breath for 3 to 5 seconds after each inhalation SITUATION: Health care delivery system affects the health status of every filipino. As a Nurse, Knowledge of this system is expected to ensure quality of life. 71. When should rehabilitation commence? a. The day before discharge b. When the patient desires c. Upon admission d. 24 hours after discharge 77. 72. What exemplified the preventive and promotive programs in the hospital? a. Hospital as a center to prevent and control infection b. Program for smokers c. Program for alcoholics and drug addicts d. Hospital Wellness Center 73. Which makes nursing dynamic? a. Every patient is a unique physical, emotional, social and spiritual being b. The patient participate in the overall nursing care plan c. Nursing practice is expanding in the light of modern developments that takes place d. The health status of the patient is constantly changing and the nurse must be cognizant and responsive to these changes 74. Prevention is an important responsibility of the nurse in: a. Hospitals b. Community c. Workplace d. All of the above 75. This form of Health Insurance provides comprehensive prepaid health services to enrollees for a fixed periodic payment. a. Health Maintenance Organization b. Medicare c. Philippine Health Insurance Act d. Hospital Maintenance Organization Situation: Nursing ethics is an important part of the nursing profession. As the ethical situation arises, so is the need to have an accurate and ethical decision making. 76. The purpose of having a nurses’ code of ethics is: a. Delineate the scope and areas of nursing practice b. identify nursing action recommended for specific health care situations c. To help the public understand professional conduct expected of nurses d. To define the roles and functions of the health care givers, nurses, clients The principles that govern right and proper conduct of a person regarding life, biology and the health professionals is referred to as: a. Morality b. Religion c. Values d. Bioethics 78. A subjective feeling about what is right or wrong is said to be: a. Morality b. Religion c. Values d. Bioethics 79. Values are said to be the enduring believe about a worth of a person, ideas and belief. If Values are going to be a part of a research, this is categorized under: a. Qualitative b. Experimental c. Quantitative d. Non Experimental 80. The most important nursing responsibility where ethical situations emerge in patient care is to: a. Act only when advised that the action is ethically soundb. Not takes sides, remain neutral and fair c. Assume that ethical questions are the responsibility of the health team d. Be accountable for his or her own actions 81. Why is there an ethical dilemma? a. the choices involved do not appear to be clearly right or wrong b. a client’s legal right co-exist with the nurse’s professional obligation c. decisions has to be made based on societal norms. d. decisions has to be mad quickly, often under stressful conditions 82. According to the code of ethics, which of the following is the primary responsibility of the nurse? a. Assist towards peaceful death b. Health is a fundamental right c. Promotion of health, prevention of illness, alleviation of suffering and restoration of health d. Preservation of health at all cost 83. Which of the following is TRUE about the Code of Ethics of Filipino Nurses, except: a. The Philippine Nurses Association for being the accredited professional organization was given the privilege to formulate a Code of Ethics for Nurses which the Board of Nursing promulgated b. Code for Nurses was first formulated in 1982 published in the Proceedings of the Third Annual Convention of the PNA House of Delegates c. The present code utilized the Code of Good Governance for the Professions in the Philippines d. Certificates of Registration of registered nurses may be revoked or suspended for violations of any provisions of the Code of Ethics. 84. Violation of the code of ethics might equate to the revocation of the nursing license. Who revokes the license? a. PRC b. PNA c. DOH d. BON 12 85. Based on the Code of Ethics for Filipino Nurses, what is regarded as the hallmark of nursing responsibility and accountability? a. Human rights of clients, regardless of creed and gender b. The privilege of being a registered professional nurse c. Health, being a fundamental right of every individual d. Accurate documentation of actions and outcomes Situation: As a profession, nursing is dynamic and its practice is directed by various theoretical models. To demonstrate caring behaviour, the nurse applies various nursing models in providing quality nursing care. 86. When you clean the bedside unit and regularly attend to the personal hygiene of the patient as well as in washing your hands before and after a procedure and in between patients, you indent to facilitate the body’s reparative processes. Which of the following nursing theory are you applying in the above nursing action? a. Hildegard Peplau b. Dorothea Orem c. Virginia Henderson d. Florence Nightingale 87. A communication skill is one of the important competencies expected of a nurse. Interpersonal process is viewed as human to human relationship. This statement is an application of whose nursing model? a. Joyce Travelbee b. Martha Rogers c. Callista Roy d. Imogene King 88. The statement “the health status of an individual is constantly changing and the nurse must be cognizant and responsive to these changes” best explains which of the following facts about nursing? a. Dynamic b. Client centred c. Holistic d. Art 89. Virginia Henderson professes that the goal of nursing is to work interdependently with other health care working in assisting the patient to13 gain independence as quickly as possible. Which of the following nursing actions best demonstrates this theory in taking care of a 94 year old client with dementia who is totally immobile? a. Feeds the patient, brushes his teeth, gives the sponge bath b. Supervise the watcher in rendering patient his morning care c. Put the patient in semi fowler’s position, set the over bed table so the patient can eat by himself, brush his teeth and sponge himself d. Assist the patient to turn to his sides and allow him to brush and feed himself only when he feels ready 90. In the self-care deficit theory by Dorothea Orem, nursing care becomes necessary when a patient is unable to fulfil his physiological, psychological and social needs. A pregnant client needing prenatal check-up is classified as: a. Wholly compensatory b. Supportive Educative c. Partially compensatory d. Non compensatory Situation: Documentation and reporting are just as important as providing patient care, As such, the nurse must be factual and accurate to ensure quality documentation and reporting. 91. Health care reports have different purposes. The availability of patients’ record to all health team members demonstrates which of the following purposes: a. Legal documentation b. Research c. Education d. Vehicle for communication 92. When a nurse commits medication error, she should accurately document client’s response and her corresponding action. This is very important for which of the following purposes: a. Research b. Legal documentation c. Nursing Audit d. Vehicle for communication 93. POMR has been widely used in many teaching hospitals. One of its unique features is SOAPIE charting. The P in SOAPIE charting should 94. include: a. Prescription of the doctor to the patient’s illness b. Plan of care for patient c. Patient’s perception of one’s illness d. Nursing problem and Nursing diagnosis The medical records that are organized into separate section from doctors or nurses has more disadvantages than advantages. This is classified as what type of recording? a. POMR b. Modified POMR c. SOAPIE d. SOMR 95. Which of the following is the advantage of SOMR or Traditional recording? a. Increases efficiency in data gathering b. Reinforces the use of the nursing process c. The caregiver can easily locate proper section for making charting entries d. Enhances effective communication among health care team members Situation: June is a 24 year old client with symptoms of dyspnea, absent breath sounds on the right lung and chest x ray revealed pleural effusion. The physician will perform thoracentesis. 96. Thoracentesis is useful in treating all of the following pulmonary disorders except: a. Hemothorax b. Hydrothorax c. Tuberculosis d. Empyema 97. Which of the following psychological preparation is not relevant for him? a. Telling him that the gauge of the needle and anesthesia to be used b. Telling him to keep still during the procedure to facilitate the insertion of the needle in the correct place c. Allow June to express his feelings and concerns d. Physician’s explanation on the purpose of the procedure and how it will be done 98. Before thoracentesis, the legal consideration you must check is: a. Consent is signed by the clientb. Medicine preparation is correct c. Position of the client is correct d. Consent is signed by relative and physician 99. As a nurse, you know that the position for June before thoracentesis is: a. Orthopneic b. Low fowlers c. Knee-chest d. Sidelying position on the affected side 100. Which of the following anaesthetics drug is used for thoracentesis? a. Procaine 2% b. Demerol 75 mg c. Valium 250 mg d. Phenobartbital 50 mg 1415 D. Follicle stimulating hormone NURSING PRACTICE II Situation: Mariah is a 31 year old lawyer who has been married for 6 months. She consults you for guidance in relation with her menstrual cycle and her desire to get pregnant. 1. She wants to know the length of her menstrual cycle. Her previous menstrual period is October 22 to 26. Her LMB is November 21. Which of the following number of days will be your correct response? A. 29 B. 28 C. 30 D. 31 2. You advised her to observe and record the signs of Ovulation. Which of the following signs will she likely note down? 1. A 1 degree Fahrenheit rise in basal body temperature 2. Cervical mucus becomes copious and clear 3. One pound increase in weight 4. Mittelschmerz A. 1, 2, 4 B. 1, 2, 3 C. 2, 3, 4 D. 1, 3, 4 3. You instruct Mariah to keep record of her basal temperature every day, which of the following instructions is incorrect? A. If coitus has occurred; this should be reflected in the chart B. It is best to have coitus on the evening following a drop in BBT to become pregnant C. Temperature should be taken immediately after waking and before getting out of bed D. BBT is lowest during the secretory phase 4. She reports an increase in BBT on December 16. Which hormone brings about this change in her BBT? A. Estrogen B. Gonadotropine C. Progesterone 5. The following month, Mariah suspects she is pregnant. Her urine is positive for Human chorionic gonadotrophin. Which structure produces Hcg? A. Pituitary gland B. Trophoblastic cells of the embryo C. Uterine deciduas D. Ovarian follicles Situation: Mariah came back and she is now pregnant. 6. At 5 month gestation, which of the following fetal development would probably be achieve? A. Fetal movement are felt by Mariah B. Vernix caseosa covers the entire body C. Viable if delivered within this period D. Braxton hicks contractions are observed 7. The nurse palpates the abdomen of Mariah. Now At 5 month gestation, What level of the abdomen can the fundic height be palpated? A. Symphysis pubis B. Midpoint between the umbilicus and the xiphoid process C. Midpoint between the symphysis pubis and the umbilicus D. Umbilicus 8. She worries about her small breasts, thinking that she probably will not be able to breastfeed her baby. Which of the following responses of the nurse is correct? A. “The size of your breast will not affect your lactation” B. “You can switch to bottle feeding” C. “You can try to have exercise to increase the size of your breast” D. “Manual expression of milk is possible” 9. She tells the nurse that she does not take milk regularly. She claims that she does not want to gain too much weight during her pregnancy. Which of the following nursing diagnosis is a priority? A. Potential self-esteem disturbance related to physiologic changes in pregnancy B. Ineffective individual coping related to physiologic changes in pregnancy C. Fear related to the effects of pregnancy D. Knowledge deficit regarding nutritionalrequirements of pregnancies related to lack of information sources 10. Which of the following interventions will likely ensure compliance of Mariah? A. Incorporate her food preferences that are adequately nutritious in her meal plan B. Consistently counsel toward optimum nutritional intake C. Respect her right to reject dietary information if she chooses D. Inform her of the adverse effects of inadequate nutrition to her fetus Situation: Susan is a patient in the clinic where you work. She is inquiring about pregnancy. 11. Susan tells you she is worried because she develops breasts later than most of her friends. Breast development is termed as: A. Adrenarche B. Thelarche C. Mamarche D. Menarche 12. Kevin, Susan’s husband tells you that he is considering vasectomy After the birth of their new child. Vasectomy involves the incision of which organ? A. The testes B. The epididymis C. The vas deferens D. The scrotum 13. On examination, Susan has been found of having a cystocele. A cystocele is: A. A sebaceous cyst arising from the vulvar fold B. Protrusion of intestines into the vagina C. Prolapse of the uterus into the vagina D. Herniation of the bladder into the vaginal wall 14. Susan typically has menstrual cycle of 34 days. She told you she had coitus on days 8, 10, 15 and 20 of her menstrual cycle. Which is the day on which she is most likely to conceive? A. 8th day B. Day 15 C. 10th day D. Day 20 16 15. While talking with Susan, 2 new patients arrived and they are covered with large towels and the nurse noticed that there are many cameraman and news people outside of the OPD. Upon assessment the nurse noticed that both of them are still nude and the male client’s penis is still inside the female client’s vagina and the male client said that “I can’t pull it”. Vaginismus was your first impression. You know that The psychological cause of Vaginismus is related to: A. The male client inserted the penis too deeply that it stimulates vaginal closure B. The penis was too large that is why the vagina triggered its defense to attempt to close it C. The vagina does not want to be penetrated D. It is due to learning patterns of the female client where she views sex as bad or sinful Situation: Overpopulation is one problem in the Philippines that causes economic drain. Most Filipinos are against in legalizing abortion. As a nurse, Mastery of contraception is needed to contribute to the society and economic growth. 16. Supposed that Dana, 17 years old, tells you she wants to use fertility awareness method of contraception. How will she determine her fertile days? A. She will notice that she feels hot, as if she has an elevated temperature. B. She should assess whether her cervical mucus is thin, copious, clear and watery. C. She should monitor her emotions for sudden anger or crying D. She should assess whether her breasts feel sensitive to cool air 17. Dana chooses to use COC as her family planning method. What is the danger sign of COC you would ask her to report? A. A stuffy or runny nose B. Slight weight gain C. Arthritis like symptoms D. Migraine headache 18. Dana asks about subcutaneous implants and she asks, how long will these implants be effective. Your best answer is: A. One month17 B. Five years C. Twelve months D. 10 years 19. Dana asks about female condoms. Which of the following is true with regards to female condoms? A. The hormone the condom releases might cause mild weight gain B. She should insert the condom before any penile penetration C. She should coat the condom with spermicide before use D. Female condoms, unlike male condoms, are reusable 20. Dana has asked about GIFT procedure. What makes her a good candidate for GIFT? A. She has patent fallopian tubes, so fertilized ova can be implanted on them B. She is RH negative, a necessary stipulation to rule out RH incompatibility C. She has normal uterus, so the sperm can be injected through the cervix into it D. Her husband is taking sildenafil, so all sperms will be motile Situation: Nurse Lorena is a Family Planning and Infertility Nurse Specialist and currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions pertain to meeting the nursing needs of this particular population group. 21. Dina, 17 years old, asks you how a tubal ligation prevents pregnancy. Which would be the best answer? A. Prostaglandins released from the cut fallopian tubes can kill sperm B. Sperm cannot enter the uterus because the cervical entrance is blocked. C. Sperm can no longer reach the ova, because the fallopian tubes are blocked D. The ovary no longer releases ova as there is nowhere for them to go. 22. The Dators are a couple undergoing testing for infertility. Infertility is said to exist when: A. A woman has no uterus B. A woman has no children C. A couple has been trying to conceive for 1 year D. A couple has wanted a child for 6 months 23. Another client named Lilia is diagnosed as having endometriosis. This condition interferes with fertility because: A. Endometrial implants can block the fallopian tubes B. The uterine cervix becomes inflamed and swollen C. The ovaries stop producing adequate estrogen D. Pressure on the pituitary leads to decreased FSH levels 24. Lilia is scheduled to have a hysterosalphingogram. Which of the following instructions would you give her regarding this procedure? A. She will not be able to conceive for 3 months after the procedure B. The sonogram of the uterus will reveal any tumors present C. Many women experience mild bleeding as an after effect D. She may feel some cramping when the dye is inserted 25. Lilia’s cousin on the other hand, knowing nurse Lorena’s specialization asks what artificial insemination by donor entails. Which would be your best answer if you were Nurse Lorena? A. Donor sperm are introduced vaginally into the uterus or cervix B. Donor sperm are injected intra- abdominally into each ovary C. Artificial sperm are injected vaginally to test tubal patency D. The husband’s sperm is administered intravenously weekly Situation: You are assigned to take care of a group of patients across the lifespan. 26. Pain in the elder persons requires careful assessment because they: A. experienced reduce sensory perception B. have increased sensory perception C. are expected to experience chronic pain D. have a decreased pain threshold 27. Administration of analgesics to the older persons requires careful patient assessment because older people: A. are more sensitive to drugsB. have increased hepatic, renal and gastrointestinal function D. Chronic poverty C. have increased sensory perception D. mobilize drugs more rapidly 28. The elderly patient is at higher risk for urinary incontinence because of: A. increased glomerular filtration B. decreased bladder capacity C. diuretic use D. dilated urethra 29. Which of the following is the MOST COMMON sign of infection among the elderly? A. decreased breath sounds with crackles B. pain C. fever D. change in mental status 30. Priorities when caring for the elderly trauma patient: A. circulation, airway, breathing B. airway, breathing, disability (neurologic) C. disability (neurologic), airway, breathing D. airway, breathing, circulation 31. Preschoolers are able to see things from which of the following perspectives? A. Their peers B. Their own and their mother’s C. Their own and their caregivers’ D. Only their own 32. In conflict management, the win-win approach occurs when: A. There are two conflicts and the parties agree to each one B. Each party gives in on 50% of the disagreements making up the conflict C. Both parties involved are committed to solving the conflict D. The conflict is settled out of court so the legal system and the parties win 33. According to the social-interactional perspective of child abuse and neglect, four factors place the family members at risk for abuse. These risk factors are the family members at risk for abuse. These risk factors are the family itself, the caregiver, the child, and A. The presence of a family crisis B. The national emphasis on sex C. Genetics 18 34. Which of the following signs and symptoms would you most likely find when assessing and infant with Arnold-Chiari malformation? A. Weakness of the leg muscles, loss of sensation in the legs, and restlessness B. Difficulty swallowing, diminished or absent gag reflex, and respiratory distress C. Difficulty sleeping, hypervigilant, and an arching of the back D. Paradoxical irritability, diarrhea, and vomiting. 35. A parent calls you and frantically reports that her child has gotten into her famous ferrous sulfate pills and ingested a number of these pills. Her child is now vomiting, has bloody diarrhea, and is complaining of abdominal pain. You will tell the mother to: A. Call emergency medical services (EMS) and get the child to the emergency room B. Relax because these symptoms will pass and the child will be fine C. Administer syrup of ipecac D. Call the poison control center 36. A client says she heard from a friend that you stop having periods once you are on the “pill”. The most appropriate response would be: A. “The pill prevents the uterus from making such endometrial lining, that is why periods may often be scant or skipped occasionally.” B. “If your friend has missed her period, she should stop taking the pills and get a pregnancy test as soon as possible.” C. “The pill should cause a normal menstrual period every month. It sounds like your friend has not been taking the pills properly.” D. “Missed period can be very dangerous and may lead to the formation of precancerous cells.” 37. The nurse assessing newborn babies and infants during their hospital stay after birth will notice which of the following symptoms as a primary manifestation of Hirschsprung’s disease? A. A fine rash over the trunk B. Failure to pass meconium during the first 24 to 48 hours after birth19 C. The skin turns yellow and then brown over the first 48 hours of life D. High-grade fever 38. A client is 7 months pregnant and has just been diagnosed as having a partial placenta previa. She is stable and has minimal spotting and is being sent home. Which of these instructions to the client may indicate a need for further teaching? A. Maintain bed rest with bathroom privileges B. Avoid intercourse for three days. C. Call if contractions occur. D. Stay on left side as much as possible when lying down. 39. A woman has been rushed to the hospital with ruptured membrane. Which of the following should the nurse check first? A. Check for the presence of infection B. Assess for Prolapse of the umbilical cord C. Check the maternal heart rate D. Assess the color of the amniotic fluid 40. The nurse notes that the infant is wearing a plastic-coated diaper. If a topical medication were to be prescribed and it were to go on the stomachs or buttocks, the nurse would teach the caregivers to: A. avoid covering the area of the topical medication with the diaper B. avoid the use of clothing on top of the diaper C. put the diaper on as usual D. apply an icepack for 5 minutes to the outside of the diaper 41. Which of the following factors is most important in determining the success of relationships used in delivering nursing care? A. Type of illness of the client B. Transference and counter transference C. Effective communication D. Personality of the participants 42. Grace sustained a laceration on her leg from automobile accident. Why are lacerations of lower extremities potentially more serious among pregnant women than other? A. lacerations can provoke allergic responses due to gonadotropic hormone release B. a woman is less able to keep the laceration clean because of her fatigue C. healing is limited during pregnancy so these will not heal until after birth D. increased bleeding can occur from uterine pressure on leg veins 43. In working with the caregivers of a client with an acute or chronic illness, the nurse would: A. Teach care daily and let the caregivers do a return demonstration just before discharge B. Difficulty swallowing, diminished or absent gag reflex, and respiratory distress. C. Difficulty sleeping, hypervigilant, and an arching of the back D. Paradoxical irritability, diarrhea, and vomiting 44. Which of the following roles BEST exemplifies the expanded role of the nurse? A. Circulating nurse in surgery B. Medication nurse C. Obstetrical nurse D. Pediatric nurse practitioner 45. According to DeRosa and Kochura’s (2006) article entitled “Implement Culturally Competent Health Care in your work place,” cultures have different patterns of verbal and nonverbal communication. Which difference does? A. NOT necessarily belong? B. Personal behavior C. Subject matter D. Eye contact E. Conversational style 46. You are the nurse assigned to work with a child with acute glomerulonephritis. By following the prescribed treatment regimen, the child experiences a remission. You are now checking to make sure the child does not have a relapse. Which finding would most lead you to the conclusion that a relapse is happening? A. Elevated temperature, cough, sore throat, changing complete blood count (CBC) with diiferential B. A urine dipstick measurement of 2+ proteinuria or more for 3 days, or the child found to have 3-4+ proteinutria plus edema.C. The urine dipstick showing glucose in the urine for 3 days, extreme thirst, increase in urine output, and a moon face. D. A temperature of 37.8 degrees (100 degrees F), flank pain, burning frequency, urgency on voiding, and cloudy urine. 47. The nurse is working with an adolescent who complains of being lonely and having a lack of fulfillment in her life. This adolescent shies away from intimate relationships at times yet at other times she appears promiscuous. The nurse will likely work with this adolescent in which of the following areas? A. Isolation B. Lack of fulfillment C. Loneliness D. Identity 48. The use of interpersonal decision making, psychomotor skills, and application of knowledge expected in the role of a licensed health care professional in the context of public health welfare and safety is an example of: A. Delegation B. Responsibility C. Supervision D. Competence 49. The painful phenomenon known as “back labor” occurs in a client whose fetus in what position? A. Brow position B. Breech position C. Right Occipito-Anterior Position D. Left Occipito-Posterior Position 50. FOCUS methodology stands for: A. Focus, Organize, Clarify, Understand and Solution B. Focus, Opportunity, Continuous, Utilize, Substantiate C. Focus, Organize, Clarify, Understand, Substantiate D. Focus, Opportunity, Continuous (process), Understand, Solution SITUATION: The infant and child mortality rate in the low to middle income countries is ten times higher than industrialized countries. In response to this, the WHO and UNICEF launched the protocol Integrated Management of Childhood Illnesses to reduce the morbidity and mortality against childhood illnesses. 20 51. If a child with diarrhea registers two signs in the yellow row in the IMCI chart, we can classify the patient as: A. Moderate dehydration B. Severe dehydration C. Some dehydration D. No dehydration 52. Celeste has had diarrhea for 8 days. There is no blood in the stool, he is irritable, his eyes are sunken, the nurse offers fluid to Celeste and he drinks eagerly. When the nurse pinched the abdomen it goes back slowly. How will you classify Celeste’s illness? A. Moderate dehydration B. Severe dehydration C. Some dehydration D. No dehydration 53. A child who is 7 weeks has had diarrhea for 14 days but has no sign of dehydration is classified as: A. Persistent diarrhea B. Dysentery C. Severe dysentery D. Severe persistent diarrhea 54. The child with no dehydration needs home treatment. Which of the following is not included in the rules for home treatment in this case? A. Forced fluids B. When to return C. Give vitamin A supplement D. Feeding more 55. Fever as used in IMCI includes: A. Axillary temperature of 37.5 or higher B. Rectal temperature of 38 or higher C. Feeling hot to touch D. All of the above E. A and C only Situation: Prevention of Dengue is an important nursing responsibility and controlling it’s spread is a priority once outbreak has been observed. 56. An important role of the community health nurse in the prevention and control of Dengue H-fever includes: A. Advising the elimination of vectors by keeping water containers covered21 B. Conducting strong health education drives/campaign directed towards proper garbage disposal C. Explaining to the individuals, families, groups and community the nature of the disease and its causation D. Practicing residual spraying with insecticides 57. Community health nurses should be alert in observing a Dengue suspect. The following is NOT an indicator for hospitalization of H-fever suspects? A. Marked anorexia, abdominal pain and vomiting B. Increasing hematocrit count C. Cough of 30 days D. Persistent headache 58. The community health nurses’ primary concern in the immediate control of hemorrhage among patients with dengue is: A. Advising low fiber and non-fat diet B. Providing warmth through light weight covers C. Observing closely the patient for vital signs leading to shock D. Keeping the patient at rest 59. Which of these signs may NOT be REGARDED as a truly positive signs indicative of Dengue Hfever? A. Prolonged bleeding time B. Appearance of at least 20 petechiae within 1cm square C. Steadily increasing hematocrit count D. Fall in the platelet count 60. Which of the following is the most important treatment of patients with Dengue H-fever? A. Give aspirin for fever B. Replacement of body fluids C. Avoid unnecessary movement of patient D. Ice cap over the abdomen in case of melena Situation: Health education and Health promotion is an important part of nursing responsibility in the community. Immunization is a form of health promotion that aims at preventing the common childhood illnesses. 61. In correcting misconceptions and myths about certain diseases and their management, the health worker should first: A. Identify the myths and misconceptions prevailing in the community B. Identify the source of these myths and misconceptions C. Explain how and why these myths came about D. Select the appropriate IEC strategies to