3-A client who is one day postpartum tells nurse that her baby cannot catch onto the breast.
The nurse determines that the client nipples are inverted. Which action should the nurse
implement?
a) Recommending using breast shield
b) Offer supplemental formula feeding
c) Teach about the use of a breast pump
d) Encourage the use of ice on the areola
Ans; A
6- The mother of a school age child calls the school to ask when her daughter can return to
school after treatment for pediculosis capitis. What is the nurse best respond?(nits liendra)
a) Until all lice are dead
b) Until the epidemic in school subside
c) Stay in home.
ANS; A
10- The mother of the 7 month old bring the infant to the clinic because the skin in the diaper
area is and red, but there are no blister or bleeding. The mother reports no evidence of
watery stools. Which nursing intervention should the nurse implement?
a) Instruct the mother to change the child’s diaper more often.
b) Tell the mother to cleanse with soap and water at each diaper change
c) Encourage the mother to apply lotion with each diaper change.
d) Ask the mother to decrease the infant’s intake of fruits for 24 hours
ANS; A
12- When conducting discharge teaching of an older client. Which instruction regarding
medication administration should the nurse include?
a) The direction of the prescription container can be enlarge for including
b) Medication should be moved for a similar condition that made... in the future
c) Don’t share meds with family and friend (older people like to share medicine)
ANS; C
15- A client was admitted to the cardiac observation unit 2 hour ago complaining of chest
pain, On admission the client’s EKG showed bradycardia, ST depression, but no ventricular
ectopic. The client suddenly reports a sharp increase in pain, telling the nurse, “I feel like an
, elephant just stepped on my chest” The EKG now shows Q waves and ST segment elevations
in the anterior leads. What interventions should the nurse perform?
a) Notify the healthcare provider of the client’s increased chest pain and call for the defibrillator
crash cart.
b) Obtain a stat 12 lead EKG and perform a venipuncture to check cardiac enzyme levels
c) Administer prescribed morphine sulfate IV and provide oxygen at 2L/minute per nasal
cannula
d) Increase the peripheral IV flow rate to 175 ml/hr to prevent hypotension and shock
ANS; C
16-Which intervention should the nurse include in the plan of care for tetanus....
a) Open the window shades toprovide natural light
b) Encourage coughing and deep breathing.
c) Minimize the amount of stimuli in the room
d) Reposition from side to site every hour.
ANS; B or C ojo, I put C
23- The nurse who is working on surgical unit receives change –of –shift report on a group of
clients for the upcoming shift .The client with which description requires the most immediate
attention by the nurse?
a) Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-Pratt drain
b) Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing.
c) Abdominal –resection 2 days ago with no drainage on dressing who has fever and chills.
d) Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection
container.
ANS; D , I put C
29- A client experiencing withdrawal from the Benzodiazepine alprasolan (Xanax) is
demonstrating severe agitation and tremors. What is the best initial nursing action?
a) Administer Narcan PRN protocol
b) Obtain serum drug screen
c) Instruct the family about withdrawal symptom
d) Initiate seizure precautions
ANS; D
34- The nurse is feeding a client who was admitted this morning with syncope and
generalized weakness .The client has a history of aspiration and begins coughing while
attempting to drink trough a straw. Which action should the nurse implement?
a) Elevate the head of bed for 30 minutes after meal
b) Perform oral care before meals
c) Allow small amount of liquid with meals
d) Provide nectar thickened liquids
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