Tiêu đề RECALLS 12 (NP2) - STUDENT COPY ✅

RECALLS EXAMINATION 12 NURSING PRACTICE II CARE OF HEALTHY / AT RISK MOTHER AND CHILD NOVEMBER 2024 Philippine Nurse Licensure Examination Review GENERAL INSTRUCTIONS: 1. This test questionnaire contains 100 test questions 2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalid your answer. 3. AVOID ERASURES. 4. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set. 5. Write the subject title “NURSING PRACTICE II” on the box provided 1. Regine is having her first prenatal visit. She submitted her laboratory reports to the nurse. Which laboratory result should the nurse most likely question? A. Hematocrit: 36.5% B. White blood cells (WBCs): 7,000/mm3 C. Pap smear: Negative; human papillomavirus (HPV) changes noted D. Urine pH: 7.4 2. A nurse is caring for a client who has a positive quadruple screen for Down’s syndrome at 16 weeks. Which diagnostic test can be used to confirm the diagnosis? A. Chorionic villus sampling (CVS) B. Amniocentesis C. Level II ultrasound D. Nuchal translucency testing 3. A pregnant client has an abnormal 1-hour glucose screen and completes a 3-hour, 100-gram oral glucose tolerance test. Which test result should a nurse interpret as being abnormal? A. Fasting blood sugar= 84 mg/dL B. 1 hr =186 mg/dL C. 2 hr = 146 mg/dL D. 3 hr = 129 mg/dL 4. A 24-year-old client, who is experiencing vaginal bleeding in the first trimester of pregnancy, fears that she has lost her baby at 8 weeks. Which definitive test result should indicate to a nurse that the client’s fetus has been lost? A. Falling beta human chorionic gonadotropin (BHCG) measurement B. Low progesterone measurement C. Ultrasound demonstrating lack of fetal cardiac activity D. Ultrasound determining crown–rump length 5. A nurse is teaching a woman who plans to travel by airplane during the first 36 weeks of her pregnancy to celebrate her birthday. Which is the primary risk of air travel for this woman that the nurse should address? A. Preterm labor B. Deep vein thrombosis C. Spontaneous miscarriage D. Nausea and vomiting 6. A nurse is teaching a group of women about the side effects of different types of contraceptives. What is the most frequent side effect associated with the use of an intrauterine device (IUD)? A. A tubal pregnancy B. A rupture of the uterus C. An expulsion of the device D. An excessive menstrual flow 7. A nurse explains that the efficiency of the basal body temperature method of contraception depends on fluctuation of the basal body temperature. What factor will alter its effectiveness? A. Presence of stress B. Length of abstinence C. Age of those involved D. Frequency of intercourse 8. A nurse at the clinic is counseling a couple about the tests that will be needed to determine the cause of their infertility. Which test should the nurse describe, that will evaluate the woman’s organs of reproduction? A. Biopsy B. Cystogram C. Culdoscopy D. Hysterosalpingogram 9. A nurse in the women’s health clinic is counseling clients about the signs of gynecological problems. What early manifestation of cervical cancer should prompt a client to seek professional care? A. Abdominal heaviness ‘ B. Pressure on the bladder C. Foul-smelling discharge D. Bloody spotting after intercourse 10. A client was advised to undergo hysterectomy by her attending physician. The client expresses concern about having a hysterectomy at age 45 because she has heard from friends that she will undergo severe symptoms of menopause after surgery. What is the nurse’s most appropriate response? A. “You are correct, but there are medicines you can take that will ease the symptoms.” B. “This sometimes occurs in women of your age, but you needn’t worry about it at this time.” C. “Perhaps you should talk to your surgeon because I am not allowed to discuss this with you.” D. “Some women may experience symptoms of menopause if their ovaries are removed with their uterus.” 11. The plan of care for a client with osteoporosis includes active and passive exercises, calcium supplements, and daily vitamins. How does a nurse determine that the desired effect of therapy is attained? A. Mobility increases. B. Fewer muscle spasms occur. C. There is a more regular heartbeat. D. There are fewer bruises than before therapy. 12. A nurse is assessing a client for the potential for developing osteoporosis. Which factor in the client’s history increases the risk for this disorder? A. Estrogen therapy B. Hypoparathyroidism C. Prolonged immobility D. Excessive calcium intake 13. A nurse is caring for a client who contracted a trichomonal infection. Which oral drug should the nurse anticipate the health care provider most likely will prescribe? A. Penicillin G B. Gentian violet C. Nystatin (Mycostatin) D. Metronidazole 14. A pregnant woman is admitted to the labor and delivery room. She is excited about the anticipated birth because she has three sons and the amniocentesis indicated that she will 1 | Page
have a girl. Which factor in the client’s history alerts the nurse that the newborn will be at risk for a complication? A. Her membranes ruptured two hours ago. B. Her first child was diagnosed with hemophilia. C. She used NSAIDs for frequent sinus headaches. D. She had a placenta previa in a previous pregnancy. 15. What information concerning the childbearing process should the nurse teach a client during the first trimester of pregnancy? A. Labor and birth B. Signs and symptoms of complications C. Role transition into parenthood and its acceptance D. Physical and emotional changes resulting from pregnancy 16. During a physical in the prenatal clinic the client’s vaginal mucosa is observed to have a purplish discoloration. What sign should the nurse document in the client’s clinical record? A. Hegar B. Goodell C. Chadwick D. Braxton Hicks 17. A pregnant woman reports nausea and vomiting during the first trimester of pregnancy. An increase in which hormone should the nurse explain is the precipitating cause of the nausea and vomiting? A. Estrogen B. Progesterone C. Luteinizing hormone D. Human Chorionic Gonadotropin 18. A nurse admits a woman with a diagnosis of placenta previa. Which symptom is the nurse most likely to assess in a woman with this diagnosis? A. Painful vaginal bleeding B. Painless vaginal bleeding C. Contractions D. Absence of fetal movement 19. A company nurse is evaluating a 32-weeks-pregnant client. The client presents for her routine visit with an elevated blood pressure of 142/89 mm Hg. Her urine is negative for protein and her weight gain is 2 pounds since her last routine visit at 30 weeks. She has trace pedal edema. Based on this information, the nurse should conclude that the client is most likely experiencing: A. gestational hypertension. B. chronic hypertension. C. preeclampsia. D. eclampsia. 20. A primigravida client has been pushing for 2 hours when the head emerges. The fetus fails to deliver, and the physician notes that the turtle sign has occurred. Which should be a nurse’s interpretation of this information? A. Cephalopelvic disproportion B. Shoulder dystocia C. Delivery of the placenta D. Cord prolapse 21. A nurse is caring for a client who has been in the second stage of labor for the last 12 hours. The nurse should monitor for which cardiovascular change that occurs during labor? A. An increase in maternal heart rate B. A decrease in cardiac output C. An increase in peripheral vascular resistance D. A decrease in the uterine artery blood flow during contractions 22. A nurse is caring for a 30-weeks-pregnant client who is having contractions every 11 /2 to 2 minutes with spontaneous rupture of membranes 2 hours ago. The client’s cervix is 8 cm dilated, and her cervix is 100% effaced. The nurse determines that delivery is imminent. Which nursing action is the most important at this time? A. Administering a tocolytic agent B. Providing teaching information on premature infant care C. Notifying neonatology of the impending birth D. Preparing for a cesarean birth 23. A labor and delivery nurse is caring for a postpartum client who is 16 hours post delivery. A student nurse is assisting with the care. The RN evaluates that the student needs more education about uterine assessment when the student is observed doing which of the following? A. Elevating the client’s head 30 degrees before beginning the assessment B. Supporting the lower uterine segment during the assessment C. Gently palpating the uterine fundus D. Observing the abdomen before beginning palpation 24. A postpartum client, who delivered a full-term infant 2 days previously, calls a nurse to her room and states that she is concerned because her breasts “seem to be growing.” She reports that the bra she wore during pregnancy is too small. She asks the nurse what is wrong with her. The nurse’s response should be based on which of the following statements? A. Enlarging breasts are a symptom of infection. B. Increasing breast tissue may be a sign of postpartum fluid retention. C. Thrombi may form in veins of the breast and cause increased breast size. D. Breast tissue increases in the early postpartum period as milk forms. 25. While assisting with the vaginal delivery of a full-term newborn, a nurse observes that, although the client did not have an episiotomy or a perineal laceration, her perineum and labia are edematous. To promote comfort and decrease the edema, which intervention is most appropriate as a knowledgeable nurse? A. Applying an ice pack to the perineum B. Teaching the client to relax her buttocks before sitting in a chair C. Applying a warm pack D. Providing the client with a plastic donut cushion to be used when sitting 26. While completing an assessment on a 4-hours-old newborn, a nurse notes the following documentation in the newborn’s chart: “clamping of the umbilical cord was delayed until cord pulsations ceased.” The nurse anticipates that this delayed cord clamping will result in: A. more rapid expulsion of meconium from the newborn intestinal tract. B. increased newborn alertness after birth. C. an increase in initial newborn temperature. D. an increase in the newborn’s hemoglobin and hematocrit. 27. During the initial assessment of a pre-term newborn, the NICU nurse measures both the infant’s chest and head circumference. The infant’s father observes this assessment and asks the nurse why these measurements are necessary. Which explanation by the nurse is most accurate? A. Comparing these measurements provides information about any head or chest growth abnormalities. B. Measuring the head circumference provides information about future intellectual ability. C. Measuring a newborn’s chest provides data to assist with assessment of cardiac health. D. Comparing head and chest circumference measurements provides information about future adult body size. 28. During a home-care visit to the parents of a 1-week-old newborn, a nurse correctly educates the parents about continuing care of the newborn’s umbilical cord by instructing them to: A. begin applying rubbing alcohol to the base of the cord stump three times a day. B. attempt to gently dislodge the cord if it has not fallen off in the next week. C. begin placing the infant in a tub of warm water that covers the cord twice a week until the cord falls off. D. continue to place the diaper below the cord when diapering the infant 29. A newborn who is 28-weeks gestation and 48 hours old has been diagnosed with respiratory distress syndrome (RDS). A health-care provider orders the administration of surfactant via endotracheal tube. The father asks a nurse to explain how this treatment will help his baby. The nurse explains that the preterm infant is unable to produce adequate amounts of surfactant and giving it to his baby will: A. increase PaCO2 levels in the bloodstream. B. prevent alveoli collapse. C. decrease PaO2 levels in the bloodstream. 2 | Page
D. prevent pleural effusion. 30. A nurse is teaching a class of new parents about how to position their infants during the first few weeks of life. Which position is safest? A. On the back, lying flat B. On either side, lying flat C. Head slightly elevated on the left side D. Head slightly elevated on the right side 31. The nurse is teaching a parent group about the reason for adhering to the immunization schedule. What complication of mumps is important for adolescents to avoid? A. Sterility B. Hypopituitarism C. Decrease in libido D. Decrease in androgens 32. A nurse is caring for an infant with bacterial meningitis. The parents ask how their baby could have contracted the illness. What does the nurse consider as the most likely route of transmission to the central nervous system (CNS)? A. Genitourinary tract B. Gastrointestinal tract C. Skin or mucous membranes D. Cranial apertures or sinuses 33. A 1-year-old infant has been admitted with a tentative diagnosis of bacterial meningitis. A lumbar puncture is performed to confirm the diagnosis. What laboratory report of the spinal fluid supports this diagnosis? A. Decreased cell count B. Elevated protein level C. Increased glucose level D. Low spinal fluid pressure 34. At a visit to the well-baby clinic, the parents are upset because their 9-month-old infant has a severe diaper rash; one parent wants to know how to treat it and prevent it from recurring. What cause of diaper dermatitis should the nurse include when answering the parent’s question? A. Use of disposable diapers B. Prolonged contact with an irritant C. Decreased pH of the infant’s urine D. Too early introduction of solid foods 35. A nurse who is caring for an infant with a cleft lip is concerned about preventing an infection. Why does the cleft lip predispose the infant to infection? A. Waste products accumulate along the defect. B. There is inadequate circulation in the defective area. C. Nutrition is inadequate because of ineffective feeding. D. Mouth breathing dries the oropharyngeal mucous membranes. 36. An infant with pyloric stenosis is admitted to the pediatric unit. What does the nurse expect when palpating the infant’s abdomen? A. A distended colon B. Marked tenderness around the umbilicus C. An olive-sized mass in the right upper quadrant D. Rhythmic peristaltic waves in the lower abdomen 37. A nurse is caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). What is most important for the nurse to assess? A. Quality of the cry B. Signs of dehydration C. Coughing up of feedings D. Characteristics of the stool 38. Corrective surgery for hypertrophic pyloric stenosis (HPS) is completed, and the infant is returned to the pediatric unit with an IV infusion in place. What is the priority nursing action? A. Apply adequate restraints. B. Administer a mild sedative. C. Assess the IV site for infiltration. D. Attach the nasogastric tube to wall suction. 39. If a pediatric nurse is concerned that a newborn may have congenital hydrocephalus, which assessment finding is noted? A. Bulging anterior fontanel B. Head circumference equal to the chest circumference C. A narrowed posterior fontanel D. Low-set ears 40. A client presents to a walk-in travel clinic to receive vaccinations. The client tells a nurse she thinks she may be pregnant. Which vaccines, if ordered by a physician, should the nurse prepare to administer to this client? A. Rubella B. Varicella C. Hepatitis B D. Mumps 41. A nurse admits a client who is 28 weeks pregnant and experiencing congestive heart failure. When initiating a health-care provider’s admission orders for the client, which order should the nurse question? A. Furosemide (Lasix®) 40 mg IV bid B. Captopril (Capoten®) 25 mg PO daily C. Digoxin (Lanoxin®) 0.125 mg IV daily D. Metoprolol sustained release (Toprol XL®) 50 mg PO daily 42. While caring for a client with severe preeclampsia who has been receiving intravenous magnesium sulfate for 24 hours, the ward nurse evaluates that the medication is effective when noting: A. an increase in blood pressure. B. an increase in urine output. C. a decrease in platelet count. D. an increase in hematocrit. 43. The NICU nurse is preparing to administer indomethacin to an infant diagnosed with patent ductus arteriosus (PDA). By which route should the nurse expect to administer the indomethacin for this infant? A. Intravenously (IV) B. Orally C. Rectally D. Intramuscularly (IM) 44. A nurse plans to discuss childhood nutrition with a group of parents whose children have Down syndrome in an attempt to minimize a common nutritional problem. What problem should be addressed? A. Rickets B. Obesity C. Anemia D. Rumination 45. A 1-month-old infant is admitted to the pediatric unit with a tentative diagnosis of Hirschsprung disease. What procedure does the nurse expect to be used to confirm the diagnosis? A. Colonoscopy B. Rectal biopsy C. Multiple saline enemas D. Fiberoptic nasoenteric tube 46. A nurse is caring for an infant whose vomiting is intractable. For what complication is it most important for the nurse to assess? A. Acidosis B. Alkalosis C. Hyperkalemia D. Hypernatremia 47. A nurse is teaching parents about why most children should be immunized against varicella (chickenpox) and why some receiving specific medications should not. Which medication should be included in the discussion? A. Insulin B. Steroids C. Antibiotics D. Anticonvulsants 48. When is the most appropriate time for the nurse to plan for chest percussion and postural drainage for a toddler with cystic fibrosis? A. After suctioning B. Before aerosol therapy C. One hour before meals D. Fifteen minutes after meals 49. After a tonsillectomy, which finding alerts the nurse to suspect the initial stage of hemorrhage? A. Noisy snoring B. Asking for water C. Frequent swallowing D. Gradual onset of pallor 50. A clinic nurse is evaluating a client with type 1 diabetes who intends to enroll in a tennis class. Which statement made by the client indicates that the client understands the effects of exercise on insulin demand? A. “I will carry a high-fat, high-calorie food, such as a cookie.” 3 | Page
B. “I will administer 1 unit of lispro insulin prior to playing tennis.” C. “I will eat a 15-gram carbohydrate snack before playing tennis.” D. “I will decrease the meal prior to the class by 15-grams of carbohydrates.” 51. A nurse is teaching a client who has been newly diagnosed with type 2 diabetes mellitus (DM). Which teaching point should the nurse emphasize? A. Use the arm when self-administering NPH insulin. B. Exercise for 30 minutes daily, preferably after a meal. C. Consume 30% of the daily calorie intake from protein foods. D. Eat a 30-gram carbohydrate snack prior to strenuous activity. 52. Which medication should a nurse plan to administer to a client admitted in Addisonian crisis? A. Regular insulin B. Ketoconazole (Nizoral) C. Sodium nitroprusside (Nipride) D. Hydrocortisone (Solu-Cortef) 53. A nurse is caring for a client who is experiencing symptoms associated with pheochromocytoma. Which intervention should be included in the care of this client? A. Offer distractions such as television or music. B. Encourage frequent intake of oral fluids. C. Assist with ambulation at least three times a day. D. Administer nicardipine (Cardene®) to control hypertension. 54. A nurse is teaching an athletic teenager about nutrients that provide the quickest source of energy. Which food selected from a menu indicates to the nurse that the adolescent understands the teaching? A. Glass of milk B. Slice of bread C. Chocolate candy bar D. Glass of orange juice 55. The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client’s nostril. The nurse should take which initial action? A. Lower the head of the bed. B. Test the drainage for glucose. C. Obtain a culture of the drainage. D. Continue to observe the drainage. 56. The nurse is performing an assessment on a client with pheochromocytoma. Afer a thorough assessment, the nurse would indicate a potential complication associated with this disorder? A. A urinary output of 50 mL/hr B. A coagulation time of 5 minutes C. A heart rate that is 90 beats per minute and irregular D. A blood urea nitrogen level of 20 mg/dL (7.1 mmol/L) 57. A clinical instructor is caring for a client following a liver biopsy with the assistance of a student nurse. The RN evaluates that the student understands the post procedure care when the student nurse: A. plans to monitor vital signs every hour. B. promotes ambulation 1 hour after the procedure. C. positions the client on the right side. D. encourages the client to cough and deep breathe immediately following the procedure. 58. A nurse is beginning client care and has been assigned to the following four clients. Which client should the nurse plan to assess first? A. A 50-year-old client who has chronic pancreatitis and is reporting a pain level of 6 out of 10 on a numeric scale B. A 47-year-old client with esophageal varices who has influenza and has been coughing for the last 30 minutes C. A 60-year-old client who had an open cholecystectomy 15 hours ago and has been stable through the night D. A 54-year-old client with cirrhosis and jaundice who is reporting itching 59. A nurse is caring for a client who is 6 hours post–open cholecystectomy. The client’s T-tube drainage bag is empty, and the nurse notes slight jaundice of the sclera. Which action by the nurse is most important? A. Repositioning the client to promote T-tube drainage B. Notifying the surgeon about these findings C. Checking the client’s blood pressure immediately D. Recording the findings and continuing to monitor the client 60. A health-care provider writes the following admission orders for a client with possible appendicitis. Which order should the nurse question? A. Apply heat to abdomen to decrease pain B. Withhold analgesic medications to avoid masking critical changes in symptoms C. Keep client NPO (nothing per mouth) D. Start lactated Ringer’s solution intravenously (IV) at 125 mL/hr 61. A nurse is assessing a client, with a diagnosed inguinal hernia, at a scheduled follow-up visit. The nurse suspects that the client’s hernia may be strangulated when which finding is noted on assessment? A. Shortness of breath B. Intense abdominal pain C. Constipation D. Hyperactive bowel sounds 62. A nurse is assessing a client diagnosed with acute diverticulitis. Which finding should make the nurse suspect that the client has an intestinal perforation? A. Elevated white blood cells (WBCs) B. Temperature of 101°F (38.3°C) C. Absent bowel sounds D. Abdominal pain 63. A nurse is planning care for a client who is scheduled for an intravenous pyelogram (IVP). Which intervention should the nurse include in the care of this client? A. Teaching the client that a warm, flushing sensation may be experienced as the dye is injected B. Preparing the client for a bladder catheterization before the procedure C. Keeping the client NPO after the procedure until test results are obtained D. Ambulating the client in the hall to promote excretion of the dye 64. A nurse notes blood clots in a client’s urine after a cystoscopy. Which is the most appropriate initial action by the nurse? A. Perform bladder irrigation B. Notify the health-care provider (HCP) C. Apply heat to the client’s bladder area D. Administer the prescribed antispasmodic agent 65. A nurse is completing an admission assessment for a client suspected of having an obstructing struvite calculus of the right ureter. During the assessment, which is the best question for the nurse to ask the client? A. “Are you experiencing any left flank pain?” B. “Do you like to drink cranberry, prune, or tomato juice?” C. “Have you had a history of chronic urinary tract infections (UTIs)?” D. “How often do you eat organ meats, poultry, fish, and sardines?” 66. A nurse is admitting a client with a diagnosis of renal calculi to a hospital nursing unit. Which nursing action should be performed first? A. Encourage the client to increase oral fluids B. Obtain supplies to measure and strain all urine C. Assess the severity and location of the client’s pain D. Obtain consent for an extracorporeal shock wave lithotripsy (ESWL) 67. A health care provider schedules a paracentesis. What should the nurse instruct the client to do to prepare for the procedure? A. Empty the bladder before the procedure. B. Take a laxative the evening before the procedure. C. Ingest nothing by mouth for 8 hours before the procedure. D. Self-administer a low soapsuds enema 2 hours before the procedure. 68. Which nursing assessment is most accurate in determining the patency of a client’s newly placed left forearm internal arteriovenous (AV) fistula for hemodialysis? 4 | Page