Tiêu đề RECALLS 1 (NP2) - STUDENT COPY ✅

RECALLS EXAMINATION 1 NURSING PRACTICE II CARE OF HEALTHY / AT RISK MOTHER AND CHILD MAY 2025 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 Situation: Wesley enters the labor and delivery unit in probable preterm labor at 36 weeks' gestation. The patient was informed that the fetus is in breech presentation. She has a catheterized urine specimen ordered. 1. Patient Wesley asks the nurse why such a diagnostic procedure is required. What is the MOST APPROPRIATE answer can the nurse give? A. Urinary tract infections are strongly associated with the occurrence of preterm labor B. Reduced sensation to urinate usually occur during preterm labor C. Preterm labor treatment usually causes women a bladder infection because of restricted fluid intake D. Catheterized urine is usually ordered for any woman admitted to the labor and delivery unit 2. Betamethasone (Celestone) is prescribed to be administered and the patient asks Nurse Kaye about the purpose of this medication? A. Promote fetal lung maturity. B. Prevent the premature closure of the ductus arteriosus. C. Delay delivery for at least 48 hours. D. Stop the premature uterine contractions. 3. Patient Wesley who is ordered for diagnostic pelvic ultrasound asks what preparation she'll take. Appropriate preparations for this procedure include __________. A. explanation of the procedure B. NPO 6 hours before C. informed consent D. voiding 4. Pelvic ultrasound can detect, which of the following? A. Congenital defects in the structure, fetal gender, H-mole B. Fetal DM, multiple pregnancies, fetal age of gestation C. Fetal sex, number and lung maturity D. Fetal congenital defects, placenta previa, fetal lung maturity 5. The labor progressed and the physician performed an amniotomy. Nurse Kaye should FIRST assess for ____. A. bladder distention B. maternal blood pressure C. cervical dilatation D. fetal heart rate (FHR) pattern Situation: Vienna, a patient with severe preeclampsia is admitted to the hospital. She is a student from one of the local universities and insists on continuing her studies while in the hospital, despite being instructed to rest. The patient studies approximately 10 hours a day and has numerous visits from fellow students, family and friends. 6. Which intervention should the nurse use to promote rest? A. Develop a routine with the patient to balance her studies and her rest needs. B. Include a significant other in helping the patient understand the need for rest. C. Instruct the patient that the baby's health is more important than her studies at this time. D. Ask her why she is not complying with the prescription of bed rest. 7. Patient Vienna, who seemed to be irritated with the nurse, said "I don't want to talk with you because you're only a nurse. I will wait for my doctor." Which of the following should the nurse say in response to the patient? A. Your doctor prescribed this for us to do nursing care. B. I understand. I should call your doctor. C. I'm angry with the way you dismiss me. D. So then you would prefer to speak with your doctor? 8. Nurse Lauve is now in an ethical dilemma. This occurs when ______. A. a decision had to be made quickly under stressful situation B. choices are unclear C. there is a conflict between the nurse's decision and that of his/her superior D. there is a conflict of two or more ethical principles 9. Despite the reaction of the patient, which of the ethical principles is the nurse responsible for providing all patients with caring attention and information? A. Beneficence. B. Nonmaleficence. C. Veracity D. Advocacy 10. Nurse Lauve should plan to initiate which action to provide a safe environment? A. Take the patient's vital signs every 4 hours. B. Encourage visits from family and friends for psychosocial support. C. Maintain fluid and sodium restrictions. D. Take off the room lights and draw the window shades. Situation: Nurse Janie is admitting five-year-old Kenny due to cough, respiratory distress, anxiety and signs of dehydration. The working diagnosis is pneumonia. 11. Nurse Janie is aware that history taking and physical exams are critical to the diagnostic process and often provide more information than can be gained by broad testing strategies. History taking includes the following, EXCEPT ____________. A. History of present illness. B. Religious Affiliation C. Social & Family history D. Past medical history 12. The objective of taking the history of present illness is to elicit chronologic description and duration of the chief complaint. Which of the following questions would try to answer what Nurse Janie wishes to elicit? 1. History of immunizations. 2. Aggravating and alleviating factors 3. Duration of disease onset 4. Any treatment and response to treatment A. 1, 2 & 3 1 | Page
B. 2,3 & 4 C. 1, 2, 3 & 4 D. 1, 2 & 3 13. Past medical history section of Kenny contains the following, but NOT ___________. A. Prenatal history. B. Childhood illness C. Current history D. Birth history 14. Which of the following statements is TRUE? A. History taking must be long regardless if the child appears to be well. B. No proper history can be obtained without observation of the child and the mother. C. Nurse Nanie should refrain from asking about the illness of other members of the family. D. An example of what can be elicited from a social history is how the disease started. 15. In order not to frighten small children, it is best to examine things that are uncomfortable or frightening to them last so as not to lose their cooperation. This means the LAST thing do child which of the following, EXCEPT _________. A. Inspection of the throat with a throat stick. B. Inspection of the ears with an otoscope C. Auscultation of the heart D. Undressing the child Situation: Rennie, a pregnant patient 37 weeks gestation is admitted due to fever, painful swelling of hands, feet, joints, and in labor pain who has a diagnosis of sickle cell anemia. 16. Nurse Penny administers oxygen to patient Rennie and implements additional measures to prevent a sickling crisis from occurring? A. Maintain strict asepsis. B. Maintains adequate hydration. C. Monitors the temperature. D. Reassures the patient. 17. Nurse Penny hooks a 1000 mL intravenous (IV) solution of D5Water as ordered by the physician at 9 am to infuse 80 ml/hr via macro drop infusion set (20 gtts = 1 ml). On the assessment of the infusion at what would be the level of the remaining amount in the IV bag at 2 pm? A. 500 B. 200 C. 400 D. 300 E. None of the above 18. The patient began receiving an intravenous (IV) infusion of packed red blood cells 30 minutes ago. The patient complains of difficulty breathing, itching and a tight sensation in the chest. Which is the IMMEDIATE action of the nurse? A. Recheck the unit of blood for compatibility. B. Call the physician. C. Check the patient's temperature. D. Stop the infusion. 19. Nurse Penny checks the gauge of the patient's intravenous catheter. Which is the smallest gauge catheter that the nurse can use to administer blood? A. 22-Gauge B. 18-Gauge C. 20-Gauge D. 12-Gauge 20. The nurse reviews the patient's plan of care. Which of the following nursing diagnoses will be the PRIORITY? A. Fluid volume, deficit B. Risk for pain, acute C. Coping, ineffective. D. Body image, disturbed Situation: Nurse Triny has been assigned to the Pediatric Ward for two years. She wants to join the team of nurses who will be conducting a study on sleep. The Team Leader wants to be assured that Nurse Triny is equipped with the basic knowledge of nursing research. 21. The team leader decided to ask Nurse Triny the meaning of informed consent. After being able to define what the term means, she was further asked the reasons for its use. Nurse Triny's answer should be, which of the following? 1. To fully understand what the research is all about and what will happen should the participants opt to involve themselves in the research study 2. To get assurance that participants have the right to withdraw from participating in the research at any given time. 3. To get complete and full information as to the objective of the study, procedures to be implemented, data collection, benefits and harm and options in the method of treatment. 4. To get assurance how anonymity and confidentiality will be maintained. A. 1, 2 & 3 B. 2 only C. 1, 2, 3 & 4 D. 3 only 22. As to the observance of respecting privacy, Nurse Triny explained about A. breach of contract. B. anonymity C. ethical dilemma D. confidentiality 23. In nursing, Nurse Triny explained that the MAIN goal of conducting research is to _______. A. justify the role of nurses as health care provider B. establish a credible body of evidence to support and improve the delivery of care. C. identify research priorities that will justify the oversupply of nurses. D. develop a body of knowledge to address non-nursing problems 24. In conducting a study on sleep, Nurse Triny was asked which of the types of research will be used should it involve collecting numerical data which is most often under considerable control. Her answer should be ___. A. Ethnographic B. Phenomenological C. Qualitative D. Quantitative 25. Should a 24-hour period of clinical observations and activities be considered in conducting the research on sleep, the type of study that Triny will be conducting is ______. A. Quantitative B. Descriptive C. Ethnological D. Exploratory Situation: A newly hired nurse is assigned in the OB ward. She was supervised by a senior nurse. 26. She was asked by the nurse supervisor about her concern and what are the considered ideal fetal positions for a healthy delivery? A. Right occipitoposterior with no flexion. B. Right occipitoposterior with full flexion. C. Left transverse anterior in moderate flexion D. Left sacroanterior with full flexion 27. The physician ordered sonography. The nurse informs the ultrasound unit in charge and prepares the patient for the procedure. The patient asks the importance of the procedure, the nurse's CORRECT response is A. to determine diameters of the fetal skull B. increase sensitivity for common bile duct of the fetus C. useful to a visualized cystic duct of the fetus D. to assess fetus’ well-being 28. The newly hired nurse asks for advice from the supervisor. The supervisor notices that the newly hired nurse felt uneasy upon learning that the fetus is on breech presentation. Which of the following is the BEST RESPONSE by the supervisor? A. "I understand how you feel. Tell me more." B. "Is this your first time to witness a breech presentation" C. "Are you afraid to assist the case" D. "Don't worry. There's always a first time" 29. After the successful vaginal delivery, medication was ordered to be given immediately. The supervisor reassured the newly hired nurse that everything will be fine because the medication will ______. A. promote vasoconstriction of uterine muscles B. hasten uterine contractility and control bleeding C. facilitate the return of pregnancy vital signs 2 | Page
D. promote vasodilation of uterine muscles 30. The newly-hired nurse oriented the caregiver hired by the couple. Which of the following should the nurse encourage the parents to do? A. Relate to each twin individually to enhance the attachment process. B. Avoid assistance from other family members and support groups. C. Bottle-feed the twins to prevent maternal exhaustion. D. Plan for each parent to spend equal amounts of time with each twin. Situation: Phoebe, 23-year-old pregnant woman, 37th week's gestation, is admitted in the intensive care unit due to paroxysmal ventricular tachycardia. The patient is conscious; cervix is open so they decided to induce labor. 31. When the patient was informed about induction, she asks Nurse Lora what it is all about. Which of the following statements by the nurse is correct? Induction is a _______. A. local anesthesia used for blocking pain during episiotomy B. deliberate initiation of uterine contractions that stimulates labor C. medication injected into the subarachnoid space and has a rapid onset of action D. procedure performed by artificial rupture of the membranes 32. Which of the following statements is NOT an indication for any uterine stimulants (Oxytocin)? A. Preinducting cervical ripening B. Controlling postpartum bleeding C. Inducing or augmenting labor D. Manages an incomplete abortion 33. Oxytocin drip was started to induce labor. Which assessment findings should cause the nurse to IMMEDIATELY discontinue the oxytocin infusion? (Select all that apply) I. Fatigue and drowsiness II. Early decelerations of the fetal heart rate. III. Uterine hyperstimulation IV. Late decelerations of the fetal heart rate a. III and IV b. II and III c. I and III d. I and II 34. Simultaneous with the oxytocin drip (left arm) is the prescribed intravenous (IV) lidocaine (Xylocaine). Nurse Lora should dilute the concentrated solution of lidocaine (right arm) with which solution? A. 5 percent Dextrose in water B. Normal saline 0.99 percent C. Normal saline 0.45 percent. D. Lactated Ringer's 35. Take home medications given to Patient Phoebe includes digitalis therapy which was given to the patient since she was pregnant. Which of the following would the nurse anticipate with the patient's drug therapy? A. Switching to a more potent drug. B. Continuation of the same dosage. C. Need for change in medication. D. Addition of diuretic to the regimen. Situation: Jen a unit manager is assigned to evaluate applicants for the position in the OB unit. During the interview, the applicant was asked 5 questions. 36. When a patient is admitted to the OB ward with complaints of dizziness and body weakness, this is an example of ________. A. secondary source B. primary source C. objective data D. subjective data 37. What are the possible cases that need informed consent? A. Administering skin testing B. Subjecting the patient to an invasive procedure C. Hair shampooing of patient D. Performing a laboratory procedure 38. The applicant was further asked about an incident report. Which of the following is a PRIORITY case for an incident report to be accomplished A. Patient fell from the bed. B. Refusal to go to the physical therapy session. C. A visitor encourages a patient on bed rest to ambulate. D. Nurse left before his duty ended. 39. On which occasion would a nurse be charged with negligence? A. Giving the patient the wrong medication. B. Giving competent care. C. Following standards of care. D. Communicating with another health team. 40. What tasks can be delegated to his nursing assistant during his tour of duty. A. Changing wound dressings. B. Administering analgesic drug. C. Performing a physical assessment. D. Taking vital signs. Situation: Jillian, 2-week postpartum mother is seen in the health center. On further assessment, Nurse Ally noted a localized area of redness on the left breast, and the mother is diagnosed with mastitis. 41. Which additional finding confirms the diagnosis that the patient has mastitis? A. Enlarged glands in the axilla B. Normal temperature C. Engorged both breasts D. Hard mass and reddened area 42. Jillian asks the nurse the cause of this ailment. Which of the following would the nurse explain as predisposing factors of mastitis? (Select a that apply) I. Milk stasis II. Nipple trauma III. Using alcohol in cleaning nipples IV. Baby's sitting position A. II and IV B. I and IV C. I and II D. II and III 43. Jillian complains of unbearable pain. Which of the following characteristics are EMPHASIZED in a culturally sensitive nursing care? (Select all that apply) I. The expression of pain is affected by learned behavior. II. Physiologically, all individuals experience pain in a similar manner. III. Some Asian people has high response to pain medications. IV. Patients should be assessed for pain regardless of overt symptomatology. A. III and IV B. I and II C. I and III D. II and III 44. Nurse Ally provides instructions about measures to prevent postpartum mastitis who is breast feeding her newborn. Which of the following would indicate that the mother needs further instruction? "I should____.” A. wash my hands well before breastfeeding B. breastfeed every 2 3 hours C. change the breast pads frequently D. wash my nipples with soap and water prior to feeding 45. Considering her level of knowledge and the anxiety of her condition, Patient Jillian raised questions on possible ways of relieving her breast discomfort. Which of the statements NEEDS further instructions? A. "I have to stop breastfeeding until this condition resolves." B. "I can take antibiotics, and should begin to feel better in 24 to 48 hours." C. "I can use analgesics to assist in alleviating some of these discomforts." D. "I have to wear a supportive bra to relieve the discomfort." Situation: Lena a Christian 29-year-old pregnant woman was admitted to the hospital with a complaint of moderate hypogastric pain. She intends to visit the clinic for her first prenatal check-up and informs Nurse Sandy that she did not 3 | Page
realize she's pregnant until a week ago. As a result, she has been on a diet, weightlifting at the health gym. 46. Patient Lena was seen by the physician and was ordered for a medication that is larger than the standard dose. What should the nurse do? A. Give the drug as prescribed. B. Inform the supervisor. C. Give the average dose of the medication. D. Discuss the prescription with the physician. 47. The patient refuses to take the medication because it causes diarrhea. Nurse Sandy explains the action of the drug but the patient vehemently refuses the medication. What should be the INITIAL action of the nurse? A. Discuss with a family member the need for the patient to take the medication. B. Document the patient's refusal to take the medication. C. Notify the physician of the patient's refusal to take the medication. D. Explain again to the patient the consequences of refusing to take the medication. 48. As a strong believer of her faith and the need for spiritual guidance, patient Lena requests that she wants clergy to visit her. How did nurse Parker function when she initiated the visit? A. Dependently B. Collegially C. Interdependently D. Independently 49. Patient Lena sought referral to an abortion clinic from the nurse. She reasons out that her pregnancy is a burden to her work and daily routines. What should be the BEST RESPONSE of the nurse? A. It will cause discrimination from friends and relatives. B. Inform her that abortion is morally and legally wrong by virtue of the law. C. It will cause infection. D. It is against any religion. 50. The incoming nurse on duty reported, the nurse is administering medication, and the patient says, "This pill looks different from the one I had taken before." What is the APPROPRIATE action of the nurse? A. Explain the purpose of the medication. B. Encourage the patient to take the medication. C. Check the original medication prescription. D. Ask what the other pill looked like. Situation: The indication of tracheostomy in children has changed substantially in the last two decades. Nurse Len is taking care of Patient Inna, an eight year old female child, who was admitted to the Pediatric Ward due to pneumonia. The child is hooked to a tracheostomy tube. Nurse Len is quite anxious in taking care of this patient being her first day of duty in the Pediatric Ward. 51. When preparing the patient for suctioning, what is the FIRST step? A. Perform hand hygiene B. Gather equipment C. Assess lung sounds, heart rate and rhythm D. Check physician's order and patient care plan 52. Patient Inna will be placed in which of the following positions? Select all that apply. 1. Fowler 2. Semi-Fowler 3. Supine 4. Sim A. 1, 2 & 3 B. 2 only C. 1 & 2 D. 1 only 53. Usually the common indication (s) for the tracheostomy in Patient Inna's condition is which of the following? (Select all that apply.) 1. Prolonged intubation. 2. Sepsis 3. Hypoventilation associated with neurologic disorders. 4. Severe Sleep Obstructive Apnea Syndrome (SOAS) A. 2 only B. 1 & 2 C. 1, 2, 3 & 4 D. 1 only. 54. The PRIORITY nursing objective when caring for a patient with a tracheostomy is ______. A. To increase tissue oxygenation B. To provide patent airway C. To decrease tissue oxygenation D. To improve ventilation 55. The TOP nursing expected outcome when performing suctioning is ______. A. Lessened amount of secretions leading to decreased frequency of suctioning. B. Secretions removed without complication. C. Tube-fed patient does not aspirate feeding. D. Prevention of occurrence of hypoxemia and bradycardia. Situation: Nurse Jyca is assigned to the Nursery. She is performing newborn assessment on Baby Boy Patt born at 40 weeks gestation. 56. Using APCAR Score, Nurse Jyca should bear in mind that this method of evaluating a newborn's condition is used at how many minutes after birth? A. 1 to 10 B. 1 to 3 C. 1 to 7 D. 1 to 5 57. Nurse Jyca is aware that testing of vision in infants and children has been treated separately from the testing of adults. Which of the statements is NOT true? A. Infants and children often cannot be tested with the same materials and techniques as adults. B. Special techniques often must be used, especially to test infants and preschoolers, that cannot be held to the same standards that apply to tests for adults C. Some infants who appear visually impaired early in life will not show normal visual responses several weeks or months later. D. Course of visual and cognitive development must be taken into account in evaluating infants and children's visual abilities 58. The false statement about physiologic jaundice in the statements below is A. Caused by impairment in the removal of bilirubin deficiency in the production of glucoronide transferase. B. Begins to decrease by the 6th or 7th day. C. Is visible in skin and sclera. D. Begins after 48 hours of life. 59. Neonatal jaundice FIRST becomes visible in which of the following parts? (Select all that apply.) 1. Face 2. Forehead 3. Trunk 4. Extremities A. 3 & 4 B. 1 & 2 C. 1 & 4 D. 2 & 3 60. When caring for patients with hyperbilirubinemia, the nursing care plan should focus on the following, EXCEPT ____. A. informing appropriately the significant others. B. preventing injury C. maintaining physiological homeostasis with bilirubin levels increasing D. preventing complications. Situation: The senior nurse Rem, is planning to revisit and implement a change in the management system for the Obstetric Unit. This would be a pilot unit as planned by the administration. Many problems have occurred, one of which is the present documentation system, and the charge nurse determines that a change is required. 61. What should be the INITIAL STEP in the process of change for the senior nurse. A. Set goals and priorities regarding the change process. B. Plan strategies to implement the change. C. Identify potential solutions and strategies for the change. D. Identify the inefficiency that needs improvement or correction. 4 | Page