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RECALLS EXAMINATION 12 NURSING PRACTICE III CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS (PART A) 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 III” on the box provided 1. The nurse is caring for a client who had a thyroidectomy 12 hours ago for treatment of Graves’ disease. The nurse would be MOST concerned if which of the following was observed? A. The client’s blood pressure is 138/82, pulse 84, respirations 16, oral temp 99° F (37.2° C). B. The client supports his head and neck when turning his head to the right. C. The client spontaneously flexes his wrist when the blood pressure is obtained. D. The client is drowsy and reports a sore throat. 2. The nurse prepares a client for peritoneal dialysis. Which of the following actions should the nurse take FIRST? A. Assess for a bruit and a thrill. B. Warm the dialysate solution. C. Position the client on the left side. D. Insert a Foley catheter. 3. While caring for a client receiving total parenteral nutrition (TPN) through a central line, the nurse notices a small trickle of opaque fluid leaking from around the central line dressing. It is MOST important for the nurse to take which of the following actions? A. Prepare to change the central line dressing. B. Verify that the client is on antibiotics. C. Place the client’s head lower than his feet. D. Secure the Y-port where the lipids are infusing. 4. The nurse is caring for clients on the pediatric unit. An 8-year-old client with second- and thirddegree burns on the right thigh is being admitted. The nurse should assign the new client to which of the following roommates? A. A 2-year-old with chickenpox B. A 4-year-old with asthma C. A 9-year-old with acute diarrhea D. A 10-year-old with methicillin-resistant Staphylococcus aureus (MRSA) 5. The nurse is teaching a client who is scheduled for a paracentesis. Which of the following statements by the client to the nurse indicates that teaching has been successful? A. “I will be in surgery for less than an hour.” B. “I must not void prior to the procedure.” C. “The physician will remove 2 to 3 liters of fluid.” D. “I will lie on my back and breathe slowly.” 6. The nurse is performing discharge teaching for a client with chronic pancreatitis. Which of the following statements by the client to the nurse indicates that further teaching is necessary? A. “I do not have to restrict my physical activity.” B. “I should take pancrelipase before meals.” C. “I will eat 3 meals per day.” D. “I am not allowed to drink any alcoholic beverages.” 7. An arterial blood gas is ordered for a man after a myocardial infarction. After obtaining the specimen, it would be MOST appropriate for the nurse to take which of the following actions? A. Obtain ice for the specimen. B. Apply direct pressure to the site. C. Apply a sterile dressing to the site. D. Observe the site for hematoma formation. 8. A client is seen in the outpatient clinic to rule out acute renal failure. The nurse would be MOST concerned if the client made which of the following statements? A. “My urine is often pink-tinged.” B. “It is hard for me to start the flow of urine.” C. “It is quite painful for me to urinate.” D. “I urinate in the morning and again before dinner.” 9. The nurse is inserting an IV catheter into a client’s left arm. Suddenly the client exclaims, “It feels like an electric shock is going all the way down my arm and into my hand!” What is the FIRST action the nurse should take? A. Instruct the client to take slow, deep breaths. B. Remove the needle from the client’s arm. C. Tell the client this is a common response to IV insertion. D. Withdraw the needle slightly and then push it forward. 10. A client is preparing to take her 1-day-old infant home from the hospital. The nurse discusses the test for phenylketonuria (PKU) with the mother. The nurse’s teaching should be based on an understanding that the test is MOST reliable after which of the following? A. A source of protein has been ingested. B. The meconium has been excreted. C. The danger of hyperbilirubinemia has passed. D. The effects of delivery have subsided. 11. A 6-week-old infant is brought to the hospital for treatment of pyloric stenosis. The nurse enters the following nursing diagnosis on the infant’s care plan: “fluid volume deficit related to vomiting.” Which of the following assessments supports this diagnosis? A. The infant eagerly accepts feedings. B. The infant vomited once since admission. C. The infant’s skin is warm and moist. D. The infant’s anterior fontanel is depressed. 12. The nurse cares for a client admitted for a possible herniated intervertebral disk. Ibuprofen, propoxyphene hydrochloride, and cyclobenzaprine hydrochloride are ordered PRN. Several hours after admission, the client reports pain. Which of the following actions should the nurse do FIRST? A. Administer ibuprofen. B. Call the physician to determine which medication should be given. C. Gather more information from the client about the complaint. D. Allow the client some time to rest and see if the pain subsides. 13. A client has a vagotomy with antrectomy to treat a duodenal ulcer. Postoperatively, the client develops dumping syndrome. Which of the following statements by the client indicates to the nurse that further dietary teaching is necessary? A. “I should eat bread with each meal.” B. “I should eat smaller meals more frequently.” C. “I should lie down after eating.” D. “I should avoid drinking fluids with my meals.” 1 | Page
14. A man is admitted to the hospital with a diagnosis of acquired immunodeficiency syndrome (AIDS). He is being treated for Pneumocystis jiroveci pneumonia. The nurse evaluates the care provided to this client by other members of the health care team. The nurse should intervene in which of the following situations? A. A housekeeper cleans up spilled blood with a bleach solution. B. A nursing student takes his blood pressure wearing a mask and gloves. C. A technician wears gloves to perform a veinipuncture. D. A nurse attendant allows visitors to enter his room without masks. 15. A 69-year-old female client admitted with pneumonia is receiving gentamicin. For this client, which of the following laboratory values would be MOST important for the nurse to monitor? A. BUN and creatinine B. Hemoglobin and hematocrit C. Sodium and potassium D. Platelet count and clotting time 16. The nurse is preparing a client newly diagnosed with Addison’s disease for discharge. Which of the following statements by the client indicates a need for further instruction from the nurse? A. “I understand that I will need lifelong cortisone replacement therapy.” B. “During times of stress, I will need to decrease my medication.” C. “I must be careful not to injure myself.” D. “I should always carry a medical identification card.” 17. The nurse suspects a client has meningitis. The nurse places the client in a dorsal recumbent position, puts her hands behind the client’s neck, and bends it forward. The nurse knows that pain and resistance may indicate neck injury or arthritis, but if the client also flexes the hips and knees, this positive response is which of the following? A. Trousseau’s sign B. Brudzinki’s sign C. Homans’ sign D. Chvostek’s sign 18. The nurse is preparing a client for surgery. When obtaining informed consent, the nurse should INITIALLY do which of the following? A. Explain the risks, benefits, and alternatives of the procedure. B. Tell the client that obtaining the signature is routine for all surgeries. C. Witness the client’s signature. D. Assess whether the client’s understanding of the procedure is sufficient to give consent. 19. The nurse is caring for a client receiving intravenous therapy through a peripherally inserted central catheter (PICC). Which of the following actions implemented by the nurse will decrease the risk of infection? A. Assess vital signs every 4 hours. B. Ask the physician for an order for antibiotics. C. Maintain sterile technique during all phases of PICC care. D. Administer acetaminophen (Tylenol) before dressing changes. 20. The nurse is doing a follow-up telephone call with a new mother regarding her newborn. The mother states the baby’s eyes look yellow. Which of the following is the MOST appropriate response by the nurse? A. “How often are you nursing your baby?” B. “Are you breastfeeding or bottle feeding?” C. “Do you know what your baby’s bilirubin level was before discharge?” D. “Has your baby been seen by the pediatrician?” 21. The nurse is educating a client with a history of hyponatremia on diet choices. Which of the following statements by the client BEST indicates the teaching was successful? A. “I should maintain a low-sodium diet.” B. “I can drink as much beer as I want to.” C. “I should avoid caffeine.” D. “I should drink a lot of water.” 22. The nurse receives a telephone call from the hospital admission office and is told that a client with human immunodeficiency virus (HIV) will be admitted to the nursing unit. In planning infection control measures for the client, which is the best type of isolation precaution that the nurse should prepare? A. Droplet precautions B. Contact precautions C. Standard precautions D. Airborne precaution 23. The client has a platelet count of 60,000 mm3 (60×10 9/L). The nurse should implement which measure in the care of this client? A. Using a razor for shaving the client B. Providing vigorous skin care and avoiding the use of lotions C. Measuring the temperature using a temporal thermometer D. Encouraging the client to use a firm-bristle toothbrush for mouth care 24. A client is tested for human immunodeficiency virus (HIV) with an enzyme-linked immunosorbent assay (ELISA) test, and the test result is positive. The client is very upset and asks the nurse if this means that he definitely has HIV. How should the nurse respond to the client? A. “Yes, you definitely have HIV.” B. “Another test will be done to determine if you have HIV.” C. “False-positive results are reported all of the time and you should not be worried.” D. “A positive test means that the infection was diagnosed early in the initial infection period.” 25. A client with a family history of cervical cancer has made an appointment to have a Papanicolaou test (smear) done. The nurse who schedules the appointment should make which statement to the client? A. “Sexual intercourse should be avoided for 24 hours before the test.” B. “If you are menstruating, douching will be required right before the test.” C. “A vaginal hygiene spray should be used for 2 consecutive days before the scheduled test.” D. “The test is very uncomfortable, but a local anesthetic will be injected into the vaginal area.” 26. A client has undergone cardiac catheterization using the right femoral artery for access. The nurse determines that the client is experiencing a complication of the procedure if which finding is noted? A. Urine output 40 mL/hour B. Blood pressure 118/76 mm Hg C. Pallor and coolness of the right leg D. Respirations 18 breaths per minute 27. A client has been admitted to the hospital with a fractured pelvis sustained in a motor vehicle crash. The nurse monitors for complications and should assess the client closely for which finding in the early post trauma period? A. Pain B. Fever C. Hematuria D. Bradycardia 28. The nurse is monitoring a client who is receiving magnesium sulfate for preeclampsia and is monitoring the client every 30 minutes. Which finding indicates a need to immediately contact the primary health care provider? A. Urinary output of 20 mL B. Deep tendon reflexes of 2+ C. Respirations of 10 breaths/minute D. Fetal heart rate (FHR) of 116 beats/minute 29. The nurse receives a report at the beginning of the shift about a client with an intrauterine fetal demise. When collecting data on assessment of the client, the nurse expects to note which finding? A. Intractable vomiting and dehydration B. Elevated blood pressure and proteinuria C. Uterine size greater than expected for gestational age D. Regression of pregnancy symptoms and absence of fetal heart tones 2 | Page
30. A pregnant client with a suspected diagnosis of placenta previa arrives at the health care clinic for an examination. The nurse prepares the client for the examination and tells the client that which procedure will be deferred until the diagnosis is confirmed? A. Abdominal ultrasound B. Vital sign measurement C. Urine testing for glucose D. Vaginal speculum examination 31. A postoperative client has a prescription to begin short-term therapy with enoxaparin. The nurse should explain to the client that this medication is being prescribed for which therapeutic action? A. Prevent pain B. Relieve back spasms C. Increase energy levels D. Reduce the risk of deep vein thrombosis 32. A client is being admitted to the neurological unit from the emergency department with a diagnosis of a cervical (C4) spinal cord injury. Which data should the nurse collect first when admitting the client to the nursing unit? A. Listen to breath sounds. B. Check peripheral pulses. C. Check for muscle flaccidity. D. Determine extremity muscle strength. 33. An antepartum client at 32 weeks’ gestation positioned herself supine on the examination table to await the obstetrician. The nurse enters the examination room, and the client says, “I’m feeling a little lightheaded and sick to my stomach.” The nurse recognizes that the client may be experiencing vena cava syndrome (hypotensive syndrome) and should take which immediate action? A. Give the client an emesis basin. B. Place a cool cloth on the client’s forehead. C. Call the obstetrician to see the client immediately. D. Place a folded towel or sheet under the client’s right hip 34. The nurse is caring for a client with an injury to the brainstem. The nurse should monitor which parameter as the priority? A. Urine output B. Electrolyte results C. Peripheral vascular status D. Respiratory rate and rhythm 35. A client has been newly diagnosed with diabetes mellitus. The nurse should perform which action as the first step in teaching the client about the disorder? A. Decide on the teaching approach. B. Plan for the evaluation of the session. C. Gather all available resource materials. D. Identify the client’s knowledge and needs. 36. The nurse is observing an unlicensed assistive personnel (UAP) measuring the blood pressure (BP) of a client. The nurse should intervene if which action was observed that would interfere with accurate measurement of the BP? A. Positions the client’s arm at heart level B. Exposes the extremity fully by removing constricting clothing C. Explains the procedure to the client and asks the client to rest for 5 minutes D. Palpates the carotid artery and then places the cuff of the sphygmomanometer 1 inch (2.5 cm) above the brachial artery 37. The nurse tells an unlicensed assistive personnel (UAP) that a client recovering from a myocardial infarction requires a complete bed bath. During the bath, the nurse should intervene if the nurse observed the UAP performing which action? A. Washing the client’s chest B. Giving the client a back rub C. Asking the client to wash his legs D. Washing the client’s perineal area 38. A client has undergone a laparoscopic cholecystectomy. Which of the following instructions should the nurse include in the discharge teaching? A. Empty the bile bag daily. B. If you become nauseated, breathe deeply into a paper bag. C. Keep adhesive dressings in place for 6 weeks. D. Report bile-colored drainage from any incision. 39. A client with acute pancreatitis has a blood pressure of 88/40, heart rate of 128 beats per minute, respirations of 28 per minute, and Grey Turner’s sign. Which appropriate action should the nurse perform? A. Assess the urine output. B. Place an intravenous line. C. Position on the left side. D. Insert a nasogastric tube. 40. After a bronchoscopy with biopsy, the nurse assesses the client. Which of the following signs should be reported immediately to the physician? A. Green sputum. B. Dry cough. C. Hemoptysis. D. Laryngeal stridor 41. A client is admitted to the emergency department with crushing chest injuries sustained in a car accident. Which of the following signs indicates a possible pneumothorax? A. Cheyne-Stokes respirations. B. Increased fremitus. C. Diminished or absent breath sounds on the affected side. D. Decreased sensation on the affected side 42. A client is taking phenytoin (Dilantin) as an antiepileptic medication. The nurse should instruct the client to obtain: A. Increased iron. B. Increased calcium. C. Frequent dental examinations. D. Frequent eye examinations. 43. Before an incisional cholecystectomy is performed, the nurse instructs the client in the correct use of an incentive spirometer. Why is incentive spirometry essential after surgery in the upper abdominal area? A. The client will be maintained on bed rest for several days. B. Ambulation is restricted by the presence of drainage tubes. C. The operative incision is near the diaphragm. D. The presence of a nasogastric tube inhibits deep breathing. 44. After vaginal delivery of a term neonate, the nurse determines that the placenta is about to separate when which of the following occurs? A. The uterus becomes oval shaped. B. The uterus enlarges. C. A sudden gush of dark blood occurs. D. The client expends efforts pushing. 45. Which of the following should be considered the highest priority during the fi rst 24 hours postoperatively for the client who had a total laryngectomy due to cancer of the larynx? A. Provide adequate nourishment. B. Prevent skin breakdown. C. Maintain proper bowel elimination. D. Maintain a patent airway. 46. In preparing for insertion of a peripheral I.V. catheter, the nurse must select an appropriate site. Which of the following areas should the nurse try fi rst if an appropriate vein is found? A. Back of the hand. B. Inner aspect of the elbow. C. Inner aspect of the forearm. D. Outer aspect of the forearm. 47. The nurse is assessing a client who has benign prostatic hypertrophy (BPH). The nurse should ask the client if he has: A. Impotence. B. Flank pain. C. Difficulty starting the urinary stream. D. Hematuria 48. While caring for several preterm infants in the special care nursery, which of the following actions is most important for preventing nosocomial infections in these neonates? A. Using sterile supplies for all treatments. B. Performing thorough handwashing before giving infant care. C. Donning cover gowns for nurses and visitors to the unit. D. Wearing a mask, and changing it frequently when giving care. 3 | Page
49. As part of the treatment plan, a client is prescribed steroids to treat ulcerative colitis. The nurse should assess the client for which of the following common complications related to steroid therapy? A. Peptic ulcer. B. Hypoglycemia. C. Tachycardia. D. Renal failure 50. A client’s abdominal incision eviscerates. The nurse should: A. Take the client’s vital signs and call the physician. B. Lower the client’s head and elevate the feet. C. Cover the incision with a dressing moistened with sterile normal saline solution. D. Start an emergency infusion of I.V. fluids. 51. While a client with myxedema is being admitted to the hospital, the client reports having experienced a lack of energy, cold intolerance, and puffiness around the eyes and face. The nurse plans care knowing that these clinical manifestations are caused by a lack of production of which hormones? A. Luteinizing hormone (LH) B. Adrenocorticotropic hormone (ACTH) C. Triiodothyronine (T3) and thyroxine (T4) D. Prolactin (PRL) and growth hormone (GH) 52. The nurse is admitting a client with a diagnosis of hypothyroidism to the hospital. What action should the nurse perform to obtain data related to this diagnosis? A. Inspect facial features B. Auscultate lung sounds C. Percuss the thyroid gland D. Assess the client’s ability to ambulate 53. A client is diagnosed with hypothyroidism. The nurse performs an assessment on the client, expecting to note which findings? Select all that apply. 1. Weight loss 2. Bradycardia 3. Hypotension 4. Dry, scaly skin 5. Heat intolerance 6. Decreased body temperature A. All of the Above B. 2346 C. All except 6 D. 1256 54. The nurse is monitoring a client who is receiving a blood transfusion when the client complains of diaphoresis, warmth, and a backache. The nurse suspects a transfusion reaction and should take which actions? Select all that apply. 1. Remove the IV catheter. 2. Document the occurrence. 3. Stop the blood transfusion. 4. Contact the health care provider. 5. Hang 0.9% sodium chloride solution. A. All of the above B. 2345 C. 1245 D. 145 55. The nurse is caring for a client who is receiving blood transfusion therapy. Which clinical manifestations should alert the nurse to a hemolytic transfusion reaction? Select all that apply. 1. Headache 2. Tachycardia 3. Hypertension 4. Apprehension 5. Distended neck veins 6. A sense of impending doom A. 1256 B. 1236 C. 1246 D. All of the Above 56. The nurse checks the gauge of the client’s intravenous catheter. Which is the smallest gauge catheter that the nurse can use to administer blood? A. 12-Gauge B. 20-Gauge C. 22-Gauge D. 24-Gauge 57. What is the purpose of the nurse administering diphenhydramine (Benadryl) before a blood transfusion? A. To prevent urticaria B. To prevent hypertension C. To enhance clotting factors D. To expand the blood volume 58. The nurse has an established relationship with the family of a client whose death is imminent. Which intervention should the nurse focus on in order to help the family most effectively cope with this experience? A. Limiting time in the client’s room to promote privacy B. Providing education regarding coping mechanisms to use C. Identifying spiritual measures that work best for dying clients D. Answering questions clearly and providing resources as requested 59. The nurse is caring for a client with a terminal condition who is dying. Which respiratory assessment findings should indicate to the nurse that death is imminent? Select all that apply. 1. Dyspnea 2. Cyanosis 3. Irregular respiratory pattern 4. Adventitious bubbling lung sounds A. 1 AND 2 B. 1 AND 3 C. 12 AND 4 D. ALL OF THE ABOVE 60. A coronary care unit (CCU) nurse is caring for a client admitted with acute myocardial infarction (MI). The nurse should monitor the client for which most common complication of MI? A. Heart failure B. Cardiogenic shock C. Cardiac dysrhythmias D. Recurrent myocardial infarction 61. The nurse is caring for a client with heart failure who has a magnesium level of 0.75 mg/dL. Which action should the nurse take? A. Monitor the client for irregular heart rhythms. B. Encourage the intake of antacids with phosphate. C. Teach the client to avoid foods high in magnesium. D. Provide a diet of ground beef, eggs, and chicken breast. 62. A client who is being treated for acute heart failure has the following vital signs: blood pressure (BP), 85/50 mm Hg; pulse, 96 beats per minute; respirations, 26 breaths per minute. The health care provider prescribes digoxin (Lanoxin). To evaluate a therapeutic response to this medication, which changes in the client’s vital signs should the nurse expect? A. BP 85/50 mm Hg, pulse 60 beats per minute, respirations 26 breaths per minute B. BP 98/60 mm Hg, pulse 80 beats per minute, respirations 24 breaths per minute C. BP 130/70 mm Hg, pulse 104 beats per minute, respirations 20 breaths per minute D. BP 110/40 mm Hg, pulse 110 beats per minute, respirations 20 breaths per minute 63. The nurse reviews the electrolyte values of a client with heart failure, notes that the potassium level is low, and notifies the health care provider. The health care provider prescribes a dose of intravenous (IV) potassium chloride. When administering the IV potassium chloride, which action should the nurse take? A. Inject it as a bolus. B. Use a filter in the IV line. C. Dilute it per medication instructions. D. Apply cool compresses to the IV site during administration. 64. The nurse is assessing the client with left sided heart failure. The client states that he needs to use three pillows under the head and upper torso at night to be able to breathe comfortably while sleeping. The nurse documents that the client is experiencing which clinical finding? A. Orthopnea B. Dyspnea at rest C. Dyspnea on exertion D. Paroxysmal nocturnal dyspnea 65. A client with heart failure was experiencing difficulty breathing and increased pulmonary congestion. The health 4 | Page