Medical
A patient is being admitted to the medical unit and has orders for fluid restriction of 1400 ml/24 hours. He is receiving IV medications in 50 ml QID solutions. How much fluid should the caring nurse allocate for the patient's intake in 24 hours?
A. 400 ml
B. 800 ml
C. 1000 ml
D. 1200 ml
D
1475. A 77-year-old man was diagnosed with a right renal tumor, size 3.5 cm. He underwent a radical right nephrectomy. Which of the following patient operative cares is of high priority?
A. Take body temperature
B. Measure hourly urine output
C. Provide sips of clear liquid
D. Turn client from side to side
B
pregnant client is making her first antepartum visit. She has a two-year-old son born at 40 weeks, a five-year-old daughter born at 38 weeks, and seven-year-old twin daughters born at 35 weeks. She had a spontaneous abortion three years ago at 10 weeks. Using the GTPAL format, the nurse should identify that the client is:
A. G4 T3 P2 A1 L4
B. G5 T2 P2 A1 L4
C. G5 T2 P1 A1 L4
D. G4 T3 P1 A1 L4
C
A newborn is delivered by the midwife. The umbilical cord is cut safely by following necessary aseptic techniques. The newborn is to be taken. Which of the following intervention is the most desired?
A. Assess sucking response
B.Increase mother-child bonding
C. Assess and record APGAR score
D. Keep dry and maintain thermoregulation
D
A head nurse of an intensive care unit wrote
a report about the needs of her department and gave it to the nursing supervisor. Which of the following types of communication is this?
A. Upward
B. Horizontal
C. Diagonal
D. Downward
A
A nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are wavy lines. The QRS complexes measure 0.08 seconds, but they are irregular, with a rate of 120 beats a minute. The nurse interprets this rhythm as:
A. Sinus tachycardia
B. Atrial fibrillation
C. Ventricular tachycardia
D. Ventricular fibrillation
B
Which of the following patient care plan is the most appropriate for a 37-year-old post-appendectomy woman who is at risk of pneumonia?
A. Restrict fluid intake
B. Teach how to use a spirometer
C. Encourage ambulation as tolerated
D. Avoid coughing and deep breathing
C
A woman’s last menstrual period (LMP) started on 20 August 2024.What is the expected date of delivery (EDD)?
A. 20 May 2025
B. 27 May 2025
C. 30 May 2025
D. 3 June 2025
B
A 23-year-old pregnant woman, 4 months of age or older, is presented to the antenatal clinic. The health educator educates a group of mothers in the waiting area. Which information regarding fetal circulation should the educator stress on?
A. One umbilical artery and one umbilical vein
B. One umbilical artery and two umbilical veins
C. Two umbilical arteries and one umbilical vein
D. Two umbilical arteries and two umbilical veins
C
A post-operative patient who underwent an abdominal procedure requests pain medication from the nurse and rates the pain at a level nine. There is a standing order for narcotic administration. When the nurse operates the narcotic box and performs a count, the number of pills remaining in the box is different from the number of pills recorded on the sheet. What is the most appropriate initial nursing action?
A. Notify the nursing supervisor
B. Write the finding on the narcotic sheet
C. Administer the patient's requested medication
D. Identify the last nurse who used the narcotic box
A
WA 68-year-old woman diagnosed with thrombocytopenia due to acute lymphocytic leukemia is admitted to the hospital. The nurse should assign the patient to a:
A. To a private room so she will not infect other patients and healthcare workers.
B. To a private room so she will not be infected by other patients and healthcare workers
C. To a semi-private room so she will have stimulation during her hospitalization.
D. To a semi-private room so she will have the opportunity to express her feelings about her illness
B
A nurse is planning post-operative teaching for a patient who underwent left partial mastectomy. On the third post-operative day, the nurse teaches the patient to elevate their arm above the heart several times per day. What does this exercise reduce?
A. Pain
B. Infection
C. Hematoma
D. Lymphedema
D
multiparous woman is admitted to the postpartum ward after vaginal delivery. Assessment showed lochia: steady trickle of bright red blood and indus: firm.Blood pressure: 110/70 mmHg, Heart rate: 80/min, Respiratory rate: 20/min, Temperature: 37.5, Which of the following is the most likely diagnosis?
A. Endometritis
B. Uterine atony
C. Vulvar hematoma
D. Laceration of the genital tract
D
A nurse is caring for a newborn in Well Born Nursery. She wraps the baby with a blanket and ensures the nursery temperature is suitable for the babies. What type of heat loss is the nurse preventing?
A. Radiation
B. Conduction
C. Convention
D. Evaporation
C
A surgeon instructs a nurse to serve as a witness to an elderly patient's informed consent for surgery. During the explanations to the patient, it becomes clear that the patient is confused and does not understand the procedure, but reluctantly signs the consent form. The nurse should:
A. Sign the form as a witness, making it clear that the patient did not appear to understand.
B. Not sign the form as a witness and notify the nurse supervisor.
C. Not sign the form and answer the patient's questions after the surgeon leaves the room.
B
A 62-year-old man presents to the clinic with complaints of hearing loss in the left ear. The hearing loss has been progressive over the past year. The ear is semi-transparent, a pale gray color, and clear of cerumen. A Weber test is performed, and the sound is lateralized to the right ear. Which type of hearing loss is suspected?
A. Left- sided conductive
B. Right-sided conductive
C. Left-sided sensorineural
D. Right-sided sensorineural
C
A nurse provides care for a client who is 5 days post-gastrectomy. The provider prescribes total parenteral nutrition (TPN). Which statement by the nurse to an orienting nurse explains the client's need for TPN?
A. TPN is used for clients who are at increased risk for aspiration due to swallowing inability.
B. TPN is for clients who are unable to receive nutrients by mouth for an extended period of time.
C. TPN is the usual method of providing nutrition to clients after major abdominal surgery.
D. TPN is a temporary solution and can be used for the first 24 hours after surgery.
B
mother of nine children, three of whom have congenital anomalies and one with Down syndrome, is a primary school graduate with low financial status and does not use any method of family planning. According to the primary health nurse, she has been referred for counseling. Which of the following is a model concerned with disability as a result of social injustice due to stigma or discrimination?
A. Health belief
B. Biomedical
C. Sociopolitical
D. Economic
C
If a full-term infant weighs 3 kg at birth, approximately should the infant's weight be at 12 months old?
A. 7 kg
B. 9 kg
C. 11 kg
D. 13 kg
B
The nursing director wants to evaluate the quality of nursing care in the inpatient areas. The management team will evaluate, quarterly, the documentation and the relationship between the patient's length of stay and the quality of care. Which of the following is the most important data source to identify the quality of care?
A. Patient's complaints and time taken to resolve them.
B. Patient's satisfaction level at the time of discharge.
C. Details of nursing notes for patient's progress
B
A 63-year-old man is admitted to the emergency department with complaints of severe chest pain. The apical pulse is the most appropriate site to obtain the accurate heartbeat. Where should the nurse place the stethoscope to obtain the apical pulse?
A. In the middle of the chest between the nipples
B. Over the apex of the heart between the 4th and 5th ribs
C. Between the 5th and 6th ribs slightly above the nipples
D. Between the 5th and 6th ribs, the midclavicle line below the nipple
D
A surgical unit nurse assessed a 35-year-old post-appendectomy patient who observed abdominal distention with absent bowel sounds. Which of the following interventions is most appropriate?
A. Encourage ambulation
B. Provide liquid diet as tolerated
C. Ensure patency of nasogastric tube
D. Check surgical site for signs of infection
C
During vaginal examination, did the nurse palpat the posterior fontanel to be at the right side and upper quadrant of the maternal pelvis?
A. ROP
B. LOP.
C. ROA
D. LOA
C
478. An infant with developmental dysplasia of the hip is being discharged with a Pavlik harness. Which of the following instructions should the nurse give to the infant's parents?
A. Put the baby's diaper over the harness
B. Fasten the straps for at least 2 hours every day
C. Press both legs together before applying the harness
D. Soft, thin clothing should be worn under the harness
D
A nurse accidentally dropped a medication ampoule, informed the charge nurse, and completed an incident report form. The charge nurse arranged for medication replacement.
Which of the following is the immediateك nursing action required?
A. Revise protocol for medication-related incidents
B. Allocate senior nurses to medication assignments
C. Provide missed medication dosage to patient first
D. Incident reporting must be given priority
C