COLLEGE OF THE IMMACULATE CONCEPTION

REVIEW EDUCATION AND COMPREHENSIVE APPRAISAL PROGRAM

SPECIAL ENHANCER DRILLS
Prepared by Prof. Jeremiah S. Erpelo, RN

1. The nondirective interview is best for:

A. Obtaining specific information quickly C. Enabling the nurse to control the interview
B. Building rapport with the client D. Limiting discussion
2. Which of the following statements or questions would be most likely to quickly elicit specific information?
A. “Where does it hurt?” C. “How are you today?”
B. “Describe what you are feeling.” D. “What would you like to talk about?”
3. Which of the following bests applies to the description “normal fragile, intact skin of a newborn infant?” It poses a(n):
A. Actual health problem C. Collaborative health problem
B. Wellness diagnosis D. Possible nursing diagnosis
4. Which of the following diagnoses is stated as a potential health problem?
A. Risk for injury B. Anxiety C. Sleep-pattern disturbance D. Ineffective individual coping
5. “The client will probably develop pneumonia if certain independent nursing actions are not carried out.” This constitutes a(n) _____________ nursing diagnosis.
A. Actual B. Risk C. Possible D. Wellness
6. After the assessment of a client, the nurse writes the diagnosis “ineffective breathing pattern”. What type of nursing diagnosis is this?
A. Actual B. Risk C. Wellness D. Syndrome
7. The nurse identifies a syndrome diagnosis for a client. The reason for this nurse’s decision might be that:
A. Evidence about the client’s health problem might be unclear C. The client is in transition from one level of wellness to another
B. There are cluster of other diagnoses that form the syndrome diagnosis D. A problem does not exist
8. Which of the following is a correctly written desired outcome?
A. The client will be adequately hydrated by May 6 C. The nurse will provide emotional support at least 3 times each day
B. The client will lose 5 pounds within the next 2 weeks D. The client will walk better after resting for 10 minutes
9. Which of these is a specific, measurable desired outcome?
A. Has daily bowel movement beginning on 10/21 C. Regains optimum state of health by 10/21
B. Understandable diabetic diet by dismissal D. Achieve good post-op recovery by day 3.
10. Goals can be derived from both problem and etiology of a nursing diagnosis; however, at least one goal must be derived from the:
A. Client problem B. Etiology C. Defining characteristics D. Risk factors
11. The broad goal for a client is to maintain a normal blood sugar level. Which of the following is a correctly written desired outcome?
A. The client will have adequate urinary output during the shift
B. The client will have no alteration in skin integrity during hospitalization
C. The client will have, at each ac and hs check, a blood glucose reading of 80-120
D. The client will have no decrease in peripheral circulation by discharge
12. What is the primary disadvantage of using preprinted, standardized care plans, standards of care, and protocols?
A. Standards of care do not provide enough detail for the nurse
B. Standardized care plans are too time-consuming to use on a busy unit
C. Nurses who follow a standardized agency plan are not likely to achieve acceptable standards of care
D. The nurse may overlook unique client needs that are not addressed by plans
13. The nurse makes the following entry in the client’s record: “Goal not met; client refuses to breastfeed due to dry, cracked nipples.” Since the goal has not been
met, the nurse should:
A. Reassign the client to another nurse C. Notify the physician
B. Reexamine the nursing orders D. Writing a new nursing diagnosis
14. After the assessment of a client, the nurse reviews the information and realizes that some of the information needs validation. Which of the following would need
validation?
A. Client’s weight C. Client’s urine is cloudy
B. Client’s complaint of abdominal pain D. Client’s fasting blood glucose level is 90
15. Which of the following critical-thinking activities are conducted during the assessment phase of the nursing proves?
A. Making inferences B. Finding patterns C. Stating the problem D. Categorizing data
16. During an interview, the client asks the nurse for her opinion on the medical treatment provided by her primary-care physician. Which of the following would be an
appropriate response by the nurse?
A. “If I were you, I would get a new doctor”
B. “I wouldn’t be happy either”
C. “Tell me what is causing you to question the care you’ve received”
D. “Let’s not discuss that now. How have you been feeling?”
17. The telephonic nurse is conducting an assessment of a client using a wellness model approach. Which of the following would not be included in this assessment?
A. Health history B. Genitourinary system C. Health beliefs D. Spiritual health
18. The nurse is planning to conduct an assessment using Orem’s Universal Self-Care requisites. Which of the following will be included in this assessment?
A. Role/relationship pattern C. The client is in transition from one level of wellness to another
B. Sufficient intake of air D. Solitude and social interaction
19. Which of the following is an accepted variation in format for a nursing diagnosis?
A. Including more than one problem C. Writing the diagnosis in which the two parts mean the same thing
B. Writing “unknown etiology” when the cause is unknown D. Using medical diagnosis as the etiology
20. The nurse wants to add a qualifier to a nursing diagnosis. Which of the following qualifiers would be appropriate for the phrase “made worse”?
A. Deficient B. Impaired C. Decreased D. Ineffective
21. During the formulation of a nursing diagnosis, the nurse realizes that she needs more information about the client’s problem. To support this nurse’s decision,
which of the following should be included in the nursing diagnosis?
A. Unknown etiology B. Complex factors C. Possible D. Secondary to
. The nurse is having difficulty constructing nursing diagnoses. Which of the following is not a guideline that the nurse should avoid using when formulating nursing
diagnoses?
A. State in terms of a need C. Do not be redundant
B. Use legally accepted words D. That use of medical terminology should be avoided
22. It is important to identify the etiology of a nursing diagnosis because the etiology:
A. Enables the nurse to individualize interventions for a particular client C. Determines whether the problem is actual or potential
B. Describes the pathophysiology of the client’s disease D. Includes the defining characteristics of the diagnosis
23. Identify the italicized part of this nursing diagnosis: Impaired Skin Integrity: Excoriation related to prolonged exposure to ammonia secondary to incontinence of
urine.
A. Problem statement B. Cue C. Etiology D. Contributing factor

SPECIAL ENHACER DRILLS – COURSE AUDIT 1 1

24. Identify the italicized part of this nursing diagnosis: Impaired Skin Integrity: Excoriation related to prolonged exposure to ammonia secondary to incontinence of
urine.
A. Cue B. Problem statement C. Etiology D. Diagnostic label
25. Which of the following descriptors could be used in stating the problem part of a nursing diagnosis?
A. Crying B. Possible anxiety C. Temperature 101F D. Intake 750 cc in 8 hours
26. For the nursing diagnosis “risk for injury: falls related to impaired vision,” what is/are the risk factor(s)?
A. High risk B. Injury C. Falls D. Impaired vision
27. When consulting with other health-care personnel regarding client-related issues, the nurse must:
A. Provide consultant with a detailed nursing history C. Obtain permission from the client
B. Provide the consultant with the client’s nursing care plan D. Identify the specific problem
28. Which of the following is considered a multidisciplinary (collaborative) plan of care?
A. Nursing care plan B. Critical pathway C. Standards of care D. Model (standard) care plan
29. Nursing-care plans should include all of the following except what?
A. Preventive actions C. Discharge teaching needs
B. Orders for ongoing assessment D. All the steps of a standard procedure
30. Which of the following is a goal?
A. The client will gain 2 lbs by day 3 C. The client will list 5 favorite beverages
B. The client will identify four favorite foods D. The client’s nutritional status will improve
31. According to the Nursing Outcomes Classification, an indicator is:
A. A goal B. A measure C. Desired outcome D. A taxonomy
32. The nurse is preparing to place an indwelling catheter in a female client. Which of the following should the nurse do after explaining the procedure to the client?
A. Document the client’s response to the explanation C. Offer the client something for pain
B. Provide for client privacy D. Delegate the task to a nursing assistant
33. The nurse provides care to three clients over the course of a workday. Which of the following should the nurse do to ensure all documentation is correct and
complete?
A. Use a worksheet to document prior to entering data in the clients’ medical records
B. Document care before provided
C. Document care after every intervention is completed
D. Delegate the documentation of care to a licensed practical nurse
34. Which of the following best describes the nursing-process step of evaluation?
A. It’s done at the end of the shift C. It’s done once a week
B. It’s a continuous process D. It can be done independent of other steps in the nursing process
36. The nurse, caring for clients in a skilled long-term care facility, needs to complete nursing summaries. Which of the following is true about a nursing summary?
A. It needs to be written weekly for clients receiving skilled care C. It needs to be written within seven days of admission
B. It needs to be written within four days of admission D. It needs to be written biweekly for all clients
37. A nurse forgot to document care provided to a client and returns the next day to complete the documentation. Upon review of the nurse’s progress notes section
of the record, the nurse sees that a space was left for her documentation. What should the nurse do?
A. Document in the space provided
B. Draw lines through the space and sign her name
C. Leave the blank area alone and document at the end of the section, out of sequence
D. Write an explanation of why she didn’t document in the blank area and draw arrows to her entry about the client’s care
38. The nurse providing the telephonic client care phones a client’s physician to report a change in effect along with a drop in blood pressure. Prior to hanging up with
the physician’s office, what should the nurse obtain?
A. Verbal orders for medication change C. The name of the person to whom the nurse gave the report
B. Nothing D. Driving directions to the physician’s office
39. The Nursing Department in a rural hospital is upset to learn that the hospital is going to install a computerized documentation system. Which of the following could
be the reason for this department’s anxiety?
A. The number of nursing positions will not be decreased C. The number of beds in the hospital will change
B. The number of nursing positions will now be increased D. The cost for training everyone wasn’t in the budget
40. The daylight shift is meeting with the incoming shift to provide client report. Which of the following is an integral part of this communication?
A. How the clients slept during the night C. Changed vital signs
B. Who has visitors right now D. Which doctor is on call for the next shift
41. The nurse identifies the following nursing diagnoses for a client. “deficient fluid volume; impaired nutrition: less than body requirement; anxiety over parenting role;
and risk for skin breakdown.” Which of these diagnoses should be the top priority?
A. Deficient fluid volume C. Anxiety over parenting role
B. Impaired nutrition: less than body requirements D. Risk for skin breakdown
42. Which of the following is a benefit of the NIC?
A. Hinders with communication with nurses C. Helps with the selection of nursing interventions
B. Eliminates the need for nursing diagnoses D. Proves the role of nursing to the medical community
43. The following are benefits of the NIC. Which is not included?
A. Helps with communication with nurses C. Eliminates the need for nursing diagnoses
B. Helps with panning for new equipment D. Helps with the selection of nursing interventions
44. An elderly male is a client in an extended-care facility for physical deterioration secondary to heart failure. Which of the following would be appropriate for this
client?
A. Check his care plan monthly C. Write desired outcomes based upon his physical status
B. Write goals with short endpoints to help motivate him D. Realize his health status is stable, so his interventions won’t change much
45. Before advising a 24-year old client desiring oral contraceptives for family planning, the nurse would assess the client for which signs and symptoms?
A. Weight gain B. Hypertension C. Dysmenorrhea D. Acne vulgaris
46. After instructing a 20-year old nulligravid client about adverse effects of oral contraceptives, the nurse determines that further instruction is needed when the client
states which as an adverse effect?
A. Weight gain B. Nausea C. Headache D. Ovarian cancer
47. Which information would the nurse include in the teaching plan of a 32-year old female client requesting information about using diaphragm for family planning?
A. Douching with an acidic solution after intercourse is recommended C. The diaphragm should be washed in a weak solution of bleach and water
B. Diaphragms should not be used if the client develops acute cervicitis D. The diaphragm should be left in place for 2 hours after intercourse
48. After being examined and fitted for a diaphragm, a 24-year old client receives instructions about its use. Which client statement indicates need for further teaching?
A. “I can continue to use diaphragm for about 2 to 3 years if I keep it protected in the case”
B. “If I get pregnant, I will have to be refitted for another diaphragm after childbirth”
C. Before inserting the diaphragm, I should coat the rim with contraceptive jelly”
D. “If I gain 20 pounds (9 kg), I can still use the same diaphragm”

SPECIAL ENHACER DRILLS – COURSE AUDIT 1 2

49. A 22-year old client tells the nurse that she and her husband is planning to conceive a baby. When teaching the client about reducing the incidence of neural tube
defects, the nurse would emphasize the need for increasing the intake of which food? Select all that apply.
1. Leafy green vegetables 3. Beans 5. Sunflower seeds
2. Strawberries 4. Milk 6. Lentils
A. 1,3,5,6 B. 1,2,5,6 C. 1,2,3,5,6 D. 1,3,4,6
50. A couple is inquiring about vasectomy as a permanent method of contraception. Which teaching statement would the nurse include in the teaching?
A. “Another method of contraception is needed until the sperm count is 0”
B. “Vasectomy is easily reversed if children is desired in the future”
C. “Vasectomy is contraindicated in males with prior history of cardiac disease”
D. “Vasectomy requires only a yearly follow-up once the procedure is completed”
51. A primigravid client at 15 weeks AOG has had an amniocentesis and has received teaching concerning signs and symptoms to report. Which statement indicates
that the client needs further teaching?
A. “I need to call if I start to leak fluid from my vagina” C. “If my baby does not move, I need to call my healthcare provider”
B. “If I start bleeding, I will need to call back” D. “If I start running a fever, I should let the office know”
52. During a visit to the prenatal clinic, a pregnant client at 32 weeks AOG has heartburn. The client needs further instruction when she says she must do what?
A. Avoid highly seasoned food C. Eat small, frequent meals
B. Avoid lying down after eating D. Consume only liquids between meals
53. Following a positive pregnancy test, a client begins discussing the changes that will occur in the next several months with the nurse. The nurse should include
which information about changes the client can anticipate in the first trimester?
A. Differentiating the self from the fetus C. Preparing for the reality of parenthood
B. Enjoying the role of the nurturer D. Experiencing ambivalence about pregnancy
54. A 36-year old multigravida client has missed three periods and now visits the prenatal clinic because she assumes, she is pregnant. She is experiencing
enlargement of the abdomen, a positive pregnancy test, and changes in pigmentation on her face and abdomen. These assessment findings reflect this woman is
experiencing a cluster of which signs of pregnancy?
A. Positive B. Probable C. Presumptive D. Diagnostic
55. When preparing a 20-year old client for a serum pregnancy test, what information should the nurse tell the client?
A. The test has high degree of accuracy within 1 week of ovulation C. A positive result is considered a presumptive sign of pregnancy
B. The test is identical in nature to an over-the-counter home pregnancy test D. A urine sample is needed to obtain quicker results
56. The nurse is developing a teaching plan for a client entering the third trimester of her pregnancy. The nurse should include which information in the plan? Select
all that apply.
1. Differentiating the fetus from self 4. Realignment of roles and tasks
2. Ambivalence concerning pregnancy 5. Trying various caregiver roles
3. Experimenting with maternal roles 6. Concern about labor and birth
A. 1, 3, 5 6 B. 2, 3, 5, 6 C. 3, 4, 5, 6 D. 1, 3, 4, 5
57. When preparing a prenatal class about endocrine changes that normally occur during pregnancy, the nurse should include information about which subject?
A. Human placental lactogen maintains the corpus luteum C. Estrogen relaxes smooth muscles in the respiratory tract
B. Progesterone is responsible for hyperpigmentation and vascular changes D. The thyroid enlarges with an increase in basal metabolic rate
58. A primigravid client in preparation for parenting class asks how much blood is lost during an uncomplicated vaginal birth. The nurse should tell the woman:
A. “The maximum blood loss considered within normal limits is 500 ml”
B. “The minimum blood loss considered within normal limits is 1000 ml”
C. “Blood loss during childbirth is rarely estimated unless there is hemorrhage”
D. “It would be very unusual if you lost more than 100 ml of blood during childbirth”
59. Which statement by a primigravid client about the amniotic fluid and sac indicates the need for further teaching?
A. ‘The amniotic fluid helps to dilate the cervix once labor begins”
B. “Fetal nutrients are provided by the amniotic fluid”
C. “Amniotic fluid provides cushion against impact of the maternal abdomen”
D. “The fetus is kept at a stable temperature by the amniotic fluid and sac”
60. During a birth preparation class, a primigravid client at 36 weeks gestation tells the nurse, “My lower back has really been bothering me lately.” Which exercise
would be most helpful?
A. Pelvic rocking B. Deep breathing C. Tailor sitting D. Squatting
61. A client with past medical history of ventricular septal defect repaired in infancy is seen in the prenatal clinic. She has dyspnea with exertion and is very tired. Her
vital signs are oxygen saturation of 98, pulse 80, respirations 20, blood pressure 116/72 mmHg. She has +2 pedal edema and clear breath sounds. The nurse
determines the client’s symptoms indicate which cardiac functional classification?
A. Class I B. Class II C. Class III D. Class IV
62. A primigravid client has completed her first prenatal visit and blood work. Her laboratory test for hepatitis B surface antigen (HBsAg) is positive. The nurse can
advise the client that the plan of care for this newborn will include which interventions? Select all that apply.
1. Hepatitis B immune globulin at birth 4. Isolation of infant during hospitalization
2. Series of three Hepatitis B vaccinations per recommended schedule 5. Universal precautions for mother and infant
3. Hepatitis B screening when born 6. Contraindication for breastfeeding
A. 1, 3, 4, 5 B. 1, 2, 5 C. 2, 3, 5, 6 D. 1, 4, 5, 6
63. A client in the triage area who is at 19 weeks gestation states that she has not felt her baby move in the past week, and no fetal heart tones are found. While
evaluating this client, the nurse identifies her as being the highest risk for developing which problem?
A. Abruptio placenta C. Disseminated intravascular coagulation
B. HELLP Syndrome D. Threatened abortion
64. A woman with asthma controlled through the consistent use of medication is now pregnant for the first time. Which client statement concerning asthma during
pregnancy indicates the need for further teaching?
A. “I need to continue taking my asthma medication as prescribed”
B. “It is my goal to prevent or limit asthma attacks”
C. During asthma attack oxygen needs to continue to be high for mother and fetus”
D. Bronchodilators should be used only when necessary because of the risk they present to the fetus”
65. A 40-year old client at 8 weeks gestation has a 3-year old child with Down Syndrome. The nurse is discussing amniocentesis and chorionic villi sampling as genetic
screening methods for the expected baby. The nurse is confident that the teaching has been effective when the client makes which statement?
A. “Each test identifies a different part of the infant’s genetic make-up”
B. “Chorionic villi sampling can be performed earlier in pregnancy”
C. “The test results take the same length of time to be completed”
D. Amniocentesis is a more dangerous process for the fetus”
66. For a client who is receiving intravenous MgSO4 for severe pre-eclampsia, which assessment finding would alert the nurse to suspect hypermagnesemia?
A. Decreased deep tendon reflex B. Cool skin temperature C. Rapid pulse rate D. Tingling in the toes

SPECIAL ENHACER DRILLS – COURSE AUDIT 1 3

67. Which outcome would the nurse identify as the priority to achieve when developing the plan of care for a primigravid client at 38 weeks gestation who is hospitalized
with severe pre-eclampsia and receiving intravenous MgSO4?
A. Decreased generalized edema within 8 hours C. Sedation and decreased reflex excitability within 48 hours
B. Decreased urinary output during the first 24 hours D. Absence of any seizure activity during the first 48 hours
68. The nurse is administering intravenous MgSO4 as prescribed for a client at 34 weeks gestation with severe pre-eclampsia. What are desired outcomes of this
therapy? Select all that apply.
1. Temperature 98F, pulse 72 bpm, respiratory rate 14 breaths per minute 4. Blood pressure of less than 140/90 mmHg
2. Urinary output less than 30 ml/hr 5. Deep tendon reflexes 2+
3. Fetal heart rate with less decelerations 6. Magnesium level – 5.6 mg/dl (2.8 mmol/L)
A. 1, 2, 3, 4 B. 1, 5, 6 C. 1, 2, 5, 6 D. 1, 4, 5, 6
69. As the nurse enters the room of a newly admitted primigravid client diagnosed with severe pre-eclampsia, the client begins to experience a seizure. Which action
should the nurse take first?
A. Insert an airway to improve oxygenation C. Call for immediate assistance
B. Note the time when the seizure begins and ends D. Turn the client to her left side
70. After administering hydralazine 5 mg IV as prescribed for a primigravid client with severe pre-eclampsia at 39 weeks gestation, the nurse should assess the client
for?
A. Tachycardia B. Bradypnea C. Polyuria D. Dysphagia
71. A client presents to the OB triage unit with no prenatal care and painless bright red vaginal bleeding. Which interventions are most indicated?
A. Applying external fetal monitor and completing a physical assessment
B. Applying external fetal monitor and preparing a sterile vaginal exam
C. Obtaining a fundal height physical assessment on the client
D. Obtaining fundal height and preparing for a vaginal exam
72. The nurse is caring for a 22-year old G2P2 client who has DIC (Disseminated Intravascular Bleeding) after delivering a dead fetus. Which finding is the highest
priority to report to the healthcare provider (HCP)?
A. Activated Partial Thromboplastin Time (APTT) of 30 seconds C. Urinary output of 25 ml in the past hour
B. Hemoglobin of 11.5 g/dl (115 g/L) D. Platelets at 149, 000/mm3 (149 x 109/L)
73. A 24-year old G3 T1 P1 A1 L1 at 32 weeks gestation is admitted to the hospital because of vaginal bleeding. After reviewing the client’s history, which factor might
lead the nurse to suspect abruptio placenta?
A. Several hypotensive episodes C. One induce abortion
B. Previous low transverse cesarean birth D. History of cocaine use
74. When caring for a multigravida client admitted to the hospital with vaginal bleeding at 38 weeks gestation, which therapeutic agent would the nurse anticipate
administering intravenously if the client develops DIC?
A. Ringer’s lactate solution B. Fresh frozen platelets C. 5% dextrose solution D. Warfarin
75. When assessing a 34-year old multigravida client at 34 weeks gestation experiencing moderate vaginal bleeding, which symptom would most likely alert the nurse
that placenta previa is present?
A. Painless vaginal bleeding B. Uterine tetany C. Intermittent pain with spotting D. Dull lower back pain
76. The healthcare provider (HCP) has determined that a preterm labor client at 34 weeks gestation has no fetal fibronectin present. Based on this finding, the nurse
would anticipate that within the next week:
A. The client will develop pre-eclampsia C. The client will not develop preterm labor
B. The fetal will develop mature lungs D. The fetus will not develop gestational diabetes
77. A nurse is discussing preterm labor in a prenatal class. After class, a client asks the nurse to identify again the nursing strategies to prevent preterm labor. The
client needs further instruction when she makes which statement?
A. “I need to stay hydrated at all time” C. “I should include frequent rest breaks if I travel”
B. “Even dental infections can lead to preterm labor” D. Cutting back on my smoking will not help my baby”
78. A multigravida client at 34 weeks gestation is being treated with Indomethacin to halt preterm labor. If the client gives birth to a preterm infant, the nurse should
notify the nursery personnel about this therapy because of the possibility for which complication?
A. Pulmonary hypertension C. Hyperbilirubinemia
B. Respiratory distress syndrome (RDS) D. Cardiomyopathy
79. Which statement by the client indicates an understanding of the teaching regarding of the use of corticosteroids during preterm labor?
A. “I will be taking corticosteroids until my baby’s due date so that he or she will have the best chance of doing well”
B. “The corticosteroids may help my baby’s lungs mature”
C. “The goal of corticosteroids is to stop contractions and help me get my due date”
D. “If I take corticosteroids, my baby will not have to spend any time in the neonatal intensive care unit when he or she is born”
80. In which maternal locations would the nurse place the ultrasound transducer of the external fetal heart rate monitor if a fetus at 34 weeks gestation is in the left
occiput anterior (LOA) position?
A. Near the symphysis pubis C. Below the umbilicus on the left side
B. Two inches (5.1 cm) above the umbilicus D. At the level of the umbilicus
81. The nurse is planning care for a multi gravid client hospitalized at 36 weeks gestation with confirm rupture of membranes and no evidence of labor. What prescription
would the nurse anticipate from the primary healthcare provider (HCP)
A. Frequent assessment of cervical dilatation C. Vaginal cultures for Neisseria gonorrhoeae
B. Intravenous oxytocin administration D. Sonogram for amniotic fluid volume index
82. A multigravida client at 34 weeks gestation visits the hospital because she suspects that her water has broken. After testing the leaking fluid with nitrazine paper,
the nurse confirms that the client’s membranes have ruptured when the paper turns which color?
A. Yellow B. White C. Blue D. Red
83. A primigravid client at 30 weeks gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm
dilated and 50% effaced. The nurse should next assess the client’s:
A. Red blood cell count B. Degree of discomfort C. Urinary output D. Temperature
84. A multigravida client at 34 weeks gestation with premature rupture of the membranes test positive for group B streptococcus. The client is having contractions
every 4 to 6 minutes. Her vital signs are as follows: temperature 100F (37.8C), pulse 100 bpm, respirations 18 breaths/minute. Which medication would the nurse
expect the primary healthcare provider (HCP) to prescribe?
A. Intravenous Penicillin B. Intravenous Gentamicin Sulfate C. Intramuscular Betamethasone D. Intramuscular Cefaclor
85. A primigravid client at 36 weeks gestation with premature rupture of the membranes is to be discharge home on bed rest with follow-up by the nurse. After instruction
about care while at home, which client indicates effective teaching?
A. “It is permissible to douche if the fluid irritates the vagina”
B. “I can take either a tub bath or a shower when I feel like it”
C. “I should limit my fluid intake to less than 1 quart (0.95 L) daily”
D. “I should contact the healthcare provider (HCP) if my temperature is 100.4F (38C) or higher”

SPECIAL ENHACER DRILLS – COURSE AUDIT 1 4

86. An antenatal clinic nurse is educating a client with gestational diabetes soon after diagnosis. Evaluation for this client session will include which outcome? Select
all that apply.
1. The client states that the need to maintain glucose levels between 70 to 110 mg/dl (3.9 to 6.2 mmol/L)
2. The client describes her planned walking program while pregnant
3. The client will strive to maintain a hemoglobin A1C of less than 6%
4. The client verbalizes the need to maintain dietary intake of less than 1500 calories/day to prevent hyperglycemia
5. The client will continue taking her prenatal vitamins, iron, and folic acid
A. 1, 2, 3, 5 B. 1, 2, 4, 5 C. 1, 2, 5 D. 1, 3, 5
87. A 27-year old primigravid client with Insulin-depended Diabetes Mellitus at 34 weeks gestation undergoes a non-stress test, the results of which are documented
as reactive. What should the nurse tell the client that the test results indicated?
A. A contraction stress test is necessary C. Chorionic villi sampling is needed
B. The non-stress test should be repeated D. There is evidence of fetal well-being
88. A pregnant client with IDDM tells the nurse that contraction stress test performed earlier in the day was suspicious. The nurse interprets this test result as showing
which fetal hear rate pattern?
A. Frequent late decelerations C. Inconsistent late decelerations
B. Decreased fetal movements D. Lack of fetal movement
89. Which statement about biophysical profile would be incorporated into the teaching plan for a primigravid client with IDDM?
A. It determines fetal lung maturity C. It will correlate to the newborn’s APGAR Score
B. It is non-invasive using real-time ultrasounds D. It requires the client to have an empty bladder
90. A 30-year old multigravida client at 8 weeks gestation has a history of IDDM since age 20. When explaining about the importance of blood glucose control during
pregnancy, the nurse should tell the client that which will occur regarding the client’s insulin needs during the first trimester?
A. They will increase B. They will decrease C. They will remain constant D. They will be unpredictable
91. Nursing informatics is best defined as the science of:
A. Delivering nursing care via computers
B. Supporting nursing practice with computerized systems
C. Storing nursing knowledge and literature on computer systems
D. Using electronic monitoring charting systems
92. Large amount of information is stored on computers. The volume of data is measured in:
A. RAM (random access memory) B. MHz (megahertz) C. Milliseconds D. Bytes
93. Many hospitals communicate notices, reports, lab data, and other information via a network or local area network (LAN). Which of the following best describes a
computer network?
A. The combination of a computer monitor, CPU, keyboard, and printer
B. The use of personal computers to send files from one location to another
C. Linkages between several computers that permit sharing of data files
D. Several personal computers using the same software
94. Which of the following best describes the function of a Hospital Information System (HIS)?
A. It organizes a hospital’s client and institutional databases
B. It connects a hospital’s personal computers to the internet
C. It provides instruction on hospital-related topics to clients
D. It is a national compilation of statistics on hospital characteristics
95. A nurse needs to know if there are any research studies on the optimal length of time bedridden clients can remain in one position. The electronic source most
likely to provide this information for the nurse is:
A. The World Wide Web
B. The Internet
C. Cumulative Index to Nursing and Allied Health Literature (CINAHL)
D. Computer-assisted Instruction (CAI)
96. Computers can be used to transmit data, voice, and video across long distances. When the recipient accesses the transmission at a different time than when the
person sent it, it is referred to as:
A. Synchronous B. Asynchronous C. Random access D. Digitized
97. A Filipino RN to wants to become RN in the US completes the national licensure examination for registered nursing (NCLEX-RN) at a computer terminal. A
computer is used because:
A. It scores the exam more accurately
B. Applicants cannot go back and change their answers
C. More applicants can take the test at one time
D. Each applicant receives customized questions
98. There are both advantages and disadvantages to computer-based patient records (CPRs). Which of the following is a significant concern about CPRs for both
nurses and clients?
A. Lack of standardization among systems in different health agencies C. Difficulty maintaining privacy and security
B. Possibility of the computer systems malfunctioning D. Time involved in learning how to use the systems
99. Which of the following is an example of telemedicine or telenursing?
A. Consulting in a client via live video 100miles away
B. Monitoring the EKG of a client in her room while waiting at the nurses’ station
C. Performing surgery using robotic assistance
D. Using a computer program to select an appropriate care plan based on the client-assessment data
100. One of the uses of computers in nursing administration is for quality assurance and utilization review. One of the benefits of using computers for this function is
the ability to:
A. Measure achievement of desired institutional outcomes C. Increase accuracy in billing
B. See if quality has been achieved D. Predict staffing needs
101. Which of the following is an example of computer use in the data collection/analysis step of the research process?
A. Searching literature databases to identify related studies
B. Coding data for statistical manipulation
C. Testing prospective instruments/tools
D. Word-processing study results for publication
102. The nurse is reading a memo sent by the Information Technology department in the hospital. The memo states that the server will be down between 2 and 3 a.m.
and that PCs will be inoperable during this time? What does this mean to the nurse providing patient care?
A. The nurse can use the desktop as usual
B. The nurse should use paper-and-pencil documentation between 2 and 3 a.m.
C. The call-light system will be inoperable
D. The nurse should use the handheld computer during this time period
103. The nurse is going to document care, but the terminal is missing the point-and-click device. What is the terminal missing?
A. The keyboard B. The microphone C. The mouse D. The digital converter
SPECIAL ENHACER DRILLS – COURSE AUDIT 1 5
104. A client is upset about the diagnosis of cervical dysplasia. She tells the nurse that according to the Internet, cervical dysplasia is cancer. Which of the following
would be an appropriate response for the nurse to make?
A. “There are a variety of cancer treatments available to you.” C. “I’m sure that you will be fine.”
B. “You have a good doctor, so don’t worry so much.” D. “Not all resources on the internet are reliable.”
105. Prior to attending the clinical portion of nursing school, the student nurse reviews the proper procedure for administering an intramuscular injection. The student
goes to the library and accesses the computer. Which of the following would this student most likely be reviewing on the computer?
A. Tutorial on how to give an injection C. The list of objectives the instructor placed on the website
B. The results of a literature review on medications given intramuscularly D. E-mail
106. The hospital has just hired a nurse informaticist. What purpose will this nurse serve?
A. Make sure all of the computers work on the patient-care units C. Coordinate care for clients ready for discharge
B. Develop processes to help nurses’ uses computers for patient care D. Communicate home-care referrals
107. In preparation for the next ISO survey, the hospital is implementing an additional monitoring device in the computer software. Which of the following would be
viewed as an expectation from the ISO in regards to the computer documentation system?
A. Add a spreadsheet for vital-sign documentation
B. Streamline the method for documenting medication administration
C. Figure out a way to measure quality indicators to streamline the accreditation process
D. Prove all nurses are able to use the keyboard for entering patient information
108. The profession of nursing has a number of taxonomies for electronic information. Which of the following is not an example of these taxonomies?
A. ICD-10 B. The ShieldPro system C. DSM D. NIC/NOC
109. A 63-year-old female client asks the nurse to help her decide which information on the internet is legitimate. The nurse should tell the client to look for:
1. Nothing in particular; there’s no real way to know
2. The name of the author and their credentials
3. The assurance that the web site is linked to the department of health
4. A date that states when the information was updated
5. A disclaimer that the information is not to replace medical advice
A. 1, 2, 3, 4, 5 B. 1, 3 C. 2, 4, 5 D. 2, 3, 4
110. Which among the following would be considered as benefits of information technology in nursing?
1. Better utilization of nursing staff services 5. Measurement of outcomes
2. Improved documentation, communication and planning 6. Improved cost accountability
3. Standardized nursing practice 7. Improved patient care
4. Tracking of nursing services
A. All of the above B. 2, 3, 4, 7 C. 1, 2, 3, 5, 7 D. 2, 3, 5, 6
111. Body temperature is the balance between heat production and heat loss. Which of the following healthy individuals would probably have the highest body
temperature?
A. A 16-year-old boy who just walked 2 miles C. A 65-year-old man who just walked 2 miles
B. A 16-year-old boy who is watching television D. A 65-year-old man who is watching television
112. Which of the following factors influences the body’s heat production?
A. Protein shake B. Diaphragmatic breathing C. Sympathetic stimulation D. Sweating
113. Insensible heat loss occurs through the mechanism of:
A. Radiation B. Conduction C. Convection D. Vaporization
114. During the past 24 hours, a client’s temperature has fluctuated widely above the normal range. The nurse should record this as a(n):
A. Intermittent fever B. Remittent fever C. Relapsing fever D. Constant fever
115. A 2-year-old client with a medical diagnosis of intestinal virus has a rectal temperature of 39.3C. She says she is cold. She has been vomiting for the past two
days. An appropriate nursing diagnosis would be:
A. Hyperthermia related to dehydration C. Hypothermia related to environmental temperature
B. Hyperthermia related to excess heat production D. Hypothermia related to vomiting
116. A 2-year-old client who has a rectal temperature of 39.3C begins to sweat profusely. Because she is in the flush phase of her fever, the appropriate action for the
nurse would be to:
A. Apply ice packs to axilla and groin
B. Increase her physical activity
C. Give her a tepid sponge bath
D. Provide extra blankets
117. What is the average resting heart rate for a 2-year-old child?
A. 60bpm B. 80bpm C. 110bpm D. 160bpm
118. What is the appropriate site for taking the pulse of a normal 2-year-old child?
A. Apical B. Radial C. Brachial D. Temporal
119. The thumb is not used in palpating a pulse because:
A. The index finger is more sensitive to touch C. It is more awkward
B. Thumb pressure may obliterate the pulse D. The nurse might feel his/her own thumb pulse
120. In an adult, the apex of the heart is located:
A. Left of the sternum at the 2nd intercostals space C. Left of the sternum and under the 4th, 5th, or 6th intercostals space
B. Right of the sternum at the 3rd intercostals space D. Right of the sternum and under the 4th, 5th, or 6th intercostals space
121. A 40-year-old client with fractures of both arms has bilateral casts from his shoulders to his hands. Which of the following is the best method of obtaining and
monitoring his pulse?
A. Take his temporal pulse C. Omit taking the pulse if his other vital signs are normal
B. Place the client on a cardiac monitor D. Inform the physician that the pulse cannot be monitored
122. For a 40-year-old male, which of the following sets of vital signs would be considered normal?
A. BP 110/80, respirations 16 C. BP 100/50, pulse 44, respirations 10
B. BP 90/60, pulse 44, respirations 32 D. BP 180/ 100, pulse 72, respirations 20
123. As you begin to take a client’s oral temperature, she tells you that she has just had some ice chips. The appropriate nursing action is to:
A. Give her a sip of warm water, wait five minutes, then take her temperature C. Processed to take the oral temperature
B. Take a rectal temperature D. Wait 30 minutes before taking an oral temperature
124. The interchange of oxygen and carbon dioxide between the alveoli of the lungs and the pulmonary blood is called:
A. External respiration B. Internal respiration C. Inspiration D. Ventilation
125. Normal breathing rate is referred to as:
A. Apnea B. Bradypnea C. Eupnea D. Tachypnea
126. The diastolic blood pressure is:
A. The result of the contraction of the ventricles C. The minimum pressure present at all times within the arteries
B. A reflection of changes in cardiac output D. An average of the systolic pressure and the pulse pressure

SPECIAL ENHACER DRILLS – COURSE AUDIT 1 6

127. It is especially important to watch for a decrease in blood pressure in a client who:
A. Is obese C. Has a fever
B. Is hemorrhaging D. Has been exposed to cold temperatures
128. When measuring blood pressure, the first sound you hear on release of the valve indicates the:
A. Systolic pressure B. Diastolic pressure C. Pulse pressure D. Auscultatory gap
129. In a blood pressure reading of 120/90, the 90 reflects the:
A. Pressure present in arteries during contraction of heart ventricles C. Difference between systolic and diastolic pressure
B. Pressure present in arteries while ventricles are at rest D. Pulse pressure
130. Which method should the nurse use to obtain the blood pressure of a client with both a known auscultatory gap and a peripheral circulation problem?
A. Auscultatory method in the non-dominant arm C. Palpatory method in either arm
B. Auscultatory method in the thigh D. Flush method in either arm
131. A client has a temperature of 38.3C and is shivering and complaining that he is cold. Which of the following symptoms would help to confirm that the fever is in
the onset stage?
A. Pale, cold skin B. Flushed, warm C. Increased thirst D. Sweating
132. Many agencies use electronic tympanic membrane thermometers. Which of the following is true regarding their use?
A. Repeated measurements are very consistent
B. Results are obtained very quickly
C. Readings are more accurate than rectal temperatures
D. It is a completely safe procedure
133. The nurse is unable to palpate the client’s popliteal pulse. Presence of which of the following pulses indicates adequate popliteal artery flow?
A. Femoral B. Pedal C. Brachial D. Carotid
134. While releasing the blood pressure cuff below the systolic reading, the nurse is uncertain exactly where the sound becomes muffled. What would be the best
action for the nurse to take?
A. Before releasing the cuff completely, immediately pump the cuff back up and begin lowering again
B. Release the cuff completely, wait one to two minutes, and retake the entire blood pressure
C. Ask another nurse to take the blood pressure, and compare the two readings
D. Take the blood pressure on the client’s other arm
135. The emergency room in a Baguio City hospital is extremely busy one cold January night. Which of the following clients being seen in the emergency room have
the greatest risk of being admitted with hypothermia?
A. 17-year-old male with a knife wound to his femur
B. 58-year-old homeless male
C. 38-year-old female having a spontaneous abortion
D. 47-year-old female experiencing right lower quadrant abdominal pain and nausea
136. The nurse has assessed the pulse rate of a 44-year-old female to be 110 and not regular. Which of the following terms could be used to describe this client’s
pulse?
A. Bradycardic and normal sinus rhythm
B. Tachycardic and decreased pulse volume
C. Bradycardic and dysrhythmic
D. Tachycardic and dysrhythmic
137. The nurse assesses two different pulse rates on a 78-year-old male client. The apical heart rate is 68 beats per minute, whereas the peripheral pulse rate is 55
beats per minute. What should the nurse do about this information?
A. Nothing; elderly people can have different pulse rates
B. Reassess the pulses, making sure both are counted for a full minute
C. Reassess the pulses and report the findings to the physician
D. Reassess the pulses and document the difference as stroke volume in the medical record
138. The nurse counts 10 inhalations and 9 exhalations over 30 seconds on a client experiencing chest pain. What should the nurse do with this information?
A. Document respiratory rate as bradypnic and call the physician
B. Document respiratory rate as polypnic and call the physician
C. Document respiratory rate as apneic and call the physician
D. Document respiratory rate as eupnic and reassess the rate as prescribed by the physician
139. A client is complaining of being “extremely cold” and is visibly shivering. The nurse wants to measure this client’s oxygen saturation level. What should the nurse
do?
A. Place the pulse oximeter on the client’s nose
B. Place the pulse oximeter around the client’s foot
C. Provide oxygen to the client and then measures the oxygen saturation level in one hour
D. Rethink the plan to measure the oxygen saturation since the client does not have dusky skin
140. The client comments to the nurse that the blood pressure reading she obtained was really high. Which of the following should the nurse do?
A. Wait 2 minutes; retake the blood pressure; deflate the cuff very slowly
B. Wait 2 minutes; retake the blood pressure
C. Wait 30 seconds; retake the blood pressure with a wider cuff
D. Wait 1 minute; retake the blood pressure placing the clients arm above the level of his heart
141. Which of the following is true about development in young adulthood?
A. Effective communication and problem solving are essential when dealing with marital conflicts and adjustment, which are common in this period.
B. Young adults generally accept their current life situation and are not likely to make significant changes during these years.
C. Along with the stage of formal operations, the young adults.
D. Problem solving is difficult for young adults because of their cognitive stage and lack of life experience
142. A 32-year-old single female is being discharged from the hospital in three days. She will have a full-length leg cast and will need assistance with transportation
and shopping for the next six weeks. As the nurse planning her care, you would first:
A. Notify the person listed as next of kin and ask him or her to help the client establish a good support system
B. Ask the client about her support system and significant others
C. Refer the client to a vocational rehabilitation service to help her find a means of transportation
D. Tell the client not to worry, because several transportation services are available to her at little cost.
143. The most important cancer-screening test for young adult males is a(n):
A. Monthly testicular self-examination C. Annual prostate examination
B. Monthly breast self-examination D. Annual chest x-ray
144. Which health hazard is most likely to occur in young adulthood?
A. Cancer B. Osteoporosis C. Hypertension D. Diabetes
145. Middle-aged adults are at risk for obesity because of a(n):
A. Naturally occurring decrease in metabolism C. Increase in estrogen (women)
B. Naturally occurring increase in appetite D. Decrease in gastric juice secretions and free acid

SPECIAL ENHACER DRILLS – COURSE AUDIT 1 7

146. Which of the following is characteristic of the health problems of older adults?
A. The proportion of acute conditions to chronic diseases increases
B. Cardiac problems are the most common health problems
C. Poverty ceases to contribute to their health problems because of social security and health insurance
D. They are likely to be taking several prescribed medications, and the chance of adverse reactions increases (Polypharmacy)
147. A 68-year-old woman frequently complains of being cold even though room temperature is 24 degrees Celsius. This is because many older people:
A. Become confused and think it is much colder than it really is
B. Use this complaint to get attention
C. Have a malfunction of the heat-regulating mechanism in the brain
D. Have lost subcutaneous fat as they grow old
148. A 70-year-old retired postal worker has developed brown spots on his hands and face, which his physician tells him are called Lentigo Selinis. The client asks,
“Do you think these might be skin cancer? I haven’t always had them.” The nurse should answer:
A. “Don’t be concerned. These are premalignant lesions and are easily cured.”
B. “These are only premalignant lesions that have the potential of becoming cancerous.”
C. “No, these are not cancer. Some people call them age spots. They are a normal change that occurs with aging.”
D. “What did your doctor tell you about these lesions?”
149. When providing health teaching for an elderly client with a decrease in bone density along with an increased brittleness of the bones, the nurse should:
A. Encourage the client to prevent stress fractures by avoiding long walks
B. Instruct the client to eat foods high in calcium and vitamin D
C. Encourage the client to have a yearly bone scan
D. Instruct the client to take over-the-counter anti-inflammatory drugs for discomfort and joint stiffness
150. Most elderly people have difficulty adjusting to near and far vision. This is because of eye changes that include:
A. Diplopia
B. A relative inflexibility of the lens (presbyopia)
C. Bilateral deposition of orbital fat
D. An increase in pupil diameter

SPECIAL ENHACER DRILLS – COURSE AUDIT 1 8