1.
Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). A nursing action that must be initiated as the plan of care throughout injection of the drug is:
Correct Answer
C. EKG tracings
Explanation
Answer: (C) EKG tracings
Rationale: A potential side effect of calcium gluconate administration is cardiac arrest. Continuous monitoring of cardiac activity (EKG) throught administration of calcium gluconate is an essential part of care.
2.
A pregnant client is receiving oxytocin (Pitocin)
for induction of labor. A condition that warrant
the nurse in-charge to discontinue I.V. infusion
of Pitocin is:
Correct Answer
A. Contractions every 1 ½ minutes lasting 70-80 seconds.
Explanation
Answer: (A) Contractions every 1 ½ minutes lasting 70-80 seconds.
Rationale: Contractions every 1 ½ minutes lasting 70-80 seconds, is indicative of hyperstimulation of the uterus, which could result in injury to the mother and the fetus if Pitocin is not discontinued.
3.
During vaginal examination of Janah who is in labor, the presenting part is at station plus two.Nurse, correctly interprets it as:
Correct Answer
C. Presenting part in 2 cm below the plane of the ischial spines.
Explanation
Answer: (C) Presenting part in 2 cm below the plane of the ischial spines.
Rationale: Fetus at station plus two indicates that the presenting part is 2 cm below the plane of the ischial spines.
4.
A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension(PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is:
Correct Answer
B. Absent patellar reflexes.
Explanation
Answer: (B) Absent patellar reflexes
Rationale: Absence of patellar reflexes is an indicator of hypermagnesemia, which requires administration of calcium gluconate.
5.
Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware that one of the following is unassociated with this condition?
Correct Answer
A. Excessive fetal activity.
Explanation
Answer: (A) Excessive fetal activity.
Rationale: The most common signs and symptoms of hydatidiform mole includes elevated levels of human chorionic gonadotropin, vaginal bleeding, larger than normal uterus for gestational age, failure to
detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting, and early development of pregnancy-induced hypertension. Fetal activity would not be noted.
6.
May arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. She also tells the nurse that a home pregnancy test was positive but she began to have mild cramps and is now having moderate vaginal bleeding. During the physical examination of the client, the nurse notes that May has a dilated cervix. The nurse determines that May is experiencing which type of abortion?
Correct Answer
A. Inevitable
Explanation
Answer: (A) Inevitable
Rationale: An inevitable abortion is termination of pregnancy that cannot be prevented. Moderate to severe bleeding with mild cramping and cervical dilation would be noted in this type of abortion.
7.
Nurse Ryan is aware that the best initial approach when trying to take a crying toddler’s temperature is:
Correct Answer
A. Talk to the mother first and then to the toddler.
Explanation
Answer: (A) Talk to the mother first and then to the toddler.
Rationale: When dealing with a crying toddler, the best approach is to talk to the mother and ignore the toddler first. This approach helps the toddler get used to the nurse before she attempts any procedures. It also gives the toddler an opportunity to see that the mother trusts the nurse.
8.
Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the nurse do to prevent trauma to operative site?
Correct Answer
D. Place the infant’s arms in soft elbow
restraints.
Explanation
Answer: (D) Place the infant’s arms in soft
elbow restraints.
Rationale: Soft restraints from the upper arm to
the wrist prevent the infant from touching her
lip but allow him to hold a favorite item such as
a blanket. Because they could damage the
operative site, such as objects as pacifiers,
suction catheters, and small spoons shouldn’t
be placed in a baby’s mouth after cleft repair. A
baby in a prone position may rub her face on
the sheets and traumatize the operative site.
The suture line should be cleaned gently to
prevent infection, which could interfere with
healing and damage the cosmetic appearance
of the repair.
9.
Myra is the public health nurse in a municipality
with a total population of about 20,000. There
are 3 rural health midwives among the RHU
personnel. How many more midwife items will
the RHU need?
Correct Answer
A. 1
Explanation
Answer: (A) 1
Rationale: Each rural health midwife is given a
population assignment of about 5,000.
10.
Vangie is a new B.S.N. graduate. She wants to
become a Public Health Nurse. Where should
she apply?
Correct Answer
D. Rural Health Unit
Explanation
Answer: (D) Rural Health Unit
Rationale: R.A. 7160 devolved basic health
services to local government units (LGU’s ). The
public health nurse is an employee of the LGU.
11.
When the nurse determines whether resources
were maximized in implementing Ligtas Tigdas,
she is evaluating
Correct Answer
B. Efficiency
Explanation
Answer: (B) Efficiency
Rationale: Efficiency is determining whether the
goals were attained at the least possible cost.
12.
Which of the following is the most prominent
feature of public health nursing?
Correct Answer
D. Public health nursing focuses on
preventive, not curative, services.
Explanation
Answer: (D) Public health nursing focuses on
preventive, not curative, services.
Rationale: The catchments area in PHN consists
of a residential community, many of whom are
well individuals who have greater need for
preventive rather than curative services.
13.
Mommy Linda is playing with her infant, who is
sitting securely alone on the floor of the clinic.
The mother hides a toy behind her back, and the infant looks for it. The nurse is aware that
the estimated age of the infant would be:
Correct Answer
D. 10 months
Explanation
Answer: (D) 10 months Rationale: A 10 month old infant can sit alone and understands object permanence, so he would look for the hidden toy. At age 4 to 6 months, infants can’t sit securely alone. At age 8 months, infants can sit securely alone but cannot understand the permanence of objects.
14.
Nurse Hazel is teaching a mother who plans to
discontinue breast feeding after 5 months. The
nurse should advise her to include which foods
in her infant’s diet?
Correct Answer
C. Iron-rich formula only.
Explanation
Answer: (C) Iron-rich formula only.
Rationale: The infants at age 5 months should
receive iron-rich formula and that they
shouldn’t receive solid food, even baby food
until age 6 months.
15.
Which action should nurse Marian include in the
care plan for a 2 month old with heart failure?
Correct Answer
B. Allow the infant to rest before feeding.
Explanation
Answer: (B) Allow the infant to rest before
feeding.
Rationale: Because feeding requires so much
energy, an infant with heart failure should rest
before feeding.
16.
According to Freeman and Heinrich, community
health nursing is a developmental service. Which
of the following best illustrates this statement?
Correct Answer
B. Health education and community
organizing are necessary in providing
community health services.
Explanation
Answer: (B) Health education and community
organizing are necessary in providing
community health services. Rationale: The
community health nurse develops the health
capability of people through health education
and community organizing activities.
17.
Beth a public health nurse takes an active role in
community participation. What is the primary
goal of community organizing?
Correct Answer
D. To maximize the community’s resources
in dealing with health problems.
Explanation
Answer: (D) To maximize the community’s
resources in dealing with health problems.
Rationale: Community organizing is a
developmental service, with the goal of
developing the people’s self-reliance in dealing
with community health problems. A, B and C
are objectives of contributory objectives to this
goal.
18.
The nurse is caring for a primigravid client in the
labor and delivery area. Which condition would
place the client at risk for disseminated
intravascular coagulation (DIC)?
Correct Answer
A. Intrauterine fetal death.
Explanation
Answer: (A) Intrauterine fetal death.
Rationale: Intrauterine fetal death, abruptio
placentae, septic shock, and amniotic fluid
embolism may trigger normal clotting
mechanisms; if clotting factors are depleted,
DIC may occur. Placenta accreta, dysfunctional
labor, and premature rupture of the
membranes aren't associated with DIC.
19.
A fullterm client is in labor. Nurse Betty is aware
that the fetal heart rate would be:
Correct Answer
C. 120 to 160 beats/minute
Explanation
Answer: (C) 120 to 160 beats/minute
Rationale: A rate of 120 to 160 beats/minute in
the fetal heart appropriate for filling the heart
with blood and pumping it out to the system.
20.
The skin in the diaper area of a 7 month old
infant is excoriated and red. Nurse Hazel should
instruct the mother to:
Correct Answer
A. Change the diaper more often.
Explanation
Answer: (A) Change the diaper more often.
Rationale: Decreasing the amount of time the
skin comes contact with wet soiled diapers will
help heal the irritation.
21.
Nurse Carla knows that the common cardiac
anomalies in children with Down Syndrome (trisomy
21)
is:
Correct Answer
D. Endocardial cushion defect
Explanation
Answer: (D) Endocardial cushion defect
Rationale: Endocardial cushion defects are seen
most in children with Down syndrome,
asplenia, or polysplenia.
22.
Malou was diagnosed with severe preeclampsia
is now receiving I.V. magnesium sulfate. The
adverse effects associated with magnesium
sulfate is:
Correct Answer
B. Decreased urine output
Explanation
Answer: (B) Decreased urine output
Rationale: Decreased urine output may occur in
clients receiving I.V. magnesium and should be
monitored closely to keep urine output at
greater than 30 ml/hour, because magnesium is
excreted through the kidneys and can easily
accumulate to toxic levels.
23.
A 23 year old client is having her menstrual
period every 2 weeks that last for 1 week. This
type of menstrual pattern is bets defined by:
Correct Answer
A. Menorrhagia
Explanation
Answer: (A) Menorrhagia
Rationale: Menorrhagia is an excessive
menstrual period.
24.
Nurse Gina is aware that the most common
condition found during the second-trimester of
pregnancy is:
Correct Answer
D. pHysiologic anemia
Explanation
Answer: (D) Physiologic anemia
Rationale: Hemoglobin values and hematocrit
decrease during pregnancy as the increase in
plasma volume exceeds the increase in red
blood cell production.
25.
Nurse Lynette is working in the triage area of an
emergency department. She sees that several
pediatric clients arrive simultaneously. The client
who needs to be treated first is:
Correct Answer
D. A 2 year old infant with stridorous
breath sounds, sitting up in his mother’s
arms and drooling.
Explanation
Answer: (D) A 2 year old infant with stridorous
breath sounds, sitting up in his mother’s arms
and drooling.
Rationale: The infant with the airway
emergency should be treated first, because of
the risk of epiglottitis.
26.
Maureen in her third trimester arrives at the
emergency room with painless vaginal bleeding.
Which of the following conditions is suspected?
Correct Answer
A. Placenta previa
Explanation
Answer: (A) Placenta previa
Rationale: Placenta previa with painless vaginal
bleeding.
27.
A young child named Richard is suspected of
having pinworms. The community nurse collects
a stool specimen to confirm the diagnosis. The
nurse should schedule the collection of this
specimen for:
Correct Answer
D. Early in the morning
Explanation
Answer: (D) Early in the morning
Rationale: Based on the nurse’s knowledge of
microbiology, the specimen should be collected
early in the morning. The rationale for this
timing is that, because the female worm lays
eggs at night around the perineal area, the first
bowel movement of the day will yield the best
results. The specific type of stool specimen
used in the diagnosis of pinworms is called the
tape test.
28.
In doing a child’s admission assessment, Nurse
Betty should be alert to note which signs or
symptoms of chronic lead poisoning?
Correct Answer
A. Irritability and seizures
Explanation
Answer: (A) Irritability and seizures
Rationale: Lead poisoning primarily affects the
CNS, causing increased intracranial pressure.
This condition results in irritability and changes
in level of consciousness, as well as seizure
disorders, hyperactivity, and learning
disabilities.
29.
To evaluate a woman’s understanding about the
use of diaphragm for family planning, Nurse
Trish asks her to explain how she will use the
appliance. Which response indicates a need for
further health teaching?
Correct Answer
D. “The diapHragm must be left in place for
atleast 6 hours after intercourse”
d. “I really need to use the diapHragm and
jelly most during the middle of my
menstrual cycle”.
Explanation
Answer: (D) “I really need to use the diaphragm
and jelly most during the middle of my
menstrual cycle”.
Rationale: The woman must understand that,
although the “fertile” period is approximately
mid-cycle, hormonal variations do occur and
can result in early or late ovulation. To be
effective, the diaphragm should be inserted
before every intercourse.
30.
How should Nurse Michelle guide a child who is
blind to walk to the playroom?
Correct Answer
B. Walk one step ahead, with the child’s
hand on the nurse’s elbow.
Explanation
Answer: (B) Walk one step ahead, with the
child’s hand on the nurse’s elbow.
Rationale: This procedure is generally
recommended to follow in guiding a person
who is blind.
31.
When assessing a newborn diagnosed with
ductus arteriosus, Nurse Olivia should expect
that the child most likely would have an:
Correct Answer
A. Loud, machinery-like murmur.
Explanation
Answer: (A) Loud, machinery-like murmur.
Rationale: A loud, machinery-like murmur is a
characteristic finding associated with patent
ductus arteriosus.
32.
Before adding potassium to an infant’s I.V. line,
Nurse Ron must be sure to assess whether this
infant has:
Correct Answer
D. Voided
Explanation
Answer: (D) Voided
Rationale: Before administering potassium I.V.
to any client, the nurse must first check that the
client’s kidneys are functioning and that the
client is voiding. If the client is not voiding, the nurse should withhold the potassium and notify
the physician.
33.
Nurse Carla should know that the most common
causative factor of dermatitis in infants and
younger children is:
Correct Answer
C. Laundry detergent
Explanation
Answer: (c) Laundry detergent
Rationale: Eczema or dermatitis is an allergic
skin reaction caused by an offending allergen.
The topical allergen that is the most common
causative factor is laundry detergent.
34.
In a health teaching class, Nurse Lhynnete discussed
childhood diseases such as chicken pox. Which
of the following statements about chicken pox is
correct?
Correct Answer
A. The older one gets, the more susceptible
he becomes to the complications of
chicken pox.
Explanation
Answer: (A) The older one gets, the more
susceptible he becomes to the complications of
chicken pox.
Rationale: Chicken pox is usually more severe in
adults than in children. Complications, such as
pneumonia, are higher in incidence in adults.
35.
Barangay Pinoy had an outbreak of German
measles. To prevent congenital rubella, what is
the BEST advice that you can give to women in
the first trimester of pregnancy in the Barangay?
Correct Answer
D. Consult a pHysician who may give them
rubella immunoglobulin.
Explanation
Answer: (D) Consult a physician who may give
them rubella immunoglobulin.
Rationale: Rubella vaccine is made up of
attenuated German measles viruses. This is
contraindicated in pregnancy. Immune globulin,
a specific prophylactic against German measles,
may be given to pregnant women.
36.
Myrna a public health nurse knows that to
determine possible sources of sexually
transmitted infections, the BEST method that
may be undertaken is:
Correct Answer
A. Contact tracing
Explanation
Answer: (A) Contact tracing
Rationale: Contact tracing is the most practical
and reliable method of finding possible sources
of person-to-person transmitted infections,
such as sexually transmitted diseases.
37.
A 33-year old female client came for
consultation at the health center with the chief
complaint of fever for a week. Accompanying
symptoms were muscle pains and body malaise.
A week after the start of fever, the client noted
yellowish discoloration of his sclera. History
showed that he waded in flood waters about 2
weeks before the onset of symptoms. Based on
her history, which disease condition will you
suspect?
Correct Answer
D. Leptospirosis
Explanation
Answer: (D) Leptospirosis
Rationale: Leptospirosis is transmitted through
contact with the skin or mucous membrane
with water or moist soil contaminated with
urine of infected animals, like rats.
38.
Mickey a 3-year old client was brought to the
health center with the chief complaint of severe
diarrhea and the passage of “rice water” stools.
The client is most probably suffering from which
condition?
Correct Answer
B. Cholera
Explanation
Answer: (B) Cholera
Rationale: Passage of profuse watery stools is
the major symptom of cholera. Both amebic
and bacillary dysentery are characterized by the
presence of blood and/or mucus in the stools.
Giardiasis is characterized by fat malabsorption
and, therefore, steatorrhea.
39.
The student nurse is aware that the
pathognomonic sign of measles is Koplik’s spot
and you may see Koplik’s spot by inspecting the:
Correct Answer
B. Buccal mucosa
Explanation
Answer: (B) Buccal mucosa
Rationale: Koplik’s spot may be seen on the
mucosa of the mouth or the throat.
40.
In Integrated Management of Childhood Illness,
the nurse is aware that the severe conditions
generally require urgent referral to a hospital.
Which of the following severe conditions DOES
NOT always require urgent referral to a hospital?
Correct Answer
B. Severe dehydration
Explanation
Answer: (B) Severe dehydration
Rationale: The order of priority in the
management of severe dehydration is as
follows: intravenous fluid therapy, referral to a
facility where IV fluids can be initiated within 30
minutes, Oresol or nasogastric tube. When the
foregoing measures are not possible or
effective, then urgent referral to the hospital is
done.
41.
Marie brought her 10 month old infant for
consultation because of fever, started 4 days
prior to consultation. In determining malaria
risk, what will you do?
Correct Answer
B. Ask where the family resides.
Explanation
Answer: (B) Ask where the family resides.
Rationale: Because malaria is endemic, the first
question to determine malaria risk is where the
client’s family resides. If the area of residence is
not a known endemic area, ask if the child had
traveled within the past 6 months, where she
was brought and whether she stayed overnight
in that area.
42.
Susie brought her 4 years old daughter to the
RHU because of cough and colds. Following the
IMCI assessment guide, which of the following is
a danger sign that indicates the need for urgent
referral to a hospital?
Correct Answer
A. Inability to drink
Explanation
Answer: (A) Inability to drink
Rationale: A sick child aged 2 months to 5 years
must be referred urgently to a hospital if
he/she has one or more of the following signs:
not able to feed or drink, vomits everything,
convulsions, abnormally sleepy or difficult to
awaken.
43.
Jimmy a 2-year old child revealed “baggy pants”.
As a nurse, using the IMCI guidelines, how will
you manage Jimmy?
Correct Answer
A. Refer the child urgently to a hospital for
confinement.
Explanation
Answer: (A) Refer the child urgently to a
hospital for confinement.
Rationale: “Baggy pants” is a sign of severe
marasmus. The best management is urgent
referral to a hospital.
44.
Gina is using Oresol in the management of
diarrhea of her 3-year old child. She asked you
what to do if her child vomits. As a nurse you will
tell her to:
Correct Answer
D. Let the child rest for 10 minutes then
continue giving Oresol more slowly.
Explanation
Answer: (D) Let the child rest for 10 minutes
then continue giving Oresol more slowly.
Rationale: If the child vomits persistently, that
is, he vomits everything that he takes in, he has
to be referred urgently to a hospital. Otherwise,
vomiting is managed by letting the child rest for
10 minutes and then continuing with Oresol
administration. Teach the mother to give Oresol
more slowly.
45.
Chris a 4-month old infant was brought by her
mother to the health center because of cough.
His respiratory rate is 42/minute. Using the
Integrated Management of Child Illness (IMCI)
guidelines of assessment, his breathing is
considered as:
Correct Answer
C. Normal
Explanation
Answer: (C) Normal
Rationale: In IMCI, a respiratory rate of
50/minute or more is fast breathing for an
infant aged 2 to 12 months.
46.
Maylene had just received her 4th dose of
tetanus toxoid. She is aware that her baby will
have protection against tetanus for
Correct Answer
A. 1 year
Explanation
Answer: (A) 1 year
Rationale: The baby will have passive natural
immunity by placental transfer of antibodies.
The mother will have active artificial immunity
lasting for about 10 years. 5 doses will give the
mother lifetime protection.
47.
Nurse Ron is aware that unused BCG should be
discarded after how many hours of
reconstitution?
Correct Answer
B. 4 hours
Explanation
Answer: (B) 4 hours
Rationale: While the unused portion of other
biologicals in EPI may be given until the end of
the day, only BCG is discarded 4 hours after
reconstitution. This is why BCG immunization is
scheduled only in the morning.
48.
The nurse explains to a breastfeeding mother
that breast milk is sufficient for all of the baby’s
nutrient needs only up to:
Correct Answer
B. 6 months
Explanation
Answer: (B) 6 months
Rationale: After 6 months, the baby’s nutrient
needs, especially the baby’s iron requirement,
can no longer be provided by mother’s milk
49.
Nurse Ron is aware that the gestational age of a
conceptus that is considered viable (able to live
outside the womb) is:
Correct Answer
C. 24 weeks
Explanation
Answer: (C) 24 weeks
Rationale: At approximately 23 to 24 weeks’
gestation, the lungs are developed enough to
sometimes maintain extrauterine life. The lungs
are the most immature system during the gestation period. Medical care for premature
labor begins much earlier (aggressively at 21
weeks’ gestation)
50.
Which finding might be seen in baby James a
neonate suspected of having an infection?
Correct Answer
C. Decreased temperature
Explanation
Answer: (C) Decreased temperature
Rationale: Temperature instability, especially
when it results in a low temperature in the
neonate, may be a sign of infection. The
neonate’s color often changes with an infection
process but generally becomes ashen or
mottled. The neonate with an infection will
usually show a decrease in activity level or
lethargy.