NP 2 Part 2 2021

89問 • 3年前

問題一覧

Situation: 1. Nurse Margie is collecting data from a newly admitted patient, Mrs. De la Cruz who is pregnant with twins. She has a healthy 3-year-old child that was delivered at 38 weeks. She also revealed that she does not have a history of abortion nor fetal demise. Her last menstrual period began February 7, 2017 and ended February 12, 2017. What is the GTPAL for Mrs. De la Cruz?

G = 2, T = 1, P = 0, A = 0, L = 1

2. What is the expected change in the hematologic system that occurs during the end of the first trimester of pregnancy that Nurse Margie should recognize?

An increase in blood volume.

3. Mrs. De la Cruz asks about the functions of placenta. Which of the following items should Nurse Marina include in the teaching plan? 1)The placenta filters the fetal urine. 2)Fetal and maternal blood mix in the placenta to exchange nutrients. 3)The placenta filters the alcohol from the mother’s blood. 4)Substances are exchanged by the placenta without mixing the maternal and fetal blood. 5)Fetal respiration, nutrition, and excretion are carried out by the placenta.

4, 5

4. Mrs. De la Cruz asks “When will be my expected date of delivery (EDD)?” Based on her knowledge of Naegele’s Rule, which should be the CORRECT answer of the nurse?

November 14, 2017

5. In explaining the development of her baby, Nurse Margie identified in chronological order of growth of the fetus as it occurs in pregnancy as ___.

Ovum, zygote, morula, embryo, fetus, infant

Situation: 6. Nurse Katrina admitted a labouring primigravida, Yolanda, brought by an anxious taxi driver. Nurse Katrina calms down the similarly anxious patient that the definitive sign that labor is about to begin is ________.

Initiation of contraction.

7. The discomfort expected with true labor contractions is most accurately described by which of the following?

Discomfort begins in the lower back and abdomen and then radiates over the entire abdomen.

8. Nurse Katrina completed the vaginal examination on the patient. Nurse Katrina recorded: 75%, 7cm, 0. Which of the following is a CORRECT interpretation of the data?

Fetal presenting part is engaged.

9. Nurse Katrina would further estimate that the above data means the cervix is _______.

¼ of its length

10. When does the membranes of a patient in labor MOST likely to rupture?

During the active phase of the first stage of labor, usually at the peak of a contraction.

Situation: 11. Mrs. Alim, gravida 3 para 3003, is admitted to the postpartal unit after an uncomplicated labor and vaginal delivery. She opted to breastfeed her baby. Nurse Imee is around to take care of her. The first day after delivery, Mr. Alim tells the nurse that his wife has been talking constantly about her recent delivery experience. He asks if this is a sign of postpartal blues. What should be the BEST response of the nurse?

"This is a normal reaction. It allows her to accept the reality of the birth of your baby.”

12. Later that day, Mrs. Alim tells Nurse Imee that she has urinated four times within the last hour but only in small amounts. What should be the INITIAL ACTION of the nurse?

Palpate Mrs. Alim’s fundus to assess uterine consistency and location.

13. Which assessment finding is MOST indicative that Mrs. Alim is developing postpartal (puerperal) infection?

Foul-smelling lochia.

14. Mrs. Alim asks Nurse Imee when her menstrual period will return. The nurse answers that a breastfeeding patient typically resumes menstruating in about_________ .

4 to 6 months.

15. Mrs. Alim complains of pain due to breast engorgement. What will the nurse do to encourage her to continue breastfeeding?

Let her continue breastfeeding on demand.

Situation: 4 Nurse Ariane, a public health nurse, brought a pregnant patient to the nearest hospital. Patient Marife’s data include the following: 28 y/o 24 weeks AOG, diagnosed by the Municipal Health doctor as one with mild preeclampsia and who is being monitored for gestational hypertension. 16. Which findings would lead Nurse Ariane to suspect that patient Marife has mild preeclampsia?

Hypertension, edema, proteinuria.

17. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the physician?

Complaints of a headache and blurred vision.

18. Patient Marife progressed to severe preeclampsia with BP 160/ 110 proteinuria, and severe pitting edema. Which of the following would be MOST important for Nurse Ariane to include in the patient’s plan of care?

Seizure precautions.

19. The nurse prepares a plan of care for the patient and documents in the plan that if the she progresses from preeclampsia to eclampsia, which the following will be the FIRST action of the nurse

Clear and maintain an open airway.

20. One of the doctor’s orders is to administer magnesium sulfate. Which of the following determines that the magnesium sulfate therapy is EFFECTIVE?

Seizures do not occur.

Situation 5 One of the responsibilities of a nurse in a fertility specialist’s office is to provide health teaching to the patient in relation to timing of intercourse to achieve pregnancy. 21. Which instruction to the patient addresses the BEST time to achieve a pregnancy?

14 days before the next period is expected.

22. In a lecture on sexual functioning, the nurse plans to include the fact that ovulation occurs on which of the following conditions?

Luteinizing hormone level is high.

23. After ovulation has occurred, the nurse teaches women in the fertility clinic that the ovum is thought to remain viable for how many hours?

24 to 36.

24. When teaching clients to determine the time of ovulation by taking the basal temperature, the nurse explains that the change in the basal temperature during ovulation is shown in which of the following observations? The temperature ________.

drops slightly and then rises again

25. In response to a client’s question on the chief function of progesterone, which of the following would be the CORRECT answer? It _________.

Prepares the uterus to receive a fertilized ovum.

Situation 6 Gabriel, a 6 years old kindergarten pupil is seen at the school clinic for growth and development monitoring by the clinic nurse. 26. Which of the following characterizes the rate of growth during this period?

A decline in growth rate.

27. In assessing Gabriel’s growth and development, the nurse is guided by the principles of growth and development. Which of the following is NOT included?

Rate and pattern of growth can be modified.

28. What type of play will be ideal for Gabriel at this period?

Make believe.

29. Which of the following information indicate that Gabriel is normal for his age?

Has the ability to try new things.

30. Based on Kohlberg’s theory, what is the stage of moral development of the 6 years old Gabriel?

“Good boy-Nice girl”.

Situation 7 Preterm newborns are considered high risk because of their immaturity to adapt to the extrauterine life. They need special treatment and specialized process of nursing care. 31. The goal of a neutral thermal environment is to assist the newborns to stabilize its temperature that does not drop below which of the following?

97.7 degrees F

32. Nurses should be alert when caring for a preterm newborn, particularly for which of the following signs?

Hypoglycemia.

33. The nurse starts giving information about preterm newborns to the parent. She tells them that preterm newborns exhibit which of the following characteristics/signs?

Allows elbows to be brought past the midline of the chest.

34. Hypothermia is common in preterm newborns because of their inability to control heat. Which of the following is an EXCEPTION to the APPROPRIATE nursing intervention to prevent heat loss?

Placing the crib beside the wall.

35. Which of the following conditions is NOT INCLUDED among the effects of cold stress?

Increase intracranial pressure. (ICP)

Situation 8 Nurse Andrea is caring for a toddler Michael with Bronchiolitis and diagnostic tests have confirmed respiratory syncytial virus (RSV). 36. Based on this finding, which of the following is the APPROPRIATE nursing action?

Move the toddler to a room with another child with RSV.

37. Ribavirin (Virazole) is prescribed for Michael with respiratory syncytial virus. The nurse prepares to administer this medication via which of the following routes?

Oxygen tent.

38. Nurse Andrea is teaching the mother of Michael about the disease. Which statement by the mother indicates that teaching has been effective?

“I know that this disease is serious and can lead to asthma.”

39. Nurse Andrea was alarmed because the child is progressing to epiglottitis. Assessing the child, the nurse monitors for which indication that the child may be experiencing airway obstruction?

The child is leaning forward with the chin thrust out.

40. Nurse Andrea told the mother that epiglotitis can be prevented by what EPI vaccine?

Hib vaccine

Situation 9 Benedict 10 years old was admitted with a presenting complaint of polyuria, polydipsia, polyphagia. The doctor’s diagnosis after FBS is type 1 diabetes. Nurse Stephen was assigned to this patient 41. When planning to provide teaching about self-administration of insulin to a school-age child newly diagnosed with diabetes mellitus, what should Nurse Stephen do FIRST?

Assess the child’s developmental level.

42. Benedict told Nurse Stephen that he has soccer practice three afternoons a week. Nurse Stephen provides instructions regarding on how to prevent hypoglycemia during practice, which is to ___________.

Eat six graham crackers or drink a cup of orange juice before soccer practice.

43. Nurse Stephen is teaching Benedict about insulin administration and rotation sites. Which statement, if made by Benedict, would indicate effective teaching?

“I need to use one major site for 2 to 3 weeks before changing major sites.”

44. One week later, the mother of Benedict calls Nurse Stephen and narrated that her child has been sick. She added that she checked the child's urine and it was positive for ketones. What will the nurse instruct the mother? To_____.

Encourage the child to drink calorie-free liquids

45. Benedict case worsens and he is brought to the emergency room by the mother, who states that the child has been complaining of abdominal pain and has a fruity odor of the breath. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, what will the nurse prepare to be administered?

Normal saline IV infusion.

Situation 10 Letty is now 15 years old. She goes to an exclusive school but she seldom interact with her classmates nor is interested to join school activities. Her mother brought her to an adolescent specialist and was diagnosed of Malnutrition. 46. Which of the following is NOT a CORRECT statement about malnutrition? Malnutrition is ______.

Underweight increases with income.

47. Advertisements (ads) on television is said to be a contributory factor for obesity. What could be a GOOD advise or adolescents like Letty regarding these ads that can be contributory to malnutrition?

“Check nutritional contents before buying foods.”

48. Letty went to see a nutritionist. She is overweight for her height. What is the normal weight for Letty who is 5 feet tall?

115 pounds

49. How can Letty be helped to reduce her weight? She can be advised to cut intake of which of the following?

Carbohydrates, fats and salts.

50. Which of the following can Letty do to help her with her obesity problem?

Exercise 30 minutes three times a week.

Situation 11 Liza is a new nurse in the Obstetrics Ward. From her learnings in the undergraduate school, she remembered her Cl saying that nurses must learn how to communicate well with her patients. 51. . One of Liza’s learning is active listening. She uses this in one of her patients named Grace. How will Liza demonstrate this on her patient? She should ___. 1. Listen to what Grace verbalizes and observes how she expresses her feelings. 2. Demonstrate interest on what Grace is talking about by avoiding her eyes. 3. Maintain a close body posture such as keeping arms crossed. 4. Tune out other thoughts and refrain from interrupting Grace while she is talking.

1 and 4

52. Which of the following should NOT be considered by the nurse in interpreting nonverbal messages of a patient?

Eye contact with all patients at all times regardless of race.

53. Demonstrating what she learned from school in terms of obtaining feedback, Liza’s APPROPRIATE response to Grace’s complaint: “My breasts are engorged and it is so painful,” should be _______.

“Tell me about the pain. Is it tolerable, moderate or severe?”

54. Liza also recalled her learning on how to REFOCUS conservations. Thus, when Grace’s subsequent messages were: “I am have this painful engorged breasts and my mother-in-law wants me to bottle feed instead of breastfeed”. What will be Liza’s BEST answer using refocusing technique?

"I think we were talking about breast engorgement which brought about …”

55. In the course of Liza’s duty in the OB Ward, she also learned that she has to adjust her style of communication with different types of paients . Thus, Liza should adjust to which of the following characteristics of Grace? 1.Level of usual communication. 2.Pace of interaction. 3.Display of emotions. 4.Full development of topic.

1, 2, 3, 4

Situation 12 Teddy, 14 years old, son of Demos couple, is brought by “friends” to the Emergency Room (ER) of Medical Center Jericho, because of fainting. He has hematomas and bruises at his arms, buttocks and lower extremities. Nurse Carl is the ER-on-duty. 56. Whom should Nurse Carl call first to inform that Teddy is in the hospital? The ___________.

Parents

57. Based from hospital protocol and from the principle of records management, where should information about the medico-legal cases be recorded FIRST? In the hospital’s ____________.

Security blotter

58. Nurse Carl understands that Teddy’s refusal to give information about his experience is based from the covenant of fraternities that all rituals should be kept “secret”. To calm down the couple’s agitation, he counselled them to talk to a _________.

School authorities

59. Nurse Carl made a thorough health assessment of Teddy. Aside from the external signs of hazing, he should also include which of the following? 1. Drug intoxication. 3. Bleeding. 2. Alcohol intoxication. 4.Blunt Injuries.

1,2,3,4

60. Before the discharge of Teddy, what should Nurse Carl do to help him make sound decisions related to joining organizations/clubs? The nurse can refer him to the ___________________.

Adolescent family counsellor

Situation 13 Breastfeeding is one of the major responsibilities of OPD Nurse Nancy. Along this line she gathers pregnant women to provide them health education about the topic. 61. Nancy explains that exclusive breastfeeding is giving the baby.

Only breast milk for 6 months.

62. She further explains that the specific objectives of exclusive and extended breastfeeding are the following EXCEPT ______.

The median duration of breastfeeding is 12 months.

63. A mother questioned Nurse Nancy in the event that she does not produce milk, what should she do? The BEST answer of Nurse Nancy would be ____.

"Just continue breastfeeding. This will stimulate the hypothalamus to produce milk.”

64. Isabel, one of the pregnant women, asked Nurse Nancy to teach her the proper positioning of the baby while breastfeeding. Among Nurse Nancy’s answers, which one is NOT CORRECT?

The baby can lie down with the mother to promote better bonding.

65. To convince the pregnant mothers to breastfeed their newborn upon delivery, the BEST thing that Nurse Nancy must do is to _______________.

Prepare the mothers emotionally and psychologically.

Situation 14 The hospital training officer asks a staff nurse to relate situations that represents examples of upholding and/or violating the Code of Ethics for Nurses. 66. Which of the following is a violation of the right to privacy of patients?

Letting the patient remove her upper garment before a vaginal ultrasound.

67. A patient receives a medication that was intended for another person. What is the APPROPRIATE way to record the event?

10 mg of Calcitonin administered to patient. Observed closely. No adverse reaction noted. Physician-in-charge notified.

68. If a mother of a child wishes to use herbal supplements instead of antibacterial agents, what is the ethical principle used?

Autonomy

69. Sharon, a pediatric patient and who sustained injury due to vehicular accident, was being wheeled to the X-ray Department. Along the way, the straps suddenly broke and the patient fell to the floor hitting her head. In this situation, the nurse is ____.

Liable along with the employer for use of defective equipment that harmed the patient.

70. While staff nurse Christine was doing her night rounds, she saw staff OB patient Mrs. Pascual meditating and afterwards started to sing prayerful hymns. What is the BEST response of the nurse?

Respect the patient’s actions.

Situation 15 Sarah a 5 year old child is at the ER because of dislocated shoulder. She is silent and somewhat afraid of the people around her. During assessment Nurse Maita noted that the child has multiple bruises on the chest, thighs and upper arms. Nurse Maita suspected child abuse. 71. During blood extraction, Sarah remained still and unaffected. What will be the nurse APPROPRIATE remarks?

It is alright to cry when it hurts.

72. The case can be brought to the court of law through the hospital’s Women’s Desk and the police authority who accompanied Sarah to the hospital. While in the hospital under the care of the physician and the nurse, which of the following actions should be given UTMOST IMPORTANCE?

Document the physical findings, behavior and statements during interactions.

73. According to Special Protection of Children Against Child Abuse Law, if a nurse fails to report a case of child abuse to proper authority within 48 hours, she can be charged in the court of law for which of the following?

Breach of duty.

74. Which of the ff. should Maita understand as the primary outcome to her profession in case she is proven guilty? Administratively,

Her license to practice nursing can be suspended for a period of time by the PRC.

75. What should be a GOOD action of the hospital administration in order that such incident of failure to report will not happen again?

In-service training on how to handle child and woman abuse.

Situation 16 A pregnant patient, Marissa, was diagnosed with Deep Vein Thrombosis (DVT). She was admitted for possible treatment. To Nurse Monica, This is her first time to handle such case and she believes that the experience will make her grow professionally. 76. Nurse Monica recalls that as part of the inflammation process and edema, the patient’s skin will be stretched making it shiny and white known as “milk leg”. What is the medical term for this?

Phlagmasia Alba Dolens.

77. Marissa is give Heparin as treatment for deep venous thrombophlebitis. Which of the following ADVERSE SIGNS AND SYMPTOMS for the treatment should be monitored regularly by Nurse Monica?

Hematuria, ecchymosis, and epistaxis.

78. With intravenous heparin therapy, what medication should nurse Monica has to make available in the event of an overdose of heparin?

Protamine Sulfate.

79. Marissa is now being maintained on heparin therapy for DVT. Nurse Monica must closely monitor which of the following laboratory values?

Activated Partial Thromboplastin Time.

80. As per doctor’s order, the nurse should teach her patient to AVOID which of the medicines that can aggravate the bleeding tendency of the patient?

Salicylates.

Situation 17 Marco, 3 years old who underwent ventricular septal defect repair is placed on a maintenance dosage of digoxin (Lanoxin) elixir. Nurse Rita complete with the knowledge of the disease is assigned to him. 81. The dosage is 0.07 mg/kg/day, and the client's weight is 7.2 kg. The physician orders the Digoxin to be given twice daily. How much Digoxin should Nurse Rita prepare to administer at each dose?

0.25 mg.

82. Nurse Rita provides home care instructions to the parents of Marco regarding the procedure for the administration of digoxin (Lanoxin). Which statement, if made by the parent, indicates the need for further instructions?

"If the child vomits after medication administration, I will repeat the dose.”

83. Which of the following instructions about ORAL pediatric medications is TRUE as these interfere with milk and milk products or food eaten by young children? Oral medication should be given _____________.

On an empty stomach.

84. Marco has a blood pressure of 92/78; resting pulse of 60; respirations 28 and a potassium level of 4.8 mEq/L. He is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity?

Bradycardia

85. Considering Marco’s age, which of the following is the BEST approach by the nurse when administering medication?

Would you like to take your medicine from a spoon or a cup?“

Situation 18 Nurse May Ann is caring for a mother-infant dyad. The mother has just given birth to a baby boy two days ago. Today, the charge nurse is doing a chart audit to determine whether the nursing process was properly done from prenatal to postnatal periods. The laboratory results of the mother and baby boy are shown below. 86. Using the chart data, which nursing intervention was CORRECTLY done by Nurse May Ann for Mrs. Andrea Santiago?

Rubella vaccination.

87. Nurse May Ann charted an IMPORTANT plan of care during the period of pregnancy of Mrs. Santiago. She indicated in her charting that Mrs. Santiago should be careful and should report immediately signs and symptoms of Rubella because the virus may affect the cardiovascular system of the fetus during which of the period of pregnancy?

First month of pregnancy.

88. Looking at the medication sheet, the charge nurse noted that Nurse May Ann used the CORRECT ROUTE in the administration of the Rubella vaccine, which was ____________.

Subcutaneous.

89. After administration of Rubella vaccine, health teaching was also charted by the staff nurse. Which of the following is the CORRECT one?

No pregnancy for 3 months.

Critical Med Surg Pentagon

Castle Aranza · 31問 · 3年前

Critical Med Surg Pentagon