INP RBE

1. The nurse is reviewing laboratory a. "With type 2 diabetes, the body of the
results for the clinic patients to seen pancreas becomes inflamed."
today. Which patients meets the b. "With type 2 diabetes, insulin secretion is
diagnostic criteria for diabetes mellitus? decreased, and insulin resistance is
a. A 48-year-old woman with a increased."
hemoglobin A1C of 8.4% c. "With type 2 diabetes, the patient is
b. A 58-year-old man with a fasting blood totally dependent on an outside source of
glucose of 111 mg/dL insulin."
c. A 68-year-old woman with a random d. "With type 2 diabetes, the body produces
plasma glucose of 190 mg/dL autoantibodies that destroy β-cells in the
d. A 78-year-old man with a 2-hour pancreas."
glucose tolerance plasma glucose of 5. The nurse is assigned to the care of a
184 mg/dL 64-year-old patient diagnosed with type
2. The nurse teaches a 38-year-old man 2 diabetes. In formulating a teaching
who was recently diagnosed with type 1 plan that encourages the patient to
diabetes mellitus about insulin actively participate in management of
administration. Which statement by the the diabetes, what should be the nurse's
patient requires an intervention by the initial intervention?
nurse? a. Assess patient's perception of what it
a. “I will discard any insulin bottle that is means to have diabetes.
cloudy in appearance.” b. Ask the patient to write down current
b. “The best injection site for insulin knowledge about diabetes.
administration is in my abdomen.” c. Set goals for the patient to actively
c. “I can wash the site with soap and participate in managing his diabetes.
water before insulin administration.” d. Assume responsibility for all of the
d. “I may keep my insulin at room patient's care to decrease stress level.
temperature (75o F) for up to a 6. The nurse is evaluating a 45-year-old
month.” patient diagnosed with type 2 diabetes
3. The nurse instructs a 22-year-old mellitus. Which symptom reported by
female patient with diabetes mellitus the patient is considered one of the
about a healthy eating plan. Which classic clinical manifestations of
statement made by the patient indicates diabetes?
that teaching was successful? a. Excessive thirst
a. "I plan to lose 25 pounds this year by b. Gradual weight gain
following a high-protein diet." c. Overwhelming fatigue
b. "I may have a hypoglycemic reaction if I d. Recurrent blurred vision
drink alcohol on an empty stomach." 7. A patient, who is admitted with
c. "I should include more fiber in my diet diabetes mellitus, has a glucose level of
than a person who does not have diabetes." 380 mg/dL and a moderate level of
d. "If I use an insulin pump, I will not need ketones in the urine. As the nurse
to limit the amount of saturated fat in my assesses for signs of ketoacidosis,
diet. which respiratory pattern would the
4. A 54-year-old patient admitted with nurse expect to find?
type 2 diabetes asks the nurse what a. Central apnea
"type 2" means. What is the most b. Hypoventilation
appropriate response by the nurse? c. Kussmaul respirations
INP RBE

d. Cheyne-Stokes respirations the client diagnosed with DKA who has

8. The nurse has taught a patient just been admitted to the ICU?
admitted with diabetes, cellulitis, and a. Glucose.
osteomyelitis about the principles of b. Potassium.
foot care. The nurse evaluates that the c. Calcium.
patient understands the principles of d. Sodium.
foot care if the patient makes what 12. A client is admitted to the hospital
statement? with signs and symptoms of diabetes
a. "I should only walk barefoot in nice dry mellitus. Which findings is the nurse
weather." most likely to observe in this client?
b. "I should look at the condition of my feet a. Excessive thirst
every day." b. Excessive hunger
c. "I am lucky my shoes fit so nice and tight c. Frequent, high-volume urination
because they give me firm support." d. All of the above
d. "When I am allowed up out of bed, I 13. A diabetic patient has a serum
should check the shower water with my glucose level of 824 mg/dL (45.7
toes." mmol/L) and is unresponsive. After
9. The diabetic educator is teaching a assessing the patient, the nurse
class on diabetes Type 1 and is suspects diabetic ketoacidosis rather
discussing sick-day rules. Which than hyperosmolar hyperglycemic
interventions should the diabetes syndrome based on the finding of
educator include in the discussion? a. polyuria.
a. Take diabetic medication even if b. severe dehydration.
unable to eat the client's normal c. rapid, deep respirations.
diabetic diet. d. decreased serum potassium.
b. If unable to eat, drink liquids that are 14. Which assessment data indicate to
equal to the client's normal caloric the nurse the clients gastric ulcer has
intake. perforated?
c. Call the health-care provider if glucose A. Complaints of sudden, sharp, substernal
levels are higher than 180 mg/dL. pain
d. All of the above B. Rigid, boardlike abdomen with rebound
10. The client diagnosed with type 2 tenderness
diabetes is admitted to the intensive C. Frequent, clay-colored, liquid stool
care unit with hyperosmolar D. Complaints of vague abdominal pain in
hyperglycemic nonketonic syndrome the right upper quadrant
(HHNS) coma. Which assessment data 15. Which specific data should the nurse
should the nurse expect the client to obtain from the client who is suspected
exhibit? of having peptic ulcer disease?
a. Kussmaul's respirations. A. History of side effects experienced from
b. Diarrhea and epigastric pain. all medications
c. Dry mucous membranes. B. Use of non steroidal anti inflammatory
d. Ketone breath odor. drugs (NSAIDs)
11. Which electrolyte replacement C. Any known allergies to drugs and
should the nurse anticipate being environmental factors
ordered by the health-care provider in D. Medical histories of at lease 3 generations
INP RBE

16. Which physical examination should bleeding. Which priority intervention

the nurse implement first when should the nurse implement?
assessing the client diagnosed with A. Maintain a strict record of intake and
peptic ulcer disease? output
A. Auscultate the clients bowel sounds in all B. Insert a nasogastric tube and begin saline
four quadrants lavage
B. Palpate the abdominal area for tenderness C. Assist the client with keeping a detailed
C. Percuss the abdominal borders to identify calorie count
organs D. Provide a quiet environment to promote
D. Assess the tender area progressing to rest
nontender 21. The client with peptic ulcer disease
17. Which expected outcome should the (PUD) asks the nurse whether licorice
nurse include for a client diagnosed and slippery elm might be useful in
with peptic ulcer disease? managing the disease. What is the
A. The clients pain is controlled with the use nurse's best response?
of NSAIDs A. "No, they probably won't be useful. You
B. The client maintains lifestyle modifications should use only prescription medications in
C. The client has no signs and symptoms of your treatment plan."
hemoptysis B. "These herbs could be helpful. However,
D. The client take s antacids with each meal you should talk with your physician before
18. The nurse has been assigned to care adding them to your treatment regimen."
for a client diagnosed with peptic ulcer C. "Yes, these are known to be effective in
disease. Which assessment data require managing this disease, but make sure you
further intervention? research the herbs thoroughly before taking
A. Bowel sour s auscultated 15 times in 1 them."
minute D. "No, herbs are not useful for managing
B. Belching after eating a heavy and fatty this disease. You can use any type of over-
meal late at night the-counter drugs though. They have been
C. A decrease in systolic BP of 20 mm Hg shown to be safe."
from lying to sitting 22. The nurse would increase the
D. A decreased frequency of distress located comfort of the patient with appendicitis
in the epigastric region by:
19. The nurse has administered an a. Having the patient lie prone
antibiotic, a proton pump inhibitor, and b. Flexing the patient's right knee
Pepto- Bismol for peptic ulcer disease c. Sitting the patient upright in a chair
secondary to H. pylori. Which data d. Turning the patient onto his or her left
would indicate to the nurse the side
medications are effective? 23. A client is admitted with a diagnosis
A. A decrease in alcohol intake of acute appendicitis. When assessing
B. Maintaining a bland diet the abdomen, the nurse would expect to
C. A return to previous activities find rebound tenderness at which
D. A decrease in gastric distress location?
20. The client with a history of peptic a) Left lower quadrant
ulcer disease is admitted into the b) Left upper quadrant
intensive care unit with frank gastric c) Right upper quadrant
d) Right lower quadrant
INP RBE

24.The nurse is monitoring a client pylorus, duodenum or in the esophagus-

diagnosed with appendicitis who is generally occur alone, commonly found
scheduled for surgery in 2 hours. The in the duodenum
client begins to complain of increased a. Peptic ulcer disease
abdominal pain and begns to vomit. On b. Appendicitis
assessment, the nurse notes that the c. Gastritis
abdomen is distended and bowel sounds d. Stomach cancer
are diminished. Which is the appropriate 29. A client is in DKA, secondary to
nursing intervention? infection. As the condition progresses,
a. Notify the Physician which of the following symptoms might
b. Administer the prescribed pain the nurse see?
medication a) Kussmaul's respirations & a fruity odor
c. Call and ask the operating room team to on breath
perform the surgery as soon as possible b) Shallow respirations & severe abd pain
d. Reposition the client and apply a heating c) Decreased respirations & increased urine
pad on warm setting to the client's output
abdomen d) Cheyne-stokes respirations & foul-
25. A client telephones the health clinic smelling urine
with complaints of generalized 30. A client with a diagnosis of diabetic
abdominal pain which is aggravated by ketoacidosis (DKA) is being treated in
moving or walking. The client has not the ER. Which finding would a nurse
been able to eat for a day and is expect to note as confirming this
nauseated. Which advice should the diagnosis?
nurse provide to this client? a) Elevated blood glucose level & low
A. "Take a warm shower and apply a heating plasma bicarbonate
pad to the abdomen." b) Decreased urine output
B. "Rest in bed and drink warm fluids." c) Increased respirations & increase in pH
C. "Seek immediate medical attention." d) Comatose state
D. "Take an over-the-counter laxative." 31. The nurse assisting in the admission
26. Which clinical manifestation does of a client with diabetic ketoacidosis will
the nurse expect with acute anticipate the physician ordering which
appendicitis? of the following types of intravenous
A. High fever solution if the client cannot take fluids
B. Nausea and vomiting orally?
C. Rebound tenderness a. Lactated Ringer's solution
D. Pain relieved with ambulation b. 0.9 normal saline solution
27. A client presents with suspected c. 5% dextrose in water (D5W)
appendicitis. The nurse should prepare d. 0.45% normal saline solution
the client for which collaborative 32. Which of the following if stated by
intervention? the nurse is correct about
A. Chest x-ray Hyperglycemic Hyperosmolar
B. Abdominal ultrasound Nonketotic Syndrome (HHNS)?
C. Electrolytes a. This syndrome occurs mainly in people
D. Complete blood count (CBC) with Type I Diabetes
28. Refers to an excavation that forms b. It has a higher mortality rate than
in the mucosal wall of the stomach, the Diabetic Ketoacidosis
INP RBE

c. The client with HHNS is in a state of 37. You are teaching the patient with
overhydration chronic kidney disease about what
d. This condition develops very rapidly symptoms to report to the doctor when
33. Dr. Hugo has prescribed outside of the hospital. Which
sulfonylureas for Rebecca in the statement, if made by the patient,
management of diabetes mellitus type indicates correct understanding?
2. As a nurse, you know that the A) "I should call my doctor if my stomach
primary purpose of sulfonylureas, such starts feeling sick or my breath smells
as long-acting glyburide (Micronase), is funny like pea"
to: B) "Muscle weakness and abdominal
A. Induce hypoglycemia by decreasing cramps are a sign of worsening condition
insulin sensitivity. and I should report this to my doctor"
B. Improve insulin sensitivity and decrease C) "My doctor wants me to call him if I feel
hyperglycemia. a vibrating or buzzing sensation over my
C. Stimulate the beta cells of the pancreas hemodialysis graft.
to secrete insulin. D) "I should call immediately if I see
D. Decrease insulin sensitivity by swelling at my dialysis port"
enhancing glucose uptake. 38. Nurse Shelby is preparing to
34. When a client is first admitted with administer selvemer hydrochloride
hyperglycemic hyperosmolar nonketotic (Renagel) to the patient with CKF
syndrome (HHNS), the nurse's priority (Chronic Kidney Disease). Which of the
is to provide: following does the nurse know to be
a) Oxygen true?
b) Carbohydrates A) This medication should be given on an
c) Fluid replacement empty stomach
d) Dietary instruction B) It is used to treat hyperphosphatemia
35. A nurse performs a physical C) To administer at bedtime
assessment on a client with type 2 D) Renagel can be used to help with
diabetes mellitus. Findings include a hypercalcemia
fasting blood glucose of 120 mg/dL, 39. Nurse Vincent is looking over the
temp of 101 F, pulse of 88 bpm, patient chart and is preparing to
respirations of 22, and blood pressure administer erythropoietin to the patient
of 100/72. Which finding would be of with CKF. Which of the following pieces
most concern to the nurse? of information in the chart would cause
Nurse Heather to question this order?
a) Pulse A) Hgb of 9
b) Respiration B) Hx of uncontrolled HTN
c) Temperature C) Pt. complains of fatigue
d) Blood pressure D) Ferric Gluconate (Ferrlecit) is also
36. The principal goals of therapy for ordered
older patients who have poor glycemic 40. You are teaching the patient starting
control are: hemodialysis. Which statement, if made
A. Enhancing quality of life. by the patient, indicates the need for
B. Decreasing the chance of complications. further teaching?
C. Improving self-care through education. A) "To protect my fistula I shouldn't wear
D. All of the above. tight fitting clothing on that side"
INP RBE

B) "If I see any redness or swelling on the B) "In order to have hemodialysis you need
site I should call my doctor" to have friends or family to help you. Do
C) "I shouldn't sleep on my side with the you even have any friends?"
graft but it's ok to take a blood pressure on C) "Home hemodialysis is a possibility but
that arm" it will be necessary to inspect your home"
D) "I need to wait to take my medications D) "Because of your preexisting conditions,
until after my dialysis treatment" you would not be a good candidate for
41. A patient with CKF arrives for his home dialysis"
dialysis treatment complaining of 44. The nurse is performing peritoneal
muscle aches and digestive upset. He dialysis exchange on the patient with
also says "my skin has been feeling CKF. This is the first peritoneal dialysis
itchy and gets red if I scratch too much" treatment. The nurse inspects the
The patients vitals are BP 146/73 HR 89 drainage. Which should the nurse report
RR 24 T 99.5 Spo2 94%. The nurse to the physician immediately?
suspects which of the following? A) Bloody drainage
A) The patient is experiencing adverse B) More than 2 L of drainage
reaction from his erythropoietin C) Cloudy drainage
B) Most likely a clot has formed at the D) Glucose in drainage
dialysis access, broken off, and spread 45. The nurse is performing peritoneal
systemically dialysis and infuses 2 L of fluid into the
C) These signs indicate worsening CKF. patient. The drainage is measured to be
Dialysis treatment may need to be only 1800 ml. What is the nurse's
adjusted priority action?
D) The patient is experiencing a rejection A) Raise the head of the bed
reaction from the dialysis procedures B) Administer 02
42. Nurse Felix is preparing to teach the C) Call the doctor
patient with CKF about dietary D) Infuse 200 ml
modifications. Which of the following 46. The patient undergoing peritoneal
aspects of the patient is most important dialysis complains of abdominal pain.
for the nurse evaluate before teaching The nurse notes the drainage to be
begins? cloudy. She also palpates rebound
A) Family Hx tenderness. Which complication does
B) Attention span the nurse suspect?
C) Uric Acid level A) Leakage around catheter
D) Support system B) Internal Bleeding
43. You are working at a dialysis center C) Hypertriglycerdemia
and are taking care of Ms. Hector. She D) Peritonitis
has a history of diabetes, CKF, and HTN. 47. You have a patient that is receiving
She says "I hate having to come here all peritoneal dialysis. What should you do
the time. Can't I just do this stuff at when you notice the return fluid is
home?" What is the nurse's best slowly draining?
response? a. Check for kinks in the outflow tubing.
A) "Yes, home hemodialysis is an option for b. Raise the drainage bag above the level
you. In fact, we can start setting you up of the abdomen.
within the next week" c. Place the patient in a reverse
Trendelenburg position.
INP RBE

d. Ask the patient to cough. b. Anxiety related to lack of fetal

48. What is the appropriate infusion movement
time for the dialysate in your 38 y.o. c. Deficient knowledge related to the
patient with chronic renal failure? need for good prenatal care for
A. 15 minutes healthy fetal well-being
B. 30 minutes d. Pain related to fetal movements
C. 1 hour 52. Which among the statement below
D. 2 to 3 hours indicates a nursing process for
49. A 30 y.o. female patient is "Evaluation"
undergoing hemodialysis with an a. Couple attends all scheduled prenatal
internal arteriovenous fistula in place. visits
What do you do to prevent b. Nurse helps couple to understand the
complications associated with this importance of implementing healthy
device? behaviors, such as eating well and
A. Insert I.V. lines above the fistula. avoiding substances that may be
B. Avoid taking blood pressures in the arm dangerous to a fetus such as
with the fistula recreational drugs
C. Palpate pulses above the fistula c. Anxiety related to lack of fetal
D. Report a bruit or thrill over the fistula movement
to the doctor d. Nurse includes ways to educate patient
50. Your patient becomes restless and potential parents about teratogens
tells you she has a headache and feels 53. Which of the following is true about
nauseous during hemodialysis. Which hormone progesterone?
complication do you suspect? a. It helps maintain the endometrial
A. Infection lining during the pregnancy
B. Disequilibrium syndrome b. It is also known as “hormone of
C. Air embolus women.”
D. Acute hemolysis c. Mammary gland development in
51. Mrs. Gian, an 18-year-old, is 20 preparation for lactation
weeks pregnant. although she says she d. Stimulates uterine growth to
knows she should have stopped accommodate growing fetus
smoking before pregnancy, she has not 54. A systematic method of observation
been able to do this as yet. twice during and palpation to determine fetal
the pregnancy (at the 4th and 10th presentation and position and are done
week), she drank beer at summer as part of a physical examination. What
picnics. today, at a clinic visit, she tells do you call this method?
you she has felt her fetus move. she a. Leopold’s maneuver
states, "feeling the baby move made me b. Palwik’s maneuver
realize there's someone inside me, you c. Ritgen’s maneuver
know what i mean? it made me realize d. Brandt-andrews maneuver
it's time i started being more careful 55. In what phase of puerperium when
with what i do." what is the most the postpartum mother prefers having a
relevant nursing diagnosis with this nurse attend her needs and make
statement? decisions for her rather than do these
a. Readiness for enhanced knowledge things herself?
related to usual fetal development a. Taking-in phase
INP RBE

b. Taking-hold phase 60. A gravid woman at G2P1, just

c. Letting-go phase arrived in the clinic this afternoon,
d. Letting-in phase reported abdominal pains, with varied
56. A nurse is knowledgeable when she contractions and reported frequency in
knows that “puerperium” or postpartum urinations. Which among the following
period refers to? are signs of TRUE LABOR contractions?
a. 10 weeks period after childbirth a. Begin irregular but become
b. 12 weeks period after childbirth regular and predictable
c. 3 weeks period after childbirth b. Begin and remain irregular
d. 6 weeks period after childbirth c. Increase in duration,
57. Mrs. Allawic has expressed that she frequency and intensity
is excited to "get to know" her new d. Has achieved cervical
baby. the nurse determines which of the dilatation
following actions will support Mrs. e. Often disappears with
Allawic's transition into a postpartal ambulation or sleep
taking-hold phase? f. Felt first in lower back and
a. Tell her that she did well in labor and sweep around to the
that it was “all worth it.” abdomen in a wave
b. Encourage her to take as much time g. Does not increase in
as she needs to recover from her labor duration, frequency or
c. Help her to give her new baby a bath intensity
d. Help her and her husband to choose h. Continues no matter what
their baby’s name as soon as possible the woman’s level of activity
58. Mrs. Villorente, a community health i. Felt first abdominally and
nurse (CHN) in Samar assesses the remains confined to the
vaginal discharge of a recently abdomen and groin
postpartum woman, Mrs. Samson, a. A B C D G
G5P1T3A0L1, went on a home visit. The b. A C D F H
patient manifests a sanguinous blood, c. B C E G I
mucus and invading leukocytes with the d. B E G I
discharge. The nurse is knowledgeable 61. This is known as the shortening and
that this is a normal manifestation if it thinning of the cervical canal during
lasts for a period of how many days? labor and delivery.
a. 1-3 days a. Engagement
b. 3-10 days b. Effacement
c. 10-14 weeks c. Station
d. 4 weeks to 6 weeks d. Dilatation
59. Uterine involution: Nurse Nondevilla 62. A manifestation for decreased heart
is knowledgeable if she documents that rate or deceleration would indicate that
uterus of a postpartal woman recedes the vagal nerve compression
under the pubic area after how many stimulating the Parasympathetic
days? Nervous System, that this nerve is
a. 5 days affected during a contraction, hence
b. 8 days lowering the fetal heart rate. What type
c. 10 days of deceleration does this belong in
d. 14 days periodic changes in FHR?
INP RBE

a. Late deceleration 65. It is the softening of the cerix. This

b. Variable deceleration is called as?
c. Early deceleration a. Hegar’s sign
d. Sinusoidal Pattern b. Goodell’s sign
63. Mrs. Teopiz, a pregnant woman on c. Chadwick’s sign
oxytocin, verbalized that “it seems my d. None of the above
baby isn’t well inside.” Immediately 66. Is a color change in the vagina from
nurse Shiela assessed the contractions pink to purple because of increased
and fetal heart tone and stopped the formation of blood vessels and blood
oxytocin. Findings shows that the paper flow.
strip is showing Late Decelerations a. Hegar’s sign
indicating uteroplacental insufficiency b. Goodell’s sign
leading to hypoxia. What should the c. Chadwick’s sign
nurse do next? d. All of the above
a. Place the patient in lateral 67. Lauren Maxwell’s doctor told her she
or side lying position had a positive Chadwick’s sign. When
b. Provide oxygen as she asks the nurse what this means, the
prescribed best answer would be which of the
c. Intravenous fluids following?
d. Report findings and status a. “Your abdomen feels soft and tender,
to the Physician a normal finding.”
e. Document findings and b. “Your uterus has tipped forward, a
interventions and evaluation potential complication.”
a. D E B A C c. “Your cervical mucus feels sticky, just
b. D B A C E as it should feel.”
c. A B C D E d. “Your vagina looks dark in color, a
d. B A C D E typical pregnancy sign.”
64. A pregnant woman happens to come 68. Which among the following is NOT
to a birthing home experiencing labor true about Braxton Hicks Contraction?
contractions and believed that they are a. These are manifestation of true labor
true signs of labor. She realizes after b. Can cause true discomfort
being assessed and educated by the c. Also known as false labor
nurse that they are false contractions. d. It is a problem sign of pregnancy
Although the woman has been advised 69. Psychological changes: The woman
to stay in the hospital for admission. and her partner both spend time
What nursing diagnosis is applicable for recording from the surprise of learning
this situation? (5pts) they are pregnant and concentrate on
a. Pain related to labor contractions what it feels to be pregnant. A common
b. Anxiety related to process of labor and reaction is ambivalence
birth a. First trimester task: Accepting the
c. Health seeking behaviors related to pregnancy
management of discomfort of labor b. Second trimester task: Accepting the
d. Situational low self-esteem related to fetus
inability to use prepared childbirth c. Third trimester task: Preparing for the
method baby and end of pregnancy
d. None of the above
INP RBE

70. What psychological change when a. Whole grain roll with baked chicken
the woman and her partner move and pea soup and milk
through emotions such as narcissism b. Sandwich with smoked salmon
and introversion as they concentrate on lunchmeat, green beans, and banana
what it will feel like to be parent. Role pudding
playing and increased dreaming are c. Baked ham, mashed potatoes, tomato
common? soup and peanut butter cookies
a. First trimester task: Accepting the d. Low-sodium chicken noodle soup,
pregnancy apple slices, white-wheat roll and rice
b. Second trimester task: Accepting the 75. A client with acute renal failure
fetus develops severe hyperkalemia. What
c. Third trimester task: Preparing for the would the nurse anticipate to be used to
baby and end of pregnancy treat this imbalance?
d. None of the above a. Furosemide (Lasix)
71. The woman and her partner b. Amphojel (aluminum hydroxide)
prepares clothing and sleep c. 50% glucose and regular insulin
arrangements for the baby but also d. Epoetin (Procrit)
grow impatient as they ready 76. A client with chronic renal failure
themselves for birth. has been prescribed calcium carbonate.
a. First trimester task: Accepting the What is the rationale for this particular
pregnancy medication?
b. Second trimester task: Accepting the a. Diminishes incidence of gastric ulcer
fetus b. Alleviates constipation
c. Third trimester task: Preparing for the c. Binds with phosphorus to lower
baby and end of pregnancy concentration
d. None of the above d. Increase tubular reabsorption of
72. Your patient is complaining of sodium
muscle cramps while undergoing 77. A client with chronic kidney failure
hemodialysis. Which intervention is has an internal venous access site for
effective in relieving muscle cramps? hemodialysis on her left forearm. What
a. Increase the rate of dialysis action will the nurse take to protect this
b. Infuse normal saline solution access site?
c. Administer a 5% dextrose solution a. Irrigate with heparin and NS q8 hrs
d. Encourage active ROM exercises b. Apply warm moist packs to the area
73. Following delivery of the newborn, after hemodialysis
which nursing intervention should be c. Do not use the left arm to take blood
carried out immediately? pressure readings
a. Weigh the infant d. Keep the arm elevated above the level
b. Warm the infant of the heart
c. Bathe the infant 78. A nurse is assessing the patency of
d. Inoculate the infant a client’s left arm arteriovenous fistula
74. The nurse is taking care of the prior to initiating hemodialysis. Which
patient with chronic kidney disease. finding indicates that the fistula is
Which of the following meal trays would patent?
be the best for this patient? a. Palpation of a thrill over the fistula
INP RBE

b. Presence of a radial pulse in the left a. Prolactin

wrist. b. Colostrum
c. Absence of a bruit on auscultation of c. False milk
the fistula d. Whey
d. Capillary refill less than 3 seconds in 84. What should be included in a
the nail beds of the fingers of the left teaching plan regarding breast
hand engorgement?
79. A client with chronic renal failure a. It typically occurs on the first
has completed a hemodialysis postpartum day
treatment. The nurse would use which b. It is usually first observed in the
of the following standard indicators to axillary region
evaluate the client’s status after c. It occurs only in women who are not
dialysis? breastfeeding
a. Vital signs and weight d. It occurs near the nipple on the third
b. Potassium level and weight postpartum day
c. Vital signs and BUN 85. When is breast engorgement most
d. BUN and creatinine levels likely to occur?
80. A patient with diabetes mellitus and a. When the infant’s mouth surrounds
renal failure begins hemodialysis. Which the areola when feeding
diet is best on days between dialysis b. When the breast tissue becomes
treatments? congested
a. Low-protein diet with unlimited c. When the breast is emptied
amounts of water completely at each feeding
b. Low-protein diet with a prescribed d. When the infant’s mouth grasps the
amount of water nipple firmly
c. No problem in the diet and use of a 86. Which statement would be a correct
salt substitute description of colostrum?
d. No restrictions a. Slightly yellow and low in protein
81. when assessing a mother 12 hours b. Slightly yellow and provides antibodies
following the delivery of a baby, where c. Creamy and high in fat and protein
should the nurse expect to palpate the d. Colorless and high in fats and
fundus? carbohydrates
a. 2 cm below the umbilicus 87. The new mother has decided not to
b. At the umbilicus breastfeed the baby. How should the
c. 1 cm below the umbilicus nurse correctly instruct the mother to
d. Halfway between the umbilicus and suppress her milk supply?
the symphysis pubis a. Pump the breasts to remove milk
82. What is the name of the vaginal b. Apply warm, moist compresses
discharge that occurs immediately c. Restrict oral fluids
following delivery? d. Apply a firm bra and ice packs
a. Lochia serosa 88. During the immediate postpartum
b. Lochia rubra period, the mother has a temperature of
c. Lochia palatine 100.2’F, pulse 52, respirations 18, BP
d. Lochia alba 138/84. What should the nurse do?
83. What is the first secretion produced a. Report the temperature as abnormal
by the breast? b. Continue to monitor every 15 minutes
INP RBE

c. Report the pulse as abnormal d. Put slippers on her feet

d. Nothing as the vital signs are normal 93. A mother delivered her baby at
89. Within the first hour following a midnight and it is now 9am. She wants
vaginal delivery, the nurse assesses the to sleep and asks the nurse to take care
mother and finds the fundus is firm and of the baby. What is this considered?
there is a trickle of bright red blood. a. Fatigue from labor
What should be the nurse's reaction to b. Normal “taking in” response
the assessment? c. Abnormal “taking in” response
a. This is a normal occurrence. d. Risk for altered maternal-infant
b. This is abnormal and should be bonding
reported. 94. Which of the following would be
c. The patient should be administered a considered a normal assessment finding
blood thinner. in a 1-day postpartum patient?
d. The patient should be restricted to a. Pinkish to brown lochia
bed rest. b. Voiding frequency 50mL to 75mL of
90. What is the appropriate way to urine
assess the fundus of the postpartum c. Complaining of “after pains”
patient? d. Fundus 1 cm above the umbilicus
a. Using the side of one hand moving 95. A new Native American mother tells
down from the umbilicus the nurse that when she goes home, her
b. Using one hand over the lower mother-in-law will be caring for the
segment of the uterus baby while she rests. The nurse has
c. Using one hand pushing upward from concerns. What should the nurse do?
the lower uterus a. Explain the importance of ambulating
d. Using one hand on the lower uterine to recover
segment while the other hand locates b. Explain the importance of maternal-
the fundus of the uterus infant bonding
91. The postpartum mother with a third c. Explore ways to blend this with safe
degree laceration tells the nurse she is health teaching
afraid to have a bowel movement d. Encourage this cultural behavior
because of her painful episiotomy. What 96. The nurse is caring for a 54-year-old
should the nurse do? unconscious female patient who has
a. Offer a suppository or enema just been admitted to the post
b. Encourage ambulation anesthesia care unit after abdominal
c. Offer stool softeners as prescribed hysterectomy. How should the nurse
d. Offer pain medication before position the patient?
defecating a. Left lateral position with head
92. A new mother had spinal anesthesia supported on a pillow
during a cesarean delivery. She now has b. Prone position with a pillow supporting
a desire to void and can wiggle her toes. the abdomen
What should be the nurse’s response c. Supine position with head of bed
when the mother asks to go the elevated 30 degrees
bathroom? d. Semi-fowler’s position with the head
a. Assess her blood pressure turned to the right
b. Obtain a wheelchair 97. The nurse is providing discharge
c. Palpate her bladder teaching to a 51-year-old female patient
INP RBE

who has had a laparoscopic a. Administering adequate analgesics to

cholecystectomy at an ambulatory promote relief or control of pain
surgery center. Which statement, if b. Asking the patient to demonstrate the
made by the patient, indicates an postoperative exercises every 1 hour
understanding of the discharge c. Giving the patient positive feedback
instructions? when the activities are performed
a. “I will have someone stay with me for correctly
24 hours in case I feel dizzy.” d. Warning the patient about possible
b. “I should wait for the pain to be complications if the activities are not
severe before taking the medication.” performed
c. “Because I did not have general
anesthesia, I will be able to drive
home.”
d. “It is expected after this surgery to
have a temperature up to 102.4’F.”
98. The nurse is working on a surgical
floor and is preparing to receive a
postoperative patient from the post-
anesthesia care unit (PACU). What
should the nurse’s initial action be upon
the patient’s arrival?
a. Assess the patient’s pain
b. Assess the patient’s vital signs
c. Check the rate of the IV infusion
d. Check the physician’s postoperative
orders
99. When assessing a patient’s surgical
dressing on the first postoperative day,
the nurse notes new, bright-red
drainage about 5cm in diameter. In
response to this finding, what should
the nurse do first?
a. Recheck in 1 hour for increased
drainage
b. Notify the surgeon of a potential
hemorrhage
c. Assess the patient’s blood pressure
and heart rate
d. Remove the dressing and assess the
surgical incision
100. In planning postoperative
interventions to promote repositioning,
ambulation, coughing, and deep
breathing, which action should the
nurse recognize will best enable the
patient to achieve the desired outcome?