Medical Surgical 1 Practice Questions PDF

MEDICAL SURGICAL 1 (Answers) mistakes. 😀 Remember: Every mistake ❌ is an opportunity to learn ✅ Be grateful for your Now is your chance to correct them. God bless you, RN ♥️ Situation: E...

MEDICAL SURGICAL 1 (Answers) mistakes. 😀 Remember: Every mistake ❌ is an opportunity to learn ✅ Be grateful for your Now is your chance to correct them. God bless you, RN ♥️ Situation: ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS. 1. During colostomy irrigation, the client complains of a cramping sensation with the fluid introduced. Which of the following is a CORRECT nursing action? A. Temporarily stop the irrigation B. Clamp the irrigating tube C. Pinch or kink the irrigating tube temporarily D. Continue the irrigation 2. When is the colostomy appliance best emptied? A. When there is a sensation of pressure B. When there is the sensation of taste C. When there is the sensation of smell D. When it is full 3. The client asked the nurse when the best time to perform irrigation is. The nurse would answer: A. Early morning, before meals, upon arising B. Early morning, before meals C. Early morning D. Early morning, After meals 4. The nurse is teaching a client how to irrigate his stoma. Which action indicates that the client needs more teaching? A. Hanging the irrigation bag 24" to 36" (60 to 90 cm) above the stoma B. Filling the irrigation bag with 500 to 1,000 ml of lukewarm water C. Stopping irrigation for cramps and clamping the tubing until cramps pass D. Washing hands with soap and water when finished 5. The physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen from the colostomy stoma should: A. take the specimen to the laboratory immediately. B. collect the specimen in a clean container. C. collect the specimen in a sterile container. D. perform a midstream clean catch collection. 6. You plan to teach Fermin how to irrigate the colostomy when: A. The perineal wound heals, And Fermin can sit comfortably on the commode B. Fermin can lie on the side comfortably, about the 3rd postoperative day C. The abdominal incision is closed, and contamination is no longer a danger D. The stools start to become formed around the 7th postoperative day 7. When preparing to teach Fermin how to irrigate colostomy, you should plan to do the procedure: A. When Fermin would have regular bowel movement B. At least 2 hours before visiting hours C. Before breakfast and morning care D. After Fermin accepts alteration in body image 8. When observing a return demonstration of colostomy irrigation, you know that more teaching is required if Fermin: A. Lubricate the tip of the catheter before inserting it into the stoma B. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion C. Discontinues the insertion of fluid after 500 ml of the liquid has been instilled D. Clamps the flow of fluid when feeling uncomfortable 9. You are aware that teaching about colostomy care is understood when Fermin states, “I will contact my physician and report: A. If I have difficulty inserting the irrigating tub into the stoma.” B. If I notice a loss of sensation to touch in the stoma tissue.” C. The expulsion of flatus while the irrigating fluid is running out.” D. When mucus is passed from the stoma between the irrigations.” 10. You would know after teaching Fermin that dietary instruction for him is effective when he states, “It is essential that I eat: A. Soft food easily digested and absorbed by my large intestines.” B. Bland food so that my intestines do not become irritated.” C. Food low in fiber so that there are fewer stools.” D. I ate everything before the operation while avoiding foods that cause gas.” SITUATION: A Client was rushed to the emergency room, and you are his attending nurse. You are performing a vital sign assessment. 11. All of the following are correct methods in the assessment of blood pressure EXCEPT: A. Take the blood pressure reading on both arms for comparison B. Listen to and identify the phases of Korotkoff’s sound C. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated D. Observe procedures for infection control 12. You attached a pulse oximeter to the client. You know that the purpose is to: A. Determine if the client’s hemoglobin level is low and if he needs a blood transfusion B. Check the level of the client’s tissue perfusion C. Measure the efficacy of the client’s anti-hypertensive medications D. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develop 13. After a few hours in the Emergency Room, The client is admitted to the ward with an order for hourly blood pressure monitoring. The nurse finds that the cuff is too narrow, and this will cause the blood pressure reading to be: A. inconsistent B. low systolic and high diastolic C. higher than what the reading should be D. lower than what the reading should be 14. From the client’s health history, you gather that the patient smokes and drinks coffee. How long should the nurse wait before taking the blood pressure of a client who recently smoked or drank coffee to get an accurate reading? A. 15 minutes B. 30 minutes C. 1 hour D. 5 minutes 15. While the client has a pulse oximeter on his fingertip, you notice the sunlight shining on the area where the oximeter is. Your action will be to: A. Set and turn on the alarm of the oximeter B. Do nothing since there is no identified problem C. Cover the fingertip sensor with a towel or bedsheet D. Change the location of the sensor every four hours 16. The nurse finds it necessary to recheck the blood pressure reading. In case of such reassessment, the nurse should wait for a period of: A. 15 seconds B. 1 to 2 minutes C. 30 minutes D. 15 minutes 17. If the arm is said to be elevated when taking the blood pressure, it will create a: A. False high reading B. False low reading C. True-false reading D. Indeterminate 18. You are to assess the client's temperature the following day and find out that he ate ice cream. How many minutes should you wait before evaluating the client’s oral temperature? A. 10 minutes B. 20 minutes C. 30 minutes D. 15 minutes 19. When auscultating the client’s blood pressure, the nurse hears the following: From 150 mmHg to 130 mmHg: Silence, Then a thumping sound continuing down to 100 mmHg; muffled sound continuing down to 80 mmHg and then silence. What is the client’s blood pressure? A. 130/80 B. 150/100 C. 100/80 D. 150/100 20. In a client with a previous blood pressure of 130/80 4 hours ago, how long will it take to release the blood pressure cuff to obtain an accurate reading? A. 10-20 seconds B. 30-45 seconds C. 1-1.5 minutes D. 3-3.5 minutes Situation: Oral care is integral to hygienic practices and promoting client comfort. 21. An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and the presence of sores. Which of the following is BEST to use for oral care? A. lemon glycerine B. hydrogen peroxide C. Mineral oil D. Normal saline solution 22. When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs? A. Put the client on a side-lying position with the head of the bed lowered B. Keep the client dry by placing a towel under the chin C. Wash hands and observe appropriate infection control D. Clean mouth with oral swabs in a careful and orderly progression. 23. The advantages of oral care for a client include all of the following EXCEPT: A. decreases bacteria in the mouth and teeth B. reduces the need to use commercial mouthwash, which irritates the buccal mucosa C. Improves client’s appearance and self-confidence D. improves appetite and taste of food 24. A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to the lungs. This can be avoided by: A. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing the buccal cavity B. swabbing the inside of the cheeks and lips, tongue, and gums with dry cotton swabs C. use fingers wrapped with the wet cotton washcloth to rub inside the cheeks, tongue, lips, and gums D. suctioning as needed while cleaning the buccal cavity 25. Your client has difficulty breathing and is mouth breathing most of the time. This causes dryness of the mouth and an unpleasant odor. Oral hygiene is recommended for the client, and in addition, you will keep the mouth moistened by using: A. salt solution B. water C. petroleum jelly D. mentholated ointment Situation – Ensuring safety before, during, and after a diagnostic procedure is an essential responsibility of the nurse. 26. To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the following before the procedure? A. Clenching his fist every 2 minutes B. Breathing in and out through the nose with his mouth open C. Tensing the shoulder muscles while lying on his back D. Holding his breath periodically for 30 seconds 27. Following a bronchoscopy, which of the following complaints to Fernan should be noted as a possible complication: A. Nausea and vomiting B. Shortness of breath and laryngeal stridor C. Blood-tinged sputum and coughing D. Sore throat and hoarseness 28. Immediately after bronchoscopy, you instructed Fernan to: A. Exercise the neck muscles B. Breathe deeply C. Refrain from coughing and talking D. Clear his throat 29. Thoracentesis may be performed for the cytologic study of pleural fluid. As a nurse, your most important function during the procedure is to: A. Keep the sterile equipment from contamination B. Assist the physician C. Open and close the three-way stopcock D. Observe the patient’s vital signs 30. Right after thoracentesis, which of the following is the most appropriate intervention? A. Instruct the patient not to cough or deep breathe for two hours B. Observe for symptoms of tightness of chest or bleeding C. Place an ice pack on the puncture site D. Remove the dressing to check for bleeding Situation: Knowledge of the acid-base disturbance and the functions of the electrolytes is necessary to determine appropriate intervention and nursing actions. 31. A client with diabetes mellitus has a blood glucose level of 644 mg/dL. The nurse interprets this as being at the most risk of developing which type of acid-base imbalance? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis 32. In a client in the health care clinic, arterial blood gas analysis gives the following results: pH 7.48, PCO2 32 mmHg, PO2 94 mmHg, HCO3 24 mEq/L. Does the nurse interpret that the client has an acid-base disturbance? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis 33. A client has an order for ABG analysis on radial artery specimens. The nurse ensures which of the following has been performed or tested before the ABG specimens are drawn. A. Guthrie test B. Allen’s test C. Romberg’s test D. Weber’s test 34. A nurse reviews a client's arterial blood gas values and notes that the pH is 7.31, Pco2 is 50 mmHg, and the bicarbonate is 27 mEq/L. Does the nurse conclude which acid-base disturbance is present in this client? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis 35. Allen’s test checks the patency of the: A. Ulnar artery C. Carotid artery B. Radial artery D. Brachial artery Situation 6: Eileen, 45 years old, is admitted to the hospital with a diagnosis of renal calculi. She is experiencing severe flank pain, nauseated, and a temperature of 39 C. 36. Given the above assessment data, the nurse's most immediate goal would be which of the following? A. Prevent urinary complication B. maintains fluid and electrolytes C. Alleviate pain D. Alleviating nausea 37. The nurse prepares to auscultate fetal heart tones in a pregnant client. Abdominal palpation reveals a complex, round mass under the left side of the rib cage; a softer, round mass just above the symphysis pubis; small, irregular shapes in the right side of the abdomen; and a long, firm mass on the left side of the abdomen. Based on these findings, what is the best place to auscultate fetal heart tones? A. Right lower abdominal quadrant B. Right upper abdominal quadrant C. Left upper abdominal quadrant D. Left lower abdominal quadrant 38. A measurement tool to articulate the nursing workload for a specific patient or groups of patients over a particular period is called: A. Staffing pattern C. Benchmarking B. Skill mix D. Patient classification 39. The mother of a 9-month-old infant is concerned that the head circumference of her baby is greater than the chest circumference. The BEST response by the nurse is: A. “These circumferences normally are the same, but in some babies, this just differs.” B. “Perhaps your baby was small for gestational age or premature.” C. “This is normal until the age of 1 year when the chest will be greater.” D. “Let me ask you a few questions, and perhaps we can figure out the cause of this difference.” 40. Karen, A 28-year-old post-hysterectomy client, has visited the health center. She inquired about BSE and asked you when BSE should be performed. You answered her that BSE Is best performed: A. 7 days after menstruation B. On the same day each month C. During menstruation D. Before menstruation Situation: Leukemia is the most common type of childhood cancer. Acute Lymphoid Leukemia is the cause of almost 1/3 of all cancer that occurs in children under age 15. 41. The survival rate for Acute Lymphoid Leukemia is approximately: A. 25% B. 40% C. 75% D. 95% 42. Whereas acute nonlymphoid leukemia has a survival rate of: A. 25% B. 40% C. 75% D. 95% 43. The three main consequences of leukemia that cause the most danger are: A. Neutropenia causing infection, anemia causing impaired oxygenation, and thrombocytopenia leading to bleeding tendencies B. Central nervous system infiltration, anemia causing impaired oxygenation, and thrombocytopenia leading to bleeding tendencies C. Splenomegaly, hepatomegaly, fractures D. Invasion by the leukemic cells to the bone, causing severe bone pain 44. The gold standard in leukemia diagnosis is by which of the following? A. Blood culture and sensitivity B. Bone marrow biopsy C. Blood biopsy D. CSF aspiration and examination 45. Adriamycin, Vincristine, Prednisone, and L asparaginase are given to the client for long-term therapy. One common side effect, especially of adriamycin, is alopecia. The child asks: “Will I get my hair back once again?” The nurse's best response is by saying: A. “Don’t be silly; you will get your hair back.” B. “We are unsure; let’s hope it’ll grow.” C. “This side effect is usually permanent, But I will get the doctor to discuss it for you.” D. “Your hair will regrow in 3 to 6 months but of different colors, usually darker, and of different textures.” 46. If Aling Violeta will sustain a fracture, you would expect that the MOST LIKELY bone to be fractured in an elderly client is the: A. Femur or Hips C. Tibia or Shin B. Clavicle or Collarbone D. Spinal Column or Back 47. Which of the following activities is highly recommended for Aling Violeta? A. Non-weight-bearing activities such as SWIMMING B. Weight-bearing activities such as WALKING C. Passive range of motion exercises D. Active range of motion exercises 48. Aling Violeta is correct in understanding the best activities for her when she states: A. “I can’t wait to bungee jump! I am sure it will be exciting!” B. “I need to buy new taekwondo clothes because I don’t have one.” C. “I need to buy knee and elbow pads for tomorrow. I will start my rollerblade tutorial.” D. “I can’t wait to do the Waltz with my dance instructor tomorrow afternoon.” 49. Calcitonin, an important hormone necessary to suppress the activities of the Osteoclasts, is secreted by the: A. Parathyroid gland B. Anterior pituitary gland C. Thyroid gland D. Hypothalamus 50. If ever the Osteoporosis of the client is due to autoimmune HYPOPARATHYROIDISM, which of the following instructions is appropriate? A. use OTC vitamin D preparation B. avoid strenuous exercises C Supplement calcium intake D. avoid diuretics to minimize calcium loss SITUATION: HIV/AIDS is a worldwide problem. Until a Vaccine is developed, The nurse should focus on Primary prevention and eliminating factors that cause the condition. 51. Which of the following is NOT an effective prevention for HIV/ AIDS? A. The addition of N-9 or NONOXYNOL gel intravaginally before sexual intercourse together with a condom B. Using condoms before sexual intercourse C. Instructing drug addicts to participate in needle exchange programs D. Discouraging the use of IUDs as a form of contraception 52. There is a global concern about AIDS. There are legal and ethical concerns, especially: A. duty siblings and spouse B. need for universal testing C confidentiality D. public support and understanding 53. The school nurse teaches a health education and hygiene course to a group of high school males, including several young men on competitive sports teams. Which of the following health practices would the nurse most stress in preventing the transmission of human immunodeficiency virus (HIV) virus in case any team member has HIV or acquired immunodeficiency syndrome (AIDS)? A. No sharing of underarm deodorant or shower soap B. No sharing of razors or toothbrushes C. Making sure towels have been washed in boiling water D. Avoiding physical contact such as sports hugs or swats 54. EIA is performed on a client with HIV/AIDS to: A. Used to confirm ELISA B. Detects ANTIGEN directed specifically against HIV/AIDS C. Detects ANTIBODY directed specifically against HIV/AIDS D. Detects the CD4 cell count to determine if the client is positive 55. A term concerning body resistance that refers to the protein present in the serum of the blood: A. antibodies B. antitoxin C. antigen D. Allergen SITUATION: Physical examination and health assessment are essential in rendering care. The nurse must use assessment knowledge to determine and prioritize the client's response to his or her illness. 56. The component that should receive the highest priority before physical examination is the: A. Psychological preparation of the client B. Physical Preparation of the client C. Preparation of the Environment D. Preparation of the Equipments 57. When inspecting a client’s skin, the nurse finds a cyst on the client’s arm. Which description applies to a vesicle? A. A flat, nonpalpable, and colored B. Solid, elevated, and circumscribed C. Circumscribed, elevated and filled with serous fluid D. Elevated, pus-filled, and circumscribed 58. When assessing a client with abdominal pain, the nurse should assess: A. Any quadrant first B. The symptomatic quadrant first C. The symptomatic quadrant last D. The symptomatic quadrant, either the second or third 59. To assess the client's dorsal pedal pulse, the nurse should palpate the: A. Medial surface of the ankle B. Lateral surface of the ankle C. Ventral aspect of the top of the foot D. Medial aspect of the dorsum of the foot 60. Which of the following assessments would be a priority for a 2 year old after bronchoscopy? A. Cardiac rate B. Respiratory quality C. Sputum color D. Pulse pressure changes 61. The nurse checks the client's gag reflex. The recommended technique for testing the gag reflex is to: A. touch the back of the client's throat with a tongue depressor B. observe the client for evidence of spontaneous swallowing when the neck is stroked C. place a few milliliters of water on the client's tongue and note whether or not he swallows D. observe the client's response to the introduction of a catheter for endotracheal suctioning 62. The nurse is evaluating a client’s lung sounds. Which of the following breath sounds indicate adequate ventilation when auscultated over the lung fields? A. Vesicular B. Bronchial C. Bronchovesicular D. Adventitious 63. The night nurse informs the primary nurse that a client receiving intermittent gavage feedings is not tolerating them. The primary nurse should first: A. Change the feeding schedule to omit nights B. Request that the type of solution be changed C. Observe the night nurse administering a feeding D. Suggest that the prescribed antiemetic be given first 64. A client has a chest tube attached to a pleural drainage system. When caring for this client, the nurse should: A. Palpate the surrounding area for crepitus B. Clamp the chest tubes when suctioning the client C. Change the dressing daily using an aseptic technique D. Empty drainage chamber at the end of the shift 65. The nurse, aware of a client’s 25-year history of excessive alcohol use, would expect the physical assessment to reveal a: A. Liver infection B. Low blood ammonia C. Small liver with a rough surface D. High fever with a generalized rash SITUATION: Nursing is a profession. Miss Linda is a newly appointed nurse in a hospital in Manila. Born in May 1985, her knowledge of nursing’s professional development is required to protect the profession and raise its standards. 66. Mrs. Linda defined nursing as one of the following EXCEPT: A. Assisting individuals, families, and communities in attaining health B. Assisting basic health needs C. Establishing nursing diagnosis and implementing nursing care D. Diagnosing, treating, prescribing medication, and doing minor surgery 67. PNA was established in: 1. 1922 2. 1926 3. With Mrs. Rosario Delgado as first president 4. With Mrs. Anastacia Tupas as first president A. 1,3 B. 1,4 C. 2,3 D. 2,4 68. As a national nurses association, it is characterized as follows: A. Both a professional body and a labor union B. Affiliated with the International Council Of Nurses C. Advocating for improved work and life conditions for Nurses D. Accrediting body for continuing education program 69. CPE Units per year are needed for license renewal. The number of CPE units per year should be: A. 20 units B. 30 units C. 60 units D. 100 units 70. As a nurse, R.A 1080 Exempts her from: A. Paying her professional tax B. Examination for civil service eligibility C. Qualifying for the CGFNS D. Paying business permit 71. In resigning from her job as a staff nurse, she must give advance notice of: A. 15 days B. 30 days C. 45 days D. 60 days SITUATION: Developing countries such as the Philippines suffer from high infant and child mortality rates. Thus, to manage the existing problem, the WHO and UNICEF launched the IMCI. 72. A 6-month-old baby, Len, was brought to the health center for two days because of a fever and cough. She weighs 5 kg. Her temperature is 38.5 via the axilla. Further examination revealed that she has general rashes, her eyes are red, and she has mouth ulcers that are nondeep and nonextensive. There was no pus draining from her eyes. Most probably, Baby Len has: a. Severe complicated measles d. Measles b. Fever: No MALARIA e. Measles with eye or mouth complications c. Very severe febrile disease 73. The dosage of Vit. A supplement given to Baby Len would be: A. 100,000 IU B. 200,000 IU C. 10,000 IU D. 20,000 IU 74. Using IMCI Chart, this child can be managed with: A. Treat the child with paracetamol and follow up in 2 days if the fever persists B. Give the first dose of antibiotic and Vit. A. Apply Gentian Violet for mouth ulcers and refer urgently to the hospital. C. Give 100,000 international units of Vit. A D. Give 200,000 international units of Vit. A E. Give Vit. A, apply Gentian violet for mouth ulcers and follow up in 2 days 75. The following are signs of severe complicated measles: A. Clouding of the cornea B. Deep or extensive mouth ulcers C. Pus draining from the eyes D. A and B only E. All of the above 76. If the child is having 2 1⁄2 weeks of ear discharges, how would you classify and treat the child: 1. Green 5. Dry the ear by wicking 2. Yellow 6. 5 days antibiotic 3. Pink 7. Urgent referral with first dose of antibiotic 4. Red a. 4,7 b. 2,5,6 c. 1,5 d. 3,7 e. 2,5 77. The following are treatments for acute ear infections: a. Dry the ear by wicking​ ​ d. A and c only b. Give antibiotics for 5 days ​​ e. All of the above c. Follow up in 5 days 78. A child with ear problems should be assessed for the following, except: a. Ear pain b. If the discharge is present, for how long? c. Ear discharge d. Is there any fever? e. None of the above 79. What should you do as a nurse if the child does not have ear problems using IMCI? a. Go to the next question and check for malnutrition b. Check for ear pain c. Check for tender swelling behind the ear d. Check for ear discharge 80. An ear discharge that has been present for more than 14 days can be classified as: a. Complicated ear infection b. Acute ear infection c. Chronic ear infection d. Mastoiditis 81. An ear discharge that has been present for less than 14 days can be classified as: a. Complicated ear infection b. Acute ear infection c. Chronic ear infection d. Mastoiditis 82. If the child has severe classification because of ear problems, what would be best for you to do as a nurse? a. Dry the ear by wicking b. Give an antibiotic for 5 days c. Refer urgently d. Instruct mother when to return immediately Situation: The WHO defines Primary Health Care (PHC) as essential health care made universally accessible to individuals, families, and communities. 83. The WHO held a meeting in this place where Primary Health Care was discussed. What is this place? A. Alma Ata B. Russia C. Vienna D. Geneva Situation: The national objective of maintaining Filipino health is the DOH's primary responsibility. 84. The following is the mission of the DOH, except: a. Ensure accessibility b.Quality of health care c.Health for all Filipinos d.Quality of Life of all Filipinos e. None of the above 85. The basic principles to achieve health improvement include all BUT: a. Universal access to essential health services must be ensured b. The health and nutrition of vulnerable groups must be prioritized c. Performance of the health sector must be enhanced d. Support the frontline workers and the local health system e. None of the above 86. Which of the following is not a primary strategy to achieve health goals: a. Support of local health system development b. Development of national standards for health c. Assurance of health care for all d. Support the frontline workers. e. None of the above 87. According to the WHO, health is: A. state of complete physical, mental, and social well-being, not merely the absence of disease B. A science and art of preventing disease and prolonging life C. A science that deals with the optimum level of functioning of the Individual, family, and community D. All of the above 88. Assistance in physical therapy of a trauma patient is a: A. Primary level of prevention B. Secondary level of prevention C. Tertiary level of prevention D. Specialized level of prevention 89. Local health boards were established at the provincial, city, and municipal levels. At the municipal level, the chairman of the board is the: A.Rural Health physician B.Governor C.Mayor D.Chairman of the Committee on Health 90. The emphasis of community health nursing is on: A. Treatment of health problems B. Preventing health problems and promoting optimum health C. Identification and assessment of health problems D. Illness end of the wellness-illness continuum. 91. In asking the mother about her child’s problem, the following communication skills should be used: a. Use words that the mother understands b. Give time for the mother to answer the questions c. Listen attentively d. Ask checking questions e. None of the above 92. Which of the following is the principal focus of the CARI program of the Department of Health? a. Teach other community health workers how to assess patients b. Mortality reduction through early detection c. Teach mothers how to detect signs and where to refer d. Enhancement of health team capabilities 93. You identified factors leading to respiratory problems in your health facility's community. Your primary role, therefore, to reduce morbidity due to pneumonia is to? a. Seek assistance and mobilize the BHW to meet with mothers b. Refer cases to hospitals c. Make home visits to sick children d. Teach mothers how to recognize early signs and symptoms of pneumonia 94. Which of the following is the most critical responsibility of a nurse in preventing unnecessary deaths from pneumonia and other severe diseases? a. Weighing of the child b. Provision of careful assessment c. Taking of the temperature of the sick child d. Giving of antibiotics 95. A 4-month-old child was brought to your clinic because of a cough and cold. Which of the Following is your primary action? a. Teach the mother how to count her child’s breathing. b. Refer to the doctor c. Assess the patient using the chart on management of children with cough d. Give cotrimoxazole tablet or syrup e. All of the above 96. In responding to the care concerns of children with severe disease, referral to the hospital is of the essence, mainly if the child manifests which of the following? a. Stopped feeding well c. Wheezing b. Fast breathing d. Difficulty to awaken Situation: Elvira Magalpok is a 26-year-old woman you admit to a birthing room. She’s been having contractions 45 seconds long and 3 minutes apart for the last 6 hours. She tells you she wants to have her baby “naturally” without any analgesia or anesthesia. Her husband is in the Army and assigned overseas, so he is not with her. Although her sister lives only two blocks from the hospital, Elvira doesn’t want her called. She asks if she can talk to her mother on the telephone instead. As You finish assessing contractions, she screams with pain and shouts, “Ginagawa ko na ang lahat ng makakaya ko! Kailan ba matatapos ang paghihirap kong ito?” 97. Elvira didn’t recognize that she was in labor for over an hour. A sign of TRUE labor is: A. Sudden increase in energy from epinephrine release B. “Nagging” but constant pain in the lower back. C. Urinary urgency from increased bladder pressure. D. “Show” or release of the cervical mucus plug. 98. Elvira asks you which fetal position and presentation are ideal. Your best answer would be: A. Right occiput anterior with full flexion. B. Left transverse anterior in moderate flexion. C. Right occiput posterior with no flexion. D. Left sacroanterior with full flexion. 99. Elvira is having long and hard uterine contractions. What length of contraction would you report as abnormal? A. Any length over 30 seconds. B. A contraction over 70 seconds in length. C. A contraction that peaks at 20 seconds. D. A contraction shorter than 60 seconds. 100. You assess Elvira’s uterine contractions. About the contraction, when does a late Does deceleration begin? A. Forty-five seconds after the contraction is over. B. Thirty seconds after the start of a contraction. C. After every tenth or more contraction. D. After a typical contraction ends. Prepared by: Nurse Resty 🧿