SCFHS MCQs 5.2
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A. Distribution
B. Excretion
C. Metabolism
D. Absorption
2. The healthcare provider is caring for a patient with a diagnosis of first-
degree atrioventricular (AV) block. Which of these waveform patterns identifiedon the cardiac monitor is consistent with this arrhythmia?
A. QRS complexes are dropped randomly
B. No association between the P waves and QRS complexes
C. Significant shortening of the PR interval
D. Slowed conduction through the AV node.
3. The nurse is assisting a doctor with the removal of a central venous catheter. To prevent complications, the patient should be instructed to
A. Turn his head to the left side and hyperextend the neck while looking up
B. Take slow, deep breaths as the catheter is advanced.
C. Perform the Valsalva maneuver as the catheter is pulled.
D. Turn his head to the right while grasping the siderails.
4. During an assessment of a patient's abdomen, a pulsating abdominal mass isnoted by the healthcare provider. Which of the following should be the healthcare provider's next action?
A. Ask the patient to perform a Valsalva maneuver
B. Measure the abdominal circumference
C. Obtain an order for a bladder scan
D. Assess femoral pulses
5. Rhogam is most often used to treat mothers that have a infant.
A. RH negative, RH negative
B. RH negative, RH positive
C. RH positive, RH negative
D. RH positive
6. At her first prenatal appointment, the client states that her last menstrual period began on February 5, 2017
and ended on February 10, 2017. Using Naegele’s rule her estimated date of birth would be
A. November 5, 2017
B. November 17, 2017
C. November 12, 2017
D. October 29, 2017
7. The healthcare provider is caring for a 3-month-old infant diagnosed with infectious gastroenteritis. The infant is lethargic and the mucous membranes are dry. Which additional finding would support a diagnosis of moderate dehydration?
A. Increased capillary refill
B. Sunken fontanelle
C. Increased thirst
D. Anuria
8. The earliest identifying sign for a developing pressure sore is a localized.
A. loss of sensation
B. change in color
C. edema
D. coolness to touch
9. A patient who is diagnosed with Parkinson's disease (PD) states, I can't tie my shoelaces anymore." The healthcare provider recognizes that this patient's problem is due to a deficiency in which of these neurotransmitters?
A. Norepinephrine
B. Glutamate
C. Dopamine
D. Serotonin
10. When the nurse on duty accidentally bumps the bassinet. the neonate throws out its arms. hands opened. and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes?
A. Startle reflex
B. Babinski reflex
C. Grasping reflex
D. Tonic neck reflex
11. A primigravida client at 25 weeks gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform:
A. Tailor sitting
B. Leg lifting
C. Shoulder circling
D. Squatting exercises
12. Which type of lochia should the nurse expect to find in a client 2 days PP?
A. Foul-smelling
B. Lochia serosa
C. Lochia alba
D. Lochia rubra
13. On the first PP night. a client requests that her baby be sent back to the nursery so she can get some sleep. The client is most likely in which of the following phases?
A. Depression phase
B. Letting-go phase
C. Taking-hold phase
D. Taking-in phase
14. What type of milk is present in the breasts 7 to 10 days PP?
A. Colostrum
B. Hind milk
C. Mature milk
D. Transitional milk
15. A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. When the nurse locates the fundus. She notes that the uterus feels soft and boggy. Which of the following nursing interventions would be most appropriate initially?
A. Massage the fundus until it is firm
B. Elevate the mother’s legs
C. Push on the uterus to assist in expressing clots
D. Encourage the mother to void
16. Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position. and her vital signs are stable and fall within a normal range. Contractions are intense. last 90 seconds. and occur every 1 1/2 to 2 minutes. The nurse's immediate action would be to:
A. Change the woman’s position
B. Stop the Pitocin
C. Elevate the woman’s legs
D. Administer oxygen via a tight mask at 8 to 10 liters/minute
17. A laboring client is in the first stage of labor and has progressed from 4 to 7 cm in cervical dilation. In which of the following phases of the first stage does cervical dilation occur most rapidly?
A. Preparatory phase
B. Latent phase
C. Active phase
D. Transition phase
18. A client arrives at the hospital in the second stage of labor. The fetus' head is crowning. the client is bearing down. and the birth appears imminent. The nurse should:
A. Transfer her immediately by stretcher to the birthing unit
B. Tell her to breathe through her mouth and not to bear down
C. Instruct the client to pant during contractions and to breathe through her mouth
D. Support the perineum with the hand to prevent tearing and tell the client to pant
19. After doing Leopold's maneuvers. the nurse determines that the fetus is
in the ROP position. To best auscultate the fetal heart tones. the Doppler is placed:
A. Above the umbilicus at the midline
B. Above the umbilicus on the left side
C. Below the umbilicus on the right side
D. Below the umbilicus near the left groin
20. A nurse in the labor room is performing a vaginal assessment on a
pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action?
A. Place the client in Trendelenburg’s position
B. Call the delivery room to notify the staff that the client will be transported immediately
C. Gently push the cord into the vagina
D. Find the closest telephone and stat page the physician
21. A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn. the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery?
A. The umbilical cord shortens in length and changes in color
B. A soft and boggy uterus
C. Maternal complaints of severe uterine cramping
D. Changes in the shape of the uterus
22. A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa?
A. Disseminated intravascular coagulation
B. Chronic hypertension
C. Infection
D. Hemorrhage
23. A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction?
A. Early decelerations
B. Variable decelerations
C. Late decelerations
D. Short-term variability
24. A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at (-1) station. The nurse determines that the fetal presenting part is:
A. 1 cm above the ischial spine
B. 1 fingerbreadth below the symphysis pubis
C. 1 inch below the coccyx
D. 1 inch below the iliac crest
25. A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate?
A. Document the findings and tell the mother that the monitor indicates fetal well-being
B. Take the mother’s vital signs and tell the mother that bed rest is required to conserve oxygen.
C. Notify the physician or nurse-midwife of the findings.
26. A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate?
A. Encourage the client’s coach to continue to encourage breathingexercises
B. Encourage the client to continue pushing with each contraction
C. Continue monitoring the fetal heart rate
D. Notify the physician or nurse midwife
27. A nurse is performing an assessment of a client who is scheduled for a Cesarean delivery. Which assessment finding would indicate a need to contact the physician?
A. Fetal heart rate of 180 beats per minute
B. White blood cell count of 12.000
C. Maternal pulse rate of 85 beats per minute
D. Hemoglobin of 11.0 g/dL
28. A nurse is caring for a client in labor. The nurse determines that the client is beginning in the second stage of labor when which of the following assessments is noted?
A. The client begins to expel clear vaginal fluid
B. The contractions are regular
C. The membranes have ruptured
D. The cervix is dilated completely
29. A pregnant woman at 32 weeks' gestation complains of feeling dizzy and lightheaded while her fundal height is being measured. Her skin is pale and moist. The nurse's initial response would be to:
A. Assess the woman’s blood pressure and pulse
B. Have the woman breathe into a paper bag
C. Raise the woman’s legs
D. Turn the woman on her left side..
30. When involved in prenatal teaching. the nurse should advise the clients that an increase in vaginal secretions during pregnancy is called leukorrhea and is caused by increased:
A. Metabolic rates
B. Production of estrogen
C. Functioning of the Bartholin glands
D. Supply of sodium chloride to the cells of the vagina
31. A 60-year-old women is admitted to the following a neck dissection for laryngeal cancer lymph nodes and the sternocleidomastoid muscle, Which of the following is the best post-operative
A. Risk for infection
B. Impaired nutrition
C. Ineffective airway clearance
D. Impaired verbal communication
32. A mother brings her 2-month-old child in to the urgent care clinic reporting that shortly after the child developed a fever, his voice became muffled, and he began drooling. Inspiratory stridor is present. The priority action of the healthcare provider is to
A. Obtain an order for an antibiotic
B. Inspect the child's throat for a foreign object
C. Ask the mother if the child has any allergies
D. Call for immediate assistance
33. What major factor should alert a nurse to discount an infant who is febrile?
A. Shivering
B. Tachycardia
C. Mottled skin
D. Increased respiratory rate
34. A female patient complains of abdominal discomfort. Watery stool has been eaking from her rectum. This could be a sign of
A. fecal impaction
B. constipation
C. bowel incontinence
D. diarrhea
35. Which of the following terms applies to the tiny. blanched. slightly raised end arterioles found on the face. neck. arms. and chest during pregnancy?
A. Epulis
B. Linea nigra
C. Striae gravidarum
D. Telangiectasias
36. The nurse was evaluating nursing care plan for 50 year-old female patient who has been scheduled for lithotripsy due to urinary calculusWhich of the following is the priority evaluation?
A. Edema
B. Acute pain *
C. Knowledge deficits
D. Urinary tract infection
37. A nurse diagnosis a patient with readiness for the This diagnosis is classified within which of the Nursing diagnoses?
A. Acute nursing diagnoses
B. Risk nursing diagnoses
C. Wellness nursing diagnoses
D. Possible nursing diagnoses
38. A nurse enters the room of a patient who is on the patient complains of not feeling well, the (see image). What is the most likely interpretation?
A. Sinus tachycardia
B. Ventricular fibrillation
C. Normal sinus rhythm
D. Ventricular tachycardia
39. A child with a peanut allergy has also recently been diagnosed with asthma.The healthcare provider instructs the parents on ways to prevent the child coming in contact with peanuts. This is because the child is at increased risk for which of these problems?
A. Painful rash and urticaria
B. Anaphylaxis and respiratory failure
C. Headache and seizures
D. Projectile vomiting and diarrhea
40. A 40-year-old man is admitted to a Coronary pain. The ECG has normal sinus rhythm with leads V1-V4.
Blood pressure 123/69 mmHg What is the most likely nursing diagnosis?
A. Acute chest pain
B. Myocardial in fraction
C. Decreased cardiac output
D. Ineffective tissue perfusion
41. A cardiac monitor for a patient in a Coronary abnormal ECG rhythm with heart rate of 159 be a Complex (0.18 second), and absent P wave. What could be the type of possible dysrhythmia?
A. Sinus tachycardia
B. Ventricular tachycardia
C. Ventricular fibrillation
D. Supraventricular tachycardia
42.40-year-old man. smoker, presents to the clinic On examination, the toes are cold to the touch. extremities is pale to blue. The pedal pulse Examination of the fingers shows small ulceration the skin. Blood glucose testing is normal and then history of diabetes.
On admission
Blood pressure 140/90 mmHg
Heart rate 86 /min
Respiratory rate 22 /min
Oxygen saturation 98% room air Which of the following would be most effective?
A. Antibiotic administration
B. Reduced fat intake
C. Smoking cessation
D. Regular exercise
43. A 60-year-old man client had a permanent complains of chest pain and dyspnoea with rapid feels suffocated and appears restless.
Blood pressure 100/70 mmHg
Heart Rate 96 /min
Respiratory rate 32 /min Temperature 37.2 C What is the immediate nursing intervention?
A. Monitor and report findings of chest
B. Chest X-ray to identify dislocation of
C. Manage pain with medication as ordered
D. Administer oxygen as ordered
A. Heart rate of 105 bpm
B. Urinary output of 15 ml
C. Respiratory rate of 30 cpm
D. Temperature of 39 degree Celsius
45. A nurse enters the room of a patient who is on the patient complains of not feeling well, the (see image).
What is the most likely interpretation?
A. Sinus tachycardia
B. Ventricular fibrillation
C. Normal sinus rhythm
D. Ventricular tachycardia
46. patient is being admitted to the Recovery Room following a thyroidectomy. The back of the neck wound is covered with dressing. During the first 15 minutes, the patient started working and having diarrhea. A general assessment is performed with special attention given for the high risk for hemorrhage.Where would bleeding most likely occur?
A. Stool
B. Vomitus
C. Dressing
D. Back of neck
47. 49-year-old women presented to the Emergency Department complaint of severe chest pain. The ECG showed that the patient myocardial infarction. The doctor ordered the nurse to give the 800 mg of aspirin. What is the primary indication of aspirin in this case?
A. Breaks down the thrombus
B. Decreases the formation of platelet plugs
C. Inhibits the conversion of prothrombine to
D. Interferes with vitamin k to maintain
48. A newly nursing director assigned to a hospital. That is the first should he do?
A. Evaluates the staff
B. Change the head nurses
C. Change the roles
D. Nothing to do
What is the best place the nurse should meet with the student?
A. House
B. Canteen
C. Playground
D. Nursing office
50. Five minutes post-birth a neonate has a heart rate of 98, irregular breathing, acxvity moves all extremities, but has bluish hands and feet, as well as a weak and
timid cry Which is the correct APGAR assessment score?
A. 9
B. 8
C. 7
D. 6
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