Southeast Asian College, Inc.

College of Nursing
2 E. Rodriguez Sr. Ave., Quezon City
SY 2014 2015

RLE on Leadership and Management
(Head Nursing)
Quezon Institute

POST TEST

1. A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned to care for the client must institute
appropriate precautions. The nurse should:
a. Place the client in a private room.
b. Wear an N 95 respirator when caring for the client.
c. Put on a gown every time when entering the room.
d. Don a surgical mask with a face shield when entering the room.

Answer & Rationale: B. The N 95 respirator is a high-particulate filtration mask that meets the CDC performance criteria for a
tuberculosis respirator.

2. A client is diagnosed with Tuberculosis and respiratory isolation is initiated. This means that:
a. Gloves are worn when handling the clients tissue, excretions, and linen.
b. Both client and attending nurse must wear masks at all times.
c. Nurse and visitors must wear masks until chemotherapy is begun. Client is instructed in cough and tissue techniques.
d. Full isolation; that is, caps and gowns are required during the period of contagion.
Answer & Rationale: C. Proper handling of sputum is essential to allay droplet transference of bacilli in the air. Clients need to be
taught to cover their nose and mouth with tissues when sneezing or coughing. Chemotherapy generally renders the client
noninfectious within days to a few weeks, usually before cultures for tubercle bacilli are negative. Until chemical isolation is
established, many institutions require the client to wear a mask when visitors are in the room or when the nurse is in attendance.
Client should be in a well-ventilated room, without air recirculation, to prevent air contamination.
3. The right forearm of a client who had a purified protein derivative (PPD) test for tuberculosis is reddened and raised about 3mm
where the test was given. This PPD would be read as having which of the following results?
a. Indeterminate
b. Needs to be redone
c. Negative
d. Positive
Answer & Rationale: C. This test would be classed as negative. A 5 mm raised area would be a positive result if a client was HIV+
or had recent close contact with someone diagnosed with TB. Indeterminate isnt a term used to describe results of a PPD test. If
the PPD is reddened and raised 10mm or more, its considered positive according to the CDC.
4. Which of the following diagnostic tests is definitive for TB?
a. Chest x-ray
b. Mantoux test
c. Sputum culture
d. Tuberculin test
Answer & Rationale: C. The sputum culture for Mycobacterium tuberculosis is the only method of confirming the diagnosis.
Lesions in the lung may not be big enough to be seen on x-ray. Skin tests may be falsely positive or falsely negative.
5. A client with a positive Mantoux test result will be sent for a chest x-ray. For which of the following reasons is this done?
a. To confirm the diagnosis
b. To determine if a repeat skin test is needed
c. To determine the extent of the lesions
d. To determine if this is a primary or secondary infection
Answer & Rationale: C. If the lesions are large enough, the chest x-ray will show their presence in the lungs. Sputum culture
confirms the diagnosis. There can be false-positive and false-negative skin test results. A chest x-ray cant determine if this is a
primary or secondary infection.
6. A client with a positive skin test for TB isnt showing signs of active disease. To help prevent the development of active TB, the
client should be treated with isoniazid, 300 mg daily, for how long?
a. 10 to 14 days
b. 2 to 4 weeks
c. 3 to 6 months
d. 9 to 12 months
Answer & Rationale: D. Because of the increased incidence of resistant strains of TB, the disease must be treated for up to 24
months in some cases, but treatment typically lasts for 9-12 months. Isoniazid is the most common medication used for the
treatment of TB, but other antibiotics are added to the regimen to obtain the best results.
7. A client is diagnosed with active TB and started on triple antibiotic therapy. What signs and symptoms would the client show if
therapy is inadequate?
a. Decreased shortness of breath
b. Improved chest x-ray
c. Nonproductive cough
d. Positive acid-fast bacilli in a sputum sample after 2 months of treatment.
Answer & Rationale: D. Continuing to have acid-fast bacilli in the sputum after 2 months indicated continued infection.
8. Isoniazid (INH) and rifampin (Rifacin) have been prescribed for a client with TB. A nurse reviews the medical record of the
client. Which of the following, if noted in the clients history, would require physician notification?
a. Heart disease
b. Allergy to penicillin
c. Hepatitis B
d. Rheumatic fever
Answer & Rationale: C. Isoniazid and Rifampin are contraindicated in clients with acute liver disease or a history of hepatic injury.
9. A nurse is caring for a client diagnosed with TB. Which assessment, if made by the nurse, would not be consistent with the usual
clinical presentation of TB and may indicate the development of a concurrent problem?
a. Nonproductive or productive cough
b. Anorexia and weight loss
c. Chills and night sweats
d. High-grade fever
Answer & Rationale: D. The client with TB usually experiences cough (non-productive or productive), fatigue, anorexia, weight
loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever.
10. A nurse is teaching a client with TB about dietary elements that should be increased in the diet. The nurse suggests that the client
increase intake of:
a. Meats and citrus fruits
b. Grains and broccoli
c. Eggs and spinach
d. Potatoes and fish
Answer & Rationale: A. The nurse teaches the client with TB to increase intake of protein, iron, and vitamin C.
11. The nurse obtains a history from a client diagnosed with hepatitis A. which of the following factors is MOST likely related to the
diagnosis?
a. The client performs missionary work in Brazil
b. The client had polio as a child
c. The client gave blood 4 weeks ago.
d. The client has recently been bitten by an insect.
Answer & Rationale: A. Hepatitis A is transmitted by the fecal-oral route. It is associated with contaminated food and water.
Missionary work usually takes places outside major cities.
12. The nurse prepares an older client for discharge after cataract surgery. The client is to use external contact lenses. Which of the
following information in the clients history is MOST important for the nurse to know?
a. The client takes medication for hypertension
b. The client lives in a second floor
c. The client has rheumatoid arthritis
d. The client had pervious eye surgery
Answer & Rationale: C. this disease would affect the fine motor movements needed for inserting the contact lenses.
13. The nurse cares for a client with a history of long-term alcohol abuse. During acute period, the nurse expects the physician to
order which of the following?
a. An antiemetic, vitamins and minerals administered in IV fluids
b. Cool compresses, bedrest and an appetite stimulant
c. Full diet as tolerated, thiamine and a tranquilizer
d. Oral fluids, antabuse and a barbiturate
Answer & Rationale: C. the regular diet is used to meet the patients nutritional needs. Thiamine is given because the patient may
be deficient in the vitamin, and a tranquilizer is used to reduce agitation.
14. The client is admitted to the hospital for treatment of head injuries he sustained in a motor vehicle accident. The client has
pronounced swelling of the forehead. Vital signs are BP 110/80, pulse 88, respirations 20. Which of the following indicates to the
nurse that the patients status is deteriorating?
a. BP 90/54; pulse 50; respirations 22
b. BP 110/66; pulse 120; respirations 32
c. BP 140/70; pulse 60; respirations 14
d. BP 120/90; pulse 90; respirations 16
Answer & Rationale: B. You are looking for vital signs indicating that the patient is getting worse. There is a decrease in blood
pressure with a widening pulse pressure (the difference between systolic and diastolic blood pressure). There is also an increase in
pulse and respirations, indicating increased intracranial pressure.
15. The nurse plans care for a patient receiving TPN. Which of the following should the nurse check MOST frequently?
a. Liver function studies
b. White cell count and differential count
c. Hemoglobin and hematocrit
d. Blood glucose and urine specific gravity
Answer & Rationale: D. You should check for blood sugar every 6 hours for hyperglycemia, and check the urine for an altered
specific gravity that would indicate osmotic diuresis.
16. The nurse cares for a woman who began chemotherapy 4 days ago for treatment of colon cancer. When planning care for this
patient, the nurse recognizes an early side effect of chemotherapy includes which of the following?
a. Weight loss
b. Skin ulcers
c. Mouth ulcerations
d. Malnutrition
Answer & Rationale: C. Stomatitis and mouth ulcers are an early problem associated with chemotherapy. You should assess the
patients mouth twice a day and perform good mouth care every 2 to 3 hours while awake. Use a soft toothbrush. The patient
should avoid extremely hot or cold foods, spices and all citrus juices along with alcohol and smoking. The patients diet should
consist of soft or pureed foods with supplements.
17. A patient with type 1 diabetes is admitted to the hospital with a blood glucose level of 740 gm/dl; serum acetone and urine
ketones are positive. IV fluids and insulin are ordered. To evaluate the effect of the IV fluids and insulin, the nurse shoul d expect
which of the following?
a. Decreased BP; decreased pulse, decreased respirations
b. Decreased BP, increased pulse, increased respirations
c. Increased BP, decreased pulse, decreased respirations
d. Increased BP, increased pulse, increased respirations
Answer & Rationale: C. Dehydration will be corrected and volume will be restored. There will be improved skin turgor. The
weight will increase and hematocrit will drop to normal.
18. A patient with gestational diabetes mellitus delivers a 6-lb 11oz baby boy at 37 weeks gestation. Which of the following nursing
diagnosis is MOST important for the nurse to consider when planning the infants care?
a. Altered tissue perfusion r/t decreased blood viscosity
b. Altered nutrition, more than body requirements r/t decreased glucose metabolism
c. Impaired gas exchange r/t respiratory distress syndrome
d. Potential for altered parenting r/t mother-infant separation
Answer & Rationale: C. this involves the most important physical need; a clear airway. Surfactant synthesis may be altered because
of high fetal levels on insulin.
19. The nurse evaluates the care provided to a patient hospitalized for treatment of adrenal crisis. Which of the following changes
indicates to the nurse that the patient is responding favorably to medical and nursing treatment?
a. The patients urinary output has increased
b. The patients blood pressure has increased
c. The patient has lost weight
d. The patients peripheral edema has decreased
Answer & Rationale: B. Hypotension is a symptom of adrenal insufficiency. Without treatment the sodium level falls, resulting in
volume depletion and hypotension. The potassium level rises, resulting in cardiac dysarhytmias
20. The nurse in the recovery room admits a patient after supratentorial surgery for treatment of a brain tumor. Which of the
following actions should the nurse take FIRST?
a. Assess the patients LOC
b. Offer the patient sips of water.
c. Elevate the head of the patients bed
d. Position the patient on the operated side.
Answer & Rationale: C. The head of the bed should be elevated 30 degrees. This promotes venous drainage and prevents
increased intracranial pressure. You should avoid hip or neck flexion and keep the head in a midline position.


Prepared by: Approved by:



Loretta Maria A. Pineda Dr. Lucy De Leon
Head Nurse Clinical Instructor




Southeast Asian College, Inc.
College of Nursing
2 E. Rodriguez Sr. Ave., Quezon City
SY 2014 2015

RLE on Leadership and Management
(Head Nursing)
Quezon Institute

Student Name: Jeffrey Cierva
Date: 8/29/14
POST TEST


1. A client with tuberculosis is to be admitted in the
hospital. The nurse who will be assigned to care for the
client must institute appropriate precautions. The nurse
should:
a. Place the client in a private room.
b. Wear an N 95 respirator when caring for the
client.
c. Put on a gown every time when entering the
room.
d. Don a surgical mask with a face shield when
entering the room.
2. A client is diagnosed with Tuberculosis and respiratory
isolation is initiated. This means that:
a. Gloves are worn when handling the clients
tissue, excretions, and linen.
b. Both client and attending nurse must wear
masks at all times.
c. Nurse and visitors must wear masks until
chemotherapy is begun. Client is instructed in
cough and tissue techniques.
d. Full isolation; that is, caps and gowns are
required during the period of contagion.
3. The right forearm of a client who had a purified
protein derivative (PPD) test for tuberculosis is
reddened and raised about 3mm where the test was
given. This PPD would be read as having which of the
following results?
a. Indeterminate
b. Needs to be redone
c. Negative
d. Positive
4. Which of the following diagnostic tests is definitive for
TB?
a. Chest x-ray
b. Mantoux test
c. Sputum culture
d. Tuberculin test
5. A client with a positive Mantoux test result will be sent
for a chest x-ray. For which of the following reasons is
this done?
a. To confirm the diagnosis
b. To determine if a repeat skin test is needed
c. To determine the extent of the lesions
d. To determine if this is a primary or secondary
infection
6. A client with a positive skin test for TB isnt showing
signs of active disease. To help prevent the
development of active TB, the client should be treated
with isoniazid, 300 mg daily, for how long?
a. 10 to 14 days
b. 2 to 4 weeks
c. 3 to 6 months
d. 9 to 12 months
7. A client is diagnosed with active TB and started on
triple antibiotic therapy. What signs and symptoms
would the client show if therapy is inadequate?
a. Decreased shortness of breath
b. Improved chest x-ray
c. Nonproductive cough
d. Positive acid-fast bacilli in a sputum sample
after 2 months of treatment.
8. Isoniazid (INH) and rifampin (Rifacin) have been
prescribed for a client with TB. A nurse reviews the
medical record of the client. Which of the following, if
noted in the clients history, would require physician
notification?
a. Heart disease
b. Allergy to penicillin
c. Hepatitis B
d. Rheumatic fever
9. A nurse is caring for a client diagnosed with TB. Which
assessment, if made by the nurse, would not be
consistent with the usual clinical presentation of TB
and may indicate the development of a concurrent
problem?
a. Nonproductive or productive cough
b. Anorexia and weight loss
c. Chills and night sweats
d. High-grade fever
10. A nurse is teaching a client with TB about dietary
elements that should be increased in the diet. The nurse
suggests that the client increase intake of:
a. Meats and citrus fruits
b. Grains and broccoli
c. Eggs and spinach
d. Potatoes and fish
11. The nurse obtains a history from a client diagnosed
with hepatitis A. which of the following factors is
MOST likely related to the diagnosis?

a. The client performs missionary work in Brazil
b. The client had polio as a child
c. The client gave blood 4 weeks ago.
d. The client has recently been bitten by an
insect.
12. The nurse prepares an older client for discharge after
cataract surgery. The client is to use external contact
lenses. Which of the following information in the
clients history is MOST important for the nurse to
know?
a. The client takes medication for hypertension
b. The client lives in a second floor
c. The client has rheumatoid arthritis
d. The client had pervious eye surgery
13. The nurse cares for a client with a history of long-term
alcohol abuse. During acute period, the nurse expects
the physician to order which of the following?
a. An antiemetic, vitamins and minerals
administered in IV fluids
b. Cool compresses, bedrest and an appetite
stimulant
c. Full diet as tolerated, thiamine and a
tranquilizer
d. Oral fluids, antabuse and a barbiturate
14. The client is admitted to the hospital for treatment of
head injuries he sustained in a motor vehicle accident.
The client has pronounced swelling of the forehead.
Vital signs are BP 110/80, pulse 88, respirations 20.
Which of the following indicates to the nurse that the
patients status is deteriorating?
a. BP 90/54; pulse 50; respirations 22
b. BP 110/66; pulse 120; respirations 32
c. BP 140/70; pulse 60; respirations 14
15. The nurse plans care for a patient receiving TPN.
Which of the following should the nurse check MOST
frequently?
a. Liver function studies
b. White cell count and differential count
c. Hemoglobin and hematocrit
d. Blood glucose and urine specific gravity
16. The nurse cares for a woman who began chemotherapy
4 days ago for treatment of colon cancer. When
planning care for this patient, the nurse recognizes an
early side effect of chemotherapy includes which of the
following?
a. Weight loss
b. Skin ulcers
c. Mouth ulcerations
d. Malnutrition
17. A patient with type 1 diabetes is admitted to the
hospital with a blood glucose level of 740 gm/dl; serum
acetone and urine ketones are positive. IV fluids and
insulin are ordered. To evaluate the effect of the IV
fluids and insulin, the nurse should expect which of the
following?
a. Decreased BP; decreased pulse, decreased
respirations
b. Decreased BP, increased pulse, increased
respirations
c. Increased BP, decreased pulse, decreased
respirations
d. Increased BP, increased pulse, increased
respirations
18. A patient with gestational diabetes mellitus delivers a 6-
lb 11oz baby boy at 37 weeks gestation. Which of the
following nursing diagnosis is MOST important for the
nurse to consider when planning the infants care?
a. Altered tissue perfusion r/t decreased blood
viscosity
b. Altered nutrition, more than body
requirements r/t decreased glucose
metabolism
c. Impaired gas exchange r/t respiratory distress
syndrome
d. Potential for altered parenting r/t mother-
infant separation
19. The nurse evaluates the care provided to a patient
hospitalized for treatment of adrenal crisis. Which of
the following changes indicates to the nurse that the
patient is responding favorably to medical and nursing
treatment?
a. The patients urinary output has increased
b. The patients blood pressure has increased
c. The patient has lost weight
d. The patients peripheral edema has decreased
20. The nurse in the recovery room admits a patient after
supratentorial surgery for treatment of a brain tumor.
Which of the following actions should the nurse take
FIRST?
a. Assess the patients LOC
b. Offer the patient sips of water.
c. Elevate the head of the patients bed
d. Position the patient on the operated side.

Prepared by:


Loretta Maria A. Pineda
Head Nurse

Approved by:


Dr. Lucy De Leon
Clinical Instructor