Situation I -- Nurse Caria is assigned in the emergency unit meeting. Varied opportunities that developed her nursing skills.
1. A 17-year old is admitted following an automobile accident He is very anxious, dyspneic, and in severe pain. The left chest wall moves in during inspiration and balloons out when he exhales. The nurse understands these symptoms are most suggestive of:
b. Flail chest
d. Pleural effusion
2. A young man is admitted with a flail chest following a car accident. He is intubated with an endotracheal tube and is placed on a mechanical ventilator (control mode, positive pressure). Which physical finding alerts the nurse to an additional problem in respiratory function?
a. Dullness to percussion in the third to 5th intercostals space, midclavicular line
b. Decreased paradoxical motion
c. Louder breath sounds on the right chest
d. pH of 7.36 In arterial blood gases
3. The nurse is caring for a client who has just had a chest tube attached to a water seal drainage system (Pleur-evac). To ensure that the system functions effectively the nurse should:
a. Observe for intermittent bubbling in the water seal chamber
b. Flush the test tube with 30 to 60 ml of NSS 4 to 6 hours
c. Maintain the client in an extreme lateral position
d. Strip the chest tubes in the direction of the client
4. The nurse enter the room of a client who has a chest tube attached to a water seal drainage system and notices the chest tube is dislodge from the chest. The most appropriate nursing intervention is to:
a. Notify the physician
b. Insert a new chest tube
c. Cover the insertion site with new petroleum gauze
d. Instruct the client to breath deeply until the help arrives
5. A 71-year old is admitted to the hospital with congestive heart failure. She has shortness of breath and a +3 - 4 peripheral edema. The care plan to reduce the client's edema should include nursing strategies for:
a. Establishing limits on activity
b. Fostering a relaxed environment
c. Identifying goals for self care
d. Restricting IV fluids
Situation 2 - Oxygen is the most vital physiologic need for survival.
6. Mr. Sison, 65 years old has been smoking since he was 11 years old. He has long history of emphysema. Mr. Sison is admitted to the hospital because of a respiratory infection, which has not improved with outpatient therapy. Which finding would the nurse expect to observe during Mr. Sison's nursing assessment?
a. Electrocardiogram changes
b. Increased anterior-posterior chest diameter
c. Slow labored respiratory pattern
d. Weight-Height relationship indicating obesity
7. Mr. Sison is ordered oxygen via nasal prongs. The nurse administering the oxygen via the low-flow system recognizes that this method of delivery:
a. Mixes room air with oxygen
b. Delivers a precise concentration of oxygen
c. Requires humidity during delivery
d. Is less traumatic to the respirator tract
8. Which statement by Mr. Sison indicates that client teaching regarding oxygen therapy has been effective?
a. "I was feeling fine so I removed my nasal prongs."
b. "I've increased my fluids to six glasses of water daily."
c. "Don’t forget to come back quickly when you get me out of the bed; I don't want to be without my oxygen for too long."
d. "My family was angry when I told them they could not smoke in my room."
9. Supplemental low-flow oxygen therapy is prescribed for a man with emphysema. Which is the most essential for the nurse to initiate?
a. Anticipate the need for humidification
b. Notify the physician that this order is contraindicated
c. Place client in high Fowler's position
d. Schedule nursing care to allow frequent observations of the client
Situation 3 - Mr. Silverio, 56 years old, has had significant problem with alcohol abuse for the past 15 years. His wife brings him to the emergency department because he is increasingly confused and is coughing blood. His medical diagnosis is cirrhosis of the liver. He has ascites and esophageal varices.
10. Assessment of Mr. Silverio would reveal all of the following, except:
a. Bulging flanks
b. Protruding umbilicus
c. Abdominal distension
d. Bluish discoloration of the umbilicus
11. Which laboratory value would the nurse expect to find in a client as a result of liver failure?
a. Decreased serum creatinine
b. Decreased sodium
c. Increased ammonia
d. Restricted sodium
12. The major dietary treatment for ascites calls for:
a. High protein
b. Increased potassium
c. Restricted fluids
d. Restricted sodium
13. A Sengstaken-BIakemore tube is inserted in an effort to stop the bleeding. Base on this information, the first action the nurse should take is to:
a. Deflate the esophageal balloon
b. Encourage him to take the deep breath
c. Monitor his vital signs
d. Notify the physician
14. Because the detoxification of alcohol damages tissues a high-calorie diet, fortified with vitamins should be encouraged to protect Mr. Silverio's:
Situation 4 - Rape is one of the most tragic things that could happen to anyone especially with young girls. Incidence such as these could develop into a crisis situation involving not only the rape victims but also their families.
15. This type of crisis could be an example of which of the following?
a. Combination of developmental and situational
16. Noemi, a staff nurse in the emergency room, realizes that she has an important role to play as a patient advocate to rape victims. To demonstrate this role, she takes note of one of the responsibilities?
a. Since this is a legal case, call the press about the incidence of rape
b. Perform thorough physical assessment and documenting objectively all the evidences of rape
c. Ask the patient to stay in one isolated room first to provide privacy while attending to other patients
d. Provide emotional support first and postponed physical assessment when patient is already calm
17. Which of the following is a form of active, focused, emotional environmental first aid for patients in crisis?
a. Attitude therapy
c. Crisis intervention
d. Re-motivation technique
18. Which of the following is true with regards to crisis?
a. Crisis is self-limiting
b. After crisis, the individual always return to a pre-crisis state or condition
c. Crisis always result in adaptive behavior
d. The person in crisis is not susceptible for any help
19. If help is not provided in a crisis situation, an individual may spontaneously resolve in negatively or positively by returning to pre-crisis state, usually within which of the following duration?
a. 2-3 weeks
b. 3-4 weeks
c. 1-2 weeks
d. 4-6 weeks
Situation 6 - One Important fact that will guide the nurse in the practice of the profession is her knowledge of the nursing law.
20. The nurse practice Act of 1991 regulates the practice of nursing in the Philippines. Which of the following statements about this Act is true?
a. This Act delineates the practice of nursing and midwifery
b. It was enacted in November 1991
c. The primary purpose is to protect the public
d. The Act defines the practice of nursing in the Philippines
21. When a nurse starts working In a hospital but without a written contract, which of the following is expected of her?
a. She's not bound to perform according to the standards of nursing practice
b. Provides nursing care within the acceptable standards of nursing practice
c. She's not obligated to provide professional service
d. The employer does not hold the nurse responsible for her action
22. A patient, G8P5, refused to be injected with the 3rd dose of Depoprovera. The
nurse insisted inspite of the patients refusal and forcibly injected the contraceptive. She can be sued for which of the following?
b. Assault and Battery
23.A patient has been in the ICU for 2 weeks. The relatives have consented to a "Do not resuscitate order," When the patient develops a cardiac arrest, the nurse will carry out which of the following actions?
a. Only medication will be given
b. All ordinary measure will be stopped
c. Basic and advance life support will not be given
d. Mechanical ventilation and NGT will be stopped
24. When a patient falls from bed, which of the following is your immediate action?
a. Report to the head nurse and calls someone to help
b. Determine any injury or harm
c. Refer to the resident on duty
d. Put back patient to bed
Situation 7 - Ms. May Mansur encountered vehicular accident on her way to the office and he remains conscious. Police officers brought her to the hospital.
25. You have to observe for increase intracranial pressure. Which of the following is not a sign of increased intracranial pressure?
d. Changes on the level of consciousness
26. Which of the following drug may be given to reduce increase intracranial pressure?
27. Since she medicated to reduce increased intracranial pressure. What nursing measure must be done to prevent further complication?
a. Encourage her to observe bed rest
b. Check blood pressure every shift
c. Observe complete best rest
d. Measure intake and output
28. In what manner would you be able to assess accurately her motor strength?
a. Observe how he talks
b. Instruct her to squeeze her hands
c. Allowing him to stand alone
d. Pricking her skin with pin
29.Which of the following activities would cause her a risk in the increase of intracranial pressure?
Situation 8 - Basic Psychiatric concepts a nurse should be aware of...
30. Mental experiences, operate on different levels of awareness. The level that best portrays one's attitudes, feelings, and desire is the:
31. The ability to tolerate frustration is an example of one of the functions of the:
32. In the process of development the individual strives to maintain, protect, and enhance the integrity of the self. This normally accomplished through the use of:
a. Affective reactions
b. Ritualistic behavior
c. Withdrawal patterns
d. Defense mechanisms
33. Sublimation is a defense mechanism that helps the individual:
a. Act out in a reverse something already one or thought
b. Return to an earlier, less mature stage of development
c. Exclude fro the conscious things that are psychologically disturbing
d. Channel an acceptable sexual desire into socially approved behavior
34. An example of displacement is:
a. Imaginative activity to escape reality
b. Ignoring unpleasant aspects of reality
c. Resisting any demands made by others
d. Pent-up emotion directed to other than the primary source
Situation 9 - Joan, age 34, is hospitalized because of alcoholism.
35. Joan denied that she has a problem with alcohol. The nurse understands that Joan uses denial for which of the following reasons:
a. To reduce her feelings of guilt
b. To iive up to others' expectation
c. To make her seem more independent
d. To make her look better in the eyes of others
36. Joan appears suspicious of others and blames them for her personal problems. The nurse understands the client is using this behavior because which of the following difficulties?
a. In telling the truth
b. Meeting an ego ideal
c. With dependence and independence
d. In identifying who is creating the problem
37. When thinking about alcohol and drug abuse, the nurse is aware that:
a. Most polydrug abusers also abuse alcohol
b. Most alcoholics become polydrug abusers
c. Addictive individuals tend to use hostile abusive behavior
d. An unhappy childhood is a causative factor in many addictions
38. The most important factor in rehabilitation of a client addicted to alcohol is:
a. The availability of community resources
b. The accepting attitude of the client’s family
c. The client's emotional or motivational readiness
d. The qualitative level of the client's physical state
39. Joan asks if attendance of Alcoholics Anonymous is required. Which of the following would reflect the nurse's reply?
a. "You'll find you need their support."
b. "Do you have feelings about going to these meetings?"
c. "No its best to wait until you feet you really need them."
d. "Yes, because you will learn how to cope with your problem."
Situation 10 - Nurse Medie has been encountering schizophrenic and different psychotic disorders. .
40. A male client who has delusions of persecution and auditory hallucination is admitted for psychiatric evaluation after stabbing a friend. Later a nurse on the unit greets the client by saying, "Good evening. How are you?" The client who has been referring to himself as "man," answers, "The man is bad." This is example of:
d. Reaction formation
41. A disturb client starts to repeat phrase that others have just said. This type of speech is known as:
42. Projection, rationalization, denial, and distortion by hallucinations and delusions are examples of a disturbance in:
c. Reality testing
d. The thought process
43. The major reasons for treating severe emotional disorders with tranquilizers is to:
a. Reduce the neurotic syndrome
b. Prevent secondary complication
c. Prevent destructiveness by the client
d. Make the client more amenable to psychotherapy
44. The nurse recognizes that dementia of the Alzheimer's type is characterized by :
a. Aggressive acting out behavior
b. Periodic remissions and exacerbations
c. Hypoxia of selected areas of brain tissue
d. Areas of brain destruction called senile plaques
Situation 11 - Aisa, is a 4-year old with severe anemia. She is seen by the nurse in the clinic.
45. In addition to weakness and fatigue, which of the following problems should the nurse expect Aisa to exhibit?
a. Cold, clammy skin
b. Increased pulse rate
c. Elevated blood pressure
d. Cyanosis of the nail beds
46. Which of the following problems associated with anemia best explains why Aisa becomes dizzy during periods of physical activity?
a. An inflammation of the inner ear
b. Insufficient cerebral oxygenation
c. A sudden drop in blood pressure
d. Decreased level of serum glucose
47. Aisa is to receive a liquid iron preparation. Which of the following directions would be appropriate for the nurse to teach Aisa's mother?
a. Administer this at least an hour before meals
b. Explain that loose stools are common with iron
c. Have Aisa take the diluted iron preparation through a straw
d. Avoid giving Aisa orange or other citric juices with the iron preparation
48. Aisa is to have blood transfusion. Which of the following problems is most likely associated with blood transfusion?
a. Serum hepatitis
b. Allergic response
c. Pulmonary edema
d. Hemolytic reaction
Situation 12 - Eric Pineda is admitted to hospital to have his urethra dilated by the physician. A urinary retention catheter is inserted following the procedure.
49. A routine urinalysis is ordered for Mr. Pineda. If the specimen cannot be sent immediately to the laboratory, the nurse should:
a. Take no special action
b. Refrigerate the specimen
c. Store on dry side of utility room
d. Discard and collect a new specimen later
50. The nurse understands that the structure that encircles the male urethra is the:
b. Prostate gland
c. Seminal vesicle
d. Bulbourethral gland
51. The nurse can best prevent the contamination from Mr. Pineda's retention catheter by:
a. Perineal cleansing
b. Encouraging fluids
c. Irrigating the catheter
d. Cleansing around the meatus periodically
52. When Mr. Pineda, who has urinary retention catheter in place, complaints of discomfort in the bladder and urethra the nurse should first:
a. Notify the physician
b. Milk the tubing gently
c. Check the patency of the catheter
d. Irrigate the catheter with prescribed solutions
53. Mr. Pineda experiences difficulty in voiding after his indwelling urinary catheter is removed. This is probably related to:
a. Fluid imbalance
b. Mr. Pineda's recent sedentary lifestyle
c. An interruption in normal voiding habits
d. Nervous tension following the procedure
Situation 13 - Helen Alcantara is admitted to hospital with complaints of hematuria, frequency, urgency, and dysuria.
54. Mrs. Alcantara's signs and symptoms would most likely be associated with:
55. Mrs. Alcantara has a higher risk of developing cystitis than does a male. This is
a. Altered urinary pH
b. Hormonal secretions
c. Position of the bladder
d. Proximity of the urethra and anus
56. The family of an elderly, aphasic client complain that the nurse failed to obtain a signed consent before insertion of indwelling catheter to measure hourly output. This is an example of:
a. A catheter inserted for the client's benefit
b. A treatment that does not need a separate consent form
c. Treatment without consent of the client, which is an invasion of rights
d. Inability to obtain consent for treatment because the client was aphasic
57. When caring for a client with continuous bladder irrigation, the nurse should:
a. Monitor urinary specific gravity
b. Record urinary output every hour
c. Subtract irrigant from output to determine urine volume
d. Include irrigating solution in any 24 hour urine tests order
58. When urinary catheter is removed, the client is unable to empty the bladder. A drug is used to relieve urine retention is:
a. Carbachol injection
b. Neosporin GU irrigant
c. Bethanecol (Urecholine)
d. Pilocarpine hydrochloride (Pilocar)
Situation 14 - Arman Adriatico is admitted to hospital with extensive carcinoma of the descending portion of the colon with metastasis to the lymph nodes.
59. The operative procedure that would probably be perform to Mr. Adriatico is a (an):
60. The primary step toward long-range goals in Mr. Adriatico's rehabilitation involves his:
a. Mastery of techniques of ostomy care
b. Readiness to accept an altered body function
c. Awareness of available community resources
d. Knowledge of the necessary dietary modifications
61. When teaching Mr. Adriatico to care for a new stoma, the nurse should advice him that irrigations be done at the same time every day. The time selected should:
a. Be appropriate hour before breakfast
b. Provide ample uninterrupted bathroom use at home
c. Approximate Mr. Adratico's usual daily time for elimination
d. Be about halfway between the two largest meals of the day
62. When performing the colostomy irrigation, the nurse inserts the catheter into the stoma:
63.Mr. Adriatico should follow a diet that is:
a. Rich in protein
b. Low in fiber content
c. High in carbohydrate
d. As close to normal possible
Situation 15 - Richard Gabatan, a 32-year-old car salesman, suffered a spinal cord injury in a motor vehicle accident resulting to paraplegia.
64. A nurse finds Mr. Gabatan under the wreckage of the car. He is conscious, breathing satisfactorily, and lying on the back complaining of pain in the back and an inability to move his legs. The nurse should first:
a. Leave Mr. Gabatan lying on his back with instructions to move and then go seek additional help
b. Gently raise Mr. Gabatan to a sitting position to see if the pain either
c. Roll Mr. Gabatan on his abdomen, place, a pad under his head, and cover
him with any material available
d. Gently lift Mr. Gavatan into a flat piece of lumber and using any available transportation, rush him to the nearest medical institution
65. Once admitted to hospital the physician indicates that Mr. Gubatan is a paraplegic. The family asks the nurse what that means. The nurse explains that:
a. Upper extremities are paralyzed
b. Lower extremities are paralyzed
c. One side of the body is paralyzed
d. Both lower and upper extremities are paralyzed
66. The nurse recognizes that the major early problem for Mr. Gabatan will be:
a. Bladder control
b. Client education
c. Quadriceps setting
d. Use of aids for ambulation
67. The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
a. Active exercise
b. Deep massage
c. Use of tilt board
d. Proper positioning
68. Rehabilitation plans for Mr. Gabatan;
a. Should be left up to Mr. Gabatan and his family
b. Should be considered and planned for early in his care
c. Are not necessary, because he will return to former activities
d. Are not necessary, because he will probably not able to work again
Situation 16- Karen Boltron, age 16, is withdrawn and non communicative. She spends
most of her time lying on her bed.
69. Which nursing intervention would be the most appropriate way to help Karen accept the realities of daily living?
a. Assist her to care for personal hygiene needs
b. Encourage her to keep up with school studies
c. Encourage her to join the other clients in group singing
d. Leave her alone when these appears to be a disinterest in the activities at hand
70. Which is the best plan of nursing intervention to encourage Karen to talk:
a. Try to get her discuss feelings
b. Focus oh non threatening subjects
c. Ask simple questions that require answers
d. Sit and look magazines with her
71. Which of the following is an important aspect of nursing intervention when caring for Karen?
a. Help keep her oriented to reality
b. Involve her in activities throughout the day
c. Encourage her to discuss why mixing with other people is avoided
d. Help her understand that it is harmful to withdraw from situations
72. One day Karen suddenly walks up to the nurse and shouts. "You think you're so damned perfect ad good. i think you stink," Which response should the nurse make?
a. "You seem angry with me."
b. "Stink? I don't understand."
c. "Boy, you're in a bad mood."
d. "I can't be all that bad, can I?"
73. On being discharged, a client with psychiatric problems should be encouraged to:
a. Go back to regular activities
b. Call the unit whenever upset
c. Continue in an after care situation
d. Find a group that has similar problem
Situation 17 - Danny Dasigao, age 63, has an obsessive-compulsive behavior disorder. He believes that the doorknobs are contaminated and refuses to touch them except with the tissue.
74. Which intervention should the nurse make when dealing with Danny's fear of doorknobs?
a. Supply rim with paper tissue to help him function until his anxiety is reduced
b. Explain to him that this idea about doorknob is part of his illness and is not necessary
c. Encourage him to scrub the doorknobs with a strong antiseptic so he does not need to use tissues
d. Encourage him to touch doorknobs by removing all available paper tissue until he learns to deal with the situation
75. Which stimulus is possibly motivating Danny to use paper towels to open doors?
a. He is using the method to punish himself
b. He is listening to voices telling him that the doorknobs are unclean
c. He wants to unconsciously control unacceptable impulses or feelings
d. He has a need to punish others by carrying out an annoying procedure
76. Which action by the nurse would most likely decrease Danny's anxiety?
a. Explore with him the nature of his anxiety
b. Stimulate him to express his ritualistic actions regularly
c. Encourage him to participate in his therapeutic plan of care
d. Provide him with an environment that is both supportive and non-opinionated
77. Which intervention should be included in Danny's initial treatment plan?
a. Deny his time for the ritualistic behavior
b. Give a schedule for the ritualistic behavior
c. Determine the purpose of the ritualistic behavior
d. Suggest a symptom substitution technique to refocus the behavior
78. The most appropriate way to decrease a clients anxiety is by:
a. Avoiding unpleasant objects and events
b. Prolonged exposure to fearful situation
c. Acquiring skills with which to face stressful events
d. Introducing an element of pleasure into fearful situations
Situation 18 - Jennifer Yadao, age 16, is admitted with the diagnosis of anorexia nervosa. She has lost 10 kg in 5 weeks. She is very thin but excessively concerned about being overweight. Her daily intake is 10 cups of coffee.
79. Which nursing intervention should the nurse initially perform for Jennifer?
a. Explain the value of good nutrition
b. Compliment her on her lovely figure
c. Try to establish a relationship of trust
d. Explore the reasons why she does not eat
80. Which stimulus is the most likely cause of Jennifer's disorder?
a. Allow self-esteem
b. Feelings of unworthiness
c. Anger directed at the parents
d. An unconscious fear of growing up
81 Jenifer is to be placed on behavior modification. Which is appropriate to include in the nursing care plan?
a. Remind frequently the client to eat all the food served on the tray
b. Increase phone calls allowed the client by or a per day for each pound gained
c. Include the family with the client in therapy sessions two times per week
d. Weigh the client each day at 6:00 A.M. in hospital gown and slippers after she voids
82. Another patient, Kara, 17 years old, is also diagnosed with anorexia nervosa. You have been assigned to sit with her while she eats her dinner. Kara says to you, "My primary nurse trusts me. I don't see why you don't." Your best response is:
a. "I do trust you, but S was assigned to be with you."
b. "It sounds as if you are manipulating me."
c. "OK. When S return, you should have eaten everything."
d. "Who is your primary nurse."
83. Which observation of the client with anorexia indicates that the client is improving?
a. The client eats meals in the dining room
b. The client gains one pound per week
c. The client attends group therapy sessions
d. The client has a more realistic self-control
Situation 19 - Mr. Pascua is pacing about the unit and wringing his hands. He is breathing rapidly and complains of palpitations and nausea and he has difficulty focusing on what the nurse is saying. •
84. Mr. Pascua is experiencing a high degree of anxiety. It is important to recognize if additional help is required because:
a. If the client is out of control, another person will help to decrease his anxiety level
b. Being alone with an anxious client is dangerous
c. It will take another person to direct the client into activities to relieve anxiety
d. Hospital protocol for handling anxious clients requires at least two people
85. He says he is having a heart attack but refuses to rest. The nurse would be Interpret his level of anxiety as:
86.What should the nurse include in the care plan to Mr. Pascua when he is having
a panic attack?
a. Calm reassurance, deep breathing and modication as ordered
b. Teach Mr. Pascua problem solving in relation to his anxiety
c. Expiam the physiologic responses of anxiety
d. Explore alternate methods for dealing with the cause of his anxiety
Situation 20 - Joel is a toddler who has classical hemophilia.
87. Which of the following statements is true regarding Joel's disorder?
a. Hemophilia is an autosomal dominant disorder in which the woman carries
b. Hemophilia follows regular laws of Mendelian inherited disorders such as sickle ceil anemia
c. This disorder can be carried by either male or female but occurs in the sex opposite that of the carrier
d. Hemophilia is an X-linked disorder in which the mother is usually the carrier of the illness but is not affected by it
88. Joel has some internal bleeding. At which of the following sites is the most common for the child with hemophilia to bleed?
d. Ends of the log bones
89. Which of the following blood products is most likely to be given to Joel?
b. Fresh frozen plasma
c. Factor VIII concentrate
d. Factor II, Vll, IX, X complex
90. Joel's parents ask if-their other children will be affected by the disorder. Which of the following statements should guide the nurse in her response?
a. All the girls will be normal and the other son a carrier
b. All the girls will be carriers and one half the boys will be affected
c. Each son has a chance of being affected and each daughter a 50% chance of being a carrier
d. Each son has 50% chance of being affected or a carrier, and the girls will be all carriers.
91. A child is to receive a blood transfusion, if an allergic reaction to the blood occurs, the nurse's first intervention should be:
a. Call the physician
b. Slow the flow rate
c. Stop the blood immediately
d. Relieved the symptoms with an ordered antihistamines
Situation 19 - Mr. Villa who was admitted to the respiratory floor with COPD. The nurse finds him extremely restless, incoherent, and showing signs of acute respiratory distress. He Is using accessory muscles for breathing and Is diaphoretic and cyanotic.
92. The best initial action by the nurse is to:
a. Administered oxygen as ordered
b. Assess vital signs and neural vital signs
c. Administered medication which has been ordered for pain
d. Call respiratory therapy for a prescribed ABG (arterial -blood gas) analysis
93. An order is written for oxygen by nasal cannula at 2 liters per minute. Which assessment is most useful in assessing the adequacy of the oxygen therapy?
a. Respiratory rate
b. Color of mucus membranes
c. Pulmonary function tests
d. Arterial blood gases
94. Mr. Villa needs frequent monitoring of arterial blood gases. Following the drawing of arterial blood gasses it is essential for the nurse to do which of the following?
a. Encourage the client to cough an deep breath
b. Apply pressure to the puncture site for 5 minutes
c. Shake the vial of blood before transporting it to the lab
d. Keep the client on bed rest for 2 hours
95. The nurse is interpreting the results of a blood gas analysis performed on an adult client. The value include pH of 7.35, pC02 of 60, HC03 of 35. and 02 of 60. Which interpretation is most accurate?
a. The client is in metabolic acidosis
b. The client is in compensated metabolic alkalosis
c. The client is in respiratory alkalosis
d. The client is in compensated respiratory acidosis
Situation 20 - The nurse is assigned in a counseling clinic about preventive measures for cancers.
96. Cancer is the second major cause of death in this country. What is the first step toward effective cancer control?
a. Increasing governmental control of potential carcinogens
b. Changing habits and customs that predispose the individual to cancer
c. Conducting more mass screening programs
d. Educating public and professional people about cancer
97. In order to educate clients, the nurse should understand that the most common site of cancer for a female is the:
a. Uterine cervix
b. Uterine body
d. Fallopian tube
98.A client has just completed a course in radiation therapy and is experiencing radio-dermatitis. The most effective method of treating the skin is to:
a. Wash the area with soap and warm water
b. Apply a cream or lotion to the area
c. Leave the skin alone until it is clear
d. Avoid applying creams or lotion to the area
99.A client with cancer that has metastazised to the liver is started on chemotherapy- His physician has specified divided doses of the antimetabolite. The client asks why he could take the drug in divided doses. The appropriate response is:
a. " There really is no reason your doctor just wrote the orders that way."
b. "This schedule will reduce the side effect of the drug."
c. "Divided doses produce greater cytotoxic effects on the diseased cells."
d. "Because these drugs prevent cell division, they are more effective in divided doses,"
100. A client has possible malignancy of the colon, and surgery is scheduled. The rationale for administering Neomycin preoperatively is to:
a. Prevent infection postoperatively
b. Eliminate the need for preoperative enemas
c. Decreased and retard the growth of normal bacteria in the intestines
d. Treat cancer of the colon
Monday, January 28, 2008
100 Practice Test Questions for Nursing Licensure Examinations (Board Examinations) with answers - Psychiatric Nursing Subject
Situation I -- Nurse Caria is assigned in the emergency unit meeting. Varied opportunities that developed her nursing skills.
100 Practice Test Questions for Nursing Licensure Examinations (Board Examinations) with answers - Medical Surgical/Fundamentals of Nursing Subject
Situation 1: A nurse who is assigned in a medical ward took time to be prepared with her task and give quality nursing care.
1. If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe:
a. Flexion of both upper and lower extremities
b. Extension of elbows and knees, plantar flexion of feet, and flexion of the wnsts
c. Flexion of elbows, extension of the knees, and plantar flexion of the feet
d. Extension of upper extremities, flexion of lower extremities
2.The physician orders propranolol (Inderal) for a client's angina. The effect of this drug is to:
a. Act as a vasoconstrictor
b. Act as a vasodilator
c. Block beta stimulation in the heart
d. Increase the heart rate
3. A client with alcoholic cirrhosis with ascites and portal hypertension is to receive neomydn. The desired effect of this drug is to;
a. Sterilize the bowel
b. Reduce abdominal distention
c. Decrease the serum ammonia
d. Prevent infection
4. A retention catheter for a male client is correctly taped if it is:
a. On the lower abdomen
b. On the umbilicus
c. Under the thigh
d. On the inner thigh
5. When assessing a client for Cournadin therapy, the condition that will eyclude this client from Coumadin therapy is:
d. Peptic ulcer disease
6. Preparing for an intravenous pyelosram (IVP), the nurse instructs a 25-year-old male client to restrict her:
a. Fluid intake
b. Physical activity
c. Use of stimulants such as tobacco
d. Use of any medications
7. Immediately following a thoracentesis, which clinical manifestations indicate that a complication has occurred and the physician should be notified?
a. Serosanguimeous drainage from the puncture site
b increased temperature and blood pressure
c. increased pulse and pallor
d. Hypotension and hypothermia
8. The nurse is collecting a urine specimen from a client who has been catheterized. When the urine begins to flow through ths catheter, the next action is to:
a. Inflate the catheter balloon with sterile water
b. Place the catheter tip into the specimen container
c. Connect the catheter into the drainage tubing
c. Place the catheter tip into the urine collection receptacle
9. During a retention catheter insertion or bladder irrigation, the nurse must use:
a. Sterils equipment and wear sterile gloves
b. Clean equipment and maintain surgical asepsis
c. Sterile equipment and maintain medical asepsis
d. Clean equipment and technique
10. If a client continues to hypoventilate, the nurse will continually assess for a complication of this condition;
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
Situation 2: Diabetes Meilitus is a common disease among Filipinos. Caring for these patients require meticulous assessment and follow-up.
11. The nurse will know a diabetic client understands exercise and its relation to glucose when he says that he eats bread and milk before, or juice or fruit during exercise activity because
a. Exercise enhances the passage of glucose Into muscle celts
b. Exercise stimulates pancreatic insulin production
c. A diabetic's muscle require more glucose during exercise
d. The pancreas utilizes more glucose during exercise
12. The ADA exchange diet is compiled of lists of foods. The statement that indicates the diabetic has an understanding of the purpose of these food lists is:
a. Exchanges are allowed within groups
b. Exchanges are allowed between groups
c. Only meat and fat exchanges can be interchanged
d. Vegetables and fruit exchanges can be Interchanged
13. The non-insulin-dependent diabetic who is obese is best controlled by weight
loss because obesity
a. Reduces the number of insulin receptors
b. Cause pancreatic islet cell exhaustion
c. Reduces insulin binding at receptor cites
d. Reduces pancreatic insulin production
14. A person with a diagnosis of adult diabetes (NIDDM) should understand the symptoms of a hyperglycemic reaction. The nurse wiiS know tills client understands if she says these symptoms are:
a. Thirst, poiyuria and decreased appetite
b. Flushed cheeks, acetone breath, and increased thirst
c. Nausea, vomiting and diarrhea
d. Weight gain, normal breath, and thirst
15. The diabetic client the nurse is counseling is a young man who occasionally goes drinking with his buddies. The nurse will know the client understands the diet when he says that when he consumes alcohol, he includes il as part of:
b. Simple carbohydrates
c. Complex carbohydrates
16. The nurse is teaching a Type 1 diabetic client about her diet, which is based on the exchange system. The nurse wiil know the dient has learned correctiy when she says that she can have as much as she wants of:
c. Grapefruit juice
d. Skim milk
17. The nurse should evpiain to a dient with diabetes meliitus that self-monitoring of blood glucose is preferred to urine glucose testing because it is:
a. More accurate .
b. Easier to perform
c. Done by the cient
d. Not influenced by drugs
18.A client is diagnosed as having non-insulin-dependent diabetes mellitus how to
provide self-care to prevent infections of the feet. The nurse recognizes that the
teaching was effective when the client says, I should:
a. "Massage my feet and feet with oil or lotion."
b. "Apply heat intermittently to my feet and legs."
c. "Eat foods high in kilocalories of protein and carbohydrates."
d. "Control my diabetes through diet, exercise, and medication."
19. A client is admitted to the hospital with diabetic ketoadosis. The nurse understands that the elevated ketone level present with this disorder is caused by the incomplete oxidation of:
20. A client with insulin-dependent diabetes is pjaced on an insulin pump. The most appropriate short-term goal in teaching this client to control the diabetes: " The client will:
a. Adhere to the medical regimen."
b. Remain normogtycemic for 3 weeks."
c. Demonstrate the correct use of the insulin pump."
d. List three self-care activities necessary to control the diabetes."
Situation 3: In the CCU, the nurse has a patient who needs to be,watched out.
21. To determine the status of a clients carotid pulse, the nurse should palpate:
a. In the lateral neck region
b. Immediately below the mandible
c. At the anterior necK, lateral to the trachea
d. At the base of the neck", along the clavicle
22. To help reduce a client's risk factors for a heart disease, the nurse, in discussing dietary guidelines, should teach the client to:
a. Avoid eating between meals
b. Decrease the amount of uhsaturated fat
c. Decrease the amount of fat-binding fiber
d. Increase the ratio of complex carbohydrates
23. The nurse would expect a client diagnosed as having hypertension to report
experiencing the most common symptom associated with this disorder, which is:
d. Flushed face
24. A client with a history of hypertension develops pedal edema and demonstrates dyspnea on exertion. The nurse recognizes that the client's dyspnea on exertion is probably;
a. Caused by cor pulmonale
b. A result of left ventricular failure
c. A result of right ventricular failure
d. Associated with wheezing and coughing
25. A client who has been admitted to the cardiac care unit with myocardial infarction complains of chest pain. The nursing intervention that would be most effective in relieving the client's pain would be to administer the ordered:
a. Morphine sulfate 2 mg IV
b. Oxygen per nasal cannula
c. Nitroglycerine sublingually
d. Lidocaine hydrochloride 50 mg IV bolus
26. The nurse admitting a client with a myocardial Infarction to ICU understands that the pain the client is experiencing is a result of:
a. Compression of the heart muscle
b. Release of myocardia! isoenzymes
c. Inadequate perfusion of the myocardium
d. Rapid vasodilation of the coronary arteries
27. A male client who is hospitalized following a myocardial infarction asks the nurse why he is receiving morphine. The nurse replies that morphine;
a. Dilates coronary blood vessels
b. Relieve pain and prevents shock
c. Helps prevent fibrillation of the heart
d. Decreases anxiety and restlessness
28. Several days following surgery a client develops pyrexia. The nurse should monitor the client for other adaptations related to the pyrexia including:
b. Chest pain
c. Increased pulse rate
d. Elevated blood pressure
29. The nurse recognizes that a pacemaker is indicated when a client is
b. Chest pain
c. Heart block
30. When assessing a client with a diagnosis of left ventricular failure (congestive heart failure), the nurse should expect to find:
a. Crushing chest pain
b. Dyspnea on exertion
c. Jugular vein distention
d. Extensive peripheral edema
Situation 4: In the recall of the fluids and electrolytes, the nurse should be able to understand the calculations and other conditions related to loss or retention.
31. After a Whippie procedure for cancer of the pancreas, a client is to receive the following intravenous (IV) fluids over 24 hours; 1000 ml D5W; 0.5 liter normal saline; 1500 ml D5NS. In addition, an antibiotic piggyback in 50 ml D5W is ordered every 8 hours. The nurse calculates that the clients IV fluid intake Tor 24 hours will be:
b. 3200 ml
c. 3650 ml
32. The dietary practice that will help a client reduce the dietary intake of sodium is
a. Increasing the use of dairy products
b. Using an artificial sweetener in coffee
c. Avoiding the use of carbonated beverages
d. Using catsup for cooking and flavoring foods
33. When evaluating a client's response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organ is;
a. Urinary output of 30 ml in an hour
b. Central venous pressure reading of 2 cm H20
c. Pulse rates of 120 and 110 in a 15- minute period
d. Blood pressure readings of 50/30 and 70/40 mm Hg within 30 minutes
34. When monitoring for hypernatremia, the nurse should assess the client for:
a. Dry skin
d. Pale coloring
35. Serum albumin Is to be administered intravenously to client with ascites, The expected outcome of this treatment will be a decrease in:
a. Urinary output
b. Abdominal girth
c. Serum ammonia level
d. Hepatic encephalopathy
36. A client with a history of cardiac dysrhythmias is admitted to the hospital with the diagnosis of dehydration. The nurse should anticipate that the physician will order;
a. A glass of water every hour until hydrated
b. Small frequent intake of juices, broth, or milk
c. Short-term NG replacement of fluids and nutrients
d. A rapid IV infusion of an electrolyte and glucose solution
37.The nurse, in assessing the adequacy of a client's fluid replacement during the first 2 to 3 days following full-thickness burns to the trunk and right thigh, would be aware that the most significant data would be obtained from recording
a. Weights every day .
b. Urinary output every hour
c. Blood pressure every 15 minutes
d. Extent of peripheral edema every 4 hours
38. A client with ascites has a paracentesis, and 1500 ml of fluid is removed. Immediately following the procedure it is most important for the nurse to observe for:
a. A rapid, thready pulse
b. Decreased peristalsis .
c. Respiratory congestion
d. An increased in temperature
39. The nurse is aware that the shift of body fluids associated with the intravenous administration of albumin occurs by the process of:
d. Active Transport
40. A client's IV fluid orders for 24 hour's are 1500 ml D5W followed by 1250 ml of NS. The IV tubing has a drop factor of 15 gtt/ml. To administer the required fluids the nurse should set the drip rate at;
a. 13 gtt/min
b. 16 gtt/min
c. 29 gtt/min
d. 32 gtt/min
Situation 5: Protection of self and patient can be done by supporting the body's immunity.
41. Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:
a. Obtain vita! signs
b. Stop the transfusion
c. Assess the pain further
d. Increase the flow of normal saline
42.A client comes to the clinic complaining of weight loss, fatigue, and a low-grade fever. Physical examination reveals a slight enlargement of the cervical lymph nodes. To assess possible causes for the fever, it would be most appropriate for the nurse to initially ask:
a. "Have you bee sexually active lately?"
b, "Do you have a sore throat at the present time?"
c. "Have you been exposed recently to anyone with an infection?"
d. "When did you first notice that your temperature had gone up?"
43. The nursing staff has a team conference on AIDS and discusses the routes of transmission of the human immunodeficiency virus (HSV). The discussion reveals that an individual has no risk of exposure to HIV when that individual;
a. Has intercourse with just the spouse
b. Makes a donation of a pint of whole blood
c. Limits sexual contact to those without HIV antibodies
d. Uses a'condom each time there is a sexual intercourse
44. The knows that a positive diagnosis for HIV infection is made based on;
a. A history of high-risk sexual behaviors
b. Positive ELISA and Western blot tests
c. Evidence of extreme weight loss and high fever
d. Identification of an associated opportunistic infection
45. When taking the blood pressure of a client who has AIDS the nurse must;
a. Wear dean gloves
b. Use barrier techniques
c. Wear a mask and gown
d. Wash the hands thoroughly
46. The nurse should plan to teach the client with pancytopenia caused by a
a. Begin a program of aggressive, strict mouth care
b. Avoid traumatic injuries and exposure to any infection
c. increase oral fluid intake to a minimum of 3000 ml daily
d. Report any unusual muscle cramps or tingling sensations in the extremities
47. An elderly client develops severe bone barrow depression from chemotheraphy for cancer of the prostate. The nurse should;
a. Monitor for signs of alopecia
b. Increase dally intake of fluids
c. Monitor Intake and output of fluids
d. Use a soft toothbrush for oral hygiene
48. A tuberculin skin test with purified protein derivative (PP!) tuberculin is performed as part of a routine physical examination. The nurse should instruct the client to make an appointment so the test can be read in:
a. 3 days
b. 5 days
c. 7 days
d. 10 days
49.A client is admitted with cellulites of the left teg a temperature of 103°F. The physician orders IV antibiotics. Before instituting this therapy, the nurse should;
a. Determine whether the client has allergies
b. Apply a warm, moist dressing over the area
c. Measure the amount of swelling in the client's leg
d. Obtain the results of the culture and sensitivity tests
50. Following multiple bee stings, a client has an anaphylactic reaction. The nurse is aware that the symptoms the client is experiencing are caused by;
a. Respiratory depression and cardiac standstill
b. bronchial constriction and decreased peripheral resistance
c. Decreased cardiac out and dilation of major biood vessels
d. Constriction of capillaries and decreased peripheral circulation
Situation 6: Following these diagnostic tests, Mr. Mangoni's physical discussed possible therapies with him. It was decided that a partial gastrectomy, vagotomy, and gastrojejunostomy would be performed.
51. Mr. Mangoni asks why the vagotomy is being done. You explain that a vagotomy is done in conjunction with a subtotal gastrectomy because the vagus nerve:
a. Stimulates increased gastric motility.
b. Decreases gastric motiiity, thereby preventing the movement of HCl out of the stomach.
c. Stimulates both increased gastric secretion and gastric motiiity.
d. Stimulates decreased gastric secretion, thereby increasing nausea and vomiting.
52. Which of the following nursing interventions would be included. in the preoperative period for Mr. Mangoni?
a. Insertion of a nasogastric tube on the morning of surgery.
b. Administration of Vallum 4 mg with 4 oz water 1 hour before surgery.
c. Detailed description of the possible complications that could happen postoperatively
d. Instructions to avoid taking pain medication too frequently in the first 2 postoperative days to avoid drug dependency.
53. Which of the following complications, would you primarily anticipate in Mr. Mangoni's postoperative period?
a. Thrombophlebitis from decreased mobility.
b. Abdominal distention due to air swallowing
c. Atelectasis due to shallow breathing
d. Urinary retention due to prolonged use of antichoiinergic medications.
54. The nurse would recognize drainage from the nasogastric tube after surgery as abnormal If:
a. It after 6 hours
b. It continued for a period greater than 12 hours.
c. ft turned greenish yeiiow in less than 24 hours.
d. It was dark red in the immediate postoperative period.
55. Which of the following statements would the nurse include in teaching regarding nasogastric tubes?
a. Nasogastric tubes should be irrigated with sterile water.
b. Client should be in sitting position with head slightly flexed for tube Insertion
c. When resistance is met while irrigating a nasogastric tube, pressure should be increased to complete that irrigation, and the physician should be notified at the completion. d. Ice chips- can be taken as often as desired to promote comfort in the
56. The nurse must observe for which of the following imbalances to occur with prolonged nasogastric suctioning?
c. Metabolic alkalosis
57. Of the following mouth care measures by the nurse, which one should be used with caution when a client has a nasogastric tube?
a. Regularly brushing teeth and tongue with soft brush.
b. Sucking on ice chips to relieve dryness.
c. Occasionally rinsing mouth with a nonastringent substance and massaging gums.
d. Application of lemon juice and glycerine swabs to the lips.
58. The nurse tells Mr. Mangoni that the nasogastric tube will be removed:
a. Standardly on the fourth postoperative day.
b. When bowel sounds are established and the client has passed flatus or Stool
c. Thirty-six hours after the cessation of bloody drainage.
d. After 2 days of alternate clamping and unclamping of the tube.
59. Following surgery the nurse must observe for signs of pernicious anemia, which may be a problem after gastrectomy because:
a. The extrinsic factor is produced In the stomach.
b. The extrinsic factor is absorbed in the antral portion of the stomach.
c. The intrinsic factor Is produced in the stomach.
d. Decreased hydrochloric acid production Inhibits vitamin B12 reabsorption.
60.The nurse will usually ambulate the post gastrectomy patient beginning;
a. The day after surgery
b. Three to four days after surgery
c. After 4 days bedrest
d. immediately upon awakening .
Situation 7: Donald Lee, a 70-year-old retired businessman, went .to his ophthalmologist wilt's complaints of decreasing peripheral vision. Tonometry revealed increased intraocular pressures. Mr. Lee was admitted to the hospital with a diagnosis of open-angle glaucoma.
61. The signs and symptoms of open-angle glaucoma are related to:
a. An imbalance between the rats of secretion of intraocular fluids and the rate of absorption of aqueous humor.
b. A degenerative disease characterized by narrowing of the arterioles of the retina and areas of ischemia.
c. An infectious process that causes clouding and scarring of the cornea.
d. A dysfunction of aging in which the retina of the eye buckles from inadequate fluid pressures. .
62. Assessment of the intraocular pressure as measured by tonometry would be normal if the value is in the range;
a. 5-10 mm Hg
b. 12-22 mm Hg
c. 10-20 cm H20
d. 20-30 mm Hg
63. While taking Mr. Lee's history, the nurse would be alerted to a sudden increase in intraocular pressure if he complained of;
a. Generalized decrease in peripheral vision over the past year.
b. Difficulty with close vision.
c. increasing discomfort in the left eye with radiation to his forehead and left
d. Halos around lights.
64. Client teaching about glaucoma should include a comparison of the two types. Open-angle, or chronic, glaucoma differs from close-angle, or acute, glaucoma in, that
a. Open-angle glaucoma occurs less frequently than closed-angle glaucoma.
b. Open-angle glaucoma's symptomatology Includes pain, severe headache, nausea, and vomiting; whereas closed-angle glaucoma has a slow, silent, and generally painless onset.
c. The obstruction to aqueous flow In open-angle glaucoma generally occurs somewhere in Schlemm's canal or aqueous veins. It does not narrow or close the angle of the anterior chamber, as in closed-angle glaucoma.
d. Open-angle glaucoma rarely occurs in families; however, there is a heredity predisposition for closed-angle glaucoma.
65. Piiocarpine is the drug of choice in the treatment of open-angle glaucoma. The expected outcome following administration would be:
a. Blocked action of cholinesterase at the cholinergic nerve endings, and therefore increased pupil size.
b. Constricted pupil and therefore widened outflow channels and increased flow of aqueous fluid.
c. Impaired vision from decreased aqueous humor production.
d. Constriction of aqueous veins and therefore decreased venous pooling in the eye.
66. Bedrest is ordered for Mr, Lee because activity tends to increase intraocular pressure. Which of the following activities of daily living should he be instructed to avoid?
a. Watching television
b. Brushing teeth and hair
d. Passive range-of-motion exercises
67. To correctly instill pilocarpine in Mr. Lee's eyes, the nurse should gently pull down the lower lid of the eye and instill the drop:
a. Dirediy on the central surface of the cornea
b. On the inner canthus of the eye
c. into the conjunctive sac
d. Directly on the dilated pupil
68. Which of the following aspects of open angle glaucoma and its medical treatment is the most frequent cause of client noncompliance?
a. Loss of mobility due to severe-driving restrictions
b. The painful insidious progression of this type of glaucoma.
c. Decreased light and near-vision accommodation due to miotic effects of pilocarpine.
d. The frequent nausea and vomiting accompanying use of miotic drugs.
Situation 8: Gladys Meeker is a 30-year-oid advertising executive with a history of ulcerative colitis since age 22. Her chief complaint is severe abdominal cramping and 18- 20 stools per day for four days.
69. Blood and fluid loss from frequent diarrhea may cause hypovolemia. You can quickly assess volume depletion In Miss Meeker by;
a. Measuring the quantity and speciflc gravity of her urine output
b. Taking her blood pressure first supine, then sitting, noting any changes.
c. Comparing the client's present weight with her weight on her last admission.
d. Administering the oral water test.
70. The nurse would recognize other signs of hypovolemia, which include:
a. Dry mucous membranes and soft eyeballs.
b. Decreased hematocrit and hemoglobin
c. Decreased pulse rate and widened pulse pressure.
d, Dyspnea and crackles.
71. With severe diarrhea, electrolytes as well as fluid are lost. The nurse would conclude that the client is experiencing hypokalemia if which of the following were observed?
a. Spasms, diarrhea, irregular pulse.
b. Kussmaul breathing, thirst, furrowed tongue.
c. Apathy, weakness, GI disturbance
72. Three days after admission Ms. Meeker continued to have frequent stools. Her oral intake of both fluids and solids was poor. Her physician ordered parenteral hyperalimentation. While administering the ordered solution, It is important to remember that hyperalimentation solutions are:
a. Hypotonic solutions used primarily for hydration when hemoconcentration is present.
b. Hypertonic solutions used primarily to increase osmotic pressure of blood plasma.
c. Alkalizing solutions used to treat metabolic acidosis, thus reducing cellular swelling.
d. Hyperosmoiar solutions used primarily to reverse negative nitrogen balance.
73.Maintaining the infusion rate of hyperalimentation solutions is a nursing responsibility. What side effects from too rapid an infusion rate would the nurse expect Ms. Meeker to demonstrate?
a. Cellular dehydration and potassium depletion
b. Circulatory overload and hypoglycemia.
c. Hypoglycemia and hypovolemia.
d. Potassium excess and congestive heart failure.
74.Which of the following statements is correct regarding nursing care of Ms. Meeker while she is receiving hyperlimentation?
a. The client's urine should be tested for glucoseacetone every 8-12 hours.
b. The hyperlimentation subclavian line may be utilized for CVP readings and/or blood withdrawal.
c. Occlusive dressings at the catheter insertion site are changed every 48 hours using the clean technique.
d. Records of intake and output and daily weights should be kept. .
Situation 9: After 10 days of therapy, Ms. Meeker's physician decided to perform an iieostomy. For 3 days prior to surgery she was given neomycin. On the morning of surgery she catheterized and nasogastric tube was inserted.
75. Neomycin was administered by the nurse prior to surgery:
a. To decrease the incidence of postoperative atelectasis due to decreased depth of respirations.
b. To increase the effectiveness of the body's immunologic response following surgical trauma.
c. To reduce the incidence of wound infections by decreasing the number of intestinal organisms.
d. To prevent postoperative bladder atony due to catheterization.
76. Following iieostomy, the nurse would expect the drainage appliance to be applied to the stoma;
a. 24 hours later, when edema has subsided.
b. In the operating room.
c. After the ileostomy begins to function.
d. When the client is able to begin self-care procedures.
77.Which of the goals would be described to Ms. Meeker as the highest postoperative nursing priority?
a. Relief of pain to promote rest and relaxation.
b. Assisting the client with self-care activities.
c. Maintenance of fluid, electrolyte, and nutritional balances.
d. Skin care and control of odors.
78. During the early postoperative period, the nurse initiates ileostomy teaching with Ms. Meeker. The primary objective of this procedure is;
a. To facilitate maintenance of intake and output records
b. To control unpleasant odors.
c. To prevent excoriation of the skin around the stoma.
d. To reduce [he risk of postoperative wound infection.
79. After discharge, Ms. Meeker calls you at the hospital to report the sudden onset of abdominal cramps, vomiting, and watery discharge from her iieostomy. What would you advise?
a. Call the physician if symptoms persist for 24 hours.
b, Take 30 cc of m.o.m. (milk of magnesia).
c. NPO until vomiting stops.
d. Call the physician immediately.
Situation 10: Joseph Clifford, age 38, has extensive bums over much of his trunk and arms. He complains of intense pain during wound cleansing, dressing change, debridement, and physical therapy.
80. This pain most likely is related to:
a. Thermal stimulation
b. Menta! stimulation
c. Mechanical stimulation
d. Chemical stimulation
81. Mr. Clifford dreads physical therapy and resists activity; he has difficulty sleeping due to pain and fatigue after the treatments. He lacks appetite for food or fluid. Based on this information, his priority nursing diagnosis would be:
a. Activity Intolerance related to pain secondary to bums.
b. Altered Nutrition; Less Than Body Requirements related to pain secondary to bums.
c. Sleep Pattern Disturbance reiated to pain secondary to bums.
d. Pain related to bums.
82. Mr. Clifford continues to experience significant pain after his expensive bum wounds have healed - 6 months after his injury. He also expresses concern over possible loss of job and disfigurement. At this; stage, the nurse can most effectively intervene for his pain by:
a. Referring him for his counseling and occupational therapy.
b. Staying with him as much as possible and building trust
c. Providing cutaneous stimulation and pharmacoiogic therapy.
d. Providing distraction and guided imagery.
83. Eventually, Mr- Clifford's chronic pain and anxiety about his appearance did contribute to his losing his job and disrupting his plans for marriage.
He finally heeded the nurse's recommendation and sought treatment at a pain center, after which his pain subsided and he permitted his former fiancee to participate in his rehabilitation process, including looking for a new job.
Evaluation criteria for Mr. Clifford's successful rehabilitation should include which of the following:
a. The patient has no aftermath phase of his pain experience.
b. The patient experiences decreased frequency of acute pain episodes.
c. The patient continues normal growth and development with his support systems intact.
d. The patient develops increased tolerance for severe pain in the future.
84. Which of the following statements regarding pain is incorrect?
a. intractable pain may not be relieved by treatment.
b. Pain is an objective sign of a more serious problem.
c. Psychologic factors can contribute to a patient's pain perception.
d. Pain sensation is affected by a patient's anticipation of pain.
85. Billy Bragg, aged 5, received a small paper cut on his finger. His mother left him wash it and apply a smail amount of bacitracin and a Band-aid. She then let him watch TV and eat an apple Her intervention for pain are examples of:
a. Providing pharmacologic therapy
b. Providing control and distraction
c. Altering Billy's environment
d. Providing cutaneous stimulation
Situation 11: Mrs. Smith, age 64, has been diagnosed with COPD. Although she was hospitalized several times in the last year for acute respiratory failure, she is presently in stable condition.
86. The primary focus of care in the long-term nursing care for Mrs. Smith would be to:
a. Decrease activity to conserve functional Sung tissue.
b. Increase the frequency of postural drainage to every 2 hours he awake.
c. Increase the RV.
d. improve and maintain pulmonary ventilation and gas exchange.
87. Mrs. Smith's condition has changed over a period of days,, and her arterial blood studies now indicate she is again in acute respiratory failure. The primary nursing intervention most commonly required .in the care of patient with COPD who are in acute respiratory failure is to:
a. Establish initial stage of activity.
b. Discourage patient from sitting in Fowler's position in order to reduce work of heart.
c. Remove bronchia! secretions, and manage oxygen therapy.
d. Plan with family for home care.
88. Mrs. Smith has been treated aggressively for acute respiratory failure and has improved over the past four weeks. She experienced anxiety about being prepared for discharge. The nurse who cares for her should help her develop ways to cope with her chronic obstructive lung disease by:
a. Encouraging the family to take increased responsibility for the patients care.
b. Discouraging the patient from performing activities of daily living if they make her tired.
c. Teaching the patient relaxation techniques and breathing refraining exercises.
d. Protecting the patient from knowing the prognosis of her disease.
Situation 12: Mrs. Lippett, age 66, is experiencing sensory and perceptual problems that affect her right visual field (right homonymous hemianopia).
89. When placing a meal tray in front of Mrs. Lippett, the nurse should;
a. Place all the food on the right side of the tray.
b. Before leaving the room, remind the patient to look over all the tray.
c. Place food and utensils within the patient's left visual field.
d. Stay with the patient & periodically draw her attention of the food on the right side of the tray to prevent unilateral neglect
90. The nurse should include which of the following in preprocedure teaching for a patient scheduled for carotid angiography?
a. "You will be put to sleep before the needle Is inserted."
b. "The test will take several hours."
c. "You may fee! a burning sensation when the dye is injected."
d. "There will be no complications."
91.What deficits would the nurse expect in a right-handed person experiencing a stroke affecting the left side of the cortex?
a. Expressive aphasia and paralysis on the right side of the body.
b. Expressive aphasia and paralysis on the left side of the body. .
c. Dysarthria and paralysis on the right side of the body.
d. Mixed aphasia and paralysis on the right side of the body.
92. What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
a. Wait for the patient to complete the sentence.
b. Immediately begin showing the patient various objects In the environment.
c. Leave the room and come back later.
d. Begin naming various objects that the patient could be referring to.
93. Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs?
a. "What would you like to do first, brush your teeth?"
b. "Where is y our toothbrush?"
c. "When would you like to have your bath?"
d. "Would you like to brush your teeth, or do you want me to do it for you? it's good to do things for yourself."
94. Which of the following positions would be most appropriate for a patient with right-sided paralysis following a stroke?
a. On the side with support to the back, with pillows to keep the body in alignment, hips slightly flexed, and hands tightly holding a rolled washcloth.
b. On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
c. On the back with two large pillows under the head, pillow under" the knees, and a footboard.
d. On the back with no pillows used, with trochanter rolls and a footboard.
95.To prevent infection in a patient with a subdura! intracranial pressure monitoring system in place, the nurse should;
a. Use aseptic technique for the insertion site.
b. Use clean technique for cleansing connections and aseptic technique for the insertion site.
c. Use sterile technique when cleansing the insertion site
d. Close any leaks in the tubing with tape.
Situation 13: Mrs. Taylor, age 74, suffers from degenerative joint disease due to osteoarthritis and is admitted for a total joint replacement of the right hip.
96. During the preoperative period, the nurse should focus assessment primarily on:
a. Local and systemic infections
b. Self-care ability
c. Response to pain medications
d. Range of motion in the affected joint
97. Following arthroplasty, the nurse should maintain correct position of Mrs, Taylor's operative leg by:
a. Placing an abductor wedge or pillows between the legs.
b. Placing sandbags or pillows to Keep leg abducted.
c. Elevating the affected leg on two pillows or supports.
d. Positioning her supine and on the operative side.
98. When discussing physical activities with Mrs. Tayior, the nurse should instruct her to;
a. Avoid weight bearing until the hip is completely heated.
b. Intermittently cross and uncross legs several times daily.
c. Maintain hip flexion at 90 degrees when sitting.
d. Limit hip flexion to only 45 to 50 degrees.
99. Before discharge, the nurse reviews the signs and symptoms of joint dislocation with Mrs. Tayior. The nurse would determine that Mrs. Taylor understands the instructions by her identification of which of the following symptoms?
a. Positive Homan's sign and Inability to bear weight.
b. Painiess, sudden deformity of the affected hip joint.
c. Severe hip pain with shortening of the extremity.
d. Severe pain and swelling of the affected hip joint.
100. As part of treatment of gouty arthritis for Mrs. Martin, age 66, the physician orders antiuric acid medication to be given in large doses until the maximum safe dosage can be determined. The nurse would determine the maximum dosage and the need for dosage reduction by asking Mrs. Martin to report which of the following symptoms?
a. Bleeding gums and bruising
b. Nausea, vomiting, and diarrhea
c. Gastric irritation and heartburn
d. Blurred vision and nausea
1. 60 years old post CVA (cardio vascular accident) patient is taking TPA for his disease, the nurse understands that this is an example of what level of prevention?
2. A female client undergoes yearly mammography. This is a type of what level of prevention?
3. A Diabetic patient was amputated following an unexpected necrosis on the right leg, he sustained and undergone BKA. He then underwent therapy on how to use his new prosthetic leg. this is a type of what level of prevention?
4. As a care provider, The nurse should do first:
a. Provide direct nursing care.
b. Participate with the team in performing nursing intervention.
c. Therapeutic use of self.
d. Early recognition of the client’s needs.
5. As a manager, the nurse should:
a. Initiates nursing action with co workers.
b. Plans nursing care with the patient.
c. Speaks in behalf of the patient.
d. Works together with the team.
6. The nurse shows a patient advocate role when
a. defend the patients right
b. refer patient for other services she needs
c. work with significant others
d. intercedes in behalf of the patient.
7. Which is the following is the most appropriate during the orientation phase ?
a. patients perception on the reason of her hospitalization
b. identification of more effective ways of coping
c. exploration of inadequate coping skills
d. establishment of regular meeting of schedules
8. Preparing the client for the termination phase begins
a. pre orientation
9. A helping relationship is a process characterized by :
a. recovery promoting
b. mutual interaction
c. growth facilitating
d. health enhancing
10. During the nurse patient interaction, the nurse assess the ff: to determine the patients coping strategy :
a. How are you feeling right now?
b. Do you have anyone to take you home?
c. What do you think will help you right now?
d. How does your problem affect your life?
11. As a counsellor, the nurse performs which of the ff: task?
a. Encourage client to express feelings and concerns
b. Helps client to learn a dance or song to enable her to participate in activities
c. Help the client prepare in group activities
d. Assist the client in setting limits on her behaviour
12. Freud stresses out that the EGO
a. Distinguishes between things in the mind and things in the reality.
b. Moral arm of the personality that strives for perfection than pleasure.
c. Reservoir of instincts and drives
d. Control the physical needs instincts.
13. A 16 year old child is hospitalized, according to Erik Erikson, what is an appropriate intervention?
a. tell the friends to visit the child
b. encourage patient to help child learn lessons missed
c. call the priest to intervene
d. tell the child’s girlfriend to visit the child.
14. Neuroleptic malignant syndrome (NMS) is characterized by :
a. hypertension, hyperthermia, flushed and dry skin.
b. Hypotension, hypothermia, flushed and dry skin.
c. Hypertension, hyperthermia, diaphoresis
d. Hypertension, hypothermia, diaphoresis
15. Which of the following drugs needs a WBC level checked regularly?
Angelo, an 18 year old out of school youth was caught shoplifting in a department store. He has history of being quarrelsome and involving physical fight with his friends. He has been out of jail for the past two years
16. Initially, The nurse identifies which of the ff: Nursing diagnosis:
a. self centred disturbance
b. impaired social interaction
c. sensory perceptual alteration
d. altered thought process
17. Which of the ff: is not a characteristic of PD?
a. disregard rights of others
b. loss of cognitive functioning
c. fails to conform to social norms
d. not capable of experiencing guild or remorse for their behaviour
18. The most effective treatment modality for persons if anti social PD is
b. gestalt therapy
c. behaviour therapy
d. crisis intervention
19. Which of the following is not an example of alteration of perception?
a. ideas of reference
b. flight of ideas
20. The type of anxiety that leads to personality disorganization is :
21. A client is admitted to the hospital. Twelve hours later the nurse observes hand tremors, hyperexicitability, tachycardia, diaphoresis and hypertension. The nurse suspects alcohol withdrawal. The nurse should ask the client:
a. At what time was your last drink taken?
b. Why didn’t you tell us you’re a drinker?
c. Do you drink beer or hard liquor?
d. How long have you been drinking?
22. Client with a history of schizophrenia has been admitted for suicidal ideation. The client states "God is telling me to kill myself right now." The nurse's best response is:
a. I understand that god’s voice are real to you, But I don’t hear anything. I will stay with you.
b. The voices are part of your illness, it will stop if you take medication
c. The voices are all in your imagination, think of something else and itll go away
d. Don’t think of anything right now, just go and relax.
23. In assessing a client's suicide potential, which statement by the client would give the nurse the HIGHEST cause for concern?
a. My thoughts of hurting my self are scary to me
b. I’d like to go to sleep and not wake up
c. I’ve thought about taking pills and alcohol till I pass out
d. Id like to be free from all these worries
24. A client with paranoid schizophrenia has persecutory delusions and auditory hallucinations and is extremely agitated. He has been given a PRN dose of Thorazine IM. Which of the following would indicate to the nurse that the medication is having the desired effect?
a. Complains of dry mouth
b. State he feels restless in his body
c. Stops pacing and sits with the nurse
d. Exhibits increase activity and speech
25. A client who was wandering aimlessly around the streets acting inappropriately and appeared disheveled and unkept was admitted to a psychiatric unit and is experiencing auditory and visual hallucinations. The nurse would develop a plan of care based on:
a. borderline personality disorder
b. anxiety disorder
26. A decision is made to not hospitalize a client with obsessive-compulsive disorder. Of the following abilities the client has demonstrated, the one that probably most influenced the decision not to hospitalize him is his ability to:
a. Hold a job.
b. Relate to his peers.
c. Perform activities of daily living.
d. Behave in an outwardly normal
27. A client is admitted to the inpatient psychiatric unit. He is unshaven, has body odor, and has spots on his shirt and pants. He moves slowly, gazes at the floor, and has a flat affect. The nurse's highest priority in assessing the client on admission would be to ask him:
a. How he sleeps at night.
b. If he is thinking about hurting himself.
c. About recent stresses.
d. How he feels about himself.
28. The nurse should know that the normal therapeutic level of lithium is :
a. .6 to 1.2 meq/L
b. 6 to 12 meq/L
c. .6 to .12 cc/ml
d. .6 to .12 cc3/L
29. The patient complaint of vomiting, diarrhea and restlessness after taking lithane. The nurse’s initial intervention is :
a. Recognize that this is a sign of toxicity and withhold the next medication.
b. Notify the physician.
c. Check V/S to validate patient’s concerns.
d. Recognize that this is a normal side effects of lithium and still continue the drug.
30. The client is taking TOFRANIL. The nurse should closely monitor the patient for :
c. Increase Intra Ocular Pressure
d. Increase Intra Cranial Pressure
31. A client was hospitalized with major depression with suicidal ideation for 1 week. He is taking venlafaxine (Effexor), 75 mg three times a day, and is planning to return to work. The nurse asks the client if he is experiencing thoughts of self-harm. The client responds, "I hardly think about it anymore and wouldn't do anything to hurt myself." The nurse judges:
a. The client to be decompensating and in need of being readmitted to the hospital.
b. The client to need an adjustment or increase in his dose of antidepressant.
c. The depression to be improving and the suicidal ideation to be lessening.
d. The presence of suicidal ideation to warrant a telephone call to the client's physician
32. The client is taking sertraline (Zoloft), 50 mg q AM. The nurse includes which of the following in the teaching plan about Zoloft?
a. Zoloft causes erectile dysfunction in men.
b. Zoloft causes postural hypotension
c. Zoloft increases appetite and weight gain
d. It may take 3-4 weeks before client will start feeling better.
33. After 3 days of taking haloperidol, the client shows an inability to sit still, is restless and fidgety, and paces around the unit. Of the following extrapyramidal adverse reactions, the client is showing signs of:
d. Tardive dyskinesia
34. After 10 days of lithium therapy, the client's lithium level is 1.0 mEq/L. The nurse knows that this value indicates which of the following?
a. A laboratory error.
b. An anticipated therapeutic blood level of the drug.
c. An atypical client response to the drug.
d. A toxic level.
35. When caring for a client receiving haloperidol (Haldol), the nurse would assess for which of the following?
a. Hypertensive episodes
b. Extrapyramidal symptoms
36. A client is brought to the hospital’s emergency room by a friend, who states, "I guess he had some bad junk (heroin) today." In assessing the client, the nurse would likely find which of the following symptoms?
a. Increased heart rate, dilated pupils, and fever.
b. Tremulousness, impaired coordination, increased blood pressure, and ruddy complexion.
c. Decreased respirations, constricted pupils, and pallor.
d. Eye irritation, tinnitus, and irritation of nasal and oral mucosa.
37. The client has been taking the monoamine oxidase inhibitor (MAOI) phenelzine (Nardil), 10 mg bid. The physician orders a selective serotonin reuptake inhibitor (SSRI), paroxetine (Paxil), 20 mg given every morning. The nurse:
a. Gives the medication as ordered.
b. Questions the physician about the order.
c. Questions the dosage ordered.
d. Asks the physician to order benztropine (Cogentin) for the side effects.
38. Which of the following client statements about clozapine (Clozaril) indicates that the client needs additional teaching?
a. "I need to have my blood checked once every several months while I’m taking this drug."
b. "I need to sit on the side of the bed for a while when I wake up in the morning."
c. "The sleepiness I feel will decrease as my body adjusts to clozapine."
d. "I need to call my doctor whenever I notice that I have a fever or sore throat."
39. A client has been taking lithium carbonate (Lithane) for hyperactivity, as prescribed by his physician. While the client is taking this drug, the nurse should ensure that he has an adequate intake of:
40. The client has been taking clomipramine (Anafranil) for his obsessive-compulsive disorder. He tells the nurse, "I'm not really better, and I've been taking the medication faithfully for the past 3 days just like it says on this prescription bottle." Which of the following actions would the nurse do first?
a. Tell the client to continue taking the medication as prescribed because it takes 5 to 10 weeks for a full therapeutic effect.
b. Tell the client to stop taking the medication and to call the physician.
c. Encourage the client to double the dose of his medication.
d. Ask the client if he has resumed smoking cigarettes.
41. The nurse judges correctly that a client is experiencing an adverse effect from amitriptyline hydrochloride (Elavil) when the client demonstrates:
a. An elevated blood glucose level.
d. Urinary retention
42. Which of the following health status assessments must be completed before the client starts taking imipramine (Tofranil)?
a. Electrocardiogram (ECG)
b. Urine sample for protein
c. Thyroid scan
d. Creatinine clearance test
43. A client comes to the outpatient mental health clinic 2 days after being discharged from the hospital. The client was given a 1-week supply of clozapine (Clozaril). The nurse reviews information about clozapine with the client. Which client statement indicates an accurate understanding of the nurse's teaching about this medication?
a."I need to call my doctor in 2 weeks for a checkup."
b."I need to keep my appointment here at the hospital this week for a blood test."
c. "I can drink alcohol with this medication."
d. "I can take over-the-counter sleeping medication if I have trouble sleeping."
44. The client is taking risperidone (Risperdal) to treat the positive and negative symptoms of schizophrenia. Which of the following negative symptoms will improve?.
a. Abnormal thought form
b. Hallucinations and delusions
c. Bizarre behaviour
d. Asocial behaviour and anergia
45. The nurse would teach the client taking tranylcypromine sulfate (Parnate) to avoid which food because of its high tyramine content?
b. Aged cheeses
c. Grain cereals
d. Reconstituted milk
46. Which of the following clinical manifestations would alert the nurse to lithium toxicity?
a. Increasingly agitated behaviour
b. Markedly increased food intake
c. Sudden increase in blood pressure
d. Anorexia with nausea and vomiting
47. The client with depression has been hospitalized for 3 days on the psychiatric unit. This is the second hospitalization during the past year. The physician orders a different drug, tranylcypromine sulfate (Parnate), when the client does not respond positively to a tricyclic antidepressant. Which of the following reactions should the client be cautioned about if her diet includes foods containing tryaminetyramine?
a. Heart block
b. Grand mal seizure
c. Respiratory arrest
d. Hypertensive crisis
48. After the nurse has taught the client who is being discharged on lithium (Eskalith) about the drug, which of the following client statements would indicate that the teaching has been successful?
a. "I need to restrict eating any foods that contain salt."
b. "If I forget a dose, I can double the dose the next time I take it."
c. "I'll call my doctor right away for any vomiting, severe hand tremors, or muscle weakness."
d. "I should increase my fluid”
49. A nurse is caring for a client with Parkinson's disease who has been taking carbidopa/levodopa (Sinemet) for a year. Which of the following adverse reactions will the nurse monitor the client for?
d. respiratory depression
50. A client is taking fluoxetine hydrochloride (Prozac) for treatment of depression. The client asks the nurse when the maximum therapeutic response occurs. The nurse's best response is that the maximum therapeutic response for fluoxetine hydrochloride may occur in the:
a. 10-14 days
b. First week
c. Third week
d. Fourth week
Sunday, January 13, 2008
SITUATION : Arthur, A registered nurse, witnessed an old woman hit by a motorcycle while crossing a train railway. The old woman fell at the railway. Arthur rushed at the scene.
1. As a registered nurse, Arthur knew that the first thing that he will do at the scene is
A. Stay with the person, Encourage her to remain still and Immobilize the leg while
While waiting for the ambulance.
B. Leave the person for a few moments to call for help.
C. Reduce the fracture manually.
D. Move the person to a safer place.
2. Arthur suspects a hip fracture when he noticed that the old woman’s leg is
A. Lengthened, Abducted and Internally Rotated.
B. Shortened, Abducted and Externally Rotated.
C. Shortened, Adducted and Internally Rotated.
D. Shortened, Adducted and Externally Rotated.
3. The old woman complains of pain. John noticed that the knee is reddened, warm to touch and swollen. John interprets that this signs and symptoms are likely related to
D. Degenerative disease
4. The old woman told John that she has osteoporosis; Arthur knew that all of the following factors would contribute to osteoporosis except
B. End stage renal disease
C. Cushing’s Disease
D. Taking Furosemide and Phenytoin.
5. Martha, The old woman was now Immobilized and brought to the emergency room. The X-ray shows a fractured femur and pelvis. The ER Nurse would carefully monitor Martha for which of the following sign and symptoms?
A. Tachycardia and Hypotension
B. Fever and Bradycardia
C. Bradycardia and Hypertension
D. Fever and Hypertension
SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of OLFU Lagro is admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis.
6. As a nurse, you instructed Mr. Rojas how to use a cane. Mr. Rojas has a weakness on his right leg due to self immobilization and guarding. You plan to teach Mr. Rojas to hold the cane
A. On his left hand, because his right side is weak.
B. On his left hand, because of reciprocal motion.
C. On his right hand, to support the right leg.
D. On his right hand, because only his right leg is weak.
7. You also told Mr. Rojas to hold the cane
A. 1 Inches in front of the foot.
B. 3 Inches at the lateral side of the foot.
c. 6 Inches at the lateral side of the foot.
D. 12 Inches at the lateral side of the foot.
8. Mr. Rojas was discharged and 6 months later, he came back to the emergency room of the hospital because he suffered a mild stroke. The right side of the brain was affected. At the rehabilitative phase of your nursing care, you observe Mr. Rojas use a cane and you intervene if you see him
A. Moves the cane when the right leg is moved.
B. Leans on the cane when the right leg swings through.
C. keeps the cane 6 Inches out to the side of the right foot.
D. Holds the cane on the right side.
SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood
9. The nurse performs a Mantoux Test. The nurse knows that Mantoux Test is also known as
10. The nurse would inject the solution in what route?
11. The nurse notes that a positive result for Alfred is
A. 5 mm wheal
B. 5 mm Induration
C. 10 mm Wheal
D. 10 mm Induration
12. The nurse told Alfred to come back after
A. a week
B. 48 hours
C. 1 day
D. 4 days
13. Mang Alfred returns after the Mantoux Test. The test result read POSITIVE. What should be the nurse’s next action?
A. Call the Physician
B. Notify the radiology dept. for CXR evaluation
C. Isolate the patient
D. Order for a sputum exam
14. Why is Mantoux test not routinely done in the Philippines?
A. It requires a highly skilled nurse to perform a Mantoux test
B. The sputum culture is the gold standard of PTB Diagnosis and it will definitively determine the extent of the cavitary lesions
C. Chest X Ray Can diagnose the specific microorganism responsible for the lesions
D. Almost all Filipinos will test positive for Mantoux Test
15. Mang Alfred is now a new TB patient with an active disease. What is his category according to the DOH?
16. How long is the duration of the maintenance phase of his treatment?
A. 2 months
B. 3 months
C. 4 months
D. 5 months
17. Which of the following drugs is UNLIKELY given to Mang Alfred during the maintenance phase?
18. According to the DOH, the most hazardous period for development of clinical disease is during the first
A. 6-12 months after
B. 3-6 months after
C. 1-2 months after
D. 2-4 weeks after
19. This is the name of the program of the DOH to control TB in the country
B. National Tuberculosis Control Program
C. Short Coursed Chemotherapy
D. Expanded Program for Immunization
20. Susceptibility for the disease [ TB ] is increased markedly in those with the following condition except
A. 23 Year old athlete with diabetes insipidus
B. 23 Year old athlete taking long term Decadron therapy and anabolic steroids
C. 23 Year old athlete taking illegal drugs and abusing substances
D. Undernourished and Underweight individual who undergone gastrectomy
21. Direct sputum examination and Chest X ray of TB symptomatic is in what level of prevention?
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
22. Michiel shows the BEST adaptation with the new colostomy if he shows which of the following?
A. Look at the ostomy site
B. Participate with the nurse in his daily ostomy care
C. Ask for leaflets and contact numbers of ostomy support groups
D. Talk about his ostomy openly to the nurse and friends
23. The nurse plans to teach Michiel about colostomy irrigation. As the nurse prepares the materials needed, which of the following item indicates that the nurse needs further instruction?
A. Plain NSS / Normal Saline
B. K-Y Jelly
C. Tap water
D. Irrigation sleeve
24. The nurse should insert the colostomy tube for irrigation at approximately
A. 1-2 inches
B. 3-4 inches
C. 6-8 inches
D. 12-18 inches
25. The maximum height of irrigation solution for colostomy is
A. 5 inches
B. 12 inches
C. 18 inches
D. 24 inches
26. Which of the following behavior of the client indicates the best initial step in learning to care for his colostomy?
A. Ask to defer colostomy care to another individual
B. Promises he will begin to listen the next day
C. Agrees to look at the colostomy
D. States that colostomy care is the function of the nurse while he is in the hospital
27. While irrigating the client’s colostomy, Michiel suddenly complains of severe cramping. Initially, the nurse would
A. Stop the irrigation by clamping the tube
B. Slow down the irrigation
C. Tell the client that cramping will subside and is normal
D. Notify the physician
28. The next day, the nurse will assess Michiel’s stoma. The nurse noticed that a prolapsed stoma is evident if she sees which of the following?
A. A sunken and hidden stoma
B. A dusky and bluish stoma
C. A narrow and flattened stoma
D. Protruding stoma with swollen appearance
29. Michiel asked the nurse, what foods will help lessen the odor of his colostomy. The nurse best response would be
A. Eat eggs
B. Eat cucumbers
C. Eat beet greens and parsley
D. Eat broccoli and spinach
30. The nurse will start to teach Michiel about the techniques for colostomy irrigation. Which of the following should be included in the nurse’s teaching plan?
A. Use 500 ml to 1,000 ml NSS
B. Suspend the irrigant 45 cm above the stoma
C. Insert the cone 4 cm in the stoma
D. If cramping occurs, slow the irrigation
31. The nurse knew that the normal color of Michiel’s stoma should be
A. Brick Red
D. Pale Pink
SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
32. Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error?
A. Hyperventilating James with 100% oxygen before and after suctioning
B. Instilling 3 to 5 ml normal saline to loosen up secretion
C. Applying suction during catheter withdrawal
D. Suction the client every hour
33. What size of suction catheter would Wilma use for James, who is 6 feet 5 inches in height and weighing approximately 145 lbs?
A. Fr. 5
B. Fr. 10
C. Fr. 12
D. Fr. 18
34. Wilma is using a portable suction unit at home, What is the amount of suction required by James using this unit?
A. 2-5 mmHg
B. 5-10 mmHg
C. 10-15 mmHg
D. 20-25 mmHg
35. If a Wall unit is used, What should be the suctioning pressure required by James?
A. 50-95 mmHg
B. 95-110 mmHg
C. 100-120 mmHg
D. 155-175 mmHg
36. Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner and outer cannulas was removed and left hanging on James’ neck. What are the 2 equipment’s at james’ bedside that could help Wilma deal with this situation?
A. New set of tracheostomy tubes and Oxygen tank
B. Theophylline and Epinephrine
C. Obturator and Kelly clamp
D. Sterile saline dressing
37. Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?
A. Wilma places 2 fingers between the tie and neck
B. The tracheotomy can be pulled slightly away from the neck
C. James’ neck veins are not engorged
D. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process.
38. Wilma knew that James have an adequate respiratory condition if she notices that
A. James’ respiratory rate is 18
B. James’ Oxygen saturation is 91%
C. There are frank blood suction from the tube
D. There are moderate amount of tracheobronchial secretions
39. Wilma knew that the maximum time when suctioning James is
A. 10 seconds
B. 20 seconds
C. 30 seconds
D. 45 seconds
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
40. What specific manifestation would nurse Jet see in Acute close angle glaucoma that she would not see in an open angle glaucoma?
A. Loss of peripheral vision
B. Irreversible vision loss
C. There is an increase in IOP
41. Nurse jet knew that Acute close angle glaucoma is caused by
A. Sudden blockage of the anterior angle by the base of the iris
B. Obstruction in trabecular meshwork
C. Gradual increase of IOP
D. An abrupt rise in IOP from 8 to 15 mmHg
42. Nurse jet performed a TONOMETRY test to Mr. Batumbakal. What does this test measures
A. It measures the peripheral vision remaining on the client
B. Measures the Intra Ocular Pressure
C. Measures the Client’s Visual Acuity
D. Determines the Tone of the eye in response to the sudden increase in ICP.
43. The Nurse notices that Mr. Batumbakal cannot anymore determine RED from BLUE. The nurse knew that which part of the eye is affected by this change?
c. RODS [RETINA]
D. CONES [RETINA]
44. Nurse Jet knows that Aqueous Humor is produce where?
A. In the sub arachnoid space of the meninges
B. In the Lateral ventricles
C. In the Choroids
D. In the Ciliary Body
45. Nurse Jet knows that the normal IOP is
A. 8-21 mmHg
B. 2-7 mmHg
c. 31-35 mmHg
D. 15-30 mmHg
46. Nurse Jet wants to measure Mr. Batumbakal’s CN II Function. What test would Nurse Jet implement to measure CN II’s Acuity?
A. Slit lamp
B. Snellen’s Chart
C. Wood’s light
47. The Doctor orders pilocarpine. Nurse jet knows that the action of this drug is to
A. Contract the Ciliary muscle
B. Relax the Ciliary muscle
C. Dilate the pupils
D. Decrease production of Aqueous Humor
48. The doctor orders timolol [timoptic]. Nurse jet knows that the action of this drug is
A. Reduce production of CSF
B. Reduce production of Aquesous Humor
C. Constrict the pupil
D. Relaxes the Ciliary muscle
49. When caring for Mr. Batumbakal, Jet teaches the client to avoid
A. Watching large screen TVs
B. Bending at the waist
C. Reading books
D. Going out in the sun
50. Mr. Batumbakal has undergone eye angiography using an Intravenous dye and fluoroscopy. What activity is contraindicated immediately after procedure?
A. Reading newsprint
B. Lying down
C. Watching TV
D. Listening to the music
51. If Mr. Batumbakal is receiving pilocarpine, what drug should always be available in any case systemic toxicity occurs?
A. Atropine Sulfate
B. Pindolol [Visken]
C. Naloxone Hydrochloride [Narcan]
D. Mesoridazine Besylate [Serentil]
SITUATION : Wide knowledge about the human ear, it’s parts and it’s functions will help a nurse assess and analyze changes in the adult client’s health.
52. Nurse Anna is doing a caloric testing to his patient, Aida, a 55 year old university professor who recently went into coma after being mauled by her disgruntled 3rd year nursing students whom she gave a failing mark. After instilling a warm water in the ear, Anna noticed a rotary nystagmus towards the irrigated ear. What does this means?
A. Indicates a CN VIII Dysfunction
53. Ear drops are prescribed to an infant, The most appropriate method to administer the ear drops is
A. Pull the pinna up and back and direct the solution towards the eardrum
B. Pull the pinna down and back and direct the solution onto the wall of the canal
C. Pull the pinna down and back and direct the solution towards the eardrum
D. Pull the pinna up and back and direct the solution onto the wall of the canal
54. Nurse Jenny is developing a plan of care for a patient with Menieres disease. What is the priority nursing intervention in the plan of care for this particular patient?
A. Air, Breathing, Circulation
B. Love and Belongingness
C. Food, Diet and Nutrition
55. After mastoidectomy, Nurse John should be aware that the cranial nerve that is usually damage after this procedure is
A. CN I
B. CN II
C. CN VII
D. CN VI
56. The physician orders the following for the client with Menieres disease. Which of the following should the nurse question?
A. Dipenhydramine [Benadryl]
B. Atropine sulfate
C. Out of bed activities and ambulation
D. Diazepam [Valium]
57. Nurse Anna is giving dietary instruction to a client with Menieres disease. Which statement if made by the client indicates that the teaching has been successful?
A. I will try to eat foods that are low in sodium and limit my fluid intake
B. I must drink atleast 3,000 ml of fluids per day
C. I will try to follow a 50% carbohydrate, 30% fat and 20% protein diet
D. I will not eat turnips, red meat and raddish
58. Peachy was rushed by his father, Steven into the hospital admission. Peachy is complaining of something buzzing into her ears. Nurse Joemar assessed peachy and found out It was an insect. What should be the first thing that Nurse Joemar should try to remove the insect out from peachy’s ear?
A. Use a flashlight to coax the insect out of peachy’s ear
B. Instill an antibiotic ear drops
C. Irrigate the ear
D. Pick out the insect using a sterile clean forceps
59. Following an ear surgery, which statement if heard by Nurse Oca from the patient indicates a correct understanding of the post operative instructions?
A. Activities are resumed within 5 days
B. I will make sure that I will clean my hair and face to prevent infection
C. I will use straw for drinking
D. I should avoid air travel for a while
60. Nurse Oca will do a caloric testing to a client who sustained a blunt injury in the head. He instilled a cold water in the client’s right ear and he noticed that nystagmus occurred towards the left ear. What does this finding indicates?
A. Indicating a Cranial Nerve VIII Dysfunction
B. The test should be repeated again because the result is vague
C. This is Grossly abnormal and should be reported to the neurosurgeon
D. This indicates an intact and working vestibular branch of CN VIII
61. A client with Cataract is about to undergo surgery. Nurse Oca is preparing plan of care. Which of the following nursing diagnosis is most appropriate to address the long term need of this type of patient?
A. Anxiety R/T to the operation and its outcome
B. Sensory perceptual alteration R/T Lens extraction and replacement
C. Knowledge deficit R/T the pre operative and post operative self care
D. Body Image disturbance R/T the eye packing after surgery
62. Nurse Joseph is performing a WEBERS TEST. He placed the tuning fork in the patients forehead after tapping it onto his knee. The client states that the fork is louder in the LEFT EAR. Which of the following is a correct conclusion for nurse Josph to make?
A. He might have a sensory hearing loss in the left ear
B. Conductive hearing loss is possible in the right ear
C. He might have a sensory hearing loss in the right hear, and/or a conductive hearing loss in the left ear.
D. He might have a conductive hearing loss in the right ear, and/or a sensory hearing loss in the left ear.
63. Aling myrna has Menieres disease. What typical dietary prescription would nurse Oca expect the doctor to prescribe?
A. A low sodium , high fluid intake
B. A high calorie, high protein dietary intake
C. low fat, low sodium and high calorie intake
D. low sodium and restricted fluid intake
SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch.
Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.
64. Which of the following is the appropriate nursing diagnosis?
A. Fluid volume deficit R/T furrow tongue
B. Fluid volume deficit R/T uncontrolled vomiting
C. Dehydration R/T subnormal body temperature
D. Dehydration R/T incessant vomiting
65. Approximately how much fluid is lost in acute weight loss of .5kg?
A. 50 ml
B. 750 ml
C. 500 ml
D. 75 ml
66. Postural Hypotension is
A. A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting.
B. A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting
C. A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting
D. A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting
67. Which of the following measures will not help correct the patient’s condition
A. Offer large amount of oral fluid intake to replace fluid lost
B. Give enteral or parenteral fluid
C. Frequent oral care
D. Give small volumes of fluid at frequent interval
68. After nursing intervention, you will expect the patient to have
1. Maintain body temperature at 36.5 C
2. Exhibit return of BP and Pulse to normal
3. Manifest normal skin turgor of skin and tongue
4. Drinks fluids as prescribed
SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment.
69. Which of the following is a characteristic of a patient with advanced Parkinson’s disease?
A. Disturbed vision
C. Mask like facial expression
D. Muscle atrophy
70. The onset of Parkinson’s disease is between 50-60 years old. This disorder is caused by
A. Injurious chemical substances
B. Hereditary factors
C. Death of brain cells due to old age
D. Impairment of dopamine producing cells in the brain
71. The patient was prescribed with levodopa. What is the action of this drug?
A. Increase dopamine availability
B. Activates dopaminergic receptors in the basal ganglia
C. Decrease acetylcholine availability
D. Release dopamine and other catecholamine from neurological storage sites
72. You are discussing with the dietician what food to avoid with patients taking levodopa?
A. Vitamin C rich food
B. Vitamin E rich food
C. Thiamine rich food
D. Vitamin B6 rich food
73. One day, the patient complained of difficulty in walking. Your response would be
A. You will need a cane for support
B. Walk erect with eyes on horizon
C. I’ll get you a wheelchair
D. Don’t force yourself to walk
SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
74. The nurse will assess a loss of ability in which of the following areas?
75. Mr. Dela Isla said he cannot comprehend what the nurse was saying. He suffers from:
76. The nurse is aware that in communicating with an elderly client, the nurse will
A. Lean and shout at the ear of the client
B. Open mouth wide while talking to the client
C. Use a low-pitched voice
D. Use a medium-pitched voice
77. As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching?
A. I know the hallucinations are parts of the disease
B. I told her she is wrong and I explained to her what is right
C. I help her do some tasks he cannot do for himself
D. Ill turn off the TV when we go to another room
78. Which of the following is most important discharge teaching for Mr. Dela Isla
A. Emergency Numbers
B. Drug Compliance
C. Relaxation technique
D. Dietary prescription
SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders.
79. What is the action of this drug?
A. Increases glandular secretion for clients affected with cystic fibrosis
B. Dissolve blockage of the urinary tract due to obstruction of cystine stones
C. Reduces secretion of the glandular organ of the body
D. Stimulate peristalsis for treatment of constipation and obstruction
80. What should the nurse caution the client when using this medication
A. Avoid hazardous activities like driving, operating machineries etc.
B. Take the drug on empty stomach
C. Take with a full glass of water in treatment of Ulcerative colitis
D. I must take double dose if I missed the previous dose
81. Which of the following drugs are not compatible when taking Probanthine?
82. What should the nurse tell clients when taking Probanthine?
A. Avoid hot weathers to prevent heat strokes
B. Never swim on a chlorinated pool
C. Make sure you limit your fluid intake to 1L a day
D. Avoid cold weathers to prevent hypothermia
83. Which of the following disease would Probanthine exert the much needed action for control or treatment of the disorder?
A. Urinary retention
B. Peptic Ulcer Disease
C. Ulcerative Colitis
SITUATION : Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
84. Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco?
A. Level of awareness and response to pain
B. Papillary reflexes and response to sensory stimuli
C. Coherence and sense of hearing
D. Patency of airway and adequacy of respiration
85. Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment?
A. Hand bell and extra bed linen
B. Sandbag and trochanter rolls
C. Footboard and splint
D. Suction machine and gloves
86. What is the rationale for giving Mr. Franco frequent mouth care?
A. He will be thirsty considering that he is doesn’t drink enough fluids
B. To remove dried blood when tongue is bitten during a seizure
C. The tactile stimulation during mouth care will hasten return to consciousness
D. Mouth breathing is used by comatose patient and it’ll cause oral mucosa dying and cracking.
87. One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence?
A. Massage reddened areas with lotion or oils
B. Turn frequently every 2 hours
C. Use special water mattress
D. Keep skin clean and dry
88. If Mr. Franco’s Right side is weak, What should be the most accurate analysis by the nurse?
A. Expressive aphasia is prominent on clients with right sided weakness
B. The affected lobe in the patient is the Right lobe
C. The client will have problems in judging distance and proprioception
D. Clients orientation to time and space will be much affected
SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
89. Which result of the lab test will be significant to the diagnosis?
A. RBC : 4.5 TO 5 Million / cu. mm.
B. Hgb : 13 to 14 gm/dl.
C. Platelets : 250,000 to 500,000 cu.mm.
D. WBC : 12,000 to 13,000/cu.mm
90. Stat appendectomy was indicated. Pre op care would include all of the following except?
A. Consent signed by the father
B. Enema STAT
C. Skin prep of the area including the pubis
D. Remove the jewelries
91. Pre-anesthetic med of Demerol and atrophine sulfate were ordered to :
A. Allay anxiety and apprehension
B. Reduce pain
C. Prevent vomiting
D. Relax abdominal muscle
92. Common anesthesia for appendectomy is
93. Post op care for appendectomy include the following except
A. Early ambulation
B. Diet as tolerated after fully conscious
C. Nasogastric tube connect to suction
D. Deep breathing and leg exercise
94. Peritonitis may occur in ruptured appendix and may cause serious problems which are
1. Hypovolemia, electrolyte imbalance
2. Elevated temperature, weakness and diaphoresis
3. Nausea and vomiting, rigidity of the abdominal wall
4. Pallor and eventually shock
A. 1 and 2
B. 2 and 3
D. All of the above
95. If after surgery the patient’s abdomen becomes distended and no bowel sounds appreciated, what would be the most suspected complication?
B. Paralytic Ileus
D. Ruptured colon
96. NGT was connected to suction. In caring for the patient with NGT, the nurse must
A. Irrigate the tube with saline as ordered
B. Use sterile technique in irrigating the tube
C. advance the tube every hour to avoid kinks
D. Offer some ice chips to wet lips
97. When do you think the NGT tube be removed?
A. When patient requests for it
B. Abdomen is soft and patient asks for water
C. Abdomen is soft and flatus has been expelled
D. B and C only
Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell while getting out of the bed one morning and was brought to the hospital, and she was diagnosed to have cerebrovascular thrombosis thus transferred to a nursing home.
98. What do you call a STROKE that manifests a bizarre behavior?
A. Inorganic Stroke
B. Inorganic Psychoses
C. Organic Stroke
D. Organic Psychoses
99. The main difference between chronic and organic brain syndrome is that the former
A. Occurs suddenly and reversible
B. Is progressive and reversible
C. tends to be progressive and irreversible
D. Occurs suddenly and irreversible
100. Which behavior results from organic psychoses?
A. Memory deficit
C. Impaired Judgment
D. Inappropriate affect