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:
a. Hemothorax
b. Flail chest
c. Atelectasis
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:
a. Liver
b. Kidneys
c. Adrenals
d. Pancreas
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
b. Situational
c. Emotional
d. Developmental
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
b. Psychotherapy
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?
a. Misrepresentation
b. Assault and Battery
c. Malpractice
d. Negligence
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?
a. Headache
b. Vomiting
c. Vertigo
d. Changes on the level of consciousness
26. Which of the following drug may be given to reduce increase intracranial pressure?
a. Scopalamine
b. Lanoxin
c. Coumadin
d. Mannitol
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?
a. Coughing
b. Reading
c. Turning
d. Sleeping
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:
a. Conscious
b. Unconscious
c. Preconscious
d. Foreconscious
31. The ability to tolerate frustration is an example of one of the functions of the:
a. Id
b. Ego
c. Superego
d. Unconscious
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:
a. Dissociation
b. Transference
c. Displacement
d. Reaction formation
41. A disturb client starts to repeat phrase that others have just said. This type of speech is known as:
a. Autism
b. Echolalia
c. Neologism
d. Echopraxia
42. Projection, rationalization, denial, and distortion by hallucinations and delusions are examples of a disturbance in:
a. Logic
b. Association
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:
a. Epididymis
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:
a. Pyelitis
b. Cystitis
c. Nephrosis
d. Pyelonephritis
55. Mrs. Alcantara has a higher risk of developing cystitis than does a male. This is
due to:
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):
a. lleostomy
b. Colectomy
c. Colostomy
d. Cecostomy
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:
a. 5cm
b.10cm
c.15cm
d.20cm
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:
a. Mild
b. Moderate
c. Severe
d. Panic
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
the trait
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?
a. Joints
b. Intestines
c. Cerebrum
d. Ends of the log bones
89. Which of the following blood products is most likely to be given to Joel?
a. Albumin
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
c. Vagina
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
Representing our candidates for Mr. and Ms. Cebu South General Hospital,
cast your votes now!
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Hello fellow Nurses, pls like the picture (not the post) , representing our
candidate for Mr. and Ms. Cebu South General Hospital.
Click the link and HIT L...
