Situation 1
- The PRC regulates the practice of 42 professions in the Philippines.
1. What is is the basic basic requiremen requirementt of the state state for a nurse nurse to practic practice e her profession profession? ? A. Willingnes Willingness s to practice practice the profession profession B. A BSN BSN degree degree C. A nursing nursing license license D. An NCLEX NCLEX and CGFNS CGFNS passer passer CORRECT ANSWER: C RATIONALE: RATIONALE: Based on the definition of a professional nurse, a professional nurse is a p erson who has completed a basic nursing education program and is licensed in his/her country or state to practice professional nursing. Source: Professional Nursing in the Philippines 10th edition, page 3. 2. The Code Code of Good Governa Governance nce for the the profession professions s in the Philipp Philippines ines shall shall be adapted adapted by: A. all register registered ed profession professionals als B. all Filipino Filipino professi professionals onals C. all professio professionals nals D. all regist registered ered nurses nurses CORRECT ANSWER: C RATIONALE: RATIONALE: Governance is high on the agenda in all sectors – public, private and voluntary. As voluntary and community organisations working for public benefit, we are increasingly expected to demonstrate how well we are governed. Good governance is a vital part of how voluntary and community organisations operate and are he ld accountable. 3.
The standardized standardized guidelines guidelines and procedures for for the implementation of Continuing Continuing Professional Professional Education (CPE) for all professional. Resolution Number 2004-179 provides that the total CPE credit units for registered professionals with baccalaureate degree should be: A. 20 credit credit units units per year year B. 30 credit credit units units for 3 years years C. 60 credit credit units for 3 years years D. 10 Credit Credit units requir required ed CORRECT ANSWER: C RATIONALE: RATIONALE: Through PRC Resolution No. 2004-179 Series of 2004, Registered professionals are required a total of sixty (60) CPE credit units for Three (3) years. Any excess credit units shall not be carried over to the next three-year period except credits earned for doctoral and masters degrees. Source: Professional Nursing in the Philippines 10th edition, page 206
4. The Board Board of Nursing Nursing is vested vested with with power power to issue, issue, suspend, suspend, or revoke revoke for for cause, cause, the: A. certificat certificate e of Good Moral Character Character B. certificat certificate e of Practic Practice e C. certificat certificate e of Registrat Registration ion D. certificat certificate e of Employment Employment CORRECT ANSWER: B RATIONALE: RATIONALE: The license to practice nursing is not permanent or vested right since it may be granted upon condition and it may be held subject to conditions. If these conditions are breached or violated, the authority that issues such may revoke this license. A license cannot be revoked arbitrarily, arbitrarily, it can only be revoked for special th causes. Source: Professional Professional Nursing in the the Philippines 10 edition, page 19 5. RA 7193 stipulat stipulates es the removal removal examinatio examination n of the nurse licensur licensure e examination examination shall shall be taken: taken: A. Within 3 years years after the last failed failed examination B. Anytime the examinee wants to take the the examination C. Within 2 years years after the last failed failed examination D. Within the same same year after the last failed failed examination examination CORRECT ANSWER: C RATIONALE: RATIONALE: Renewal examination shall be taken within 2 years after the last failed examination. Source: Professional Nursing in the Philippines 10th edition, page 16 Situation 2 –
Mr. Garzon, 35 years old, an accountant of one of the banks in Iloilo went to the clinic complaining of headache and difficulty sleeping at night. 6. Nurse Nurse Anne is assessing assessing the the blood pressure pressure (BP) (BP) of Mr. Garzon. Garzon. She explains explains to to him that the basis basis for the diagnosis of hypertension should be established by: A. Five re readin dings one mo month nth ap apart art B. At leas leastt 3 readi reading ngs s wit with h aver averag age e blo blood od pres pressu sure re of 140/ 140/90 90 C. One One read readin ing g of blo blood od pr pressu essure re gre great ater er tha than n 140/ 140/90 90 D. Three Three blood blood pres pressur sure e read reading ings s take taken n on the same same day day in in diffe differen rentt posit position ions s Reproduction is strictly prohibited… RN International Review Center 1
CORRECT ANSWER: B RATIONALE: RATIONALE: The National Institutes of Health (NIH) Committee has defined hypertension as a systolic pressure of 140 or higher and diastolic of 90 or higher when 2 or more blood pressure measurements are averaged on 2 or more subsequent visits. Options 1, 3, and 4 are incorrect. Source: Page 1491 med-surg Black 7. A. B. C. D.
Mr. Garzon Garzon is beginning beginning medication medication therapy with furosemide furosemide (Lasix) (Lasix) once daily. daily. Nurse Anne should instruct him him to take the medication at which of the following optimal times? 8:00 A.M. 12 noon 6:00 P.M. At bedtime CORRECT ANSWER: A RATIONALE: A client taking a diuretic such as furosemide should self administer the medication in the morning to allow for diuresis throughout the day. This will help to prevent nocturia, which could cause disruption to the client's nightly sleep pattern. The timeframe in option 2 is not as early as option 1, while options 3 and 4 clearly increase the risk of nocturia.
8. A. B. C. D.
During the discharge teaching, teaching, Mr. Garzon mentions mentions that he he will stop taking her antihypertensive antihypertensive medications medications as soon as his blood pressure is under control. Which of the following should be included in your instructions? "In order order to main maintai tain n control control of of your bloo blood d pressur pressure, e, the medi medicat cation ion must must be cont contin inued ued indef indefini initel tely." y." "Onl "Only y the the phy physi sici cian an can can answ answer er this this ques questi tion on." ." "The "The medic medicati ation on wil willl proba probably bly be stop stopped ped after after your your blood blood pres pressur sure e is is norm normal al "The "The medi medica cati tion on will will be decr decrea ease sed d in in tim time. e."" CORRECT ANSWER: A RATIONALE: RATIONALE: Emphasis should be placed on the client's adherence to the plan of treatment to avoid serious consequences of noncompliance. The complications of high blood pressure include stroke, cardiac failure, and chronic renal failure.
Situation 3 -
Pain is always associated to surgery:
9. As a surgical surgical nurse, which which of the following following nursing nursing interventi intervention on will allay allay anxiety anxiety and pain among surgical surgical patients? A. Assess the client for for concerns especially those those that can potentially potentially cause pain B. Verify that that the operative operative permit permit is signed C. Discourage the client client from discussing the the details of the surgical surgical procedure D. Ensure safety of client while in surgery CORRECT ANSWER: A RATIONALE: RATIONALE: All patients undergoing surgery will have fear and anxiety, especially post ope ratively when they experience pain. As a priority nursing intervention, a nurse should assess further the patient in relation to pain and verbalization of feelings may allay anxiety. Choices B and D are important but do not answer the question, choice C always discourage verbalization 10. Rhizotomy is a condition surgical surgical procedure to manage those that can potentially cause pain. pain. What is the crucial in determining a good candidate for rhizotomy? A. Pain which is resistant resistant to non-pharmacologic non-pharmacologic protocol for 6 month B. Pain which is is resistant to pharmacologic protocol for 12 months C. Local pain with no radiating pain or signs signs of nervous compression compression D. Deep pain with with obvious signs of peripheral nerve damage CORRECT ANSWER: B RATIONALE: 1. Non pharma pharmacol cologi ogic c manage managemen ment. t. 2. Phar Pharma macol colog ogic ic manage manageme ment nt.. 3. Surger Surgery y includ including ing rhiz rhizoto otomy my to reli relieve eve pain pain 11. Which of the following would be the nurse's appropriate response to a crying female client scheduled for
emergency surgery who is verbalizing fear of pain but afraid to go to sleep? A. Let her cry and tell signifi significant cant other other to stand by B. Squeeze her hand and assure her that there will will be no pain at ail because she will be given anesthesia C. Stand by her side and quietly ask her to describe describe her feelings D. Check her name tag and request anesthesiologist to sedate client CORRECT ANSWER: C Reproduction is strictly prohibited… RN International Review Center 2
RATIONALE: RATIONALE: Choice B is false reassurance, choice choice D is not therapeutic, choice C is is offering self, and encouraging verbalization of clients 12. Which of the following client's client's statement indicates that he understands understands the nurse's instruction about postoperative wound pain? A. "I shall call call the nurse when my wound wound itches and smells". smells". B. "I shall expect slight slight pain and discomfort discomfort from the surgical incision". C. "I should call my doctor doctor if my wound has no drainage, and intact". intact". D. "I should not touch touch my surgical surgical wound". CORRECT ANSWER: B RATIONALE: RATIONALE: this is an expected finding during the post-op period OPTION A – The dressing over the surgical incision must be checked frequently. If it is soiled, note the color, type and amount of drainage. Reinforce the dressing but do not change it or open it without a physician’s order. Although correct, it is not related to post-op wound pain but rather it is related to post-op infection risk Source: page 303 MS Black 13. What do you think is is an important responsibility responsibility related to to pain that is subjective subjective in nature? A. Divert Divert attention attention of client client in pain B. Leave the patient patient alone alone while while in pain C. Believe what the patient says about the pain D. Assume responsibility responsibility to eliminate pain pain as described by the client CORRECT ANSWER: D RATIONALE: RATIONALE: Pain is an expected outcome postoperatively and yet one of the most frequent postoperative problems is inadequate analgesic administration. You must carefully and regularly assess the client’s level of pain. Pain may be caused by a factor unrelated to the surgical procedure such as positioning that occurred during surgery. Source: page 304 MS Black Situation 4
– Nurse Bryan is taking care of the client who was diagnosed with osteomyelitis.
14. Nurse Bryan is knowledgeable knowledgeable that the primary primary organism responsible responsible for osteomyelitis osteomyelitis is: A. Staphylococcus aureus B. Escherichia coli C. Streptococcus D. Pseudomonas CORRECT ANSWER: A RATIONALE: RATIONALE: The most common causative agent in clients clients with osteomyelitis is is Staphylococcus aureus. The other organisms could contribute but are not usually the primary the primary organism; organism; look for key words. Source: page 610 MS Black 15. Which of the following nursing nursing interventions is contraindicated contraindicated in the care of a client with acute osteomyelitis? osteomyelitis? A. Appl Apply y hea heatt com compr pres esse ses s to to the the affe affect cted ed area area B. Immobi obilize th the af affect ected ar area C. Admi Admini nist ster er narc narcot otic ic anal analge gesi sics cs for for pai pain n D. Adm Administ nister er OTC ana anallgesi gesics cs for for pai pain n CORRECT ANSWER: A RATIONALE: RATIONALE: Options 2, 3, and 4 are appropriate nursing interventions when caring for a client diagnosed with osteomyelitis. The application application of heat can increase edema and pain in the affected area and spread b acteria through vasodilatation. Source: page 610 MS Black Situation 5 -
Nurses' attitudes toward pain influence the way they perceive and interact with clients in pain.
16. Nurses should be aware aware that older adults are at risk of underrated underrated pain. Nursing Nursing assessment and management of pain should address the following beliefs EXCEPT: A. Older patients seldom tend to to report pain than the younger ones B. Pain is is a sign of weakness weakness C. Older patients do not believe in analgesics; analgesics; they are tolerant D. Complaining of pain pain will lead to being labeled a "bad” patient patient CORRECT ANSWER: A RATIONALE: RATIONALE: Elderly: May consider it unacceptable to admit or show pain, May withhold complaining of pain because of fear of the treatment, of any lifestyle changes that may be involved o r of becoming dependent Source: page 1138-1139 Funda Kozier 17. Nurses should understand that when a client responds favorably to a placebo, placebo, it is known known as the placebo effect. effect. Placebos do not indicate whether or not a client has: Reproduction is strictly prohibited… RN International Review Center 3
A. consci conscienc ence e B. real real pain pain C. dise diseas ase e D. drug drug toleranc tolerance e CORRECT ANSWER: B RATIONALE: RATIONALE: A positive response to a placebo dose is not indicative of a lack of real pan but only of the the reality of the placebo effect, which can be expected in 30% or more of any population. Because placebos fail to relieve pain for many people it is recommended that the deceptive use of placebos b e considered unacceptable in the management of pain Source: page 1154 Funda Kozier 18. You are the nurse in the pain clinic where you have a client who who has difficulty specifying the location location of pain. How can you assist such client? A. The pain pain is is vague vague B. By chartingcharting-it it hurts hurts all over over C. Identify Identify the absence absence and presence presence of pain D. Ask the client to to point to the painful painful area by just one finger finger CORRECT ANSWER: D RATIONALE: RATIONALE: To ascertain the specific location o f the pain, ask the individual to point to the site of the discomfort. A chart consisting of drawings of the body can assist in identifying pain location. The client marks the location on the chart. This tool can be especially effective with clients who have more than one source of pain Source: page 1142 Funda Kozier 19. What symptom, more more distressing than pain, pain, should the nurse monitor monitor when giving opioids opioids especially among elderly clients who are in pain? A. Forget Forgetful fulnes ness s B. Consti Constipat pation ion C. Drowsi Drowsines ness s D. Allergic Allergic reactions reactions like pruritus pruritus CORRECT ANSWER: C RATIONALE: RATIONALE: Opiods relieve pain and euphoria largely by binding to opiate receptors and activating endogenous pain suppression in the CNS. Opiods cause a CNS depressant effect like drowsiness, nausea, vomiting, constipation and respiratory depression Source: page 1152 Funda Kozier 20. Physical dependence occurs in in anyone who takes opioids over a period of time. time. What do you tell tell a mother of a “dependent” when asked for advice? A. Start another drug and slowly slowly lessen the opioid dosage B. Indulge in in recreational recreational outdoor activities C. Isolate opioid opioid dependent to a restful restful resort D. Instruct slow tapering of the drug dosage and alleviate alleviate physical withdrawal symptoms symptoms CORRECT ANSWER: A RATIONALE: RATIONALE: Tolerant patients can still be given additional opioids on top of their withdrawal-preventing maintenance levels to achieve adequate postsurgical pain control. This can be accomplished by using opioids different from those in the patient's maintenance regimen, to which he or she may have less cross-tolerance, or by combining opiates with other pa in-control modalities. In addition, tolerance to the side effects of opioids, particularly respiratory depression, is usually greater than any tolerance to their pain-relieving effects; dosages can be titrated carefully to prevent adverse events. Slowing the withdrawal of the patient taking an opioid will prevent withdrawal manifestation of the client. Situation 6 -
As a perioperative nurse, you are aware of the correct processing methods for preparing instruments and other devices for patient use to prevent infection. 21. Items that enter sterile tissue or vascular system are categorized categorized as critical critical items and should be: A. Clean lean B. Decont Decontami aminat nated ed C. Steri Steriliz lized ed D. Disinf Disinfect ected ed CORRECT ANSWER: C RATIONALE: RATIONALE: since the tissue or vascular system is sterile, it should only have contact with a sterile item or articles which makes option C the correct answer (following principles of surgical asepsis) 22. As an OR nurse, what are your foremost foremost considerations for selecting chemical agents agents for disinfection? disinfection? A. Material Material compatibil compatibility ity and efficiency efficiency B. Odor and avail availabili ability ty Reproduction is strictly prohibited… RN International Review Center 4
C. Cost and duration of disinfection process D. Duration of of disinfection disinfection and efficiency CORRECT ANSWER: D RATIONALE: 23. Before you use a disinfected disinfected instrument, it is essential essential that you: A. Rinse with with tap water followe followed d by alcohol B. Wrap the instrumen instrumentt with sterile sterile towel towel C. Dry the instrume instrument nt thoroughly thoroughly D. Rinse with with steril sterile e water CORRECT ANSWER: D RATIONALE: RATIONALE: Rinsing is the most important part of the cleaning process. Rinsing removes the debris loosened with manual and/or ultrasonic cleaning and residual cleaning agent. Sterile deionized/distilled water is preferred for the final rinse to prevent mineral deposits and reduce the potential for pyrogens. The water should not be reused/ 24. You have a critical heat labile instrument instrument to sterilize and you are considering considering to use a high level disinfectant. What should you do? A. Cover the soaking vessel to contain the vapor B. Double the amount of high level disinfectant C. test the potency potency of the high level disinfectant disinfectant D. Prolong the exposure exposure time according according to manufacturer's manufacturer's direction direction CORRECT ANSWER: D RATIONALE: 25. As a nurse, you know that intact skin acts as an effective effective barrier to most microorganisms. microorganisms. Therefore, items that that come in contact with the intact skin should be: A. Disinf Disinfect ected ed B. Ster Steril ile e C. Clea Clean n D. Alcoho Alcoholi lized zed CORRECT ANSWER: B RATIONALE: Situation 7 -
The OR is divided into three zones to control traffic flow and contamination.
26. What OR attires are worn in the the restricted area? area? A. Scrub Scrub suit, OR OR shoes, head cap B. Head cap, scrub scrub suit, suit, mask, OR shoes shoes C. Mask, OR OR shoes, shoes, scrub suit suit D. Cap, mask, mask, gloves, gloves, shoes shoes CORRECT ANSWER: B RATIONALE: RATIONALE: The surgical area is divided into three zones: Unrestricted zone – where street clothes are allowed Semi-restricted Semi-restricted zone – where attire consists of scrub clothes, caps & shoe cover Restricted zone – where scrub clothes, shoe covers, caps and mask are worn Source: MS Brunner, page 420 27. Which of the following nursing nursing interventions should be given the highest priority priority when receiving a client in the OR? A. Check for presence of dentures, dentures, jewelry, nail polish, and other other accessories B. Receive the client client at the the semi-restricted semi-restricted area and change change his gown C. Assess Assess level of consciou consciousness sness D. Verify the the identification identification and informed informed consent CORRECT ANSWER: D RATIONALE: RATIONALE: Although all options are correct, verifying for the correct patient and checking for the signed consent will be the priority. (How can you do options A, B & C if it was a wrong patient and/or a consent form has not been signed yet?) 28. Conversation while while in the operation is ongoing is minimized minimized because: A. full concentration concentration is demanded during the entire entire procedure B. it annoys annoys the surgeo surgeon n C. it is unethical unethical to talk talk about the client D. it enhances the spread of microorganism to the the incision site Reproduction is strictly prohibited… RN International Review Center 5
CORRECT ANSWER: D RATIONALE: RATIONALE: The number of personnel and unnecessary physical movements and talking may be restricted to minimize bacteria in the air in the OR. Source: MS Brunner, page 422 29. Spaulding categorized instruments according to to use. Where do you classify classify endoscopic instrument? instrument? A. Decontamin Decontaminated ated instrumen instruments ts B. High level disinfe disinfected cted instrument instruments s C. High technology technology instrumen instruments ts D. Sterile Sterile instrum instruments ents CORRECT ANSWER: B RATIONALE: 30. In the OR. "Surgical "Surgical Conscie Conscience" nce" means. means. A. Observance of Operating Operating Room Protocol at all times B. Use of prescribed prescribed OR attire attire in all areas of the the OR C. Honest adherence to to surgical aseptic aseptic techniques all all the time time D. Strict implementation implementation of "Standard Precaution" CORRECT ANSWER: C RATIONALE: Surgical Conscience: All patients have the right to expect and receive exceptional and ethical care. It is the p atient that we, in health care, work for. Operating room personnel are keenly aware of the potential for harm to the patient. While in the operating room, the patient is generally unable to provide self-protection. The patient may be partially or completely impaired due to anesthetic needs. It is personal moral values and professional ethics that guide health care professionals to carefully and vigilantly protect their patients. When there is a breach in aseptic technique or when it is noticed that instruments are contaminated, this must be reported so corrective action can take place immediately, regardless of personal consequences or embarrassment. A delay in reporting such incidents unnecessarily places the patient at great risk. Placing of the patient's well being above personal/professional embarrassment demonstrates good surgical conscience. www.geocities.com/alamedacounty/repspolicy.html Situation 8 -
Nurses have the responsibility to assist diabetic clients with insulin administration it is essential that both nurse and client learns how to measure insulin dosage accurately. 31. Insulin concentration is labeled labeled and measured in: A. units units/m /mll B. gm/ gm/ml C. grai grain n D. mg/m mg/mll CORRECT ANSWER: A RATIONALE: RATIONALE: Insulin is commercially available in concentrations of 1 00 or 500 or 500 units/ml (designated U-100 and U500, respectively; 1 unit equals 36 µg of insulin). insulin). U-500 is only used in rare casesof cases of insulin resistance when the patient requires extremely large doses 32. Each unit of insulin provides the client client with the same effect regardless of its its concentration per 1 ml of solution. Is Is insulin of 500 "u" per ml more potent that insulin of 100 "u" per ml? A. Modera Moderate te potency potency B. Less Less pote potent nt C. More More poten potentt D. Same Same potency potency CORRECT ANSWER: C RATIONALE: RATIONALE: Insulin is commercially available in concentrations of 1 00 or 500 or 500 units/ml (designated U-100 and U500, respectively; 1 unit equals 36 µg of insulin). insulin). U-500 is only used in rare casesof cases of insulin resistance when the patient requires extremely large doses 33. Nursing intervention for a patient patient on low dose IV insulin therapy includes includes the following, EXCEPT: EXCEPT: A. elevation of serum ketones to monitor monitor ketosis B. vital signs including including BP BP C. estimate estimate serum serum potassium potassium D. elevation elevation of blood glucose glucose levels levels CORRECT ANSWER: C RATIONALE: RATIONALE: A nurse in Insulin IV administration should monitor vital signs and for signs of fluid overload, monitor potassium levels, glucose levels and urinary output and signs for increased intracranial pressure. Reproduction is strictly prohibited… RN International Review Center 6
Source: page 642 Saunders 34. The doctor ordered to incorporate 1000 “u” insulin insulin to the remaining on going IV. The strength strength is 500 u/ml. How much should you incorporate into the IV solution? A. 10 ml B. 2 ml C. 0.5 0.5 ml ml D. 5 ml ml CORRECT ANSWER: B RATIONALE: RATIONALE: 1000u / 500u /ml = 2 ml 35. Multiple vial-dose-insulin vial-dose-insulin when in use should be: A. kept at at room temperatu temperature re B. kept in in the refri refrigerat gerator or C. kept in the the narcotic narcotic cabinet cabinet D. stored stored in the the freezer freezer CORRECT ANSWER: A RATIONALE: RATIONALE: Vials of insulin not in use should be refrigerated. Extreme Extreme temperatures (<36 or >86°F, <2 or >30°C) and excess agitation should be avoided to prevent loss of potency,clumping, potency,clumping, frosting, or precipitation. Specific storage guidelines provided by the manufacture manu facturerr should be followed. Insulin Insu lin in use may be kept at room temperature to limit local irritation at the injection site, which may occur when cold insulin is used. Situation 9
- Collaborative planning is essential if nursing and health care are to be made available to all people.
36. Perioperative examples examples of collaboration collaboration are the the following EXCEPT: A. Communicate with other members of the the health profession to to improve the integrity integrity B. Communicate with health officials the the incidence of Hepatitis Hepatitis B among OR personnel C. Collaboration with other other OR personnel regarding the practices of surgeons surgeons collecting exorbitant professional professional fees D. Collaborate with with DOM regarding regarding disposal or specimens CORRECT ANSWER: C RATIONALE: RATIONALE: collaboration means a collegial working relationship with another health care provider in the provision of patient care. Collaborative practice requires the discussion of patient diagnosis and cooperation in the management and delivery of care. Source: page 111 funda kozier 37. The nurses collaborate with other other members of the health profession to improve improve the integrity of the hospital working environment through the following ways EXCEPT: A. Joining Joining barangay barangay health club club projects projects B. Joining Joining the Mayo Mayo Uno Labor Labor Union Union C. Joining labor day rally to increase wages of healthcare healthcare workers and improve dilapidated health health centers D. Affiliating with The All Healthcare Healthcare Alliance CORRECT ANSWER: C RATIONALE: RATIONALE: Collaboration means a collegial working relationship with another health care provider in the provision of patient care, but it does not entail joining a rally to increase wages 38. An example of a collaborating collaborating effort on on public service particularly particularly during summer summer is: A. Boto Mo. Ipatrol Ipatrol Mo Mo B. Operat Operation ion Linis Linis C. Clean Clean and Gree Green n D. Operat Operation ion Tuli Tuli CORRECT ANSWER: D RATIONALE: RATIONALE: Usually during summer season, children are on vacation leading to a program in the government to conduct an operation tuli 39. When does a nurse accept the interdependence of providers and patients in achieving access to health care?
A. B. C. D.
"Our hospital does not honor visiting visiting doctors " When the nurse replies to to a client's relative relative "You have the best doctor doctor in town". When the nurse communicates to the attending physician physician the desire of the patient to be seen by a urologist “The doctor doctor is not on duty duty today." today."
CORRECT ANSWER: C RATIONALE: RATIONALE: As a nurse she can become a client advocate when he/she can provide what is best for the patient not for the doctor or the hospital, it’s for the client’s best interest Reproduction is strictly prohibited… RN International Review Center 7
40. Individual patients and society as a whole benefit benefit from nursing participation participation in decisions made about health care. This is exemplified in: A. Supporting, political political candidates that advance nursing nursing health care care issues B. Bringing Bringing the NCLEX NCLEX in the Philippin Philippines es C. Supporting the proliferation proliferation of colleges colleges of nursing in the country country D. Following the decision of CGFNS CGFNS to retake test III and V to to validate the visa screen for the U.S. CORRECT ANSWER: A RATIONALE: RATIONALE: The patient and society can benefit from the nurse’s participation in supporting country’s political advances towards the health care development system and issues.
Situation 10 -
Pain management is not limited to pharmacological means.
41. Ronald, one of your clients who is being worked worked out for AIDS, tells you that that he has been using acupuncture to help with his pain. You questioned his treatment because: A. acupuncture uses needles to stimulate stimulate certain points points on the body to treat treat pain B. acupuncture uses a variety of herbs and oils from wild plants C. acupuncture uses manipulation manipulation of the skeletal muscles to relieve stress stress and pain D. acupuncture uses pressure from the fingers and hands to to stimulate body responses responses CORRECT ANSWER: A RATIONALE: RATIONALE: Acupuncture is to restore balance and free flow of body’s vital energy in order to help the body to heal itself. This is achieved by the insertion of fine, sterile needles into specific points along meridians, in various areas of the body. 42. Your younger brother came home with a right right black eye. He asked you for an eye ointment to relive the pain and swelling. You should offer: A. ice pack pack over the the right right eye B. tetracycl tetracycline ine ophthalmic ophthalmic ointment ointment C. hot compress compress over the the right eye eye D. ice cold cold drink drinks s CORRECT ANSWER: A RATIONALE:Cold RATIONALE:Cold lowers the temperature of the skin and underlying tissues and causes vasoconstriction. Vasoconstriction reduces blood flow to the affected area and thus reduces the supply of oxygen and metabolites, decreases the removal of wastes and produces skin pallor and coolness. Cold compresses usually indicated for the first 24H in sport injuries ( e.g. sprains, strains, fractures) Source: page 884 funda kozier 43. Menstrual pain and discomfort discomfort account for absences in schools and offices. offices. A non-pharmacological non-pharmacological remedy for menstrual pain is: A. regular regular bowel bowel moveme movement nt B. knee-chest exercises before menstruation and hot water bag application over lower abdomen during onset C. warm shower during onset of menstrual period period D. diet restriction on fatty foods and liberal liberal fluid intake intake CORRECT ANSWER: C RATIONALE: RATIONALE: Dysmenorrhea or painful menstruation menstruation is usually caused by prostaglandin synthesis that causes spasm during menstruation. Usual management is knee-chest p osition, regular exercise, hot compress or analgesics for pain. 44. Among burn clients, especially especially 1st and 2nd degree, one of the primary nursing functions is to alleviate alleviate pain. The following are appropriate nursing interventions, EXCEPT : A. using cold cold water for hydrot hydrotherapy herapy B. avoiding avoiding exposure exposure to to draft C. administering morphine S04 S04 as proscribed D. using of bed cradle cradle to relive relive pain CORRECT ANSWER: A RATIONALE: RATIONALE: flame and scald burns should be coo led by submerging small burns in cool water NOT COLD until the sensation of burning stops. Major burn victims should have an initial “wet down” at the scene to stop the burning process, but not submerged in water. Source: 1446 med-surg Black 45. Nurses taking care of post skin graft patients know that the post-op pain is at the:
A. B. C. D.
Butt Buttock ocks s Dono Donorr site site Recipient Recipient site Inject Injection ion site site Reproduction is strictly prohibited… RN International Review Center 8
CORRECT ANSWER: B RATIONALE: Case specific to debrided wounds includes assessment of bleeding and pain control. Many patients report more pain in donor sites (owing to exposed nerve endings) than the recipient sites. Page 1460 funda kozier Situation 11
- One learns by doing especially when you practice the best methods
46. Which action by a new nurse signifies a need for further teaching teaching in infection control? control? A. The nurse places places the side rails rails the time time to an unconscious patient B. The nurse nurse elevates elevates the head of the be bed d to check the BP C. The nurse uses her bare hands to change the dressing D. The nurse applies applies oxygen mask to the mouth mouth CORRECT ANSWER: C RATIONALE: RATIONALE: Infection control in changing d ressing to patient is always a lways considered to be sterile technique to prevent infection 47. You are on PM shift and about 5 patients are for discharge. discharge. You noted that the orderly was looking through through the items of one of the patients. Which action should you pursue? A. Call the attention of the orderly in private B. Ignore Ignore the situation situation because because you are busy busy C. Report Report this behavior behavior to the nurse in charge D. Monitor the situation situation and note whether any other items are reported reported missing CORRECT ANSWER: A RATIONALE: RATIONALE: the nurse should 1st confront the person concerned before reporting to the immediate head. 48. What appropriate action action should you do when you you overhear the nursing attendant attendant speaking harshly to an elderly patient? A. Try to explore explore the interaction interaction with the nursing attendant attendant concerned B. Change Change the attendant's attendant's assignm assignment ent C. Initiate a group discussion discussion with all other nursing attendants D. Discuss the matter matter with the patient's family family CORRECT ANSWER: A RATIONALE: RATIONALE: Ensuring a therapeutic communication, a nurse overhearing the nursing attendant should first confront the nursing attendant for reasons of his/her actions 49. You have been in the surgical ward for almost a year and have cared for a nu mber of clients with CVP. Which
observation from a colleague would indicate a need for further teaching, EXCEPT? A. The colleague turns the the stop-cock to the off off position from the the IV fluid to to the patient B. The nurse colleague colleague notes the level at the the top of the the meniscus C. The colleague instructs the client client to perform the valsalva maneuver during the CVP CVP reading D. The nurse colleague charting charting medication administration administration that she she has not yet given CORRECT ANSWER: A RATIONALE: RATIONALE: Pt is relaxed, activities that increase intrathoracic pressure such as coughing or straining will cause false increase in the reading, although charting if the drug is not given yet is wrong, but it does not answer to the question regarding CVP. Source: page 784 Saunders 50. You saw one co lleague charting medication administration that she has not yet administered. After talking to her,
you also report the incident to the charge nurse. The charge n urse should: A. require the staff to submit an incident report report B. terminate terminate the nurse C. charge the erring erring nurse nurse with dishonest dishonest D. report report to the Board of Nursi Nursing ng CORRECT ANSWER: A RATIONALE: RATIONALE: Error that is usually committed should be required to submit an incident report Situation 12 –
You are assigned at the PACU at 9:30 AM, post-op clients started to be wheeled in from the OR.
51. Which nursing diagnosis diagnosis has priority priority among client client in the the PACU? A. Acute pain related related to discomfort discomfort of wound wound and immobility immobility B. Body image disturbance disturbance because of wound dressing and drains C. Ineffective airway airway clearance related related to general anesthesia D. Knowledge deficit related related to lack of information because patients patients are all sedated sedated CORRECT ANSWER: C Reproduction is strictly prohibited… RN International Review Center 9
RATIONALE: RATIONALE: The primary objective in the immediate postoperative period is to maintain pulmonary ventilation to prevent hypoxemia and hypercarpnia because both can occur if the airway is o bstructed and ventilation is reduced (hypoventilation). That is why in all the options the nursing diagnosis ineffective airway clearance has the priority. Source: MS Nursing by Brunner 9 th ed., vol. 1, p. 349 52. Which of the following clients at the PACU will demonstrate demonstrate the effectiveness of preoperative preoperative teaching? A. The client demonstrates demonstrates deep breathing, coughing, coughing, splinting chest and and leg exercises B. The client manifests manifests normal normal temperature temperature C. The client client sleeps sleeps well well D. The client client has good good balance balance I and O CORRECT ANSWER: A RATIONALE: RATIONALE: Important preoperative patient education includes: i. Teaching Teaching deep deep breath breathing ing and and coughing coughing exercises exercises (preventio (prevention n of pneumonia pneumonia and atelec atelectasi tasis) s) and and splinti splinting ng wound when coughing (reduce pain and prevent wound dehiscence) ii. Encouragin Encouraging g mobility mobility and active active body moveme movement nt (preventi (prevention on of thromb thrombosis/ osis/DVT DVT,, promotes promotes circu circulatio lation n and respiratory function) iii. iii. Expla Explaini ining ng pain pain manage managemen mentt and cogni cognitiv tive e coping coping strat strategi egies es (pain (pain reli relief) ef) th Source: MS Nursing by Brunner 9 ed., vol. 1, p. 324 53. Which of the following remark remark indicates that the client's relative relative understood the discharge instruction for wound wound care? A. "If the wound is painful, painful, I will say it is normal." normal." B. "It is alright to to use adhesive tape over the the wound to keep it intact." intact." C. "It is ok for his pet to remain at his his bedside to keep him company." D. "I will report any redness or swelling swelling of the wound.” CORRECT ANSWER: D RATIONALE: RATIONALE: Reporting of redness and swelling is important to monitor infection risk Option A – Painful wound is not always normal Option B – Sterile dressings are used to cover wounds not adhesive tape Option C – Animal saliva might come in contact with the wound (risk for infection) 54. You just transferred out a post-op client client to her room. What would your instruction instruction to the family include to prevent accidents? A. Report when the the IV infusion infusion is almost almost finished B. Test the the call system system if functioni functioning ng C. Keep the room room lights lights on for 24 hours D. Make sure sure the side rails rails are are up CORRECT ANSWER: D RATIONALE: RATIONALE: Side rails up en sures safety of patient while he/she is on the bed. Option A – It is the nurse’s responsibility to monitor IV. The nurse in charge of the patient should know when the IV fluid will be consumed. Option B – Does not answer safety Option C – There is no assurance that when lights are turned on, patient will be free from falling from the bed. 55. One of your post-op patients has a temperature of 37.9°C 37.9°C and was shivering. You covered him with with a blanket and later took his temperature again and it is now 38.9°C. The nursing student asked you to explain the absence of shivering even if the temperature was higher. A. The patient is no longer longer febrile thus he is no longer chilling chilling B. Shivering normally normally disappears disappears as temperature temperature becomes higher C. The body has reached its new set point thus the absence of shivering shivering D. The patient patient is feeling feeling better better CORRECT ANSWER: C RATIONALE: Option A & D - 37.9°C to 38.9°C is still febrile The body maintains stability within this range by balancing the heat produced by the metabolism with the heat lost to the environment. The "thermostat" that controls this process is located in the hypothalamus, a small structure located deep within the brain. The nervous system constantly relays information about the body's temperature to the thermostat, which in turn activates different physical responses designed to cool or warm the body, depending on the circumstances. These responses include: decreasing or increasing the flow of blood from the body's core, where it is warmed, to the surface, where it is cooled; slowing down or speeding up the rate at which the body turns food into energy (metabolic rate); inducing shivering, which generates heat through muscle contraction; and inducing sweating, which cools the body through evaporation. A fever occurs when the thermostat resets at a higher temperature, primarily in response to an infection. To reach the higher temperature, the body moves blood to the warmer interior, increases the metabolic rate, and induces shivering. The "chills" that often accompany a fever are caused by the movement of blood to the body's core, leaving the surface and extremities cold. Once the higher temperature is achieved, the shivering and chills stop. Reproduction is strictly prohibited… RN International Review Center 10
Source: http://www.answers.com/topic/ http://www.answers.com/topic/fever?cat=health fever?cat=health Situation 13 -
Patients with chest tubes can be very challenging to new nurses.
56. The chest tube drainage of Tirso has continuous continuous bubbling in the water seal drainage. Which of the the following condition is the possible cause of the malfunctioning sealed drainage? A. A suction suction being being too too high high B. An air air leak leak C. A tube being being too too small small D. A tension tension pneumothor pneumothorax ax CORRECT ANSWER: B RATIONALE: RATIONALE: Bubbling in the water-seal compartment is caused by the air passing out of the pleural space into the fluid in the chamber. Intermittent bubbling is normal and indicates that the system is accomplishing one of its purposes, that is, removing air from the pleural space. Continuous bubbling during both inspiration and expiration, however, indicates that air is leaking in the drainage system or pleural cavity. Source: MS Nursing by Black and Hawks 7th ed., vol. 2, p. 1864 57. While you were making making your endorsement, you you found out the chest tube tube of a client was was disconnected. What would would be your appropriate action? A. Assist the client client back to his bed and place place him on the affected affected side B. Cover the end of the chest tube with sterile gauze C. Reconnect the tube to the chest tube system D. Put the end of the the chest tube into a cup of sterile normal saline CORRECT ANSWER: D RATIONALE: RATIONALE: If the tube becomes disconnected, it is best to reattach it to the drainage system or to submerge it the end in a bottle of sterile water or saline to reestablish a water seal. Source: MS Nursing by Black and Hawks 7th ed., vol. 2, p. 1865 58. Dr. Reyes asked you to assist him with with the removal of Tirso's chest tube. You would would instruct the client to : A. continuously breathe normally during during the normal of the chest tube B. take a deep breath, breath, exhale, exhale, and bear bear down C. exhale exhale upon actual actual removal removal of the tube D. hold breath until until the chest tube is pulled pulled out CORRECT ANSWER: B RATIONALE: RATIONALE: When removing the chest tube, instruct the patient to perform valsalva maneuver by exhaling fully and bearing down. Valsalva maneuver effectively increases intrathoracic pressure thus preventing entry of air in the incision site in the lungs. Source: Lippincott’s Nurse’s Quick Check: Skills. P. 115 59. Chest tube diameter is measured or expressed in : A. fren french ch B. gaug gauge e C. milli millilit litres res D. inch inches es CORRECT ANSWER: A RATIONALE: RATIONALE: French catheter scale (most commonly abbreviated with Fr., FR or F) is commonly used to measure the outer diameter of cylindrical medical instruments including catheters. Source: Wikipedia.com Option B – gauge are used to measure needle sizes 60. When transporting clients with with chest tube, the system should be: A. discon disconnec nected ted B. clos closed ed C. placed placed lower than the patient' patient's s chest D. placed between the the legs of the client to to prevent breakage breakage CORRECT ANSWER: C RATIONALE: RATIONALE: to promote drainage Situation 14
- The perioperative nurse collaborates with the client, significant others, and healthcare providers
61. Patient outcome reflect the the collaborative interdisciplinary interdisciplinary effort and independent nursing activities. activities. Who is the primary partner of the nurse in health care? A. The The famil family y B. The The doct doctor or C. The client client Reproduction is strictly prohibited… RN International Review Center 11
D. The signifi significant cant other other CORRECT ANSWER: B RATIONALE: RATIONALE: Test taking strategies: Option A, C & D all refer to our clientele 62. To control environmental hazards hazards in the OR, the nurse collaborates with with the following departments EXCEPT: EXCEPT: A. biomedical biomedical division division B. chaplaincy chaplaincy services services C. infection infection control control committee committee D. pathology pathology departm department ent CORRECT ANSWER: B RATIONALE: RATIONALE: Chaplaincy services provide objective crisis intervention and competent spiritual support. All other options are concerned with the control of OR environmental hazards. 63. Waste disposal poses a big problem for the hospital. hospital. Biological wastes (i.e. (i.e. amputated limbs) disposal should should be coordinated with the following agencies EXCEPT: A. Cremat Crematori orium um B. DOH C. MMDA MMDA D. DILG ILG CORRECT ANSWER: A RATIONALE: RATIONALE: Crematorium is not a government agency in the 1st place. The rest of the options render service that is concerned with solid waste disposal and management. 64. Tess, the PACU nurse, discovered discovered that Malou, who weighs 110 lbs prior to to surgery, is in severe pain 3 hrs after cholecystectomy. Upon checking the chart, Malou found out that she has an order of Demerol 100 mg I.M. prn for pain, Tess should verify the order with: A. A Nurse Nurse supervisor supervisor B. Anesthesiol Anesthesiologist ogist C. Surg Surgeo eon n D. Intern Intern on on duty duty CORRECT ANSWER: C RATIONALE: RATIONALE: It is the Surgeon who is responsible for giving medication orders for the patient so verifications should be addressed to the person in charge of the medication order. 65. Rosie, 57 who is a diabetic is for debridement debridement of incision wound. When the circulating circulating nurse checked the present IV fluid, she found out that there is no insulin incorporated as ordered. What should the circulating nurse do? A. Double check the the doctor's order and call the the attending MD MD B. Communicate with the ward nurse to verify verify if insulin insulin was incorporated or not C. Communicate with the client to verify verify if insulin insulin was incorporated. D. Incorporat Incorporate e insulin insulin as ordered. CORRECT ANSWER: A RATIONALE: RATIONALE: Verify to the person who made the order – the doctor. Situation 15 –
Technology and patient’s education h as dramatically improved the management of the diabetic client.
66. The current insulin pumps available available in the market have the following capability. capability. EXCEPT ; A. prevent unexpected saving in blood glucose measurements B. detect signs and symptoms of hypoglycemia and hyperglycemia hyperglycemia C. deliver a pre-meal pre-meal bolus dose of insulin before each meal meal D. deliver a continuous basal rate of insulin insulin at 0.5 units to 2.0 2.0 units per hour CORRECT ANSWER: B RATIONALE: RATIONALE: Insulin pumps commonly improve blood glucose control by means of continuous subcutaneous insulin infusion. However they do not have a built-in feedback mechanism for monitoring blood glucose levels. Therefore hypoglycemia and hyperglycemia are not detected. Option A – Option C & D– insulin is normally infused at a low basal rate (a rate that matches the client’s basal metabolic needs) with additional infusion of larger a mounts (boluses) before meals. Source: MS Nursing by Black 7 th Ed, Vol. 1, p. 1255 67. Discharge plan of diabetic clients clients include injection-site-rotation. injection-site-rotation. You should emphasize that the the space between sites should be : A. 6 cm B. 5 cm C. 2.5 2.5 cm cm Reproduction is strictly prohibited… RN International Review Center 12
D. 4 cm CORRECT ANSWER: C RATIONALE: RATIONALE: Systemic rotation of injection sites within an anatomic area is recommended to prevent localized changes in fatty tissue (lipodystrophy). It is recommended to administer injection 0.5 – 1 inch (approximately 2.5 cm) away from the previous injection. Source: MS Nursing by Brunner 9 th ed., vol. 1, p. 1001 68. It is critical also that a diabetic diabetic client should be educated in the possible sites of regular regular insulin injection. The The fastest absorption rate happens at the tissue areas of: A. glutea gluteall area area B. deltoi deltoid d area area C. anterior anterior thigh thigh D. abdomi abdominal nal area area CORRECT ANSWER: D RATIONALE: RATIONALE: The four main areas for injection are the abdomen, arms (posterior surface), thighs (anterior surface) and hips. Insulin is absorbed faster when injected in certain areas. The speed of absorption is greatest in the abdomen and decreases progressively in the arm, thigh and hips. Source: MS Nursing by Brunner 9 th ed., vol. 1, p. 1001 Sell-monitoring of blood glucose (SMBG) is recommended for patient's use. You will recommend this technology 69. Sell-monitoring in the following diabetic patients, EXCEPT : A. client client with proliferative proliferative retinopath retinopathy y B. unstable unstable diabetes diabetes C. hypoglycem hypoglycemia ia without warning warning D. Abnormal Abnormal renal glucose glucose threshold threshold CORRECT ANSWER: A RATIONALE: RATIONALE: Proliferative retinopathy will eventually lead to blindness. A blind p erson needs assistance when monitoring blood glucose level that is why SMDG is not recommended for these individuals. Blood glucose monitoring is a useful procedure for all people with diabetes. It is a cornerstone of treatment for any intensive insulin therapy regimen and for managing diabetes in a pregnant woman. It is highly recommended for patients with: i. Unstable di diabetes ii. ii. A ten tende denc ncy y for for sever severe e ket ketos osis is or hypo hypogl glyc ycem emia ia iii. iii. Hypo Hypogl glyc ycem emia ia with without out warn warnin ing g sym sympt ptom oms s iv. iv. Abno Abnorm rmal al rena renall gl glucos ucose e thr thres esho hold ld Source: MS Nursing by Brunner 9 th ed., vol. 1, p. 986 70. It is necessary for a diabetic client to to exercise regularly. What is the effect of regular exercise to a diabetic client? client? A. It burns burns excess excess glucose glucose B. It improves insulin utilization utilization and lowers lowers blood glucose glucose C. It lowers glucose, improves insulin insulin utilization, decrease total total triglyceride levels D. It will make make you fit and and energized energized CORRECT ANSWER: C RATIONALE: RATIONALE: Exercise lowers blood glucose by increasing the uptake of glucose by the bod y muscles and by improving insulin utilization. Exercise also alters blood lipids, increasing high density lipoproteins and decreasing total clolesterol and triglyceride levels. Source: MS Nursing by Brunner 9 th ed., vol. 1, p. 984 Situation 16 -
RN's should always be conscious that the contents in charting are admissible in court as e vidence.
71. If there is any deviation from normal normal practice or procedure e.g. streptomycin streptomycin was given by IV not IM, this should documented in the: A. progre progress ss notes notes B. incide incident nt report report C. nurse' nurse's s note note D. patient's patient's chart CORRECT ANSWER: B RATIONALE: RATIONALE: An incident report (also called an unusual occurrence report) is an agency record of an accident or unusual occurrence. Source: Funda by Kozier p. 63 72. Documentation of all nursing nursing activities performed is legally legally and professionally vital. Which Which of the following should NOT be included in the patient's chart? A. Presence of prosthetics, prosthetics, devices such as dentures, dentures, artificial limbs, limbs, hearing aid. etc. B. Baseline physical, physical, emotional, emotional, and psychosocial psychosocial data data Reproduction is strictly prohibited… RN International Review Center 13
C. Arguments between between nurses and residents residents regarding treatments D. Observed untoward signs and symptoms and interventions interventions including concomitant intervening intervening factors CORRECT ANSWER: C RATIONALE: RATIONALE: Information related to patient care should be included in the patient’s chart. By virtue of professionalism, arguments between health care providers should not be reflected in the chart. 73. During your morning rounds. Mr. Tipol, Tipol, 60 year old widower, tried tried to sit up and instead of holding to the side rail held the IV stand causing the IV bottle to fall and break. You wrote an incident report to show: A. document document the the inciden incidentt B. be a part of the the patient's patient's chart chart C. present present confidentia confidentiall report D. evidence evidence of the quality quality of care care CORRECT ANSWER: A RATIONALE: RATIONALE: An incident report (also called an unusual occurrence report) is an agency record of an accident or unusual occurrence. Incident reports are use to make all the facts available to agency personnel, to contribute to statistical data about the accidents or incidents, and to help health personnel prevent future incidents or accidents. The purpose of this is to document the event. Source: Funda by Kozier p. 63 74. Erasures, alterations, alterations, and additions in medical records and the nurse's notes can be avoided. The The following are some tips on how to do corrections EXCEPT: A. Cross out blank blank spaces spaces B. Cross out wrong wrong word or phrase with one one or two lines making the crossed out out word discernible discernible C. Insert Insert additions additions or corrections corrections D. State the reason for any deviation from normal procedure/practice procedure/practice CORRECT ANSWER: D RATIONALE: RATIONALE: Deviation from normal procedure/practice is a negligent act and should be recorded in the incident report. It is not about tips on doing charting corrections. All other options are correct 75. Kathy is one of your patient's: Her uncle, uncle, who is a doctor, wants to read her chart. Your appropriate appropriate action would be to: A. Instruct Kathy's uncle uncle to present a written written authorization signed signed by the patient B. Refer to to the hospital hospital director director C. Instruct Kathy’s uncle to present a written request to the Medical Records Section of the hospital D. Refer to the attending attending physici physician an CORRECT ANSWER: RATIONALE: Situation 17 -
During the month of July, you noticed that there is an incidence of upper respiratory disorders.
76. One of your cases is with acute pharyngitis. pharyngitis. Your nursing management includes the following following EXCEPT? EXCEPT? A. Suggest a soft or liquid diet during acute stage B. Encourage liberal liberal amount of color fruit juices juices C. Encourage bed rest during during febrile stage D. Apply ice collar for symptomatic relief relief of severe sore throat CORRECT ANSWER: B RATIONALE: Option A – a liquid or soft diet is provided during the acute stage of the disease, depending on the patient’s appetite and the degree if discomfort with swallowing. Option C – nurse instructs the patient to stay in bed during the febrile stage of illness Option D – Severe sore throat can be relieved using ice collars. Source: MS Nursing by Brunner 9 th ed., vol. 1, p. 407 77. For a nurse to assess assess an upper respiratory tract tract infection, you you should palpate the following: following: A. The ears. ears. eyes, nose, nose, and throat throat B. Adenoids, Adenoids, tonsil tonsils s and nose nose C. Nose and and throat throat only only D. The tracheal and and nasal mucosa including the frontal sinuses sinuses CORRECT ANSWER: D RATIONALE: RATIONALE: When assessing patient with upper respiratory tract infection, the nurse palpates the frontal and maxillary sinuses for tenderness. Also the nurse palpates the trachea to determine its midline position in the neck and to identify any masses or deformities. The neck lymph nodes are palpated to detect enlargement and tenderness. Option B – adenoids are palpated but tonsils and throat are assessed through inspection Reproduction is strictly prohibited… RN International Review Center 14
Option C – nose is assessed through inspection and palpation while throat is assesses through inspection Source: MS Nursing by Brunner 9 th ed., vol. 1, p. 409 78. Among patients with upper airway airway infection, airway clearance clearance can be facilitated by the following, following, EXCEPT: A. regularly administering administering prescribed vasoconstrictive vasoconstrictive medications B. decreasing decreasing systemic systemic hydratio hydration n C. positional positional drainage drainage D. humidifyi humidifying ng inspired inspired room air CORRECT ANSWER: B RATIONALE: Option B – decreasing systemic hydration will not facilitate airway clearance but rather increasing fluid intake helps thin mucus Option A – Vasoconstrictive medications like decongestants work by reducing swelling of the mucous membranes in the nasal passages thus relieving nasal congestion Option C – Allow drainage of nasal secretions by gravity Option D – Humidifying the environment with room vaporizers or inhaling steam also loosens secretions and reduces inflammation of the mucous membrane. 79. A friend asked you some nursing measures of uncomplicated uncomplicated common colds. You will include include the following measures. EXCEPT: A. instruct client client about symptoms of secondary infections infections B. administer administer prescribed prescribed antibioti antibiotics cs C. teach that the causative causative virus is contagious even even before symptoms appear D. suggest suggest adequate adequate of fluids fluids and rest CORRECT ANSWER: B RATIONALE: RATIONALE: This is not nursing measure. It is a dependent nursing action. All other options are nursing interventions. 80. The following are your nursing suggestions suggestions for a patient with acute or chronic sinusitis sinusitis EXCEPT: EXCEPT: A. Local heat applica application tion to promote promote drainage drainage B. Consult Consult an ENT surgeon surgeon C. Increase Increase humidity humidity D. Advice Advice adequate adequate fluid intake intake CORRECT ANSWER: B RATIONALE: RATIONALE: The nurse should teach the patient to promote sinus drainage by increasing the environment humidity (steam bath, how shower, facial sauna), increasing fluid intake, and applying a local heat (hot wet packs). The nurse also instructs the patient about ways to prevent a sinus infection and how to recognize early signs and symptoms. Source: MS Nursing by Brunner 9 th ed., vol. 1, p. 405 Situation 18 -A
specimen is a piece of tissue or body fluid taken from the disease body organ or tissue to aid the health care team in diagnosis and effective treatment. Necessarily, the nurse assumes responsibility in the care of the specimen. 81. Carmen is suspected to have left breast CA. CA. She is scheduled in your room for frozen section. section. How will you prepare the specimen for laboratory? A. Refrigerate and send it along along with the the day's specimens B. Send to pathology immediately immediately without without soaking solution C. Soak Soak it in in NSS NSS D. Soak itit in formal formalin in CORRECT ANSWER: B RATIONALE: RATIONALE: The frozen section procedure is a pathological laboratory procedure to perform rapid microscopic analysis of a specimen. It is used most often in oncological surgery. surgery. The technical name for this procedure is cryosection. The report given by the pathologist is usually limited to a "benign" or "malignant" diagnosis, traditionally shouted into an intercom Special Instructions: Notify Pathology 48 hours in advance. Request must state operative diagnosis and source of specimen. Specimen: Fresh tissue Container: Sterile towel, sterile Petri dish, or sterile jar (no a dded fixative or fluid) Collection: Container must be labeled with patient's full name, date, operating room, and surgeon requesting the frozen section. Causes for Rejection: Reproduction is strictly prohibited… RN International Review Center 15
Specimen submitted in fixative, water, or saline; improper labeling; incomplete or improperly filled out request form Sources: http://en.wikipedia.org/wiki/Frozen_section http://www.labcorp.com/datasets/l http://www.labcorp.com/datasets/labcorp/html/chapter/m abcorp/html/chapter/mono/ap002500.htm ono/ap002500.htm 82. How will you you label this specimen? specimen? What information information is essential in the the label? A. Name of client, client, age, sex. sex. hospital hospital number B. Name of of client, client, age, sex sex C. Name, age, site, type of specimen, hospital hospital number, doctor D. Name, doctor, type of specimen, specimen, hospital number CORRECT ANSWER: C RATIONALE: Option C is the most complete information about specimen collection 83. Foreign body extracted extracted from the body like like pins, needles, seeds or bullets or bullets are also considered as specimen. You assisted in the multiple gun-shot wound exploration. During the surgery 3 bullets were recovered. You should send the specimen to: A. the departm department ent of pathol pathology ogy B. the National National Bureau Bureau of Investigatio Investigation n C. the OR OR head head nurse nurse D. client's client's family family CORRECT ANSWER: B RATIONALE: 84. A post dilation and curettage (D and C) client client is for discharge. Follow-up Follow-up of lab result should be part of the discharge plan. You will instruct the client to follow up result at the: A. Medica Medicall record record B. Labora Laborator tory y C. Doctor's Doctor's clinic clinic D. Nurse's Nurse's station station CORRECT ANSWER: B RATIONALE: 85. You are the circulating nurse in OR 2. You You have 4 thyroidectomy cases for the day. How do you prevent switching switching of specimens? A. Send specimens to laboratory laboratory right away after after the operation with with the proper labels labels B. Collect all specimens specimens and send to laboratory laboratory at the end of the the day C. Label specim specimen en at once once D. Prepare 4 specimen specimen vials first first thing in in the morning morning CORRECT ANSWER: A RATIONALE: RATIONALE: Specimens must be handled quickly so that they are placed into the collection transport media as soon as possible after extraction. since this is the right thing to do, option option B will then be wrong. Option C – Labelling of specimen is right but it should be sent right away to the laboratory after the surgical procedure Option D – Specimen vials are prepared during the surgical procedure. The sterile field should be prepared as close as possible to the time of use. The sterility of supplies used during a surgical procedure can be affected by the events taking place within the operating room, and the length of time the items have been exposed to the environment. Source: http://www.precisiontherapeutics http://www.precisiontherapeutics.com/healthcare/idealS .com/healthcare/idealSpecimenCollection.ht pecimenCollection.htm m Situation 19
– Nurse Paul is providing care for clients with rheumatoid arthritis admitted in the unit.
86. A health history and physical assessment assessment on a client with rheumatoid arthritis arthritis (RA) may reveal which of the the following assessment data? A. Heberd Heberden' en's s nodes B. Morning Morning stiffness stiffness no longer than than 30 minutes C. Asymmetri Asymmetric c joint swelling swelling D. Swan neck neck deformi deformities ties CORRECT ANSWER: D RATIONALE: RATIONALE: Swan neck deformities of the hand are classic deformities associated with rheumatoid arthritis secondary to the presence of fibrous connective tissue within the joint space. Clients with RA do experience morning stiffness, but it can last from 30 minutes up to several hours. RA is characterized by symmetrical joint involvement, and Heberden's nodes are characteristic of osteoarthritis.
Reproduction is strictly prohibited… RN International Review Center 16
87. Which of the following is a priority priority when providing health teaching to a client client with rheumatoid arthritis arthritis (RA)? Instruct the client: A. On weight weight reduction reduction.. B. To decrease activity to avoid joint pain. pain. C. To pace activities activities to decrease decrease joint stress. stress. D. To contact the the Arthritis Arthritis Foundation for for support services. services. CORRECT ANSWER: C RATIONALE: RATIONALE: Although options 1, 2, and 4 are a re all important interventions in the health teaching of clients with rheumatoid arthritis, instructing the client on energy conservation techniques and pacing activities early in the teaching plan will help to provide immediate symptom control. Decreasing activity (option 2) may further limit range-of-motion. Notice the stem asks for the priority the priority intervention. intervention. Situation 20 -
During the surgical procedure, contamination should be confined and contained within the immediate vicinity of the surgical field to prevent the spread of pathogenic microorganisms. 88. The following technique technique illustrates the concept "confine and contain", contain", EXCEPT: EXCEPT: A. contaminated items items like sponges are handled using gloves B. all blood, tissue, and body fluid specimens specimens should be placed in leak-proof leak-proof C. surgeons conduct their their patient's rounds rounds in scrub suit D. prompt cleanup of accidental accidental spills of contaminated contaminated debris e.g. Blood, body fluids CORRECT ANSWER: C RATIONALE: RATIONALE: OR attire should be worn within the OR room. If a doctor goes on rounds, he/she should change his/her attire to reduce spread of microorganisms. All other options are correct. 89. The OR is a 'restricted area' where OR OR attire is worn. Temperature Temperature and humidity are set for patient and personnel safety and reduce bacterial contamination. contamination. During surgery, movement of personnel personnel including the circulating nurse is : A. kept kept to a minim minimum um B. eliminate eliminated d when possibl possible e C. restri restricte cted d D. monit monitore ored d CORRECT ANSWER: A RATIONALE: RATIONALE: Movement within and around a sterile area is kept to a minimum to avoid contamination of sterile items or persons. Source: OR Technique Instructional Manual by Barela et al, p. 8 90. Sterility is the condition condition of almost all items, devices devices or supplies used in the OR are ready for any surgical procedure. Shelf-life of packaged sterile item is event related and depends on the following. EXCEPT: A. type of sterilizer used to "sterilize” items B. amount of handli handling ng C. the quality of packaging material used used D. storage storage conditions conditions CORRECT ANSWER: A RATIONALE: RATIONALE: Shelf life refers to the period of time a sterilized or disinfected item is safe to use. How long an item remains suitable for use is more event-related than time-related. Actual sterility of a packaged item may be indefinite depending on the package materials (Option C), the item itself and the handling (Option B) and storage (Option D). Source: http://www.unimaxsupply.com/sit http://www.unimaxsupply.com/sitepgs/1shelflife.htm epgs/1shelflife.htm 91. Precaution recommends recommends that the use of standard standard personal protective protective equipment (PPE) to prevent cross contamination. Which is NOT considered a piece of PPE? A. Cove Coverr gown gown B. Eyew Eyewear ear C. Glov Gloves es D. Steri Sterile le gauze gauze CORRECT ANSWER: D RATIONALE: RATIONALE: Personal Protective equipment: All health care providers must apply clean or sterile gloves, gowns masks and protective eyewear according to risk of exposure to potentially infective materials. Sterile Sterile gauze is not part of PPE Source: Funda by Kozier p. 650 92. Traffic Traffic patterns patterns in the OR suite suite should: A. prevent unauthorized unauthorized personnel from entering entering the OR B. prevent transmission of pathogenic pathogenic microorganisms microorganisms C. assure that personnel personnel walk in in the same direction direction D. allow personnel to move move freely between restricted restricted and unrestricted unrestricted areas Reproduction is strictly prohibited… RN International Review Center 17
CORRECT ANSWER: B RATIONALE: Traffic Patterns Movement in and around the surgical suite should be limited to that which is absolutely necessary only. Air turbulence is created with movement that in turn increases the likelihood of bacterial fallout from the skin and lint from draping materials to contaminate the sterile field a nd wound. When it is necessary to move around a functioning operating room, you should face the sterile field at all times. This may require some unusual pathways. However, one should never take a pathway between two sterile fields. Sterile fields consist of any two objects that have draped with sterile materials and have sterile supplies and or instruments/ equipment on them. Some possibilities are personnel, patients, furniture, equipment, or instrument tables. It is the responsibility of the entire surgical team to monitor and protect the sterile field and the integrity of the room. Entry into and exit from a surgical room should be done only when absolutely necessary. Source: http://www.geocities.com/alame http://www.geocities.com/alamedacounty/repspolicy.htm dacounty/repspolicy.htmll Option D - Movement in and around the surgical suite should be limited limited to that which is absolutely necessary only. Option A & C – are correct options but generally these are pe rformed to reduce if not prevent transmission of microorganisms. (Umbrella effect) - Nokia is so powerful to "connect people" from continent to continent, all through communication via the cellphone. Other ways of communication to relay information or instructions exist even in the healthcare setting.
Situation 21
93. An anesthesiologist is preparing to do a spinal anesthesia to a 220 lb. 30 year old athlete. athlete. She requests the the circulating nurse to prepare a pink spinal set with another blue set as stand by. What gauge spinal sets will you make available in the OR suite? A. Gauge Gauge 16 16 and and 22 B. Gauge Gauge 18 18 and and 23 C. Gauge Gauge 16 and 20 20 D. Gauge Gauge 25 and 22 22 CORRECT ANSWER: B RATIONALE: Option A – White & Black Option B – Pink & Blue Option C – White & Yellow Option D – Orange & Black Spinal Needle Hub Color Codes: 16G - White 17G - Violet 18G - Pink 19G - Cream 20G - Yellow 21G - Green 22G – Black 23G - Blue 24G - Purple 25G - Orange 26G - Brown 27G - Gray 29G - Red Source: http://www.mycomedical.com/s http://www.mycomedical.com/spinepid.html pinepid.html 94. Medical gases are used a lot in the OR. Some gases are used to operate operate equipment and some some are used to administer general anesthesia through inhalation. What is the identifying color of the tank which contains 'laughing gas'? A. Yell Yellow ow B. Gree Green n C. Blac Black k D. Blue Blue CORRECT ANSWER: D RATIONALE: RATIONALE: Laughing gas medically known to be as nitrous oxide is a blue colored tank. Option B – Green tank – oxygen tank 95. On a traffic light, yellow yellow means "proceed with caution". In the field field of healthcare, where do you discard your used tissue papers? A. Yellow bin infectious B. Orange bin radioactive waste C. Green bin biodegradable D. Black bin chemical waste Reproduction is strictly prohibited… RN International Review Center 18
CORRECT ANSWER: A RATIONALE: RATIONALE: Used tissue papers may contain secretions thus classified as infectious Trash bin color codes: Black non-biodegradable Green biodegradable Yellow infectious Orange radioactive waste Red sharps Yellow with black band chemical waste 96. An instrument tray with with black striped autoclave/steam chemical chemical indicator tape communicates communicates that the instrument tray: A. Is clea clean n B. is ready ready for use use in surgery surgery C. Is ster steril ile e D. Has undergone the sterilization sterilization process CORRECT ANSWER: D RATIONALE: Option A – autoclaving completely destroys microorganisms therefore not considered clean. Option B – not all the time true (ex. Presence of black strips on the tape but was autoclaved months ago will reduce the sterility of the item therefore not ready fro use in surgery) Option C – not true all the time (ex. Presence of black strips on the tape but presence of a puncture on the package is noted therefore it can’t be considered sterile anymore) Option D - Regardless if it has a puncture or stored for a long months already, you are certain that it has undergone sterilization process as evidenced by black strips in the autoclave indicator tape. It is safe to say that it has undergone sterilization process than by saying it is sterile or is ready for surgery. 97. In health care, when when lead apron is required required in any procedure like like orthosurgery, there is danger of exposure to: A. Water and blood blood splashe splashes s B. pseudo pseudomon mona a C. radiat radiation ion D. bone bone fragment fragments s CORRECT ANSWER: C RATIONALE: wearing of lead shield reduces transmission of radiation Source: Saunders NCLEX-RN 3rd ed, p. 583 Situation 22 -
Nurse Ervin is a newly registered nurse who works as a volunteer in the burn unit.
98. A client is admitted to the burn unit with with 50 percent burns to the chest and arms. The skin is is white, dry, and there is no pain. Nurse Ervin assesses the type of burn the client has as which of the following? A. Superfici Superficial al thickn thickness ess B. Superfici Superficial al partial partial thickness thickness C. Deep partial partial thick thickness ness D. Full thickness thickness CORRECT ANSWER: D RATIONALE: RATIONALE: There is no sensation of pain to light touch in full thickness burns because the pain and touch receptors have been destroyed. There may not be pain with some partial thickness degree burns, but the appearance described is characteristic of full thickness. 99. A young boy is brought to the unit with a chemical burn burn to the face. Priority assessment would would include which of the following? A. Skin Skin integri integrity ty B. Blood pressure pressure and and pulse pulse C. Patency Patency of airway airway D. Amount Amount of pain pain CORRECT ANSWER: C RATIONALE: RATIONALE: A burn involving the face, neck, or chest may cause airway closure because of the edema that occurs within hours. Remember the ABCs: airway, breathing, and circulation. Airway always comes first, even before pain. The nurse will also assess skin integrity (option 1), blood pressure and pulse (option 2), and pain (option 4), but these are not the highest priority assessments. 100. A client who presents with a burn to the anterior anterior chest and both arms anterior anterior and posterior posterior is said said to have burned what percentage of the body using the Rule of Nines? A. 27 percent Reproduction is strictly prohibited… RN International Review Center 19
B. 45 percent C. 37 pe percent D. 36 pe percent CORRECT ANSWER: D RATIONALE: RATIONALE: Remember that according to the Rule of Nines, the anterior chest is 18 percent and both arms are 9 percent each, totaling 36 percent.
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