NURSING PRACTICE 3 Situation 1 - Concerted work efforts among members of the surgical team is essential to the success of the surgical procedure. The sterile nurse or sterile personnel touch only sterile supplies and instruments. When there is a need for sterile supply which is not in the sterile field, who hands out these items by opening its outer cover? Circulating nurse Anesthesiologist Surgeon Nursing aide CORRECT ANSWER: A RATIONALE: The circulating nurse is responsible for the overall running of the OR before, during and after the operative procedure. Also he/she is responsible for the opening of the outer wrapper of sterile supplies that will be used during the operative procedure. OPTION B: The anesthesiologist is the person that administers the anesthetic to the patient. OPTION C: The surgeon is responsible in performing the surgical procedure safely and correctly. OPTION D: The nursing aide is not a part of the surgical team. SOURCE: Barela et. al. Operating Room Technique Instructional Manual 1st Ed. pp. 42-44 The OR team performs distinct roles for one surgical procedure to be accomplished within a prescribed time frame and deliver a standard patient outcome. Who monitors the status of the client like urine output, blood loss while the surgeon performs the surgical procedure? Scrub nurse Surgeon Anesthesiologist Circulating nurse CORRECT ANSWER: C RATIONALE:The anesthesiologist or nurse anesthetist maintains the airway, ensures adequate gas exchange, monitors circulation and respiration, estimates blood and fluid loss, infuses blood and fluids, administers medications to maintain hemodynamic stability, and alerts the surgeon immediately to any complication. OPTION A: Scrub nurse organize the surgical equipment and hand the surgeon the appropriate instruments required for the operative procedure. OPTION B: The surgeon heads the surgical team and makes decision about the surgical procedure. OPTION D: the circulating nurse maintains the coordination of all team members. SOURCE: Black and Hawks. Medical-Surgical Nursing. Volmue 1. 7th ed. p. 284 The following are members of the sterile team EXCEPT for one. Surgeon Surgical Assistant Anesthetist Scrub nurse CORRECT ANSWER: C RATIONALE:Anesthetist is the answer. Sterile team are perioperative caregivers who provide direct care within the sterile field. Nonsterile team are perioperative
caregivers who provide direct care from the pheripery of the sterile field and environment. An Anesthetist is a member of the nonsterile team who administers anesthetics during the surgical procedure OPTIONS A, B & D: Sterile members of the surgical team SOURCE: Phillips. p. 50 Before blood transfusion, the nurse started an IV infusion as ordered. Which of the following is commonly ordered before BT? a. Sterile water solution b. D5LR c. Dextrose 5% in water d. Normal saline solution CORRECT ANSWER: D RATIONALE:Normal saline solution is the only solution compatible for blood transfusion OPTION A: is not for blood transfusion OPTION B: Solutions containing calcium, such as Ringer’s lactate may cause clotting. OPTION C: Dextrose may lead to clumping of red blood cells and hemolysis. SOURCES: Timby. Clinical Nursing Procedures. p. 138; Luckmann and Sorensen. Medical Surgical Nursing. 3rd Ed. p. 1029 Situation 2 - You are assigned in the Orthopedic Ward where clients are complaining of pain in varying degrees upon movement of body parts. Troy is a one day post open reduction and internal fixation (ORIF) of the left hip and is in pain. Which of the following observation would prompt you to call the doctor? Dressing is intact but partially soiled Left foot is cold to touch and pedal pulse is absent Left leg in limited functional anatomic position BP 114/78, pulse of 82 beats/minute CORRECT ANSWER: B RATIONALE: These assessment is a sign of decrease blood flow to the area that may require immediate intervention before complications (e.g. necrosis) may happen. OPTION A: Not alarming to report to physician. Reinforcing of dressing can be done. OPTION C: it is normal because the patient has just undergone a surgery OPTION D: Within normal range There is an order of Demerol 50 mg I.M. now and every 6 hours prn, You injected Demerol at 5 pm. The next dose of Demerol 50 mg I.M. is given: When the client asks for the next dose When the patient is in severe pain At 11 pm At 12 pm CORRECT ANSWER: C RATIONALE: Demerol is given at 5pm. If pain is still present, the next dose of this will be 6 hours after at 11 pm. A patient is in pain following surgery. Which of the following instructions should the nurse give to the patient regarding pain management?
“Try to bear the pain as long as you can.” “Pain should be reported in the early stages.” “Higher levels of pain are easier to reduce than lower levels.” “Our goal is to keep you pain free.” CORRECT ANSWER: B RATIONALE: Medicating before pain begins will require less medication. Therefore, the nurse should advise the postoperative patient that pain should be reported in the early stages to best manage the pain. OPTION A: Trying to bear as long as possible will only require more medication and/or greater frequency to get the pain under control. OPTION C: Higher levels of pain are not easier to reduce than lower levels. OPTION D: It is not always realistic to expect to keep the patient totally pain free at all times. But through frequent assessment, reassessment and proper intervention, the nurse should be able to manage the patient’s pain throughout the healing process until pain relief is no longer needed. SOURCE: CGFNS Qualifying Exam. 5th ed. p. 134 When assessing a patient for pain, the nurse observes facial grimacing with movement, and blood pressure and pulse elevation. Which of the following measures should the nurse take next? Realize that patient has the right to refuse medication. Explain the reasons for taking pain medication. Tell the patient to notify the nurse when the pain becomes severe. Leave the medication at the bedside in case the patient desires it later. CORRECT ANSWER: B RATIONALE: Regardless of its source, pain that is inadequately treated as harmful has harmful effects beyond the discomforts it causes. Unrelieved pain affects various body systems, including the cardiovascular system, and can initiate the stress response, resulting in increased pulse and BP and a distressed appearance. By providing an explanation such as this, the nurse can help the patient to accept the drugs needed to relieve pain. OPTION A: Patients have the right to refuse therapy. The nurse can play an important role in determining the reason for refusal and should first make that attempt before accepting refusal. OPTION C: A general principle for administering analgesics is to administer them before pain increases in severity. OPTION D: Medications should never be left at the bedside for the patient to take later. SOURCE: CGFNS Qualifying Exam 5th ed. p. 141 In some hip surgeries, an epidural catheter for fentanyl epidural analgesia is given. What is your nursing priority care in such a case? Instruct client to observe strict bed rest Check for epidural catheter drainage Administer analgesia through epidural catheter as prescribed Assess respiratory rate carefully CORRECT ANSWER: D RATIONALE: fentanyl (sublimaze) is a narcotic agonist analgesic (Other name: Neuroleptanalgesic) It is 75-100 times more potent than morphine! In very high doses it can cause respiratory depression. Assess respiratory rate to monitor impending signs of respiratory depression. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1, 10th ed. p. 426 Situation 3 – Rita just retired from government service and was admitted for
pneumonectomy. As the nurse on duty, you should check for the medical clearance of your client for surgery among other pre-op requirements. This clearance primarily covers: Stress-coping mechanism of the client Socio-economic status of the client Smoking and eating habits of the client Cardio-pulmonary system CORRECT ANSWER: D RATIONALE: The goal in preparing any patient for surgery is to ensure a wellfunctioning cardiovascular system to meet the oxygen, fluid and nutritional needs of the perioperative period. Also a goal for potential surgical patients is optimal respiratory function. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1, 10th ed. p. 403 Preoperative tests were done. Particularly, the nurse should assess the lung capacity by checking the: Serum creatinine level Chest x-ray Serum protein levels Arterial blood gas CORRECT ANSWER: D RATIONALE: Arterial blood gases provide information about alveolar ventilation, oxygenation, and acid-base balance. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 281 OPTION A: this blood test is essential in the evaluation of renal function OPTION B: chest x-ray identify various abnormalities of the lungs and structures in the thorax, including the heart, great vessels, ribs or diaphragm. OPTION C: this blood test helps diagnose hepatic, gastrointestinal, and renal disease; protein abnormalities; cancer and blood dyscrasias. SOURCE: Gaedeke. Laboratory and Diagnostic Test Handbook The main objective in postoperative pneumonectomy is to: Maintain a patent airway Provide maximum remaining lung capacity Provide early rehabilitation measures Recognize early symptoms of complications CORRECT ANSWER: A RATIONALE: Using ABC, airway patency is the priority during postoperative pneumonectomy OPTIONS B, C & D: correct intervention but airway patency is still the priority There is an order of central venous pressure (CVP) reading. As a nurse, you should know that this is a measure observing signs of: Hypoxia Hypovolemia Hypothermia Hypoxemia CORRECT ANSWER: B RATIONALE: The CVP is an indirect method of determining right ventricular filing pressure (preload). This makes the CVP a useful hemodynamic parameter to observe when managing an unstable patient’s fluid volume status.
SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 678 Pulmonary edema is a potential danger that we nurses should monitor in post pneumonectomy. This is usually due to: Cardiac output goes to the remaining lung Liberal fluid intake Rapid infusion of IV fluids Fluid retention due to prolonged bed rest CORRECT ANSWER: A RATIONALE: Pulmonary edema most commonly occurs as a result of increased microvascular pressure from abnormal cardiac function. The backup of blood into the pulmonary vasculature resulting from inadequate left ventricular function causes a increased microvascular pressure, and fluid begin to leak into the interstitial space and alveoli. Other causes of pulmonary edema are hypervolemia or a sudden increase in the intravascular pressure in the lung. One example of this is in the patient who has undergone a pneumonectomy. When one lung has been removed, all the cardiac output then goes to the remaining lung. If the patient’s fluid status is not monitored closely, pulmonary edema can quickly develop in the post operative period as the patient’s pulmonary vasculature attempt to adapt. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 542 Situation 4 - In the OR, there are safety protocols that should be followed. The OR nurse should be well versed with all these to safeguard the safety and quality to patient delivery outcome. Which of the following should be given highest priority when receiving patient in the OR? a. Assess le level of of co consciousness b. Veri Verify fy pati patien ent t ide ident ntif ific icat atio ion n and and info inform rmed ed cons consen ent t c. Assess vital signs d. Chec Check k for for jewe jewelr lry, y, gown gown, , man manic icur ure e and and den dentu ture res s CORRECT ANSWER: B RATIONALE: Patient safety in the preoperative area is a priority. Using process to verify patient identification, the surgical procedure, and the surgical site maximizes patient safety and allows for early identification and intervention if any discrepancies are identified. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 414 In the OR, you will position a patient for TURP in: Supine Lithotomy Semi-fowler Trendelenburg CORRECT ANSWER: B RATIONALE: Surgery is performed in lithotomy position - Keep in mind: Functional residual capacity decreases, predisposing patients to atelectasis and hypoxia. Rapid lowering of the legs at the end of the operation acutely decreases venous return and can result in severe hypotension, especially when combined with blood loss during surgery. SOURCE: http://www.rph.wa.gov.au/anaesth/downloads/TURP_Titze.pdf OR nurses should be aware that maintaining the client's safety is the overall goal of nursing care during the intraoperative phase. As the circulating nurse, you make certain that throughout
the procedure: a. the the surg surgeo eon n gree greets ts his his cli clien ent t befo before re ind induc ucti tion on of of anes anesth thes esia ia b. the the sur surge geon on and and ane anest sthe hesi siol olog ogis ist t are are in tand tandem em c. strap strap made made of stron strong g non-a non-abra brasiv sive e mate materia rial l are are faste fastene ned d secur securely ely around around the joints of the knees and ankles and around the 2 hands around an arm board d. clien client t is mon monito itored red throug throughou hout t the the surge surgery ry by by the the assis assistan tant t anest anesthe hesio siolog logist ist CORRECT ANSWER: C RATIONALE: Preventing physical injury includes using safety straps and bed rails and not leaving the sedated patient unattended. OPTIONS A & B: does not answer safety question OPTION D: inappropriate SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 435 You refer postoperative patients under general anesthesia to the doctor when he has: Cold clammy skin and filiform pulse Snoring respiration and rapid pulse Accidental removal of the airway A drop in blood pressure and rapid pulse CORRECT ANSWER: D RATIONALE: It is the responsibility of the surgeon and the anesthetist or anesthesiologist to monitor and manage complications. However, a nurse plays an important role. Being alert to and reporting changes in vital signs and symptoms of nausea and vomiting, anaphylaxis, hypoxia, hypothermia, malignant hyperthermia and disseminated intravascular coagulation and assisting with their management is an important factor (Smeltzer, 434). The anesthesia provider functions as the guardian of the patient throughout the entire care period, the anesthesia provider manage the patient’s physiology using the principle of aseptic technique (Phillips, 51). Maintaining the patency of airway is the responsibility of the anesthesia provider, an accidental removal of airway is negligent. SOURCES: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 434 Phillips. p. 51 Some different habits and hobbies affect postoperative respiratory function. If your client smokes 3 packs of cigarettes a day for the part 10 years, you will anticipate increased risk for: a. perio rioper perati ative anx anxiet iety and str stress ess b. delayed coagulation time c. delayed wound healing d. posto stoper perati ative re respir pirato atory fu functi ction CORRECT ANSWER: D RATIONALE: Patients who smoke are encouraged to stop 2 months before surgery. These patients should be counseled to stop smoking at least 24 hours prior to surgery. Research suggest that counseling has a positive effect on the patient’s smoking behavior 24 hors preceding surgery, helping reduce the potential for adverse effect associated with smoking such as increased airway reactivity, decreased mucocilliary clearance, as well as physiologic changes in the cardiovascular and immune systems. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 403 Situation 5 - Nurses hold a variety of roles when providing care to a perioperative patient. Which of the following role would be the responsibility of the scrub nurse? a. Asse Assess ss the the rea readi dine ness ss of the the cli clien ent t pri prior or to surg surger ery y
b. Ensur sure that hat the air airway is adequ equate c. Accou Account nt for the number number of spong sponges, es, needl needles, es, suppl supplies ies, , Used Used during during the surgical procedure d. Evalu Evaluate ate the the type type of anest anesthes hesia ia appro appropri priate ate for the surgi surgical cal client client CORRECT ANSWER: C RATIONALE: The duties of the scrub nurse include gathering all equipment for the procedure, preparing all supplies and instruments using sterile technique, maintaining sterility within the sterile field during surgery, handling instruments and supplies during surgery, and cleaning up after the case. During surgery, the scrub nurse maintains an accurate counting of sponges, sharps and instruments on the sterile field and counts the same materials with the circulating nurse before and after the surgery. OPTIONS B & D – These are the roles of the anesthesiologist SOURCE: Black and Hawks. Medical-Surgical Nursing. 7th ed. pp. 284-285 As a perioperative nurse, how can you best meet the safety need of the client after administering preoperative narcotic? a. Put Put sid side e rai rails ls up and and not not leav leavin ing g the the seda sedate ted d pat patie ient nt b. Send the cli clie ent to to OR OR wit with th the fa family ily c. Allo Allow w cli clien ent t to to get get up to go to the the com comfo fort rt room room d. Obtain consent form CORRECT ANSWER: A RATIONALE: Preventing physical injury includes using safety straps and bed rails and not leaving the sedated patient unattended. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 434 It is the responsibility of the pre-op nurse to do skin prep for patients undergoing surgery. If hair at the operative site is not shaved, what should be done to lessen chance of incision infection? a. Draped b. Pulled c. Clipped d. Shampooed CORRECT ANSWER: D RATIONALE: Immediate preoperative nursing care: Preparing the skin: Explain shower and bathing protocols for the night before the planned surgical procedure. Usually the operative area is cleaned the night before surgery with soap and water or an antimicrobial solution to reduce the number of microbes on the skin. OPTION A: inappropriate OPTION B: inappropriate OPTION C: Electric clippers are used for safe hair removal immediately before the operation if hair must be removed. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 413; Black and Hawks. Medical-Surgical Nursing. 7th ed. p. 277 A nurse is assessing the operative site in a client who underwent a breast reconstruction. The nurse is inspecting the flap and the areola of the nipple and notes that the areola is a deep red color around the edge. The nurse takes which action first? Document the findings Elevate the breast
Encourage nipple massage Notify the physician CORRECT ANSWER: D RATIONALE: Following breast reconstruction, the flap is inspected for color, temperature, and capillary refill. Assessment of the nipple areola is made, and dressings are designed so this area can be observed. An areola that is deep red, purple, dusky, or black around the edge is reported to the physician immediately because this may indicate a decreased blood supply to the area. The nurse would also document the findings once the physician is notified. OPTIONS B & C: are incorrect actions. When performing a surgical dressing change of a client’s abdominal dressing, a nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse would do which of the following in the initial care of this wound? a. Leav Leave e the the inci incisi sion on open open to the the air air to dry dry the the area area b. Apply Apply a steri sterile le dressi dressing ng soaked soaked in povid povidone one-io -iodin dine e (Betad (Betadine ine) ) c. Irri Irriga gate te the the wou wound nd and and app apply ly ster steril ile e dre dress ssin ing g d. Appl Apply y a ster steril ile e dre dress ssin ing g soa soake ked d wit with h nor norma mal l sal salin ine. e. CORRECT ANSWER: D RATIONALE: Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the appearance of underlying tissues. Dehiscence usually occurs 6-8 days after surgery. The client should be instructed to remain quiet and to avoid coughing and straining. The client should be positioned to prevent further stress on the wound. The nurse must notify the physician after applying a sterile dressing soaked with normal saline. OPTION A: will dry and will be prone to infection if exposed to air OPTION B: Betadine will irritate the tissues SOURCE: Silvestri. Saunders NCLEX-RN Examination. 3rd ed. Situation 6 - Carlo, 16 years old, comes to the ER with acute asthmatic attack. RR is 46/min and he appears to be in acute respiratory distress, Which a. b. c. d.
of the following nursing actions should be initiated first? Promote em emotional su support Administer oxygen at 6L/min Suction the cl client every 30 min Admi Admini nist ster er bron bronch chod odil ilat ator or by nebu nebuli lize zer r
CORRECT ANSWER: D RATIONALE: Asthma exacerbations are best managed by early treatment and education of the patient. Quick-acting beta-adrenergic medications are first used to prompt relief of airflow obstruction. OPTION A: This is not a priority OPTION B: Should only be at 2L/min OPTION C: Suctioning the client increases respiratory distress SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. Volume I. p. 592 Aminophylline was ordered for acute asthmatic attack. The mother asked the nurse, “what is its indication?” the nurse will say: a. Rela Relax x smo smoot oth h mus muscl cles es of the the bro bronc nchi hial al airw airway ay b. Promote ex expectoration c. Preve event thi thicke ckenin ning of sec secreti etions ons d. Suppress cough
CORRECT ANSWER: A RATIONALE: Classification: Bronchodilator Mechanism of action: relaxes smooth muscle of bronchial airways and pulmonary blood vessels. OPTION B: Expectorants OPTION C: Mucolytic – reduces the viscosity of pulmonary secretions. OPTION D: Antitussive – suppresses the cough reflex by direct action on the cough center in the medulla. SOURCE: Nursing 2006 Drug handbook 26th ed. You will give health instructions to Carlo, a case of bronchial asthma. The health instruction will include the following EXCEPT: a. Avoi Avoid d emot emotio iona nal l stre stress ss and and extr extrem eme e temp temper erat atur ure e b. Avoid pollution like smoking c. Avoid pollens, dust seafood d. Pract actice ice respi spirat ratory ory isola olatio tion CORRECT ANSWER: D RATIONALE: Asthma is not an infectious disease. Practicing respiratory isolation is a wrong teaching instruction. The asthmatic client asked you what breathing technique he can best practice when asthmatic attack starts. What will be the best position? a. Sit Sit in high high-F -Fow owle ler' r's s posi positi tion on with with exte extend nded ed legs legs b. Sit-up wi with sh shoulders ba back c. Push on abdom domen duri uring exhal halati ation d. Lean Lean forw forwar ard d 30-4 30-40 0 degr degree ees s with with each each exha exhala lati tion on CORRECT ANSWER: D RATIONALE: Orthopneic position provides maximum lung expansion As a nurse you are always alerted to monitor status asthmaticus who will likely and initially manifest symptoms of: a. metabolic alkalosis b. respiratory acidosis c. respiratory al alkalosis d. metabolic acidosis CORRECT ANSWER: C RATIONALE: Status asthmaticus is severe persistent asthma that does not respond to conventional therapy. The attacks last longer than 24 hours. The basic characteristic of asthma decreases the diameter of the bronchi and is apparent in status asthmaticus. A ventilation-perfusion abnormality results in hypoxemia and respiratory alkalosis initially, followed by respiratory acidosis. There is a reduced PaO2 and an initial respiratory alkalosis, with a decreased PaCO2 and an increased pH. As status asthmaticus worsens, the PaCO2 increases and pH falls, reflecting respiratory acidosis. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. p. 595 Situation 7 – P. Cruz, 65 years old, was admitted in the hospital because of signs and symptoms of acute MI. You are expected to recognize ECG readings on the cardiac monitor. Which of the following will appear abnormal in the ECG when ischemia and injury occur in the myocardium?
a. b. c. d.
QRS interval ST segment and T wave P wave PR interval
CORRECT ANSWER: B RATIONALE: The first ECG signs of acute MI are from myocardial ischemia and injury. Myocardial injury causes a T wave to become enlarged and symmetric. As the area of injury becomes ischemic, myocardial repolarization is altered and delayed, causing the T wave to invert. The ischemic region may remain depolarized while adjacent areas of the myocardium return to resting state. Myocardial injury also causes ST-segment changes. The injured myocardial cells depolarize normally but repolarize more rapidly than normal cells, causing the ST segment to rise at least 1 mm above the isoelectric line (area between the T wave and the next P wave is used as a reference for isoelectric line) when measured 0.08 seconds after the end of the QRS. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. p. 726 From an ECG reading, a QRS complex represents; Ventricular depolarization Ventricular repolarization End of ventricular depolarization Atrial depolarization CORRECT ANSWER: A RATIONALE: QRS complex represents ventricular muscle depolarization OPTION B: T wave represents ventricular muscle repolarization OPTION D:P wave represents atrial muscle depolarization SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. p. 686 33. Which of the following represents ventricular repolarization? T wave ST segment QRS complex PR interval CORRECT ANSWER: A RATIONALE: T wave represents ventricular muscle repolarization OPTION B: ST segment represents early ventricular repolarization OPTION C: QRS complex represents ventricular muscle depolarization OPTION D: PR interval represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. p. 686 It is important that the nurse measures interval of QRS complex. Which if the following represent the normal interval of QRS complex? a. Greater than .20 sec b. .20 sec c. .10 sec d. .12 sec to .20 sec CORRECT ANSWER: C RATIONALE:The QRS is normally less than 0.12 seconds in duration SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. p. 686 35. Later in the acute phase of MI, which of the following typically appears as
the first sign of tissue death? a. ST se segment su suppression Short T wave Prolonged PR interval Pathologic Q wave CORRECT ANSWER: A RATIONALE:Typically, an evolving acute myocardial infarction will show ST segment elevation on an ECG, which indicate acute, evolving myocardial necrosis. OPTION D – the emergence of Q wave may be an indication of worsening ischemia and necrosis. SOURCE: Schumacher & Chernecky. Critical Care and Emergency Nursing. p. 132 Situation 8 - Mrs. Cruz was admitted in the Medical Floor due to pyrosis, dyspepsia and difficulty of swallowing. 36. Based from the symptoms presented, Nurse Yoshi might suspect: a. Esophagitis b. Hiatal hernia c. GERD d. Gastric Ulcer CORRECT ANSWER: C RATIONALE: GERD is the backflow of gastric or duodenal contents into the esophagus caused by incompetent lower esophageal sphincter. Pyrosis or heartburn, dyspepsia and dysphagia are cardinal symptoms. 37. What diagnostic test would confirm the type of problem Mrs. Cruz have? a. Barium enema b. Barium swallow c. Colonoscopy d. Lower GI series CORRECT ANSWER: B RATIONALE: Barium swallow or upper GI series would confirm GERD. Endoscopy is another diagnostic test. OPTIONS A and D: are the same OPTION C: is incorrect 38. Mrs. Cruz complained of pain and difficulty in swallowing. This term is referred as: Odynophagia Dysphagia Pyrosis Dyspepsia CORRECT ANSWER: A RATIONALE: When difficulty of swallowing is accompanied with pain this is now referred as odynophagia OPTION D – Dysphagia is difficulty of swallowing alone. 39. To avoid acid reflux, Nurse Yoshi should advice Mrs. Cruz to avoid which type of diet? Cola, coffee and tea High fat, carbonated and caffeinated beverages Beer and green tea Lechon paksiw and bicol express
CORRECT ANSWER: B RATIONALE: All are correct but OPTION B is the best answer. In patients with GERD, this type of diet must be avoided to avoid backflow of gastric contents. Excessive caffeine reduces the tone of lower esophageal sphincter. Test Taking Skills: look for the umbrella effect 40. Mrs. Cruz’ body mass index (BMI) is 25. You can categorize her as: Normal Overweight Underweight Obese CORRECT ANSWER: B RATIONALE: Mr. Cruz’ BMI belongs to the overweight category (24 – 26), malnourished (less than 17), underweight (17 – 19), normal (20 – 23), obese (27 – 30) and morbidly obese (greater than 30). BMI is weight in kilograms divided by height in square meters Situation 9 - Colostomy is a surgically created anus. It can be temporary or permanent, depending on the disease condition. 41. Skin care around the stoma is critical. Which of the following is not indicated as a skin care barriers? a. Appl Apply y lib liber eral al amou amount nt of mine minera ral l oil oil to the the are area a b. Use Use kar karay aya a pow powde der r and and ring rings s aro aroun und d the the stom stoma a c. Clea Clean n the the area area dail daily y wit with h soa soap p and and wat water er befo before re appl applyi ying ng bag bag d. Apply ta talcum powder twice a da day CORRECT ANSWER: A RATIONALE: OPTION B: Mild skin irritation may require the use of karaya powder before attaching the pouch. OPTION C: Soap acts as a mild abrasive agent to remove enzyme residue from fecal spillage. The nurse advises the patient to protect the peristomal skin by washing the area with gently with a moist, soft cloth and mils soap. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. pp.1062-1063 42. A nurse instructs the patient who had an ileostomy to avoid which of the following foods? Potatoes Beef Popcorn Yogurt CORRECT ANSWER: C RATIONALE: Food which can cause a potential obstruction in an ileostomy includes nuts, raisins, popcorn, seeds, chocolate, raw vegetables, celery and corn. OPTIONS A, B & D – These foods are not contraindicated for patients who have an ileostomy SOURCE: CGFNS qualifying exam. 5th ed. p. 194 43. The patient patient who has had an ileo ileostom stomy y says says to to the the nurse, nurse, “I will will have to be isolated for the rest of my life because no one will be able to stand this terrible odor.” Which of the following responses by the nurse would most likely be reassuring? “The odor will gradually become less noticeable.” “I can understand your concern, but remaining in isolation does not reduce the
odor.” “There are techniques that can reduce the odor.” “The odor is a normal part of your condition and will not offend people.” CORRECT ANSWER: C RATIONALE: There are techniques that the nurse can use to reduce odor of the ileostomy, such as placing charcoal in the ileostomy bag. The charcoal will absorb the odor in the bag. OPTION A – the odor does not gradually become less noticeable unless steps are taken to reduce it. OPTION B – While it is important to help the patient ventilate, this response does not answer the issue of the odor. OPTION D – This statement is not necessarily true. Others may be offended by the odor. Teaching the patient measures that will help to reduce odor will be most beneficial. SOURCE: CGFNS qualifying exam 5th ed. p. 194 44. The following are appropriate nursing interventions during colostomy irrigation EXCEPT: a. Incre Increase ase the the irrig irrigat ating ing soluti solution on flow flow rate rate when when abdo abdomi minal nal cramps cramps is felt felt b. Inser Insert t 2-4 2-4 inche inches s of of an an adeq adequat uately ely lubri lubricat cated ed cathet catheter er to the stoma stoma c. Position cl client in in se semi-Fowler d. Hand Hand the the sol solut utio ion n 18 18 inc inche hes s abo above ve the the sto stoma ma CORRECT ANSWER: A RATIONALE: If cramping occurs, clamp off the tubing and allow the patient to rest before progressing. Painful cramps are often caused by too rapid flow or by too much solution. 300 ml of fluid maybe all that is needed to stimulate evacuation. Volume may be increased with subsequent irrigation to 500, 1000, or 1500ml as needed by the patient for effective results. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. p. 1065 The nurse is assessing the colostomy of a client who had an abdominal perineal resection for a bowel tumor. Which of the following assessment findings indicate that the colostomy is beginning to function? Blood drainage from the colostomy Change the dressing as prescribed Absent bowel sounds The passage of flatus CORRECT ANSWER: D RATIONALE: Following abdominal perineal resection, the nurse would expect the colostomy to begin to function within 72 hours after surgery, although it may take up to 5 days. The nurse should assess for the return of peristalsis and listen for bowel sounds and check for the passage of flatus. Absent bowel sounds would not indicate the return of peristalsis. The client would remain NPO until bowel sounds return and the colostomy is functioning. Bloody drainage is not expected in a colostomy. SOURCE: Silvestri. Saunders NCLEX-RN Examination.3rd ed. P. 612 Situation 10 - As a beginner in research, you are aware that sampling is an essential element of the research process. 46. What does a sample group represent? a. Control group b. Study participants c. General population
d.
Universe
CORRECT ANSWER: B RATIONALE: Study participants are the people who are being studied; such study participants comprise the sample. SOURCE: Polit and Beck. Nursing Research Principles and Methods 7th Ed. p. 26 This kind of research gathers data in detail about individual or groups and presented in narrative form, which is Case study Historical Analytical Experimental CORRECT ANSWER: A RATIONALE: Case studies are in-depth investigations of a single entity or a small number of entities. The entity may be an individual, family, group, institution, community or other social unit. In case study, researchers obtain a wealth of descriptive information and may examine relationships among different phenomena, or may examine trends over time. OPTION B: Historical research- systematic studies designed to discover facts and relationship about past events Analytical epidemiologic studies are most useful for testing an hypothesized association between human exposure and adverse health effects. OPTIION D: Experimental is a study in which the researcher controls (manipulates) the independent variable and randomly assigns subjects to different conditions. SOURCE: Polit,D.E. and Beck C.T. Nursing Research principles and methods. 7th ed. pp. 259, 716, 718 48. Random sampling ensures that each subject has: a. Been se selected sy systematically b. An equal change of selection c. Been selec lected ted ba based on set cri crit teria ria d. Char Charac acte teri rist stic ics s tha that t mat match ch othe other r sam sampl ples es CORRECT ANSWER: B RATIONALE: Random sampling is a selection of the sample such that each member of the population has an equal probability of being included. SOURCE: Polit and Beck. Nursing Research Principles and Methods 7th Ed. p. 730 49. Which of the following sampling methods allows the use of any group of research subject? a. Purposive b. Convenience c. Snow-bail d. Quota CORRECT ANSWER: B RATIONALE: Convenience sampling – selection of the most readily available persons as participants in the study; also known as accidental sampling. OPTION A: Purposive sampling – a non-probability sampling method in which the researcher selects participants based on personal judgment about which one will be most representative or informative; also known as judgmental sampling OPTION C: Snowball sampling is the selection of participants through referrals from other participants; also known as network sampling OPTION D: Quota sampling – a nonrandom selection of participants in which the researcher prespecifies characteristics of the sample to increase its representative
SOURCE: Polit and Beck. Nursing Research Principles and Methods 7th Ed 50. You decided to include 5 barangays in your municipality and chose a sampling method that would get representative samples from each barangay. What should be the appropriate method for you to use in this care? a. Cluster sampling b. Random sampling c. Stratified random sampling d. Systematic sampling CORRECT ANSWER: A RATIONALE: Cluster sampling – a form of sampling in which large groupings (“clusters”) are selected first (e.g. nursing schools) with successive sampling of smaller units (e.g. nursing students) OPTION B: Random sampling – the selection of the sample such that each member of the population has an equal probability of being included OPTION C: The random selection of study participants from two or more strata in the population independently OPTION D: Systematic sampling – the selection of the study participants such that every nth person (or element) in a sampling frame is chosen SOURCE: Polit and Beck. Nursing Research Principles and Methods 7th Ed
