ARELLANO UNIVERSITY UNIVERSITY College of Nursing
MS 1 Course Audit 2
: Select the correct answer for each of the following questions. Mark only one answer for each item by shading the box corresponding to the letter of your choice on the answer sheet provided. STRICTLY NO ERASURES ALLOWED.
Alma, 24 years old medical student was admitted in the medical ward with the complaint of severe right iliac pain, nausea and vomiting: 1. Alma’s fear that she will be absent from her classes classes for several d ays. The reassurance that you can give to minimize her anxiety is to:
2.
a.
Observe CBR for one week.
b.
Follow the doctor’s order
c.
Follow the health teaching of her nurse
d.
Observe Br only for three d ays.
To ensure early recovery, what should you include in your nursing care plan? a. Allow her to observe observe CBR b. Allow her to observe observe BD only after after 3 days c.
Let her ambulate a day after the surgery
d. Allow her to have have a shower a day after the surgery 3.
You are her nurse. Your nursing measure to prevent complication of pneumonia is: a.
Turn her to sides every one and half houts
b. Assist her in passive exercise exercise
4.
5.
c.
Turn her to sides every three hours
d.
Encourage deep breathing
You assess alma of the presence of pneumonia, the following are symptoms of pneumonia, except: a.
Tactile fremitus is increase over the affected area
b.
Crackling sounds are heard over affected areas
c.
Percussion is dulled over the affected areas
d.
Expansion of the chest wall are equal during inspirations
In determining the antibiotic that Alma will respond best, what test should be prescribed? a.
Rubin’s test
b.
Culture and Sensitvity Test
c.
Widal’s test
d.
Schick’s test
: Stella, a dressmaker has Raynaud’s disease 6.
Her nurse let her know that her conditions may improve and response to: a.
Calm emotional environment
b.
Cool climate
c.
Warm weather
d.
Hectic schedule
7. As a head nurse, you have to emphasize emphasize to her in your counselling and health teaching to to avoid: a.
Smoking
b. Alcohol beverages
8.
c.
Weight loss
d.
Coffee and tea
With her ailment, which of these activities is contraindicated: a.
Swimming in cold water
b.
Dancing
c.
Driving
d.
Horse riding
9. An obese client with peripheral vascular disease, diet should contain all of the following, except: a.
Minimal weight reduction
b.
Rapid weight reduction
c.
Increase fat intake
d.
Increase carbohydrate intake
10. Stella underwent peripheral arterial bypass graft, the most vital nursing management is to: a.
Measure intake and output
b. Apply elastic bandage c.
Take pedal pulse
d.
Medicated for incisional pain
: Mrs. Sison, 30 year old tuberculosis patient is one of the recipients of the Short Course Chemotherapy (SCC) drugs. Her appointment to take her supply of drugs was 3 days ago but she failed to come. This is the third month of treatment. 11. You plan to visit Mrs. Sison in order to: a. Advice her to consult the physician for changed in her treatment b.
Check whether she is no longer coughing so that she can terminate her treatment
c.
Inform her to have another sputum examination as basis for continuing treatment
d.
Motivate her to collect her drugs r egularly
12. You will explain to Mrs. Sison that the treatment if tuberculosis depend on: a.
Rest and hospitalization
b.
Special diet
c.
Rest
d.
Quality and duration of chemotherapy
13. As part of your preparation for the home visit to Mrs. Sison, you review the minor signs of adverse reactions to the SCC drugs and these are: a.
Fatigue or weakness and vomiting
b.
Loss of appetite, nausea and vomiting, weakness, rashes and fever
c.
Loss of appetite, nausea and vomiting
d.
Rashes or itchiness and fever
14. A yellowish discoloration of the skin and eyeballs of a patient taking SCC drugs us a sign to discontinue taking the: a. All the SCC drugs and refer patient to physician for evaluation b.
Rifampicin and pyrazinamide for one week
c.
Pyrazinamide and refer to physician
d.
Rifamcpicin and refer patient
15. In your scheduled visit to Mrs. Sison you will also advise her to bring her school children without BCG to the health center for: a.
Chest x-ray
b.
Sputum examination
c.
Tuberculin testing
d.
BCG vaccination
Carding, 50nyears old, has been admitted to the hospital with a diagnosis of cirrhos is of the liver. He has dependent edema and is complaining of jaundice, anorexia, and weakness. The following questions relate to his care. 16. The organic change occurring in cirrhosis of the liver is: a.
Infection of hepatic cells
b.
Scar formation following cell necrosis
c.
Impairment of bile flow due to choledochitis
d.
Obliteration of the portal vessels
17. The primary cause of cirrhosis of the liver is: a.
Malnutrition
b. Alcoholism c.
Physical damage of the liver
d.
Exposure to infection
18. Foods usually omitted from the diet of Carding with cirrhosis of the liver are:
a.
Whole grain cereals
b.
Milk product
c.
Cereal products
d.
Rich gravies and sauces
19. Carding develop ascites. This is causd by: a.
Pulmonary failure
b.
Portal obstruction
c.
Capillary obstruction
d. Arterial obstruction 20. Clay colored stool are caused by: a.
Improper utilization of Vit K by the body
b.
The absence of bile salts in the feces
c.
The absence of bile pigments in the feces
d.
Faulty diet
Mr. Ben, 35 years old underwent cholycestectomy and was brought to the ward with T -tube and NGT. 21. Immediately, you connect the nasogastric tube to the suction apparatus. In this case, you should be observant to any indication of: a.
Metabolic acidosis
b.
Tetany
c.
Metabolic alkalosis
d.
Cardiac arrest
22. NGT tube was removed 2 days after surgery and he began to have diarrhea. D5LR 1 liter and D5n5NSS 1 liter was ordered for intravenous infusion. If each bottle has to run for 12 hours, how many drops will be there in one minute? a.
32 gtts.
b.
41 gtts.
c.
20 gtts.
d.
50 ggts.
23. If his diarrhea persists and not controlled right away, he might develop: a.
Metabolic acidosis
b.
Metabolic alkalosis
c.
Cardiac arrest
d.
Tetany
24. You cautioned him that if i ntravenous infusion is regulated faster than the prescribed rate, he may be apt to have: a.
Respiratory overload
b.
Metabolic acidosis
c.
Cardiac arrest
d.
Tetany
25. He has been informed the rationale of his having I.V. the following are the signs of dehydration, except: a.
Sunken eyeballs
b.
Concentrated urine
c.
Puffy eyelids
d.
Thirst
Gabriel, 18-year-old is suffering from asthma after he returned home from mountaineering. 26. Upon auscultation, you hear: a.
Dull sound of the affected area
b.
Wheezing sound
c.
Murmur sound
d.
Gurgling sound
27. Which of these manifestations is not expected to occur: a.
Bradycardia
b. Apprehension c.
Tachypnea
d.
Cool and moist skin
28. Initially, the physician order aminophylline 350mg STAT IV push with 10 cc of D5%W. Drug on hand is 500mg/5cc in a vial. How many cc of the drug will you aspirate? a.
1.5 cc
b.
3.0 cc
c.
3.5 cc
d.
2.5 cc
29. One toxic effect of aminophylline: a.
Nystagmus
b.
Ringing of the ears
c.
Cardiac arrest
d.
Cardiac arrhythmias
30. The priority of your nursing care is: a. Administration of aminophylline b.
Force fluid intake
c.
Give bronchodilator
d.
Keep the bed elevated
Ms Felis, 19 years old, single, the only child is scheduled for mastectomy. 31. You are her nurse. Which of these is not included in your preoperative care? a.
Instructing exercises that will benefit her postoperatively
b. Allay her fear about the surgery c.
Giving health teaching to client and relatives regarding her surgery
d.
Giving him health teaching what to do when discharged.
32. You informed her that the most common breast tumor occurring in young women is a.
Fibrocystic
b.
Papilloma
c.
Gynecomastia
d.
Fribroadenoma
33. Which of these work-up is not related to her surgery? a.
CBC
b.
Urinalysis
c.
B.T.
d.
C.T.
34. Which of these activity should you encourage her to do in early A.M. prior to the surgery? a.
Sign the consent for surgery
b.
Take a bath
c.
Sponge bath only
d.
Take her temperature
35. How would you allay her/their fear for the surgery? Tell her/them that: a.
Your doctor is the best in town, he does all kinds of surgery
b.
Your doctor is the topnotcher in the board examination for medicine that would make him very capable to do the surgery.
c.
Your doctor is a thoracic surgeon and have a lot of breast surgery
d.
Your doctor will specialize breast surgery.
Ms Liza, 35-years old is experiencing intermittent abdominal pain for the past few days. Her physician recommends STAT exploratory laparotomy after blood examination. 36. Preoperative medications were ordered. Which of these drugs is given to suppress salivation? a.
Benadryl
b.
Scopolamine
c.
Demerol
d.
Valium
37. In preoperative patient like Liza, which of these is given the last priority to be accomplished 30 minutes before the schedul ed time: a.
Signing consent for surgery
b.
Giving pre-operative medications
c.
Instructing the patient to empty the bladder
d.
Taking vital signs
38. Which of the following techniques is best applied to minimize pain when asking post -operative patient to do coughing exercise? a.
Support her abdomen with a small pillow
b.
Cover her mouth when coughing
c.
Support her chest with your hands
d.
Put her in Fowler’s position with knee flexed
39. Post-operative order is 1 bottle D5% i n water 500cc with 1 ampule Solucortef incorporated to run 10 hours using a microdrip tubing. Find the number of drops per minutes: a.
100 gtts.
b.
22 gtts.
c.
80 gtts.
d.
20 gtts.
40. Liza made queries to the charge nurse during the rounds, when will her stitches be removed? Your answer is: a.
“Normally seven days after surgery.”
b.
“Normally three days after operations.”
c.
“Alternating stitches will be removed after four days.”
d.
“Two weeks from now.”
A retired operation manager, Mr. Solis, is confined with peripheral vascular disease of the lower extremities. 41. After a series of examinations, he is diagnosed as having complete arterial obstructions of the left leg. Most likely the clinical manifestation would be: a. Aching back b.
Burning sensations
c.
Numbness and tingling
d.
Coldness
42. He underwent below knee amputation. From the OR the stump was dry, but 30 minutes later, a small amount of bloody drainage was noticed. Prioritize your nursing action: a.
Reinforce the dressing
b.
Change the dressing
c.
Mark the area of the drainage with a ballpen
d.
Notify the doctor
43. During the first 24 hours postoperatively, your nursing care is to: a.
Keep stump flat on bed
b. Apply traction to the stump c.
Elevate the stump on a pillow
d. Abduct the stump on a scheduled basis 44. Which of these nursing goals take priority when considering Mr. Solis physical mobility following amputation? a. Assess phantom limb pain b. Assess phantom limb sensation c. Assess edema d.
Prevent contractures
45. The patient’s wife who will prepare his meals is given dietary instructions. His diet is low cholesterol low sodium. Your fir st step in giving Mr. Solis specific instruction is: a.
Explain the importance of complying his prescribed diet
b. Ask how to name foods high in fat and salt c.
Determine her knowledge about cholesterol
d. Assess the patient’s food preference Mr. Jaime , a senior executive is admitted in the CCU with a diagnosis of CHF.
46. The best indicator of client’s condi tion if he has CHF: a.
Cardiac rate
b.
Pulse rate
c.
Respiration
d.
Blood pressure
47. The symptoms that Mr. Jaime is expected to manifest would be: a.
Edema of the affected extremity
b.
Edema of the abdominal cavity
c.
Eupnea, cyanosis and hemoptysis
d.
Orthopnea, moist rales and cough
48. He has now acute pulmonary edema, rotating tourniquets is ordered. The desired of this is to: a.
Increased temporarily the total volume of circulating blood.
b.
Increase the blood flow in order to rest the heart
c.
Reduce blood flow to the extremities in order to rest the heart.
d.
Reduce temporarily the total volume of circulating blood
49. The most comfortable position for him is: a.
Low-Fowler’s
b.
Prone
c.
Jack-knife
d.
Sims
50. Since he is suffering from pulmonary edema. Digoxin was prescribed this is primarily to: a.
Decrease cardiac rate
b.
Increase cardiac output
c.
Increase cardiac rate
d.
Increase urinary output
: Marmie is the OR nurse manager of MMC. 51. How would she position Ela who is scheduled for throidectomy: a.
Supine
b.
Trendelenburg’s
c.
Reverse Trendelenburg’s
d.
Fowler’s
52. To expose her thyroid for surgery, which of these is use? a.
Trochanter roll
b.
Small pillow
c.
Elevator bridge
d.
Donut
53. Halothane is the anesthetic agent that will be used for Ela’s anesthesia. The disadvantage of this anesthetic agent is: a.
Induces bronchodilation
b.
Depressant to the cardiovascular system
c.
Non flammable
d.
Non-irritating to respiratory tract
54. The following are antiemetics sedatives premedication, except: a.
Inapsin
b.
Vistaril
c.
Phenergen
d.
Valium
55. The following antimuscarinics premedication use to decrease secretions and provides amnesia is a.
Scopolamine
b.
Glycopyriolate
c.
Robinul
d. Atropine sulphate Mr. Chit5o, 72, businessman with 8 siblings. The two youngest ages 3 and 1 year old is suffering from cirrhosis of the liver.
56. One of your finding in assessment upon admission is: a.
Pneumothorax
b.
Transitory weakness
c. Abdominal distention d. Ascites 57. Since cirrhosis of the liver progresses slowly, the most stressful condition in the part of the family is to learn that he ha s: a. Anemia b.
Decrease prothrombin time
c.
Encephalopathy
d.
Increase SGPT
58. One your concerns in caring for Mr. Chito is prevention of infection, which could be attained by the following, except a. Adequate exercise b. Adequate diet c.
Control of the environment
d. Adequate rest 59. Stress response is the opposite of relaxation response. Which of these occurs during relaxation response? a.
The heart rate become irregular
b.
Breathing is shallow
c.
Breathing is deeper
d.
The cardiac rate increase
60. One of the queries of the relative and significant others of which of these, triggers to cirrhosis of the liver. Your response is: a.
Malnutrition
b.
Life style
c.
Faulty diet
d. Alcohol Mila a cafeteria owner, went for check-up due to fatigue, exertional dyspnea and dizziness. 61. Her doctor suspects anemia. The blood examinations that would help diagnosis her condition is: a.
Hematocrit count
b.
Platelets count
c.
White blood cell count
d.
Haemoglobin count
62. Blood examination revealed anemia. The drug preparation that would be appropriate is: a.
Hematemic
b.
ferrous sulphate
c.
antihistaminic
d.
revicon
63. The intrinsic factor necessary for the manufacture of red blood cells is found in the: a.
Intestine
b.
Liver
c.
Blood
d.
Stomach
64. The cause of pernicious anemia is: a. An absence of the intrinsic factor b. An absence of extrinsic factor c.
Over production of red blood cells
d.
Poor diet
65. The following are characteristics of pernicious anemia except: a.
Neurologic symptoms
b. A fatal outcome unless lifelong injections of vitamin B is given c. Abnormally large erythrocytes d.
Hypochlorhydia
Tommy, 39 years old, labourer is often readmitted to the hospital for acute upper respiratory infection.
66. When assessing breath sound, you perform: a.
Percussions
b. Auscultation, percussion and inspection c. Auscultation and percussion d.
Consultation
67. When assessing the quality of respiration you will note the: a.
Breath sounds and effort exerted on b reathing
b.
Effort exerted on breathing
c.
Respiratory rate and chest movement
d.
Breath sounds and respiratory rate
68. This describes an abnormal breath sounds: a.
Hollow
b.
Crackling
c.
Dull
d.
Silent
69. A self care principle to teach him before discharge is: a.
Breathing exercise to develop living potential
b.
Prevent outcleaning a cold
c.
Take antibodies as prophylaxis
d.
Intake of protein to increase resistance
70. You know that your teaching is effective if Tommy will: a.
Practice diaphragmatic breathing
b.
Takes breathing exercises daily
c.
Keeps clinic appointment regularly
d.
Seeks consultation when symptoms recover
Mang Caloy, a carpenter was rushed to the hospital in semi-conscious condition after a fall from a building under construction. He was place under observation. 71. During the immediate minutes of trauma, your first goal is to: a. Assess extent of injury b.
Call the physician on duty
c.
Check for bleeding
d.
Establish an open airway
72. He should sign shock. To p revent irreversible shock, your priority goal is to: a.
Prevent chilling
b.
Restore blood volume
c.
Increase oral fluid
d. Allay apprehension 73. For a patient in shock, you would expect: a.
Increase capillary permeability
b.
Hypoxia
c. A pH less than 7.35 d.
Hypercapnia
74. You monitored his blood pressure. Intracranial pressure is increasing when there is: a.
Decrease in respiratory rate
b.
Decrease in pulse rate
c.
Low level of consciousness
d. A widening pulse pressure 75. The code blue team was called after his B/P became zero. The cardiopulmonary resuscitation is effective when the: a.
Pupils are dilated
b.
Carotid pulse is palpable
c.
The skin is normal in color
d.
Easily nailbeds blanched
Bong, a wrestler, 50-year-old was found unconscious in the morning and was rushed to the hospital. 76. Lumbar puncture disclosed that he is suffering from cerebral hemorrhage. The finding would be: a.
Spinal fluid is cloudy and under decrease pressure
b.
Spinal fluid is clear and under increase pressure
c.
Spinal fluid is bloody and under increase pressure
d.
Spinal fluid is clear
77. Bong’s present symptoms probably occurred from rupture of a branch of the: a.
Middle cerebral artery
b. Anterior cerebral artery c.
Posterior cerebral artery
d.
Vertebral artery
78. Bong would be most apt to demonstrate which type of paralysis upon awaking from coma: a.
Flaccid
b.
Bilateral
c.
Spastic
d.
Periodic
79. In caring for Bong while his aphasis is severe, the nurse should: a. Anticipate his desire to be alone b.
Encourage him to communicate with you by gesture
c.
Encourage him to talk at every possible opportunity
d.
Communicate by means of gesture
80. In teaching Bong to speak again, you should begin his instruction with: a.
Title of his favourite book
b.
Numbers and alphabet
c.
Names of famous personality
d.
Newspaper headline
From Honeymoon, Ms. Enya Romas sought consultations with probable diagnosis of acute cystitis. 81. Your assessment for acute cystitis would be: a.
Fever, chills, and lumbar pain
b.
Hematuria
c.
Nocturia
d.
Burning sensation and frequency of urination
82. Instruction from her nurse on how to secure a “clean catch urine”, specimen is to: a.
Save the first urine voided
b.
Discard the first urine and then void directly into the specimen bottle.
c.
Void directly into the specimen bottle and stop collection of urine when bladder is empty
d.
Void directly into the specimen bottle.
83. The common cause of cystitis is: a.
Complete emptying of the bladder after each voiding
b.
Infection from the ureter and kidney
c. Ascending infection from the urethra d.
Descending infection to the urethra
84. The nurse health teaching to Ms. Cathy for fast recovery should include: a. At least a glass of water after each day b.
Force fluids
c. At least 10 glasses each day d.
A lot of juices and water each day
85. After successful water therapy while preparing for her discharge, which statement would indicate that she is at risk for recurrence of cystitis? a.
“”I can tolerate 6 to 8 hours, without needing to empty bladder.”
b.
“I drink a lot of juices during the day.”
c.
“After voiding I flushed, washed from back to front.”
d.
“I take a bath every morning.”
Manie, a manager of the CSR for the local hospital has develop anorexia, nausea, epigastric irritation and slight yellowish discoloration of the skin. He was admitted and was diagnosed as infectious hepatitis. 86. The doctor’s orders for urobilinogen evaluation which h as been excreted from Manie. What must be the nurses first action? a.
Shake the tube
b.
Store the specimen in the refrigerator
c.
Take blood sample
d.
Protect the specimen
87. Which of these understanding about infectious hepatitis should the nurse know in order to help prepare Manie for discharge? a.
Normal liver function tests are prerequisite for g oing home
b.
Liver abscess is a frequent complication of infectious hepatitis
c.
Prophylactic antibiotic therapy will be instituted.
d.
The convalescent period at home is likely to be relatively long
88. Which of these drugs is used to protect individuals who have been exposed to infectious hepatitis? a.
Heap vaccine
b.
Eltroxin 100 mg tablet
c.
Immune serum globulin (human)
d.
Tapazole
89. It is important for the nurse to know the mode of transmission of the organisms responsible for infectious hepatitis because this knowledge provides the basis for: a.
Determining the type of isolation precautions
b.
Preventing auto infection
c.
Planning a rehabilitative program
d.
Estimating the length of isolation period
90. The diet most likely to be ordered for Manie during the acute phase of his illness would most probably be: a.
High carbohydrate, high protein, fat free
b.
High carbohydrate, low protein, high fat
c.
High carbohydrate, low protein, low fat
d.
Low carbohydrate, low protein, high fat
Mang Beloy, 26 years old labourer, fell from a 4-storey building under construction. He was rushed to the emergency room and admitted. He became unconscious after two hours. 91. The priority nursing goal of patient with sensory alteration is: a.
Maintaining adequate communication
b.
Ensuring proper nutrition
c.
Providing a safe environment
d.
Promoting social interaction
92. In the case of Mang Beboy, you will consider the following goals. The one to receive first priority is to: a.
Monitor neurological status including vital signs
b.
Maintain his fluid-electrolyte balance
c.
Maintain an open airway
d.
Control his pain and restlessness
93. An unconscious patient is unable to: a.
Move spontaneously
b.
React to painful stimuli
c.
Hear voices
d.
Control elimination
94. You should refrain from discussing an unconscious patient’s condition at his bedside because: a.
Critical condition of an unconscious patient is confidential information
b.
Level of awareness of patient is h igh
c.
It is unethical to discuss a critical condition of patient
d.
The hearing sense is not entirely lost when unconscious
95. The most sensitive indicator of an unconscious patient with head injury is the:
a.
Muscle twisting
b.
Papillary changes
c.
Blood pressure and pulse
d.
Motor functions
You were newly assigned to Mang Macoy, an unconscious patient with right-sided paralysis. You noted reddening of his skin over the coccygeal area. 96. What is the first sign that decubitus ulcer is developing? a.
Rash appearance
b.
Skin is taut
c.
Skin is blanched
d.
Papules appear
97. How often should the patient be repositioned? a. As often as necessary b.
Every 2 to 3 hours
c.
Every 4 to 6 hours
d.
Every shift
98. Which of the following techniques of moving would most likely cause bedsore formation? a.
Moving a patient to a chair without support
b.
Rolling patient to his side with a draw sheet
c.
Lifting patient from bed to stretcher
d.
Sliding patient on a sheet to move him up on bed
99. When transferring patient from bed to stretcher, where should the stretcher be placed in relation to the bed? a. At right angle at foot of bed b.
Parallel to the side of the bed
c. At a 45 degree angle near the middle of the bed d.
Diagonally at the foot of the bed
100. What is the diet of the patient with developing decubitus ulcer? a.
Low fat diet
b.
High calorie diet
c.
High protein diet
d.
high vitamin diet.
