NURSING PRACTICE PRACTICE III – Care of Clients with Physiologic and Psychosocial Psychosocial Alterations (Part A) SITUATIONAL Situation 1 – Concerted work efforts e fforts among members of the surgical team is essential to the success of the surgical procedure. procedure. 1. 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? A. B. C. D.
Circul Circ ulat atin ing g Nur Nurse se Anae Anaest sthe hesi siol olog ogis istt Surgeon Nurs Nursin ing g Aid Aide e
2. The OR team performs distinct roles for one surgical procedure to be accomplished within a prescribed time frame and deliver a standard patient outcome. While the surgeon performs the surgical procedure, who monitors the status of the client like urine output, blood loss? A. B. C. D.
Scru Scrub b Nur Nurs se Surgeon Anae An aest sthe hesi siol olog ogis istt Circ Circul ulat atin ing g Nurse Nurse
3. Surgery schedules are communicated to the OR usually a day prior to the procedure by the nurse of the floor or ward where the patient is confined. For orthopedic cases, what department is usually informed to be present in the OR? A. B. C. D.
Rehabil ehabilita itatio tion n departme department nt Labo Labora rato tory ry depar departm tmen entt Mainte Maintena nance nce depart departmen mentt Radio Ra diolog logy y dep depart artmen mentt
4. Minimally invasive surgery is very much into technology. Aside from the usual surgical team, who else has to be present when a client undergoes laparoscopic laparoscopic surgery? A. B. C. D.
Inform Informati ation on techni technicia cian n Biomed Biomedica icall techni technicia cian n Elec Electr tric icia ian n Labora Lab orator tory y tec techni hnicia cian n
5. In massive blood loss, prompt replacement of compatible blood is crucial. What department needs to be alerted to coordinate closely with the patient’s family for immediate blood component therapy? A. Secu Securi rity ty Divi Divisi sion on B. Chai Chaipl plai ainc ncy y C. Soc Socia iall Serv Service ice Sec Sectio tion n D. Patho Patholog logy y depart departmen mentt
Situation 2 – You are assigned in the Orthopedic Ward where clients are complaining of pain in varying degrees upon movement of body parts. 6. Troy 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? A. B. C. D.
Dressing Dressing is intact intact but but partia partially lly soile soiled d Leftt foot is Lef is cold to touch touch and pedal pedal puls pulse e is absent absent Left Left leg in limite limited d functional functional anatom anatomic ic position position BP 114/78, 114/78, pulse of 82 beats/min beats/minute ute
7. There is an order of Demerol 50 mg I.M. now and every 6 hours p r n. You injected Demerol at 5 pm. The next dose of Demerol 50 mg I.M. is given: A. B. C. D.
When the clien clientt asks asks for for the next next dose dose When When the pati patient ent is is in sever severe e pain pain At 11 pm At 12 pm
8. You You continuously evaluate the client’s adaptation to pain. Which of the following behaviors indicate appropriate adaptation? A. B. C. D.
The client client reports reports pain pain reduction reduction and and decreas decreased ed activity activity The client client denie denies s exist existence ence of pain pain The client client can distr distract act himself himself during during pain pain episodes episodes The client client reports reports indepe independen ndence ce from watche watchers rs
9. Pain in ortho cases may not be mainly due to the surgery. There might be other factors such as cultural or psychological that influence pain. How can you alter these factors as the nurse? A. B. C. D.
Explain Explain all the possible possible interve interventions ntions that that may cause cause the client client to worry Establish Establish trusting trusting relati relationshi onship p by giving his medicat medication ion on time Stay with the clien clientt during during pain pain episode episodes s Promote client’s client’s sense sense of control control and participation participation in in control by listening listening to his concerns
10. In some hip surgeries, an epidural catheter for Fentanyl Fentanyl epidural analgesia is given. What is your nursing priority care in such a case? A. B. C. D.
Instruct Instruct client client to observe observe strict strict bed rest rest Check Check for epidur epidural al cathet catheter er drainag drainage e Administ Administer er analgesia analgesia through through epidural epidural catheter catheter as prescribed prescribed Assess Asse ss respi respiratory ratory rate car carefull efully y
Situation 3 – Records are vital tools in any institution and should be properly maintained for specific use and time. 11. The patient’s medical record can work as a double edged sword. When can the medical record become the doctor’s/nurse’s worst enemy? A. B. C. D.
When When the recor record d is volu volumin minous ous When a medical medical record record is is subpoena subpoenaed ed in court When When it is miss missin ing g When the medical medical record record is inaccurate inaccurate,, incomplete, incomplete, and inadequa inadequate te
12. Disposal of medical records in government hospitals/institutions hospitals/institutions must be done in close coordination with what agency? A. B. C. D.
Department Department of Interior Interior and and Local Local Govern Government ment (DILG (DILG)) Metro Metro Manila Manila Developme Development nt Authori Authority ty (MMDA) (MMDA) Record Re cords s Manageme Management nt Archive Archives s Office Office (RMAO) (RMAO) Depart Dep artmen mentt of Hea Health lth (DO (DOH) H)
13. In the hospital, when you need the medical record of a discharged patient for research research you will request permission through: A. B. C. D.
Doct Doctor or in in char charge ge The The hospi hospita tall direc directo torr The The nurs nursin ing g serv servic ice e Medica Med icall recor records ds sec sectio tion n
14. You readmitted a client who was in another department a month ago. Since you will need the previous chart, from whom do you request the old chart? A. B. C. D.
Centra Centrall supply supply sectio section n Previ Previous ous doctor doctor’s ’s clinic clinic Department Department wher where e the patient patient was previo previously usly admitte admitted d Medica Med icall recor records ds sec sectio tion n
15. Records Management and Archives Office of the DOH is responsible for implementing its policies on record disposal. You know that your institution is covered by this policy if: A. B. C. D.
Your hospit hospital al is considere considered d tertiary tertiary Your hospit hospital al is is in Metro Metro Manila Manila It obtaine obtained d permit permit to operate operate from DOH Your hospital hospital is PhilH PhilHealt ealth h accredited accredited
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 of patient delivery outcome. 16. Which of the following should be given highest priority when receiving patient in the OR? A. B. C. D.
Assess Assess leve levell of consc consciou iousne sness ss Verif erify y patient patient identifica identification tion and informe informed d consent consent Asse Assess ss vita vitall sig signs ns Check Check for jewelry jewelry,, gown, manicure, manicure, and denture dentures s
17. Surgeries like I and D (incision and drainage) and debridement are relatively short procedures but considered ‘dirty cases’. When are these procedures best scheduled? A. B. C. D.
Last case In betw betwee een n case cases s Accordin According g to availab availabilit ility y of anaesthe anaesthesiol siologist ogist Accordin According g to the surgeon’s surgeon’s prefere preference nce
18. OR nurses should be aware that maintaining the client’s client’s safety is the overall goal of nursing care during the intraoperative phase. As the circulating circulating nurse, you make certain that throughout the procedure… procedure… A. the surgeon surgeon greets greets his his client client before before induction induction of anesthe anesthesia sia B. the surgeo surgeon n and anesth anesthesio esiologis logistt are in tandem tandem C. strap made of strong non-abrasive materials are fastened securely around the joints of the knees and ankles and around the 2 hands around an arm board. D. Client Client is monitored monitored throughout throughout the surger surgery y by the assistant assistant anesthesiologist 19. Another nursing check that should not be missed before the induction of general anesthesia is: A. B. C. D.
check check for for presen presence ce under underwe wear ar check check for for pres presenc ence e dentu denture res s chec check k pat patie ient nt’s ’s ID check che ck basel baseline ine vita vitall signs signs
20. Some lifetime habits and hobbies affect postoperative respiratory function. If your client smokes 3 packs of cigarettes a day for the p ast 10 years, you will anticipate increased risk for: A. B. C. D.
periop periopera erativ tive e anxiety anxiety and and stress stress delaye delayed d coag coagula ulatio tion n time time delaye del ayed d wou wound nd hea healin ling g postoperati postoperative ve respirato respiratory ry function function
Situation 5 – Nurses hold a variety of roles when providing care to a perioperative patient. 21. Which of the following role would be the responsibility of the scrub nurse? A. Assess Assess the readines readiness s of the client client prior prior to surgery surgery B. Ensur Ensure e that that the airwa airway y is adequ adequate ate supplies, used during the C. Account for the number of sponges, needles, supplies, surgical procedure. procedure. D. Evaluate the type of anesthesia anesthesia appropriate appropriate for for the surgical client 22. As a perioperative nurse, how can you best meet the safety need of the client after administering preoperative narcotic? A. B. C. D.
Put side side rails rails up up and ask ask the clie client nt not to to get out out of bed Send Send the clie client nt to OR with with the the famil family y Allow client client to get get up to go to to the comfort comfort room Obta Obtain in con conse sent nt form form
23. It is the responsibility 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 make suturing easy and lessen chance of incision infection? A. Draped B. Pulled C. Clipped
D. Sha Shampoo mpooe ed 24. It is also the nurse’s function to determine when infection is developing in the surgical incision. incision. The perioperative nurse should observe for what signs of impending infection? A. B. C. D.
Localize Local ized d heat heat and and redn redness ess Serosangu Serosanguinous inous exudates exudates and skin skin blanchi blanching ng Separa Separatio tion n of the incis incision ion Blood clots clots and and scar scar tissue tissue are are visible visible
25. Which of the following nursing interventions is done when examining the incision wound and changing the dressing? A. B. C. D.
Observe the dress Observe dressing ing and type type and and odor of drainage drainage if any Get patien patient’s t’s conse consent nt Wash ha hands nds Reques Re questt the client client to expose expose the the incisio incision n wound
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. 26. Which of the following nursing actions should be initiated first? A. B. C. D.
Promo Promote te emot emotion ional al suppor supportt Admini Administe sterr oxyge oxygen n at 6L/m 6L/min in Suctio Suction n the client client eve every ry 30 min min Administ Admi nister er broncho bronchodila dilator tor by nebu nebulize lizerr
27. Aminophylline was ordered for acute asthmatic attack. The mother asked the nurse, what is its indication, the nurse will say: A. B. C. D.
Relax smooth Relax smooth muscle muscles s of the the bronchial bronchial airw airway ay Promo Promote te expec expectora toratio tion n Prevent Prevent thicken thickening ing of secre secretions tions Supp Suppre ress ss coug cough h
28. You You will give health instructions to Carlo, a case of bronchial asthma. The health instruction will include the following, EXCEPT: A. B. C. D.
Avoid Avoid emotional emotional stre stress ss and extre extreme me temperatur temperature e Avoid void pollut pollution ion lik like e smokin smoking g Avoid void pollen pollens, s, dust, dust, sea seafood food Practice Prac tice res respirat piratory ory isol isolatio ation n
29. The asthmatic client asked you what breathing techniques he can best practice when asthmatic attack starts. What will be the best position? A. B. C. D.
Sit in high-F high-Fowle owler’s r’s position position with with extende extended d legs Sit-up Sit-up with with shou shoulde lders rs back back Push Push on abdomen abdomen durin during g exhala exhalatio tion n Lean forwar forward d 30-40 degree degrees s with each each exhalati exhalation on
30. As a nurse, you are always alerted to monitor status asthmaticus who will likely and initially manifest symptoms of:
A. B. C. D.
meta metabo boli lic c alkal alkalos osis is resp respir irat atory ory acido acidosi sis s respi respirat ratory ory alka alkalos losis is meta me tabo boli lic c acido acidosi sis s
Situation 7 – Joint Commission on Accreditation Accreditation of Hospital Organization (JCAHO) patient safety goals and requirements include the care and efficient use of technology in the OR and elsewhere in the healthcare facility. 31. As the head nurse in the OR, how can you improve the effectiveness of clinical alarm systems? A. B. C. D.
Limit suppli suppliers ers to a few few so that that quality quality is mainta maintained ined Implement Implement a regul regular ar inventory inventory of of supplies supplies and and equipment equipment Adherenc Adherence e to manufac manufacture turer’s r’s recom recommenda mendation tion Implement Imple ment a regular regular maintenan maintenance ce and testing testing of alarm alarm systems systems
32. Overdosage of medication or anesthetic can happen even with the aid of technology like infusion pumps, sphygmomanometer and similar devices/machines. As a staff, how can you yo u improve the safety of using infusion pumps? A. B. C. D.
Check the functi Check functionali onality ty of the the pump befor before e use Select Select your brand brand of infusion infusion pump like like you do with your your cellphone cellphone Allow the technic technician ian to set set the infusion infusion pump pump before before use use Verify erify the flow flow rate agains againstt your computat computation ion
33. JCAHOs universal protocol for surgical and invasive procedures procedures to prevent wrong site, wrong person, and wrong procedure/surgery includes the following, EXCEPT: A. B. C. D.
Mark Mark the opera operativ tive e site site if possib possible le Conduct Conduct pre-pro pre-procedu cedure re verific verification ation process process Tak ake e a video of the entire entire intra-operat intra-operative ive procedur procedure e Conduct Conduct ‘time out’ out’ immediatel immediately y before starti starting ng the procedure procedure
34. You identified a potential risk of pre-and postoperative clients. To reduce the risk of patient harm resulting from fall, you can implement the following, EXCEPT: A. Assess Assess potential potential risk risk of fall associated associated with with the patient’s patient’s medicat medication ion regimen B. Take action to address address any identified identified risks through Incident Incident Report Report (IR) C. Allow clie client nt to walk walk with with relati relative ve to the the OR D. Assess and periodically periodically reassess individual client’s risk for falling 35. As a nurse, you know you can improve on accuracy of patient’s identification identification by 2 patient identifiers, EXCEPT: A. B. C. D.
identify identify the client client by his/her his/her wrist tag and verify verify with with family members members identify identify client client by his/her his/her wrist wrist tag and call call his/her his/her by name name call the client client by by his/her his/her case case and and bed number number call the patien patientt by his/her his/her name name and and bed number number
Situation 8 – Team efforts is best demonstrated in the OR.
36. If you are the nurse in charge for scheduling surgical cases, what important information do you need to ask the surgeon? A. Who Who is you yourr inte intern rnis istt B. Who is your assistant assistant and and anesthesi anesthesiologi ologist, st, and what what is your preferre preferred d time and type of surgery? C. Who are your your anesthes anesthesiolog iologist, ist, intern internist, ist, and and assistan assistantt D. Who is your your anes anesthe thesio siolog logist ist 37. In the OR, the nursing tandem for every surgery is: A. B. C. D.
Instrument Instrument technician technician and circ circulati ulating ng nurse nurse Nurse anesth anesthetis etist, t, nurse assistan assistant, t, and instrument instrument technicia technician n Scrub Scrub nurse nurse and and nurse nurse anesth anestheti etist st Scrub Scr ub and and circul circulati ating ng nurses nurses
38. While team effort is needed in the OR for efficient and quality patient care delivery, we should limit the number of people in the room for infection control. Who comprise this team? A. B. C. D.
Surgeon, Surgeon, anesthes anesthesiolog iologist, ist, scrub scrub nurse, radiologi radiologist, st, orderly orderly Surgeon, Surge on, assistant assistants, s, scrub nurse, circula circulating ting nurse, nurse, anesthesiol anesthesiologist ogist Surgeon, assistant surgeon, anesthesiologist, anesthesiologist, scrub nurse, nurse, pathologist Surgeon, assistant surgeon, anesthesiologist, anesthesiologist, intern, scrub nurse
39. When surgery is on-going, who coordinates the activities outside, including the family? A. B. C. D.
Orde Orderl rly/ y/cl cler erk k Nurs Nurse e Super Supervi viso sorr Circ Ci rcul ulat atin ing g Nurs Nurse e Anes Anesth thes esio iolo logi gist st
40. The breakdown in teamwork is often times a failure in: A. B. C. D.
Elec Electr tric icit ity y Inad Inadeq equa uate te supp supply ly Leg wo work Comm Co mmun unic icat atio ion n
Situation 9 – Colostomy is a surgically created 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. B. C. D.
Apply libe liberal ral amount amount of of mineral mineral oil oil to the are area a Use karay karaya a paste paste and and rings rings around around the stoma stoma Clean Clean the area area daily with with soap soap and water water before before applying applying bag Apply Apply talcu talcum m powder powder twice twice a day day
42. What health instruction will enhance regulation of a colostomy (defecation) of clients? A. Irriga Irrigate te afte afterr lunch lunch every everyday day
B. Eat fruits fruits and and vegetab vegetables les in in all thre three e meals meals C. Eat b balan alanced ced meals meals at regul regular ar interva intervals ls D. Re Restric strictt exerc exercise ise to to walking walking only only 43. After ileostomy, which of the following condition is NOT expected? A. B. C. D.
Increa Incr ease sed d wei weigh ghtt Irrita Irritatio tion n of skin skin around around the the stoma stoma Liqu Liquid id sto stool ol Establish Establishment ment of regular regular bowel bowel movem movement ent
44. The following are appropriate nursing interventions during colostomy irrigation, EXCEPT: A. B. C. D.
Increase Increas e the irrigating irrigating solution solution flow flow rate when abdomin abdominal al cramps cramps is felt Insert Insert 2-4 inches inches of an adequate adequately ly lubricat lubricated ed catheter catheter to the stoma stoma Position Position client client in in semi-F semi-Fowle owlerr Hang the the solution solution 18 18 inches inches above above the the stoma stoma
45. What sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained? A. B. C. D.
Sens Sensat atio ion n of of tas taste te Sensat Sen sation ion of pr pres essur sure e Sens Sensat atio ion n of of sme smell ll Urge Urge to defe defeca cate te
Situation 10 – As a beginner in research, you are aware that sampling is an essential elements of the research process. 46. What does a sample group represent? A. B. C. D.
Contro Cont roll grou group p Stud Study y sub subje ject cts s Gene Ge nera rall popu popula lati tion on Uni Univers verse e
47. What is the most important characteristic of a sample? A. B. C. D.
Rando andomi miza zati tion on Appr Approp opri riat ate e loca locati tion on Appr Approp opri riat ate e numb number er Repr epres esent entati ativen veness ess
48. Random sampling ensures that each subject has: A. B. C. D.
Been Been selecte selected d systema systematic tical ally ly An equal equal cha chance nce of selec selectio tion n Been selected selected based based on set criteria criteria Characteri Characteristic stics s that that match match other samples samples
49. Which of the following methods allows the use of any group of research subject? A. Purpo urpos sive B. Co Conv nven enie ienc nce e
C. Snow Snow-b -ba all D. Quota 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 ofor you to use in this care? A. B. C. D.
Cluste Clus terr sa samp mpli ling ng Rand Random om samp sampli ling ng Star Starti tifi fied ed amp ampli ling ng System Systemati atic c sampl sampling ing
Situation 11 – After an abdominal surgery, the circulating and scrub nurses have critical responsibility responsibility about sponge and instrument count. 51. When is the first sponge/instrument count reported? A. B. C. D.
Before Before closing closing the subcut subcutaneo aneous us layer layer Before Before perito peritoneu neum m is clos closed ed Before Before closin closing g the the skin skin Before Bef ore the the fasc fascia ia is sutu sutured red
52. What major supportive layer of the abdominal wall must be sutured with long tensile strength such as cotton or nylon or silk suture? A. B. C. D.
Fascia Muscle Perito riton neum eum Skin
53. Like sutures, needles also also vary in shape and uses. If you are the scrub nurse for a patient who is prone to keloid formation and has low threshold of pain, what needle would you prepare? prepare? A. B. C. D.
Round ound need needle le Atra At raum umat atic ic ne need edle le Reverse everse cuttin cutting g need needle le Taper apered ed needl needle e
54. Another alternative “suture” for skin closure is the use of ____________ A. B. C. D.
Staple Ther Therap apeu euti tic c glue glue Abso Absorbe rbent nt dres dressi sing ng Invi Invisi sibl ble e sutu suture re
55. Like any nursing interventions, counts should be documented. To To whom does the scrub nurse report any discrepancy of counts so that immediate and appropriate action is instituted? A. B. C. D.
Anes Anesth thes esio iolo logi gist st Surgeon OR nur nurse se supe superv rvis isor or Circ Ci rcul ulat atin ing g nurse nurse
Situation 12 – As a nurse, you should be aware and prepared of the different roles you play. 56. What role do you play when you hold all client’s information entrusted to you in the strictest confidence? A. B. C. D.
Pat atie ient nt’s ’s advo advoca cate te Educator Patie atient nt’s ’s Liai Liaiso son n Patie Patient’ nt’s s arbite arbiterr
57. As a nurse, you can help improve the effectiveness of communication among healthcare givers by: A. B. C. D.
Use of remi reminde nders rs of ‘what ‘what to to do’ Using standar standardize dized d list of abbreviat abbreviations, ions, acrony acronyms, ms, and symbols symbols One-onOne-on-one one oral oral endor endorse semen mentt Text messagin messaging g and and e-mail e-mail
58. As a nurse, your primary focus in the workplace is the client’s safety. safety. However, personal safety is also a concern. You You can communicate hazards to your co-workers through the use of the following EXCEPT: A. B. C. D.
Forma ormall trai traini ning ng Posters Posti Po sting ng IR in in the bull bulleti etin n board board Use of labe labels ls and and sign signs s
59. As a nurse, what is one of the best way to reconcile medications across the continuum of care? A. Endors Endorse e on a casecase-to-c to-cas ase e basis basis B. Communicat Communicate e a complete complete list list of the patient’ patient’s s medication medication to the the next provider of service C. En Endo dors rse e in in wri writi ting ng D. Endorse Endorse the routine routine and ‘stat’ ‘stat’ medic medication ations s every shift shift 60. As a nurse, you protect yourself and co-workers from misinformation and misrepresentations through the following EXCEPT: A. Provide Provide informat information ion to clients clients about a variety variety of services services that can can help alleviate the client’s pain and other conditions B. Advising Advising the client, client, by virtue virtue of your expertis expertise, e, that which which can contribute contribute to the client’s well-being C. Health Health education education among clients clients and signific significant ant others regard regarding ing the use of chemical disinfectant D. Endors Endorsemen ementt thru trimedia trimedia to adve advertise rtise your your favorite disinfec disinfectant tant solution solution Situation 13 – You are assigned at the surgical ward and clients have been complaining of post pain at varying degrees. Pain as you know, is very subjective. 61. A one-day postoperative abdominal surgery client has been complaining of severe throbbing abdominal pain described as 9 in a 1-10 pain rating. Your assessment revelas revelas bowel sounds on all quadrants and the dressing is dry and intact. What nursing intervention would you take
A. B. C. D.
Medica Medicate te clien clientt as pres prescri cribed bed Encour Enc ourage age cli client ent to do imag imagery ery Encourage Encourage deep breathin breathing g and and turning turning Call Ca ll sur surge geon on sta statt
62. Pentoxidone Pentoxidone 5 mg IV every 8 hours was prescribed for post abdominal pain. Which will be your priority nursing action? A. B. C. D.
Check Check abdominal abdominal dressing dressing for for possible possible swelling swelling Explain Explain the proper proper use use of PCA to allev alleviate iate anxie anxiety ty Avoid Avoid overdosin overdosing g to prevent prevent dependenc dependence/tol e/toleranc erance e Monito Mon itorr VS, more more import important antly ly RR
63. The client complained of abdominal distention and pain. Your nursing intervention that can alleviate pain is: A. B. C. D.
Instruct Instruct clien clientt to go go to sleep sleep and relax relax Advice the client client to close the lips and and avoid deep breathing breathing and and talking Offe Offerr hot hot and and clea clearr soup soup Turn to sides sides frequent frequently ly and avoid avoid too much much talking talking
64. Surgical pain might be minimized by which nursing action in the O.R. O.R. A. B. C. D.
Skill of surgical surgical team and and lesser lesser manip manipulat ulation ion Appropria Appropriate te preparat preparation ion for the schedul scheduled ed procedur procedure e Use of of modern modern technol technology ogy in in closing closing the wound wound Proper Prop er position positioning ing and and draping draping of clie clients nts
65. One very common cause of postoperative pain is: A. B. C. D.
Forc Forcefu efull tractio traction n during during surger surgery y Prol Prolong onged ed surg surger ery y Break Break in asep aseptic tic techniq technique ue Inadeq Ina dequat uate e anes anesthe thetic tic
Situation 14 – You were were on duty at the medical ward when Zeny came in for admission for tiredness, cold intolerance, constipation, and weight gain. Upon examination, the doctor’s diagnosis was hypothyroidism. 66. Your independent nursing care for hypothyroidism includes: A. B. C. D.
administe administerr sedati sedative ve round the clock administe administerr thyroid thyroid hormone hormone repla replaceme cement nt providing providing a cool, cool, quiet, quiet, and and comfortabl comfortable e environme environment nt encourage encou rage to drink drink 6-8 6-8 glasses glasses of water water
67. As the nurse, you should anticipate to administer which of the following medications to Zeny who is diagnosed to be suffering from hypothyroidism? A. B. C. D.
Levoth Levo thyr yro oxi xine ne Lido Lidoc caine ine Lipitor Levop evophe hed d
68. Your Your appropriate nursing diagnosis for Zeny who is suffering from hypothyroidism would probably include which of the following? A. B. C. D.
Activity intolera Activity intolerance nce related related to tiredness tiredness associat associated ed with disorder disorder Risk to to injury relat related ed to incomple incomplete te eyelid eyelid closur closure e Imbalance Imbalance nutrition nutrition to hyper hypermeta metabolis bolism m Deficient Deficient fluid fluid volume volume related related to to diarrhea diarrhea
69. Myxedema coma is a life threatening complication of long standing and untreated hypothyroidism with one of the following characteristics. A. B. C. D.
Hype Hyperg rgly lyce cemi mia a Hypo Hy poth ther erm mia Hype Hypert rthe herm rmia ia Hypo Hypogl glyc ycem emia ia
70. As a nurse, you know that the most common type of goiter is related to a deficiency of: A. B. C. D.
thyr thyro oxine xine thyr thyrot otrropin opin iron iodine
Situation 15 – Mrs. Pichay is admitted to your ward. The MD ordered “Prepare “Prepare for thoracentesis this pm to remove excess air from the pleural cavity.” 71. Which of the following nursing responsibilities is essential in Mrs. Pichay who will undergo thoracentesis thor acentesis? ? A. B. C. D.
Support Support and reassu reassure re client client during during the the procedur procedure e Ensure Ensure that informed informed consent consent has been been signed signed Determine Determine if client client has allergi allergic c reaction reaction to local anesthe anesthesia sia Ascertain Asce rtain if chest chest x-rays and and other tests tests have been been prescribed prescribed and completed
72. Mrs. Pichay who is for thoracentesis is assigned by the nurse to any of the following positions, EXCEPT: A. B. C. D.
straddling straddling a chair chair with with arms and and head resting resting on the the back of the chair chair lying lying on the unaffecte unaffected d side with with the bed elevat elevated ed 30-40 degre degrees es lying lyin g prone with with the head head of the the bed lowere lowered d 15-30 degree degrees s sitting sitting on the edge of the the bed with her her feet supported supported and and arms and and head on a padded overhead table
73. During thoracentesis, which of the following nursing intervention will be most crucial? a. Place Place patie patient nt in a quie quiett and cool cool room room b. Mainta Maintain in stric strictt asepti aseptic c techni technique que c. Advi Advice ce patient patient to sit perfect perfectly ly still still during needle needle inserti insertion on until it has has been withdrawn from the chest d. Apply pressu pressure re over over the puncture puncture site site as soon as the the needle needle is withdrawn withdrawn
74. To prevent leakage of fluid in the thoracic cavity, how will you position the client after thoracentesis? A. B. C. D.
Plac Place e fla flatt in in bed bed Turn on on the unaf unaffec fected ted side side Turn on on the affe affecte cted d side side On bed bed re rest
75. Chest x-ray was ordered after thoracentesis. When your client asks what is the reason for another chest x-ray, you will explain: A. B. C. D.
to rul rule e out out pne pneumo umotho thorax rax to rule rule out any any possib possible le perfo perforat ration ion to dec decon ong gest est to rule rule out out any any forei foreign gn body body
Situation 16 – In the hospital, you are aware that we are helped by the use of a variety of equipment / devices to enhance quality patient care delivery. 76. You are to initiate an IV line to your patient, Kyle, 5, who is febrile. What IV administration set will you prepare? A. B. C. D.
Bloo Blood d trans transfu fusi sion on set set Macroset Volum olumet etri ric c chambe chamberr Micr Mi cros ose et
77. Kyle is diagnosed to have measles. What will your protective personal attire include? A. B. C. D.
Gown Eyewear Face ma mask Gloves
78. What will you do to ensure that Kyle, Kyle, who is febrile, will have a liberal oral fluid intake? A. Provide Provide a glass glass of fruit fruit juice juice every meal B. Re Regula gulate te his his IV IV to 30 drops drops per per minute minute C. Provide a calibrated calibrated pitcher of drinking water water and juice at the bedside bedside and monitor intake and output D. Provide Provide a writing writing pad pad to record record his his intake intake 79. Before bedtime, you went to ensure Kyle’s safety in bed. You will do which of the following: A. B. C. D.
Put Put the the ligh lights ts on Putt the Pu the sid side e rail rails s up Test est the the call call sys system tem Lock Lock the the doo doors rs
80. Kyle’s room is fully mechanized. What do you teach the watcher and Kyle to alert the nurses for help?
A. B. C. D.
How How to loc lock k side side rai rails ls Number Number of of the tele telephon phone e operat operator or Calll sys Ca syste tem m Remot emote e con contr trol ol
Situation 17 – Tony, 11 years old, has ‘kissing tonsils’ and is scheduled for tonsillectomy and adenoidectomy or T and A. 81. You are the nurse of Tony who will undergo T and A in the morning. His mother asked you if Tony will be put to sleep. Your teaching will focus on: A. B. C. D.
spin spinal al anes anesth thes esia ia anesth anesthesi esiolo ologis gist’s t’s prefer preferenc ence e loca locall ane anest sthe hesi sia a genera gen erall an anest esthes hesia ia
82. Mothers of children undergoing tonsillectomy and adenoidectomy usually ask what food to prepare and give their children after surgery. You as the nurse will say: A. B. C. D.
balanc balanced ed diet diet when when fully fully awa awake ke hot soup soup whe when n awak awake e ice cream cream when when fully fully awa awake ke softt diet sof diet when when fully fully awak awake e
83. The RR nurse should monitor for the most common postoperative complication of: A. B. C. D.
hemorrrha hemo hage ge endotra endotrache cheal al tube tube perfo perforat ration ion osop osopha hary ryng ngea eall edema edema epig epiglo lott ttis is
84. The PACU nurse will maintain postoperative postoperative T and A client in what position? A. B. C. D.
Supine Supine with neck neck hyperex hyperextende tended d and supported supported with with pillow pillow Prone Pron e with with the head head on pillow pillow and turned turned to to the side side Semi-f Semi-fow owler ler’s ’s with with neck flex flexed ed Revers Re verse e trendelenb trendelenburg urg with with extended extended neck neck
85. Tony is to be discharged in the afternoon of the same day after tonsillectomy and adenoidectomy. You as the RN will make sure that the family knows to: A. B. C. D.
offer offer osteri osterize zed d fee feedin ding g offer soft soft foods for a week week to minimize minimize discomf discomfort ort while while swallowi swallowing ng supplemen supplementt his diet with with Vitamin Vitamin C rich juices juices to enhance enhance healing healing offer clear clear liquid liquid for 3 days days to preven preventt irritation irritation
Situation 18 – Rudy was diagnosed to have chronic renal failure. Hemodialysis is ordered so that an A-V shunt was surgically created. 86. Which of the following action would be of highest priority with regards to the external shunt? A. Avoid Avoid taking taking BP or blood blood sample sample from from the a arm rm with the the shunt shunt B. Instruct Instruct the clien clientt not to exerci exercise se the arm arm with with the shunt shunt C. Hepari Hepariniz nize e the the shunt shunt daily daily
D. Change Change dressi dressing ng of the shunt daily daily 87. Diet therapy for Rudy, who has acute renal failure is low-protein, low potassium and low sodium. The nutrition instructions should include: A. Recomme Recommend nd protein protein of high biologic biologic value value like eggs, eggs, poultry poultry and lean lean meats B. Encourage Encourage client client to include include raw cucumbers, cucumbers, carrot carrot,, cabbage, cabbage, and tomatoes tomatoes C. Allowing Allowing the client client chees cheese, e, canned canned foods and and other process processed ed food D. Bananas, cantaloupe, orange and other other fresh fruits can be included included in the diet 88. Rudy undergoes hemodialysis for the first time and was scared of disequilibrium syndrome. He asked you how this can be prevented. Your response is: A. maintain maintain a conduc conducive ive comforta comfortable ble and and cool envir environmen onmentt B. maintain maintain fluid and electroly electrolyte te balan balance ce C. initi initial al hemodial hemodialysis ysis shall shall be done 30 minutes minutes only only so as not to rapidly rapidly remove the waste from the blood than from the brain D. maintain maintain aseptic aseptic techniqu technique e throughout throughout the hemodialys hemodialysis is 89. You are assisted by a nursing aide with the care of the client with renal failure. Which delegated function to the aide would you particularly check? A. B. C. D.
Monitorin Monito ring g and reco recordi rding ng I and and O Checki Checking ng bowel bowel moveme movement nt Obtaini Obtaining ng vital vital signs signs Moni Mo nito tori ring ng diet diet
90. A renal failure patient was ordered for creatinine clearance. As the nurse you will collect… A. B. C. D.
48 hou hourr urine urine spe speci cime men n firs firstt mor morni ning ng urin urine e 24 hou hourr urine urine spe speci cime men n random random urine urine specim specimen en
Situation 19 – Fe is experiencing left sharp pain and occasional hematuria. She was advised to undergo IVP by her physician. 91. Fe was so anxious about the procedure and particularly expressed her low pain threshold. Nursing health instruction will include: A. assure assure the client client that the pain pain is associate associated d with the warm warm sensation sensation during the administration of the Hypaque by IV B. assu assure re the the client client that that the proc procedur edure e painles painless s C. assure assure the client client that that contrast contrast medium medium will will be given orally orally D. assure the client that x-ray procedure like IVP is only done by experts 92. What will the nurse monitor and instruct the client and significant others post IVP? A. Report Report signs signs and symptoms symptoms for for delayed delayed allergi allergic c reaction reaction B. Obse Observ rve e NPO NPO for for 6 hou hours rs C. Inc Increa rease sed d fluid fluid int intak ake e
D. Monito Monitorr intak intake e and and output output 93. Post IVP, Fe should excrete the contrast medium. You instructed the family to include more vegetables in the diet and: A. B. C. D.
increas incre ase e flui fluid d inta intak ke bari barium um ene enema ma clea cleans nsin ing g enem enema a gast gastri ric c lava lavage ge
94. The IVP reveals that Fe has small renal calculus that can be passed out spontaneously. To increase the chance of passing the stones, you instructed her to force fluids and do which of the following? A. B. C. D.
Bala Balanc nced ed diet diet Ambu Ambula late te more more Stra St rain in al alll ur urin ine e Bed rest
95. The presence of calculi in the urinary tr act is called A. Cole Coleli lith thia iasi sis s B. Neph Nephro roli lith thia iasi sis s C. Uret Ureter erol olit ithi hias asis is D. Uroli Urolithias thiasis is
Situation 20 – At the medical-surgical medical-surgical ward, the nurse must also be concerned about drug interactions. 96. You have a client with TPN. You know that in TPN like blood transfusion, these should be no drug incorporation. However the MD’s order read; incorporate insulin to present TPN. Will you follow the order? A. No, because because insulin insulin will will induce hypergl hyperglycem ycemia ia in patients patients with TPN B. Yes, bec because ause insulin insulin is chemically chemically stable with with TPN and can enhance enhance blood glucose level C. No, becaus because e insulin insulin is not compat compatible ible with TPN D. Yes, becaus because e it was order ordered ed by the MD 97. The RN should also know that some drugs have increased adsorption when infused in the PVC container. How will you administer drugs such as insulin, nitroglycerine hydralazine to promote better therapeutic drug effects? A. B. C. D.
Admini Administe sterr by by fas fastt drip drip Inject Inject the drugs drugs as as close close to the the IV inject injection ion site site Incorpo Incorporat rate e to the the IV solu solutio tions ns Use vol volume umetri tric c cham chamber ber
98. One patient had a ‘runaway’ IV of 50% dextrose. To prevent temporary excess of insulin or transient hyperinsulin reaction what solution you prepare in anticipation of the doctor’s order? A. Any IV IV soluti solution on avail availabl able e to KVO KVO B. Is Isot oton onic ic so solu luti tion on C. Hype Hypert rton onic ic sol solut utio ion n
D. Hypo Hypoto toni nic c solut solutio ion n 99. How can nurses prevent drug interaction including adsorption? A. B. C. D.
Always Always flush flush with with NSS after after IV adminis administrati tration on Administ Administering ering drugs with more diluents diluents Improving Improving on prep preparati aration on techni techniques ques Refer Re ferring ring to manufac manufacture turer’s r’s guideli guidelines nes
100. In insulin administration, it should be understood that our body normally releases insulin insulin according to our blood glucose level. When is insulin and glucose level highest? A. B. C. D.
After fter exc excit item emen entt After After a good good nigh night’s t’s rest rest After fter an an exer exerci cise se After Af ter ing ingest estion ion of food food
