Nursing Practice IV - Naga Nov 2023

NLE

Situation 1 - Because of the serious consequences of severe burns

management requires a multi disciplinary approach. You have important
responsibilities as a nurse.
1. While Sergio was lighting a barbecue grill with a lighter fluid, his shirt
burst into flames. The most effective way to extinguish the flames with as
little further damage as possible is to:
*
1/1
a. log roll on the grass/ground
b. slap the flames with his hands
c. remove the burning clothes
d. pour cold liquid over the flames
2. Once the flames are extinguished, it is most important to:
*
0/1
a. cover Sergio with a warm blanket
b. give him sips of water
c. calculate the extent of his burns
d. assess Sergio's breathing
3. Sergio is brought to the Emergency Room after the barbecue grill
accident. Based on the assessment of the physician, Sergio sustained
superficial partial thickness bums on his trunk, right upper extremities ad
right lower extremities. His wife asks what that means. Your most accurate
response would be:
*
1/1
a. Structures beneath the skin are damaged
b. Dermis is partially damaged
c. Epidermis and dermis are both damaged
d. Epidermis is damaged
4. During the first 24 hours after thermal injury, you should assess Sergio
for
*
1/1
a. hypokalemia and hypernatremia
b. hypokalemia and hyponatremia
c. hyperkalemia and hyponatremia
d. hyperkalemia and Hypernatremia
5. Teddy, who sustained deep partial thickness and full thickness burns of
the face, whole anterior chest and both upper extremities two days ago,
begins to exhibit extreme restlessness. You recognize that this most likely
indicates that Teddy is developing:
*
1/1
a. Cerebral hypoxia
b. Hypervolemia
c. Metabolic acidosis
d. Renal failure .
Situation 2 - You are now working as a staff nurse in a general hospital. You
have to be prepared to handle situations with ethico-legal and moral
implications.
6. You are on night duty in the surgical ward. One of our patients Martin is
prisoner who sustained an abdominal gunshot wound. He is being guarded
by policemen from the local police unit. During your rounds you heard a
commotion. You saw the policeman trying to hit Martin. You asked why he
was trying to hurt Martin. He denied the matter. Which among the following
activities will you do first?
*
0/1
a. Write an incident report
b. Call security officer and report the incident
c. Call your nurse supervisor and report the incident:
d. Call the physician on duty
7. The nurse gives an inaccurate dose of a medication to a client. Following
assessment of the client, the nurse completes an incident report. The nurse
notifies the nursing supervisor of the medication error and calls the physician
to report the occurrence. The nurse who administered the inaccurate
medication dose understands that the:
*
0/1
a. error will result in suspension
b. incident report is a method of promoting quality care and risk management
c. incident will be reported to the board of nursing
d. incident will be documented in the personnel file.
8. The nurse hears a client call for help. The nurse hurries down the hallway
to the client’s room and finds the client lying on the floor. The nurse
performs a thorough assessment and assists the client back to bed. The
nurse notifies the physician of the incident and completes an incident report.
Which of the following would the nurse document on the incident report?
*
1/1
a. the client was found lying on the floor
b. the client climbed over the side rails
c. the client fell out of bed
d. the client became restless and tired to get out of bed
9. You are on duty in the medical ward. The mother of your patient who is
also a nurse came running to the nurse station and informed you that Fiolo
went into cardiopulmonary arrest. Which among the following will you do
first?
*
1/1
a. Start basic life support measures
b. Call for the Code
c. Bring the crash cart to the room
d. Go to see Fiolo and assess for airway patency and breathing problems
10. A client is brought to the emergency medical services after being hit by
a car. The name of the client is not known. The client has sustained a severe
head injury, multiple fractures, and is unconscious. An
emergency craniotomy is required. Regarding informed consent for the
surgical procedure, which of the following is the best action?
*
0/1
a. call the police to identify the client and locate the family
b. obtain a court order for the surgical procedure.
c. ask the emergency medical services team to sign the informed consent
d. transport the victim to the operating room for surgery
Situation 3 - Colorectal cancer can affect old and younger people. Surgical
procedures and other modes of treatment are done to ensure quality of life.
You are assigned in the Cancer institute to care of patients with this type of
cancer.
11. Larry, 55 years old, who is suspected of having colorectal cancer, is
admitted to the CI. After taking the history and vital signs the physician does
which test as a screening test for colorectal cancer.
*
0/1
a. Barium enema
b. Carcinoembryonic antigen
c. Annual digital rectal examination
d. Proctosigmoidoscopy
12. To confirm his impression of colorectal cancer, Larry will require which
diagnostic study?
*
1/1
a. carcinoembryonic antigen
b. incisional biopsy of the colon
c. stool hematologic test
d. abdominal computed tomography (CT) test
13. The following are risk factors for colorectal cancer, EXCEPT:
*
1/1
a. inflammatory bowels
b. low fat, high fiber diet
c. smoking
d. genetic factors-familial adenomatous polyposis
14. Symptoms associated with cancer of the colon include:
*
1/1
a. constipation, ascites and mucus in the stool
b. diarrhea, heartburn and eructation
c. blood in the stools, anemia, and pencil-shaped, stools
d. anorexia, hematemesis, and increased peristalsis
15. Several days prior to bowel surgery, Larry may be given sulfasuxidine
and neomycin primarily to:
*
1/1
a. promote rest of the bowel by minimizing peristalsis
b. reduce the bacterial content of the colon
c. empty the bowel of solid waste
d. soften the stool by retaining water in the colon
Situation 4 - ENTEROSTOMAL THERAPY is now considered especially in
nursing. You are participating in the OSTOMY CARE CLASS.
16. You plan to teach Fermin how to irrigate the colostomy when:
*
1/1
a. The perineal wound heals and Fermin can sit comfortably on the commode
b. Fermin can lie on the side comfortably, about the 3rd postoperative day
c. The abdominal incision is close and contamination is no longer a danger
d. The stool starts to become formed, around the 7th postoperative day
17. When preparing to teach Fermin how to irrigate his colostomy, you
should plan to do the procedure:
*
0/1
a. When Fermin would have normal bowel movement
b. At least 2 hours before visiting hours
c. After breakfast
d. After Fermin accepts alteration in body image
18. When observing a rectum demonstration of colostomy irrigation, you
know that more teaching is required if Fermin:
*
0/1
a. Lubricates the tip of the catheter prior to inserting into the stoma
b. Hands the irrigating bag on the bathroom door doth hook during fluid insertion
c. Discontinues the insertion of fluid after only 500 ml of fluid had been insertion
d. Clamps off the flow of fluid when feeling uncomfortable
19. You are aware that teaching about colostomy care is understood when
Fermin states, "I will contact my physician and report:
*
0/1
a. If I have any difficulty inserting the irrigating tube into the stoma."
b. If I notice a loss of sensation to touch in the stoma tissue."
c. The expulsion of flatus while the irrigating fluid is running out."
d. When mucus is passed from the stoma between irrigation."
20. You would know after teaching. Fermin that dietary instruction for him is
effective when he states, "It is important that I eat:
*
1/1
a. Soft foods that are easily digested and absorbed by my large intestine."
b. Bland food so that my intestines do not become irritated."
c. Food low in fiber so that there is less stool."
d. Everything that I ate before the operation, while avoiding foods that cause gas."
Situation 5 - Ensuring safety is one of your most important responsibilities.
You will need to provide instructions and information to your clients to
prevent complications.
21. Randy has chest tubes attached to a pleural drainage system. When
caring for him you should:
*
0/1
a. empty the drainage system at the end of the shift
b. clamp the chest tube when suctioning
c. palpate the surrounding areas for crepitus
d. change the dressing daily using aseptic techniques
22. Fanny came in from PACK after pelvic surgery. As Fanny's nurse you
know that the sign that would be indicative of a developing thrombophlebitis
would be:
*
0/1
a. a tender, painful area on the leg
b. a pitting edema of the ankle
c. a reddened area at the ankle
d. pruritus on the calf and ankle
23. To prevent recurrent attacks on Terry who has acute glomerulonephritis,
you should instruct her to:
*
1/1
a. seek early treatment for respiratory infections
b. take showers instead of tub bath
c. continue to take the same restrictions on fluid intake
d. avoid situations that involve physical activity
24. Herbert has a laryngectomy and he is now for discharge. He verbalized
his concern regarding his laryngectomy tube being dislodged, what should
you teach him first?
*
1/1
a. Recognize that prompt closure of the tracheal opening may occur
b. Keep calm because there is no immediate emergency
c. Reinsert another tubing immediately
d. Notify the physician at once
25. When caring for Larry after an exploratory chest surgery and
pneumonectomy, your priority would be to maintain:
*
1/1
a. supplementary oxygen
b. ventilation exchange
c. chest tube drainage
d. blood replacement
Situation 6 - Infection can cause debilitating consequences when host
resistance is compromised and virulence of microorganisms and
environmental factors are favorable. Infection control is one important
responsibility of the nurse to ensure quality of care.
26. Honrad, who has been complaining of anorexia and feeling tired,
develops jaundice. After a workup he is diagnosed of having Hepatitis A. His
wife asks you about gamma globulin for herself and her household help. Your
most appropriate response would be:
*
1/1
a. "Don't worry your husband's type of hepatitis is no longer communicable"
b. "Gamma globulin provides passive immunity for Hepatitis B"
c. "You should contact your physician immediately about getting gamma globulin."
d. "A vaccine has been developed for this type of hepatitis"
27. Voltaire develops a nosocomial respiratory tract infection. He asks you
what that means.
*
1/1
a. "You acquired the infection after you have been admitted to the hospital."
b. "This is a highly contagious infection requiring complete isolation."
c. "The infection you had prior to hospitalization flared up."
d. "As a result of medical treatment, you have acquired a secondary infection."
28. As a nurse you know that one of the complications that you have to
watch out for when caring for Omar who is receiving total parenteral
nutrition is:
*
0/1
a. stomatitis
b. hepatitis
c. dysrhythmia
d. infection
29. A solution used to treat Pseudomonas wound infection is:
*
0/1
a. Dakin's solution
b. Half-strength hydrogen peroxide
c. Acetic acid
d. Betadine
30. Which of the following is most reliable in diagnosing a wound infection?
*
0/1
a. Culture and sensitivity
b. Purulent drainage from a wound
c. WBC count of 20,000/pL
d. Gram stain testing
Situation 7 - As a nurse you need to anticipate the occurrence of
complications of stroke so that life threatening situations can be prevented.
31. Wendy is admitted to the hospital with signs and symptoms of stroke.
Her Glasgow Coma Scale is 6 on admission. A central venous catheter was
inserted and an I.V. infusion was started. As a nurse assigned to Wendy what
will he your priority goal?
*
1/1
a. Prevent skin breakdown
b. Preserve muscle function
c. Promote urinary elimination
d. Maintain a patent airway
32. Knowing that for a comatose patient hearing is the best last sense to be
lost, as Judy's nurse, what should you do?
*
1/1
a. Tell her family that probably she can't hear them
b. Talk loudly so that Wendy can hear you
c. Tell her family who are in the room not to talk
d. Speak softly then hold her hands gently
33. Which among the following interventions should you consider as the
highest priority when caring for June who has hemiparersis secondary to
stroke?
*
0/1
a. Place June on an upright lateral position
b. Perform range of motion exercises
c. Apply antiembolic stocking
d. Use hand rolls or pillows for support
34. Ivy, age 40, was admitted to the hospital with a severe headache, stiff
neck and photophobia. She was diagnosed with a subarachnoid hemorrhage
secondary to ruptured aneurysm. While waiting for surgery, you can provide
a therapeutic by doing which of the following?
*
0/1
a. honoring her request for a television
b. placing her bed near the window
c. dimming the light in her room
d. allowing the family unrestricted visiting privileges
35. When performing a neurological assessment on Walter, you find that his
pupils are fixed and dilated. This indicated that he:
*
1/1
a. probably has meningitis
b. is going to be blind because of trauma
c. is permanently paralyzed
d. has received a significant brain injury
Situation 8 - With the improvement in life expectancies and the emphasis in
the quality of life it is important to provide quality care to our older patients.
There are frequently encountered situations and issues relevant to the older,
patients.
36. Hypoxia may occur in the older patients because of which of the
following physiologic changes associated with aging.
*
0/1
a. Ineffective airway clearance
b. Decreased alveolar surface area
c. Decreased anterior-posterior chest diameter
d. Hyperventilation
37. The older patient is at higher risk for in incontinence because of:
*
1/1
a. dilated urethra
b. increased glomerular filtration rate
c. diuretic use
d. decreased bladder capacity
38. Merle, age 86, is complaining of dizziness when she stands up. This may
indicate:
*
1/1
a. dementia
b. a visual problem
c. functional decline
d. drug toxicity
39. Cardiac ischemia in an older patient usually produces:
*
1/1
a. ST-T wave changes
b. Very high creatinine kinase level
c. chest pain radiating to the left arm
d. acute confusion
40. The nurse is providing medication instructions to an older adult who is
taking digoxin (Lanoxin) daily. The nurse bears in mind that which age-
related body changes could place the client at risk for digoxin toxicity?
*
0/1
a. decreased cough efficiency and decreased vital capacity
b. decreased lean body mass and decreased glomerular filtration rate
c. decreased salivation and decreased gastrointestinal motility
d. decreased muscle strength and loss of bone density
Situation 9 - A "disaster" is a large-scale emergency—even a small
emergency left unmanaged may turn into a disaster. Disaster preparedness
is crucial and is everybody's business. There are agencies that are in charge
of ensuring prompt response. Comprehensive Emergency Management
(CEM) is an integrated approach to the management of emergency program
and activities for all four emergency phases (mitigation, preparedness,
response, and recovery), for all type of emergencies and disasters (natural,
man-made, and attack) and for all levels of government and the private
sector.
41. Which of the four phases of emergency management is defined as
"sustained action that reduces or eliminates long-term risk to people and
properly from natural hazards and the effect"?
*
0/1
a. Recovery
b. Mitigation
c. Response
d. Preparedness
42. You are a community health nurse collaborating with the Red Cross and
working with disaster relief following a typhoon which flooded and
devastated the whole province. Finding safe housing for survivors, organizing
support for the family, organizing counseling debriefing sessions and
securing physical care are the services you are involved with. To which type
of prevention are these activities included.
*
0/1
a. Tertiary prevention
b. Primary prevention
c. Aggregate care prevention
d. Secondary prevention
43. During the disaster you see a victim with a green tag, you know that the
person:
*
1/1
a. has injuries that are significant and require medical care but can wait hours will
threat to life or limb
b. has injuries that are life threatening but survival is good with minimal
intervention
c. indicates injuries that are extensive and chances of survival are unlikely even
with definitive care
d. has injuries that are minor and treatment can be delayed from hours to days
44. The term given to a category of triage that refers to life threatening or
potentially life threatening injury or illness requiring immediate treatment:
*
1/1
a. Immediate
b. Emergent
c. Non-acute
d. Urgent
45. Which of the following terms refer to a process by which the individual
receives education about recognition of stress reactions and management
strategies for handling stress which may be instituted after a disaster?
*
0/1
a. Critical incident stress management
b. Follow-up
c. Debriefing
d. Defusion
Situation 10 - As a member of the health and nursing team you have a
crucial role to play in ensuring that all the members participate actively is
the various tasks agreed upon,
46. While eating his meal, Matthew accidentally dislodges his IV line and
bleeds. Blood oozes on the surface of the over-bed table. It is most
appropriate that you instruct the housekeeper to clean the table with:
*
0/1
a. Acetone
b. Alcohol
c. Ammonia
d. Bleach
47. The nurse manager has implemented a change in the method of the
nursing delivery system from functional team nursing. A nursing assistant is
resistant to the change and is not taking an active part in facilitating the
process of change. Which of the following would be the best approach in
dealing with the nursing assistant?
*
1/1
a. ignore the resistance
b. exert coercion with the nursing assistant.
c. provide a positive reward system for the nursing assistant
d. confront the nursing assistant to encourage verbalization of feelings regarding
the change.
48. Part of your responsibility as a member of the diabetes core group is to
get referrals from the various wards regarding diabetic patients needing
diabetes education. Prior to discharge today 4 patients are referred to
you. How would you start prioritizing your activities?
*
1/1
a. Bring your diabetes teaching kit and start your session taking into consideration
their distance from your office
b. Contact the nurse-in-charge and find out from her the reason for the referral
c. Determine their learning needs then prioritize
d. involve the whole family in the teaching class
49. The nurse is working in a long-term care facility and is administering
medications to assigned clients. A client refuses to take the prescribed
medication, and the nurse threatens the client and tells the client that if
the medication is not taken orally, then restraints will be applied and the
medication will be given by injection. This statement by the nurse constitutes
which legal tort?
*
1/1
a. invasion of privacy
b. negligence
c. assault
d. battery
50. The nurse is reviewing the critical paths of the clients on the nursing unit.
In performing a variance analysis, which of the following would indicate the
need for further action and analysis?
*
1/1
a. a client’s family attending a diabetic teaching session
b. canceling physical therapy sessions on the weekend
c. normal vital signs and absence of wound infection in a postoperative client
d. a client demonstrating accurate medication administration following teaching
Situation 11 - One of the realities that we are confronted with is mortality.
It is important for us nurses to be aware of how we view suffering, pain,
illness, and even our death as well as its meaning. That way we can help our
patients cope with death and dying.
51. Nurse Fay is assigned to client Irma. Irma is terminally ill she speaks to
Nurse Fay in confidence. Nurse Fay now feels that Irma's family could be
helpful if they knew what Irma has told her. What should Nurse Fay do first?
*
0/1
a. Tell the physician who in turn could tell the family
b. Obtain Irma's permission to share the information with the family
c. Tell Irma that she has to tell her family what she told you
d. Make an appointment to discuss the situation with the family
52. Nurse Nathalie Angie is assigned to client Ruby. Ruby who has been told
she has terminal cancer turns away and refuses to respond to Nurse Nathalie
Angie. Nurse Nathalie Angie can best help her by:
*
1/1
a. Coming back periodically and indicating your availability if she would like you to
sit with her
b. Insisting that Ruby should talk with you because it is not good to keep everything
inside
c. Leaving her alone because she is uncooperative and unpleasant to be with
d. Encouraging her to be physically active as possible
53. Eddy who is terminally ill and recognizes that he is in the process of
losing, everything and everybody he loves, is depressed. Which of the
following would best help him during depression?
*
0/1
a. Arrange for visitors who might cheer him
b. Sit down and talk with him for a while
c. Encourage him to look at the brighter side of things
d. Sit silently with him
54. Which of the following statements would best indicate that Chun Lee;
who is dying has accepted this impending death?
*
0/1
a. "I'm ready to die."
b. "I have resigned myself to dying"
c. "What's the use"?
d: "I'm giving up"
55. Piola, 90 years old has planned ahead for her-death-philosophically,
socially, financially and emotionally. This is recognized as:
*
0/1
a. Acceptance that death is inevitable
b Avoidance of the true sedation
c. Denial with planning for continued life
d. Awareness that death will soon occur
Situation 12 - Brain tumor, whether malignant or benign, has serious
management implications nurse, you should be able to understand the
consequences of the disease and the treatment.
56. Nurse Farrah Faye is caring for Conrad who has a brain tumor and
Increased Intracranial Pressure (ICP). Which intervention should Nurse Farrah
Faye include in her plan to reduce ICP?
*
0/1
a. Administer bowel Softener
b. Position Conrad with his head turned toward the side of the tumor
c. Provide sensory stimulation
d. Encourage coughing and deep breathing
57. Nurse Glaiza Mae helps in positioning patient Conrad. Keeping Conrad's
head and neck in alignment results in:
*
0/1
a. increased intrathoracic pressure
b. increased venous outflow
c. decreased venous outflow
d. increased intra abdominal pressure
58. Which of the following activities may increase intracranial pressure
(ICP)?
*
1/1
a. Raising the head of the bed
b. Manual hyperventilation
c. Use of osmotic Diuretics
d. Valsava's maneuver
59. After Nurse Ma. Erma assessed Conrad, she suspected increased ICP.Her
most appropriate respiratory goal is to:
*
0/1
a. maintain partial pressure of arterial 02 (Pa02) above 80 mmHg
b. lower arterial pH
c. prevent respiratory alkalosis
d. promote C02 elimination
60. Conrad underwent craniotomy. As his nurse; you know that drainage on a
craniotomy dressing must be measured and marked, which findings should
you report immediately to the surgeon?
*
0/1
a. Foul-smelling drainage
b. yellowish drainage
c. Greenish drainage
d. Bloody drainage
61. Which of the following instructions should Nurse Julie Lorraine provide to
a patient who has diabetes and hypertrophic lipodystrophy?
*
1/1
a. Rotate insulin injection sites
b. Inject insulin at the edge of the affected area
c. Withhold injection of insulin until the area heals
d. Use a longer needle to administer the insulin
62. The registered nurse’s signature as a witness on an informed consent
indicates that the patient
*
0/1
a. has been informed regarding the procedure.
b. was medicated for pain before the consent was signed.
c. can describe how the procedure will be done.
d. voluntarily agreed to having the procedure performed.
63. Nurse Aileen is assessing a patient with hypovolemic shock, which of the
following manifestations would Nurse Aileen most likely see first?
*
0/1
a. Nervousness and apprehension
b. Decreased urinary output
c. Systolic blood pressure below 90 mmHg
d. Hypoventilation and tachycardia
64. Staff nurses, Allen and Mary Jane, learn that a patient they have been
caring for during the last few weeks has just been diagnosed with
tuberculosis. When the nurses express concern about contracting
tuberculosis themselves, the charge nurse’s response should be based on
which of the following statements?
*
0/1
a. Tuberculosis is not highly infectious when standard precautions are followed.
b. The Mantoux test is used to confirm diagnosis of tuberculosis.
c. Tuberculosis is easily treated with a short course of antibiotics.
d. Vaccination with Bacillus Calmette Guerin (BCG) will be used to immunize the
nurses against infection.
65. To which of the following nursing diagnosis would a nurse manager give
priority when an impaired nurse returns to work?
*
1/1
a. Ineffective individual coping
b. Situational low self-esteem
c. Growth and development; altered
d. Ineffective family coping; compromised
66. A woman who is dependent on alcohol is admitted to the detoxification
unit. The answer to which of the following question is essential for the nurse
to obtain from the patient immediately?
*
1/1
a. How does her husband react to her problem?
b. When did she have her last drink?
c. How old she was when she began to drink?
d. What did she eat in the past four hours?
67. A patient seems unconcerned about the sudden loss of vision in both
eyes. Physical examination fails to reveal a physical cause for this problem.
Which of the following terms should the nurse use to describe this
phenomenon when charting the behavior?
*
0/1
a. La belle indifference
b. Malingering - faking
c. Hypochondria
d. Confabulation
68. Nurse May is assigned to patient with PTSD. Which of the following
observations would be most definitive when Nurse May is assessing a patient
with posttraumatic stress disorder?
*
1/1
a. Substance abuse
b. Aggression
c. Flashbacks
d. Depression
69. Disulfiram (Antabuse) is prescribed for a patient. Which of the following
comments, if made by the patient, would indicate correct understanding of
the action of this medication?
*
1/1
a. “ I’ll drink fruit juice at social gatherings”
b. “ I’ll take my pulse four times a day”
c. “ I’ll lie down for half an hour after I take the pill”
d. “ I’ll take an antacid before my antabuse”
70. Which of the following arterial blood gas levels would nurse expect to
observe when monitoring a patient who has metabolic alkalosis?
*
0/1
a. pH, 7.50; pCO2, 38 mmHg; HC03, 30mEq
b. pH, 7.30; pCO2, 56 mmHg; HCO3, 24 mEq
c. pH, 7.38; pCO2, 42 mmHg; HCO3, 25 mEq
d. pH, 7.26; pCO2, 37 mmHg; HCO3, 18 mEq
71. While Jayvee, a burn patient is being transferred by Nurse Vicky from
the burn unit to the operating room, the IV bottle fell on Jayvee’s head. He
sustained a laceration on his forehead. Nurse Vicky was proven guilty of
negligence. Which of the following did nurse Vicky fail to do?
*
0/1
a. Hold the IV bottle
b. Check the IV stand
c. Place the IV stand on the foot part of the stretcher
d. Restrain Jayvee
72. Nurse Krystel is caring for client Olga. Olga is receiving D5W 1 liter
regulated at 30 drops/min to be consumed in 8 hrs. It was started at 8am. At
10 am her relative informed Nurse Krystel that the bottle is empty. Which of
the following will Nurse Krystel do first?
*
1/1
a. Refer to nurse manager
b. Assess Olga and check level of fluid left in the bottle
c. Discontinue IV and assess Olga
d. Replace the IV fluid with prescribed follow-up
73. When Nurse Lynchen Jeanne volunteers to work in a hospital setting
and she commits a mistake, who is legally responsible?
*
0/1
a. Volunteer nurse, hospital and the nurse in charge
b. The professional organization which the volunteer nurse represents
c. Hospital
d. Volunteer nurse because there is no employer employee relationship
74. Nurse Mark Lawrence is reviewing the laboratory results of Clare who
has rheumatoid arthritis. Which laboratory result should the nurse expect to
find?
*
0/1
a. Increased platelet count
b. Altered blood urea nitrogen (BUN) and creatinine levels
c. Electrolyte imbalance
d. Elevated erythrocyte sedimentation rate (ESR)
75. Nurse Joseph T. accidentally administer 40 mg of Propanolol (Inderal) to
a client instead of 10 mg. Although the client exhibits no adverse reactions
to the larger dose, Nurse Joseph T should:
*
1/1
a. Complete an incident report
b. Call the hospital attorney
c. Inform the clients family
d. Do nothing because the clients condition is stable
Situation 13 – Nurses Denice and Cynthia are going to participate in a
Cancer Consciousness Week. They are assigned to take charge of the women
to make them aware of cancer, most especially cervical cancer. They
reviewed their manifestations and management.
76. The following are risk factors for cervical Cancer EXCEPT:
*
1/1
a. immunosuppressive therapy
b. sex at an early age, multiple partners, exposure to socially transmitted diseases,
male partner's sexual habits
c. viral agents like the Human Papilloma Virus
d. smoking
77. Late signs and symptoms of cervical cancer include the following
EXCEPT:
*
1/1
a. urinary/bowel changes
b. pain in pelvis, leg of flank
c. uterine bleeding
d. lymph edema of lower extremities
78. When a total hysterectomy is performed due to cancer of the cervix,
which of the following organs are removed?
*
0/1
a. the uterus, cervix, fallopian tubes and one ovary
b. the uterus, cervix, and two-thirds of the vagina
c. the uterus, cervix, tubes and ovaries
d. the uterus and cervix
79. A client with cervical cancer is being treated with a radioactive cervical
implant. The client's husband asks the nurse if he can spend the night with
his wife. The nurse should explain that:
*
1/1
a. Overnight stays by family members is against hospital policy.
b. There is no need for him to stay because staffing is adequate.
c. His wife will rest much better knowing that he is at home.
d. Visitation is limited to 30 minutes when the implant is in place.
80. A client with bladder cancer is being treated with iridium seed implants.
The nurse's discharge teaching should include telling the client to:
*
1/1
a. Strain his urine
b. Increase his fluid intake
c. Report urinary frequency
d. Avoid prolonged sitting
Situation 14 - Mr. Muscle, age 63, is admitted to the hospital with a
diagnosis of Congestive Heart Failure (CHF). The physician’s orders include
500 mg of chlorothiazide (Diuril) P.O. twice daily and 0.25 mg of Digoxin
(Lanoxin) P.O. daily.
81. Assessment of Mr. Muscle would most likely reveal:
*
0/1
a. Crushing chest pain unrelieved by rest or nitroglycerin ( Nitro-Bid)
b. Diaphoresis with cool, clammy skin
c. Distended neck veins and dependent pitting edema
d. Fever and elevated white blood cell count.
82. Mr. Muscle is in the acute phase of left ventricular heart failure. To
alleviate his symptoms, the nurse should place him in:
*
1/1
a. The dorsal recumbent position with elevated feet to reduce edema.
b. An upright position to promote chest expansion.
c. The low-fowlers position with elevated knees to slow the return of blood to the
heart.
d. The left lateral sims position to promote emptying to ride side of the heart.
83. Nurse Charm administers chlorothiazide. This drug should alleviate Mr.
Muscle’s symptoms by:
*
0/1
a. Reducing circulatory volume through dieresis
b. Strengthening the force of ventricular contractions
c. Reducing the rate of metabolism and the body’s need for oxygen
d. Slowing the rate of heart contractions.
84. Mr. Muscle is placed on a strict low-sodium, high potassium diet. Which
lunch menu is most appropriate for him?
*
1/1
a. Bologna sandwich on low-sodium bread, carrot sticks, orange, and skim milk.
b. Tuna fish, noodle and vegetable casserole, banana and coffee.
c. Boiled egg sandwich on low-sodium toast; lettuce, tomato, onion salad; banana;
skim milk.
d. Chicken sandwich on low sodium bread, celery sticks, apple, and tea with lemon.
Tomatoes is high in sodium
85. When assessing Mr. Muscle for sign and symptoms of digoxin toxicity,
the nurse should watch for all of the following except:
*
0/1
a. Bradycardia, tachycardia, begimeny, ectopic beats, and pulse deficits.
b. Anorexia, nausea and vomiting, diarrhea, and abdominal pain.
c. Headache, double or blurred vision, drowsiness, confusion, restlessness, and
muscle weakness.
d. Abdominal distention, weakness, paralysis, apathy, depression and hallucinations
Situation 15 - Mr.Pakyaw has had a persistent cough for about 4 months.
One week ago, he noted blood in his sputum. He is admitted in the hospital
for diagnostic testing. The physician orders a bronchoscopy.
86. Immediately after the bronchoscopy, the nurse should withhold food and
fluid until Mr. Pakyaw’s gag reflex returns, to prevent:
*
1/1
a. Aspiration
b. Abdominal distention
c. Dyspnea
d. Dyspepsia
87. Mr Pakyaw is diagnosed with lung cancer. The physician orders various
pulmonary function tests, including measurements of forced vital capacity
and forced expiratory volume. The test results are used before surgery to:
*
0/1
a. Evaluate the spread of the disease
b. Estimate the amount of anesthesia needed for surgery
c. Determine the amount of lung tissue to be removed
d. Calculate whether the contemplated surgery will leave enough functioning lung
tissue
88. After lobectomy, Mr. Pakyaw is returned to the unit with chest tubes in
place. The nurse assigns a nursing diagnosis of Impaired gas exchange
related to lung alterations after surgery. With this diagnosis, the expected
outcome is that the patient will:
*
1/1
a. Report less chest pain
b. Assume a semi-fowlers position
c. Request pain medication frequently
d. Exhibit a respiratory rate of less than 20 breaths / minute without dyspnea
89. Mr. Pakyaw will undergo radiation therapy on an outpatient basis to treat
the lung cancer. When teaching Mr. Pakyaw about skin care, the nurse
should encourage him to:
*
0/1
a. Use skin lotions and powders on the irradiated area
b. Avoid washing off the marks placed on his skin to guide radiation therapy
c. Wear constrictive clothing
d. Massage the irradiated area to increase circulation
90. Mr. Pakyaw’s wife, Chenny, is concerned about his poor appetite and
weight loss. Nurse Erika explains to her that radiation treatment, anxiety,
and the disease itself can cause anorexia in cancer patients. Nurse Erika
should encourage Mr. Pakyaw to:
*
1/1
a. Limit activity before and after meals
b. Force fluids
c. Eat high calorie foods
d. Eat hot meat dishes with special sauces
Situation 16 - Mrs.Dyangga, age 53, has been experiencing bone pain,
recurrent infections and abdominal pain for the past 5 years. After ordering a
battery of tests, including x-ray studies, the physician diagnoses Multiple
Myeloma.
91. The physician orders administration of melphalan (Alkeran) for Mrs.
Dyangga because this drug causes pancytopenia, the nurse should assess
the patient for:
*
1/1
a. Alopecia
b. Skin pigmentation changes
c. Thrombophlebitis
d. Decreased WBC count
92. Nursing care for Mrs. Dyangga should include:
*
0/1
a. Giving 2,000 ml of fluids daily
b. Giving more than 3,000 ml of fluid daily
c. Restricting fluid intake to equal the patient’s insensible fluid loss
d. Encouraging increased intake of fluids, particularly milk
Situation 17 - Nurse Lucille is caring for Madame L, age 59, in the hospital
with tentative diagnosis of stage III B Hodgkins disease.
93. Which assessment finding strongly indicates Hodgkin’s disease?
*
0/1
a. Night sweats
b. Enlarged lymph nodes
c. Reed-Sternberg cells
d. Hepatomegaly
94. The usual drug therapy for the patient with stage III B Hodgkin’s disease
is called MOPP. The “O” in MOPP stands for:
*
0/1
a. Prednisone (Orasone)
b. Vincristine (Oncovin)
c. Oxacillin (Bactocill)
d. Oxamniquine (Vansil)
95. Which nursing intervention is most effective in relieving nausea and
vomiting associated with MOPP therapy?
*
1/1
a. Administering an antiemetic simultaneously with the drug
b. Encouraging the patient to drink hot liquids, such as coffee or tea
c. Giving an antiemetic 1 to 3 hours before MOPP administration
d. Provide frequent oral hygiene
96. A patient who has sustained a fracture of femur is at risk for which of the
following complications in the immediate post-fracture period?
*
0/1
a. Electrolyte imbalance
b. Fat embolus
c. Fluid Volume deficit
d. Disuse Syndrome
97. A patient who has a long leg cast says to Nurse Hazel, “My thigh is
itching under the cast.” To provide relief, Nurse Hazel should?
*
0/1
a. teach patient guided imagery techniques.
b. apply heat to the cast at the site of the itching.
c. elevate the patients affected leg on pillows
d. encourage the patient to move his/her toes.
98. Nurse Cherry is caring for a patient who is receiving litium carbonate
(Eskalith). Prior to administration of the next dose, Nurse Cherry finds that
the patient’s lithium blood level is 1.6 mEq /dL. Which of the following
actions should Nurse Cherry take first?
*
0/1
a. Call the patient’s physician
b. Withhold the dose
c. Take the patients Vital signs
d. Repeat the blood lithium level
99. Which of the following goals would be given priority in the care plan of a
two year old child who has acute gastroenteritis?
*
1/1
a. Promote hydration.
b. Reduce lethargy
c. Preserve skin integrity
d. Maintain comfort
100. A priority nursing intervention for the care of a terminally ill patient
diagnosed with metastatic cancer is
*
0/1
a. Maintaining bowel function
b. Alleviating and relieving pain
c. Preventing respiratory arrest
d. managing chemotherapy.