NURSING PPACTICE III - CARE OF CLIENTS (PART A)

INSTRUCTION: 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.
SITUATIONAL

Situation- You are assigned in the PACU and is currently caring for patients
undergoing different types of surgical operations.

1. Nursing interventions indicated during the patient`s recovery form the

general anesthesia in the PACU includes which of the following?

A. Encouraging deep breathing and coughing

B. Withholding analgesics until the patient is discharged from the PACU
C. Placing the patient in supine position
D. Restraining patients during episodes of emergence delirium

2. Post-operative nausea and vomiting presents the greatest risk for _______.

A. An 81 year old, 55 kg. Woman following cystoscopy under local

anesthesia
B. A 45 year old, 70 kg. Man following an arthroscopy under epidural
anesthesia
C. A 23 year old, 125 kg. Woman following a diagnostic laparoscopy under
general anesthesia
D. A 14 year old, 40 kg. Boy following an orchiopexy under general
anesthesia

3. In preparation for discharge after surgery, which of the following should

the nurse advise the patient?

A. The rationale for abstinence from sexual intercourse for 4 to 6 weeks

B. A timeframe for when various physical activities can be required
C. The necessity if a referral to a nutritional center for management of
dietary restrictions
D. The need to call the hospital clinical unit to report any abnormal
signs and symptoms

4. Which of the following nursing actions during the immediate postoperative

period has the HIGHEST priority?

A. Observing for hemorrhage

B. Maintaining a patent airway
C. Recording intake and output
D. Checking vital signs every 15 minutes

5. An informed consent is required for EXCEPT?

A. Irrigation of the external ear canal

B. Closed reduction of a fracture
C. Urethral catheterization
D. Insertion of an intravenous catheter

Situation – A domain is the development of the competency of the practicing nurse

is one’s legal responsibility.

6. The graduates from the colleges of nursing are being prepared to take the
nursing licensure Examination (NLE) with the main goal to ______.
A. Provide opportunity for overseas employment
B. Determine the Standards of nursing practice
C. Protect the public from incompetent nurse practitioner
D. Limit the practice of profession

7. Ms. Libby is a professional nurse who was approached by her cousin to be in

a television show where she was to wear the nurses uniform and advertise a
commercially prepared beauty product for use in their work setting her
mother is presently having dialysis so she accepted the offer. Ms. Libby is
violating the_______.
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 A. Nursing law C. Nursing jurisprudence
B. Nursing code of ethics D. Consumer Fraud law

8. Mr. Larson is scheduled for coronary artery-by-pass graft (CABG) surgery. He

has to sign an informed consent prior to operation. The validity of this
consent is how long?
A. 36 hours after surgery C. After the surgical procedure
B. 24 hours after surgery D. 12 hours after surgery

9. A patient was admitted in a medical center by his physician for an

Exploratory laparotomy. After discharge for two days, he was complaining of
chills and fever. The abdominal incision was passing out yellowish purulent
discharge. He had an abdominal Xray and was found out to have 2 pcs of gauze
inside the abdomen. A libel suit was filed by the family. Who is liable in
this case?
1. Surgeon
2. Circulating nurse
3. Anesthesiologist
4. Hospital

A. 1, 2, 3, & 4 C. 1& 2
B. 1, 2, 3 D. 2 & 3

10. Nurse Cristine is assigned to a patient in ICU who is dying due to

cardiac arrest. After Two hours, the patient was pronounced dead. Which of
the following health status should guide the nurse if the patient is
declared dead?
A. All body system are no longer functioning
B. Flat sign of electro-cardiogram
C. Has no more pain sensation
D. Stoppage of heart beat and blood pressure

Situation- Kayla, a cashier in a bookstore consulted the ER because of abdominal

cramps, nausea and vomiting and slight fever. She has been experiencing there for
almost 3 days now. After a complete physical examination, laboratory and
diagnostic tests, the physician ordered her to be admitted for exploratory
laparotomy. You are the Nurse-in-charge of this patient.

11. As a nurse, the responsibility for your pre-operative care for patient
Kayla include which of the following EXCEPT ________.
A. Providing adequate nutrition and elimination
B. Preparing the operative site of the abdominal region
C. Explaining the surgical procedure while admitting the patient
D. Ensuring the patient is psychologically ready for the surgery

12. Which of the following pre-operative medications do you expect to be

ordered by the surgeon the night BEFORE surgery?
A. Morphine sulfate C. Valium
B. Phenergan D. Demerol

13. The patient is scheduled or operation at 8`o'clock. In the morning,

the pre-operative medications are administered an hour before the surgery.
What priority nursing measures should you perform before transferring the
patient to the operating room?
A. Ask her to sign the consent
B. Check if she is using her identification bracelet
C. Assist the patient to urinate
D. Determine what type of anesthesia will be done

14. What medicine is ordered by the surgeon to reduce salivation and

bronchial secretions before the operation?
A. Benadryl C. Magnesium SO4
B. Atropine SO4 D. Codeine

15. After 36 hours post exploratory laparotomy, which of the following

priority physical findings should be reported immediately to the attending
physician?
A. Presence of flatus C. Rigid abdomen
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 B. No bowel sounds D. Nausea and vomiting

Situation - Mrs. Dolly, 65 years old was admitted in the medical unit because of
malnutrition. She has been anorexic for the last 6 months due to family problems.
She always feel fatigue with body weakness and have lost weight (12 lbs in 2
months) due to poor appetite.

16. As the nurse-in-charge of this patient, if an individual has a caloric

deficiency in the diet, what specific manifestations do you expect to be
present? EXCEPT ________
A. Loss of subcutaneous fat C. Muscle wasting
B. Sparse hair D. Listlessness

17. In order to improve the nutritional needs of patient Dolly, the

physician ordered insertion of nasogastric tube (NGT). What is the
appropriate size of the feeding tube you should prepare for this purpose?
A. Fr. 13 to 14 C. Fr. 16 to 18
B. Fr. 15 to 16 D. Fr. 8 to 12

18. When inserting NGT to patient Dolly, the SAFETY ALERT and decision
points you should implement are the following:
I. Identify the patient using name birthday
II. Determine length of the tube to be inserted and mark location
III. Position her at 45 degrees head of bed elevation
IV. Let her breath and swallow during the procedure
V. Measure gastric residual volume during tube feeding

A. I, II, III and IV C. II and III

B. I, II, III, IV and V D. I and II

19. After inserting the NGT to patient Dolly, you would like to be sure
the tube is in the stomach. Which of the following PH VALUE of the gastric
aspirate indicates it is in place?
A. 6 C. 8
B. 7 D. 5

20. While you were feeding patient Dolly, you observed that the tube is
clogged. Which of the following solutions is appropriate to use in flushing
the NG?
A. 22 to 25 ml. Ice H20 C. 18 to 25 ml. Lukewarm H20
B. 20 to 30 ml. Of NSS D. 15 to 20 ml of distilled H20

Situation – Nurse G is assigned in the morning shift of the Post-Anesthesia Care

Unit (PACU) and has a patient for admission.

21. The INITIAL priority assessment performed by the nurse, when admitting
a patients the unit after abdominal surgery is to check for ______.
A. surgical site for drainage and hemorrhage
B. skin color and temperature
C. responsiveness to painful stimuli and noise
D. respiratory function and airway

22. How should the nurse position the patient who is in a somnolent status
and still under the effect of anesthesia?
A. Supine position with head bed slightly elevate.
B. Prone position with a pillow under the abdomen.
C. Semi-Fowler's position with the head turned to the right.
D. Left lateral position with a pillow supporting the head.

23. What a patient has bleeding after surgery the PACU nurse, expects
which color if coming from the arterial source?
A. Darkly-colored, blood flows fast.
B. Bright red and spurts with the heartbeat.
C. slow, dark-colored, generally ooze.
D. Pinkish colored- slowly flowing.

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 24. During the immediate post-operative phase , the PRIMARY goal of the
health care team is to maintain ventilation. Which of the following
situations should be observed as a result of hypoxemia?
A. Excess carbon dioxide in the blood
B. Increasing ammonia in the blood
C. Decreased oxygen saturation
D. Reduction of blood Ph

25. When a patient develops a temperature of 39.8 degree centigrade after

an abdominal surgery with an ongoing blood transfusion, the PACU nurse
should notify the surgeon as this may indicate ______.
A. abdominal tissue injury
B. on going potential infection
C. post-anesthesia drug reaction
D. allergic reaction from blood transfusion

Situation - Communication is a basic competency needed by the nurses in the

health care delivery system as a means of building relationships with patients
and significant others.

26. Mrs Lim ,52 year old has been in the hospital for almost a week. She
approached Nurse Alma who was doing her rounds and said" I wish that my
children will visit me today" Your BEST response to the patient is ______.
A." do you have their cell phones, If you want I can call them"
B. "just relax, I am sure they will come and visit you today"
C. "you sound to be lonely, do you want me to be with you for a while".
D. there is so much traffic, anyway it is not yet time for visiting hours"

27. Nurse Linda observed that her patient who was just admitted for
abdominal pain, looks tense and quite restless. The patient tells the nurse
" I am afraid to undergo the physical examination". The BEST response of
Nurse Linda is ______.
A. "I will inform the physician that you are afraid to undergo the physical
examination"
B. "there are several patients waiting for me, the examination has to be done
now"
C." I will call your relative to be with you, while you are being examined"
D. "the examination will not hurt you, would you like to sit down first and
rest"

28. Ms Cynthia, a college student is being admitted on and off in the

hospital for Bronchial asthma verbalizes to the nurse " Do you think I
should stop attending my classes? What is the best response of the nurse?
A." Well to ne, that is a good decision for now especially with your asthma"
B. "You said, you are thinking of stopping from attending your classes?"
C. "Let us consult your physician, which one is better for you"
D. "Do you feel that us good decision for you and your parents"

29. An elderly patient looks depressed, tells the nurse while her blood to
you anymore". The Nurse best response is ____.
A. "don't say that, otherwise I will not come and see you anymore"
B ."I will be back in an hour, by that time, you might want to talk to me"
C. "If you need me just inform your watcher for some help."
D. “ I don't say that, I will just attend to the other patients in the ward"

30. Patient Alma, is receiving insulin injection for her diabetes. She
tells the nurse I don't want to have that insulin injection anymore." The
MOST therapeutic response of the nurse is _______.
A. "you need the insulin injection, otherwise your diabetes will not be
controlled."
B. "just have your insulin injection now, I will refer you later to you.
attending physician."
C. "your physician will get mad, if you will not have your insulin injection."
D. let us sit down, I will explain to you, why you have to receive the insulin
injection."

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Situation - Nurse Lina is assigned in the Medical ward and has admitted patient
Sonia, 52 year old accountant, who was suspected to have Crohn's disease by her
family physician.

31. Nurse Lina should assess the patient for the presence of ______.
I left lower quadrant abdominal pain
II diarrhea, unrelieved by defecation
III abdominal tenderness and spasm
IV increase in weight
V excessive fat in he feces

A. II & III C. II, III & V

B. II, III & IV D. 1 & II

32. The physician in-charge of the patient ordered laboratory and

diagnostic studies in order to confirm its diagnosis. Which of the following
examinations is conclusive of the presence of Crohn's disease?
A. Upper GI series C. Barium enema
B. Proctosigmoidoscopy D. Abdominal radiography

33. During Ms. Sonia's hospitalization, she had fever, loose bowel
movement with foul smelling odor with abdominal pain. Considering these
manifestations, Nurse Lina should monitor the patient on what specific
condition?
A. Hypercalcemia C. Hyperbulemia
B. Thrombocytopenia D. Hypokalemia

34. Ms. Sonia was ordered by her physician to have total parenteral
nutrition (TPN) to improve her hydration, skin turgor and improve the
overall well being of the patient, Which of the following nursing measures
should Nurse Lina implement to facilitate positive patients outcome?
I Weighing the patient daily
II Measure intake and output
III Provide relief of pain & discomforts
IV Monitor IV infusion rate daily

A. I, II, & III C. II, III, & IV

B. I & III D. I & II

35. The patient is preparing to go home in few days time. What specific
health teaching on HOME PARENTERAL NUTRITION (PN) should be given
considering the level of education of the patient. These include the
following EXCEPT
A. use of aseptic technique in changing the dressing.
B. how to store & preparing the solution properly.
C. setting up of the infusion pump safely.
D. flushing the parenteral nutrition line with antibiotics.

Situation- A nasogastric tube (NGT) was ordered by the emergency physician to a

male patient suffering from head trauma after undergoing thorough physical
examinations and diagnostic tests. The physician diagnosed him to have a basilar
skull fracture.

36. What priority nursing action should be done to the patient considering
his present condition?
A. Test the gastric content for blood
B. Attempt to place the tube into duodenum
C. Check patency of airway before nasogastric tube
D. Use extra lubrication when inserting the nasogastric tube

37. Another patient is in need of nasogastric tube. The nurse, while

inserting the tube, observes that the patient started to cough and showed
difficulty of breathing. Which of the following is the best nursing action
to be done in this situation?
A. Quickly remove the tube and let the patient rest
B. Remove the tube and reinsert when difficulty of breathing subsides
C. Notify the doctor at once and inform him of your observation
D. Pull back the tube and wait for further order
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 38. Nurse May is assessing the correct placement for the tube, aspiration
of the stomach contents as well as checking for PH. Which PH value result
confirms the placement of the tube is in place?
A. 6. 0 C. 6. 50
B. 7. 35 D. 5. 2

39. What is the recommended position during NGT insertion?

A. Supine position C. Semi-Fowler position
B. High Fowler`s D. Low fowler`s

40. Nurse May is preparing to remove the NGT from the patient. Which of
the following priority instruction should be given to the patient before she
removes the tube?
A. Exhale and rest for a while
B. Inhale and exhale quickly
C. Take and hold a deep breath
D. Perform a Valsalva maneuver

Situation- Mr JC 50 - year-old is having episode of Bronchial asthma and was

examined in the ER by the physician and ordered to be admitted.

41. Nurse Tita admitted the patient and was observed to be dyspneic.
Breadth sounds are diminished upon auscultation. Which INITIAL nursing.
action should she implement first?
A. Position him on a in semi-fowler's position
B. Administer oxygen therapy as ordered
C. Instruct patient to nebulize self if available
D. Administer bronchodilator as ordered

42. Based on the health history, the patient is working in a cement

factory. This occupational hazard can bring about asthmatic trigger as a/an
_____.
A. contactant C. infiltrant
B. inhalant D. ingestant

43. The physician ordered Theophylline 300 mg, per day to relieve
patient's asthmatic attack. Which of the following is NOT a mechanism of
action of this drug?
A. regulating the immune system of the body
B. relaxing the smooth tissue of the bronchial airways
C. reducing inflammation of the airways of the lungs,
D. relaxing the skeletal muscle of the bronchial airways.

44. Select from the following potential adverse effects of theophylline,

the nurse should observe when the drug is taken orally _____.
A. dry mucosal membrane C. irregular heart beat
B. inability to sleep D. increased blood pressure

45. The patient is preparing to go home with his bronchodilator drugs. He

asked the nurse, how will I know if the drug is effective? Her APPROPRIATE
response is, there will be an initial decreased in ______.
A. allergic reaction C. body temperature
B. breath sounds D. wheezing

Situation - Nurse Dina is caring for several patients in the medical unit mostly
suffering from Endocrine disorders. Evelyn, is a 45 year old, government employee
who has been diagnosed by their doctor to be suffering from Graves disease. Based
on her health history she has been having insomnia, palpitation and heat
intolerance.

46. A classic finding that Nurse Dina would expect to find in addition to
the above complaints which is SPECIFIC to her condition is ______.
A. decreased libido C. infertility
B. exopthalmos D. hoarseness of the voice

47. Select the two (2) primary laboratory tests findings ordered by his
physician that will confirm that patient Evelyn has Graves disease.
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I Decreased TSH levels
II Elevated free thyroxin levels
III Increased TSH levels
IV Decreased free thyroxin levels

A. I & IV C. III & IV

B. III & IV D. II & III

48. Choose from the listed drug therapy that should be administered to Ms.
Evelyn in order to inhibit the synthesis of thyroid hormones and block the
conversion of T3 and T4 ______.
A. adrenergic blockers (Inderal) C. levothyroxine (Synthroid)
B. radioactive iodine (RAIU) D. propylthiouracil (Propyl Thyracil)

49. While Ms. Evelyn is being prepared physically and psychologically for
possible thyroid surgery, her nutritional needs was also being met with a
diet that is
A. high fibrous, low protein, high CHO
B. high caloric, high CHO, low protein
C. high caloric, high CHO, and protein
D. high protein, low Vitamin A & C

50. Ms. Evelyn underwent thyroidectomy, six hours after surgery, she
complained of numbness of the fingers, toes and twitching of the mouth, this
is MOST likely caused by _____.
A. thyrotoxicosis C. hypothyroidism
B. hypoparathyroidism D. infection

Situation - Mr. Santi a salesman was admitted because of severe abdominal pain.
Based on the data gathered, he smokes and drinks 3-4 bottles of beer every day.
He appeared jaundice, dyspneic with enlarged abdomen. The physician suspected
that he has a liver disorder and beginning esophageal varices.

51. Whish of the following clinical manifestations is not included in

client with hepatic
A. Indigestion C. Nausea and vomiting
B. Diarrhea D. Abdominal bloating

52. Liver function test was ordered. In a damaged liver the following
tests will reveal-
I. Prothrombin time is prolonged.
II. Albumin level is increased.
III Globulin level is decreased.
IV. Ammonia level is decreased.

A. I and II C. I only
B I, II and III D. I,II,III, and IV

53. Mr. Santos esophageal varices bleed. His doctor ordered Sengstaken-
blakemore tube to stop bleeding. Two hours after, the client developed
difficulty of breathing. What PRIORITY action should the nurse?
A. Monitor vital signsC. Deflate the esophageal balloon
B. Asked client to take a deep breathD. Call the physician at once

54. In client with esophageal varices, which of the following doctors

order do you anticipate?
A. Monitoring progression of anxiety
B. Observing signs of epistaxis
C. Monitoring urine output
D. Preparing client for blood transfusion

55. Which of the following medications is likely to be given to quickly

stop bleeding from esophageal varices ______.
A. Meperidine C. Aldactone
B. Furosemide D. Vasopressin

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Situation - Mr. Leo, an insurance agent was ordered by his physician to be
admitted to the hospital for Coronary Artery Bypass Graft (CABG) due to three
vessels blockage.

56. As a nurse, you are aware that cardiac surgery is a source of stress
to the patient and family. Which of the following strategies should the
nurse implement FIRST to overcome this stress?
A. Identify coping mechanism helpful to the patient and family members.
B. Recognize fears and concerns regarding surgery and future status.
C. Explore support system available during the entire hospitalization period.
D. Reinforce understanding of the surgical procedure, hospitalization and
recovery.

57. Mr. Leo, underwent an invasive diagnostic test to determine the

location of the blockage which is needed for his CABG . This procedure is
______.
A. cardiac CT scan C. magnetic resonance imaging
B. carotid Doppler D. cardiac catheterization

58. The nurse is teaching breathing exercises to Mr. Leo. At what phase of
the peri-operative care is this BEST performed?

A. After surgery when he is inside the recovery room

B. Immediately after he has signed the informed consent.
C. During the briefing period prior to the surgical procedure.
D. When he is back to his room from the recovery unit.

59. Which of the following is a blood thinning drug and temporarily

stopped by the physician prior to CABG due to possible bleeding ?

A. Pradaxal C. Aspirin
B. Ibuprofen D. Toradol

60. The nurse formulates a nursing diagnosis" Decreased cardiac output R/T
blood loss" Which of the following is the HIGHEST priority nursing action ?
A. Auscultate for heart sounds and rhythm.
B. Assess peripheral pulses, pedal, tibial and radial.
C. Monitor EKG pattern for cardiac dysrhythmia.
D. Assess arterial blood pressure very 15 min. until stable.

Situation - Venus, 32 year old a government employee has been having abdominal
pain which was on and off for almost 6 months. She has been having flatulence,
and recently lost weight because of vomiting. She consulted their office
physician and she was suspected to be suffering from chronic pancreatitis. She
was advised to be hospitalized for further work-up

61. You are the admitting Nurse when Ms. Venus arrived in the hospital.
When doing a comprehensive pain assessment, you should conduct the procedure
during the _____.
A. evaluation of nursing pain Management
B. Initial contact with the patient
C. course of pain management
D. the time the physician instructed you to do

62. When a patient is having pain due to Pancreatitis, you expect that the
pain is located in the ______.
A. hypogastrium, right upper quadrant of the abdomen radiating to the left
lumbar area
B. epigastrium, right upper quadrant of the abdomen radiating to the left
lumbar area
C. hypogastrium, left upper quadrant of the abdomen radiating to the left
lumbar area
D. epigastrium, left upper quadrant of the abdomen radiating to the left
lumbar area

63. You are aware of several manifestations when a patient is in pain.

Which of the following is a behavioral response to pain?

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 A. Changes in skin color C. Depth respiration
B. Increase in blood pressure D. Moaning and grimacing.

64. When a patient is ordered corticosteroids, which of the following

drugs will produce therapeutic effects of reducing pain?
A. Spironolactone C. Atropine S04
B. Diazepam D. Prednisone

65. When severe vomiting occurs in this patient, it results to what

particular condition?
A. Hyperkalemia C. Alkalosis
B. Hypocalcemia D. Acidosis

Situation - Roy, 65 years old, came to the outpatient clinic due to dyspnea,
fever and on and off productive cough. He smokes one pack of cigarette per day
for the last 30 years. The doctor ordered sputum examination, chest x-ray and
blood culture.

66. In collecting sputum specimen, the nurse should instruct Roy to _____.
A. breathe slowly, cough and expectorate into the specimen container
B. breathe deeply and cough, expectorate into the sputum container,
C. cough and expectorate saliva into the specimen container.
D. cough and expectorate into the specimen container.

67. The patient's diagnostic tests revealed he was positive for bacterial
pneumonia. The MOST likely causative organism of this type of pneumonia is
______.
A. legionella pneumonia C. streptococcus pneumoniae
B. mycoplasma pneumonia D. Haemophilus pneumoniae

68. The nurse did an admission procedure. The best position to be assumed
by Roy is _____.
A. left lateral position with the affected side inferior.
B. semi-fowler position at least 30 degrees.
C. dorsal position with pillows under the chest.
D. lying on his side, the affected side of the lungs should be superior.

69. When a patient is diagnosed to have pneumonia, the breath sounds

detected by the nurse on auscultation of the affected area would be ______.
A. wheezing sounds C. fine crackles
B. stridor D. deep and low-pitched breath sounds

70. When there is respiratory depression resulting from drug overdose, the
nurse have to watch for which of the following?
A. Hyperventilation C. Biot's respiration
B. Tachypnea D. Bradypnea

Situation - Ms Bel 66 year-old consulted the OPD due changes in energy level,
fatigue and not able to tolerate performance of activities of daily living. The
physician suspected that she has hypothyroid disorder and advised admission for
further work-up.

71. When a patient is with hypothyroidism, the assessment findings of the

nurse that is NOT present is ______.
A. brittle nails C. Dry skin
B. hair loss D. fine tremors of hands

72. In assessing the thyroid gland for size, shape, symmetry consistency
and presence of tenderness, the MOST appropriate examination modality is
_____.
A. auscultation C. palpation
B. percussion D. inspection

73. After several thyroid diagnostic tests, Ms Bel was ordered to take
thyroid hormone (Levothyroxine). Which of the following nursing actions is
NOT ADVISABLE in administering this drug? The nurse should give ______.
A. a single dose daily before breakfast
B. a single dose daily after breakfast
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 C. it with a full glass of water
D. it without mixing with fruit juices

74. In monitoring the effectiveness of the drug therapy Which of the

following is NOT expected as a POSITIVE patient's outcome
A. regular bowel function
B. excessive sweating at night time
C. participates in self- care activities.
D. metabolism returns to normal

75. The nurse is developing a nursing care plan for Ms Bel. If the Nursing
diagnosis is
" Activity intolerance R/T fatigue and depressed cognitive process", which of the
following is an APPROPRIATE intervention?
A. Increase mobility through early ambulation.
B. Allow self-care activities with active exercises.
C. Space nursing activities to promote rest and sleep.
D. Avoid a stimulating interesting conversation.

Situation - Nurse Adela is on duty in the medical unit and has two patients for
discharge. Ella, 38 year old diagnosed with Diabetes Mellitus and on insulin
therapy for the first time and Eileen, 42 years old who had myocardial infarction
(MI),

76. When preparing a teaching plan for patient Eliza, the following are
the instructions provided to patients with Diabetes Mellitus. Which one of
the teaching plan is considered not a PRIORITY concern when discussing the
list with the patient?
A. Diet and genetic counselling.
B. Exercise in extreme heat and cold.
C. Regular exercise, diet and medications.
D. Monitoring of blood sugar and urine ketones.

77. Eliza was taught by Nurse Adela on how to administer self - injection
insulin and rotation sites with the use of the chart every day till her
discharge. The following is the procedure for the Self - injection of
Insulin. Which of the following are the CORRECT sequence in self
administration of the drug?

I. Inject the insulin, push the plunger all the way in

II. with one hand stabilize the skin by spreading a large area
III pull the needle straight out of the skin & press cotton ball over injection
site
IV. Pick - up syringe with the other hand, hold and insert needle to the skin.
V. Dispose syringe in a hard plastic container.

A. I, IV, III, II & V C. III, II, I, V & IV

B. II, IV, I, III & V D. IV, III, I, V & II

78. The doctor ordered a low- saturated fat, low - cholesterol diet to
patient Eileen who was also going home. From the following list of foods,
which meals has to be included in the instructional plan of Nurse Adela to
her patient?
A. pork steak, mixed vegetables with butter and cheese.
B. Hamburger, macaroni salad and milk shake.
C. Fried chicken, green beans, and skim milk.
D. Baked fish, green beans, coffee

79. Considering that patient Eileen is a post MI patient, she was taught
by the nurse on home exercises on leg movements while resting on bed. The
expected goal of this intervention is to
A. facilitate better digestion of food
B. prevent stasis of urine and stone formation
C. facilitate circulation for skin integrity
D. prevent venous stasis in the lower extremities

80. The resumption of sexual activity is an important activity that has to

be included in the home instructions to be given to patient Eileen together
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 with her husband. Which of the following is the SAFE period for an
uncomplicated MI to resume sexual activity?
A. One month after MI. C. Two months after MI.
B. 12 to 14 days after MI. D. 7 to 10 days after MI.

Situation - A computer analyst of a company, was rushed to the Emergency room

due to abdominal pain, nausea and vomiting, ascites and shallow breathing due to
enlarged abdomen. The physician suspected that the patient is suffering from
peritonitis and was advised to be admitted for further workout.

81. In assessing a patient suffering from peritonitis, which of the

following manifestations is NOT likely to be present?
A. Rebound tenderness C. Abdominal guarding
B. Abdominal gas D. Abdominal rigidity

82. The overall goals set by the members of the health team once the
patient is admitted include which of the following?
I Relief of the abdominal pain
II Resolution of inflammation
III Provision of normal nutritional statue
IV Prevention from complications
A. I, II, III C. II & III
B. I & II D. I, II, II, & IV

83. Diagnostic tests were ordered to the patient which included: complete
blood count (CBC) and abdominal CT scan the primary purpose for ordering CT
scan is to determine PRESENCE of ______.
A. amylase content C. fluid shifts
B. bacteria D. abscess

84. Which of the following drugs do you expect be ordered by the physician
for severe acute pain?
A. Acetaminophen (Tylenol) C. Percodan (Aspirin)
B. Levorphanol (Levo-Dromoran) D. Codeine (Ambenyl)

85. The physician ordered the patient for paracentesis. Which of the
following pre- procedure nursing actions should the nurse perform EXCEPT
A. place him in upright position on the edge of the bed
B. place him in low-lying position with knees straight
C. check for the signed consent form
D. instruct patient to urinate to empty bladder

Situation- Mila, a 35-year old female was brought in the emergency unit
complaining of cold, clammy skin, disorientation, restlessness and confusion. The
nurse suspects the patient is developing cardiogenic shock.

86. Nurse Victor who admitted patient Mila is aware that a decrease in
cardiac output results in cerebral blood flow. Which of the following
symptoms is one of the EARLIEST signs of cardiogenic shock?
A. Tachycardia C. Presence of fourth heart sound (S4)
B. Altered level of consciousness D. Decreased urine output

87. Nurse Victor assesses patient Mil. Decrease of which the following
factors would help detect that the patient is at risk at developing
cardiogenic shock?
A. Heart rate C. Cardiac index
B. Cerebral blood flow D. Blood pressure

88. Nurse Victor reviews the medical history of patient Mila. Which of the
following conditions is the MOST common cause of cardiogenic shock?
A. Decreased hemoglobin level C. Acute Myocardial infarction
B. Hypotension D. Coronary artery disease

89. Which of the following procedures would be MOST helpful to Nurse

Victor to confirm the underlying cause of cardiogenic shock?
A. Monitoring pulmonary artery pressure
B. Monitoring cardiac enzymes
C. Monitoring mean arterial pressure
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 D. Measuring central venous pressure

90. The physician prescribes a treatment plan for patient Mila. Nurse
Victor understands that the initial treatment goal is which of the following?
A. Prevent infection C. Correct hypoxia
B. Correct metabolic acidosis D. Increase myocardial oxygen supply

Situation - A 55 year old male is admitted to the medical unit with a diagnosis
of Myocardial infarction (MI). He complains of difficulty of breathing, excessive
sweating, nausea and vomiting and chest pain.

91. Nurse Bin performs pain assessment. Which of the following

characteristics of pain is manifested in MI?
1. The patient may experience crushing substernal pain
2. Pain may radiate to the jaw, back and left arm
3. Pain may occur without cause, primarily early in the morning
4. Pain is unrelieved by rest or nitroglycerin and is relieved only
opioids
5. Pain lasts 30 minutes or longer

A. 2, 3, 4 C. 1, 3, 5
B. 3, 4, 5 D. 1, 2, 3, 4, 5

92. The physician orders laboratory tests on the patient. Which of the
following findings would MOST concern the nurse?
A. Creatinine kinase (CK): 150 U/ml
B. Hematocrit (HCT): 42 %
C. Serum glucose: 100mg /dL
D. Erythrocyte sedimentation rate (ESR): 10mm/h

93. The physician further orders an arterial blood gas measurement. The
nurse obtains the specimen. What is the most appropriate action of nurse
immediately after obtaining the specimen? the nurse should ______.
A. Obtain ice for the specimen
B. Apply a sterile dressing to the site
C. Apply direct pressure to the site
D. Observe the site for hematoma formation

94. The nurse reviews the arterial blood gas results of the patient. The
laboratory report indicates a pH of 7. 30, PCO2 of 58 mm, PO2 of 80 mmHg,
and a HCO3 of 27mEq/L. Which acid-base disturbance is the patient
experiencing?
A. Metabolic acidosis C. Respiratory acidosis
B. Metabolic alkalosis D. Respiratory alkalosis

95. Nurse Bin assessing another client with angina pectoris. Which of the
following are characteristics of the substernal chest pain that occurs with
this condition?
1. Occurs without cause
2. Radiates to the left arm
3. Lasts less than 15 minutes
4. Usually occurs in the morning
5. Is relieved by rest and nitroglycerine
6. Is precipitated by exertion or stress

A. 2, 3, 4, 6 C. 2, 3, 5, 6
B. 1, 3, 4, 5 D. 1, 2, 3, 4, 5

Situation - Documentation is a basic competency expected of a graduate nurse when

performing her role in the clinical setting.

96. Mr. Rey had his insulin therapy on the day of his admission. On
the second day he developed allergic reactions after 2 hours of the
insulin administration. What clinical manifestations do you expect the nurse
to write in her documentation as a reaction to this drug?
1. Redness 2. Swelling 3. Tenderness 4. Induration

A. 1, 2, & 3 C. 1 2, 3,& 4
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 B. 2 & 4 D. 1 & 2

97. Mr. Rey has been anxious regarding his diagnosis as well as the
recent reaction to the insulin therapy. as a nurse, the
PRIORITY nursing actions to overcome this anxiety behavior is to ________.
A. conduct a family conference for the concern of the patient
B. refer to the physician for an order of tranquilizer
C. express your empathy and respect for his feelings
D. take time to explain his disease process and effects of insulin

98. When a patient is suffering from Ketoacidosis, you expect that the
entry of Nurse assessment findings in the chart will include the
following clinical manifestations EXCEPT
A. Kussmaul respiration C. Lethargy
B. Cheyne stokes breathing D. acetone breath odor

99. Nurse Gladys who is on morning shift was making the rounds when
she observed Mr. Joe, who 18 suffering from Congestive heart failure
is Complaining of heaviness of his legs. She observed the patient to have an
edema of his Lower extremities. If the edema is 3+, what do you expect the
nurse to write in her assessment findings?
A. Deeper Pit, rebounds in 30 seconds
B. Barely the pit is not perceptible.
C. Deeper pit, rebounds in only few seconds.
D. Deep pit, rebounds in 10-20 seconds.

100. When auscultating the breath sounds of patients with

respiratory disorder they are instructed to breath thru their mouth. A
possible complaint the nurse has to watch and be written in her
documentation when performing this procedure is which of the following?
A. Palpitation. C. Tachycardia
B. Dizziness D. Bradycardia

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