practice exam 4 Flashcards
(99 cards)
1
Q
Annie was diagnosed with Systemic Lupus Erythematosus. It is an immune disease which is characterized by multi-system involvement. Nurse Katarina, the nurse assigned to Annie, is aware of the signs and symptoms of SLE which involves the following, except
● rash on the face across the nose bridge of the nose and on the cheeks.
● blood dyscrasias.
● dementia.
● none of the above.
A
dementia
2
Q
The following laboratory findings indicate complications of SLE, except
● increased creatinine.
● ECG changes.
● elevated antinuclear antibody level.
● none of the above.
A
elevated antinuclear antibody level.
3
Q
Annie is undergoing continuous treatment of SLE. Which among the following is not an appropriate treatment for SLE?
● Corticosteroids
● Antimalarial drugs
● Plasmapheresis
● None of the above
A
● None of the above
4
Q
Annie is undergoing periodic plasmapheresis for the treatment of SLE. The purpose of plasmapheresis is to
● suppress the immune system of the patient.
● clear the plasma of antibodies of SLE.
● provide the patient with new antibodies.
● all of the above
A
● clear the plasma of antibodies of SLE.
5
Q
Annie, with SLE, is scheduled for discharge tomorrow. The following are appropriate discharge instructions for Annie, except
● avoiding sun exposure from 9 – 3 PM.
● maintain 6-8 hours of sleep a day.
● making sure to eat fresh vegetables and fruits.
● applying ice compress to affected joints.
A
applying ice compress to affected joints.
6
Q
Michael Rodriguez is a 45 year old patient with a history of human immunodeficiency virus
who is hospitalized with fever, chills and cough that has lasted for 5 days. The doctor suspects
Pneumocyctis jiroveci pneumonia. Which of the following isolation precautions should be instituted for Mr. Rodriguez?
● Standard precautions
● Blood and body fluid precautions
● Enteric precautions
● No isolation precaution care needed at this time
A
Standard precautions
7
Q
The nurse noted dime-size, non-blanching macules on Mr. Rodriguez’s legs and notified the doctor. These macules may indicate
● petechiae from platelet destruction.
● cutaneous acquired immunodeficiency syndrome.
● telengiectasis.
● Kaposi’s Sarcoma
A
Kaposi’s Sarcoma
8
Q
Mr. Rodriguez begins alpha interferon therapy for Kaposi sarcoma. The nurse discusses
adverse effects of interferon therapy, which typically include
● bradycardia.
● thromboembolism.
● influenza-like symptoms.
● hypertension
A
influenza-like symptoms.
9
Q
Michael Rodriguez is a 45 year old patient with history of human immunodeficiency virus who
is hospitalized with fever, chills and cough that has lasted for 5 days. The doctor suspects
Pneumocyctis jiroveci pneumonia.
Based on the current condition of Mr. Rodriguez, you would suspect that the patient is in what
stage of HIV/AIDS?
● Primary Infection
● Symptomatic Stage
● Asymptomatic Stage
● Full-blown AIDS
A
Full-blown AIDS
10
Q
Mr. Rodriguez is taking Didanosine for his HIV/AIDS. Which among the following will you
monitor?
● Creatinine and BUN
● AST and ALT
● Serum Calcium Level
● Serum Amylase
A
Serum Amylase
11
Q
Eddard Stark, 56 years old post thyroidectomy with modified neck dissection due to papillary
carcinoma of the thyroid gland with lymph node metastasis was admitted for radioactive
therapy.
He asks the nurse to explain how the radiation therapy he will be receiving for his cancer is
effective. What is the nurse’s best response?
● Radiation causes breakage in the strands of DNA helix, which leads to cell
death.
● Oxygen cannot enter cells that have been irradiated, so the cell converts to anaerobic
metabolism that causes its death.
● Radiation is antagonistic to glucose, which cells need for energy replication; radiation
prevents glucose from entering cells leading to cell death.
● Cell walls are broken down by gamma rays during radiation therapy, leading to cell
death.
A
● Radiation causes breakage in the strands of DNA helix, which leads to cell
death.
12
Q
If you were the nurse who admitted him, which of the following will you consider as the reason
for this intervention?
● To determine existence of known distant metastatic tumor
● To mark the site where the radioactive iodine will be administered
● To measure size of remaining thyroid tissue
● To explore the operative site for the baseline data
A
To mark the site where the radioactive iodine will be administered
13
Q
You are formulating a care plan for him, which of the following nursing interventions is least
relevant to ensure a safe environment once treatment has started?
● Utilize preferably only disposable items for client’s personal use
● Have all frequently handed items in the room covered with absorbent material
● Provide hand sanitizers in the corridor outside the client’s room
● Dispose appropriately garbage bags marked radioactive
A
Provide hand sanitizers in the corridor outside the client’s room
14
Q
As the nurse assigned to care for clients under radiation therapy, you should be aware that
you are least protected by the use of
● Rubber gloves
● Thyroid shield
● Lead Apron
● Eye Shield
A
Rubber gloves
15
Q
When planning for discharge of the client, safety of other people should also be considered.
Which of the following instructions will you consider for reduction of radioactive exposure to
others?
- Use private toilet facilities and flush 2-3 times after use
- Wash eating utensils separately from others
- Maintain adequate fluid intake
- Bathe daily and wash hands frequently
- Stay in isolation at home two weeks after the treatment
• All except 3
• 2, 3, and 5
• 2, 4, and 5
• 1, 2, and 4
A
1, 2, and 4
16
Q
Mrs. Pearl is a 75 year old patient with a history of hypertension and transient ischemic attack.
She is admitted to the neurosurgical ward due to cerebrovascular accident involving the left
side of the brain.
Her husband asked the nurse to differentiate CVA from Transient Ischemic Attack (TIA). The
nurse should know that TIA
● has permanent long-term focal deficits.
● is intermittent with spontaneous resolution of the neurological deficit.
● is intermittent with permanent and motor deficits.
● has permanent long term neurologic deficits.
A
is intermittent with spontaneous resolution of the neurological deficit.
17
Q
The nurse evaluates her. The nurse expects to see the following in a left-sided brain damage.
1. Paralyzed right side
2. Aphasia
3. Left-sided neglect
4. Paralyzed left side
5. Depression
6.Denial of Deficits
● 1, 2, 5
● 3, 4, 5
● All except 4
● All of the above
A
1, 2, 5
18
Q
During the first 72 hours following a stroke, the nurse should position Mrs. Pearl
● in bed and lying on the side.
● with the head of the bed elevated 30 degrees and her head in a midline
neutral position.
● with the head of the bed elevated 60 degrees and the knee elevated.
● flat on bed with his head elevated on a pillow
A
with the head of the bed elevated 30 degrees and her head in a midline
19
Q
Aside from the neurological signs and symptoms of stroke,the nurse also monitors the patient
for signs of increasing intracranial pressure which includes all of the following, EXCEPT
● systolic hypertension.
● unequal pupil size.
● bradycardia.
● none of the above.
A
none of the above.
20
Q
Nurse Jacob was the nurse assigned to care for Mrs. Pearl the next day. He is about to
administer Mannitol to the patient. The nurse is aware that the action of Mannitol is to
decrease
● cerebral edema by increasing drainage of CSF from the ventricles.
● cerebral edema by decreasing the production of CSF.
● cerebral edema by increasing serum osmolality resulting in dehydration of the
cerebral tissue.
● cerebral edema by decreasing leakage of fluid from the blood vessels.
A
cerebral edema by increasing serum osmolality resulting in dehydration of the
cerebral tissue.
21
Q
Mr. Robert Baratheon is a 48 year old overweight man who was seen for a routine check-up.
His fasting blood glucose is 135 mg/dL so he was scheduled by his physician for a repeat test.
Mr. Baratheon asks the nurse why there is a need for a repeat test. The nurse’s best
response is,
● “Your fasting blood glucose was abnormal and needed to be tested again.”
● “Your fasting blood glucose level was normal, but we need confirmation of the result.”
● “You have type 2 diabetes mellitus, so the test must be repeated.”
● “Fasting blood glucose level tests are always repeated.”
A
“Your fasting blood glucose was abnormal and needed to be tested again.”
22
Q
Mr. Baratheon is learning about diabetic foot care. Which of the following should you instruct
him to avoid?
● Lotions
● Nail files
● Antiperspirants
● Foot Soaks
A
Foot Soaks
23
Q
When teaching Mr. Baratheon about insulin therapy, the nurse should instruct him to avoid
which over-the-counter preparation that can interact with insulin?
● Salicylate preparations
● Antacids
● Acetaminophen preparations
● Vitamin with Iron
A
Salicylate preparations
24
Q
A client with type 2 DM comes to the clinic for a follow up appointment. The physician ordered
Glyburide (Micronase) to manage his condition. Which statement from the client would alert
the nurse?
● “I usually stay up late. I have a lot of deadlines to beat so I overtime at the office most
of the time.”
● ”I usually experience headache after taking this medication.”
● “I always remind myself to limit my alcohol intake every time we have a night out. I usually consume 2 glasses.”
A
“I always remind myself to limit my alcohol intake every time we have a night out. I usually consume 2 glasses.”
25
If a client is taking Novolin PH, an intermediate acting insulin, you expect that the peak effect
will last for
● 12 to 16 hours.
● 15 minutes to 1 hour.
● 6 to 12 hours.
● 2 to 3 hours
6 to 12 hours.
26
You are preparing discharge instructions for a client with chronic syndrome of inappropriate
antidiuretic hormone (SIADH). Which statement indicates that the client understands these
instructions?
● “I will check all food labels to make sure that I restrict my sodium intake.”
● “I will measure my urine and check the specific gravity with a refractometer. If it begins
to gradually rise, l will contact my doctor.”
● “I will keep a diary of my daily weight and call the doctor if I gain 2 lbs or more in
a day without changing my eating habits.”
● “I will check my pulse every morning and will contact my doctor if it’s irregular or rapid.”
“I will keep a diary of my daily weight and call the doctor if I gain 2 lbs or more in
a day without changing my eating habits.”
27
Jon Arryn, a client diagnosed with hyperthyroidism is being prepared for surgery. Before his
scheduled thyroidectomy, there is an order for Lugol’s solution. In administering Lugol’s
solution, the precautionary measure should include
● administering the drug with milk and drink it.
● administering the drug with glass of water only.
● Diluting with juice and administering the drug with straw.
● following drug with milk of magnesia.
Diluting with juice and administering the drug with straw.
28
Jon Arryn has successfully undergone thyroidectomy 12 hours ago. You would be most
concerned if which of the following was observed?
● Jon Arryn is drowsy and complains of a sore throat
● Jon Arryn supports his head and neck when turning his head to the right
● Jon Arryn spontaneously flexes his wrist when the blood pressure is obtained
● Blood pressure 138/82, pulse 84, respirations 16, oral temperature 99°F
Jon Arryn spontaneously flexes his wrist when the blood pressure is obtained
29
A client presents to the Emergency Department with muscle weakness, complaints of nausea
and decreased appetite, vital signs reveal blood pressure of 90/50 mmHg. The physician
suspects Addison’s disease and orders a 24-hour urine collection to confirm the diagnosis. An
important nursing responsibility during a 24 hour urine collection for the client
● assess the client for signs of edema.
● keep the client quiet and reduce stress.
● monitor the client for an elevation of blood pressure.
● restrict the client’s fluid intake for the next 24 hours
keep the client quiet and reduce stress.
30
Which of the following statements accurately describes Cushing’s disease?
● It is the overproduction of adrenal medulla hormone
● Women ages 20-40 years are five times more likely than men to develop
Cushing’s syndrome
● This disease is characterized by muscle weakness, anorexia and dark skin
pigmentation
● In this condition, there is depletion of sodium and water in the body
Women ages 20-40 years are five times more likely than men to develop Cushing’s syndrome
31
Chronic Obstructive Pulmonary Diseases is one of the conditions contributing to the NCD
burden in our country. Among the following statements, which does not reflect COPD?
● Chronic cough for at least a month in 4 consecutive years
● Sustained hyperinflation of alveoli sacs on chest x-ray
● The most significant risk factor for COPD is smoking.
● None of the above
Chronic cough for at least a month in 4 consecutive years
32
The management of COPD is complex. It is aimed at increasing quality of life and preventing
exacerbations. Which among the following treatments can prevent exacerbation?
● Short-acting bronchodilators
● Leg Exercises
● Inhaled corticosteroids
● All of the above
Inhaled corticosteroids
33
A patient is suffering from Acute Respiratory Distress Syndrome. All of the following are true
regarding ARDS, except that
● septic shock may lead to ARDS.
● patient may need to be intubated.
● It is characterized by paradoxical breathing & pleuritic pain.
● ARDS is a severe life-threatening condition
It is characterized by paradoxical breathing & pleuritic pain.
34
Susan, 63 years old, is diagnosed with ARDS. She is currently on mechanical ventilation. The
following are included in the management of patients on mechanical ventilator, except
● placing the patient in Semi-Fowler's position.
● stopping the infusion of diazepam for an hour everyday.
● providing oral care every 2 hours.
● All of the above
providing oral care every 2 hours.
35
Susan, 63 years old, is diagnosed with ARDS. She is currently on mechanical ventilation.
While on the mechanical ventilator, the high pressure alarm on Susan’s MV was triggered. The
most appropriate action to take is to
● assess the patient for coughing and biting.
● turn off the mechanical ventilator.
● remove the patient from the MV and manually ventilate the patient during the course of
admission.
● turn off the alarm only.
assess the patient for coughing and biting.
36
Diana, 17 years old, was brought to the clinic due to sudden onset of difficulty breathing.
Further assessment was done and the patient was diagnosed with Asthma. Nurse Vincent
was the one who assessed Diana when she was admitted to the Emergency Department.
Nurse Vincent is aware of the signs and symptoms of asthma which include
● tachypnea, wheezing & rales.
● wheezing, paradoxical breathing & dyspnea.
● I:E ratio of 1:1, wheezing and tachypnea.
● pleural friction rub, dyspnea and tachypnea
I:E ratio of 1:1, wheezing and tachypnea.
37
Nurse Vincent was doing health history. Which of the following statements of the patient may
be the possible trigger of her asthma?
● “I just came from Tagaytay 2 weeks ago.”
● “I was upset I wasn’t able to continue the concert I was watching.”
● “I had a cup of concocted lagundi last night.”
● All of the above
“I had a cup of concocted lagundi last night.”
38
Diana is scheduled for ABG analysis today. Two hours later, her ABG result arrived and
showed the following results: pH 7.55, pCO2
28 mmHg and HCO3 30 mmol/L. Nurse Vincent will interpret the result as
● partially-compensated metabolic alkalosis.
● partially-compensated respiratory alkalosis.
● fully-compensated metabolic alkalosis.
● fully-compensated respiratory alkalosis
partially-compensated metabolic alkalosis.
39
Diana, 17 years old, was brought to the clinic due to sudden onset of difficulty breathing.
Further assessment was done and the patient was diagnosed with Asthma. She was
prescribed with inhaled corticosteroids and a short-acting beta-agonist. Which of the following
should guide Diana in taking her medications?
● Nebulize with the beta-agonist first followed by the inhaled corticosteroids
● Rinse mouth before nebulization
Drink plenty of water after administering the drugs
● Watch out for bradycardia after taking a beta-agonist
Nebulize with the beta-agonist first followed by the inhaled corticosteroids
40
Diana, 17 years old, was brought to the clinic due to sudden onset of difficulty breathing.
Further assessment was done and the patient was diagnosed with Asthma.
Nurse Vincent is preparing the discharge teaching for Diana. This will include all of the
following, except
● avoiding exposing yourself to pollens, dust and mites.
● engaging in exercises for long periods of hours.
● eating a well-balanced diet
● taking medications as prescribed.
engaging in exercises for long periods of hours.
41
Baby Kennen, 7 months old, is suffering from right pneumothorax due to persistent
pneumonia.
On auscultation of Kennen’s chest, which finding suggests a right pneumothorax?
● Bilateral inspiratory and expiratory crackles
● Diminished breaths sound in the right thorax
● Inspiratory wheezes in the right thorax
● Bilateral pleural friction rub
Diminished breaths sound in the right thorax
42
Baby Kennen, 7 months old, is suffering from right pneumothorax due to persistent
pneumonia. Two days after admission, the child suddenly developed severe shortness of
breath. His right pneumothorax was converted to tension pneumothorax.
In assessing a patient with tension pneumothorax, you should know that the trachea will
deviate towards the
● contralateral side of the lung with tension pneumothorax.
● affected side.
● contralateral side of the left lung.
contralateral side of the lung with tension pneumothorax.
43
Baby Kennen, 7 months old, is suffering from right pneumothorax due to persistent
pneumonia. He had a chest tube in place for lung decompression.
When caring for Kennen, the nurse must
● monitor fluctuations in the water-seal chamber.
● clamp the chest tube once every shift.
● encourage coughing and deep breathing.
● milk the chest tube every two hours
monitor fluctuations in the water-seal chamber.
44
Baby Kennen, 7 months old, is suffering from right pneumothorax due to persistent
pneumonia.
As the nurse caring for Kennen turns the patient to his side, the chest tube accidentally
disconnects. The initial nursing action is to
● call the physician.
● place the tube in a bottle of sterile water.
● immediately replace the chest tube system.
● place a sterile dressing over the disconnection site
place the tube in a bottle of sterile water.
45
Baby Kennen, 7 months old, is suffering from right pneumothorax due to persistent
pneumonia.
While doing her rounds, Nurse Annie noted gentle intermittent bubbling in the suction control
chamber of Kennen’s chest tube system. The appropriate action is to
● check the suction chamber.
● record this as a normal finding.
● immediately replace the chest tube system.
● report this finding to the physician.
check the suction chamber.
46
Alesso, 45 years old, was diagnosed with Hypertension. Upon the nurse’s health history, it
was found that the patient has genetic predisposition. His father,Mang Topacio was
diagnosed with Congestive Heart Failure secondary to hypertension. The Philippine Package
of Essential Non-communicable Diseases Interventions (Phil-PEN) contains guidelines
on the management of Hypertension for Primary Health Care Facilities.
Which among the following is not a risk factor for hypertension?
● Smoking
● Increased BP
● Obesity
● Four drinks of alcohol in one occasion
Four drinks of alcohol in one occasion
47
Alesso, 45 years old, was diagnosed with Hypertension. Upon the nurse’s health history, it
was found that the patient has genetic predisposition. His father, Mang Topacio was
diagnosed with Congestive Heart Failure secondary to hypertension. The Philippine
Package of Essential Non-communicable Diseases Interventions (Phil-PEN) contains
guidelines on the management of Hypertension for Primary Health Care Facilities.
When the nurse took the BP of Alesso, the result was 167/80. His Hypertension can be
classified as
● Stage 1 Hypertension.
● Stage 2 Hypertension.
● Stage 3 Hypertension.
● Borderline Hypertension.
Stage 2 Hypertension.
48
Alesso is taking Atenolol (Tenormin) 50 mg orally once daily. The nurse understands that the
specific action is to block
● beta receptor stimulation of the heart.
● effects of the angiotensin II on receptors.
● calcium entry into the myocardium cells.
● alpha receptors in vascular smooth muscle.
beta receptor stimulation of the heart.
49
Alesso, 45 years old, was diagnosed with Hypertension. Upon the nurse’s health history, it
was found that the patient has genetic predisposition. His father,Mang Topacio was
diagnosed with Congestive Heart Failure secondary to hypertension. The Philippine Package
of Essential Non-communicable Diseases Interventions (Phil-PEN) contains guidelines
on the management of Hypertension for Primary Health Care Facilities.
Mang Topacio was curious how he developed Congestive Heart Failure from his hypertension.
The nurse is correct when he states
● "There is an increase in peripheral vascular resistance resulting in increased
workload of the heart."
● "There is no exact mechanism to explain the relationship between the two."
● "There is widening of the lumen of the arteries."
● All of the above
"There is no exact mechanism to explain the relationship between the two."
50
The nurse reviewed the health history of Mang Topacio. The nurse noted that one night, the
patient was rushed to the ER due to complaints of difficulty breathing and persistent coughing.
After the event, it was also noted that the patient cannot sleep in a flat position and needs 3
pillows when sleeping. Based on the findings, the patient may be suffering from
● left-sided heart failure.
● Acute Respiratory Distress Syndrome.
● orthopnea.
● right-sided heart failure.
left-sided heart failure.
51
Irelia, a 36-year old pregnant mother, was admitted to a Tertiary Hospital due to hypovolemic
shock.
Nurse Karmela is assigned to take care of Irelia. She is aware of the signs and symptoms of
shock which include all of the following, except
● urine specific gravity of 1.063.
● tachycardia.
● diminished pulse.
● none of the above.
none of the above.
52
Irelia, a 36-year old pregnant mother, was admitted to a Tertiary Hospital due to hypovolemic
shock.
Karmela is preparing her nursing care plan for the patient. Which among the following
evaluation outcomes is least appropriate for the patient?
● The patient will be able to maintain adequate blood pressure.
● The patient will be able to maintain a patent airway.
● The patient will be able to maintain a normal urine output.
● The patient will be able to maintain adequate tissue perfusion.
The patient will be able to maintain a patent airway.
53
If none of the following bed positions is contraindicated, which position would be the best
choice for Irelia with hypovolemic shock?
● Supine position
● Semi-Fowler’s position
● Supine with the legs elevated 15 degrees
● Trendelenburg’s position
Supine with the legs elevated 15 degrees
54
Which of the following would be the best indication that fluid replacement for the client with
hypovolemic shock is adequate?
● Urine output greater of 50 cc for 90 minutes
● Systolic BP above 110 mmHg
● Diastolic BP above 90mmHg
● Urine output of 20 to 30 cc per hour
Urine output greater of 50 cc for 90 minutes
55
The management of shock involves maintaining vascular fluid volume. Which among the
following are appropriate in the management of shock?
● Dopamine, Epinephrine IM, Lactated Ringer’s
● Dopamine,Norepinephrine, Lactated Ringer’s
● Dobutamine, Epinephrine IM, PRBC
● Urine output of 20 to 30 cc per hour
Dopamine,Norepinephrine, Lactated Ringer’s
56
General Thunder, a 73 year old retired military general, experiences episodes of knife-like
chest pain. The patient underwent a thorough physical examination and findings revealed
Atherosclerotic Heart Disease with concomitant Angina Pectoris.
The nurse is instructing General Thunder about the proper intake of Nitroglycerin. General
Thunder understands the instruction when he says,
● “I will take a nitroglycerin tablet twice a day.”
● “I will take a nitroglycerin tablet whenever I feel pain and repeat the dose if pain
persists for a maximum of two tablets.”
● “I can take a maximum of three tablets for my persisting pain with an interval of
5 minutes every tablet.”
● “If a nitroglycerin tablet didn’t relieve my pain, I will go to the hospital immediately.”
● “I can take a maximum of three tablets for my persisting pain with an interval of
5 minutes every tablet.”
57
General Thunder, a 73 year old retired military general, experiences episodes of knife-like
chest pain. The patient underwent a thorough physical examination and findings revealed
Atherosclerotic Heart Disease with concomitant Angina Pectoris.
Which among the following health teachings is appropriate for General Thunder?
● Eat a high fiber diet
● Limit Smoking
● Limit alcohol intake to 10 bottles a day
● All of the above
All of the above
58
One evening, General Thunder, was brought to the emergency department due to severe
chest pain. He is diaphoretic and his pulse rate is 110 bpm. The admitting diagnosis is
Myocardial Infarction. General Thunder wants to defecate. The nurse should
● place him on to a bedpan.
● help him into the bathroom.
● roll him on to a bedpan.
● assist him for a bedside commode
assist him for a bedside commode
59
One evening, General Thunder, was brought to the emergency department due to severe
chest pain. He is diaphoretic and his pulse rate is 110 bpm. The admitting diagnosis is
Myocardial Infarction. General Thunder is on ASA therapy. What is the mechanism of action
for the use of the drug in General Thunder’s condition?
● To inhibit prostaglandin synthesis
● To alter pain perception in the cerebellum
● To directly affect the central nervous system
● To target the pain-producing effect of kinins
To inhibit prostaglandin synthesis
60
Nurse Tenten is teaching General Thunder who has recovered from MI how to prevent a
future episode.
The nurse evaluates that further teaching is needed when General Thunder states, "I
should
● restrict my physical activity."
● take one baby aspirin everyday."
● continue my smoking cessation program."
● try to lose the extra weight I am carrying around."
restrict my physical activity."
61
Nurse Daenerys is assigned to care for Drogo, a 23 year old client admitted recently for a
possible diagnosis of Aplastic Anemia. His chief complaints include muscle weakness and
fatigue. Which of the following data is most important for Nurse Daenerys to elicit during the
interview with the client that can support the diagnosis of Aplastic Anemia?
● Any drug allergies
● Any recent travel or vacation outside the country
● Previous exposure to certain chemicals and drugs D. D. History of blood transfusion
● History of blood transfusion
Previous exposure to certain chemicals and drugs D. D. History of blood
transfusion
62
A diagnosis of Aplastic Anemia has been confirmed to Drogo. When admitting this client,
Nurse Daenerys should assign him in
● a private isolation room equipped with a negative flow pressure.
● a semiprivate room with a client diagnosed with urosepsis.
● a semiprivate room shared with a client experiencing thrombophlebitis.
● a regular private room at the end of the hall.
a regular private room at the end of the hall.
63
For clients suffering from Acute Lymphoid Leukemia, the nurse would most likely expect to
assess which of the following signs and symptoms?
● Enlarged lymph nodes, low grade fever and night sweats
● Fever, pallor, bone and joint pain
● fever, ruddy complexion and petechiae
● Abdominal pain, cystitis and swollen joints
Fever, pallor, bone and joint pain
64
A client diagnosed with chronic lymphocytic leukemia is admitted to the hospital for treatment
of hemolytic anemia. Which of the following measures, if incorporated into the nursing care
plan, would best address the client’s needs?
● Encourage activities with other clients in the day room
● Provide a diet high in Vitamin C
● Provide a quiet environment to promote adequate rest
● Isolate him from visitors and clients to avoid infection
Provide a quiet environment to promote adequate rest
65
Henry, 65 years old underwent Transurethral Resection of the Prostate (TURP). He was
admitted to the Post Anesthetic Care Unit (PACU). The client is on continuous bladder
irrigation with NSS infusing at 200 ml per hour.
After 210 minutes, the nurse obtained an output of 1300 ml from the drainage container.
Which among the following will be recorded as the client’s urinary output?
● 1300 ml
● 700 ml
● 2000 ml
● 600 ml
600 ml
66
Henry, 65 years old underwent Transurethral Resection of the Prostate (TURP). He was
admitted to the Post Anesthetic Care Unit (PACU). The client is on continuous bladder
irrigation with NSS infusing at 200 ml per hour.
While a nurse was doing his rounds, he noticed that the fluid coming from Henry’s Foley
catheter is red. It was 7 hours ago since he was transferred to PACU. The best action of the
nurse is to
● stop the infusion.
● increase the infusion rate.
● milk the catheter away from the patient.
● record the finding as normal.
record the finding as normal.
67
Henry, 65 years old underwent Transurethral Resection of the Prostate (TURP). He was
admitted to the Post Anesthetic Care Unit (PACU). The client is on continuous bladder
irrigation with NSS infusing at 200 ml per hour.
Henry is now scheduled for discharge. Which of the following instructions should the nurse
provide to this client as part of the discharge teaching?
● Reduce your fluid intake so you won’t need to void as often
● Call the doctor immediately if you notice blood in your urine
● You may drive yourself home
● Avoid strenuous activity and heavy lifting for 4-8 weeks
Avoid strenuous activity and heavy lifting for 4-8 weeks
68
Ms. Osorio is diagnosed with renal calculi. She is now on low calcium diet to decrease the
total intake of calcium and prevent renal calculi. You instruct the client to avoid foods such as
● oats, potatoes, soybean.
● oranges, yogurt, spinach.
● rice. malunggay leaves, carrots. whole grain, leafy vegetables, milk.
oranges, yogurt, spinach.
69
Ms. Osorio is diagnosed with renal calculi. During a follow-up, the doctor ordered to monitor
Ms. Osorio for signs of renal calculi. What is the most appropriate nursing intervention to
accomplish the order?
● Visually examine urine after urination
● Use glass container when measuring urinary output
● Strain all urine output
● Do nothing
Strain all urine output
70
Karen, 34 years old, has a history of renal insufficiency. Her renal function worsened and she
is now admitted due to chronic renal failure.
The nurse assesses Karen for signs related to chronic renal failure which includes
● facial flushing.
● edema and pruritus.
● dribbling after voiding.
● diminished force and caliber of urine stream
edema and pruritus.
71
In chronic renal failure, symptoms may not become apparent until later stages of the disease
because
● The kidneys have great functional reserves.
● Liver hormones mask the symptoms.
● Other body systems take over some of the kidney’s functions.
● The adrenal glands compensate for the kidney’s decreased function.
The kidneys have great functional reserves.
72
Karen, 34 years old, has a history of renal insufficiency. Her renal function worsened and she
is now admitted due to chronic renal failure. The nurse notes that the latest potassium level of
Karen is 6.2 mEq/L. The first action by the nurse is to
● alert the cardiac arrest team.
● call the laboratory to repeat the test.
● take the vital signs and notify the physician.
● instruct the patient to increase fluid intake.
take the vital signs and notify the physician.
73
Karen is undergoing regular peritoneal dialysis to treat her renal failure. Which of the following
statements would the nurse include in a discussion with the client?
● The solutes in the dialysate will enter the bloodstream through the peritoneum.
● The peritoneum is more permeable because of the presence of excess metabolites.
● The peritoneum acts as a semi permeable membrane through which wastes
move by diffusion and osmosis.
● The metabolites will diffuse from the interstitial space to the bloodstream mainly
through diffusion and ultrafiltration.
The peritoneum acts as a semi permeable membrane through which wastes
move by diffusion and osmosis.
74
While Karen was on peritoneal dialysis, she suddenly developed shortness of breath while
infusion of the dialysate solution was ongoing. In this situation, the nurse should
● increase the rate of infusion.
● auscultate the lungs for breath sounds.
● drain the fluid from the peritoneal cavity.
● place the client in a low fowler’s position.
drain the fluid from the peritoneal cavity
75
Alterations in fluid and electrolyte balance that may produce minor changes in young and
middle-aged adults have the potential to produce profound changes in older adults,
accompanied by a rapid onset of signs and symptoms.
Which of the following is a contributing factor in the development of hypernatremia?
● Syndrome of Inappropriate Antidiuretic Hormone
● Adrenal insufficiency
● Diabetes insipidus
● Loss of GI fluids
Diabetes insipidus
76
A client sought medical assistance due to nausea and general muscle weakness.
Assessment revealed bradycardia and increasedpotassium level. When serum potassium
levels are dangerously elevated, it may be necessary to administer
● insulin.
● naloxone.
● calcuim gluconate.
● epinephrine.
calcuim gluconate.
77
Hypophosphatemia may be suspected in which of the following clients?
● Gilly who is suffering from renal failure awaiting the first dialysis to run
● Osha, a client with osteoporosis taking vitamin D and calcium supplements
● Davos, a client with hypoparathyroidism secondary to thyroid
surgery
● Podrick, an alcoholic client receiving parenteral nutrition
Osha, a client with osteoporosis taking vitamin D and calcium supplements
78
Intravenous calcium has been ordered to a client with hypocalcemia. Nurse Ramsay is aware
that IV calcium should be diluted with which solution?
● Solutions containing phosphate
● Solutions containing bicarbonate
● D5W
● PNSS
PNSS
79
Laboratory results of Mr. Bolton revealed a magnesium level of 1.4 mEq/L. He is currently
receiving an intravenous magnesium infusion to correct the imbalance. Which of the following
assessments would alert the nurse to immediately stop the infusion?
● Absence of patellar reflex
● Increase in blood pressure
● Diarrhea
● Premature ventricular contractions
Absence of patellar reflex
80
Nurse Pycelle has been assigned to several clients with gastrointestinal disorders. Tommen
has a history of Peptic ulcer disease. He has had numerous bleeding episodes in the past. He
developed peritonitis related to a perforated duodenal ulceration. What would Nurse Pycelle
expect to find during the assessment?
● Decreased or absent bowel sounds
● Alternating episodes of constipation and diarrhea
● Colicky abdominal pain
● High pitched bowel sounds
Decreased or absent bowel sounds
81
Tommen has a history of Peptic ulcer disease. He has had numerous bleeding episodes in
the past. He developed peritonitis related to a perforated duodenal ulceration. Upon browsing
Tommen’s chart, you noted that the physician has an order of Tagamet. What is the primary
reason for Tommen to take this drug?
● Tagamet releases basal gastric acid.
● Tagamet blocks the secretion of gastric hydrochloric acid.
● Tagamet coats the gastric mucosa with a protective membrane.
● Tagamet increases the sensitivity of H2 receptors.
Tagamet blocks the secretion of gastric hydrochloric acid.
82
Tywin has been placed on steroids and he states that he has heard that taking steroids can
be dangerous and asks Nurse Pycelle why steroids are prescribed. Which among the
following statements of Nurse Pycelle is correct about the use of steroid therapy in the
treatment of ulcerative colitis?
● The side effects of steroids outweigh their benefits to clients with ulcerative colitis.
● Ulcerative colitis can be cured by the use of steroids.
● Steroids are used in severe flare-ups because they can decrease the
incidence of bleeding.
● Long-term use of steroids will prolong periods of remission.
Steroids are used in severe flare-ups because they can decrease the
incidence of bleeding.
83
Hepatic dysfunction results from damage to the liver’s parenchymal cells, either directly from
primary liver diseases or indirectly from obstruction of bile flow or derangements of hepatic
circulation. Bronn has been abusing alcohol for the past 15 years now. He was brought to the
Emergency Department because he is increasingly confused and vomiting blood. His medical
diagnosis is cirrhosis of the liver.
Upon assessment, Bronn has developed ascites and esophageal varices. Which symptoms
will Bronn least likely to have?
● Abdominal distention
● Bulging flanks
● Protruding umbilicus
● Bluish discoloration of the umbilicus
Bluish discoloration of the umbilicus
84
Bronn has been abusing alcohol for the past
15 years now. He was brought to the Emergency Department because he is increasingly
confused and vomiting blood. His medical diagnosis is cirrhosis of the liver.
Bronn began vomiting large amounts of dark red blood. A Sengstaken-Blakemore tube was
inserted to compress the bleeding esophageal varices. While the balloon tamponade is in
place, priority intervention should be
● performing frequent mouth care.
● assessing Bronn’s stools for occult blood.
● Evaluating capillary refill in extremities.
● auscultating breath sounds.
auscultating breath sounds.
85
Bronn has been abusing alcohol for the past
15 years now. He was brought to the Emergency Department because he is increasingly
confused and vomiting blood. His medical diagnosis is cirrhosis of the liver.
Several days after admission, Bronn’s condition was worsening. In the intensive care unit,
nursing orders required all nurses to assess regularly for early manifestations of portal
systemic encephalopathy. Which of the following will the nurse note during her observation?
● Presence of papilledema
● Development of disorientation and incoherence
● Signs and symptoms of increased intracranial pressure
● Occurrence of asterixis
Development of disorientation and incoherence
86
Serum ammonia of the client remained to be elevated. The following may be considered by
the nurse to be true regarding this observation except that
● ammonia accumulates in the blood due to inability of the kidney to excrete ammonia.
● ammonia is formed as proteins and amino acids are broken down by intestinal
bacteria.
● since liver function is destroyed, ammonia can no longer be converted to a less
toxic form.
● due to bleeding, a blood in the intestinal tract is digested as protein, thereby
increasing serum ammonia.
since liver function is destroyed, ammonia can no longer be converted to a less
toxic form.
87
Which of the following symptoms can the nurse expect from a client positive of viral hepatitis
exhibit during the icteric phase of the disease?
● Watery stool
● Shortness of breath
● Yellow sclera
● Tarry Stool
Yellow sclera
88
One of the primary conditions affecting the musculoskeletal system is arthritis. The most
common types are osteoarthritis, gouty arthritis and rheumatoid arthritis. Mr. Dimasalang is
diagnosed with gouty arthritis. Nurse Alex is aware of the pathophysiologic mechanism
involved in the disease. Which among the following is true of the condition?
● There is an increase in the level of uric acid which accumulates in joints, called
Heberden’s node.
● This is a result of “wear and tear.”
● When urate crystals precipitate within a joint, this results in an inflammatory
reaction.
● All of the above
When urate crystals precipitate within a joint, this results in an inflammatory
reaction.
89
Colchicine is prescribed during the acute phase of gouty arthritis. Nurse Alex is aware that the
action of the drug is to
● provide fast symptomatic relief.
● lower serum uric acid.
● block the conduction of pain sensation.
● interfere with the inflammation response of uric acid crystals in the joints.
interfere with the inflammation response of uric acid crystals in the joints.
90
Mr. Dimasalang is diagnosed with gouty arthritis. The nurse is preparing his discharge
teaching for Mr. Dimasalang to prevent acute attack. It should include the following, except
● protecting yourself from injury.
● limiting alcohol intake.
● eating a well-balanced diet.
● None of the above
limiting alcohol intake.
91
Lolo Cesar is diagnosed with osteoarthritis. Which statement regarding the condition is true?
● It significantly affects the quality of life of patient.
● Obesity is yet to be established as a risk factor.
● The weight of a patient is inversely proportional to the pain and discomfort
he/she experiences.
● None of the above
The weight of a patient is inversely proportional to the pain and discomfort
he/she experiences.
92
Lolo Cesar is complaining of pain on his right knee especially during movement. The pain in
osteoarthritis is due to
● uric acid deposits.
● autoimmune reaction in the synovium.
● an inflamed synovium and irritation of nerve endings by the patient's own antibodies.
● muscle spasm, tendinitis and inflamed synovium
muscle spasm, tendinitis and inflamed synovium
93
Perioperative registered nurses are relied upon for their professional judgment and critical
thinking skills. They may work closely with the surgical patient, family members, and other
health care professionals. They help plan, implement, and evaluate treatment of the patient.
Nurse Robb was assigned in the OR to attend to Mrs. Talisa who is scheduled for exploratory
laparotomy. Which statement made by Mrs. Talisa indicates that she needs more information
prior to signing an informed consent for abdominal operation?
● “I will be glad to get back to my gardening when I get home.”
● “I will have to take deep breaths and cough after I wake up.”
● “I should not lift more than 5 pounds after my surgery.”
● “I should tell the nurse if I am having pain after my surgery.”
“I will be glad to get back to my gardening when I get home.”
94
Nurse Robb was assigned in the OR to attend to Mrs. Talisa who is scheduled for exploratory
laparotomy.
In assisting Mrs. Talisa to prepare for immediate surgery, what would Nurse Robb do?
● Remove Mrs. Talisa’s wedding band
● Begin exploring Mrs. Talisa’s fears and anxieties about surgery
● Assist in removing dentures and nail polish
● Remind the client to void following preoperative medication
i
Begin exploring Mrs. Talisa’s fears and anxieties about surgery
95
As a perioperative nurse, how can you meet the safety needs of the client after administering
preoperative narcotic?
● Obtain consent form
● Put side rails up and ask the client not to get out of bed
● Send the client to OR with the family
● Assist client to get up to go to the comfort room
Put side rails up and ask the client not to get out of bed
96
Which of the following roles would be the responsibility of the scrub nurse?
● Assess the readiness of the client prior to procedure
● Evaluate the type of anesthesia appropriate for the surgical client
● Ensure that the airways is adequate
● Account for the number of sponges, needles, supplies used during the surgical
procedure
Account for the number of sponges, needles, supplies used during the surgical
procedure
97
The perioperative period encompasses a patient’s total surgical experience including the
perioperative, intraoperative, and postoperative phases. The following questions apply.
The scrub nurse ensures that aseptic technique is maintained throughout the procedure. The
scrub nurse demonstrated adequate knowledge regarding gloving technique when she serves
the right gloves
to the surgeon.
● Keeping thumbs away from the cuff
● Sliding the gloves by holding under the glove cuff and spreading to create wide
opening
● Picking up the gloves and placing the palm towards her
● Maintaining fingers of the gloves facing her
Keeping thumbs away from the cuff
98
The scrub nurse has to unwrap a sterile linen pack on the back table in preparation for a
cholecystectomy. Which of the following is the correct technique of unwrapping the sterile
linen pack?
● Unfold layers gently towards the other side of the table
● Layers are always pulled away from the person opening the pack
● Handle only the edge of the linen
● Place the sterile linen pack on the edge of the table close to the person opening
the pack
Place the sterile linen pack on the edge of the table close to the person opening
the pack
99
The surgeon is about to finish suturing after an exploratory laparotomy. The nurse is about to
place dressing on the incision. Which of the following techniques should the nurse consider?
● Place the dressing, remove the glove and place the tape
● Remove the gloves and place the dressing and tape
● Place the dressing and tell the nursing assistant to assist you in placing the tape then
remove the gloves
● Place the dressing and tape and remove the gloves
Place the dressing, remove the gloves and place the tape
