NCLEX EXAM REVIEW

SITUATION : Arthur, A registered nurse, witnessed an old woman hit by a

motorcycle while crossing a train railway. The old woman fell at the railway. Arthur
rushed at the scene.
1. As a registered nurse, Arthur knew that the first thing that he will do at the scene is

A. Stay with the person, Encourage her to remain still and Immobilize the leg
while While waiting for the ambulance.
B. Leave the person for a few moments to call for help.
C. Reduce the fracture manually.
D. Move the person to a safer place.
2. Arthur suspects a hip fracture when he noticed that the old woman’s leg is

A. A. Lengthened, Abducted and Internally Rotated.

B. Shortened, Abducted and Externally Rotated.
C. Shortened, Adducted and Internally Rotated.
D. Shortened, Adducted and Externally Rotated.
3. The old woman complains of pain. John noticed that the knee is reddened, warm to
touch and swollen. John interprets that this signs and symptoms are likely related to

A. Infection
B. Thrombophlebitis
C. Inflammation
D. Degenerative disease
4. The old woman told John that she has osteoporosis; Arthur knew that all of the
following factors would contribute to osteoporosis except

A. Hypothyroidism
B. End stage renal disease
C. Cushing’s Disease
D. Taking Furosemide and Phenytoin.
5. Martha, The old woman was now Immobilized and brought to the emergency room.
The X-ray shows a fractured femur and pelvis. The ER Nurse would carefully monitor
Martha for which of the following sign and symptoms?

A. Tachycardia and Hypotension

B. Fever and Bradycardia
C. Bradycardia and Hypertension
 D. Fever and Hypertension
SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of OLFU Lagro is
admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis.
6. As a nurse, you instructed Mr. Rojas how to use a cane. Mr. Rojas has a weakness
on his right leg due to self immobilization and guarding. You plan to teach Mr. Rojas
to hold the cane

A. On his left hand, because his right side is weak.

B. On his left hand, because of reciprocal motion.
C. On his right hand, to support the right leg.
D. On his right hand, because only his right leg is weak.
7. You also told Mr. Rojas to hold the cane

A. 1 Inches in front of the foot.

B. 3 Inches at the lateral side of the foot.
C. 6 Inches at the lateral side of the foot.
D. 12 Inches at the lateral side of the foot.
8. Mr. Rojas was discharged and 6 months later, he came back to the emergency room
of the hospital because he suffered a mild stroke. The right side of the brain was
affected. At the rehabilitative phase of your nursing care, you observe Mr. Rojas use a
cane and you intervene if you see him

A. Moves the cane when the right leg is moved.

B. Leans on the cane when the right leg swings through.
C. keeps the cane 6 Inches out to the side of the right foot.
D. Holds the cane on the right side.
SITUATION: Alfred, a 40 year old construction worker developed cough, night
sweats and fever. He was brought to the nursing unit for diagnostic studies. He told
the nurse he did not receive a BCG vaccine during childhood
9. The nurse performs a Mantoux Test. The nurse knows that Mantoux Test is also
known as

A. PPD
B. PDP
C. PDD
D. DPP
10. The nurse would inject the solution in what route?

A. IM
B. IV
C. ID
 D. SC
11. The nurse notes that a positive result for Alfred is

A. 5 mm wheal
B. 5 mm Induration
C. 10 mm Wheal
D. 10 mm Induration
12. The nurse told Alfred to come back after

A. a week
B. 48 hours
C. 1 day
D. 4 days
13. Mang Alfred returns after the Mantoux Test. The test result read POSITIVE. What
should be the nurse’s next action?

A. Call the Physician

B. Notify the radiology dept. for CXR evaluation
C. Isolate the patient
D. Order for a sputum exam
14. Why is Mantoux test not routinely done in the Philippines?

A. It requires a highly skilled nurse to perform a Mantoux test

B. The sputum culture is the gold standard of PTB Diagnosis and it will
definitively determine the extent of the cavitary lesions
C. Chest X Ray Can diagnose the specific microorganism responsible for the
lesions
D. Almost all Filipinos will test positive for Mantoux Test
15. Mang Alfred is now a new TB patient with an active disease. What is his category
according to the DOH?

A. I
B. II
C. III
D. IV
16. How long is the duration of the maintenance phase of his treatment?

A. 2 months
B. 3 months
C. 4 months
D. 5 months
17. Which of the following drugs is UNLIKELY given to Mang Alfred during the
maintenance phase?

A. Rifampicin
B. Isoniazid
C. Ethambutol
D. Pyridoxine
18. According to the DOH, the most hazardous period for development of clinical
disease is during the first

A. 6-12 months after

B. 3-6 months after
C. 1-2 months after
D. 2-4 weeks after
19. This is the name of the program of the DOH to control TB in the country

A. DOTS
B. National Tuberculosis Control Program
C. Short Coursed Chemotherapy
D. Expanded Program for Immunization
20. Susceptibility for the disease [ TB ] is increased markedly in those with the
following condition except

A. 23 Year old athlete with diabetes insipidus

B. 23 Year old athlete taking long term Decadron therapy and anabolic
steroids
C. 23 Year old athlete taking illegal drugs and abusing substances
D. Undernourished and Underweight individual who undergone gastrectomy
21. Direct sputum examination and Chest X ray of TB symptomatic is in what level of
prevention?

A. Primary
B. Secondary
C. Tertiary
D. Quarterly
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in
colostomy.
22. Michiel shows the BEST adaptation with the new colostomy if he shows which of
the following?

A. Look at the ostomy site

 B. Participate with the nurse in his daily ostomy care
C. Ask for leaflets and contact numbers of ostomy support groups
D. Talk about his ostomy openly to the nurse and friends
23. The nurse plans to teach Michiel about colostomy irrigation. As the nurse prepares
the materials needed, which of the following item indicates that the nurse needs
further instruction?

A. Plain NSS / Normal Saline

B. K-Y Jelly
C. Tap water
D. Irrigation sleeve
24. The nurse should insert the colostomy tube for irrigation at approximately

A. 1-2 inches
B. 3-4 inches
C. 6-8 inches
D. 12-18 inches
25. The maximum height of irrigation solution for colostomy is

A. 5 inches
B. 12 inches
C. 18 inches
D. 24 inches
26. Which of the following behavior of the client indicates the best initial step in
learning to care for his colostomy?

A. Ask to defer colostomy care to another individual

B. Promises he will begin to listen the next day
C. Agrees to look at the colostomy
D. States that colostomy care is the function of the nurse while he is in the
hospital
27. While irrigating the client’s colostomy, Michiel suddenly complains of severe
cramping. Initially, the nurse would

A. Stop the irrigation by clamping the tube

B. Slow down the irrigation
C. Tell the client that cramping will subside and is normal
D. Notify the physician
28. The next day, the nurse will assess Michiel’s stoma. The nurse noticed that a
prolapsed stoma is evident if she sees which of the following?
 A. A sunken and hidden stoma
B. A dusky and bluish stoma
C. A narrow and flattened stoma
D. Protruding stoma with swollen appearance
29. Michiel asked the nurse, what foods will help lessen the odor of his colostomy.
The nurse best response would be

A. Eat eggs
B. Eat cucumbers
C. Eat beet greens and parsley
D. Eat broccoli and spinach
30. The nurse will start to teach Michiel about the techniques for colostomy irrigation.
Which of the following should be included in the nurse’s teaching plan?

A. Use 500 ml to 1,000 ml NSS

B. Suspend the irrigant 45 cm above the stoma
C. Insert the cone 4 cm in the stoma
D. If cramping occurs, slow the irrigation
31. The nurse knew that the normal color of Michiel’s stoma should be

A. Brick Red
B. Gray
C. Blue
D. Pale Pink
SITUATION: James, A 27 basketball player sustained inhalation burn that required
him to have tracheostomy due to massive upper airway edema.
32. Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which
of the following, if made by Wilma indicates that she is committing an error?

A. Hyperventilating James with 100% oxygen before and after suctioning

B. Instilling 3 to 5 ml normal saline to loosen up secretion
C. Applying suction during catheter withdrawal
D. Suction the client every hour
33. What size of suction catheter would Wilma use for James, who is 6 feet 5 inches
in height and weighing approximately 145 lbs?

A. Fr. 5
B. Fr. 10
C. Fr. 12
D. Fr. 18
34. Wilma is using a portable suction unit at home, What is the amount of suction
required by James using this unit?

A. 2-5 mmHg
B. 5-10 mmHg
C. 10-15 mmHg
D. 20-25 mmHg
35. If a Wall unit is used, What should be the suctioning pressure required by James?

A. 50-95 mmHg
B. 95-110 mmHg
C. 100-120 mmHg
D. 155-175 mmHg
36. Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner
and outer cannulas was removed and left hanging on James’ neck. What are the 2
equipment’s at james’ bedside that could help Wilma deal with this situation?

A. New set of tracheostomy tubes and Oxygen tank

B. Theophylline and Epinephrine
C. Obturator and Kelly clamp
D. Sterile saline dressing
37. Which of the following method if used by Wilma will best assure that the
tracheostomy ties are not too tightly placed?

A. Wilma places 2 fingers between the tie and neck

B. The tracheotomy can be pulled slightly away from the neck
C. James’ neck veins are not engorged
D. Wilma measures the tie from the nose to the tip of the earlobe and to the
xiphoid process.
38. Wilma knew that James have an adequate respiratory condition if she notices that

A. James’ respiratory rate is 18

B. James’ Oxygen saturation is 91%
C. There are frank blood suction from the tube
D. There are moderate amount of tracheobronchial secretions
39. Wilma knew that the maximum time when suctioning James is

A. 10 seconds
B. 20 seconds
C. 30 seconds
D. 45 seconds
SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with
Acute Close Angle Glaucoma. He is being seen by Nurse Jet.
40. What specific manifestation would nurse Jet see in Acute close angle glaucoma
that she would not see in an open angle glaucoma?

A. Loss of peripheral vision

B. Irreversible vision loss
C. There is an increase in IOP
D. Pain
41. Nurse jet knew that Acute close angle glaucoma is caused by

A. Sudden blockage of the anterior angle by the base of the iris

B. Obstruction in trabecular meshwork
C. Gradual increase of IOP
D. An abrupt rise in IOP from 8 to 15 mmHg
42. Nurse jet performed a TONOMETRY test to Mr. Batumbakal. What does this test
measures

A. It measures the peripheral vision remaining on the client

B. Measures the Intra Ocular Pressure
C. Measures the Client’s Visual Acuity
D. Determines the Tone of the eye in response to the sudden increase in IOP.
43. The Nurse notices that Mr. Batumbakal cannot anymore determine RED from
BLUE. The nurse knew that which part of the eye is affected by this change?

A. IRIS
B. PUPIL
C. RODS [RETINA]
D. CONES [RETINA]
44. Nurse Jet knows that Aqueous Humor is produce where?

A. In the sub arachnoid space of the meninges

B. In the Lateral ventricles
C. In the Choroids
D. In the Ciliary Body
45. Nurse Jet knows that the normal IOP is

A. 8-21 mmHg
B. 2-7 mmHg
C. 31-35 mmHg
D. 15-30 mmHg
46. Nurse Jet wants to measure Mr. Batumbakal’s CN II Function. What test would
Nurse Jet implement to measure CN II’s Acuity?

A. Slit lamp
B. Snellen’s Chart
C. Wood’s light
D. Gonioscopy
47. The Doctor orders pilocarpine. Nurse jet knows that the action of this drug is to

A. Contract the Ciliary muscle

B. Relax the Ciliary muscle
C. Dilate the pupils
D. Decrease production of Aqueous Humor
48. The doctor orders timolol [timoptic]. Nurse jet knows that the action of this drug
is

A. Reduce production of CSF

B. Reduce production of Aquesous Humor
C. Constrict the pupil
D. Relaxes the Ciliary muscle
49. When caring for Mr. Batumbakal, Jet teaches the client to avoid

A. Watching large screen TVs

B. Bending at the waist
C. Reading books
D. Going out in the sun
50. Mr. Batumbakal has undergone eye angiography using an Intravenous dye and
fluoroscopy. What activity is contraindicated immediately after procedure?

A. Reading newsprint
B. Lying down
C. Watching TV
D. Listening to the music
51. If Mr. Batumbakal is receiving pilocarpine, what drug should always be available
in any case systemic toxicity occurs?

A. Atropine Sulfate
B. Pindolol [Visken]
C. Naloxone Hydrochloride [Narcan]
D. Mesoridazine Besylate [Serentil]
SITUATION : Wide knowledge about the human ear, it’s parts and it’s functions will
help a nurse assess and analyze changes in the adult client’s health.
52. Nurse Anna is doing a caloric testing to his patient, Aida, a 55 year old university
professor who recently went into coma after being mauled by her disgruntled 3rd year
nursing students whom she gave a failing mark. After instilling a warm water in the
ear, Anna noticed a rotary nystagmus towards the irrigated ear. What does this means?
A. Indicates a CN VIII Dysfunction
B. Abnormal
C. Normal
D. Inconclusive
53. Ear drops are prescribed to an infant, The most appropriate method to administer
the ear drops is

A. Pull the pinna up and back and direct the solution towards the eardrum
B. Pull the pinna down and back and direct the solution onto the wall of the
canal
C. Pull the pinna down and back and direct the solution towards the eardrum
D. Pull the pinna up and back and direct the solution onto the wall of the canal
54. Nurse Jenny is developing a plan of care for a patient with Menieres disease. What
is the priority nursing intervention in the plan of care for this particular patient?

A. Air, Breathing, Circulation

B. Love and Belongingness
C. Food, Diet and Nutrition
D. Safety
55. After mastoidectomy, Nurse John should be aware that the cranial nerve that is
usually damage after this procedure is

A. CN I
B. CN II
C. CN VII
D. CN VI
56. The physician orders the following for the client with Menieres disease. Which of
the following should the nurse question?

A. Dipenhydramine [Benadryl]
B. Atropine sulfate
C. Out of bed activities and ambulation
D. Diazepam [Valium]
57. Nurse Anna is giving dietary instruction to a client with Menieres disease. Which
statement if made by the client indicates that the teaching has been successful?
 A. I will try to eat foods that are low in sodium and limit my fluid intake
B. I must drink atleast 3,000 ml of fluids per day
C. I will try to follow a 50% carbohydrate, 30% fat and 20% protein diet
D. I will not eat turnips, red meat and raddish
58. Peachy was rushed by his father, Steven into the hospital admission. Peachy is
complaining of something buzzing into her ears. Nurse Joemar assessed peachy and
found out It was an insect. What should be the first thing that Nurse Joemar should try
to remove the insect out from peachy’s ear?

A. Use a flashlight to coax the insect out of peachy’s ear

B. Instill an antibiotic ear drops
C. Irrigate the ear
D. Pick out the insect using a sterile clean forceps
59. Following an ear surgery, which statement if heard by Nurse Oca from the patient
indicates a correct understanding of the post operative instructions?

A. Activities are resumed within 5 days

B. I will make sure that I will clean my hair and face to prevent infection
C. I will use straw for drinking
D. I should avoid air travel for a while
60. Nurse Oca will do a caloric testing to a client who sustained a blunt injury in the
head. He instilled a cold water in the client’s right ear and he noticed that nystagmus
occurred towards the left ear. What does this finding indicates?

A. Indicating a Cranial Nerve VIII Dysfunction

B. The test should be repeated again because the result is vague
C. This is Grossly abnormal and should be reported to the neurosurgeon
D. This indicates an intact and working vestibular branch of CN VIII
61. A client with Cataract is about to undergo surgery. Nurse Oca is preparing plan of
care. Which of the following nursing diagnosis is most appropriate to address the long
term need of this type of patient?

A. Anxiety R/T to the operation and its outcome

B. Sensory perceptual alteration R/T Lens extraction and replacement
C. Knowledge deficit R/T the pre operative and post operative self care
D. Body Image disturbance R/T the eye packing after surgery
62. Nurse Joseph is performing a WEBERS TEST. He placed the tuning fork in the
patients forehead after tapping it onto his knee. The client states that the fork is louder
in the LEFT EAR. Which of the following is a correct conclusion for nurse Josph to
make?
 A. He might have a sensory hearing loss in the left ear
B. Conductive hearing loss is possible in the right ear
C. He might have a sensory hearing loss in the right hear, and/or a conductive
hearing loss in the left ear.
D. He might have a conductive hearing loss in the right ear, and/or a sensory
hearing loss in the left ear.
63. Aling myrna has Menieres disease. What typical dietary prescription would nurse
Oca expect the doctor to prescribe?

A. A low sodium , high fluid intake

B. A high calorie, high protein dietary intake
C. low fat, low sodium and high calorie intake
D. low sodium and restricted fluid intake
SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was
admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak
rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the
skin was noted when the nurse released her pinch.
Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural
hypotension. There was no infection.

64. Which of the following is the appropriate nursing diagnosis?

A. Fluid volume deficit R/T furrow tongue
B. Fluid volume deficit R/T uncontrolled vomiting
C. Dehydration R/T subnormal body temperature
D. Dehydration R/T incessant vomiting
65. Approximately how much fluid is lost in acute weight loss of .5kg?

A. 50 ml
B. 750 ml
C. 500 ml
D. 75 ml
66. Postural Hypotension is

A. A drop in systolic pressure less than 10 mmHg when patient changes

position from lying to sitting.
B. A drop in systolic pressure greater than 10 mmHg when patient changes
position from lying to sitting
C. A drop in diastolic pressure less than 10 mmHg when patient changes
position from lying to sitting
D. A drop in diastolic pressure greater than 10 mmHg when patient changes
position from lying to sitting
67. Which of the following measures will not help correct the patient’s condition

A. Offer large amount of oral fluid intake to replace fluid lost

B. Give enteral or parenteral fluid
C. Frequent oral care
D. Give small volumes of fluid at frequent interval
68. After nursing intervention, you will expect the patient to have

1. Maintain body temperature at 36.5 C

2. Exhibit return of BP and Pulse to normal
3. Manifest normal skin turgor of skin and tongue
4. Drinks fluids as prescribed
A. 1,3
B. 2,4
C. 1,3,4
D. 2,3,4
SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The
charge nurse is going to make an initial assessment.
69. Which of the following is a characteristic of a patient with advanced Parkinson’s
disease?

A. Disturbed vision
B. Forgetfulness
C. Mask like facial expression
D. Muscle atrophy
70. The onset of Parkinson’s disease is between 50-60 years old. This disorder is
caused by

A. Injurious chemical substances

B. Hereditary factors
C. Death of brain cells due to old age
D. Impairment of dopamine producing cells in the brain
71. The patient was prescribed with levodopa. What is the action of this drug?

A. Increase dopamine availability

B. Activates dopaminergic receptors in the basal ganglia
C. Decrease acetylcholine availability
D. Release dopamine and other catecholamine from neurological storage sites
72. You are discussing with the dietician what food to avoid with patients taking
levodopa?
 A. Vitamin C rich food
B. Vitamin E rich food
C. Thiamine rich food
D. Vitamin B6 rich food
73. One day, the patient complained of difficulty in walking. Your response would be

A. You will need a cane for support

B. Walk erect with eyes on horizon
C. I’ll get you a wheelchair
D. Don’t force yourself to walk
SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process
disturbances.
74. The nurse will assess a loss of ability in which of the following areas?

A. Balance
B. Judgment
C. Speech
D. Endurance
75. Mr. Dela Isla said he cannot comprehend what the nurse was saying. He suffers
from:

A. Insomnia
B. Aphraxia
C. Agnosia
D. Aphasia
76. The nurse is aware that in communicating with an elderly client, the nurse will

A. Lean and shout at the ear of the client

B. Open mouth wide while talking to the client
C. Use a low-pitched voice
D. Use a medium-pitched voice
77. As the nurse talks to the daughter of Mr. Dela Isla, which of the following
statement of the daughter will require the nurse to give further teaching?

A. I know the hallucinations are parts of the disease

B. I told her she is wrong and I explained to her what is right
C. I help her do some tasks he cannot do for himself
D. Ill turn off the TV when we go to another room
78. Which of the following is most important discharge teaching for Mr. Dela Isla

A. Emergency Numbers
 B. Drug Compliance
C. Relaxation technique
D. Dietary prescription
SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine]
Is necessary in treatment of various disorders.
79. What is the action of this drug?

A. Increases glandular secretion for clients affected with cystic fibrosis

B. Dissolve blockage of the urinary tract due to obstruction of cystine stones
C. Reduces secretion of the glandular organ of the body
D. Stimulate peristalsis for treatment of constipation and obstruction
80. What should the nurse caution the client when using this medication

A. Avoid hazardous activities like driving, operating machineries etc.

B. Take the drug on empty stomach
C. Take with a full glass of water in treatment of Ulcerative colitis
D. I must take double dose if I missed the previous dose
81. Which of the following drugs are not compatible when taking Probanthine?

A. Caffeine
B. NSAID
C. Acetaminophen
D. Alcohol
82. What should the nurse tell clients when taking Probanthine?

A. Avoid hot weathers to prevent heat strokes

B. Never swim on a chlorinated pool
C. Make sure you limit your fluid intake to 1L a day
D. Avoid cold weathers to prevent hypothermia
83. Which of the following disease would Probanthine exert the much needed action
for control or treatment of the disorder?

A. Urinary retention
B. Peptic Ulcer Disease
C. Ulcerative Colitis
D. Glaucoma
SITUATION : Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak
at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
84. Which of the following is the most important assessment during the acute stage of
an unconscious patient like Mr. Franco?
 A. Level of awareness and response to pain
B. Papillary reflexes and response to sensory stimuli
C. Coherence and sense of hearing
D. Patency of airway and adequacy of respiration
85. Considering Mr. Franco’s conditions, which of the following is most important to
include in preparing Franco’s bedside equipment?

A. Hand bell and extra bed linen

B. Sandbag and trochanter rolls
C. Footboard and splint
D. Suction machine and gloves
86. What is the rationale for giving Mr. Franco frequent mouth care?

A. He will be thirsty considering that he is doesn’t drink enough fluids

B. To remove dried blood when tongue is bitten during a seizure
C. The tactile stimulation during mouth care will hasten return to
consciousness
D. Mouth breathing is used by comatose patient and it’ll cause oral mucosa
dying and cracking.
87. One of the complications of prolonged bed rest is decubitus ulcer. Which of the
following can best prevent its occurrence?

A. Massage reddened areas with lotion or oils

B. Turn frequently every 2 hours
C. Use special water mattress
D. Keep skin clean and dry
88. If Mr. Franco’s Right side is weak, What should be the most accurate analysis by
the nurse?

A. Expressive aphasia is prominent on clients with right sided weakness

B. The affected lobe in the patient is the Right lobe
C. The client will have problems in judging distance and proprioception
D. Clients orientation to time and space will be much affected
SITUATION : a 20 year old college student was rushed to the ER of PGH after he
fainted during their ROTC drill. Complained of severe right iliac pain. Upon
palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was
ordered. Diagnosis is acute appendicitis.

89. Which result of the lab test will be significant to the diagnosis?
A. RBC : 4.5 TO 5 Million / cu. mm.
B. Hgb : 13 to 14 gm/dl.
 C. Platelets : 250,000 to 500,000 cu.mm.
D. WBC : 12,000 to 13,000/cu.mm
90. Stat appendectomy was indicated. Pre op care would include all of the following
except?

A. Consent signed by the father

B. Enema STAT
C. Skin prep of the area including the pubis
D. Remove the jewelries
91. Pre-anesthetic med of Demerol and atrophine sulfate were ordered to :

A. Allay anxiety and apprehension

B. Reduce pain
C. Prevent vomiting
D. Relax abdominal muscle
92. Common anesthesia for appendectomy is

A. Spinal
B. General
C. Caudal
D. Hypnosis
93. Post op care for appendectomy include the following except

A. Early ambulation
B. Diet as tolerated after fully conscious
C. Nasogastric tube connect to suction
D. Deep breathing and leg exercise
94. Peritonitis may occur in ruptured appendix and may cause serious problems which
are

1. Hypovolemia, electrolyte imbalance

2. Elevated temperature, weakness and diaphoresis
3. Nausea and vomiting, rigidity of the abdominal wall
4. Pallor and eventually shock
A. 1 and 2
B. 2 and 3
C. 1,2,3
D. All of the above
95. If after surgery the patient’s abdomen becomes distended and no bowel sounds
appreciated, what would be the most suspected complication?
 A. Intussusception
B. Paralytic Ileus
C. Hemorrhage
D. Ruptured colon
96. NGT was connected to suction. In caring for the patient with NGT, the nurse must

A. Irrigate the tube with saline as ordered

B. Use sterile technique in irrigating the tube
C. advance the tube every hour to avoid kinks
D. Offer some ice chips to wet lips
97. When do you think the NGT tube be removed?

A. When patient requests for it

B. Abdomen is soft and patient asks for water
C. Abdomen is soft and flatus has been expelled
D. B and C only
Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell
while getting out of the bed one morning and was brought to the hospital, and she
was diagnosed to have cerebrovascular thrombosis thus transferred to a nursing
home.
98. What do you call a STROKE that manifests a bizarre behavior?

A. Inorganic Stroke
B. Inorganic Psychoses
C. Organic Stroke
D. Organic Psychoses
99. The main difference between chronic and organic brain syndrome is that the
former

A. Occurs suddenly and reversible

B. Is progressive and reversible
C. tends to be progressive and irreversible
D. Occurs suddenly and irreversible
100. Which behavior results from organic psychoses?

A. Memory deficit
B. Disorientation
C. Impaired Judgement
D. Inappropriate affect