THE SULTAN REVIEW GROUPNURSING REVIEW

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Nursing Practice Test III SET (A)

Care of Clients with Physiologic and Psychosocial Alterations (Part A) JUNE 2009 N.L.E.
GENERAL INSTRUCTIONS: 1. This test booklet contains 100 test questions 2. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet. 3. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer. 4. AVOID ERASURES. INSTRUCTIONS: 1. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set. 2. Write the subject title "Nursing Practice III" on the box provided. 3. Shade Set Box "A" on your answer sheet if your test booklet is Set A; Set Box "B" if your test booklet is Set B.
Situation: You are assigned at the PACU, 1. Which nursing diagnosis has priority among client in the PACU. a. Acute pain related to discomfort off wound and immobility. b. Body image disturbance because of wound dressing and drains. c. Ineffective airway clearance related to general anesthesia. d. Knowledge deficit related to lack of information because patients are all sedated. 2. Which of the following remark indicates that the clients relative understood the discharge instruction for wound care? a. If the wound is painful, I will say it is normal. b. It is alright to use adhesive tape over the wound to keep it intact. c. It is ok for his pet to remain at his bedside to keep him company. d. I will report any redness or swelling of the wound. 3. You must transfer out a post-op client to her room. What would your instruction to the family include to prevent accidents? a. Report when the IV infusion is almost finished. c. Keep the room lights on for 24 hours. 4.

b. Test the call system if functioning. d. Make sure the side rails are up. One of your post-op patients has a temperature of 37.9C and was shivering. You covered him with a blanket and later took his temperature again and it is now 38.9C.the nursing student asked you to explain the absence of shivering. Even if the temperature was higher. a. The patient is no longer febrile thus he is no longer chilling b. Shivering normally disappears as temperature becomes higher. c. The body has reached its new set point thus the absence of shivering. d. The patient is feeling better.

Situation: One learns by doing especially when you practice the best methods. 5. Which action by a new nurse signifies a need for further teaching in infection control? a. The nurse places the side rails the time to an unconscious patient. b. The nurse elevates the head of the bed to check the BP. c. The nurse uses her bare hands to change the dressing. d. The nurse applies oxygen catheter to the mouth. Gloves are worn for three reasons: first, they protect the hands when the nurse is likely to handle body substances. Kozier, et. al., Fundamentals of Nursing, Edition 7, Page 650. 6. a. b. c. d. 7. a. b. c. d. 8. You are on PM shift and about 5 patients are of discharge. You noted that the orderly was looking through the items of one of the patients. Which action should you pursue? Call the attention of the orderly in private. Ignore the situation because you are busy. Report this behavior to the nurse in change. Monitor the situation and note whether any other items are reported missing. What appropriate action should you do when you overhear the nursing attendant speaking harshly to an elderly patient? Try to explore the interaction with the nursing attendant concerned. Change the attendants assignment. Initiate a group discussion with all other nursing attendants. Discuss the matter with the patients family. Disposal of Medical Record in the Government hospital needs collaboration with which of the following department: DOH. b. MMDA. c. DILG. d. RMAO After taking to her you also report the incident to the charge nurse. The charge nurse should. Require the staff to submit an incident report. c. Charge the erring nurse with dishonesty. Terminate the nurse. d. Report to the Board of Nursing.

a.
9.

a. b.

The incident report is an agency record of an accident or unusual occurrence. Kozier, et. al., Fundamentals of Nursing, Edition 7, Page 63. Situation: The preoperative nurse collaborates with the client significant others and healthcare providers. 10. To control environmental hazards in OR, the nurse collaborates with the following departments EXCEPT: THE SULTAN REVIEW GROUPNURSING REVIEW NURSING PRACTICE TEST III (SET A) 1

a. b.

Biomedical division.

c. Infection control committee.

Chaplaincy services. d. Pathology department. 11. Waste disposal poses a big problem for the hospital. Biological wastes (I.e. amputated limbs) disposal should be coordinated with following agencies: a. Crematorium. b. DOH. c. MMDA. d. DILG

12.

Karla, the PACU nurse, discovered that Malou, who weights 110 lbs prior to surgery, is in severe pain 3 hrs after cholecystectomy. Upon checking the chart, Malou found out that she has an order of Demerol 100mg I.M. pm for pain. Karla should verify the order with: a. Nurse supervisor. b. Anesthesiologist. c. Surgeon d. Intern on duty.

13. Rosita, 57, who is diabetic, is for debridement if Incision wound. When the circulating nurse checked the present I.V. fluid, she
found out that there is no insulin incorporated as ordered. What should the circulating nurse do? a. Double check the doctors orders and calls the attending MD. b. Communicate with the ward nurse to verify if insulin was incorporated. c. Communicate with the client to verify if insulin was incorporated or not. d. Incorporate insulin as ordered. 14. The documentation of all nursing activities performed is legally and professionally vital. Which of the following should NOT be included in the patients chart? a. Presence of prosthetoid devices such as dentutes, artificial limbs hearing aid, etc. b. Baseline physical, emotional, and psychosocial data. c. Arguments between nurses and residents regarding treatments. d. Observed untoward signs and symptoms and interventions including contaminant intervening factors. Situation: Technology and patients education has improved the management of the diabetic client. 15. The current insulin pumps, available I the market have following capability EXCEPT: a. Prevent unexpected saving in blood glucose measurements. b. Detect signs and symptoms of hypoglycemia and hypercalcemia. c. Deliver a pre-meal bolus dose of insulin before each meal. d. Deliver a continuous basal rate of insulin at 5.0 units to 2.0 units per hour. 16. Discharge plan of diabetic clients include injection-site-rotation. You should emphasize that the space between sites should be: a. 6 cm. b.5 cm. c.2.5 cm. d.4 cm. Situation: Frances was unrestrained driver involved in a motor vehicle. She's complaining of neck pain and a cervical spine injury is suspected. 17. Because Frances is suspected of having cervical spine injury, initial intervention should include: a. transporting the patient in the position she was found without moving her extremities b. transporting the patient with her arms flexed across her chest and her neck hyperextended to ensure airway patency c. transporting the patient in a neutral position with a cervical collar applied d. transporting the patient n her side with her head immobilized to prevent aspiration 18. The minimum number of nurses required to logroll Ms. Frances is:

a. Two b. three c. four d. five 19. Which of the assessment findings would indicate a need for possible glaucoma testing? a. Intermittent loss of vision. c. Halos around lights. b. Presence of floaters. d. Pruritus and erythema of the conjunctiva. 20. The patient demonstrates knowledge of the psychological response to the operation and other invasive procedure when she asks
about: a. Who will be with me in the OR? c. Will be naked during the operation. d. Is it cold inside the OR

b.

How is the post operative pain over the site like?

21. In teaching the mother the proper administration of tetracycline eye ointment, which of the following is MOST crucial?
a. Squirt a small amount on the inside of the infected eyes lower lid. b. Use clean, wet cloth to gently wipe away the pus. c. Wash hands before medication administration. d. Do not use other eye ointments or drops or put anything else in eyes. 22. Ensuring patient comfort, Mr. Salvador, a 35 year old male, has been admitted with the diagnosis of peptic ulcers. The nurse recognizes which drugs as those MOST commonly used in these patients to decrease acid sections? a. Erythromycin and flagyl. b. Tagamet and zantac. c. Maalox and kayexalate. d. Dyanzide and carafate. 23. When reading the urinalysis report, the nurse recognizes this result as abnormal? a. Red blood cells 15-20 b. Turbid. c. Glucose negative. d. Ph 6.0.

24. Mr. Dee has had cataract surgery. Discharge teaching would include:
a. Wearing eye patches for the first 72 hours. b. Bending at the waist acceptable if done slowly. c. Bending at the knees and keeping the head straight. d. Lifting light objects is acceptable. Please check option C, patient is for D/C

25. Endoscopic minimally invasive surgery has evolved from diagnostic modality to a widespread surgical technique. What department
should the nurse collaborate. Which is unusual in conventional surgery? a.Engineering department. b. X-ray department c. Blood bank services. Please check option A. 26. When the client is discharged from the hospital and is not capable of doing the needed care services, the following can assume the role EXCEPT: a. Family members. b. Chaplain. c. Significant others. d. Responsible caregiver. 27. R.N. denotes that a nurse: a. Has satisfactorily completed with the requirements to practice nursing as set by the state. b. Missing. THE SULTAN REVIEW GROUPNURSING REVIEW NURSING PRACTICE TEST III (SET A) 2 d. Line section.

c. Is professionally ready to practice nursing. d. Just a little. Situation: Mr. Macaspac 50 is to undergo cystoscopy due to multiple problems like scantly urination, hematuria, and dysuria. 28. You are the nurse in charge in Mr. Macaspac. When asked what are the organs to be examined during cystoscopy, you will enumerate as follow: a. Urethra, kidney, bladder, urethra. c. Bladder wall, uterine wall, and urethral opening.

b. Urethra, bladder wall, trigone, urethral opening. d. Urethral opening, ureteral opening, bladder. 29. In the O.R. you will position Mr. Macaspac who is cystoscopy in: a. Supine b. Lithotomy c. Semi-fowler d. Trendelenburg 30. After cystoscopy, Mr. Macaspac is asked you to explain why there is no incision of any kind. What do you tell him? a. Cystoscopy is direct visualization and examination by urologist.
b. Cystoscopy is done by x-ray visualization of the urinary tract. c. Cystoscopy is done by using lasers on the urinary tract. d. Cystoscopy is an endoscopic procedure of urinary tract. 31. Within 24-48 hours post cystoscopy, it is normal to observe one the following: a. Pink-tinged urine. b. Distended bladder. c. Signs of infection. 32. Leg cramps are NOT uncommon post cystoscopy. Nursing intervention includes: a. Bed rest. b. Warm moist soak. c. Early ambulation would be acceptable for her? a. Liver, fried potatoes and avocado. Whole milk, rice and pastry. 34. Negligence in the practice of nursing can be a ground for: a. Revocation of license by the Ombudsman.

d. Prolonged hematuria. d. Hot sits bath.

33. Ms. Victoria. has been admitted with right upper quadrant pain and has been placed on a low fat diet. Which of the following trays
c. Ham, mashed potatoes, cream peas. d. Skim milk, lean fish, tapioca pudding. c. Revocation of license by the DOH.

b.

b. Revocation of license by the BON. d. Revocation of license by the Nursing Department. 35. One way of verifying that the right message/doctors order was communicated effectively is by. a. Phrasing intelligently. b. Repeating the order message. c. Documenting. d. Missing. 36. Sheena is administering a cleaning enema to a patient with fecal impaction. Before administering the enema, she should place the
patient in which of the following positions? a. On the right side of the body with the head of the bed elevated 45 degrees. b. Left Sims position. c. On the left side of the body with the head of the bed elevated 45 degrees. d. Right Sims position. 37. The functionality and integrity of instruments and medical devices used in surgical procedure, is the responsibility of the: a. Surgeon b. Bio-med technician. c. OR nurse. d. Scrub nurse.

38. Sheena will be preparing a patient for thoracacentesis. She should assist the patient to which of the following positions for the
procedure? a. Prone with the turned to the side and supported by a pillow. b. Lying in bed on the affected side with the head of the bed elevated 45 degrees. c. Sims position with the head of the bed flat. d. Lying in bed on the unaffected side with, the head of the bed elevated 45 degrees. When a patient comes to the clinic for an eye examination the ophthalmologist administers phenylephrine 2.5% drops to:

39.

a. b.

Dilate retinal blood vessels. Anesthetize the cornea.

c. Dilate the pupil. d. Removed any obstruction on the cornea.

40. Which of the following statements by Ms. S.O. a chemotherapy patient with a low

WBC count a low platelet count and a hemoglobin measurement of 56 g would indicate the need for further teaching? a. My lips are dry and cracking I need some lubricant. b. My husband and I have been vaginal lubrication before my intercourse. c. I check my mouth and teeth after each meal. d. Ive been very constipated and need an enema. 41. Patients undergoing surgery display different levels of anxiety. This is researchable. Present, it has been found out that music can decreases anxiety. What other factors can reduce anxiety that is currently done among post operative cases? a. Pre-anesthetic drugs b. pre-operative c. Shower prior to surgery d. Presence of any members of the family. 42. A heavily researched topic in infection control is about the single most important procedure for preventing hospital-acquired infections. What is this procedure called? a. Hand washing. b. Uses of scrub suite. c. Use of facemask. d. Brain washing. 43. A most critical strategy in nursing communication is: a. Non-verbal communication. b. Giving stereotyped comments. c. Verbal communication. d Active listening. 44. Mr. Jag. has undergone surgery for lyses of adhesions. He is transferred from Post Anesthesia care Unit (PACU) to the surgical flood the nurse should obtain pressure, pulse and respiratory every: a. 3 minutes. b. 5 minutes. c. 15 minutes. d. 10 minutes. 45. Mr. Tan age 13 is diagnosed with chronic bronchitis. He is very dyspneic and must sit up to breath. An abnormal condition in which there is discomfort in breathing in any bed or sitting position is: a. Cheyne- strokes. b. Orthopnea. c. Eupnea. d. Dyspnea. 46. The nurse recognizes that the MOST common causative organism in pyelonephritis is: a. E. Coli b. Klebsiella c. Canida Albican d. Pseudomonas 47. Mr. Kaisier is cleaning the garage and splashes a chemical to his eyes. The initial priority care following the chemical burn is to: a. Irrigate with normal saline for 1 to 15 minutes. b. Transport to a physician immediately. c. Irrigate with water for 15 minutes or longer. d. Cover the eyes with sterile gauze. 48. Licensed nurses from foreign countries can practice nursing in the Philippines in the following condition: a. Employed in state colleges and universities. c. Employees by private hospitals. b. Special projects with hospital with a fixed fee. d. Medical mission whose services are free. THE SULTAN REVIEW GROUPNURSING REVIEW NURSING PRACTICE TEST III (SET A) 3

49. A patient diagnosed with breast cancer has been offered the treatment choices of breast conservation surgery with radiation or a
modified radical mastectomy. When questioned by the patient about these options, the nurse informs the patient that the lumpectomy with radiation: a. Reduce the fear and anxiety that accompany the diagnosis and treatment of cancer. b. Has about the same 10 year survival rate as the modified radical mastectomy. c. Provides a shorter treatment period with a fewer long term complications. d. Preserves the normal appearance and sensitivity of the breast. 50. The patient has a right to information regarding the operation or other invasive procedure and potential effects. This right is achieved trough: a. Informed consent b. Preoperative visit c. Chatting d. Doctors round. 51. Which statement about a persons character is evident in the OR team? a. It assists in the control of feelings, thoughts and emotions in the face of difficulty. b. It reflects the moral values and beliefs that are used as guides to personal behavior and actions. c. It encourages the constructive use of the pleasure of the senses. d. It refers to the quality of being righteous, correct fair and impartial. ANSWER: D OR team must be righteous, correct, fair and impartial all the time.

52. Mrs. Villanueva underwent D and C for dysfunctional bleeding. What is inserted vaginally to prevent postoperative bleeding?
a. Perineal pad. b. Vaginal packing c. vaginal suppository d. Gelfoam ANSWER: B Rationale: Vaginal packing works for several reasons: 1. The pelvic mass created by the packing elevates the uterus up and out of the pelvis, placing the uterine arteries on stretch and decreasing their perfusion pressure. 2. The tight packing exerts direct pressure on at least some branches of the uterine arteries, decreasing blood flow to the uterus. 3. By disallowing the escape of uterine blood loss out the vagina, the packing contributes to a back-up pressure that helps tamponade uterine bleeding. (http://www.brooksidepress.org/Products/Military_OBGYN/Textbook/AbnormalLandD/PPHemorrhage.htm)

Situation: Mr. Joseph Thomas Pascual, a 50 year old executive, is admitted to the hospital for the 3rd time with primary complaint of severe eye pain. His diagnosis is glaucoma. 53. Mr.Joseph Thomas Pascual has closed-angle glaucoma. Which symptoms will the patient likely manifest episodic blindness and no pain d. sensation of curtain drawn across the visual field ANSWER: C Rationale: Acute Angle-closure glaucoma causes severe pain and blurred vision or vision loss. Some clients see rainbow halos around lights, and some experiences nausea and vomiting (MS by Black and Hawks, 1945) 54. The nurse instructs the patient ways on how to cope with his illness. Which statement by the patient indicates a need for further instruction? a. "I should avoid using sedative" b. "I should avoid activities that increases intraocular pressure" c. " I should eat more fiber foods and drink plenty of water" d. " I should bring with me my eye medication all the time" ANSWER: A Rationale: Mydriatic agents should be avoided because it restricts the outflow of aqueous humor. (MS by Black, 1945) 55. A client suddenly experiences seizure, and the nurse notes that the client exhibits unrontrollable jerking movements. The nurse documents that the client experienced which type of seizure? a. absence seizures b. myoclonic seizure c. clonic seizure d. tonic seizure ANSWER: B Rationale: Myoclonic seizures involve sudden uncontrollable jerking movements of either a single muscle group or multiple groups, sometimes causing the client to fall. (MS by Black and Hawks, 2076) Situation: Alma, 19 years old, was admitted due to mass about the size of five centavos in the lower quadrant of the left nipple 56. After your palpation, you observed that the mass is movable, this is indicative of: a. benign tumor c. malignant tumor spread of cancer ells d. invasion of cancer cells ANSWER: A Rationale: Benign tumors round shaped, soft or firm, mobile Malignant tumors irregular shape, firm, hard, embedded in the surrounding tissue. (MS by Brunner, 1449) 57. Cancer risk can be reduced by a. regular exercise c. yearly papanicolau's smear regular self-examination d. dietary and environmental precaution ANSWER: D Rationale: A possible but not the best answer B part of early detection but not of risk reduction C not relevant to Breast CA D best answer. Dietary and environmental precaution may help to reduce risk of having Breast CA (example: obesity management, reducing alcohol intake) (MS by Brunner, 1459) She inquired about the predisposing factor of cancer, and these are the following except:

a. b.

diplopia and photophobia

c. blurred vision and colored rings around lights

b.

b.

58.

a.

Sex b. ultraviolet radiation c. age ANSWER: D Rationale: Precipitating factors/ risk factors for Breast CA: Age and Ethnicity THE SULTAN REVIEW GROUPNURSING REVIEW NURSING PRACTICE TEST III (SET A)

d. stress

59.

Family history Early menarche and late menopause Obesity, alcohol intake High dose radiation exposure to chest (Ex.: mantle radiation for Hodgkins disease) (MS by Black and Hawks 1049, Saunders, 549) It is essential to do biopsy. If the entire mass that was palpate removed, this is known as:

open biopsy b. needle biopsy c. excision biopsy d. frozen section ANSWER: C Rationale: Excisional biopsy is the usual procedure for any palpable breast mass. The entire lesion, plus a margin of surrounding tissue, is removed. (MS by Brunner, 1453) 60. It is vital that she should be taught to perform regular breast self examination (BSE) for early detection of breast tumor. This BSE is perform: a. three to four days before her menstruation c. second week after her menstruation first week after her menstruation d. fourth day after her menstruation ANSWER: D Rationale: BSE is best performed after menses (day 5 to day 7, counting the first day of menses as day 1) (MS by Brunner, 1450) Situation: Ms. Jessica Alba RN is assigned to MS. Lilia post thyroidectomy patient 61. Assessing her condition, the physician ordered stat tracheostomy, the clinical parameters for doing so are the following EXCEPT: a. Hypoventilation b. fatigue c. hypertension d. ineffective cough due to body weakness ANSWER: C Rationale: Hypertension is not a clinical parameter for tracheostomy. 62. Which of these is not the nursing management following tracheostomy? a. prevent infection c. avoid misalignment by securing tracheostomy tube with clean cloth provide proper humidification d. maintain patent airway every two hours only ANSWER: D Rationale: patent airway must always be maintained not every 2 hours only. A,B,C are all correct. The following are the nursing intervention to be observed after tracheostomy EXCEPT:

a.

b.

b.

63.

observe indication of shock d. monitor vital signs 30 minutes ANSWER: A Rationale: After tracheostomy, frequent assessment is required, including VS monitoring, assessing amount, color, and consistency of secretions, observing indications of shock, hemorrhage and respiratory insufficiency. (MS by Black, 1782) 64. This is an intervention for tracheostomy care a. put on sterile gloves always b. soak the trochanter tube with sterile water c. never position knots directly over the spinal cord, carotid artery if tracheostomy tie is changed d. wash hands and clean under fingernails ANSWER: C Rationale: A non sterile gloves are also used B Hydrogen peroxide is used not sterile water D possible answer but this is done prior tracheostomy care C BEST ANSWER. (specific to tracheostomy care) (FON, Kozier 5th Ed., 1166) 65. The solution to be instilled into the trachea if tracheal secretions are thick is: a. potassium permanganate b. dextrose 10% NSS c. sterile normal saline d. sterile water ANSWER: C Rationale: If tracheal secretions are thick and not easily removed, instill 3 to 5 ml of sterile normal saline into trachea, the saline reduces viscosity of secretions for easier removal and acts mechanically stimulate cough reflex. (MS by Black, 1783) Situation: Tammy, 56 years old, has gangrene on her right ankle and scheduled for amputation of the knee 66. Post operatively, how should you position her after amputation? a. flat n bed with the stump elevated on a pillow c. Fowler's with stump flat on bed Trendelenburg d. Flat on bed ANSWER: A Rationale: Edema is controlled by elevating the stump for the first 24 hours after surgery. Then, the stump is placed flat on bed to reduce hip contracture (MS by Black, 1524) 67. The nurse should have this ready at patient's bedside following amputation? a. Thermometer b. stethoscope c. tourniquet d. ice bag ANSWER: C Rationale: Because major blood vessels have been severed, massive bleeding may occur (MS by Brunner, 2103 & 2108) 68. The purpose of post amputation rehabilitation is to: a. help her go back to work again c. help her attain self respect help her attain the highest possible level of independence d. help her face the reality of life ANSWER: B Rationale: The multidisciplinary rehabilitation team (patient, nurse, physician, social worker, psychologist, prosthetist, vocational rehabilitation worker) helps the patient achieve the highest possible level of function and participation in life activities. (MS by Brunner, 2104) Jena's wound is completely healed. Stump care at this point should include

a. b.

evaluate mucous membrane color

c. monitor level of consciousness

b.

b.

69.

massage the stumps gently twice a day d. apply baby oil in the stump ANSWER: B Rationale: Massage skin toward the suture line to increase circulation. Stump should not be kept exposed. Wash stump with mild soap and water, creams and oils soften skin too much which is unsafe with prosthesis use (Saunders, 951 and MS by Black, 1527) 70. A client's diet is modified to eliminate foods that act as cardiac stimulants. The nurse should teach the client to avoid: THE SULTAN REVIEW GROUPNURSING REVIEW NURSING PRACTICE TEST III (SET A) 5

a. b.

keep the stump expose

c. soak the stump for 10 minutes

a. Yogurt b. club soda c. chocolate d. red meats ANSWER: C 71. The nurse should teach the clients with phosphatic calculi that their diets may include a. Apples b. chocolate c. rye bread d. American cheese ANSWER: D Rationale: Calcium phosphate stones diet: acid-ash diet which include cheese, eggs, meat, fish, pastries, cranberries, prunes, plums, tomatoes. (Saunders, 817) 72. When a colostomy is the transverse colon, the RN explains to the client that the normal stool from the colostomy will be: a. Liquid b. soft and formed c. mushy d. hard and formed ANSWER: C Rationale: Transverse colostomy produces a malodorous, mushy drainage because some of the liquid has been reabsorbed. (FON, Kozier 5th Ed., 1209) 73. During colostomy irrigation, the client complained of abdominal pain, the nurse should: a. place the enema can 1 feet above the level of the stoma c. . slow down the flow rate instillation temporarily stop the procedure d. put the client in an upright position ANSWER: B Rationale: During colostomy irrigation, if abdominal pain/ cramps occur, temporarily stop the irrigation then resume once pain/cramps has been resolved. 74. The purpose of initial colostomy irrigation three days after abdomino-perineal resection is to: a. release the constriction of the stoma c. stimulate peristalsis resume normal diet d. relieve flatus retention ANSWER: D Rationale: The purpose of irrigating a colostomy is to empty the colon of gas, mucus, & feces (MS by Brunner, 1063) 75. The preoperative nurse is assessing a client for risk for latex allergies if they are allergic to all the following except: a. Avocados b. apples c. kiwi d. peaches ANSWER: B Rationale: Cross reactions have been reported in people who are allergic to certain food products such as kiwis, bananas, pineapples, avocados, passion fruits, chestnuts, tropical fruits, & citrus. (MS by Brunner, 1601, MS by Black, 2325, Saunders, 981) Situation: Mr. Reginald Manasan, an Engineer, was accompanied by his mother to the hospital because he looked yellowish for almost one week. 76. The following are the nursing problems in dealing with client suffering from hepatic disorders, EXCEPT: a. Emotional factors b. Nutrition c. Pruritus d. Blurred vision ANSWER: D Rationale: Manifestations include jaundice, lethargy, irritability, anorexia, nausea, vomiting, abdominal pain, pruritus (MS by Black, 1328) 77. Because of the presence of pigment in the skin he normally feels itchy, the drug management to control itchiness is: a. Diuril b. Stugerone c. Tacaryl d. Decadrone ANSWER: D Rationale: Decadron is a dexamethasone used for inflammatory and Pruritic manifestation of dermatoses that are steroid responsive. (Lippincotts Drug Guide 2004, 373) 78. Since he is very sensitive about is look, this item should be removed from his surrounding a. Television b. Mirror c. Radio d. Powder ANSWER: B 79. Your nursing intervention to help meet his nutritional requirements a. High in protein and carbohydrates, no fat c. High in protein and carbohydrates, low fat b. Low fat and carbohydrates, low fat d. High in protein and fat, low carbohydrates ANSWER: C Rationale: Diet should include High carbohydrates, low fat foods. (Saunders, 650) 80. The hepatoxic agent that is deleterious to his health is: a. Juice b. candies c. carbonated drinks ANSWER: C Situation: Engineer Deogracias fell on the ground from the first floor of the building. The workers brought him to the hospital via ambulance 81. Immediately following his fall, your most important nursing care would be: Place him on the fracture board c. Cover him with a blanket to prevent from chilling b. Apply normal traction to realign the extremities d.Splint the injured part before moving him ANSWER: D Rationale: Immediately after injury, whenever fracture is suspected, it is important to immobilize the body part before the patient is moved. Adequate splinting, including joints adjacent to the fracture is essential. (MS by Brunner, 2080) 82. The cause of the shortening of his left leg would be that the femoral fragment are: a. Related b.Compacted c.Overriding d. Comminuted ANSWER: B Rationale: Compacted fracture is when bone fragments are forced into each other during an injury. (http://ezinearticles.com/?Bone-Fracture&id=1440192)

b.

b.

a.

83

How should you prepare his leg foe Buck's extension traction: a. Applying a coaling of talcum powder b. Shaving the legs with sharp razor. c. Soaking the skin in antiseptic solution to prevent further infection. d. Applying philovex 84. The rationale of applying Buck's extension is to: a. Provide balance support. b. Treat fracture of the shaft of the femur. c. Hold the head in extension to treat strain muscle spasm. d. Immobilize to reduce muscle spasm. ANSWER: D Rationale: Bucks extension is a skin traction used to control muscle spasm and to immobilize an area before surgery. (MS by Brunner, 2026) 85. Hence, he is in traction which of these is the inappropriate nursing intervention: THE SULTAN REVIEW GROUPNURSING REVIEW NURSING PRACTICE TEST III (SET A) 6

Alignment of traction apparatus. c. Alignment of trapeze. Alignment of injured part. d. ROM exercises in as many joint as possible. ANSWER: D Rationale: To maintain effective traction, it is important to avoid wrinkling and slipping of the traction bandage and to maintain countertraction. Proper positioning must be maintained to keep the leg in neutral position. To prevent bony fragments from moving each other, the patient should not turn from side to side, however, the patient may shift position slightly with assistance. (MS by Brunner, 2027) 86. The physician orders intestinal decompression with Cantor tube for the client. The primary purpose of a nasoenteric tube such as a Cantor tube is: a. To prevent fluid gas from the intestine. c. To break up the obstruction.

a.

b.

To prevent fluid accumulation in the stomach. d. To provide an alternative route for drug administration ANSWER: A Rationale: Cantor tube is used for aspirating intestinal contents and has only one lumen. It is 3 meter (10 feet long) and is larger than other tubes. (MS by Black, 745) 87. Which of the following nursing diagnoses would be most appropriate for a client with an intestinal obstruction? a. Impaired swallowing related to NPO status. c. Deficient fluid volume related to nausea and vomiting. b. Urinary retention related to deficient fluid volume. d. none of the above ANSWER: C Rationale: The patient may pass blood and mucus but not fecal matter and no flatus. Vomiting occurs. If the obstruction is complete, peristaltic waves initially become extremely vigorous and eventually assume a reverse direction, with the intestinal contents propelled toward the mouth. (MS by Brunner, 1055) 88. A client's friend volunteers to donate blood for the client. Which of these conditions would not allow the friend to donate? d. all of the above ANSWER: C Rationale: A history of untreated syphilis or malaria not gonorrhea B history of exposure to infectious disease within the past 3 weeks, 4 years is quite long C BEST ANSWER. History of viral hepatitis any time in the past is a contraindication for blood donation. (MS by Brunner, 924 925) 89. The nurse recognizes that the main role of the liver in relation to fat metabolism is: a. Producing phospholipids c. Oxidizing fatty acids to produce energy. Storing fat for energy reserves d. Converting fat to lipoproteins for rapid transport out into the body. ANSWER: C Rationale: Fatty acids can be broken down for the production of Ketone bodies. This primarily occurs when available glucose for metabolism is limited. (MS by Brunner, 1076) 90. A client with cirrhosis of the liver has long standing poor nutrition, including a protein deficiency. This deficiency leads to: a. Decrease bile in the blood. b. Fat accumulation in the liver tissue. c. Coagulation of blood in microcirculation. d. Tissue anabolism and positive nitrogen balance. ANSWER: D Rationale: Use of Amino acids from protein gluconeogenesis results in the formation of ammonia as a by-product. The liver converts this metabolically generated ammonia into urea. (MS by Brunner, 1076) 91. The dietary practice that will help a client reduce the dietary intake of sodium is: a. Increasing the use of dairy products. c. Avoiding the use of carbonated beverages b. using an artificial sweetener in coffee d. using catsup for cooking and flavoring foods ANSWER: C Rationale: This Reduces dietary intake of sodium. 92. After the acute phase of left ventricular failure (congestive heart failure), the nurse should expect the dietary management of the client to include the restriction of: a. sodium b. calcium c. potassium d. magnesium ANSWER: A Rationale: A low sodium (< or equal to 2 to 3 g/day) diet and avoidance of excessive amounts of fluid are usually recommended. (MS by Brunner, 800) 93. After a short hospitalization for an episode of a transient ischemic attack (TIA) related to hypertension, a client is discharged on a regimen that includes chlorothiazide (DIURIL). The nurse should instruct the client to: a. take protein supplement c. avoid eating fruits and vegetables b. increase the intake of potassium d. return to normal eating habits once home ANSWER: B Rationale: Diuril is a thiazide diuretic. Hypokalemia may occur (Lippincotts Drug Guide 2004, 282) 94. The nurse notes that 2 weeks after severe burns, a client is losing 2 pounds of weight daily. The nurse's best action would be adjust the client's diet by adding a. low sodium milk c. fruit juices low in potassium b. high protein drinks d. 10% more calories in the form of fats ANSWER: B Rationale: Major metabolic abnormality seen after a burn injury include rapid skeletal muscle breakdown with amino acids serving as the energy source; lack of ketosis, indicating that fat is not a major source of calories. Nutritional support with optimized protein intake can decrease protein losses by approximately 50%. (MS by Brunner, 1726) 95. A client with chronic renal failure who is receiving dialysis is prescribed a protein-sodium and potassium restricted diet. The nurse would know that the dietary teaching was effective when the client says: a. "I cannot add seasoning to my food c. "I can eat canned, no-salt vegetables." b. "I should avoid using salt substitutes d. " I should get the protein I eat from meat" Situation: Regine, 35 years old single pharmacist in a drugstore was gasping for breath with wheezing sound when brought to the hospital. This asthmatic attack was preceded by the death of her mother: 96. In the emergency room, the admitting nurse identified this nursing diagnosis a. impaired gas exchange THE SULTAN REVIEW GROUPNURSING REVIEW NURSING PRACTICE TEST III (SET A) 7

b.

a. b.

History of gonorrhea within the last year. History of bacterial endocarditis within the last 4 years

c. History of hepatitis within the last 5 years.

b.

b. ineffective airway clearance potential for suffocation altered tissue perfusion ANSWER: B Rationale: Airway clearance is always a problem with asthmatic attack. 97. The initial goal for medical and nursing intervention is: a. attend to her physical needs c. teach relaxation technique b. provide safe environment d. assist her to control her feedings ANSWER: A Rationale: Physiologic needs (like Oxygen, etc.) are always the priority over psychological needs. (Maslows Hierarchy of Needs) 98. Regine is not aware that she deals with stress through physical symptoms. The nurse can help her to increase insight into her condition by": a. pointing out her that the physical symptoms are not real b. teaching her about the illness and its symptoms c. help her identify the connection between occurrence of symptoms and stress d. encouraging her to focus in her physical symptoms ANSWER: C Rationale: A non therapeutic B possible answer but lacks patient participation C BEST ANSWER. Encourages participation from the patient D non therapeutic 99. The defense mechanism commonly used by asthmatic patient is reaction formation describes as follows: a. conscious pulling off of awareness of disturbing situation or feelings c. d. attributing an unconscious impulse, altitude or behavior to someone else c. an acceptable feeling regarding an object or person kept out awareness and acted out consciously in an opposite manner d. none of the above ANSWER: C Rationale: A repression B identification C reaction formation 100.After the physical symptoms are controlled the nurse implemented this nursing intervention a. help her perform activities of daily living

b.

b. c.

encourage problem solving to increase feeling of control in her own life

encourage her to talk about her feelings of control in her own life d. lessen environmental stimuli ANSWER: C Rationale: Encouraging verbalization is a therapeutic intervention.

THE SULTAN REVIEW GROUPNURSING REVIEW NURSING PRACTICE TEST III (SET A)