ILOILO DOCTORS COLLEGE

COLLEGE OF NURSING
RLE 106 FINAL EXAM
AY 2013-2014
INSTRUCTION:
1. WRITE THE LETTER OF THE CORRECT ANSWER IN THE TEST OO!LET.
2. ALL ANSWERS MUST E IN CA"ITAL LETTERS.
3. ALL ANSWERS MUST E IN A LUE#LAC! IN!.
4. ERASURES AND ALTERATIONS WILL NOT E ACCE"TED
21. Hepatitis B is transmitted through parenteral transmission, except
A. Blood and blood product
B. Use of contaminated instruments for injection
C. Use of contaminated hospital and laboratory euipment
!. "exual contact #ia the #aginal and seminal secretions
22. Hepatitis B can occur during labor and deli#ery through lea$s across the placenta and can be
precipitated by injury during deli#ery. %t may also occur through exposure of the infant to
maternal secretions in the birth canal.
A. &arenteral transmission C. perinatal transmission
B. "exual contact !. blood transfusion
2'. (hich is not true about )etanus *eonatorum.
A. An acute disease induced by toxin of tetanus bacillus gro+ing an aerobically in +ounds and at
site of umbilicus among infants
B. Characteri,ed by muscular contractions
C. Usually occurs through contamination of the unhealed stump of the umbilical cord
!. %ncubation period is usually 2 to - days
2.. (hich is not a sign or symptom of measles/
A. rashes C. bleeding
B. fe#er !. 0opli$ spots
2-. A suspect cases of this disease is defined as any patient belo+ 1- years of age +ith acute flaccid
paralysis for +hich no other cause can be immediately identified.
A. &ertussis C. !iphtheria
B. &oliomyelitis !. )uberculosis
26. A process by which the fetus and products of conception are expelled resulting from a
regular , progressive, frequent and strong uterine contraction.
A) Delivery .) !abor
") #ertili$ation D) %vulation
21. At +hat stage of labor does cro+ning be obser#ed/
A2 1
st
stage C2 '
rd
stage
B2 2
nd
stage !2 .
th
stage
23. )he cardinal mo#ement that occurs immediately before expulsion.
A2 4xternal rotation C2 5lexion
B2 4xtension !2 !escent
26. %n ne+born, an A&7A8 score of 9 signifies +hich of the follo+ing/
A) 7ood C2 "erious: critical condition
B2 7uarded !2 *ormal
26. (hen is the best time to start breastfeeding/
A2 %mmediately after birth C2 2 hours after deli#ery
B2 (hen the breatmil$ starts to flo+ !2 (hen the mother is ready
';. %n performing an ideal perineal prep, ho+ many cherries are needed/
A) - cherries C2 1 cherries
B2 1 cherry:s+ab !2 . cherries
'1. %mmediately after deli#ery, +here can the uterus be palpated/
A) <o+er abdomen C2 At the le#el of the umbilicus
B2 ' fingerbreaths abo#e the hypogastrium !2 All of the abo#e
'2. (hich of the follo+ing is the least priority in assessing the lochia discharges/
1
A) Amount C2 Color
B2 Clots present !2 "mell
''. "aturation of . sanitary nap$ins during the first hour of deli#ery signifies=
A2 Hemorrhage C2 4xpected phenomenon
B2 A normal occurrence !2 malignancy
'.. (hen in the intrapartal period should the blood pressure of the mother be ta$en/
A2 %mmediately after the expulsion of the baby
B2 After the separation of the placenta
C2 %mmediately after the expulsion of the placenta
!2 Anytime
>rs. )aba Chiu a 7.&2 ?.@2@;@1@22 in acti#e labor is admitted in the labor room. Her cer#ix is 2 cm. open ,
3;A effaced , in cephalic presentation +ith BB( intact, station C1. Her labor started at 3=.- +hich is
moderate in intensity and lasted for 2; seconds. At 3=-- another contraction occurs for 2; seconds. 4arlier
in the 48, an intra#enous infusion +ith !-<8 1< C 1; DuE oxytocin x 1;; cc:H +as started using a Baxter
macroset.
%n reference to the situation mentioned, ans+er the follo+ing uestions=
'-. Ho+ many children does >rs. Chiu ha#e at present/
A) & ) 2
") ' D) (
'9. (hat type of solution is !-<8/
A2 Hypertonic solution C2 Hypotonic solution
B2 %sotonic solution !2 *one of the abo#e
'1. Bxytocin is indicated in all conditions belo+, except=
A2 %nduce labor C2 %ncomplete abortion
B2 &re#ent post partum bleeding !2 &lacenta pre#ia
'3. (hat complication of pregnancy does >rs. Chiu has experienced/
A2 &reterm deli#ery C2 )hreatened abortion
") Abortion !2 4clampsia
'6. %f you are to regulate the %F infusion of >rs. Chiu, +hat +ould be the rate of flo+ in
gtts.:min./
A2 '' gtts.:min C2 .; gtts.:min
B2 '; gtts.:min !2 '3 gtts.:min
.;. "tation C1 means=
A2 )he presenting part of the fetus is engaged.
B2 )he presenting part is at the perineum
C2 )he head of the fetus is floating
D) )he presenting part of the fetus is just belo+ the ischial spine.
.1. )his term refers to the time period from the beginning of one contraction to the start of
the next contraction.
A2 5reuency C2 duration
B2 %nter#al !2 puerperium
.2. )he follo+ing are characteristics of amniotic fluid, except=
A2 Gello+ish green in color C2 &ro#ides the fetus a cushion from injury
B2 &ro#ides the fetus +ith optimum temp !2 Has fetal, urine, lanugo and epithelial cells
.'. After suctioning a term neonate +ho appears in good condition after birth, +hich of the
follo+ing +ould the nurse do next/
A2 &lace the fetus in a radiant +armer C2 %nstill erythromycin ophthalmic
B2 Bbtain the ne+born +eight !2 &ut %! bracelet in the +rist
... All of the follo+ing are contained in an BB pac$, except=
A2 Cord clamp C2 5orceps
B2 "terile go+n !2 8eceptacle for placenta
.-. 8abies #irus can be transmitted through=
a. &enetration of bro$en s$in
b. contact +ith a pre@existing +ound or scratch
c. penetration of intact mucosa
d. any of these modes of transmission
.9. )he nursing inter#ention that %s most important in a patient on %F >orphine/
a. >onitor for hypertension
2
b. Monitor for decreased respiration
c. >onitor for cardiac rates
d. >onitor for hyperglycemia
.1. A client +ith tuberculosis is gi#en the drug pyra,inamide ?&yra,inamide2. (hich one of the follo+ing
diagnostic tests +ould be inaccurate if the client is recei#ing the drug/
a. <i#er function test
b. 7all bladder studies
c. )hyroid function studies
d. Blood glucose
.3. (hich one of the follo+ing conditions could lead to an inaccurate pulse oximetry reading if the sensor
is attached to the clientHs ear/
a. Artificial nails
b. Fasodilation
c. Hypothermia
d. >o#ement of the head
.6. )he nurse is counseling a client +ith the diagnosis of glaucoma. "he explains that if left untreated, this
condition leads to
a. Blindness
b. >yopia
c. 8etrolental fibroplasia
d. U#eitis
-;. )he physician has ordered a 2.@hour urine specimen. After explaining the procedure to the client, the
nurse collects the first specimen. )his specimen is then
a. !iscarded, then the collection begins
b. "a#ed as part of the 2.@hour collection
c. )ested, then discarded
d. &laced in a separate container and later added to the collection
-1. 5ollo+ing an accident, a client is admitted +ith a head injury and concurrent cer#ical spine injury. )he
physician +ill use Crutchfield tongs. )he purpose of these tongs is to
a. Hypoextend the #ertebral column
b. Hyperextend the #ertebral column
c. !ecompress the spinal ner#es
d. Allo+ the client to sit up and mo#e +ithout t+isting his spine
-2.)he most appropriate nursing inter#ention for a client reuiring a finger probe pulse oximeter is to
a. Apply the sensor probe o#er a finger and co#er lightly +ith gau,e to pre#ent s$in brea$do+n
b. "et alarms on the oximeter to at least 1;; percent
c. %dentify if the client has had a recent diagnostic test using intra#enous dye
d. 8emo#e the sensor bet+een oxygen saturation readings
-'. A client admitted to a surgical unit for possible bleeding in the cerebrum
has #ital signs ta$en e#ery hour to monitor to neurological status. (hich of the follo+ing neurological
chec$s +ill gi#e the nurse the best information about the extent of bleeding/
a. &upillary chec$s
b. "pinal tap
c. !eep tendon reflexes
d. 4#aluation of extrapyramidal motor system
-.. Using the principles of standard precautions, the nurse +ould +ear glo#es in +hat nursing
inter#entions/
A. &ro#iding a bac$ massage
B. 5eeding a client
C. &ro#iding hair care
!. &ro#iding oral hygiene
--. )he nurse is preparing to ta$e #ital sign in an alert client admitted to the hospital +ith dehydration
secondary to #omiting and diarrhea. (hat is the best method used to assess the clientIs temperature/
A. Bral
B. Axillary
C. 8adial
!. Heat sensiti#e tape
-9. A nurse obtained a clientIs pulse and found the rate to be abo#e normal. )he nurse document this
findings as=
A. )achypnea
B. Hyper pyrexia
'
C. Arrythmia
!. )achycardia
-1. (hich of the follo+ing actions should the nurse ta$e to use a +ide base support +hen assisting a client
to get up in a chair/
A. Bend at the +aist and place arms under the clientIs arms and lift
B. 5ace the client, bend $nees and place hands on clientIs forearm and lift
C. "pread his or her feet apart
!. )ighten his or her pel#ic muscles
-3. A client had oral surgery follo+ing a motor #ehicle accident. )he nurse assessing the client finds the
s$in flushed and +arm. (hich of the follo+ing +ould be the best method to ta$e the clientIs body
temperature/
A. Bral
B. Axillary
C. Arterial line
!. 8ectal
-6. A client +ho is unconscious needs freuent mouth care. (hen performing a mouth care, the best
position of a client is=
A. 5o+lerIs position
B. "ide lying
C. "upine
!. )rendelenburg
9;. A client is hospitali,ed for the first time, +hich of the follo+ing actions ensure the safety of the client/
A. 0eep unnecessary furniture out of the +ay
B. 0eep the lights on at all time
C. 0eep side rails up at all time
!. 0eep all euipment out of #ie+
91. A +al$@in client enters into the clinic +ith a chief complaint of abdominal pain and diarrhea. )he nurse
ta$es the clientIs #ital sign hereafter. (hat phrase of nursing process is being implemented here by the
nurse/
A. Assessment
B. !iagnosis
C. &lanning
!. %mplementation
92. %t is best describe as a systematic, rational method of planning and pro#iding nursing care for
indi#idual, families, group and community
A. Assessment
B. *ursing &rocess
C. !iagnosis
!. %mplementation
9'. 4xchange of gases ta$es place in +hich of the follo+ing organ/
A. 0idney
B. <ungs
C. <i#er
!. Heart
9.. )he Chamber of the heart that recei#es oxygenated blood from the lungs is the/
A. <eft atrium
B. 8ight atrium
C. <eft #entricle
!. 8ight #entricle
9-. 7eneral anaesthesia is the loss of sensation and consciousness, local anaesthesia is associated +ith loss
of sensation but not loss ofJ
A. control B. communication C. consciousness !. appetite
99. 8ange of A<!484)4 score that the patient can already be transfer to their room of choiceJ
A. 9@1; B. 1@1; C. 3@1; !. 6@1;
99. )he objecti#e of doing the A<!484)4 score is toJ
A. )o maintain the consciousness of the patient.
B. to assess the physical status of the patient reco#ering from anaesthetic agent.
C. )o e#aluate oxygen demand post@operati#ely cause by anaesthesia.
!. )o pro#ide baseline data and monitoring for comparison purposes.
.
91. !uring +hat specific part ot the 4C7 tracing that a nurse should defibrilate the patient/
A. ") +a#e B. K8" +a#e C. & +a#e !. ) +a#e
93. %t is used in balanced combination to produce #arying le#els of loss of consciousness, pain control
and:or s$eletal muscle relaxationJ
A. general anaesthesia B. local anaesthesia C. tranuili,ers !. sedati#es
96. Used to produce pain control +ithout rendering the client unconsciousJ
A. general anaesthesia B. local anaesthesia C. tranuili,ers !. sedati#es
1;. )he stage of anaesthesia +here the patient is in complete respiratory depressionJ
A. stage 1 B. stage 2 C. stage ' !. stage .
11. )he stage of anaesthesia +here the operation beginsJ
A. stage 1 B. stage 2 C. stage ' !. stage .
12.)he stage of anaesthesia +here the client becomes dro+sy and losses consciousnessJ
A. stage 1 B. stage 2 C. stage ' !. stage .
1'. %t is also $no+n as the stage of excitementJ
A. stage 1 B. stage 2 C. stage ' !. stage .
1.. )o pre#ent air+ay obstruction in the postoperati#e patient +ho is unconscious or semiconscious, the
nurse
A. encourages deep breathing.
B. ele#ates the head of the bed.
C. administers oxygen per mas$.
!. positions the patient in a side@lying position.1-. (hich of the follo+ing should be included in the plan of
care for a patient +ho had spinal anesthesia/
A. 4le#ating the head of the bed to decrease nausea
B. 4le#ating the patientHs feet to increase blood pressure
C. %nstructing the patient to remain flat in bed for 9 hours
!. Administering oxygen to reduce hypoxia produced by spinal anesthesia
1-. (hich of the follo+ing may be left in place +hen a patient is sent to the operating room/
A. (ig
B. Hearing aid
C. 4ngagement ring
!. (ell@fitting dentures
19. (hich of the follo+ing nursing inter#entions should recei#e highest priority +hen a patient is admitted
to the postanesthesia care unit/
A. &ositioning the patient
B. Bbser#ing the operati#e site
C. Chec$ing the postoperati#e orders
!. 8ecei#ing report from operating room personnel.
11. (hat +ould be the most effecti#e +ay for a nurse to #alidate Linformed consentL/
A. As$ the family +hether the patient understands the procedure.
B. Chec$ the chart for a completed and signed consent form.
C. As$ the patient +hat he or she understands regarding the procedure.
!. !etermine from the physician +hat +as discussed +ith the patient.
13. )he reason pts are sent to a &ACU after surgery is=
A. to be monitored +hile reco#ering from anesthesia.
B. to remain near the surgeon immediately after surgery.
C. to allo+ the medical@surgical unit time to prepare for transfer.
!. to pro#ide time for the pt to cope +ith the effects of surgery.
16. &atients may experience +hich problem 2.@.3 hrs post@op as a result of anesthetics/
A. colitis
B. "tomatitis
C. &aralytic ileus
!. 7astrocolic reflux
3;. A nurse is assessing a pt +ith a closed chest tube drainage system connected to suction. (hich finding
+ould reuire additional e#aluation in the post@operati#e period/
-
A. 1-ml of bright red drainage in the system.
B.Column of +ater 2;cm high in the suction control chamber.
C. Constant bubbling in the +ater seal chamber
!.*one of the abo#e.
31. )he nurse is pro#iding teaching to a patient regarding pain control after surgery. )he nurse informs the
patient that the best time to reuest pain medication is=
A. Before the pain becomes se#ere.
B. (hen the patient experiences a pain rating of 1; on a 1@to@1; pain scale.
C. After the pain becomes se#ere and relaxation techniues ha#e failed.
!. (hen there is no pain, but it is time for the medication to be administered.
32. )he &ACU has recei#ed a semiconscious patient from the operating room and re#ie+s the chart for
orders related to positioning of the patient. )here are no specific orders on the chart related to specific
orders for the patientHs position. %n this situation, in +hat position +ill the nurse place the patient/
A. )rendelenburg position
B. &rone position
C. "ide@lying position
!. "upine position
3'. "igns of <aryngeal ner#e damage in thyroidectomy=
A. (hispering #oice C. Bleeding
B. 5reuent s+allo+ing !. no output
3'. >il$y +hite anesthetic use in sedating patients
A. Uro#ison C. Allopurinol
B. &ropofol !. )racrium
3.. !r. Mohnson is ligating the bleeders, 7ray the scrubber +ould offer
A. "il$ C. Chromic
B. &lain !. Ficryl
3-. Another term for cigarette drain
A. ':2 penrose drain C. 1 inch penrose drain
B. N penrose drain !. none of these
39. >easures the B2 saturation of the body
A. >anometer C. Cardiac monitor
B. &ulse oximeter !. &ulse probe
31. 7i#en as &re@B& medication to inhibit secretions
A. 4pinephrine C. )racrium
B. A)"B. !. &lasil
33. >rs. "anders is going to prep her patient, she +ill prepare the follo+ing=
A. Cidex C. &o#idone@iodine
B. )riiodine HC< !. Chlorhexidine gluconate
36. 5acilitates insertion of endotracheal tube=
A. )racheostomy tube C. )horacic Catheter
B. <aryngoscope !. none of these
6;. *ursing responsibility before gi#ing *ubain=
A. Chec$ B& C. >easure inta$e O output
B. Chech )emperature !. none of these
61. )he purpose of pre@op s$in prep is to=
A. 8educe the nimber of microorganism C. All of the abo#e
B. 8ender s$in sterile
62. )he primary goal of *&B before surgery is to pre#ent=
A. Aspiration C. %nfection
B. !istention !. Bbstruction
6'. (hich is not correct in the follo+ing statements about the principles of surgical asepsis/
A. Al+ays face the sterile area
B. )able are sterile only at table le#el
C. "terile persons touch only sterile items
!. )ying the go+n of the surgeon at the bac$
9
6.. &hase of preoperati#e nursing +hich begins +hen the client is transferred to the Br table and ends +ith
the admission of the clients to the reco#ery room=
A. %ntra@op C. &re@op
B. &ost@op !. none of these
6-. Another term for round nose=
A. 8ing forcep C. >ayo forcep
B. 0elly 5orcep !. Allis forcep
69. "ponge Bob is explaining some of the common term used in B8, sterile field means =
A. 5ree of microorganism
B. )he area around the incision site, mayo table , sterile drapes and instruments, surgical field
C. "terile instruments
!. none of these
61. "urgery that must be performed ")A) to preser#e life, maintain an organ or limb function and to stop
bleeding=
A. %mperati#e nursing C. 8euired surgery
B. 4lecti#e surgery !. 4mergency surgery
63. 7i#e meaning of adhesion=
A. Union of t+o normally separate surfaces C. !e#iation from the normal
B. Hypertrophy of an organ !. none of these
66. Anastomosis means=
A. Adjoining parts C. !estruction of tissue
B. Connection bet+een t+o organs of parts !. 5olds into lumen
1;;. 8rhaphy is to repairJ otomy is to=
A. "urgical remo#al C. "urgical attachment
B. "craping of body ca#ity !. none of these
GOOD LUC!$$$
&repared by=
>rs. Macueline 7. 8ios 8.*., >.A.*
Ad#iser B"* %F@5
*oted by=
>rs. >a. Mosephine B. &ro#ido 8.*., >.A.*.
!ean, College of *ursing
1