DE LA SALLE LIPA

COLLEGE OF NURSING
2nd Sem Final Examination
SY 2016-17 (NCM 104-9)
Dr. RICHARD C. LOGRO RN,MAN

NAME _______________________ SECTION ____ DATE _____SCORE _____

GENERAL DIRECTIONS:

Choose the letter of your answer and write on the answer sheet provided. No erasures. Erasures
will be considered wrong. Use only blue or black pen in answering.

1. During preparation for bowel surgery, a male client receives an antibiotic to reduce intestinal
bacteria. Antibiotic therapy may interfere with synthesis of which vitamin and may lead to
hypoprothrombinemia?
A. vitamin A
B. vitamin D
C. vitamin E
D. vitamin K
2. When evaluating a male client for complications of acute pancreatitis, the nurse would observe for:
A. increased intracranial pressure
B. decreased urine output
C. bradycardia.
D. hypertension.
3. A male client with a recent history of rectal bleeding is being prepared for a colonoscopy. How
should the nurse position the client for this test initially?
A. Lying on the right side with legs straight
B. Lying on the left side with knees bent
C. Prone with the torso elevated
D. Bent over with hands touching the floor
4. A male client is recovering from a small-bowel resection. To relieve pain, the physician prescribes
meperidine (Demerol), 75 mg I.M. every 4 hours. How soon after administration should meperidine
onset of action occur?
A. 5 to 10 minutes
B. 15 to 30 minutes
C. 30 to 60 minutes
D. 2 to 4 hours
5. When preparing a male client, age 51, for surgery to treat appendicitis, the nurse formulates a
nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the
rationale for choosing this nursing diagnosis?
A. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture.
B. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and
rupture of the appendix
C. The appendix may develop gangrene and rupture, especially in a middle-aged client.
D. Infection of the appendix diminishes necrotic arterial blood flow and increases venous
drainage.
6. To prevent gastroesophageal reflux in a male client with hiatal hernia, the nurse should provide
which discharge instruction?
A. Lie down after meals to promote digestion.
B. Avoid coffee and alcoholic beverages.
C. Take antacids with meals.
D. Limit fluid intake with meals.
7. A male client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the
clients nasogastric (NG) tube has stopped draining. How should the nurse respond?
A. Notify the physician
B. Reposition the tube
C. Irrigate the tube
D. Increase the suction level
8. A male client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing
this client, the nurse expects to note:
A. yellow sclera
B. light amber urine.
C. circumoral pallor.
D. black, tarry stools.
9. While palpating a female clients right upper quadrant (RUQ), the nurse would expect to find which
of the following structures?
A. Sigmoid colon
B. Appendix
C. Spleen
D. Liver
10. A male client has undergone a colon resection. While turning him, wound dehiscence with
evisceration occurs. The nurses first response is to:
A. call the physician
B. place saline-soaked sterile dressings on the wound
C. take a blood pressure and pulse.
D. pull the dehiscence closed.
11. A client is 1 day postoperative after a total hip replacement. The client should be placed in which of
the following position?
A. Supine
B. Semi Fowlers
C. Orthopneic
D. Trendelenburg
12. After a computer tomography scan with intravenous contrast medium, a client returns to the unit
complaining of shortness of breath and itching. The nurse should be prepared to treat the client for:
A. An anaphylactic reaction to the dye
B. Inflammation from the extravasation of fluid during injection.
C. Fluid overload from the volume of the infusions
D. A normal reaction to the stress of the diagnostic procedure.
13. Which of these nursing actions will best promote independence for the client in skeletal traction?5
A. Instruct the client to call for an analgesic before pain becomes severe.
B. Provide an overhead trapeze for client use
C. Encourage leg exercise within the limits of traction
D. Provide skin care to prevent skin breakdown.
14. To prevent foot drop in a client with Bucks traction, the nurse should:8
A. Place pillows under the clients heels.
B. Tuck the sheets into the foot of the bed
C. Teach the client isometric exercises
D. Ensure proper body positioning
15. Which of the following actions would be a priority for a client who has been in the postanesthesia
care unit (PACU) for 45 minutes after an above the knee amputation and develops a dime size
bright red spot on the ace bandage above the amputation site?36
A. Elevate the stump
B. Reinforcing the dressing
C. Calling the surgeon
D. Drawing a mark around the site
16. Following surgery, Mario complains of mild incisional pain while performing deep- breathing and
coughing exercises. The nurses best response would be:
A. Pain will become less each day.
B. This is a normal reaction after surgery.
C. With a pillow, apply pressure against the incision.
D. I will give you the pain medication the physician ordered.
17. Anas postoperative vital signs are a blood pressure of 80/50 mm Hg, a pulse of 140, and
respirations of 32. Suspecting shock, which of the following orders would the nurse question?
A. Put the client in modified Trendelenbergs position.
B. Administer oxygen at 100%.
C. Monitor urine output every hour.
D. Administer Demerol 50mg IM q4h
18. After surgery, Gina returns from the Post-anesthesia Care Unit (Recovery Room) with a
nasogastric tube in place following a gall bladder surgery. She continues to complain of nausea.
Which action would the nurse take?
A. Call the physician immediately
B. Administer the prescribed antiemetic.
C. Check the patency of the nasogastric tube for any obstruction
D. Change the patients position.
19. Mr. Perez is in continuous pain from cancer that has metastasized to the bone. Pain medication
provides little relief and he refuses to move. The nurse should plan to: 7
A. Reassure him that the nurses will not hurt him
B. Let him perform his own activities of daily living
C. Handle him gently when assisting with required care
D. Complete A.M. care quickly as possible when necessary
20. A client returns from the recovery room at 9AM alert and oriented, with an IV infusing. His pulse is
82, blood pressure is 120/80, respirations are 20, and all are within normal range. At 10 am and at
11 am, his vital signs are stable. At noon, however, his pulse rate is 94, blood pressure is 116/74,
and respirations are 24. What nursing action is most appropriate?
A. Notify his physician
B. Take his vital signs again in 15 minutes
C. Take his vital signs again in an hour
D. Place the patient in shock position
21. During the first 24 hours after thyroid surgery, the nurse should include in her care:
A. Checking the back and sides of the operative dressing
B. Supporting the head during mild range of motion exercise
C. Encouraging the client to ventilate her feelings about the surgery
D. Advising the client that she can resume her normal activities immediately
22. Immediately after cholecystectomy, the nursing action that should assume the highest priority is:
A. Encouraging the client to take adequate deep breaths by mouth
B. Encouraging the client to cough and deep breathe
C. Changing the dressing at least BID
D. Irrigate the T-tube frequently
23. Days after abdominal surgery, the clients wound dehisces. The safest nursing intervention when
this occurs is to:
A. Cover the wound with sterile, moist saline dressing
B. Approximate the wound edges with tapes
C. Irrigate the wound with sterile saline
D. Hold the abdominal contents in place with a sterile gloved hand
24. The sterile nurse or sterile personnel touch only sterile supplies and instruments. When there is a
need for sterile supply which is not in the sterile field, who hands out these items by opening its
outer cover?1
A. Circulating nurse
B. Anesthesiologist
C. Surgeon
D. Nursing aide
25. The OR team performs distinct roles for one surgical procedure to be accomplished within a
prescribed time frame and deliver a standard patient outcome. White the surgeon performs the
surgical procedure, who monitors the status of the client like urine output, blood loss?3
A. Scrub nurse
B. Surgeon
C. Anesthesiologist
D. Circulating nurse
26. Minimally invasive surgery is very much into technology. Aside from the usual surgical team who
else to be present when a client undergoes laparoscopic surgery?
A. Information technician
B. Biomedical technician
C. Electrician
D. Laboratory technician
27. Which of the following should be given highest priority when receiving patient in the OR?
A. Assess level of consciousness
B. Verify patient identification and informed consent
C. Assess vital signs
D. Check for jewelry, gown, manicure and dentures
28. Surgeries like I and D (incision and drainage) and debridement are relatively short procedures but
considered dirty cases. When are these; procedures best scheduled?
A. Last case
B. In between cases
C. According to availability of anesthesiologist
D. According to the surgeons preference
29. OR nurses should be aware that maintaining the clients safety is the overall goal of nursing care
during the intraoperative phase. As the circulating nurse, you make certain that throughout the
procedure.
A. The surgeon greets his client before induction of anesthesia
B. The surgeon and anesthesiologist are in tandem
C. Strap made of strong non-abrasive material are fastened securely around the joints of the
knees and ankles and around the 2 hands around an arm board
D. Client is monitored throughout the surgery by the assistant anesthesiologist
30. Another nursing check that should not be missed before the induction of general anesthesia is:
A. Check for presence underwear
B. Check for presence dentures
C. Check patients blood studies
D. Check baseline vital signs

GOODLUCK G3A