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a. Hemothorax
b. Flail chest
c. Atelectasis
d. Pleural effusion
3. The nurse is caring for a client who has just had a chest tube attached to
a water seal drainage system (Pleur-evac). To ensure that the system
functions effectively the nurse should:
4. The nurse enter the room of a client who has a chest tube attached to a
water seal drainage system and notices the chest tube is dislodge from the
chest. The most appropriate nursing intervention is to:
6. Mr. Sison, 65 years old has been smoking since he was 11 years old. He
has long history of emphysema. Mr. Sison is admitted to the hospital
because of a respiratory infection, which has not improved with outpatient
therapy. Which finding would the nurse expect to observe during Mr.
Sison's nursing assessment?
a. Electrocardiogram changes
b. Increased anterior-posterior chest diameter
c. Slow labored respiratory pattern
d. Weight-Height relationship indicating obesity
7. Mr. Sison is ordered oxygen via nasal prongs. The nurse administering
the oxygen via the low-flow system recognizes that this method of
delivery:
Situation 3 - Mr. Silverio, 56 years old, has had significant problem with alcohol
abuse for the past 15 years. His wife brings him to the emergency department
because he is increasingly confused and is coughing blood. His medical diagnosis is
cirrhosis of the liver. He has ascites and esophageal varices.
10. Assessment of Mr. Silverio would reveal all of the following, except:
a. Bulging flanks
b. Protruding umbilicus
c. Abdominal distension
d. Bluish discoloration of the umbilicus
11. Which laboratory value would the nurse expect to find in a client as a
result of liver failure?
a. High protein
b. Increased potassium
c. Restricted fluids
d. Restricted sodium
a. Liver
b. Kidneys
c. Adrenals
d. Pancreas
Situation 4 - Rape is one of the most tragic things that could happen to anyone
especially with young girls. Incidence such as these could develop into a crisis
situation involving not only the rape victims but also their families.
a. Since this is a legal case, call the press about the incidence of rape
b. Perform thorough physical assessment and documenting objectively all the
evidences of rape
c. Ask the patient to stay in one isolated room first to provide privacy while
attending to other patients
d. Provide emotional support first and postponed physical assessment when patient
is already calm
a. Attitude therapy
b. Psychotherapy
c. Crisis intervention
d. Re-motivation technique
a. Crisis is self-limiting
b. After crisis, the individual always return to a pre-crisis state or condition
c. Crisis always result in adaptive behavior
d. The person in crisis is not susceptible for any help
a. 2-3 weeks
b. 3-4 weeks
c. 1-2 weeks
d. 4-6 weeks
Situation 6 - One Important fact that will guide the nurse in the practice of the
profession is her knowledge of the nursing law.
20. The nurse practice Act of 1991 regulates the practice of nursing in the
Philippines. Which of the following statements about this Act is true?
a. Misrepresentation
b. Assault and Battery
c. Malpractice
d. Negligence
23.A patient has been in the ICU for 2 weeks. The relatives have consented
to a "Do not resuscitate order," When the patient develops a cardiac arrest,
the nurse will carry out which of the following actions?
24. When a patient falls from bed, which of the following is your immediate
action?
Situation 7 - Ms. May Mansur encountered vehicular accident on her way to the
office and he remains conscious. Police officers brought her to the hospital.
25. You have to observe for increase intracranial pressure. Which of the
following is not a sign of increased intracranial pressure?
a. Headache
b. Vomiting
c. Vertigo
d. Changes on the level of consciousness
a. Scopalamine
b. Lanoxin
c. Coumadin
d. Mannitol
28. In what manner would you be able to assess accurately her motor
strength?
29.Which of the following activities would cause her a risk in the increase
of intracranial pressure?
a. Coughing
b. Reading
c. Turning
d. Sleeping
a. Conscious
b. Unconscious
c. Preconscious
d. Foreconscious
a. Id
b. Ego
c. Superego
d. Unconscious
a. Affective reactions
b. Ritualistic behavior
c. Withdrawal patterns
d. Defense mechanisms
35. Joan denied that she has a problem with alcohol. The nurse understands
that Joan uses denial for which of the following reasons:
36. Joan appears suspicious of others and blames them for her personal
problems. The nurse understands the client is using this behavior because
which of the following difficulties?
37. When thinking about alcohol and drug abuse, the nurse is aware that:
a. Dissociation
b. Transference
c. Displacement
d. Reaction formation
41. A disturb client starts to repeat phrase that others have just said. This
type of speech is known as:
a. Autism
b. Echolalia
c. Neologism
d. Echopraxia
a. Logic
b. Association
c. Reality testing
d. The thought process
43. The major reasons for treating severe emotional disorders with
tranquilizers is to:
Situation 11 - Aisa, is a 4-year old with severe anemia. She is seen by the nurse in
the clinic.
46. Which of the following problems associated with anemia best explains
why Aisa becomes dizzy during periods of physical activity?
a. Serum hepatitis
b. Allergic response
c. Pulmonary edema
d. Hemolytic reaction
Situation 12 - Eric Pineda is admitted to hospital to have his urethra dilated by the
physician. A urinary retention catheter is inserted following the procedure.
49. A routine urinalysis is ordered for Mr. Pineda. If the specimen cannot be
sent immediately to the laboratory, the nurse should:
50. The nurse understands that the structure that encircles the male
urethra is the:
a. Epididymis
b. Prostate gland
c. Seminal vesicle
d. Bulbourethral gland
51. The nurse can best prevent the contamination from Mr. Pineda's
retention catheter by:
a. Perineal cleansing
b. Encouraging fluids
c. Irrigating the catheter
d. Cleansing around the meatus periodically
52. When Mr. Pineda, who has urinary retention catheter in place,
complaints of discomfort in the bladder and urethra the nurse should first:
53. Mr. Pineda experiences difficulty in voiding after his indwelling urinary
catheter is removed. This is probably related to:
a. Fluid imbalance
b. Mr. Pineda's recent sedentary lifestyle
c. An interruption in normal voiding habits
d. Nervous tension following the procedure
54. Mrs. Alcantara's signs and symptoms would most likely be associated
with:
a. Pyelitis
b. Cystitis
c. Nephrosis
d. Pyelonephritis
55. Mrs. Alcantara has a higher risk of developing cystitis than does a male.
This is
due to:
56. The family of an elderly, aphasic client complain that the nurse failed to
obtain a signed consent before insertion of indwelling catheter to measure
hourly output. This is an example of:
57. When caring for a client with continuous bladder irrigation, the nurse
should:
58. When urinary catheter is removed, the client is unable to empty the
bladder. A drug is used to relieve urine retention is:
a. Carbachol injection
b. Neosporin GU irrigant
c. Bethanecol (Urecholine)
d. Pilocarpine hydrochloride (Pilocar)
Situation 14 - Arman Adriatico is admitted to hospital with extensive carcinoma of
the descending portion of the colon with metastasis to the lymph nodes.
a. lleostomy
b. Colectomy
c. Colostomy
d. Cecostomy
61. When teaching Mr. Adriatico to care for a new stoma, the nurse should
advice him that irrigations be done at the same time every day. The time
selected should:
62. When performing the colostomy irrigation, the nurse inserts the
catheter into the stoma:
a. 5cm
b.10cm
c.15cm
d.20cm
a. Rich in protein
b. Low in fiber content
c. High in carbohydrate
d. As close to normal possible
a. Leave Mr. Gabatan lying on his back with instructions to move and then go seek
additional help
b. Gently raise Mr. Gabatan to a sitting position to see if the pain either
c. Roll Mr. Gabatan on his abdomen, place, a pad under his head, and cover
him with any material available
d. Gently lift Mr. Gavatan into a flat piece of lumber and using any available
transportation, rush him to the nearest medical institution
65. Once admitted to hospital the physician indicates that Mr. Gubatan is a
paraplegic. The family asks the nurse what that means. The nurse explains
that:
66. The nurse recognizes that the major early problem for Mr. Gabatan will
be:
a. Bladder control
b. Client education
c. Quadriceps setting
d. Use of aids for ambulation
67. The nurse should expect Mr. Gabatan to have some spasticity of the
lower extremities. To prevent the development of contractures, careful
consideration must be given to:
a. Active exercise
b. Deep massage
c. Use of tilt board
d. Proper positioning
Situation 16- Karen Boltron, age 16, is withdrawn and non communicative. She
spends
most of her time lying on her bed.
69. Which nursing intervention would be the most appropriate way to help
Karen accept the realities of daily living?
72. One day Karen suddenly walks up to the nurse and shouts. "You think
you're so damned perfect ad good. i think you stink," Which response
should the nurse make?
a. Supply rim with paper tissue to help him function until his anxiety is reduced
b. Explain to him that this idea about doorknob is part of his illness and is not
necessary
c. Encourage him to scrub the doorknobs with a strong antiseptic so he does not
need to use tissues
d. Encourage him to touch doorknobs by removing all available paper tissue until he
learns to deal with the situation
76. Which action by the nurse would most likely decrease Danny's anxiety?
Situation 18 - Jennifer Yadao, age 16, is admitted with the diagnosis of anorexia
nervosa. She has lost 10 kg in 5 weeks. She is very thin but excessively concerned
about being overweight. Her daily intake is 10 cups of coffee.
79. Which nursing intervention should the nurse initially perform for
Jennifer?
a. Explain the value of good nutrition
b. Compliment her on her lovely figure
c. Try to establish a relationship of trust
d. Explore the reasons why she does not eat
a. Allow self-esteem
b. Feelings of unworthiness
c. Anger directed at the parents
d. An unconscious fear of growing up
a. Remind frequently the client to eat all the food served on the tray
b. Increase phone calls allowed the client by or a per day for each pound gained
c. Include the family with the client in therapy sessions two times per week
d. Weigh the client each day at 6:00 A.M. in hospital gown and slippers after she
voids
82. Another patient, Kara, 17 years old, is also diagnosed with anorexia
nervosa. You have been assigned to sit with her while she eats her dinner.
Kara says to you, "My primary nurse trusts me. I don't see why you don't."
Your best response is:
83. Which observation of the client with anorexia indicates that the client is
improving?
Situation 19 - Mr. Pascua is pacing about the unit and wringing his hands. He is
breathing rapidly and complains of palpitations and nausea and he has difficulty
focusing on what the nurse is saying. •
a. If the client is out of control, another person will help to decrease his anxiety
level
b. Being alone with an anxious client is dangerous
c. It will take another person to direct the client into activities to relieve anxiety
d. Hospital protocol for handling anxious clients requires at least two people
85. He says he is having a heart attack but refuses to rest. The nurse would
be Interpret his level of anxiety as:
a. Mild
b. Moderate
c. Severe
d. Panic
86.What should the nurse include in the care plan to Mr. Pascua when he is
having
a panic attack?
88. Joel has some internal bleeding. At which of the following sites is the
most common for the child with hemophilia to bleed?
a. Joints
b. Intestines
c. Cerebrum
d. Ends of the log bones
89. Which of the following blood products is most likely to be given to Joel?
a. Albumin
b. Fresh frozen plasma
c. Factor VIII concentrate
d. Factor II, Vll, IX, X complex
90. Joel's parents ask if-their other children will be affected by the disorder.
Which of the following statements should guide the nurse in her response?
a. All the girls will be normal and the other son a carrier
b. All the girls will be carriers and one half the boys will be affected
c. Each son has a chance of being affected and each daughter a 50% chance of
being a carrier
d. Each son has 50% chance of being affected or a carrier, and the girls will be all
carriers.
Situation 19 - Mr. Villa who was admitted to the respiratory floor with COPD. The
nurse finds him extremely restless, incoherent, and showing signs of acute
respiratory distress. He Is using accessory muscles for breathing and Is diaphoretic
and cyanotic.
93. An order is written for oxygen by nasal cannula at 2 liters per minute.
Which assessment is most useful in assessing the adequacy of the oxygen
therapy?
a. Respiratory rate
b. Color of mucus membranes
c. Pulmonary function tests
d. Arterial blood gases
94. Mr. Villa needs frequent monitoring of arterial blood gases. Following
the drawing of arterial blood gasses it is essential for the nurse to do which
of the following?
95. The nurse is interpreting the results of a blood gas analysis performed
on an adult client. The value include pH of 7.35, pC02 of 60, HC03 of 35. and
02 of 60. Which interpretation is most accurate?
96. Cancer is the second major cause of death in this country. What is the
first step toward effective cancer control?
97. In order to educate clients, the nurse should understand that the most
common site of cancer for a female is the:
a. Uterine cervix
b. Uterine body
c. Vagina
d. Fallopian tube
99.A client with cancer that has metastazised to the liver is started on
chemotherapy- His physician has specified divided doses of the
antimetabolite. The client asks why he could take the drug in divided doses.
The appropriate response is:
a. " There really is no reason your doctor just wrote the orders that way."
b. "This schedule will reduce the side effect of the drug."
c. "Divided doses produce greater cytotoxic effects on the diseased cells."
d. "Because these drugs prevent cell division, they are more effective in divided
doses,"